Our Feel-Good War on Breast Cancer
nytimes.com
nytimes.com
If I remember correctly, most of the breast cancer that develops early is fast-spreading, while most of the cancer later in life is slow-spreading. So as you screen younger and younger people, you quickly reach a point where you cause more harm than good. You're only finding more disease you can do nothing about, and the false positive cause tremendous hardships on tens of thousands of women.
I also seem to remember that there's some serious discussion over the idea of categorizing cancer based on where it's first detected or starts. Cancer is much more a cell-based disorder than a location-based one. We may have created this huge categorization and treatment system that describes the problem in an inefficient way.
Good read.
Here's the link without the affiliate code: http://www.amazon.com/gp/product/1439170916
I think some people get all up in arms about it when larger publications do it, since it throws into question the validity of what they've written if they're trying to make money from referral links. However, the above is clearly someone's personal opinion , and I don't think that it should be scrutinised as if it were deceitful.
Would you also like Dropbox to add disclaimers to all their referral links reminding people that the person who sent them the referral is getting extra space as well?
1) when someone posts a book with an affiliate link and then says its a good book, it really clouds their intentions.
2) the link was obfuscated so you aren't really sure what it points to.
3) some people just won't click on an affiliate link.
By seconding his recommendation and providing a non obfuscated link everyone is better off. His recommendation has atleast been backed up and the user is certain of where the link leads to.
Everyone wins:)
I was first introduced to cancer and the methods used to combat it about 10 years ago via unfortunate circumstances.
It's fascinating stuff with surprising parallels to my work in IT.
A few years ago I built an event management website for a decently large lung-cancer awareness program. During some of the meetings, I met with a world-renowned surgeon who supported the cause and we got to talking about how the breast cancer movement had grown so large. His perspective on it shocked me. Basically he said that breast cancer, in the large scale scheme of diseases, is actually not that dangerous. The mortality rate is incredibly low. Cancers like pancreatic, however, are incredibly high. When a woman gets bc, the cause gains her, her sons/daughters, brothers/sisters, significant other, etc and that support lasts for the duration of treatment, and typically up to a year and a half to two years. With pancreatic cancer, the person usually dies, the family experiences a grieving period, and maybe only gets involved for a short period of time because they spent a large portion of their time focused on the disease in grieving. It was interesting to think about.
edit: changed prostate to pancreatic
I upvoted your comment because it is largely correct. Most cases of prostate cancer can be responded to by "watchful waiting" with no particular treatment. However, I will note for the record that the cause of death of my late father-in-law in Taiwan, who had good medical care under that country's single-payer national health insurance program, was metastasized prostate cancer. He had successful heart surgery and other treatments that prolonged his life into his eighties until the prostate cancer got him.
You may have taken away the wrong message from the surgeon, or maybe I'm reading it wrong. One of the major reasons breast cancer prognosis is so good is because it's often caught early. Pancreatic cancer has no early symptoms, so by the time it's caught it's often too late.
Indeed one school of thought is that improved detection methods system-wide are going to be the #1 factor in winning against cancer long-term.
Actually, the OP ("Our Feel-Good War on Breast Cancer") argued the very opposite.
I don't believe the statistics bear this out. In fact, there isn't a lot of evidence early detection of breast tumors does much to prolong life. If your metric is the number of years you live after the cancer is detected, then certainly early detection seems like a huge win. But that would be true even if you didn't do anything at all upon having detected the tumor.
However, having served on a hospital credentials committee, and bearing witness to what type of lawsuits medical providers have been subject to, I can assure you that if a physician advises against a screening mammogram to a woman in her early 40's despite the fact that there are "organizations" that encourage it, and she ends up with breast cancer and possibly dies, that physician will get sued and will in all likelihood lose, or have to settle. Task forces can make all kinds of recommendations, but unless there are changes to the legal system to back them up , don't expect major changes. Somewhere in this discussion it was suggested that doctors are ignorant. It is, in fact, the exact opposite.
http://www.thisamericanlife.org/radio-archives/episode/391/m...
It is not the actual screenings that I particularly care about -- that is just data. The elephant in the room is the implied massive amount of overtreatment that are justified on the basis of the screenings -- overtreatment that inflicts a tremendous physical, emotional, financial, and health toll on the patient.
What are the long term health costs of unnecessary chemotherapy? Is it ethically okay for a doctor to inflict torturous poisoning (chemotherapy) on a patient for fear of potential lawsuits, when it could easily be true that 75% of those patients gain zero medical benefit?
