Are we screening too much for skin cancer? It's complicated
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When I got there, the doctor, who was a local UCSF-trained expert, suddenly looked very stressed out and started taking pictures of it. He kept insisting I get tested for deadly skin cancer (remember, melanoma is AGGRESSIVE) in a very roundabout way, but would not give any probabilities or anything like that. The more I asked questions, the less information he would give about what was going on, other than that I should get a biopsy RIGHT NOW in his office (he even told his other patients to wait a while).
He numbed my foot with a shot, and then took the dermatology equivalent of an ice cream scooper and dug out a sizable chunk of my flesh. I was told I had to wait for two weeks for the results -- the most agonizingly stressful two weeks of my life -- hearing the news was less stressful. "We'll call you if there's any problems, if you don't get a phone call, nothing is wrong. See you at your next appointment!"
The results were a rare "spitz nevus" precancerous mole that looks exactly like melanoma but is completely benign. I had won the lottery. The doctor took even more pictures the next time.
So, to answer the article's question, no we are NOT screening too much for skin cancer; otherwise, I would have known to be in the doctor's office a LOT sooner. And I am a shut-in who does not sun bathe or even go outside for more than 30 minutes at a time on the occasional weekend...
The lesion was likely too big to comfortably remove in-office.
This is definitely the wrong way to do it. If nothing's wrong, I want to hear about it.
Is it really worth screening/treating a disease with a small chance to kill you if that treatment has a huge chance to make you impotent?
Secondly, also there is significant evidence of high incidence of depression for people with side effects, such as incontinence and impotence. I don't think people have the ability to assess that effect based on their values. To use an extreme example, should we operate something that has a 1:1000 change of killing you before something else, if it increases your suicide risk to 1:500? Should we allow patient to make that decision?
Anyway, patients can't make all decisions regarding their own health since most drugs need a medical prescription. And doctors won't just do any procedure that you ask them to.
This is further encouraged by modern western medicine being highly compartmentalised - to oversimplify, the cancer doctor has succeeded if you don't get cancer, but will probably never even find out if you get severe depression as a side effect of a side effect and certainly won't have to deal with it. Specialists also have their own professional and personal bias when they deliver their options, which is not apparent when presenting as a patient.
Is a scenario where the patient and the doctor are both acting based on short term benefit, rather than a holistic view, good for either party?
There is a role for large scale public health policy in my opinion, as morally complicated as it is.
The fact is there are tons of people for whom the side effects are a non-issue, and many for whom they would be far worse than the disease, and the statistics give no indication as to who is in which category.
The role of public health is to provide information so that doctors and patients can make better informed decisions. But the idea that decisions should be made by some third party that "knows better" is predicated entirely on the false belief that such an entity exists.
> Holism (from Greek ὅλος holos "all, whole, entire") is the idea that various systems (e.g. physical, biological, social) should be viewed as wholes, not merely as a collection of parts.
Of course it would be best if there was a universal language which everyone was proficient in, every patient had unlimited healthcare resources, had a strong understanding of medicine and every doctor was an excellent communicator, was under no personal/professional pressure to deliver specific outcomes, always took all the time a patient needed to understand every aspect of their case and care in the present and into the future and personally consulted with every possible specialist that may be involved with the potential outcomes.
Putting aside the strawman, there are significant compromises with the highly personalised approach you suggest (some of which I tried to outline, but have not been responded to), just as there are with national level approaches (which are self evident). I feel that there are applications for both.
I heard from him one of the pellets went 'missing' and was assumed to be 'wandering'.
At 63 yrs, he developed acute leukemia and basically died within a week.
I am not going to research and pursue this, but I am very bitter.
Hypothetical Bob is going to die when he's 78. We can tell Bob he has prostate cancer when he's 76, or when he's 70. Telling him does not make him live longer. But telling him does mean he may undergo treatment that degrades his quality of life, or even shortens his life.
How can we justify telling him when he's 70, when that won't make him live longer but could well make his life worse?
The thing is prostate cancer is usually a very slow cancer. Very often the proper response to a diagnosis of prostate cancer is keep an eye on it. Being aggressive about going after prostate cancer means more patients harmed by treatment (can you say "erectile dysfunction") but no lives saved. The few saved from cancer are offset by those who die from treatment.
There are basically three types of cancers and note that other than by observing what happens over time the doctors can't tell them apart:
Aggressive cancers. You're dead. The doctors putting you through hell might buy you a bit more time, but that's it.
Slow cancers. In most patients you'll die with the cancer, not of it. Prostate cancer tends to fall into this category.
Middle of the road cancers. These are the only ones where treatment is actually of much benefit to the patient. Found early enough you might even get a cure.
Ozone depletion plays a role, but interestingly, the Earth is also closer to the Sun during the southern hemisphere summer, resulting is ~7-10% greater solar UV intensity:
Australia’s unusually harsh sunshine results mainly from its location in the Southern Hemisphere. The elliptical orbit of the Earth places the Southern Hemisphere closer to the sun during its summer months than the Northern Hemisphere during its summer. This means that the summer sun in Australia is 7 to 10 percent stronger than similar latitudes in the Northern Hemisphere. Air currents high in the atmosphere sometimes bring ozone-depleted air from Antarctica’s ozone hole to Australia, letting even more UV through. And Australia’s sunny weather and relatively pollution-free air provide little additional protection from harmful UV rays
https://earthdata.nasa.gov/learn/sensing-our-planet/aerosols...
