Comment by moralestapia | Hacker News Reader

Comment by moralestapia | Hacker News Reader

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Hmm ... idk. I disagree with that (sort of) argument in so many ways.

>The disease [...] are, in the general population, pretty rare.

Cancer is not rare, particularly from a certain age. Early detection heavily skews the odds on one's side. This is such common knowledge that it feels weird having to justify it here.

I know I'm not a "survey performed under the most strict standards of quality" but among my close groups of friends and family there have been a few cases where they got lucky enough to detect this disease very early on, and their treatment and outcome was significantly better (and cheaper, while we are at it, bc you mention cost as well) than if they've just waited even a couple more months.

OTOH, I have yet to hear a story from someone who had some sort of scan done, found something worth to take a look at, that then turned out to be nothing and, for some strange reason, had its life significantly affected by that.

Doctors are not stupid, they know (or intuitively correct for) this Bayesian Base Rate you mention, plus they have other things like years of experience in their particular field. It's not like someone's going to cut your arm the moment you find a weird looking lump growing inside.

>these scares can absolutely fuck up a month of your life

That sounds quite immature, tbh. It's definitely a small price to pay compared to all the trouble you save by potentially detecting issues early on. "Oh, but needles hurt :'(", sure, but their benefit far outweigh such small nuisance. This is also an argument I would've thought anyone would just get naturally, and yet I have to explicitly bring it up here, weird.

Also, if it came to be the case that everyone got scanned regularly, that massive trove of new data would definitely help improve the accuracy of said tests. It definitely won't make matters worse, but better.

>OTOH, I have yet to hear a story from someone who had some sort of scan done, found something worth to take a look at that turned out to be nothing and that, for some strange reason, was significantly affected by that

The go-to for a lot of the "take a look at that" procedures is a biopsy, and a biopsy is not a risk free procedure. I'm surprised that you know more than one person that's had a full-body scan, but don't know anyone that's had a biopsy complication, I know one person who spent several days in the hospital on IV antibiotics after an infection after a Prostate biopsy (which was negative)

>>these scares can absolutely fuck up a month of your life

>That sounds quite immature, tbh. It's definitely a small price to pay compared to all the trouble you save by potentially detecting issues early on.

Have you ever had a cancer or other serious disease diagnosis? It can be surprisingly stressful and detrimental to your health even if it is something that can be effectively treated.

>The go-to for a lot of the "take a look at that" procedures is a biopsy

It's not, sounds like you're not familiar at all with any of this.

There's some road to cover from imaging -> biopsy. Blood tests, more detailed imaging, even keeping an eye on it for some time, etc...

Have you heard of Pap tests? A lot of them come out find signs which could be indicative of a developing cervical cancer. Do all these women get their cervix removed the next week? No, not at all. Most of the time the symptoms go away in a few weeks, after some care and treatment.

Pap tests are done for a reason. Pap tests are the single thing that completely obliterate the "screening everyone is bad" argument.

Except it is.

"Tissue is the issue"

I have yet to see any of my radiologists differentiate a lung nodule that was actually a metastasis from the colon (which can easily miss on PET ) from primary adenocarcinoma/small cell/etc. Neither a pancreatic neuroendocrine tumor from an adenocarcinoma based on a CT or PET.

I have (and often) see my patients incidentally discover masses on imaging. Perfect example- a pancreatic mass on imaging. Next stop is an anxiety filled few weeks while they wait for their biopsy to be scheduled. You then have an additional radiation exposure as these are CT guided. You hope the radiologist doesn't poke a hole in a nearby vessel, induce pancreatitis just by doing the biopsy itself, nor develop a subsequent infection related to the procedure. They then wait an additional week for pathology to result, often only to see normal pancreatic cells indicating this is a cyst.

All of this is often the result of looking for a seemingly innocent diagnosis. Eg an ultrasound to reassure your patient that their abdominal pain is not their gallbladder.

I had a similar event earlier today with a cervical lymph node seen on an ultrasound. Thyroid nodules, renal masses, lung nodules. How long do you have?

Now imagine that you started getting MRI screening every year. You'll be able to afford to wait to make sure a strange mass doesn't get larger.