I'd think in the general case, yes. The patient is going to want it, even if it is only 25% effective. I'm not an expert on medical ethics, but in my mind if the patient has complete information and still wants the treatment, the doctor is not morally bankrupt in providing it. The doctor can certainly advise otherwise if they choose, of course.
In such a case it is very easy to see how it would be possible for the patient to choose treatment which is in fact against their best interest.
Also, as mentioned elsewhere in the thread the current regulatory/legal climate leaves a vanishingly small upside and massive downside to the doctor who would advise against treatment.
The patients are scared. Doctors are playing on those fears, acting on the assumption that fast and aggressive treatment is the wisest course all the time. The patients are reacting out of fear, not getting second opinions, and are hurried into the operating table to be cut open.
That is the norm. I have seen it happen.
It is my personal opinion that, no, most doctors are not offering complete information. So your argument, while reasonable, simply does not apply.
How could you possibly know it whether or not it's necessary?
That is extremely strong evidence that American doctors are applying a painful & damaging treatment far more often than can be rationally justified.
And how are you measuring mortality?
By the number of women who actually die of breast cancer.
Suppose, normalized for population size, 1000 women of a certain age die of breast cancer in both country A and country B. In country A, 5000 women are treated with chemo. In country B, 20000 women are treated with chemo.
Which country has the more competent doctors? I think the answer is obvious.
Hint: The USA is not country A.
You're trying to oversimplify something that isn't simple.
By the way, exactly what country are you talking about here?
The "Feel-Good War" is causing a lot of harm: tens of thousands of women tortured by medically unnecessarily poisoning and radiation, inflicted by well-meaning but ignorant doctors.
My 40something wife would love it if our HMO would stop calling and emailing her 6 times a year to get a mammogram. She has explained clearly to her gynecologist her reasoning, that she is absolutely not going to get a mammogram before age 50, but the annoying calls do not stop. (We shut off our ringer, and use a Google voice number for people we want to her from.)
Much as I sympathize, breast cancer survivor groups have many characteristics of a religious cult. They have paid a high emotional and physical price for entry, and as a result they are so bought in to the idea that the treatment-torture saved their lives that they have only a limited ability to think rationally about health issues anymore.
So, doctors are ignorant? That's news to me, I know a few doctors and they don't strike me as ignorant at all.
Many of the best con artists are sincere. So if they do not recognize their own ignorance, why should you? If there was an important gap in their knowledge they were aware of, would they be confessing that to you, a non-doctor?
As for my evidence, our HMO is run by doctors. My wife's clearly reasoned decision to not get a mammogram before 50, based on her own reading of the medical literature, has proven unpersuasive to her gynecologist or the people who set the policies that "provide" the harassing phone calls.
No. Many of the best con artists can convincingly simulate sincerity. If they were sincere, by definition, they wouldn't be con artists.
A con is by definition a transaction in which one person knows something that the other person doesn't, something that's being deliberately hidden from view for the benefit of the con artist.
We are who we pretend to be.
For Jenny McCarthy to continue to believe what she claims to believe, she has to be either brain-damaged or lying. Oh -- or both.
> Does it matter what they really think?
Of course it does. An intelligent, mistaken person can be reasoned with, educated, presented with new evidence. An intelligent con man cannot.
> We are who we pretend to be.
Unrealistically cynical. The best way to derive mutual benefit from other people is to be exactly who you say you are.
"She/he is a smart, honest, kind, well-meaning, salt of the earth person. This is just not the kind of person would would lie about ______"
Ghosts. UFOs. Truthers. Vaccinations. I have heard a thousand times.
Smart people can be wrong. Honest people can be wrong. Smart and honest people can be wrong.
"She has to be either brain-damaged or lying" sets up a False Choice that will lead many people to believe the opposite to what you are (presumably) trying to argue.
The spirit of what I was trying get at (perhaps, too "cleverly") with "many of the best con artists are sincere" is that one should not take off your Mr. Skeptical Sleuth hat, just because the person in front of you seems both intelligent and honest. Focus on the quality of the argument. Focus on the quality of the evidence supporting the argument.
All true, and why we have science. But the Jenny McCarthies of the world are so egregious that such charities can't extend to them -- they've been given too many opportunities to access sources of information apart from themselves.
> Focus on the quality of the argument. Focus on the quality of the evidence supporting the argument.
Yes, but after several years of the same pattern, it dawns on you that the problem is not the argument, but its source.
Doctors are emphatically not con artists.
I applaud you wife's reasoned decision, clearly she is in control of her own destiny and her decision (if by unfortunate chance it is the wrong one) will mostly affect her and her immediate family.
