Re-evaluating the Benefits of Cancer Screening

uncleO writes "An article in the NY Times describes two studies that weigh the harm caused by cancer screenings against the benefits they provide. From the article, 'Two recent clinical trials of prostate cancer screening cast doubt on whether many lives — or any — are saved. And it said that screening often leads to what can be disabling treatments for men whose cancer otherwise would never have harmed them. A new analysis of mammography concluded that while mammograms find cancer in 138,000 women each year, as many as 120,000 to 134,000 of those women either have cancers that are already lethal or have cancers that grow so slowly they do not need to be treated. ... In recent years, researchers have found that many, if not most, cancers are indolent. They grow very slowly or stop growing altogether. Some even regress and do not need to be treated — they are harmless."

Comments

indolent

[alphatel]

Justin Bieber has stopped growing, but that doesn't make him harmless.

Re:indolent

[durrr]

Just wait until we find the metastases in his female fans. Oh god...
We need someone to do an emergency homestectomy! Someone call the US air force nuclear medicine department, we'll need a few tons of radioisotopes to ensure we can do a sucessful thermoablative intervention.

Re:indolent

[ColdWetDog]

I thought that was insolent.

OK, here are the things that can happen in a cancer screening:

1. You find a cancer that will eventually kill you AND that particular cancer has a treatment that works better when started earlier. (True Positive result)
2. You don't find a cancer that you don't have. (True Negative result)
3. You find a cancer or something that looks like a cancer however it will grow so slowly or regress so it won't cause any harm, but then you don't really know which is which so you elect to be treated for same with some morbidity or mortality. (False Positive result)
4. You don't find the cancer that existed and goes off to knock you off just before you design the next iPad killer. (False negative result).

Only #1 and #2 are unequivocally good. #3 might be a bit of a problem - say a lumpectomy for Ductal carcinoma in situ (DCIS) - which is painful and maybe slightly disfiguring but doesn't really change your overall health or it might be a radical prostatectomy for an indolent prostate cancer that would never kill you but now your are incontinent and impotent (a relatively common outcome). #4 is only bad if you would have been helped by earlier detection which is a theory often proposed but often doesn't hold up to scrutiny.

Right now the biggest noise is around breast cancer which unfortunately has problems with all four potential outcomes. You can miss aggressive cancers on mammography. It is not at all clear that getting aggressive cancers early affects any change in outcome. There are many, many false positives. There are a number of breast cancers (DCIS for example) that left alone, typically don't do anything.

So the 'preventative medicine' bandwagon needs to be taken down a notch or two. It is not helped at all that most of the bigger players in cancer research and therapy stand to gain by aggressive detection treatment strategies.

Patients, not so much.

Re:indolent

[rollingcalf]

You're leaving out #5:
You find a cancer that is so aggressive that it will kill you no matter what, but you still treat it and the treatment kills you faster or reduces the quality of your remaining life.

Re:indolent

[ColdWetDog]

That's actually a subset of #3 from the point of view of a screening test. The test was a "false positive" because although the cancer was detected, the screening didn't help you as a patient.

Re:indolent

[blair1q]

His haircut has already metastasized onto teenaged losers everywhere.

And, for no good reason, onto this dude, who currently defines "winner" in a way not made so clear since Joe Namath and James Bond were peaking.

Re:indolent

[Anonymous Coward]

Or the extremely obvious and very important #6 (although so obvious and important it probably should be higher on the list): You find a cancer that is still treatable in it's current stage, and the cancer screening ends up saving your life.

Yea, there are a lot of things that can go wrong, but as a member of a family that has 4 cancer survivors and one who didn't make it because her cancer was caught too late, I find your insinuation that oncologists don't save lives on a daily basis rather ridiculous. And I get that you're including my #6 as your #1, but just because cancer only goes into remission and is never really cured does NOT mean that all cancers will eventually kill you. My mother has been in complete, 100% remission for 25 years.

Re:indolent

[durrr]

Nothing wrong with preventative medicine, problem is the human body, including the cancers it gives rise to have such a bloody huge variability that differentiating the killer-cancer from the not-killer cancer.
We need better detection methods, to both detect and differentiate.
We need better treatment. Jumping the shark with the scalpel is old fashioned. Cancer vaccines(tailored based on sampled cancer from patient itself) would be a fantastic method if proved efficient. Although general sweeping anti-cancer vaccines would be even better as it may greatly decrease the need for screening.
Unfortunately, immunostimulant treatments get less attention than they deserve despite their absolutely enormous poential(you can vaccinate against almost anything, toxins, cancer, bacteria, parasites. And that's only the classic aspect of immunostimulation, proliferating and guiding(or warding against) immune cells could do wonders)

Re:indolent

[Artraze]

But what's the alternative? Just wait until someone's sick enough to warrant a cancer screening?

Or, to be more direct, the problem isn't the _testing_, it the _reaction_. The view of cancer is too binary... You either don't have cancer or you have ZOMG CANCER. It seems to me that by making a third category of 'mostly harmless' we could really do away with #3 altogether. How could we determine that? Early detection and study. Exactly what abandoning screens would make impossible.

Really, this is just about the money, in a couple directions:
First, no doctor is going to volunteer "this is cancer, but it doesn't look dangerous so we'll just monitor the situation" because God help them if that person dies.
Second, people usually spend other people's money (government, 'insurance') on the treatments, so to them it's only 'some side effects vs your life' and not also about 10% of their lifetime earnings too. Guess what they'll take? And so the people paying for these tests have come to realize that they're just a money pit: the (usually negative) test, the (potentially) unnecessary treatment, and finally just the cost of treating real cancer a year or so earlier then you would have had to without the screen for someone that may well die anyway (any they get the pleasure of a year of treatment). All this for how many people that earlier treatment would have helped? Well, that is the point of the study.

But the point is, that it's not the data that's bad, it's a system the encourages people to get knee jerk treatment.

Re:indolent

[sjames]

Then there's a particularly nasty subset of #3, you find an essentially harmless cancer like object and treat it aggressively. As a result of long term damage to your immune system and genetic damage from harsh chemo, you develop a lethal cancer that can't be treated. Or you just spend the rest of your shortened life in relatively poor health.

Re:indolent

[A beautiful mind]

But what's the alternative? Just wait until someone's sick enough to warrant a cancer screening?

Absolutely! If the statistics show that we're better off without early screening in terms of health outcomes, by all means! We should be doing something else with our time and money than to spend them on ineffective screening.

Re:indolent

[Anonymous Coward]

So the 'preventative medicine' bandwagon needs to be taken down a notch or two. It is not helped at all that most of the bigger players in cancer research and therapy stand to gain by aggressive detection treatment strategies.

Patients, not so much.

Don't confuse prevention with detection. This is detection, it does not prevent cancer from growing in anyway. Prevention may entail things like avoiding known carcinogens or making sure you have enough Vitamin D (implicated in 80% of breast and prostate cancer cases).

Re:indolent

[icebraining]

That #6 is #1 in GP's list...

Re:indolent

[Anonymous Coward]

I thought that was insolent.

OK, here are the things that can happen in a cancer screening:

1. You find a cancer that will eventually kill you AND that particular cancer has a treatment that works better when started earlier. (True Positive result)
2. You don't find a cancer that you don't have. (True Negative result)
3. You find a cancer or something that looks like a cancer however it will grow so slowly or regress so it won't cause any harm, but then you don't really know which is which so you elect to be treated for same with some morbidity or mortality. (False Positive result)
4. You don't find the cancer that existed and goes off to knock you off just before you design the next iPad killer. (False negative result).

Option 5: Stress from brutally smashing sensitive breast tissue into mamogram machine coupled with low-dose radiation itself causes cancer to form.

So the 'preventative medicine' bandwagon needs to be taken down a notch or two. It is not helped at all that most of the bigger players in cancer research and therapy stand to gain by aggressive detection treatment strategies.

Patients, not so much.

Detection/Screening != Prevention

Cancer can grow whether you detect it or not, so don't confuse prevention with detection. Prevention would entail things like avoiding known carcinogens or making sure you have enough Vitamin D. 80% of breast and prostate cancer are preventable with Vitamin D. Check out research my Dr. Michael Holick and how breast/prostate cancer rates correlate with lattitude and skin color.

Re:indolent

[LifesABeach]

Having had to watch a loved one die of cancer, I find that anyone who advocates less cancer screening to be sinister.

Re:indolent

[Anonymous Coward]

When he said "will eventually kill you" in #1, I'm fairly certain he meant "would eventually kill you". And that definitely includes your #6. It seems to me that #6 should be "You wouldn't have had cancer, but the X-ray-based screening gives you cancer."

Re:indolent

[NatasRevol]

It's not really the early screening that is causing poor health outcomes. It's the overly aggressive treatments based on those early screenings and making a guess as to what kind of growth rate the cancer has. Maybe we just cut out the aggressive treatments and live with cancer until you know what kind of growth rates it has. Then there's 3 outcomes.

Those with high growth rates will die sooner.
Those with average growth rates will live longer
Those with below average growth rates will live longer.

If, and it's a big if, the growth rates are spread evenly, then stopping early treatments would help 2/3 of cancer patients to live longer.

Re:indolent

[emtilt]

That's an incredibly narrow-minded view. If it is shown that some types of screening statistically make you worse off, then it is silly to continue advocating their use in the same way. I'm sorry you had to deal with a traumatic event, but that doesn't make math stop working.

Re:indolent

[Coren22]

Which university do you have a MD from? As you most likely don't have an MD, and don't have anything to add to this conversation other than overreaction, and that this study was done to find out the good and bad of screening, maybe they know more about the subject than you?

Re:indolent

[mrxak]

I've lost loved ones to cancer as well, but if early detection doesn't help you, and false positives can really hurt you, then cancer screenings are doing more harm than good and costing society dearly.

I've been growing more wary of early detection, and not just cancer, but all sorts of things. False positives are everywhere in medicine, more commonplace than we'd like to think. It's better to educate people on symptoms, screen only for things that don't have any symptoms (until it's too late), and generally people should live their lives normally and only see a doctor when they actually get sick. Annual check-ups are good for people who are uninformed about their health, or have questions they need answered, but what do they actually do for healthy people? Nothing. What do they do for sick people? Well, those sick people should've made a special appointment when they realized they were sick, not based on an arbitrary annual check-up schedule.

If something hurts, is bleeding, or isn't working right, by all means, go see a doctor, ideally a specialist who knows all about it. If there's nothing wrong, though, you're more likely to become sick going to a doctor's office or hospital than if you just stayed home. Either you'll catch something from another patient who's there legitimately, or you'll become a victim of malpractice or treatment for false positives.

While emergency medicine is based on worst case scenario, the rest of our medical system is all based on probabilities. The same three symptoms could mean you have x, y, or z, but you're treated for y because it's most likely. Only if treatment fails do we consider x or z. It's not a perfect system, but it's the best system for the most number of people, until we devise better tests to differentiate x and z from y. By all means, we should use cold hard statistics to weigh the pros and cons of screening. If the probability of harm is greater than the probability of benefit, regardless of the dangers of untreated cancer, we must advocate less screening.

Re:indolent

[chooks]

First, no doctor is going to volunteer "this is cancer, but it doesn't look dangerous so we'll just monitor the situation"

This is not universally correct. For a run-of-the-mill prostatic adenocarcinoma (your garden variety prostate cancer) there is actually the concept of active surveillance, where the patient gets yearly biopsies to track any progression. If the biopsies show cancer involving more than it should (where should is defined by a variety of factors) then treatment becomes more aggressive (read: prostatectomy).

In your defense however, AFAIK this is one of the only types of cancers were this is true, as the lifetime chance of a male getting prostate cancer verges on 100% (if they live long enough). Certain brain tumors may take a watch-and-see approach as well since their progression is not as well understood and the morbidity associated with various brain surgeries can be pretty high.

Agreed though in that not all cancers are created equal. Knowing which is which though is, as they say, the rub

Re:indolent

[theshowmecanuck]

From TFA:

A new analysis of mammography concluded that while mammograms find cancer in 138,000 women each year, as many as 120,000 to 134,000 of those women either have cancers that are already lethal or have cancers that grow so slowly they do not need to be treated.

So what you're saying is that it is not worth being able to save the lives of between 4,000 and 18,0000 breast cancer patients each year? I wonder what those 4,000 to 18,000 breast cancer patients might want to tell you. I'll hazard a guess: fuck you asshole!

As might have been mentioned, it isn't really the detection that is at issue here, if the article is of anything to go by. It is the choice of treatment. Maybe what the real issue is that we need to be better able to determine the type/subtype/stage of the cancer so that realistic treatment can be made. For example if a PSA test determines that someone likely has prostate cancer, then it would be better then to determine what kind before treating. So to say that testing for cancer is bad is well, retarded. No better way to put it. Testing for cancer is the only way to find out if you have it. Like the lottery, you can't win if you don't play. You can't possibly cure cancer if you don't know you have it. So let's get to the real heart of the issue.

Who is this group that says we shouldn't test? Do they have any affiliation with for profit medical insurance companies or any other group that stands to profit by reducing the amount of money spent on testing? Is this a possible reason for trying to stop testing? Or is is it shear academic mental masturbation? Is it just easier than finding ways to definitively identify the exact nature of the cancer so that tailored (appropriate) treatments can be made (i.e. they may not want to pay to fund cancer research for better targeted treatment... maybe these companies see diminishing returns in this). You might include no treatment at all if the cancer really is untreatable; but my feeling is no-one should ever have the right to tell someone they aren't allowed a shot at fighting for their life, no matter how slim the chances.

Re:indolent

[rikkards]

That happened to my second cousin's wife. She was diagnosed with Uterine Cancer and went through Chemo and Radiation. The latter burned up her bowel and spent the next year in bed dying painfully and drugged up. If she hadn't done it, she may have lived a couple more years.

Re:indolent

[vtcodger]

*First, no doctor is going to volunteer "this is cancer, but it doesn't look dangerous so we'll just monitor the situation" because God help them if that person dies.*

Actually, that is EXACTLY how prostate cancer is handled. Prostate cancer is very common in elderly males. It is generally a slow growing cancer. The treatment can have unpleasant consequences. In general, physicians recommend treatment for younger men as the cancer is more likely to be a comparatively rare aggressive prostate cancer. Men over the age of say 70 will generally be advised to monitor the cancer rather than treating it immediately. The meme is that old men die WITH prostate cancer, not OF prostate cancer.

Re:indolent

[rtfa-troll]

This is actually the most interesting. We know that treatment works; we know that sometimes screening finds cancer. We also know that people who are screened get more cancer even when people are a bit careful about the methodology. This means that, statistically, it seems screening causes cancer! Disturbing if true.

Re:indolent

[tibit]

Dr Bob is now AC?

Re:indolent

[rikkards]

Thanks for your comment, it is a good description of what my wife has been realizing for the last 5 years as she has been educating herself on this issue for a long time. Getting diagnosed with cancer is a horrible thing to happen to anyone but just as bad is getting a false positive and the emotional and physical damage that occurs. This happens more often than people realize. A really good book to read is:
Should I be Tested for Cancer:
http://www.amazon.com/Should-Be-Tested-Cancer-Maybe/dp/0520248368/ref=sr_1_1?ie=UTF8&qid=1320095200&sr=8-1

Re:indolent

[DarwinSurvivor]

Unless you are getting yourself screened daily, there is about a 0.0001% chance the x-ray will give you cancer. The reason doctors/etc stand behind the concrete wall when they x-ray you is because they are doing that on a regular basis.

Re:indolent

[DarwinSurvivor]

Exactly, unless the test *clearly* shows that you are screwed, the doctor should have you wait a while (time duration dependent on results of first test) and then come back in for a second test to evaluate progress.