Between the risks of melanoma and the risks of not enough vitamin D and who knows what else we need from the sun, I can't say what's worse, but I don't think staying pasty-white and avoiding all sun contact is healthy any more.
This is truly bothersome. Science should only be a hunt for the truth.
Does this bother anyone else? I really hope that level of uncertainty doesn't extend to too many other types of cancers...
The standard in this phrase is also exceedingly high. Even a test with just a 1 in 1000 rate of false positives would not pass. But are you really going to doubt a test that only has a 0.1% chance of being wrong?
I want a rate. Are half being misdiagnosed? 20%? 2%?
The real problem seems to be the knee-jerk biopsy/surgery.
If a QA engineer points out a potential bug, it's foolish immediately/blindly delete chunk of code containing the bug. It's just as foolish to say we're randomly deleting too much good code, so let's fire the QA engineers.
It's not, though. There's a cost to collecting the information, it's not always actionable, and it can be wrong. On the human side, there's a reason they say "ignorance is bliss."
That's a lot of wasted time. Time better spent having the QA engineer only look at bugs reported by users and not looking for them on their own.
In the case of the mammogram, it's even less clear cut. The mammogram only shows spots. A biopsy is necessary to determine if it's cancer. A biopsy is surgery and could have complications. And could in fact make the problem worse.
So the idea is that you only do the test if you actually have symptoms or a family history of breast cancer, until the risk level gets high enough that it warrants going to look for cancer without symptoms.
In either case you can choose to do nothing. Knowing that the bug exists should put you in a better place to make the right call.
The problem was the decision to undergo treatment when the complications outweighed the benefit. What if we did more screening but also less treatment?
Even if we perform zero treatment, this data argument should be sufficient reason to increase rather than decrease the number of MRIs we do. CT is different since there is some radiation exposure risk that must be considered.
If you do disclose the results and proceed with a normal patient relationship, you are in the same dilemma as above. You don't know if the tumor is dangerous or not, so the safe course is to do a biopsy, which is itself often invasive. Depending on the results that may lead larger surgeries to exicse large parts of organs and/or the starting of chemotherapy.
Also MRIs are expensive, and in the U.S. a significant amount of that cost (usually hundreds of dollars) is borne by the patient, even if they are insured.
But I don't think we lack for MRI or CT data, there are lots ordered every year. The biggest problem with gathering your data set would be medical privacy regulations. I would guess that medical researchers have already tried longitudinal studies on this to see if different imaging characteristics lead to different outcomes. It's a hard problem, the only data you really get from scans is tissue density, which can probably never tell you what you need to know.
Now if I could find its source...
Edit: a search revealed that it was about knee surgeries that do not always make things better.
Should it? Running around with a known cancer that your doctors refuse to treat (because they expect it to go away), is a major stress factor and may, in the end, damage your own immune response.
Actually, "more information may lead to worse performance" has been shown in another psychologically heavy field: the stock market. [0]
Humans are complicated.
[0] https://behaviouralinvestment.com/2019/01/09/can-more-inform...
From a Bayesian/logical POV, more information should still allow for a better decision.
If you have next to no risk of a disease, don’t get tested for it. You might get treated for it!
If this is true, then clinical decision makers don't understand or are not correctly applying Bayesian priors.
And I don't understand your comment about knee-jerk biopsy--if you're not going to do the biopsy why did you even bother with the mammogram??? My wife has been through that: Routine mammogram--it got read while she was still there. The radiologist didn't like a spot. Ultrasound. They still didn't like the spot. An hour of sitting around while they get authorization, then they do a biopsy there in the radiology facility.
That came back abnormal but not cancer. At that point the urgency was over, she was referred to a surgeon who removed what pathology said was a precancerous lump.
I live in a rural town in Spain where most people are still farmers ( wineries, olives ).
It means most of the men can take up to 6-7 hours, at minimum, of sun their entire life each day.
Its a small town so we know whenever someone dies. In my 27 years never heard or someone died from skin cancer.
There have been many lung cancers from smoking, prostata, belly...
I dont know where this trend about skin cancer begun, maybe is a think for northen people and not mediterranean that we are more “brown”, and like everything it propagated like fire, trying to sell to you that if the sun hits you without protection youll get skin cancer.
Sorry but no
Another factor is altitude. The risk of skin cancer is higher the higher up you are. People who spend a lot time in the mountains are at higher risk compared to people closer to sea level (at the same latitude).
Basically if you get a 'constant' amount of sun every day, are below ~1000-2000 m above sea level and stay reasonable covered up (wear a shirt, hat if you're bald etc.) the risks seem to be pretty low.
Most people here are pretty tan unless they spend all day in an office.
And then super intense exposure over vacation or sunny weekends. I am not even talking about long hours in the office or covid lockdowns, just regular situation. When its colder then logically people dress more. Add more pale skin by default, meaning less genetic predisposition for good long term protection and the result is what we see.
This is from screening. People in Australia generally understand the importance of skin cancer screening because most people know of someone who's had skin cancer.
The fact that seems that if you take sun without sunbathe you could likely get skin cancer is crazy.
As I said, I live in a rural place where most people gets lots and lots of sun and I still have to know a single old man having it.
And old mans that have taken +8 hours of sun since they are 12.
Just my two cents