But if we spend a good sized fortune and several years educating someone I really wonder why we'd bother with that if all that it would take to counteract all that effort and knowledge would be a lay persons reading of the medical literature. Most of which is not exactly written for easy consumption by the general public.
Whether you're in a risk group for certain cancers depends on a lot of factors and you'd need to know all of those to make a weighted decision. This is not always as easy as applying the general case to yourself calling it a day.
Age and sex are obviously the big ones but there are many (not sure how many) contributing factors that may cause doctors to be more concerned about one individual than another. We call those people specialists because we recognize that the amount of knowledge required is typically larger than what one person can acquire in a lifetime.
The time when I'm going to trust my own interpretation of a pile of google'd medical papers over a qualified specialist is still a while away.
In the meantime I'm terribly happy I'm not a medical doctor, I'd hate to have to continuously defend each and every minor decision to a general public that I'd be trying to help in an already time-constrained practice. It's hard enough when non-technical (read: totally clueless) customers question evaluations of technical issues based on some popular text they've been reading, at least there are usually no lives on the line.
"How do you know this is the right treatment?" and "What happens if we do nothing?" are two good questions.
Doctors are overwhelmingly not con artists or stupid, but they do make mistakes and they do have to keep up with changing science.
This is especially important with doctors. They're science based, they're educated, the stuff they do has plausible mechanism of action. But this is exactly the time we need better science; double blinded studies etc. See, for example, knee arthroscopy which was found after controlled studies with sham operations to be no more effective than the sham for many people.
Screening (especially um-necessary screening) is doing more harm than good. But who to screen and who not to screen is still a specialist decision and depending on your locality more or less care will go into the making of that decision. Categorically rejecting screening before you're 50 if you're in a risk group is not smart (not saying the OP's better half is, but these things tend to be complex).
The doctor-patient dialogue is a tricky affair and I think that somewhere along the line doctors lost the ability to clearly communicate with patients about their treatments and the necessity thereof. On top of that doctors now see so many patients that there simply isn't time enough to have a proper conversation with every patient.
Those things are the crux of the problem here, not that doctors are out to make money of unsuspecting citizens or that they would perform procedures or generate referrals because there is money in it. Though I'm sure that occurs the Hippocratic oath is still very much a part of medical education.
http://en.wikipedia.org/wiki/Hippocratic_Oath
> See, for example, knee arthroscopy which was found after controlled studies with sham operations to be no more effective than the sham for many people.
I noticed a 'many' in that sentence, that's a bit of wiggle room there, if it were a really ineffective treatment there would be an 'all' in there. So now the question becomes one of degree and how to tell the people for whom that treatment is effective from the ones for whom it isn't.
On another note, the communications problem in part stems from the vast body of knowledge in modern medicine, two specialists already have a hard time communicating their ideas to one another, a doctor explaining the intricacies of some treatment to a patient would have to be at least as good an educator as a doctor, however education is typically not their specialism.
It is a different topic, but I have a very strong impression that it is the norm for doctors under time pressure to apply the general case and call it a day. That is not necessarily a bad place to begin, as doctor's often say, "common things are common". I do not have a problem with that.
The question then becomes whether doctors are actually skilled at analyzing contra-indications in a logical fashion. I have substantial experience suggesting the answer is N-O.
Here is a paraphrase of a real world conversation my wife had with more than one doctor(!) on a different topic: Patient: "My back still hurts. I have been doing everything you suggested for 6 weeks." Doctor: "Hmmm. Can you touch your toes?" Patient: "Yes. <Demonstrating>" Doctor: "You seem fine." Patient: "No. My back still hurts. I used to be able to almost touch my elbows to my toes." Doctor: "Your range of motion is within healthy norms." Patient: "Not my norms." Doctor: "Have you tried walking every day?" Patient: "Like you suggested? Every day for the last 6 weeks, yes." Doctor: "You have what is called 'normal back pain'. Take more ibuprofen. It will eventually go away."
Does someone need to go to school to accomplish this tour de force of medical reasoning?
My personal opinion is that when Watson (or moral equivalent) sits next to the doctor with the patient, there will be a vast improvement in medical care. There will a dispassionate source for possible diagnoses for patient who happen to fall outside the bell curve.
I'm in medical school right now and we talk a lot about the differences between a paternalistic doctor-centered approach vs patient-centered approach, the latter focused on doctors and patients making decisions together and ensuring patients have an understanding of their diseases and risk. And while it requires specialized knowledge just like a mechanic, it's your body we're talking about, not your car. And it depends on the certainty of the doctor's suggestion. Screening is a more complex decision than, say, taking insulin for diabetes. And there are times when public skepticism really does become a public health threat (i.e. anti-vaccination folk).