Sort of like snake bites. If you come in with a snake bite, they will NOT give you the antidote until they have run 2 tests, usually a while apart, to determine the strength of the initial dose. Otherwise, just like cancer treatment, the antidote can literally kill you faster than the poison. They also use the results to determine how MUCH antidote to give you.

Re:indolent

[uigrad_2000]

Your comment has gotten a lot of replies, but it seems to be missing some essential information.

How frequently did the person you watch die go for screenings with their type of cancer? Was that amount above or below the recommended amount? How much did they pay for those screenings? Could the cancer have been treated into remission if caught early? If they would have doubled the amount of screenings, would the cancer been caught early to prevent death?

My aunt died of ovarian cancer. It was caught early, but there are no magical treatments, and even though she endured intense chemotherapy that essentially destroyed her quality of life, it wasn't enough. I don't have enough facts and figures to know whether she would have been better off or worse with less screenings.

If tests were free and non-invasive, and early detection guaranteed successful treatment, then obviously we should be increasing the number of screenings. Your one line comment seems to make those assumptions. It's hard for any of us with just anecdotal evidence to know whether we are screening too much or too little. Making broad generalizations like yours are just not helpful.

Re:indolent

[Anonymous Coward]

Yeah, he almost mentioned breast subluxation.

Re:indolent

[Anonymous Coward]

I think you are missing the bigger picture. Everything you mentioned is true, but how do you identify if the patient falls into category 1-4? If you have an answer, please share, because no one else can figure that out. In the US, it is better (legally, culturally) to do too much, and unforgivable to do too little. So, the conclusion is treat everyone like #1. Not ideal, but doctors aren't fortune tellers.

Re:indolent

[reboot246]

Even when there are better or alternative detection methods, they are not always allowed or used. Take breast cancer detection by thermogram for instance. Properly used, it can detect smaller growths way before a mammogram can. Here's a link to an article on the Huffington Post about it. http://www.huffingtonpost.com/christiane-northrup/the-best-breast-test-the-_b_752503.html

Also, has anyone noticed how for most ailments doctors always start off with the most conservative treatments and then increase from that, but for cancer they go straight for cut, burn and poison? Must be a money thing.

Re:indolent

[Anonymous Coward]

But what's the alternative? Just wait until someone's sick enough to warrant a cancer screening?

Or, to be more direct, the problem isn't the _testing_, it the _reaction_. The view of cancer is too binary... You either don't have cancer or you have ZOMG CANCER. It seems to me that by making a third category of 'mostly harmless' we could really do away with #3 altogether. How could we determine that? Early detection and study. Exactly what abandoning screens would make impossible.

I call bullshit. Watchful waiting is very common in Lymphoma patients:

"When you have an indolent (slow growing) lymphoma that is not causing symptoms or does not present an immediate medical danger, watchful waiting is commonly prescribed, even when the disease is diagnosed at an advanced stage."
http://www.lymphomation.org/watchfulwaiting.htm

So we already have this in place, at least for some forms of cancer.

This whole 'use less medicine' push by the establishment is almost certainly a push by greedy HMOs and heartless government bureaucrats that are looking for people to get stage 4 before seeking treatment. It is far cheaper to just give someone morphine and to give their family grief counseling than it is to fork over $125,000 for 12 rounds of chemo. It's a wonderful cost cutting strategy if you're a sociopath.

Re:indolent

[Anonymous Coward]

It is not at all clear that getting aggressive cancers early affects any change in outcome.

5 year breast cancer survival rates:
Detected at stage 1: 88%
Detected at stage 4: 15%
Source: http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-survival-by-stage

You're right, dunno why we bother screening. How about other cancers?

We'll try lung cancer (non small cell):
Detected at stage 0 49%
Detected at stage IV 1%
http://www.cancer.org/Cancer/LungCancer-Non-SmallCell/DetailedGuide/non-small-cell-lung-cancer-survival-rates

So much for that. How about hodgkin's lymphoma?

Detected at stage I About 90%
Detected at stage IV About 65%
http://www.cancer.org/Cancer/HodgkinDisease/DetailedGuide/hodgkin-disease-survival-rates
Well that would be a 25% difference. About 9% worse odds than Russian Roulette.

Re:indolent

[j-beda]

From TFA:

A new analysis of mammography concluded that while mammograms find cancer in 138,000 women each year, as many as 120,000 to 134,000 of those women either have cancers that are already lethal or have cancers that grow so slowly they do not need to be treated.

So what you're saying is that it is not worth being able to save the lives of between 4,000 and 18,0000 breast cancer patients each year? I wonder what those 4,000 to 18,000 breast cancer patients might want to tell you. I'll hazard a guess: fuck you asshole!

If you don't think that any medical system should do cost-benifit analysis, then you are a bit out of touch. I have not done the analysis (or read the article for that matter), but if the mammography of 138,000 women caused 120,000 unnecessary treatments, I would not be surprised to find that it caused a few thousand unnecessary deaths - we could ask what those patients might want to say - possibly they would be more polite than your cancer patients.

If the studies show that mammography does not increase lifespan, then regardless of how good it might make people feel to have "routine" mammograms done, it probably is worth considering not doing them absent other reasons for doing so.

Re:indolent

[j-beda]

It is not at all clear that getting aggressive cancers early affects any change in outcome.

5 year breast cancer survival rates:
Detected at stage 1: 88%
Detected at stage 4: 15%
Source: http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-survival-by-stage

You're right, dunno why we bother screening.

However, it is not at all clear that those detected at stage 1 are all the same types as those detected at stage 4. If a significant fraction of those detected at stage one would NEVER progress beyond stage one lets call them "type A", with the aggressive ones called "type B", then it is at least possible that "type A" has a 15% survival rate no matter what stage it is detected, and is responsible for much of the 12% death rate in the early detection pool, as well as the 85% death rate in the later detection pool. Treating the "type A" cancers early could provide no benefit - and since it is benign it makes it look like early detection increases survival rates even if it does not.

To be fair to the original poster, he did say "It is not at all clear that getting aggressive cancers early affects any change in outcome." Your data does not separate out the "aggressive" and "non-aggressive" cancers. Part of the problem is that it is not clear what (if anything) differentiates the different levels of cancer aggressiveness.

Re:indolent

[Anonymous Coward]

No. That's not left out because it's not a result of diagnosis. It's a result of bad treatment. That's the responsibility of different specialists, and certainly a distinct line of research. In particular, when evauating the diagnostic criteria, you should not make unfounded assumptions on treatment.

So, roughly said, we have 4 possible diagnosis results. Two lead to treatment, which can be overly aggressive, overly passive, or just right, for a total of three treatment results.

Re:indolent

[Anonymous Coward]

I'm 33 and was recently diagnosed with a per-cancerous condition (they sent me a letter from a biopsy I had). The letter was alarming, so I went in and my doctor explained that there's a small chance ( 7 percent) that it will turn into cancer (it would be a deadly esophageal type and that as long as we keep an eye on it (by checking it every 1 to 2 years) I should be good. He also gave me some materials to educate myself and said that even if it starts to get worse next year that it's early enough where we can probably get rid of it.

Re:indolent

[heathen_01]

... until we devise better tests to differentiate x and z from y. By all means, we should use cold hard statistics to weigh the pros and cons of screening. If the probability of harm is greater than the probability of benefit, regardless of the dangers of untreated cancer, we must advocate less screening.

Two problems with that.
1, "until" will become "instead of".
2, Early screening is not the problem, the treatment is the problem. Surely the solution to giving people the wrong treatment is to give them the right treatment, not give them nothing.

Re:indolent

[ababydingo]

But what's the alternative? Just wait until someone's sick enough to warrant a cancer screening?

It's important to realise what screening is and is not. Testing someone who is sick is not screening. Screening is testing the whole population (or most of it) even though they have no signs at all of the disease. The usefulness of screeing depends dramatically on the accuracy of the test used as well as the actual incidence of the disease in the target population. Testing someone who has signs and symptoms of the disease is symptomatic testing which is very different, not least in the statistics involved, as well as the particular test used. For instance, (asymptomatic) bowel cancer screening would use a fecal occult blood test to check for invisible blood in the stool. This is cheap, non-invasive, self-administered and moderately accurate. If on the other hand, you had symptoms like overt blood in the stool for a long time plus unexplained weight loss (say) then you would likely be sent straight for a colonoscopy which is expensive, invasive and pretty accurate.

Re:indolent

[shilly]

Actually, going to see a specialist is *not* the right thing to do. Specialists are prone to over-treatment. What you want is a good generalist who has access to decent, evidence-based decision-support. Primary care is much more effective than secondary care in keeping a population healthy.

Re:indolent

[Anonymous Coward]

Well that brings up a popular variant; you find a cancer, or something that looks like a cancer and is not; either way, you survive 5 years after the treatment and are considered a success. However, the treatment has left you incontinent, needing a colostomy bag, in constant pain, etc. etc. etc. And you'll never know if you really needed that treatment, or if it was a false positive.

And the other popular variant: an Alzheimer victim who is already incontinent and incapable of locomotion, can't recognize people, speak, respond to speech, or feed him/herself; but gets aggressive cancer treatment.

Could all cancers...

[Anonymous Coward]

...please follow suit and just go away?

Thanks,
Humanity

Cancer screenings are wrong

[Anonymous Coward]

They rob pharmaceutical companies of revenue streams that are rightfully theirs.

Re:Cancer screenings are wrong

[multi io]

They rob pharmaceutical companies of revenue streams that are rightfully theirs.

Well, if cancer is found during the screening, chances are all kinds of products made by pharmaceutical companies will be unleashed onto the patient full-force.

Re:Cancer screenings are wrong

[Anonymous Coward]

Not only that, but it forces health insurance companies to actually pay out for the screenings and treatments their plan says they cover.

Filesharing pirates also have the nerve to actually fully use what they pay for, so these cancer patients should be criminalized just the same.

Re:Cancer screenings are wrong

[Anonymous Coward]

50% of the annual budget of the NHS (The UK's National Health Service, about $150 Billion a year) is dedicated to the final 12 months of peoples lives. The lion's share of this money naturally goes to people with terminal illnesses.

When patients are pretty much screwed, doctors can prescribe whatever they like since the patient was going to die anyway. If nothing has been formally diagnosed, the patient will get a "come back if things get worse" lecture, rather than the comprehensive screening program that they need.

Re:Cancer screenings are wrong

[CanHasDIY]

They rob pharmaceutical companies of revenue streams that are rightfully theirs.

Well, if cancer is found during the screening, chances are all kinds of products made by pharmaceutical companies will be unleashed onto the patient full-force.

Knowingly or not, you've just touched upon my issue with privatized medical treatment: the industry has incentive to "diagnose" any number of "maladies," real or imagined, in order to drum up business and boost profits. I wonder how many of these "illnesses" that magically popped into existence in the past 20 years are actual, physical conditions.

... and don't even get me started on the incentives to "treat" illness as opposed to curing it...

Re:Cancer screenings are wrong

[Stormtrooper42]

You might have a point, but what are those

"illnesses" that magically popped into existence in the past 20 years

?

Re:Cancer screenings are wrong

[CanHasDIY]

You might have a point, but what are those

"illnesses" that magically popped into existence in the past 20 years

?

ADD and Fibromyalgia come immediately to mind...

Another big part of the problem is that "doctors" (i.e. pharmaceutical salesmen) have developed this nasty habit of treating symptoms (using expensive drugs), instead of trying to find the actual disease causing the symptoms. Thus, the condition never gets cured, and the patient spends their life taking expensive drugs they probably don't need.

Re:Cancer screenings are wrong

[LurkerXXX]

Another 'the pharma companies are hiding the cures' tinfoil nut?

I'll remind you of the ~$30 Billion a year the NIH spends for researchers on their own D.C. area campus and at universities around the nation to do medical research. Those folks aren't hiding cures.

Re:Cancer screenings are wrong

[CanHasDIY]

Another 'for-profit businesses always have our best interests in mind' sucker? Guess you didn't RTFA this slashdot story regarding an actual, effective cancer cure:

Both the National Cancer Institute and several pharmaceutical companies declined to pay for the research. Neither applicants nor funders discuss the reasons an application is turned down.

And I'm supposed to be the nut... riiiiiiiiight...

Often wondered

[Anonymous Coward]

I was told years ago that the average person has between 3 - 5 'cancers' in their body at any given time.
They are usually destroyed by your immune system and you never know it. ( the size being one interesting component).
I guess the question is how do you tell the ones that need treatment from the ones that don't before it it too late to treat the ones that do. Also, treatment itself is really dangerous. Chemo therapy had a 50% survival read for a perfectly healthy person, last time I checked. When it comes to this, we are no where near having all the answers.

Re:Often wondered

[MightyMartian]

I know in the case of prostate cancers, there are fast-growing tumors and there are slow-growing tumors. My father-in-law was diagnosed with a slow-growing tumor in his mid-70s and his doctor advised him to basically live with it, because something else would kill him first, and six or seven years later he died after a stroke.

Re:Often wondered

[durrr]

It's a fair bit more complex than that.
Genetic damage accumulates _all_ the time, however you have DNA-repair mechanisms of rather amazing complexity that constantly patch things back into their original shape, and in the case they fail they still face down the checkpoints in the mitotic cycle that halts cell divison until damage is either repair or the self-destruct/apoptosis kicks in.

And there's more, if a cell starts to produce foreign proteins these will appear in fragments on its surface, which the immune system will latch onto, and then the cell will face down the subtly named Natural Killer cells which have methods to force the aptotic machinery into action even if the intial stages have somehow mutated into uselessness.
Also, cancer that grows fast will displace itself to the point where necrotic lesions appear, these will result in inflammation, a state usually not very conductive to growth, which may self-limit the cancer(not to mention that inflammation means the presence of immune mediators, a lot of them).

As for chemo, it's not that black and white, there's a very large difference between cancer cancer and chemo and chemo. Certain lymphoma(enormous proliferation of immune cells, circulating) have very close to 100% survival rate, if you enter chemo treatment. Testicle cancer also have a very good prognosis even if metastatized. For a perspective, take a look here http://en.wikipedia.org/wiki/Chemotherapy_protocol

Re:Often wondered

[interkin3tic]

I guess the question is how do you tell the ones that need treatment from the ones that don't before it it too late to treat the ones that do

Histology at the moment. What a trained pathologist can tell from a slide of stained cells is incredible. In the near future, genomic sequencing is what experts seem to be saying. You find a tumor, you get a biopsy, look at it under the microscope and also sequence the DNA of the cancer. Between what the cells look like and the DNA sequence, they'll be able to tell how likely it is to kill you.

There are a number of well-characterized things a cancer cell must do to be really bad, and genomic sequencing will allow a good diagnosis as to what a cancer is doing exactly. If it's just that the cells are growing more than they should, but are otherwise playing by the rules (IE, unlikely to metastasize or start increasing the bloodflow to the tumor, and not in a critical location) keep an eye on it but it may not become a problem ever. If it is expressing several genes that will allow the cells to get into the bloodstream and take root elsewhere, chemotherapy now. Chances are much better that it will spread to critical areas like your lungs or brain and kill you.

Re:Often wondered

[durrr]

There's the fast growing terrible cancer variety.
And then there's hyperplasia, this only insults you by increasing the duration of the average urination by ~1000%, and UTI rate by similar numbers.

The problematic part is that there's a relationship between hyperplasia and malignitiy, and for prostates this is an eternal headache.

Re:Often wondered

[oldhack]

"Histology" - stripped bare, it's essentially heuristic eyeballing, isn't it. So screening can tell if there are tumor cells but cannot tell how they will progress.

