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Comment by TaupeRanger | Hacker News Reader

You say "utterly wrong" and yet you clearly have no idea what you're talking about and have never even approached the field of health policy. Screening has to PROVE that it makes people live longer or better, just like any other intervention. It is not the case that screening is automatically good, otherwise we would be giving 20 year olds colonoscopies. Just because you find something, doesn't mean you've helped the patient, as anyone with a modicum of understanding in this field knows.

Read this and learn something: https://www.bmj.com/content/352/bmj.h6080

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Your replies to folks in this thread contain the same hubris as the content of your message, which in turn is consistent with the hubris I've encountered in the medical community over the past five years.

My wife went to urgent care twice in three months because of a pain in her side. She was turned away with cough medicine. She finally went to the ER where a CT scan revealed massive tumors in her abdomen that had gone undetected for likely years. Genetic and semi-annual CA125 screening could yield quite a few false positives, but combined with her physical symptoms she may have had more cause to press at an incomplete conclusion and possibly could have had a different outcome. She underwent nearly $2M in medical procedures over the course of 26 months and died at 45 years old last year.

A few years prior to that I was spring cleaning one day and found a glucose test kit at the house. I had the whole family test their blood glucose. My youngest was 240mg/dL. We waited a day and tested again, same thing. We took her into the hospital and they actually admitted her for two days because they had no idea what to do with a child presenting with Type 1 diabetes that hadn't gone into full DKA. That's harmful, gross, and embarrassing. And this is a major children's hospital that was recently in the top ten in the nation for endocrinology.

In both of these situations, preventative screening could have or did have positive outcomes. I don't disagree with the effect that has been observed, but the conclusion being drawn from it is revolting to me. People should be permitted to make their own decisions about their level of knowledge of the state of their body. We only get one trip as far as we know, and I just find it unacceptable that people are willing to categorically deny diagnostic technology or bemoan its development because they they don't know how to support people trying to navigate the information it brings.

Exactly. Also my sincerest condolences to you and your family.

The level of arrogance in these responses parroting what they’ve read in a paragraph online approaches that with what we saw early in the pandemic with masks.

“Masks don’t work! Fauci said so!” And the level of confidence they said it was shocking along with the self-righteousness.

Yes, maybe people can’t put on N95 masks properly... but maybe we can teach them? Is that so mind blowing? We teach people how to wash hands for 20 seconds, is it not so hard to believe you can’t teach people to wear masks properly? Maybe make masks that are easier to put on?

It’s sad how people with no vision are Karen’ing people to not think ahead or think of the future. It’s scary that it’s happening on hacker news.

We don’t give colonoscopies to 20 years olds because it’s an expensive, invasive test with a low rate of cancer. We don’t give mammograms to under 40 year olds these days because the same and it’s notoriously inaccurate.

We give blood glucose level tests and cholesterol tests to everyone every year at the physical because they are cheap and easy to administer. Even though the effects of both may take decades to have any effect and have no correlation to ultimate death. It’s about trade off of cost and convenience.

If you detect pancreatic or colon cancer in a 20 year old patient via $1 blood test, that is immediately actionable. Cancer is ALWAYS actionable unless you’re talking about prostrate which grows slowly. But even in a 20 year old, you would want to treat that but maybe not a 70 year old.

And we’ve never had the ability to detect stage 1 cancer of the deadliest types of cancer. Imagine the new treatments that might save lives if we could.

Honestly, the number of people here who think they know better and citing unrelated research is bordering on anti-maskers parroting the surgeon general saying masks don’t work when they do.

But this isn't the argument. The argument is about all the false positives you get when you mass-screen everyone. All those people then need to be further examined, overwhelming the medical system and causing distress for the individuals (who are, remember, perfectly well).

I agree if we had a test that was 100% accurate (literally never gave a false result either way), only detected dangerous cancers, and cost $1 then that would be a game-changer, but the screening and tests so far are not that.

> It correctly identified when cancer was present in 51.5% of cases, across all stages of the disease, and wrongly detected cancer in only 0.5% of cases.

If all 300 million Americans get blood tested each year, that is 1 and a half MILLION people who are falsely told they have CANCER. One and a half MILLION people whose life gets turned upside down, WRONGLY, due to a blood test -- at least, until they take a second one. Or a third one. Or maybe they get unlucky never learn they don't have cancer, and mess up their life treating a disease they don't have.