I got bloodwork done for the first time in a long time. My liver enzymes were high. I don't have hep C. I cut out drinking for a while, liver enzymes were still high. They did some imaging and maybe saw some fat on my liver. They did some more imaging later and didn't see the fat. Enzymes are still high. My next option is a biopsy, the hepatologists tell me.

If I do the biopsy and they don't find cancer or something, they'll just tell me to drink less and eat better. Seems like mostly downside to doing the biopsy.

> Cancer is not rare. Early detection heavily skews the odds on one's side.

Depends on the cancer and even the doctors are torn. Most breast tumors and prostate tumors will not kill you or affect your life much. Treating them likely will (especially for prostate). Depending on the model, the overall health of the population is actually reduced by early detection because in most of these tumors treatment is worse than the disease.

One of my doctors is a strong believer in periodic prostate exams after 40. The other recommends only if there are other symptoms. You can guess which is the older one and which is the younger one.

Years ago there was the whole Gardasil controversy. What was often excluded in the noise was that if it were mandated for all girls as some states were recommending, it would be so expensive that funding for other health programs would need to be reduced. The studies were showing that this kind of preventative approach would again reduce the health of the state's population.

Preventive medicine is good - to an extent. Beyond that it is bad.

I'm interested in those studies. Do you have them handy or will I need to resort to some Google fu?

Here's a related one : https://www.npr.org/sections/health-shots/2014/09/02/3452005...

It mentions Angelina Jolie as a good example of how fear can lead to drastic actions.

Probably better to find an article talking about the general problem to find more references.

Wikipedia has this:

The Cochrane collaboration (2013) states that the best quality evidence neither demonstrates a reduction in cancer specific, nor a reduction in all cause mortality from screening mammography. When less rigorous trials are added to the analysis there is a reduction in mortality due to breast cancer of 0.05% (a decrease of 1 in 2000 deaths from breast cancer over 10 years or a relative decrease of 15% from breast cancer). Screening over 10 years results in a 30% increase in rates of over-diagnosis and over-treatment (3 to 14 per 1000) and more than half will have at least one falsely positive test. This has resulted in the view that it is not clear whether mammography screening does more good or harm. Cochrane states that, due to recent improvements in breast cancer treatment, and the risks of false positives from breast cancer screening leading to unnecessary treatment, "it therefore no longer seems beneficial to attend for breast cancer screening" at any age. Whether MRI as a screening method has greater harms or benefits when compared to standard mammography is not known.

>it is not clear whether mammography screening does more good or harm

> the best quality evidence neither demonstrates a reduction in cancer specific, nor a reduction in all cause mortality from screening mammography.

But you are arguing that regular screening is bad.

You forgot your lines, man!

> Depending on the model...

>it would be so expensive that funding for other health programs would need to be reduced

But that's a different thing. I'm sorry, I will not talk about that.

> But that's a different thing. I'm sorry, I will not talk about that.

For people setting policies (and that includes doctors) cost is absolutely not a different thing.

If you can afford to pay for everything without involving insurance, by all means do whatever tests you want. If you're a doctor you don't want to maybe help Betty while definitely hiring Veronica.

>I'm sorry, I will not talk about that.

You are also not the only participant in the conversation.

I think you’ve missed that he’s not a participant in your conversation at all.

I can’t guess. Which is the older one?

The one recommending it for everyone over 40.

They pushback against too much screening is relatively recent, and thus younger doctors are more likely to adopt it.

I also couldn't guess. There are equally plausible stories the other way: "obviously the older one is the one who doesn't recommend, since they're more experienced and have seen over thousands of patients how often it doesn't help...".

Untreated detectable cancers still kill relatively quickly, the only time they’re not a major concern is when people have other major medical issues.

For perspective even with all the advances in modern medicine in 2020 and thus a pandemic, cancer was still the #2 killer in the US after heart disease. It killed over 600,000 Americans in 2020 and that’s a 27% improvement over what it was doing as recently as 2001.

That said, there’s currently believed to be a long undetectable period where the body fights off most pre cancers. We’re approaching the ability to detect cancers below 0.5mm which we don’t have much clinical data on.