Re:Often wondered

[mirix]

I recall reading that a ridiculously high proportion of men that die in old age have prostate cancer, something like 75% of males over 75, iirc. Usually without posing symptoms / problems, relative to old age at least.

First world problems I guess, as historically they wouldn't have lived long enough for it to show up.

Big implications for public health across world

[shilly]

And the UK is now reviewing the entire breast screening programme it runs to see whether the evidence continues to show that, on balance, good outweighs harm. Tough decisions for all concerned, and an excellent demonstration of just why science is hard to do right.

Among the options:
1) Continue as-is
2) Use more selective screening with (hopefully) greater specificity -- eg familial history, gene markers, etc
3) Stop screening

Re:Big implications for public health across world

[SydShamino]

The problem is that the corner cases (those with no family history) whose cancer was caught by the screening are humans, and they will be very, very vocal about their desire to continue living. And over here one of our political parties will point at you and say something like, "See? In government-run health care they want to stop the screenings that saved the lives of Mrs. A and Ms. B and Mrs. C! Isn't that horrible!" And then nothing is accomplished.

Re:Big implications for public health across world

[del_diablo]

If they where scientific: 2 is the most desirable one.
If nobody does that, we can never figure out how much harm the screening is causing in the first place.

Re:Big implications for public health across world

[shilly]

No, you do the research and then use that to inform the design of the screening including selection criteria. I think you'll find that the designers of such screening programmes are pretty eminent medical scientists dealing with very difficult problems. Triviaising it does not favours to anyone.

Blood tests

[ackthpt]

I'm curious why blood tests aren't peformed regularly. You can certainly request Alpha-fetoprotein (AFP) any time you like, but it is not commonly recommended on a regular basis. AFP can indicate tumors growing in the body. Very high levels of AFP can indicate advanced cancer. In the case of a co-worker who was found to have advanced cancer, on first diagnosis, why not have this marker checked every 6 months?

I've been told a normal reading is about 100-120. Values over 10,000 should be investigated. Lance Armstrong, had levels of over 100,000 when he was diagnosed, with tumors spread throughout his body.

It seems a low impact test, why is it not advised as part of a standard checkup? We'll look for chelesterol, why not Alpha-fetoprotein?

Re:Blood tests

[Anonymous Coward]

That is a damn good point. Within countries with socialised healthcare, the benefits of such a test would easily outweigh the costs. And while you're taking those blood samples from X Million citizens, why not check for a few other maladies too? Economies of scale would surely work here.

Re:Blood tests

[ColdWetDog]

I'm curious why blood tests aren't peformed regularly. You can certainly request Alpha-fetoprotein (AFP) any time you like, but it is not commonly recommended on a regular basis. AFP can indicate tumors growing in the body. Very high levels of AFP can indicate advanced cancer. In the case of a co-worker who was found to have advanced cancer, on first diagnosis, why not have this marker checked every 6 months?

I've been told a normal reading is about 100-120. Values over 10,000 should be investigated. Lance Armstrong, had levels of over 100,000 when he was diagnosed, with tumors spread throughout his body.

It seems a low impact test, why is it not advised as part of a standard checkup? We'll look for chelesterol, why not Alpha-fetoprotein?

Because, AFP is a crummy screening test.

We look for cholesterol because heart disease is one of the major killers of society. Testicular cancer isn't. It is also not terribly sensitive, not very specific and it isn't clear that early treatment helps. You need various qualities of all three aspects for something to be a good screening test.

Re:Blood tests

[Anonymous Coward]

the idea is to catch cancer BEFORE it is advanced, which increases the chance of survival long term. ( assuming treatment IS necessarily). The problem is from what i can tell, no one knows if treatment is necessarily or not and much of the time it isn't.

The survival rate of the TREATMENT is something like 50/50 so you DON'T want to treat without better then 50/50 percent certainty you NEED too.

Re:Blood tests

[MozeeToby]

Presumably for the reasons enumerated in the summary. Too many costly, and quite frankly terrifying, false positives. Keep in mind, when you start talk about putting everyone through a screening, whether it be for cancer or HIV or terrorism, your screen had better be crazily accurate. Imagine there's a (really exceptionally good) false positive rate of 0.1% on your hypothetical test, if you give it to every person in the US twice a year you're going to produce 74,000 false positives a year. Or to put it another way, more false negatives than there are cancer deaths.

Re:Blood tests

[MozeeToby]

That's 740,000 false positives, not 74,000. Sorry for the double post.

Re:Blood tests

[Anonymous Coward]

Your link shows no evidence that "AFP is a crummy screening test". Were you hoping that nobody clicked the link, and just took your word that it was correct?

Usually I laugh when I hear the word being used on slashdot, but perhaps you are a genuine "shill" for one of the big pharmaceutical companies.

Re:Blood tests

[greed]

That's all right, he also claims serum cholesterol is a predictor of heart disease and doesn't back that one up at all.

Re:Blood tests

[njvack]

Presumably for the reasons enumerated in the summary. Too many costly, and quite frankly terrifying, false positives.

More importantly, it's important that if you screen positive, the confirmatory tests and treatment yield a better outcome than doing nothing would have. Lots of people can point to a friend or relative for whom early detection treatment saved their life; however, if someone dies from the treatment of a cancer that would never have killed them, how will you ever know?

Cancer is dangerous, but it's important to remember that cancer treatments are dangerous as well. People can and do die from complications from surgery and chemotherapy.

Re:Blood tests

[Guppy]

Your link shows no evidence that "AFP is a crummy screening test". Were you hoping that nobody clicked the link, and just took your word that it was correct?

My impression is that ColdWetDog was hoping whoever clicked the link would follow Wikipedia's explanation of how the statistics of screening tests work, and using that explanation, understand the logic of why AFP is not used as a general cancer screen by filling in the blanks themselves.

But that's ok, maybe you didn't understand him, so let me elaborate a bit in steps. The "Specificity" of the AFP test is the percentage of True Negatives (patients without cancer), divided by Reported Negatives (AFP tested negative). Now, the specificity of the AFP assay varies with the laboratory, cut-off criteria used, and particular cancer -- but something like 90% is reasonable for an AFP test (better for some cancers, worse for others, not applicable for many). That sounds good, right?

Well, next step is figuring out your Positive Predictive Value. The interesting thing about this parameter, is it varies with Prevalence. If you define your tested population as a group in which you already have reason to suspect cancer, you can get a pretty decent PPV. Now, elevated AFPs are rare in the healthy general population. Thing is -- while it might not seem that way emotionally -- statistically, cancer is also considered a rare health condition (from an epidemiological standpoint). The net result is most tumor biomarkers applied to the general population, end up with low PPVs -- even tests with specificities of 90+% can end up with PPVs in the single digits or less.

While I don't have a specific link for AFP, the general state of population-wide cancer biomarker screening is not good: http://www.nature.com/news/2011/110323/full/471428a.html

but perhaps you are a genuine "shill" for one of the big pharmaceutical companies.

Oh, you were just shitposting. Carry on then.

Re:Blood tests

[wisnoskij]

Exactly, we went through this on day is a stats course I took years ago.
it seems counter intuitive but it is not a good idea to test for medical problems without a lot of thought put into the +es and -es involved.

Re:Blood tests

[nbauman]

But what about drug tests? Big employers give everybody drug tests.

Re:Blood tests

[ackthpt]

I'm curious why blood tests aren't peformed regularly. You can certainly request Alpha-fetoprotein (AFP) any time you like, but it is not commonly recommended on a regular basis. AFP can indicate tumors growing in the body. Very high levels of AFP can indicate advanced cancer. In the case of a co-worker who was found to have advanced cancer, on first diagnosis, why not have this marker checked every 6 months?

I've been told a normal reading is about 100-120. Values over 10,000 should be investigated. Lance Armstrong, had levels of over 100,000 when he was diagnosed, with tumors spread throughout his body.

It seems a low impact test, why is it not advised as part of a standard checkup? We'll look for chelesterol, why not Alpha-fetoprotein?

Because, AFP is a crummy screening test.

We look for cholesterol because heart disease is one of the major killers of society. Testicular cancer isn't. It is also not terribly sensitive, not very specific and it isn't clear that early treatment helps. You need various qualities of all three aspects for something to be a good screening test.

Another link by way of Lance Armstrong, the blood doping tests for athletes now are sophisticated enough to establish a Base Line for certain concentrations of hormones, red count, etc. Catching a tumor on the first blood test is probably not good, but establishing norms for an individual can help identify when something is happening, by looking for spikes or dips in readings.

Re:Blood tests

[ColdWetDog]

Thanks. Sometimes I wonder why I even bother trying to explain things.

Maybe we should just go back to trolling about Apple vs. Android or whatever is the current two minute hate around here.

Sigh.

Re:Blood tests

[ColdWetDog]

The problem with super sensitive tests like that is we have a poor understanding of how, for example, erythropoetin, varies in health and disease. We know the broad strokes, but checking it routinely among healthy subjects doesn't offer much utility. We have a few limited studies of a couple of markers amongst various healthy populations (astronauts, athletes, military). AFAIK, there hasn't been much that has come out in these studies in terms of helping screen for diseases.

Remember, the God of Statistics says that if you do enough tests, some of them will be positive because you ran enough tests. Then you have to track down those false positives. That's often hard (both on pocketbooks and people).

Re:Blood tests

[guruevi]

Blood screening could come before the expensive (and sometimes dangerous) scanners and the "hunt for the lost tumor". The problem is two-fold really: too many screenings are prescribed to those that can afford good health care in order to pad the bills and too little screenings are provided for those that cannot thereby inflating the case being made for 'better screenings = less loss of life'.

You can do blood tests for just about anything, cancer, head trauma, during pregnancy to detect various things potentially wrong with the baby. I've gone through the scare of my daughter maybe having Down syndrome based on the blood tests (chance went from 1/300 to 1/25). We had the choice for a more invasive procedure which would have accurately told us but it also had a 1 in 10,000 chance of a premature birth (I forgot the exact number).

Some people may want to abort in case they cannot afford to raise a Down syndrome baby (as it is really expensive) and choose to take the test, others may not care as much. In the end it all comes down (in the US) whether you can afford to make certain choices. It's both good and bad as you can chose how much to spend on health care but on the other end, too many fall through the net and go without any health care options.

Re:Blood tests

[izomiac]

Well, with any test there are several possible outcomes:

• Test picked up a disease while it's treatable but effectively asymptomatic
• Test picked up a disease that isn't treatable
• Test picked up a disease that would have eventually shown symptoms and been treated at that time
• Test picked up a "disease" that never would have actually amounted to anything
• Test was wrong

Of these, only the first is useful. The way we determine whether to administer a screening test or not is based on the NNT (Number needed to treat before one patient benefits), NNH (number needed to harm, e.g. guy becomes impotent after you resect his prostate unnecessarily), the cost of the test and the size of the population at risk. IIRC, we can allocate ~$30k per life saved (the TSA OTOH...).

Another part of the problem is that a lot of our tests have only really been studied in patients with symptoms. E.g. patient has back pain, CT or MRI is done, it shows disease, surgery is performed to alleviate symptoms. If you start looking at people in the general population, a lot will have normal variants that look like disease. Individually, these variants ("incidentalomas") are rare, but in aggregate they're really common; a full third of people would have something abnormal on CT scan.

Re:Blood tests

[Anonymous Coward]

Well, next step is figuring out your Positive Predictive Value. The interesting thing about this parameter, is it varies with Prevalence. If you define your tested population as a group in which you already have reason to suspect cancer, you can get a pretty decent PPV. Now, elevated AFPs are rare in the healthy general population. Thing is -- while it might not seem that way emotionally -- statistically, cancer is also considered a rare health condition (from an epidemiological standpoint). The net result is most tumor biomarkers applied to the general population, end up with low PPVs -- even tests with specificities of 90+% can end up with PPVs in the single digits or less.

Applying this to my pancreatic cancer example below, the blood assay I mentioned (87% specific, 77% selective) if used as a screening test for the entire population of the USA has a PPV of 0.085%. For comparison, simply declaring that everyone in the country has pancreatic cancer has a PPV of 0.015% -- almost as accurate, and it has the benefit that it catches those 10,000 people that the blood test doesn't.

Cancer - i'ts not as bad as you think.

[gurps_npc]

Yes, that's the PSA I think we need.

Deaths caused by cancer (US numbers, 2009): 562,875

Deaths caused by heart disease (US, 2009): 616,067

We know more about Heart Disease, but it gets less press - mainly because the treatments for it are not as painful.

You know, I bet if someone created a painful, dramatic, balding cure for Heart Disease that in 10 years we would cure it entirely.

Re:Cancer - i'ts not as bad as you think.

[gurps_npc]

Note I meant a painful, dramatic, balding, PARTIAL cure for Heart Disease, then in 10 years we would cure it entirely - with a new, full cure that was not painful/dramatic/balding.

Anyway, I meant to say that cancer gets way too much press simply because our treatments for it are nasty. We should base funding on that are nasty, not ones that have nasty cures.

Re:Cancer - i'ts not as bad as you think.

[Attila Dimedici]

The thing is that cancer is not one disorder, or even just a few disorders. Heart disease can reasonably be considered one disorder (although it is probably more accurately viewed as three or four disorders). There are hundreds of different disorders that we lump together under the term cancer.

Re:Cancer - i'ts not as bad as you think.

[ColdWetDog]

Your correct. The scary thing about heart disease is how much we really don't know about it even if it is relatively 'simple'.

Good medical research is very, very hard to do. Humans are just absolutely horrid research subjects. They live too long, they are expensive to keep, they are genetically and environmentally diverse and the every time you get an Institutional Review Board involved you are in for years of meetings and paperwork.

Better for us if we were hamsters. Or Paramecium.

Re:Cancer - i'ts not as bad as you think.

[blair1q]

Heart Disease gets lots of press, it just isn't all labeled "Heart Disease", whereas anything about prostate cancer is pretty unambiguous.

Anything relating to cholesterol, "heart health", cardio anything, "eating right", etc., is ultimately about heart disease.

I also don't know why you think the treatments for heart disease are less painful than for cancer. Nothing is more painful than people digging around in your chest cavity running new pipe or replacing the pump. Chemo is pretty nasty, but compared with chopped-up thorax? Not even in the same pain ballpark.

The real difference is that 90% of heart disease is very easily *preventable*, but it means rejection of a culture foisted on us by greedheads in the junk-food industry. The economic distortions due to their business model mean that it's probably not possible to even feed us all enough calories if we have to stop eating waste products shaped as burgers and nuggets and washing it down with bubbly sugar-water all of a sudden.

Re:Cancer - i'ts not as bad as you think.

[blair1q]

Hundreds of different types, but they boil down to three or four deviations from proper operation of the DNA/RNA system. The different types do matter, though. The tissue affected initially can determine what treatments can be used, and what other tissues might be affected if it spreads.

And the thing about there being multiple types of heart disease is actually important as well, since not making the distinction means people can feel one thing, think it might be heart related, then read the symptoms for the wrong type of problem and decide they don't have heart disease and let it get worse figuring it's one of the dozens of other things that cause those pains. The ambiguities mean that cardiologists see a lot of people with acid reflux, but it also means a lot of people with blocked arteries don't go to the cardiologist.

Re:Cancer - i'ts not as bad as you think.

[nbauman]

Better for us if we were hamsters. Or Paramecium.

I wish I were a zebrafish. You cut a piece out of a zebrafish's heart, it grows right back.

They can't tell which are slow and which aren't

[sclark46]

The problem is they have difficulty, with prostate cancer, in telling which are slow growing and which are aggressive.