Now, OBVIOUSLY not all 300 million Americans are going to get tested each year. But you are completely ignoring the ethical concerns surrounding telling literally .5% of those who don't have cancer that they have cancer, and the non-insignificant proportion of people who will never learn they don't have cancer (we NEED to consider even the "miniscule" probabilities at this scale), and that makes you seem like somebody who "think[s] they know better".

> One and a half MILLION people whose life gets turned upside down, WRONGLY, due to a blood test

Culture adapts. Getting a cancer diagnosis today is a huge deal because testing is infrequent, usually in response to a problem, and the diagnosis tends to be late and accurate. If 1.5mm healthy people get a false positive every year, the general response will be stress until a second test confirms a false positive.

The lack of public trust in health policy doctrine, and the support for start-ups that can operate outside those channels, comes in large part from this type of thinking.

> Getting a cancer diagnosis today is a huge deal because testing is infrequent, usually in response to a problem, and the diagnosis tends to be late and accurate.

Getting a cancer diagnosis is a "huge deal" because getting cancer is one of the worst experiences a human can go through.

Getting cancer carries the weight of imminent death, obviously. But some cancers can be cured with high survival rate, so what's the big deal? The deal is that these cures are often brutal chemotherapy or radiotherapy or whatever treatments that destroy your body, your sleep, your appetite, your ability to go to the bathroom yourself, your ability to do chores by yourself, your ability to do anything a normal human being can do. They DESTROY you.

THAT'S the "huge deal". NOT the frequency. Cancer RUINS YOUR LIFE for the period you get treated, IF you survive the treatment at all, let ALONE the cancer. And you are proposing we tell sub-1.5 million people EACH YEAR that they might have to go through that, while STILL ignoring the proportion of the population that will never learn they have a false positive because they got unlucky (which, AGAIN, we need to consider, since even miniscule probabilities matter at this scale.)

So until the day we figure out a way to make getting rid of cancer as easy as popping a pill (we're getting closer thanks to gene therapy, but patients may still receive the destructive treatments in the meantime), culture will not "adapt", it will remain a "huge deal", and we will keep "this type of thinking".

> these cures are often brutal

Heart disease is a huge deal. It ruins your life. (Maybe not in all caps.) Nevertheless, we regularly test for it, including with techniques with high rates of false positives. Few panic because almost everyone knows someone who got a false positive and didn't promptly keel over and die.

If healthy adults are screened for cancer, there will be cultural memory of people who got a false positive. The response to a positive test result won't be chemo. It will be further testing, if non-invasive, or suggestions of lifestyle changes and increased monitoring of the suspected system.

People aren't too stupid to understand an early test with a high false positive rate. People with family histories of cancer don't wake up every morning screaming. Some may. But barring everyone because some people will overreact is why orthodox health policy is losing public trust.

I don't enough about heart disease treatment to comment on the degree it ruins your life.

People already get further testing. People already get second opinions. In the time you are changing your lifestyle (a good option for helping treatment, I agree) and increasing monitoring you could already be progressing beyond treatability.

You can argue about whether it's alright to tell sub-1.5 million people each year who don't have cancer that they have cancer (I don't think it is, but whatever). But again you can't disregard the non-insignificant number of people who get false positives.

edit: Actually, not "whatever". You probably shouldn't tell sub-1.5 million people each year who don't have cancer that they have cancer.

Hey, I can see this is emotional for you, but have you considered a world in which it is not telling this vast body of people "you definitely have cancer"? Something more like "we detected XXppm of [marker] which indicates we might need to do some more testing, can we talk about [risk factors]?".

It just doesn't need to be as dire as what you are projecting.

> In the time you are changing your lifestyle (a good option for helping treatment, I agree) and increasing monitoring you could already be progressing beyond treatability.

That's actually a very good argument for early testing.

And needlessly scaring a some people into eating better and exercising more is about as bad as not screening them at all to avoid needless anxiety.

>Getting a cancer diagnosis is a "huge deal" because getting cancer is one of the worst experiences a human can go through.

I’ve never been given a cancer diagnosis, but I’d imagine it’s much, much worse to be told you have stage 4 cancer versus stage 1. As the other person stated, the culture would adapt and people would learn to not immediately sell their house and go on a Vegas bender just because a yearly preventative test said they might, possibly, perhaps have stage 1 cancer. If you are one of the people with a false positive, you schedule a follow-up and move on accordingly.