Untrue wrt prostate cancer. Since the average date it’s detected is 70 and 2/3rds of the population is obese, then of course most people will die of something else. If you are non-obese and in good shape, then get aggressive treatment.

That aggressive treatment may leave you incontinent before you turn 50, and likely would not have killed you if untreated.

“Likely” to not have killed you only if you’re part of the obese and overweight majority. For right-sized people, it’s likely to kill you.

Citation?

> Most breast tumors and prostate tumors will not kill you or affect your life much.

This is yet another fallacy.

A prostate cancer takes about 10 years to kill you. If you're 80, then it's probably not worth pursuing aggressive treatment. You're likely to die of something else.

However, if you're 40 then it's another story entirely.

> What was often excluded in the noise was that if it were mandated for all girls as some states were recommending, it would be so expensive that funding for other health programs would need to be reduced.

This is an argument from scarcity. If you have a severely limited amount of a resource, it makes sense to sacrifice some people, so that more people can receive life-saving care.

If the resource is not scarce, then this simply doesn't apply. These days HPV vaccine (in Europe) is around $30, so it makes sense to just vaccinate everybody.

> Preventive medicine is good - to an extent. Beyond that it is bad.

Nope. It's always good, but sometimes it's too expensive.

> These days HPV vaccine (in Europe) is around $30, so it makes sense to just vaccinate everybody.

These days it's likely a very different from 2007 when it was being debated.

There argument wasn't that no one should get Gardasil. Just that it would hurt the health of the society if it was mandated for all. Obviously if you had the money it's good to get it

Yes, and this argument indeed holds in the case of extra MRI screenings. We simply don't have enough MRI units to screen everybody every year.

On the other hand, the quantity of MRI units is not fixed. We can always build more, they are just inherently very expensive. And if you can afford an MRI scan from your personal disposable income, then what's the problem?

> I have yet to hear a story from someone who had some sort of scan done, found something worth to take a look at that turned out to be nothing and that, for some strange reason, was significantly affected by that.

Silly comment. They tell you there's a 16% false positive rate. Maybe you don't know any of these people, but I'd certainly be willing to bet money that some of them got worried sick about it.

In addition, an older case is prostate cancer. At least in the older days, they would do painful procedures that left the patient with significantly lower quality of life, when in fact, many men with prostate cancer die of something else. Nowadays they're a little smarter about it.

>At least in the older days, they would do painful procedures [...]. Nowadays they're a little smarter about it.

So, what's your point? I live in 2023.

That's one well-known example. Others probably exist as well but haven't been dealt with yet.

Most men diagnosed with prostate cancer will die with it rather than from it.

You may not agree, but for context please understand this is a well discussed and researched statistical effect.

It’s hard to dial it in just right, but study after study have borne out that more diagnostics can often lead to worse outcomes.

> OTOH, I have yet to hear a story from someone who had some sort of scan done, found something worth to take a look at, that then turned out to be nothing and, for some strange reason, had its life significantly affected by that.

My friend's wife had a scan done when she was 55 and they found "something they wanted to look at" in her breasts and needed to do a biopsy.

She has anxiety. Her blood pressure spiked to a dangerous zone. It stayed elevated even as they tried to control it with medication. It didn't go back to normal until the biopsy came back negative.

During that time, she was at significant risk of having a stroke or heart attack. All for eventually nothing.

Things like women who have a small cancer that is treated with suregry and quick radiation but insist on getting a mastectomy are not rare, either.

Humans are not rational.

  > Her blood pressure spiked to a dangerous zone.

  > Humans are not rational.

total anecdote but every time i go in for a yearly health exam my blood pressure and heart rate goes up, especially right before sitting down to get my blood pressure taken!

if i take it myself, for some reason im not nervous, comes out ok...

I have a very hard time believing that your friends and family are getting PET/MRI scans routinely, as opposed to what most people actually do which is "hey I found this lump/I feel bad here, please can you check if this is bad and scan for anything else?"

This is an important distinction, because you can delude yourself and your medical team into believing you are healthy because you had a clean scan x months ago, as part of your annual deep checkup or whatever you want to call it. Leading into that part of if your friends had waited a couple more months it would have been a very different outcome!

Never said such thing.

You're arguing against something your mind made up.

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