Re:They can't tell which are slow and which aren't

[Anonymous Coward]

Just collect two data points separated by enough time to reliably determine speed of growth?

Seen this article everywhere now.

[h00manist]

Seems like someone is driving a huge PR campaign for "let's not have people visit doctors and get cancer screening". It's likely actually just costing a group of HMO insurers more money to have lots of people treat cancers early and undergo lengthy treatment, and then survive, rather than have a smaller number of people detect it too late, do a short treatment, and then just die.

After all, health services are a business. We understand. You can't just have insured people liviing a long time and making businesses lose money.

Re:Seen this article everywhere now.

[Cornwallis]

Funny, I was thinking along the same lines except from the point of view that this is a precursor for when gubmint takes over healthcare in the U.S. This would be a great way for it to hold costs down.

Re:Seen this article everywhere now.

[ColdWetDog]

Seems like we have our tin foil hat on just a little too tight.

Not everything is an Illuminati conspiracy.

Re:Seen this article everywhere now.

[Hatta]

Even if health care was completely not for profit, it would still make sense to be aware of false positives on cancer screens.

Re:Seen this article everywhere now.

[Anonymous Coward]

No, but everything is MONEY. You don't need a conspiracy to have heartless greedy fucks looking for a way to maximize money returns by playing with other people's lives.

Re:Seen this article everywhere now.

[robot256]

What people always forget when talking about the "government takeover of health care" is that there are already bureaucrats sitting between you and your doctor--the private insurance companies--and you already have limited mobility between providers, due to limited open seasons and pre-existing conditions and whatever else your employer stipulates. But instead of being handled by a government agency overseen by elected officials, you are beholden to a for-profit organization who wants everyone to pay in more than they draw out. While I'm sure there are arguments to be made that efficiency gains can be produced in a properly regulated market versus a single-payer system, I don't think the market we have meets that criteria at the moment. It will be a little better after Obamacare goes into effect, but a lot of the health insurance system is still not working in the best interests of the patients.

Re:Seen this article everywhere now.

[h4rr4r]

Holding costs down is just as important if you pay out of pocket, as if you have insurance or national healthcare.

Ignoring cost there is another important factor here, quality of life.

There is little point in killing 70 year olds on the operating table to attempt to remove a cancer that would not have killed them for another 40 years.

Re:Seen this article everywhere now.

[Attila Dimedici]

No, this is about saving the government money not about saving money for HMOs. The people who are advocating that the government pay for everybody's healthcare realize that it can't actually afford it so they are working on getting the public ready for bureaucratic triage as to who gets treatment.

Re:Seen this article everywhere now.

[MozeeToby]

Someone who catches cancer early and has 2 years of treatment is going to have a much smaller bill on average than someone who catches their cancer at stage 2 or 3 and has a 2 year death spiral of expensive, invasive, and life destroying (figuratively if not literally) treatments. Chemo and radiation is expensive, but it's a lot less so than surgery, rehab, months in the ICU, and, eventually, hospice care.

And for gods sakes people, do you really live in a world where you believe every single persons in a decision making position is a certifiable phsychopath who cares nothing for anyone's health and happiness but their own? I have no doubt that they exist in positions of power, perhaps even in significant numbers, but the kinds of conspiracy theories you're throwing out would require complacency from everyone from accountants and doctors to board members and congressmen; without a single one of them willing to step up and blow the whistle.

Re:Seen this article everywhere now.

[blair1q]

Dead people don't pay premiums. People with "cured" conditions pay higher premiums.

Re:Seen this article everywhere now.

[blair1q]

Sure. If in your fantasy world nobody in government had any sort of ethics at all, and the government doesn't pass laws enforcing ethics standards.

But here, in the real world, government workers are generally more ethical than private-sector businesses, and are bound by strict ethics regulations.

So stop buying Fox News propaganda. The dysfunction of American healthcare is due to fractionation and greed in the system. Making it one system, with one set of standards and little opportunity for gouging people who are suffering, will make it far, far better. Not worse.

Re:Seen this article everywhere now.

[RonBurk]

No, it's just one of those things that people who work in cancer research are aware of and, eventually, that awareness leaks into the public and the press realizes that the research community knows something the uneducated public would find astounding.

Let me give you a human example of the cost of screening. I was sitting in a mammography waiting room once when a women came in for her screening. The receptionist informed her that she could get screened, but the radiologist was out and she would have to wait a day to get the results. The woman became upset and demanded there be a radiologist present. The receptionist gave the same reply.

Eventually, the woman was sobbing and explaining that, though she was a nurse, false-positive mammograms had sent her in for biopsies three times already. The last time had been 5 years earlier and she simply stopped returning because she couldn't face another biopsy. This was the first time she had got her nerve up to come in for a mammogram again in all that time, and there was no way she could leave that office and not know if anything (false or not) had been found.

And that's not even a case with serious physical costs for screening, "merely" psychological costs: that caused someone to stop getting screened.

Likelihood of a false positive by your tenth mammogram? Nearly 100%. Since you're presumably working in some kind of technological field, you should really realize that technology always has a downside and not assume that anyone recommending shoving less technology down patients throats simply has a profit motive.

Re:Seen this article everywhere now.

[A beautiful mind]

No, this is not the case. The problem is that we're still far away from evidence based medicine.

When evaluating what works and what doesn't, you have to tread very carefully. Sure, most people^Wgeeks know about double blind studies, but that's just the tip of the iceberg. The second edition of Testing Treatments came out recently (available as a free pdf on the website, although I bought it to support the authors) that explains the problems in an understandable language while not dumbing down the issues. The book comes with the recommendation of well known epidemiologists like Ben Goldacre, of Bad Science.net fame.

To talk about the specifics of screening, check out Chapter 4. To recap the main points there, for screening to be worthwhile you have to look at several factors:

• The condition to be screened for has to be important - either because of it's deadliness and/or because it affects a lot of people
• There has to be a detectable early stage of the condition which to screen against
• There exists an effective and acceptable treatment for the condition
• There is a reliable screening test to detect the condition with

The problem with lots of screening is that on the level of the population it can lead to more harm than good overall for a lot of different diseases, because of false positives, because of our psychological makeup that we'd prefer surgery for even harmless varieties of lumps in our bodies, etc. (see detailed examples in the book). In a lot of cases it happened that screening was introduced before the effectiveness of screening was established in a trial, then later trials showed that the screening was ineffective in reducing deaths or harm.

The bottom line is that well designed trials should be conducted and based on the systemic review of those trials it should be decided whether to conduct screening or not, based on whether it's improving health outcomes or not. A lot of trials don't improve outcomes.

Re:Seen this article everywhere now.

[Anonymous Coward]

You are missing the point. They are trying to say in many cases the treatment of the cancer is more damaging, invasive and expensive than not doing anything at all. They are talking about cancers that grow so slowly (or stop on there own altogether) that the patient would likely die of other causes before the cancer became a health issue at all. If they do find it, the patient ends up going into expensive treatment that reduces their overall quality of life.

The article goes on to state they agree with reducing screenings for specific types of cancer...types that have been known to grow very slowly, thus decreasing the need for urgency.

Re:Seen this article everywhere now.

[stephanruby]

Are you sure it's the HMOs driving this? I don't think so. If you take a look at the recommendations this group has given in the past, many of those recommendations would go against the interests of HMOs, so I do not see any particular pattern emerging one way or another.

Re:Seen this article everywhere now.

[A beautiful mind]

Err, the last sentence should read: A lot of screening doesn't necessarily improve outcomes.

Re:Seen this article everywhere now.

[MozeeToby]

There are these things in Slashdot discussions called threads, where someone responds to someone else's post. Sometimes, their response only makes sense in light of what they are responding to. In this case, I was responding to someone trying to claim that this was something sinister being done by the insurance companies or the government to reduce healthcare costs at the expense of lives. My post was the point out the failures of logic in the OPs post, not argue for or against anything in the article.

Re:Seen this article everywhere now.

[Artraze]

Which is why sane people realize that the proper course of action isn't to replace the money grubbing bureaucrats with apathetic ones (note that there is a big difference) and instead attempt to do away with them altogether. We could break apart the back room collective bargaining and price fixing and actually make health care something that people actually pay for, like car insurance and automotive services. That way, at least, we can see some competition for price and maybe people will even understand the resources they waste every time they go to the doctor about a cold. (Well, at least after they paid $80 to hear the doc say "It's a cold, drink some juice and get some rest" they'll think twice before doing it again.) Hell, it might even help with things like smoking and obesity if people see a big old 'your lifestyle is really unhealthy' surcharge.

It would also help the problems with cancer screening: once people see a $10,000+ price tag on treating that maybe-dangerous tumor they'll definitely give waiting and seeing a thought. And, of course, they could buy their own screening if they like.

Anyways, I can't promise it will work, and I'd expect medicare might need expand to cover preexisting condition type cases (e.g. birth defects or similar). But the one _really_ nice thing is that it would be vastly easier to change to single payer if it didn't work out, whereas the other way is basically impossible.

Re:Seen this article everywhere now.

[Anonymous Coward]

As a prostate cancer survivor who's alive thanks to 15 years of regular annual PSA blood tests - I am very much in favor of regular screenings. If I'd waited to display symptoms, I'd have been diagnosed @ stage 3 or 4 instead of stage 2. (Lower stage numbers, better long term odds.) Call me suspicious. Very, very suspicious. BTW THANKS! Dr. T & Dr. K

Re:Seen this article everywhere now.

[sjames]

You mean as opposed to the private bureaucratic triage that happens now coupled with the really ugly economic triage that makes lower income people die on average 10 years early?

Re:Seen this article everywhere now.

[sjames]

And someone who doesn't needlessly get treated for something that was going to just go away saves HUGE amounts of money and quality of life.

Re:Seen this article everywhere now.

[Sponge Bath]

Dead people don't pay premiums.

1. Healthy people pay premiums.
2. Sick people pay premiums and collect benefits.
3. Dead people pay no premiums and collect no benefits.

The private insurance industry only wants #1. If you become #2, they will do everything in their power to help you progress to #3. There will always be a fresh supply of #1 (young/healthy) to replace "retired" customers.

If this sounds cynical, it comes from personal experience with private health insurance and a talk with someone whose job with a private health insurer was to comb through records of people costing "too much" money and find any excuse to rescind a person's coverage. He was amazingly successful in helping customers reach #3.

Re:Seen this article everywhere now.

[h00manist]

Even if health care was completely not for profit, it would still make sense to be aware of false positives on cancer screens.

Search the news and find articles saying pre-screening is bad for some reason, in prostrate, breast, and cervical cancer - that I have seen so far.

Yes, false positives are bad, and could be the real issue here. And greedy insurance companies could be the issue too. We haven't get the evidence or research to prove either issue yet.

But I can't see the logic of dealing with false positives by eliminating testing altogether, especially via news articles, and frases such as "cancer screening is pointless and could be bad for you". What I do see is that people don't care for their health or visit a doctor enough already. And that people visiting doctors to screen for diseases results in treatment for them, treatment that lets them live.

Re:Seen this article everywhere now.

[TheLink]

That's assuming the same person doesn't later on get cancer again or something just as expensive. And what are the odds that a person who got cancer would get cancer again?

People eventually die. So just because someone dies earlier expensively doesn't mean that the person who didn't die sooner would be cheaper in the long run, especially if it's all paid by socialized healthcare/welfare.

Lastly it's quality AND length of life that matters. You want to live longer not merely survive longer.

Re:Seen this article everywhere now.

[ISoldat53]

I wonder if an insurance company paid for this research?

Re:Seen this article everywhere now.

[Anonymous Coward]

As an MD I have to take exception. People just don't understand "screening" tests. They are meant to detect HIGH PREVALENCE (i.e., significant number) TREATABLE diseases with as few as possible false positives as possible. If you tested every student at the University where I see patients (in the U.S.) for leprosy, a positive test is likely false - because the rates of leprosy are so low in the U.S. - but there will be positive tests, and those patients will endure more tests and anxiety to prove they mostly were false positive (perhaps a true positive in a foreign student...).

Yes, costs are an issue. We only have have so much money as a nation to spend on health care. Want to spend it all on finding an undiagnosed case of true leprosy? I doubt it... At least I don't. So let's get the data to tell us where is the best bang for the buck. Screening for prostate cancer has not proven beneficial either. Makes sense, but so far not very valuable. Questions now arising re accepted wisdom of screening for breast cancer.

And no, I don't work for or represent an HMO... Just willing to "question authority" and not accept the pronouncements of special interest groups.

Re:Seen this article everywhere now.

[trout007]

I always thought it would be better to combine life insurance and health insurance. That way the interests of you and the company are both the same, your well being. Right now as a 40 year old guy I am ten years into a twenty year term policy for a million dollars. You would think if I get cancer my life insurer wouldn't mind paying a couple hundred grand to make sure I make it to the end of my policy.

Re:Seen this article everywhere now.

[trout007]

At least get rid of the laws that prohibit doctors and dentists from publishing the price list.

Re:Seen this article everywhere now.

[Anonymous Coward]

And someone who doesn't needlessly get treated for something that was going to just go away saves HUGE amounts of money and quality of life.

If people are getting needless treatment, then detection isn't the issue. The treatment is. Now it could be argued that the costs testing itself is a waste of money, but it's not fair to argue by adding the costs of unneeded treatments on. Already people are detecting prostate cancer and deciding not to treat it. There's zero reason to believe breast cancer treatments can't become more rational.

Re:Seen this article everywhere now.

[nbauman]

We could break apart the back room collective bargaining and price fixing and actually make health care something that people actually pay for, like car insurance and automotive services. That way, at least, we can see some competition for price and maybe people will even understand the resources they waste every time they go to the doctor about a cold. (Well, at least after they paid $80 to hear the doc say "It's a cold, drink some juice and get some rest" they'll think twice before doing it again.)

This is a common fallacy -- that the costs of going to doctors for minor discretionary ailments are a significant part of health care costs. As the economist Paul Krugman has explained, the major expenses in health care aren't $80 visits to the doctor, but $50,000 and $100,000 cancers, $20,000 a year lifelong treatments for diabetes, $50,000 a year lifelong treatments for multiple sclerosis, $50,000 and $100,000 heart bypass operations.

Actually, there have been many studies over at least 40 years to see whether charging patients more would produce better -- or even cheaper -- care. They all failed. Look up the Rand Health Insurance Experiment in Wikipedia. Patients who had greater copayments put off necessary care, like blood pressure medication (probably the most cost-efficient intervention we have).

U.S. corporations like IBM tried imposing co-payments on their employees, and they ended those policies when they found that they wound up spending *more* money. Patients with asthma put off maintenance care, and wound up going to the hospital more.

Health insurance isn't like car insurance. If your car is damaged, you know what the problem is and you know what's going on. If your doctor tells you that you have a disease you never heard of, and that you have to treat it right away, you don't know what's going on. It will take you more than a day of Google searches to find out.

If a nurse tells you, "You should go to the hospital right away. It could be life-threatening," what are you going to do? Look it up on the Internet?

Making health care decisions is like a graduate-level exam with questions you're unlikely to understand, and if you get one question wrong, you die.

It would also help the problems with cancer screening: once people see a $10,000+ price tag on treating that maybe-dangerous tumor they'll definitely give waiting and seeing a thought.

Ridiculous. The main thing a cancer patient wants to know is whether (or how long) he's going to live. The only concern about treating a tumor is (1) whether it really is a tumor that has to be treated and (2) what the best treatment is.

Cancer chemotherapy causes heart failure and other cancers. Is the risk of death from treatment greater than the risk of death from no treatment? Nobody takes doxorubicin just because they can get it free.