Your position is anti-progress just for the sake of being against accidentally scaring a few people. Indeed, we should let more people develop cancer and discover it at a later stage due to a small amount of false positives. Not scaring a small amount of people is more important than revolutionizing cancer screenings.

> I’ve never been given a cancer diagnosis, but I’d imagine it’s much, much worse to be told you have stage 4 cancer versus stage 1.

It's bad all the way.

> If you are one of the people with a false positive, you schedule a follow-up and move on accordingly.

People already do schedule follow-ups and additional tests and second opinions when they get a positive.

> Your position is anti-progress just for the sake of being against accidentally scaring a few people.

No, it is cautiously ethical because:

1. You probably shouldn't tell sub-1.5 million people who don't have cancer that they have cancer

2. There are more false positives than you think, if you are suggesting regular blood tests

My impression is that yours is the consensus view in the medical community. But I think that what all these people are telling you is that they'd much rather have a much higher chance of a false positive stage 1 diagnosis than even a much lower chance of false negative diagnosis until they're at stage 4. And any positive result from this would obviously be couched in a doctor consult saying "if you have cancer, which this test doesn't definitively show, it's still very early, we're just going to keep an eye on it, we didn't get any confirmation from a chest x-ray or CT", etc

And having a memento mori can be a positive thing.

Most stage 1 can be treated successfully with surgery alone, it's getting a late diagnosis that force you to go through a brutal treatment. If all cancer were detected in phase 1 it would not be seen as a "huge deal" anymore.

Do you think that technology doesn’t improve over time? You are suffering from a fixed mindset, where you think people or technology is as good as it gets now and never improve.

You should read up more on growth mindsets. People and technology aren’t fixed. They change and improve over time.

If people had your attitude about AIDS we would have let all AIDS patients die because “oh well nothing we can do.”

Luckily those with growth mindsets and optimism didn’t listen to people like you and now AIDS patients take a single pill a day.

The same could happen with cancer to, but not if people like you are in charge.

> If people had your attitude about AIDS we would have let all AIDS patients die because “oh well nothing we can do.”

No, if people had my attitude about AIDS they would say "Jesus Christ, don't tell 1 and half million people each year who don't have AIDS that they might have AIDS." I am talking about diagnosis, not treatment.

You are clearly confusing treatment with diagnosis/screening and should consider walking away from the conversation until you get a better understanding of the ideas being discussed here. Right now you're adding a lot of unnecessary noise with bad arguments.

Nope. You are confidently wrong again.

Early diagnosis means new ways of treating cancers like liver and pancreatic. You don’t seem to understand this. Right now there is practically no treatments for either because it’s detected so late. Maybe after 20 years of early diagnosis we can treat pancreatic cancer the same way we do others.

Let me guess. You were telling people in early 2020 that N95 masks don’t work.

They will not be told they have cancer. They will be told they probably should check something out. Everybody already knows they might have cancer, having a negative blood test would be a huge relief.

Maybe I'm misunderstanding this but a 0.5% false positive rate and a 51% positive rate means that you still get a 50% TRUE positive rate instead of the current rate, which is 0%. And then after you can follow up with a test that is more accurate. Everything has an error rate, even pregnancy tests do, and nobody argues that we should not use pregnancy tests.

Are you comparing that against the MILLIONS who get a correct diagnosis? I expect that the quality-adjusted life year total over all tested is higher with the test than without. Wouldn't that be worth it?

I think this leans more towards the "the needs of the many outweigh the needs of the few" and less towards "tyranny of the majority".

My father died from metastasized prostate cancer.

For every genuinely smart person on HN, there’s a handful of Google warriors who hardly know what they are talking about. I guess that’s not unique to HN, but it can be aggravating just how many commenters can be so “know-it-all” with their comments.

Try making an actual argument rather than simply attacking the attitude or character of the person you're responding to.

I was trying to agree with a comment I saw, but it appears I replied to the wrong comment.

That this test is approved implies that it to some extent at least makes people live longer. There are a number of cancers that are easily treatable in stage one - but they have no symptoms then, and so often kill people because by the time it is discovered it is too late.

False positives are a concern, but one that is manageable. People should get regular checkups, if something comes up we just do more testing as needed.

It's approved to be rolled out to a medical trial. You can read what the journal says here: https://www.annalsofoncology.org/article/S0923-7534(21)02046...

I'll stand corrected.

Though that makes this discussion completely worthless - without trial results we have no idea if it is a useful test. Once we have those results we will know something about how useful/useless might be.

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