Exactly.
> And there are times when public skepticism really does become a public health threat (i.e. anti-vaccination folk).
This is a real problem, and one that is extremely complex because fixing it involves meddling with human rights, I don't think that this is a solvable problem. The bigger issue in cases like those is that 'Gods will' is invoked but it invariably affects others (mostly children) than the people that are making the decisions.
Tricky stuff.
Turns out the scope found nothing and I'm perfectly healthy (I have a suspicion that the elevated ALT was from riding my bike to the doctor's office). The lesson I learned was that every time you step into a medical facility you're increasing your risk for disease. You shouldn't be afraid of tests, but they are absolutely not without risk. But everyone thinks that more tests and procedures make you healthier and that anything less than the most is "rationing". It's insane.
Sort of the antithesis to "primum non nocere."
On the other hand, people like me are afraid to go to the doctor for anything at all; even yearly checkups are taboo. I'm completely insured, but still hate trips to the doctors.
Essentially, the only thing that unites cancers together is that they represent a class of diseases in which your own cells multiply in an uncontrolled manner. Beyond this idea of "out of control growth", there are a number of common ways which these distinct phenotypes occurs (such as too much of pro-growth molecules, not enough "slow down" molecules etc) but genetically/molecularly there are many, many different routes which these phenotypes can be achieved.
This, again, is still only touching on the surface. After you have the molecular underpinnings of the "out of controlness", you have genetic and non-genetic factors relating to things like where the tumour is, how do the cells change once the cancer begins to progress, how your body reacts to the cancer, how your body reacts to drugs etc.
In 100 years time, I'm confident we'll look back on our present day way of thinking about cancer in the same way people now look back at our previous ideas relating to mental illness 200 years ago, or general diseases 500 years ago.
[1]: http://www.nytimes.com/2011/10/07/health/07prostate.html
What bothers me is the lack of equal awareness and emphasis of prostate cancer with breast cancer even though it has a greater incidence and more profound negative effects from treatment. When a guy gets prostate cancer and has a prostectomy, he will more often than not experience severe erectile dysfunction. I hear a lot about how women feel disempowered when they get a mastectomy even though it can be replaced without any loss in sexual function, but much less on the scarring effects of prostate cancer on men with permanent sexual dysfunction.
http://www.cancer.org/cancer/breastcancer/overviewguide/brea...
http://www.cancer.org/cancer/prostatecancer/detailedguide/pr...
You should also read the article I linked. The point is not simply that the PSA test is ineffective and treatment can be harmful, but that prostate cancer itself is not a big enough threat to justify treatment in most cases.
> not prostate exams in general (i.e. rectal exam palpation). And like mammograms it depends on the population of interest and repeated tests.
BTW do you have a source that shows this is true.
http://seer.cancer.gov/statfacts/html/breast.html http://seer.cancer.gov/statfacts/html/prost.html
23.0 deaths per 100,000 women by breast cancer 23.6 deaths per 100,000 men by prostate cancer
But, yea often prostate cancer isn't enough to warrant it because more likely than not on autopsy you'll find some kind of prostate cancer on a guy that didn't cause his death.
With regard to your question on the effectiveness of digital rectal exams for prostate screening, I'm not sure about specific studies. From the us preventative services task force site where they suggest against the PSA test for screening they mention:
"Periodic digital rectal examinations could also be an alternative strategy worthy of further study. In the only randomized trial demonstrating a mortality reduction from radical prostatectomy for clinically localized cancer, a high percentage of men had palpable cancer."
http://www.uspreventiveservicestaskforce.org/prostatecancers...
No, I'm not talking about Planned Parenthood. Komen's lobbying wing literally believes public funds should not go to any forms of womens' health, they believe it should be handled entirely by private "charities" like themselves.
http://www.southernstudies.org/2012/02/flashback-how-the-kom...
http://www.dailykos.com/story/2012/02/01/1060885/-Behind-the...
In this case, it is no big deal, but what a cool use of technology to inform and extend our knowledge.
http://www.sciencebasedmedicine.org/index.php/once-more-into...
Can anyone provide more details?
The only thing I can think of is that perhaps the radiation will cause cancer.
EDIT: Continued to read the actual article -- I didn't know about the mammography madness in the US. AFAIK doing X-Rays or CTs without reasonable suspicion is considered personal injury here (in Germany).