I know people who are doing watchful waiting, because their doctors think it's one of those false positives. I've talked about the decisions with them.

$10,000 doesn't enter into the decision. How much is your life worth?

Re:Seen this article everywhere now.

[nbauman]

This is well known in the insurance industry. It cost a lot more to have somebody crippled for life than to just kill them off.

You know why railroads have emergency axes? It's to kill of the passengers after a train wreck.

If you run over a pedestrian, back up your car and finish them off.

Re:Seen this article everywhere now.

[Artraze]

> This is a common fallacy -- that the costs of going to doctors for minor discretionary ailments are a significant part of
> health care costs. As the economist Paul Krugman has explained, the major expenses in health care aren't $80 visits
> to the doctor, but $50,000 and $100,000 cancers ...

Sure, whatever, that's obvious and wasn't my point anyways. The point I was making is that it would waste less resources, making those available to other people for less. Not only would they stop spending $80 on the useless visit, but the decreased demand would lead to further reductions in price for people that actually should be seeing the doctor. (Not having to pay the bureaucracy with also reduce prices.) So, while right now uninsured people go to the emergency room only to get turned away until they have a $100k heart thing, they could instead go to a doctor, hand them the posted $50 and chat about their chest pains / fever / etc.

The studies you quote were all performed within the broken system. It's quite hard to extrapolate their results to fundamentally different circumstances. For instance the RAND study had people paying 95%, which would almost certainly be higher than what they would pay with reduced demand and lack of health insurance overhead. Even the 50% is questionable... While it's quite probably a bit less than a no-insurance situation, it's also almost certainly more than they thought they should be paying, making them feel uncomfortable about going. This is, in particular, the case for IBM... They raised deductibles made the perceived and true cost of care increase (because I doubt they bumped salaries accordingly). Of course people are going to cut back.

And yes, I don't expect the average Joe to be able to diagnose themselves. But let's also be realistic: For basically all of human history people have had to diagnose and treat themselves. They shouldn't see the doctor very time they feel ill, they should _think_ and only go when they feel that it's something more than a cold.

> $10,000 doesn't enter into the decision. How much is your life worth?

It's not my life, it's _maybe_ my life. If I was faced with something that had a 10% chance of being dangerous cancer, and a 5% reduced change of survival waiting 6 months to know whether or not is is dangerous for sure, the expected value of my life is $2,000,000. But that's not even accounting for the possibility that I might not be cured and die anyways. So it's a lot more than that, and that's the point. People, when actually faced with situation bill like that get surprisingly good at these maths.

Re:Seen this article everywhere now.

[Serious Callers Only]

Search the news and find articles saying pre-screening is bad for some reason, in prostrate, breast, and cervical cancer - that I have seen so far. Yes, false positives are bad, and could be the real issue here. And greedy insurance companies could be the issue too. We haven't get the evidence or research to prove either issue yet.

If you'd bothered to research the news articles, or even read this FA, you'd have seen that we do have the research, and it points to cancer screening often not being a net benefit in terms of saving lives, and the treatment that results affecting quality of life in a more negative way than the cancer would have for the majority of patients. That's pretty clear cut, explained in the article, and is backed up by research around the world, and is starting to lead to policy changes. Here is a quote as you clearly can't be bothered to click the link:

Two recent clinical trials of prostate cancer screening cast doubt on whether many lives — or any — are saved. And it said that screening often leads to what can be disabling treatments for men whose cancer otherwise would never have harmed them.

But I can't see the logic of dealing with false positives by eliminating testing altogether, especially via news articles, and frases such as "cancer screening is pointless and could be bad for you".

Sometimes too much testing is a Bad Thing, the article attempted to explain this to laypeople but is, believe it or not (I suspect you will choose not), based on solid research. Screening is unlikely to be entirely phased out, but a far more targeted approach is warranted, and would save lives, save money (which means saving lives in other areas), and lead to better outcomes for many people with non-agressive tumors late in life.

Re:Seen this article everywhere now.

[doctorcisco]

Instead of being handled by a government agency overseen by elected officials, you are beholden to a for-profit organization who wants everyone to pay in more than they draw out.

Your faith in the State's benevolence is duly noted, and downright cute.

doc

Re:Seen this article everywhere now.

[Isaac-1]

Take it from someone that was there this year, your life changes when you hear it is an 80% chance of being cancer, the only way to know for sure is to remove it, and if it is cancer even if removed has a 50% chance to come back, and a 0% 5 year survival rate if not treated. Thankfully I was in the 20%,

Re:Seen this article everywhere now.

[nbauman]

The studies you quote were all performed within the broken system. It's quite hard to extrapolate their results to fundamentally different circumstances. For instance the RAND study had people paying 95%, which would almost certainly be higher than what they would pay with reduced demand and lack of health insurance overhead. Even the 50% is questionable.

No, it was 0%, 25%, 50% or 95% http://en.wikipedia.org/wiki/RAND_Health_Insurance_Experiment

25% is close to the 20% that Medicare charges. This was designed covering the full range.

What do you mean, "broken system"? That's the system we've got, and we're trying to figure out ways to improve it.

Other countries have copayments, and they don't work either. I read a series of articles, pro and con, on the Swiss health care system, in JAMA. Their copayments don't work either. For serious diseases, they quickly exhaust the maximum copayment, and the state has to take over -- at which point they have free health care. In the US, they don't have maximum copayments, and people go bankrupt.

Re:Seen this article everywhere now.

[daem0n1x]

Taking into account that the US fully-private healthcare system is rated as third-world grade and is by far the most expensive in the entire world, I would take the "gubment" plan any day of the week. But then, won't anybody think of the poor insurance companies?

Re:Seen this article everywhere now.

[sjames]

If the detection won't lead to treatment, then what does it have to offer?

Re:Seen this article everywhere now.

[Anonymous Coward]

"you are beholden to a for-profit organization who wants everyone to pay in more than they draw out"

Not always. The company I work for, and many other large companies, is 'self' insured. My company does pay an insurance company, currently BCBS, to manage the paperwork, but it foots the actual bill. While it still definitely has an interest in minimizing costs, it not nearly as heartless as the actual insurance companies.

Re:Seen this article everywhere now.

[robot256]

That sounds like a pretty nice arrangement. I can see how it would work well for a young/healthy workforce, keeping them in good shape. Do they fire you if you get a terminal illness, like diabetes or cancer or a disabled child? What if you have to quit because of it? If you have to go buy insurance yourself after that, you have a preexisting condition so you're basically screwed. I'm curious because I hear so many people say they can do just fine without insurance but it seems like a giant gamble to me.

Re:Seen this article everywhere now.

[j-beda]

As a prostate cancer survivor who's alive thanks to 15 years of regular annual PSA blood tests - I am very much in favor of regular screenings. If I'd waited to display symptoms, I'd have been diagnosed @ stage 3 or 4 instead of stage 2. (Lower stage numbers, better long term odds.) Call me suspicious. Very, very suspicious. BTW THANKS! Dr. T & Dr. K

Do we understand enough about your particular type of prostate cancer to know with high confidence that it would in fact have lead to stage 3? Are you (due to personal or family history) an individual who would have into the pool of patients for which testing would have been warranted based on these types of studies? If five people were killed by unnecessarily aggressive treatment in order to save one life due to early detection, is that a good system to continue?

These are useful questions to rigorously study.

Re:Seen this article everywhere now.

[Anonymous Coward]

You are absolutely right.

It amazes me that in 2011 the Americans are even still having this debate. The US healthcare system is broken and requires fixing. How is it that EVERY OTHER First World country has a vastly superior healthcare system to the US ? I mean, fuck Fox and the Tea Party and all the clowns, just open your fucking eyes! Everybody does healthcare better than you, better outcomes, lower costs and available to all. So why the hell can't the US get itself out of the 19th Century with this ?? It's because healthcre in the US is profit based, driven by corporates and they don't want the status quo to change as it will impact their revenues. Come on USA, wake up ! They'd throw the fucking lot of you under a bus if it meant another TRILLION dollars in their pockets over the next few years.

The Right Wing fucking crazies in US politics (ie Republicans and Democrats ---you wouldn't know a REAL Leftie if it jumped up and bit you on the ass) want to keep lining the pockets of their corporate masters with YOUR money and give YOU a shitty healthcare system in return.

And don't start about the "wonderful" medical care that are available for some in the USA.....yeah, on an individual basis, IF you have the money...otherwise you're shit out of luck.
Even that fucking crazy bitch Palin confessed that her family used to sneak across the border into Canada to use a proper healthcare system....... fucking hypocrites.

Re:Seen this article everywhere now.

[Anonymous Coward]

Only one of THEM would say that.

Re:Seen this article everywhere now.

[he-sk]

For basically all of human history people have had to diagnose and treat themselves.

For basically all of human history, people didn't live past age 40.

Re:Seen this article everywhere now.

[Anonymous Coward]

Seems like someone is driving a huge PR campaign for "let's not have people visit doctors and get cancer screening". It's likely actually just costing a group of HMO insurers more money to have lots of people treat cancers early and undergo lengthy treatment, and then survive, rather than have a smaller number of people detect it too late, do a short treatment, and then just die.

After all, health services are a business. We understand. You can't just have insured people liviing a long time and making businesses lose money.

The funny thing is, government run health systems, such as Britain, are looking at making the same decision. It seems big bureaucracies, whether public or private, tend to make dehumanized decisions.

Re:Seen this article everywhere now.

[Anonymous Coward]

That's all I could think of reading the article. It sounds like a pro-cancer PR piece.

Re:Seen this article everywhere now.

[Anonymous Coward]

"I trust my state further than large insurance companies" is merely a relative ranking, though.

Re:Seen this article everywhere now.

[shilly]

You say "Sure, whatever, that's obvious and wasn't my point anyways." But what's truly obvious is that you didn't get his point. His point was, you can't save much money by stopping people going to see the doctor about a cold. It's just not sufficiently wasteful of resources. If you want to save money in healthcare, there's only one way to do it: be more effective upstream. Prevention and active management are where it's at. Twatting about with the funding model is a waste of time.

Translation

[jmorris42]

In other words, since we are about to have huge waiting lists for routine tests, lets just declare that is a feature instead of a bug.

Just more of the stuff we find out after passing Obamacare I guess. And notice how I will be flamed for calling it that, which says it all. If this turd were actually popular I'd be called a racist if I DIDN'T give President Obama proper credit for his signature achievement.

Re:Translation

[Anonymous Coward]

You really think "Obamacare" is driving this? It would be happening regardless, driven by the insurance companies.

Re:Translation

[0123456]

You really think "Obamacare" is driving this? It would be happening regardless, driven by the insurance companies.

But people were complaining recently that health insurers drive people to have too many tests and unneccesary treatments, so that they can push up premiums.

Then today they're not paying for enough.

Seems they're damned either way.

Re:Translation

[jfmiller]

Thank you for giving President Obama credit for the most dramatic overhaul in the nation's history. When Obamacare becomes as popular as Medicare and Social Security, it will be nice to know people will remember who was responsible for it.

Re:Translation

[Volante3192]

You can blame this on Obamacare IFF you can prove without a doubt your exact same exact scenario would NOT happen in the era immediately preceding Obamacare (you know, the Golden Age of Private Insurance.)

Re:Translation

[geoffrobinson]

Yeah, Social Security and Medicare are real popular until they start bankrupting us due to foreseeable demographic changes. Kind of like cancer that doesn't do much harm until it gets out of control and kills a person.

Re:Translation

[zr]

and then we run out of other people's money for real. whats then?

Wrong interpretation

[Anonymous Coward]

It does not mean that screening is useless; it means the medical community doesn't know nearly as much about cancers as they have been trying to convince us. (and maybe they need a big dose of humility)

What this info really means is that we need better tools to distinguish which patients will benefit from treatment, and which will not. In this case, closing our eyes does not make the Ravenous Bugblatter Beast of Traal unaware of our presence.

pretentious

[Anonymous Coward]

"have cancers that are already lethal"
--> People that have lethal cancer can be treated nevertheless.
--> how do you know if a persons cancer will be lethal or not?

"cancers that grow so slowly they do not need to be treated"
--> how can you tell if a cancer will grow and kill or not?

What i read here is that you save 4.000 to 18.000 people anyways,
and for all the others you open up the evaluation of their disease.

So ... what kind of idiot wrote that pretentious article

Re:pretentious

[SteveFoerster]

"have cancers that are already lethal"
--> People that have lethal cancer can be treated nevertheless.
--> how do you know if a persons cancer will be lethal or not?

Well, you'll find out sooner or later, right?

Re:pretentious

[0123456]

So ... what kind of idiot wrote that pretentious article

One who understands that cost/benefit calculations have to, you know, include the costs as well as the benefits?

If attempting to treat supposed cancers causes debilitating harm to thousands of people but benefits another few thousand people, then it's far from clear whether treatment is beneficial to the majority.

Re:pretentious

[Attila Dimedici]

One who understands that the government cannot afford the level of care we have become accustomed to, but wants the government to pay for everybody's health care anyway.

Re:pretentious

[mosb1000]

People that have lethal cancer can be treated nevertheless.

If the cancer kills you anyway, then you went through a whole lot of pain and trouble for nothing. I'd rather not be put through all that for nothing.

how do you know if a persons cancer will be lethal or not?

You wait until they've died from it. Then you mark in your notes that the cancer was lethal. Pretty simple really. But only useful for generating statistics.

how can you tell if a cancer will grow and kill or not?

Again, you wait until they die, then you look and see if the cancer killed them, or if it was something else. Again, only really useful for generating statistics.

So ... what kind of idiot wrote that pretentious article

Some people know not to argue with the truth. That's the kind of person who would write this article. You can live your life however you want.

Re:pretentious

[h4rr4r]

Government care would be cheaper, for evidence look around the world.

This is about not torturing people with pointless treatments, not saving a couple bucks.

Re:pretentious

[Attila Dimedici]

Sure, it's cheaper because with government care, sick people don't live as long. Just look at the prognosis for someone with a specific serious illness around the world.

Re:pretentious

[h4rr4r]

Bzzt, wrong.
The USA has one of the shortest life expectancies in the first world.

Re:pretentious

[Volante3192]

One who understands that the government cannot afford the level of care we have become accustomed to, but wants the government to pay for everybody's health care anyway.

We cannot afford the level of care we have been accustomed to, period. Medicare OR through private insurance.

Health care premiums doubled between 1996 and 2006. I dare you to blame Obamacare for that.

Re:pretentious

[Attila Dimedici]

Bzzt, reading comprehension fail.
The U.S. generally has the best prognosis for someone diagnosed with a particular serious illness (specific type of cancer, diabetes, etc). That is, the five year survival rate for people diagnosed with most life-threatening diseases is better in the U.S. than in most of the rest of the first world. There are many reasons why U.S. life expectancy is shorter that have nothing to do with quality of care. For example, in many first world countries, if a child dies within the first 24 hours after birth it is considered stillborn. In the U.S., such an incident is counted as infant mortality (and thus lowers average life expectancy). As another example, the life expectancy for Japan is higher than for the U.S., yet the life expectancy for a Japanese American is higher than the life expectancy for Japan.

Re:pretentious

[Attila Dimedici]

No, I blame Medicare and Medicaid for that. Obamacare will just make medical care inflation worse. If you look at the cost of medical care over time you discover that the cost of medical care rose at basically the same rate as inflation until the year after both Medicare and Medicaid were in force. At which point, the cost of medical care began rising much faster than inflation.

Or they could do MORE frequent screenings.

[mosb1000]

Another approach is to find an imaging technique that is cheap and harmless enough that you could image someone's whole body every week. Then you could compare week to week to monitor growth and spread of the tumors, and only target tumors that are fast growing, or persist beyond a certain threshold size.

Re:Or they could do MORE frequent screenings.

[ChrisMaple]

Doesn't the TSA offer this service for free?

Re:Or they could do MORE frequent screenings.

[mosb1000]

Depends what your definition of harmless is I suppose.

Re:Or they could do MORE frequent screenings.

[RonBurk]

Two reasons that won't work. Restrict the discussion to breast/prostate cancer for simplicity. Both are highly treatable if they haven't mutated enough to have the ability to metastasize. You can't make an imaging technique that checks every cancer cell to see if even one(!) has gained the ability to metastasize.

Second, the vast majority of people will INSIST on surgery if they know they have cancer. I used to try to explain to people that most of us have already (if we've got grey hair) thyroid cancer, but it is highly unlikely to harm us. Then I realized I was just causing people to run to their doctor to demand an X-ray of their thyroid. People can't process things like "likelihood" when it comes to cancer, which is why the fact that screenings can cause more harm than good is very difficult to have a rational discussion about.

Re:Or they could do MORE frequent screenings.

[mosb1000]

You can, however, tell if cancer has metastasized or not. You can see whether or not it is spreading.

Most people are unreasonably afraid of dying. Pathologically afraid, really. People need to accept that the question is how you're going live, not whether you're going to die.

Re:Or they could do MORE frequent screenings.

[blair1q]

Here's a dirty little secret: imaging costs nothing but electricity and time.

There. I've said it.

GE have been scamming the world for decades, pretending their machines are expensive to make. They're not. And worse, they lease the damn things because the price to purchase and depreciation are so high.

But it shouldn't cost any more to roll through a CT or MRI scanner than it does to pull into a parking space in your car (which is a much more complex machine, when you decompose them).

For a few thousand dollars we could all have an MRI built into a doorframe at home (though you might want to switch your remaining CRT-based TVs out for flat-panels before you try this). Use an iPhone app to run it and produce the analysis of any differences since the day before. The whole thing would take seconds.

Think about it. The return of the American Dream:

A man walks through is own front door, which makes a loud hum, followed by a ding.
Breadwinner: "Honey, I'm home!"
Little Missus: "And you're polyp-free, dear!"

Re:Or they could do MORE frequent screenings.

[h4rr4r]

How do you plan to make a home without any metal objects?
How cheap do you think liquid hydrogen/helium are?

Re:Or they could do MORE frequent screenings.

[mangino]

And who reads the results? How accurate are the readings?

Re:Or they could do MORE frequent screenings.

[mosb1000]

I would presume this would be done in software, with subsequent analysis by a doctor only if certain screening criteria are met.

Re:Or they could do MORE frequent screenings.

[mosb1000]

I think you've underestimated the cost of these machines at least a little. Plus currently you wouldn't be able to simply walk through. It's important that you are (generally) immobile while you pass slowly through the imager. But, of course, that isn't to say such a thing couldn't be done in the future.

It's true that the cost is artificially inflated. This is true of the medical industry in general, and it's going to have to stop before there can be any significant improvements in the quality of healthcare.

Re:Or they could do MORE frequent screenings.

[tsotha]

Another approach is to find an imaging technique that is cheap and harmless enough that you could image someone's whole body every week.

Assume we have a can opener...

Re:Or they could do MORE frequent screenings.

[belg4mit]

Thanks for the info, I must have missed the press release that helium-cooled superconductors are free now.

Re:Or they could do MORE frequent screenings.

[blair1q]

They're a fuckload cheaper than what GE sells them for. The next x-ray or MRI machine you pay $500 to use for two minutes was paid for in 2005.

Re:Or they could do MORE frequent screenings.

[mosb1000]

I just thought I'd point thisout.

Re:Or they could do MORE frequent screenings.

[mangino]

You presume that software is available and accurate to screen. This is not actually the case. Reading of imaging/screening is an incredibly time consuming, inexact and high risk endeavor.

ughhh

[rish87]

I've seen these and similar studies crop up recently. They really bother me because while they are technically right, I don't think their conclusions are helpful. One problem they point out is that once you've been diagnosed, so many times it is "too late". Their conclusion? Screening test are not as important as we thought. WRONG. If anything this points to MORE FREQUENT screening of assorted cancers. It's easy to be so dismissive of cancer when you are thinking about these things statistically...it's entirely different if you know anyone who has had cancer or if you yourself get it. I am starting to get "older" and am approaching an age where I personally believe I should start getting screened. When I start, I plan on doing this very often. To me, it is worth having a finger up my ass and some amount of money not to die a slow, painful death from something I could have caught and treated. If you want to take the gamble and bet with the statistics, then by all means do. I, however, plan on living as long and healthy as possible.

Re:ughhh

[blackest_k]

booth my father and uncle have had prostate cancer treated and survived, guess that its a pretty good bet I am likely to have it at some point as well. I think i'll have the screening it's recommended for over 50's so in a few years it will be one of those things i'll have to put up with as i'd rather live to a reasonable age.

Re:ughhh

[Arrepiadd]

Actually, some of the studies on the prostate cancer are not saying "you are diagnosed too late", they are saying that "you are diagnosed too early to tell if it's a real cancer" and that detecting one risk factor and starting treatment based on just that is probably going to have more nasty consequences than doing nothing for most of them.

Men are "pretreated" for their cancer and thus, men that maybe would never have a cancer (because a bigger percentage of men are treated than the average of prostate cancer incidence) are going through all the side effects of the drugs, which include impotence, among others. Does it seem like a good trade-off? Well yes, if you do have cancer! The problem is these screenings are not saying this person has a cancer, they say due to these factors this person *may* have cancer and that should not be enough to start cancer treatment.
While not focusing just on this subject, Malcolm Gladwell had a text on this a few years back. (Worth reading and if you are in a hurry just search for "cancer").

Re:ughhh

[rish87]

I definitely would not advocate starting treatment too early, that's for sure. I would, however, prefer to have an early warning (even if it turned out false) than no warning at all. Similarly, I've had my SNP's sequenced from 23andme partly for a similar reason. One of the benefits of the results are showing more than typical risks for certain diseases. While not at all exhaustive or conclusive, it gives you a good idea of what to look out for and possible easy lifestyle changes to make. Same with a possible early indication of prostate (or any other) cancer. I'd rather know that I may be at risk and take the necessary precautions and plan future screenings than not know, get diagnosed too late and die.

Re:ughhh

[Anonymous Coward]

"I, however, plan on living as long and healthy as possible."

And that right there is the problem across the board with today's society. There are 7 billion people on the planet and growing. The planet has all the people it needs to continue society. Problem is that everyone wants to live as long as they can rather than as 'happy as they can'. You can be snuffed out tomorrow by just crossing the street. And the cost of 'living as long and healthy as possible' grows significantly with each year or even month added to a lifespan.

Better to "Live as happy as possible for as long as I have." is my motto.

Furthermore it is NOT a conspiracy that there are many treatments given because someone wants to just 'live as long as possible' that have significant negative effects on the QUALITY of life.

I certainly can't argue that people can't pick their own reason for living or desire for a long life as long as it's their decision and they have the money. Though I'd hope that society as a whole would start to see 'quality' as being a more desirable attribute of life than 'quantity'.

Re:ughhh

[tsotha]

Screening test are not as important as we thought. WRONG. If anything this points to MORE FREQUENT screening of assorted cancers.

Assuming, of course, that your test will detect cancer before its too late. I remember reading a study on mammograms which concluded they were a waste of time because cancers that were going to metastasize had already done so by the time you can detect them on a mammogram. More screening is then just a waste of time, and in fact is counterproductive because repeatedly bombarding tissue with x-rays will cause some amount of cancer that wouldn't otherwise have occurred.

What about treatments that prolong life?

[Slashdot Parent]

as many as 120,000 to 134,000 of those women either have cancers that are already lethal or

There are a lot of cancers that are incurable, but can still be controlled for a while. Statements like this make it sound as though catching these cancers early and controlling them for a while is a worthless endeavor.

My wife is one year into a battle with a cancer that she has only roughly a 25% chance of surviving with treatment. Without treatment, she would have been dead a few weeks after diagnosis. She is grateful to have spent the past year alive instead of dead, and of course the children and I are also grateful. I guess the point that I'm trying to make here is that treating a cancer that will most likely be lethal still has significant value. None of us would have been very happy if some government bureaucrat had told us that since the cancer was so likely to kill her, they wouldn't bother treating.

Re:What about treatments that prolong life?

[Anonymous Coward]

If we only had the resources to treat your wife, or one other person, and the other person had a 75% chance of survival, who should we prioritize?

I feel for you, but your wife isn't the only person in the country who needs help.

Re:What about treatments that prolong life?

[h4rr4r]

This has nothing to do with government bureaucrats, nor does it matter for your wife. No one wants to take away healthcare, they just want to know if on the whole it is worth it to keep going down this track.

The reality is treating someone who will die no matter what, if the treatment does not extend life by much is not medically worth it. If treatment adds only a month of life, a painful puking near death month, why bother? On the flipside, how many people are being treated and just did not need to be? Quality of life is much bigger issue than money.

I wish your wife well.

Re:What about treatments that prolong life?

[Anonymous Coward]

The word government in the last sentence would seem to be unnecessary, and in fact, misleading.

Re:What about treatments that prolong life?

[Anonymous Coward]

So do you want the government to tell you it's too expensive to prolong your wife's life, or do you want the private insurance company to tell you that you're too poor to do so?

Re:What about treatments that prolong life?

[ISoldat53]

You are lucky. My brother's insurance company bureaucrat did the "government bureaucrat's" part in denying his treatment.

Re:What about treatments that prolong life?

[Anonymous Coward]

I read the article to be about screening, not treatment of cancer.

Sorry to hear about your situation. I think the question the article is asking: How was your wife's cancer discovered? If it was through screening, was there an advantage gained by having her screened?

Actually strictly seen the article doesn't even cover your wife's case. The article is talking about the many false positives. I know of two elderly males that had their prostates removed due to elevated PSA. It's an interesting question: Would their quality of life have been lower had that not been done? I know neither of them is particularly fond of the side effects (and in one case post-surgery infection that took a few weeks to clear). Both are of course glad to be "cured" (or at least: So far clear of cancer).

I don't know the answer to these questions. I'm just saying that's what I think these studies are trying to address. I sure am glad that they are researching this. Statistically we all have a pretty high chance of being hit with cancer at some point of our life's.

Re:What about treatments that prolong life?

[wisnoskij]

But that is a whole lot different then if she had a 0% chance of survival, but she could be kept alive for 6 months longer in constant severe discomfort and pain in a hospital bed.

Re:What about treatments that prolong life?

[Anonymous Coward]

The report isn't suggesting that you not treat a cancer once discovered. The suggestion is that regular screening does not add value to the outcome and thus questions the value proposition of regular and frequent screening.

Take it to the 'logical conclusion' if you would. If there is a test for a disease (any disease) that could be performed daily, is very low cost (potentially self administrating), benign & 100% effective than no one would doubt the value proposition of doing so. But for many diseases this isn't the case. So "how often and when do you start and how much does it cost" are relevant questions. Heck, let's say a person gets screened for a disease and comes out 100% negative, doesn't mean that the very next day they won't contract the disease so waiting a year for their next screening would not helpful.

(It occurs to me that while pregnancy isn't considered a disease, we have 'over the shelf screening tests' for pregnancy that meet the above criteria very well and thus no one worries about it, and in fact people ask for better tests all the time.)

Obviously, for someone that feels that screening saved their life or the life of a loved one or even just extended it, than no argument against it would be seen as worthwhile.

Re:What about treatments that prolong life?

[trout007]

What scares me the most is all of the people replying to you that think they have the right to decide if your wife's life is worth an extra year or two. The beauty of a free market is that you get to decide if it is worth it. Not to sound crass but would you give up cars, houses, retirements, ect to spend another year with her? I know in my case I would. These people write that a year isn't worth the resources. Who the hell are they to decide? It's like all of these socialists governments that give free healthcare, 1950s technology of course, and then run to a modern country when they get sick. You know because they are important. Any politician promoting universal healthcare should should only get their and their families healthcare at the VA.

Re:What about treatments that prolong life?

[Slashdot Parent]

This has nothing to do with government bureaucrats

Not yet in the US, but it does in the UK.

The reality is treating someone who will die no matter what, if the treatment does not extend life by much is not medically worth it.

In reality, there is rarely that type of clarity that goes into medical decision making. In cancer patients, anyway. It's always looking at the data and seeing which options on the table have the greatest probability of success, and if the first-line treatment for a particular cancer doesn't work, the level of confidence in the probabilities drops like a rock.

By way of example, my wife's cancer has several metastases, most of which have decreased in size in response to chemotherapy (suggesting no further presence of active cancer). However, one metastasis has not decreased in size. The best available medical knowledge states that excising a single metastasis from a stage IV patient is unlikely to cure the cancer. All known metastases must be removed in order to be most confident that the cancer has been removed. However, in my wife's case, removing all remaining metastases would not be possible due to tumor presence on 2 vital organs. Luckily, the one metastasis that has not decreased in size (suggesting presence of active cancer) is located on her spleen, which is not a vital organ.

So now the question is: do you perform a splenectomy, which is a minor laparoscopic procedure, with an expected full recovery from the procedure within 1 month? The best data state that the procedure will be very unlikely to cure the cancer. On the other hand, her cancer has become resistant to all known chemotherapy drugs that are effective against her type of cancer. She will surely die soon if the cancer is not killed or removed. It is known to be that aggressive.

I do not know the answer to this question, and indeed we will discuss this very topic tomorrow with her oncologist. I guess my point here is that it is impossible to make general rules or guidelines because our medical knowledge, while vast, is nowhere near good enough. Doctors with good clinical judgment are needed.

If treatment adds only a month of life, a painful puking near death month, why bother?

No sane person, when presented with that tradeoff, would want to ruin his final days of life with the miserable side effects of useless treatment. On the other hand, such clairvoyance is pretty rare. Assuming that this splenectomy happens and it is ineffective, the remaining treatment options begin to test the "is this really going to be worth it?" question. We're looking at stuff that might cure her cancer, but will definitely cause her a great deal of suffering. It is simply not known how much, if any, extra lifespan she will gain. It may cure her cancer and she may live into old age, or it may just cause the rest of her days to suck complete ass.

So, do you do it, or not? How does anyone even begin to answer that question? I don't think there is any way to make a guideline or rule to use here.

Quality of life is much bigger issue than money.

Not if you are the payer.

I wish your wife well.

Thank you, I appreciate that.

Re:What about treatments that prolong life?

[Slashdot Parent]

You are lucky. My brother's insurance company bureaucrat did the "government bureaucrat's" part in denying his treatment.

You're correct; we are fortunate. Our insurance provider has not given us too much grief over her treatment. I know that that's not to be taken for granted.

Including the line about government, I think, set a lot of people off. As you say, it doesn't matter which payer is doing the denying. A denial from a private insurer is still a denial, although it's much easier to fight a private insurer, in my experience.

Re:What about treatments that prolong life?

[Slashdot Parent]

How was your wife's cancer discovered?

She checked into the local emergency room bleeding out of nearly every orifice of her body. There is no screening for the type of cancer that she has because it is extremely rare.

Actually strictly seen the article doesn't even cover your wife's case.

I agree, and I would even agree that prostate cancer screening does more harm than good. I was really only reacting to a particular part of the summary.

I know of two elderly males that had their prostates removed due to elevated PSA.

I am not an expert on this, but this is slashdot, so no expertise is required. :) Anyhow, I think there are less invasive alternatives to prostate removal now.

I sure am glad that they are researching this. Statistically we all have a pretty high chance of being hit with cancer at some point of our life's.

Me too. Cancer just majorly sucks, and we hardly know anything about it, really.

Re:What about treatments that prolong life?

[Slashdot Parent]

But that is a whole lot different then if she had a 0% chance of survival, but she could be kept alive for 6 months longer in constant severe discomfort and pain in a hospital bed.

Obviously, no sane person would ruin his final days of life suffering the side effects of treatment that he knows will fail. In practice, however, you will probably not know before you make the decision how much longer the treatment will prolong your life or how well you will tolerate the side effects.

Re:What about treatments that prolong life?

[BZ]

> No sane person, when presented with that tradeoff,
> would want to ruin his final days of life with the
> miserable side effects of useless treatment.

There must be a lot of insane people out there, because it is fairly common (at least in the US) to make the decision to treat for themselves or their loved ones in that situation...

Your and your wife's situation is totally different from that. I really hope things work out for you!

Re:What about treatments that prolong life?

[Anonymous Coward]

A couple years ago, my mother had lung cancer that metastasized to her brain. She lived for 8 months. (I took care of her the entire time... she was bedridden most of the time)

She didn't receive any treatment (except pain killers), because it was already stage 4, and they said it was very unlikely to work. So she didn't want to go through it.

During the last 3 weeks, she was in very modest rest home paid for by the state. (she was bedridden, couldn't talk, etc..) The home charged 25,000 per month.

That 3 weeks was about 80% of all of the healthcare expenses for her life (she was pretty healthy (minus the smoking)... she rarely needed to visit a doctor).

The problem with healthcare is that we all think its wonderful to help everyone no matter the cost. Help extend their lives no matter the cost.. "it would be inhumane to put a price on a life". But if we want reasonable healthcare costs, whether through a federal program or not, that's what we need to do. We need to decide what those extra years are worth v the cost of the treatment.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1464043/

Last-year-of-life expenses constituted 22 percent of all medical, 26 percent of Medicare, 18 percent of all non-Medicare expenditures, and 25 percent of Medicaid expenditures.

So here's an article where they are saying that 140,000 people are screened for cancer each year, and out of those, in only 7% (10000) of cases can they do anything to help. So 100/7*$200 (rounded average cost of mammogram) = $2857.

So each case where they could treat the cancer cost $2857 to find.

Is that worth it? Probably yes.

What's my point? This is the type of math we need to do for every treatment.

Re:What about treatments that prolong life?

[Anonymous Coward]

A life of being sick with intensive treatments with a near certainty of death at the end? I'd pass.

Re:What about treatments that prolong life?

[HornWumpus]

Not the original poster.

We should treat whoever can pay for (has paid for) their own health insurance.

There is no free lunch. Robbing someone of a 25% chance of survival to give a deadbeat a 75% chance is no deal. Health care is not a right. Food is not a right. Get over it.

Re:What about treatments that prolong life?

[Slashdot Parent]

There must be a lot of insane people out there, because it is fairly common (at least in the US) to make the decision to treat for themselves or their loved ones in that situation...

Like I said before, it is rarely so clear that a particular cancer treatment will, for instance, "prolong life by 4-6 weeks, but patient will be miserable".

A friend of the family has terminal cancer, and has been fighting it for about 5 years now. She knew from diagnosis that there was no cure, but it can be controlled temporarily with chemotherapy. There are several chemo regimens that are known to be effective, so she just takes one until her cancer builds resistance to it, and then she moves on to the next. Eventually she will exhaust all known regimens and when that happens, she will die of her cancer. She has lived for 5 years with the side effects of chemo, which can suck, but don't make life unlivable. She has good days and she has bad days, and she generally knows which will be which based on the day of her cycle. On the good days, she is active, and on the bad days, she stays home. I'd say it's about 70/30 good to bad day ratio.

This is a far more common situation than the one that you have described, and it is expensive to treat a patient for cancer for years upon years. If it were me, I could live with 30% bad days to have 70% good days, as opposed to having 0 days.

Re:What about treatments that prolong life?

[Slashdot Parent]

A life of being sick with intensive treatments with a near certainty of death at the end? I'd pass.

If you were standing eyeball-to-eyeball with the angel of death, I doubt you'd be so brave. It's one thing to type that into an anonymous Internet forum. It's another thing to do it in real life.

Re:What about treatments that prolong life?

[InsertCleverUsername]

Health care is not a right. Food is not a right. Get over it.

Oh! oh! oh! Can I live in your post-apocalyptic hellscape too? I can't imagine how fun it would be to live in a dystopia where the only form of government is guns and money --and people without one or both get to die miserably in the street like dogs. Can we shoot the poor for sport too? It's not like they have any money to buy human "rights."

Re:What about treatments that prolong life?

[InsertCleverUsername]

The best opinions are those based on facts. An education

Re:What about treatments that prolong life?

[Trepidity]

For some people that's true, but empirically a lot of people do make such choices, when given the option to do so legally. For example, quite a few people have do-not-resuscitate and/or "no life support" orders on file.

Re:What about treatments that prolong life?

[Anonymous Coward]

Thanks for posting. I was getting annoyed at the other comments. I have a 20% chance of survival for 5 yrs, and am almost one year into my 5yrs. My cancer has a less than 40% chance of responding to chemo / radiation, but in retrospective studies, there was an increase in survival of those who went through the treatments (I am on month 10 of chemo now, and plenty of nasty side-effects).

I am probably younger than most of the posters.

To the other posters: Yes, some large insurance corporation could probably save some money by letting folks like me die quickly. Fuck you too.

   

Re:What about treatments that prolong life?

[TxRv]

Nothing to do with government bureaucrats, but everything to do with health insurance corporation bureaucrats and lawyers, which are way worse.

Re:What about treatments that prolong life?

[Slashdot Parent]

For some people that's true, but empirically a lot of people do make such choices, when given the option to do so legally. For example, quite a few people have do-not-resuscitate and/or "no life support" orders on file.

Perhaps you're right. On the other hand, that's still a fairly large step away from facing death, allowing your survival instinct kick in in full force, and still saying, "OK, I am ready to die now." Maybe if you're 90 years old, but my wife is in her 30s.

Don't get me wrong. Over the last year or so, she (and I) have gained a lot of perspective and are beginning to accept the fact that her chances of surviving this are low. The whole family is grateful for the past year and will be grateful for every day, month, and year that she is with us going forward. That's a big change from where we were at the start of this. Where accepting 1 year with gratitude would have felt completely nuts.

Ramble ramble.

Re:What about treatments that prolong life?

[Slashdot Parent]

On the off chance that you're following this, AC, I just wanted to wish you the best. Keep strong. Cherish what time you have been given, and don't stop fighting for the future. It sucks being dealt a shitty hand, but I hope you may still make the most with what you have.

Re:What about treatments that prolong life?

[Slashdot Parent]

Nothing to do with government bureaucrats, but everything to do with health insurance corporation bureaucrats and lawyers, which are way worse.

I've fought the government, and I've fought health insurance companies. I'd take the health insurance companies any day of the week.

You can't fight city hall.

Re:What about treatments that prolong life?

[Anonymous Coward]

None of us would have been very happy if some government bureaucrat had told us that since the cancer was so likely to kill her, they wouldn't bother treating.

Something, which I must note, happened to my mother in Canada. She had to pay out-of-pocket to get operated on in the US because the Canadian Health Care System refused to operate on her. The surgery bought her another two years. Those two years might have been statistically insignificant to the government, but it had an immeasurable impact on her children who were in their teenage years. Those were the most significant years of our lives.

My mother underwent four surgeries over the course of ten years. It was painful and expensive but every year was extremely significant to us.

I am only posting anonymously in order to protect my medical history. I hope you understand.
--
http://www.endcancer.ca/

Re:What about treatments that prolong life?

[Anonymous Coward]

You people are fucking retarded. The bullshit bogeyman that the "gub'mint" faceless bureaucrats will be making decisions on who lives and dies (in their Death Camps) is just that, bullshit.

In the civilised countries (you know, Canada, Australia, New Zealand, pretty much all of Europe) people are treated by their governments and health care professionals on the basis of need and costs don't come into it.

In the USA (the actual real system , where this actually happens RIGHT NOW every day) the decisions are made not by doctors or health professionals, but by Insurance company and HMO drones in Head Office, on who gets treatment, who lives and who dies...based purely on economics, just like paying out on a fucking car insurance claim. The doctors hands are tied if the insurance company comes back with 'Ahhh..sorry...we're not paying for that" and god help you if you are under insured or don't have any at all, or your Daddy doesn't own Wal-Mart.

You are ALREADY living is a society where the Corporates make the decisions on who lives and dies depending on how profitable you are.....or how much you might end up costing them.

One fucking day you idiots might wake the hell up and discover the Workers Paradise over there isn't all it's made out to by by Pravda..oppps...sorry, Fox News.

Re:What about treatments that prolong life?

[sydbarrett74]

Yay. Another Ayn Rand groupie. *rolleyes*

Re:What about treatments that prolong life?

[Anonymous Coward]

Only if the treatment is better than the disease. Screening has much more complex issues. Bottom line is that if we cause more demonstrable harm than demonstrable good, it's not effective. Screening a population for a disease is very different from treating someone with a diagnosis.

Re:What about treatments that prolong life?

[shilly]

I'd start with the babies personally. If they can't pay for their healthcare, let 'em fucking die.

Nobber.

Re:What about treatments that prolong life?

[shilly]

Oh but you can.

For cancer, specifically, and in the UK, specifically, there are plenty of high-cost drugs of dubious cost-benefit that are being prescribed due to public pressure when the money would be better spent on other things. NICE guidelines overturned, etc etc.

Re:What about treatments that prolong life?

[shilly]

The irony of your suggestion is remarkable!

http://www.ncbi.nlm.nih.gov/pubmed/17319805

Re:What about treatments that prolong life?

[shilly]

What makes you think that you could decide in a free market? Cancer treatment is wildly expensive. Unless you're a multimillionaire, you'll run out of money. Then you can't decide any more. Not to point out the bleeding obvious, but that was the whole point of why insurance was invented -- to protect against rare but catastrophic losses by spreading the risk across a larger group. And also bleeding obvious, the minute there's any kind of risk-pooling, someone has to set rules for the risk pool, and it isn't the consumer who gets to do that.

Blame the "cure" as much as the diagnostic

[JoeMerchant]

Some diagnostic tests (breast cancer screening, for example) increase the risk of contracting the disease you are screening for.

In the case of the prostate cancer study, it seems that treatment of detected, but actually benign, tumors was causing more mortality than just living in ignorance of them.

incontinent after radiation for prostate cancer

[Anonymous Coward]

My dad got radiation for prostate cancer and the treatment seems to have been effective at mostly eliminating the cancer. His PSA score is way down now too. But, he now wears Depends because the radiation made him incontinent. He's 74. I suspect his case is typical. If they had done nothing to treat the cancer, he may well have been better off.

Re:incontinent after radiation for prostate cancer

[Anonymous Coward]

My dad got radiation for prostate cancer and the treatment seems to have been effective at mostly eliminating the cancer. His PSA score is way down now too. But, he now wears Depends because the radiation made him incontinent. He's 74. I suspect his case is typical. If they had done nothing to treat the cancer, he may well have been better off.

Well, my dad never did prostrate cancer screening. By the time he found out about it, his prostrate was so large he couldn't urinate and ended up having a catheter inserted. He's 59.

I don't know whether screening is a good idea or not, that really depends on whether early treatment helps, and whether our anecdotes are typical. If most people are completely asymptomatic, my dad just had shitty luck, but it's still better not to get checked. If most people with prostrate cancer caught early just end up with incontinence, but survive otherwise unscathed I think my dad would have preferred that.

Better Tests Are Needed

[Bacon Bits]

People read these articles and too many come away with "we shouldn't be screening for cancer". That's not what it's saying at all. It's saying "we shouldn't rely on our current screening tests". That's the key. Screening isn't a problem. Early detection isn't a problem. Inaccurate screening tests that encourage treatment when none would be necessary is the problem. That's what the US Preventive Services Task Force is trying to say: shitty tests create shitty outcomes.

It's like trying to use just a thermometer to diagnose H1N1 or Ebola. Well, you'd also catch the standard flu, or a head cold, or appendicitis, or a thousand other things that cause a fever. The prostrate screening test just tests for the known prostrate cancer antigen... but it's not very specific to the type of cancer present. That's the problem. Doctors and patients are stuck in the mindset of If (Cancer == True) { CancerTreatment(); }. That said, cancer treatment involves really dangerous and destructive things to the human body. Many cancer patients die from treatment as much as from the disease. They're akin to poisoning the whole body and hoping that you kill the cancerous bits before you kill the patient. This means that that Cancer == True test better damn well be pretty reliable and accurate. It's a reminder of the basis of medical ethics: primum non nocere -- first, do no harm. The data says doctors are doing a lot of harm if 120,000 of 138,000 cases (87%) have unwarranted treatments.

So, again, they're not saying "don't screen". They're saying "don't screen with shitty tests; get better tests, then screen."

It's their decision.

[AdamJS]

Whether the cancer was going to end up harmless or end up killing a person, it's better that they at least know if its existence and have the choice of whether or not they want treatment.

Re:It's their decision.

[trout007]

What fu(&ing country do you live in? In the US we do not own our bodies. My body, if I can even call it mine, is owned by politicians, my neighbors, doctors, and pharmaceutical companies. They all prohibit me from dealing freely with people regarding what I can do with or put in my body.

Re:It's their decision.

[Anonymous Coward]

Whether the cancer was going to end up harmless or end up killing a person, it's better that they at least know if its existence and have the choice of whether or not they want treatment.

Only one problem with that: if you're restricting yourself to non-invasive testing, you don't know if you've got cancer or not.

Let's say that everyone in the USA is screened for pancreatic cancer (a cancer that is generally asymptomatic until you reach the "dead in six weeks" stage). The standard non-invasive test is a blood assay with a 13% false positive rate, so if you give it to everyone in the country, you'll find about 39 million people with pancreatic cancer, of whom 33,000 actually have it (you'll also have missed about 10,000 cases because of the 23% false negative rate).

At this point, you need a more aggressive test. Typically, this is a CT scan to identify potential tumors followed by a biopsy to remove and inspect cells from those potential tumors. Both of these procedures are risky: a CT scan is a major dose of X-rays which increases your cancer risk, while a biopsy carries the normal risks of a surgical procedure: infection, uncontrollable bleeding, tissue damage that doesn't heal properly, and the like.

If the death rate from the aggressive test is higher than about one in a thousand, screening for pancreatic cancer will kill more people than the cancer does. For cancers that are less common, the testing needs to be even safer.

Re:It's their decision.

[Trepidity]

Maybe I'm a weird stats geek, but I wouldn't rather know that unless it actually statistically raises my odds of survival (perhaps weighted by quality of life during the survival). Knowing something that doesn't do me any good, and which will lead to pressure to take action that isn't beneficial? No thanks.

I was tested for prostate cancer recently

[Anonymous Coward]

I was tested for prostate cancer recently as part of a series of tests to check my previous cancer hadn't come back, and my doctor explained the chance of a false result, and the pros and cons of surgery if anything as found. A lot of information to read and I had to give my consent before they'd do the test.

The risk of false positives outweight the risks...

[plcurechax]

The change in policy stems from good mathematics, namely good statistics. Where the number of people who are subjected to a test may suffer from one of two failures,

a) false negative - that is the test fails to detect the presence of a disease and thus incorrectly reports a negative results, and
b) false positive, the test incorrectly reports a positive result, but the disease is not actually present.

The problem is that with a large pool of test population and a small affected sub-population, the misleading results are counter-intuitive, and can end up causing more harm (otherwise healthy individuals undergoing unnecessary biopsies, radiation, and chemotherapy increase mortality rate) to the overall population.

See The dangers of false positives by Dr. Dave Richeson, don't take my word on it.

See no evil?

[erice]

Let's see if I have this right:

When people receive bad news about their health, they often make poor decisions about treatment.
Solution: Stop screening and therefore, there won't be any bad news to report.

What? Unless the testing itself is a hazard, we shouldn't be cutting off a potentially life saving source of information. We should be working on improving the decision making process. If most prostate cancers should not be treated then recognize this and develop an alternative response. Perhaps more extensive tests for those who come up positive. Perhaps more frequent tests. Maybe just wait and see if it has grown by the time next years test rolls around.

Screening != Treatment != Side effects

[ajknott]

The general arguement is that 'screening comes with harms as well as benefits' (from TFA), which is false unless you believe that listening to the heart leads to side effects from open-heart surgery because too many false positive heart diseases or indolent heart conditions are overly treated. The problem lies within understanding the results and the possible outcomes from different treatments. For example, if cancer is found that is possibly slow growing or indolent, then go into a "watchful monitoring" treatment of more frequent and different checks. Because we have great screening systems that will be able to detect disease earlier and earlier, we need to understand that there is a point at which a disease is so early it is not worth treating. But it does not mean we should not look.

In othehr words, because bad actions can be taken as a result of getting the correct diagnosis information, then we need to fix our analysis and recommendation for treatments. Lets not stick our heads in the sand and not even look for the disease.

Re:Screening != Treatment != Side effects

[Anonymous Coward]

Breast screening in particular DOES have the chance of actually causing cancer.

Fallacy?

[GerryHattrick]

Isn't this another instance of the 'Fallacy of the Commons'? Maybe it's true that the cost of full community screening is not matched by the net benefit of all outcomes. But for me, I sure want to pay the cost of anything that might give me more life or comfort. It's clearer if you don't expect 'the community' to pay (or the insurer who mutualises community risks). How does your own money vote? And would that optimise community benefit?

So then let me be mobile

[SuperKendall]

here are already bureaucrats sitting between you and your doctor--the private insurance companies--and you already have limited mobility between providers

So the answer is to REDUCE mobility even further by having essentially just one provider? 99% of us have no preexisting conditions that would prevent us from moving, but plenty of regulations in the way like the ones barring me from purchasing insurance across state lines.

I have never understood the course of philosophy that thinks you can make something better by distilling the essence of what is wrong and making it 1000x more potent a concern.

If you are the one...

[Anonymous Coward]

Been there. Repeated medium-high PSA test results. Got a biopsy. Not painful, no harm done. If the samples show nothing, you stop here. Or you have some "core samples" that show some cancer cells in which case you get something called a Gleason score which is a measure of the cancer's aggressiveness. The combination of how many of the samples are cancer and how aggressive the cancer is determines if you should do something about it....together with your age and overall health.

There are several treatments and surgery is only one. In my case I chose radiation and had radioactive seeds implanted followed by beam radiation for 35 sessions. My doctor was able to give me a probability of cure before we started the treatments using the same criteria that the best surgical team uses.

3 years later I have tested cancer free and have no symptoms that bother me from the treatment. Expensive, yes. 20 years ago they couldn't detect the cancer and by the time they saw the patient, the cancer had spread to other parts of the body...a horrible way to die. Now they can treat the problem. Do research and choose the best doctors as the experience of the doctors is as important as which treatment you choose. Go to someone who keeps statistics on how they treat their patients and what the results are. In my case, I am tested every 6 months for life and contribute those results to the team's data base.

Glad I had the tests.

If you have a family history of prostate cancer or if you are black (which increases the probability), start getting tested at age 40.

Re:If you are the one...

[OhHellWithIt]

I'll second that. It's bad odds for the majority of the population who don't contract prostate cancer, but for those of us who have had it and have caught it early due to the PSA, it's a good deal. I've had my winning lottery ticket, thank you!

Hard to be objective here

[gestalt_n_pepper]

My colonoscopy at 53 (3 years late) detected the start of malignant cancer. My gastro guy described my situation as "having *just* missed being hit by the bus. Without treatment, I'd have been dead in less than 5 years, give or take a year.

So, better safe than sorry has become my new motto. The social and economic cost, in the scheme of things, is trivial (That is, if you have health insurance. If you don't, unofficial government policy is the usual de facto homicide applied to the poor).

Re:Hard to be objective here

[hipp5]

The problem here is that the plural of "anecdote" is not "data". What the article is saying is that although you may have been saved by the test, ten* other people who took the test got a false positive and had potentially dangerous treatments that they didn't need. So yes, from your perspective the tests look great. But when you take a step back and look at the numbers objectively we discover that some tests are doing more harm than good.

*This is a number I pulled out of my ass to illustrate the point. I'm too lazy now to go back and RTFA for the real number, but the point is the same.

Re:Hard to be objective here

[Anonymous Coward]

So, better safe than sorry has become my new motto. The social and economic cost, in the scheme of things, is trivial.

That's great news for you. But believe it or not, the people who are studying this are well aware of the unpleasantness of dying of cancer. It's not as if they simply don't care - they have arguments that deserve legitimate consideration, not just dismissal with anecdotes.

For example, the risk of colon cancer increases with age - very rare indeed in 30 year olds, not very rare in 80 year olds. However, there are other things to bear in mind. Colonoscopies have risks of perforating the bowel and causing deaths from septicemia, particularly in older patients. Older patients may also not be able to withstand invasive surgery and chemotherapy if a tumor is detected, particularly because they may have other problems such as diabetes or heart disease. Some tumors may not respond to treatment anyway, and some may spread so slowly that many such patients are likely to die from other factors before the tumor would have killed them. Can you tell in a particular patient whether that would have been the case? No, but you can do meaningful statistical work on population groups. There is also the consideration that colonoscopies are not that pleasant, and that treatment for tumors that are false positives or that would not have been lethal is very unpleasant and unproductive.

Overall this suggests that colonoscopies are only likely to be a net positive for the general population in a certain age band - hence the guidelines don't promote them to most 30 year olds or 90 year olds, even though they would detect a non-zero number of cancers in those groups. Other tests have bigger problems - PSA tests for prostate cancer have high false positive rates for example and some countries have practically dropped their use for the general population.

"Better safe than sorry" is not a practical way of living - it would lead to you never taking a car journey for a leisure activity, never taking a foreign holiday, never meeting new people. Balancing risks and benefits is not something that can be avoided, even when the stakes are as high as your life. The costs of over-screening and unnecessary treatment really aren't "trivial" when you take the time to measure them.

Re:Hard to be objective here

[Trepidity]

To be more specific, some of those other people died as a result of the unnecessary chemo/radiation; they didn't just experience some mild worry.

There's no clear "better safe than sorry" decision here, because you can die with either choice. The goal is to collect enough data so that we can recommend screening policies that result in the statistically best outcomes.

Re:Hard to be objective here

[Bacon Bits]

The issue here -- even if your case were typical -- is that a colonoscopy is probably much more accurate and reliable for identifying treatable terminal cancers than the screening test for prostrate cancer. Again, the argument isn't "don't screen" it's "screening sucks if the tests suck". The screening tests for many cancers currently suck.

How would you have felt if you found out after treatment that your cancer would have killed you in about 150 years instead of 5? How would your family have felt if you had died due to complications of treatment for a cancer that was never going to impact your life? Wouldn't you ask "why couldn't you determine this beforehand?" That's the point here.

Re:Hard to be objective here

[Anonymous Coward]

Colonoscopies are very good for detecting colon cancer, and for removing polyps which could be cancerous. The down side is that they're expensive, requiring a lot of trained staff and mission specific equipment. Financially it's better for insurance companies to only cover the cancer treatment rather than the screening.

Re:Hard to be objective here

[Anonymous Coward]

Could you give details about people who have died from chemo and didn't have colon cancer?

At least then you get a choice

[rsilvergun]

without the test you never have the choice between treating and not treating. This sounds like a study conducted by wealthy @$$es to discourage middle class people from seeking medical treatment. I don't see Senators turning down treatment. What was that qoute? "In America, If you get sick better die quick!".

Re:At least then you get a choice

[Belial6]

Maybe not Senators, but you do sometimes see extremely wealthy CEOs of international corporations turning down treatment.

Re:At least then you get a choice

[Anonymous Coward]

Exactly.

Factors affecting the efficacy of a medical test

[thomas.craig]

The efficacy of a medical test is determined by three numbers.
1) The real incidence rate - what percent of the population (after the fact) actually has the condition.
2) The false positive rate.
3) The false negative rate.

The problem with the PSA test is that while the real incidence rate is relatively high, the false positive and false negative rates are extremely high.

1) The incidence rate varies with age and ethnicity. According to the CDC (and wikipedia, for what it's worth), (http://www.cdc.gov/cancer/prostate/statistics/race.htm), the age-averaged rate is 100 per 100,000 for asians, 160 per 100,000 for white and 250 per 100,000 for black men. But they don't recommend the test for men under 45. And age really is the determining factor. (http://seer.cancer.gov/publications/prostate/inc_mort.pdf). So, let's assume an incidence rate of 10% for 55 year old men for purposes of this exercise. - for 75 year old men, it's probably closer to 90%, for 20 year old men, essentially zero.

2) According to the National Cancer Institute (http://www.cancer.gov/cancertopics/factsheet/detection/PSA), the false positive rate is 65-75%. Giving the test the best chance, I'll take the lower limit of 65%.

3) I haven't found a definitive source for the false negative rate, but wikipedia cites a paper giving a 25% false negative rate. Let's give it the benefit of the doubt and call it 20%.

Source...
^ Thompson IM, Pauler DK, Goodman PJ, Tangen CM, Lucia MS, Parnes HL, Minasian LM, Ford LG, Lippman SM, Crawford ED, Crowley JJ, Coltman CA (May 2004). "Prevalence of prostate cancer among men with a prostate-specific antigen level or 4.0 ng per milliliter". N. Engl. J. Med. 350 (22): 2239–46)

So - give a population of 1 million men a PSA test and here's what you get.

100,000 men have prostate cancer
900,000 do not have prostate cancer.

Of the 100,000 men who DO have prostate cancer...
a) 20,000 test negative (a problem, but what are you going to do? This was my father's case (see below))
b) 80,000 test positive (okay, but do you need treatment? Odds are you'll die of something else first (see below))

Of the 900,000 who do NOT have prostate cancer.
c) 585,000 test positive (the real problem)
d) 315000 test negative. (good on yer.)

The real problem is that honking huge false positive rate. If you test positive, there's still less than a 50% chance that you actually have prostate cancer, and even if you do, it's probably not going to make a damn bit of difference over the course of your life, but it's still very very scary and you get a biopsy or have radiation treatment and risk impotence and/or incontinence and possibly seriously reduce your quantity of life for the rest of your life for no good reason. It's even more complicated by the fact that the PSA level goes up naturally as you age. If your level goes from 4 to 10 over 10 years, what does it mean? Flip a coin.

That said, given that my father, both his brothers and my paternal grandfather all died from prostate cancer (between the ages of 90 and 94, I'll grant you - that's the thing. The vast majority of men will die of something else before the prostate cancer kills them), my doctor recommends continuing to take the test every 5 years.

Healthcare rationing being rationalized

[Anonymous Coward]

This is nothing but trying to whip up 'consensus' that testing is not needed. This will save the single payer hellcare system big bucks.

Just more proof that docs don't know it all.

[Anonymous Coward]

My partner has Leukemia, her oncologist told her that he expected her to have two weeks left - that was 9 years ago. The radiation accumulated from the treatments has caused at least as many health issues as the luke itself.

While her tests aren't stable or good enough for them to say she is in remission the most treatment she can have these days is heavy doses of strong antibiotics when she goes downhill.

The best way to beat a life threatening disease is to believe you can win. It may be cliched an all but you can either lay down and let it beat you or stand tall and win the fight.

"regression" != "cure"

[Anonymous Coward]

in the U.S. and the U.K. it is still illegal to claim that cancer can be cured. i find it ridiculous that it has to be called "regression"... ah well...

it's hopeless, everyone is just too stupid

[spage]

Doesn't matter what actual studies find. ABC News will film someone who'll definitively state "The only reason I'm alive today is because the prostate/breast/colorectal/whatever screening caught my cancer. I just can't understand those doctors wanting to stop the test that saved my life!" Intercut the scientifically illiterate telegenic reporter nodding sympathetically. Then go back to Diane Sawyer in the studio giving the network's medical expert 37 seconds to explain how on earth *NOT* finding cancers is a good idea. And he'll just say "Uh, it's complicated... go talk to your doctor."

This stuff is just too hard for people, they don't have the math skills for it. But that doesn't prevent them from "knowing" what's right.

the solution - research?

[vmaldia]

So what's the solution? I think its to research more so you can come up with a reliable, cheap way to differentiate between all the 4 below. preferably with minimal side effects "1. You find a cancer that will eventually kill you AND that particular cancer has a treatment that works better when started earlier. (True Positive result) 2. You don't find a cancer that you don't have. (True Negative result) 3. You find a cancer or something that looks like a cancer however it will grow so slowly or regress so it won't cause any harm, but then you don't really know which is which so you elect to be treated for same with some morbidity or mortality. (False Positive result) 4. You don't find the cancer that existed and goes off to knock you off just before you design the next iPad killer. (False negative result)." properly Identifying which tumors are slow growing and which patients are too late would solve a lot of problems. of course this is easier said than done

OMG: Obamacare

[uninformedLuddite]

Death panels. Liberal jobby chasers

Big industries spin out of control

[Rambo Tribble]

Whether it is the defense industry, the corrections industry or the healthcare industry big money and the promise of lucre cause the industry to bloat well past any benefit to society. Basic to this process is the incessant selling of FUD: "You're going to be enslaved by communists." "You're going to be victimized by criminals." "You're going to die of cancer". And so on ...

Re:Big industries spin out of control

[geoffrobinson]

You just pointed out three industries with close ties and associations with government.

Re:Big industries spin out of control

[Rambo Tribble]

Any industry sufficiently large to bankroll political campaigns, or pay bribes, will likely have close associations with government and, most often, government spending.

It might be worth noting that the American Revolutionary War is often credited with changing things in ways that it really didn't. The Constitutional Convention was dominated by moneyed interests, interests more concerned with protecting their assets than living up to the concept of "liberty and justice for all". That is why the majority of delegates were firmly opposed to the Bill of Rights. It was this corrupting influence that caused Jefferson and Adams to walk out. The so-called "class war" dates to independence; it is not a new thing.

To get a better idea of the dynamic of the times, look up "Shays' Rebellion" on Wikipedia. The popularity of the rebellion created a double-edged sword; the wealthy wanted the security a strong federal government could provide against such uprisings, while the popularity of the cause forced the inclusion of the Bill of Rights. If you read the Wikipedia article, it's worth noting Jefferson's take. He might be said to be the first populist. Another illustrative account can be found on the "Whiskey Rebellion" page. Note the accusations regarding the tilting of the deck toward large distillers.

As for the scourge of the Nazis, it should be recognized that most German industries were never truly de-Nazified. And while it seems to be reasonably well known that IBM profited from the licensing of Hollerith machines to the Nazis, it is less well known that many other American firms profited from German industry during the war. GM, for instance, was paid profits even during the war, on Opel.

Re:Big industries spin out of control

[geoffrobinson]

If you want money out of politics, get the politics out of money.