Leave your prostate alone

Yet more evidence that way to many men are getting unneeded (and often quite harmful!) surgery for prostate cancer:

A new study shows that prostate cancer surgery, which often leaves men impotent or incontinent, does not appear to save the lives of men with early-stage disease, who account for most cases, and many of these men would do just as well to choose no treatment at all.

The findings were based on the largest-ever clinical trial comparing surgical removal of the prostate with a strategy known as “watchful waiting.” They add to growing concerns that prostate cancer detection and treatment efforts over the past 25 years, particularly in the United States, have been woefully misguided, rendering millions of men impotent, incontinent and saddled with fear about a disease that was unlikely ever to kill them in the first place. About 100,000 to 120,000 radical prostatectomy surgeries are performed in the United States each year.

“I think this is game-changing,” said Dr. Leonard Marks, a professor of urology at the University of California, Los Angeles, who was not involved in the study. “What this study does is call attention to the fact that there are a lot of prostate cancers that are diagnosed today that are not dangerous.”

Obviously, in some cases you are saving lives, but more often than not, you are just leaving men saddled with really unpleasant conditions for no gain.   Surgeons want to cut (yes, I realize this is a simplification, but it does speak to a broader truth) and many, many people are not comfortable with the idea of not treating their cancer.  It’s a bad combination.

Prostate cancer death panel

Really interesting story in the Post yesterday about Medicare considering whether to continue reimbursing for a Prostate Cancer treatment that costs $93,000 to extend life an average of 4 months (from an average of 21 months to 25).  That strikes me (and I would think most people) as a horrible waste of money.   Of course, one might feel different if this was you or a loved one, but the truth is the resources we have to spend on health care are not unlimited (though we certainly act like they are).  One of the reasons Medicare is busting our budget is because it does cover hugely expensive treatments that provide only the most modest increase in life span.   If we ever hope to control medical costs in this country, it means that we need to start taking steps to not reimburse $100,000+ treatments that result in amazingly marginal increases in life span (there’s many that are a lot worse than this).

Despite the protests of the pharmaceuticals, I have a feeling that if Medicare stopped reimbursing, they’d find a way for it to still be profitable for them at dramatically less money.  Here’s the part that resonated with me:

“To charge $90,000 for four months, which comes out to $270,00 for a year of life, I think that’s too expensive,” said Tito Fojo of the National Cancer Institute. “A lot of people will say, ‘It’s my $100,000, and it’s my four months.’ Absolutely: A day is worth $1 million to some people. Unfortunately, we can’t afford it as a society.”

Others agreed, especially given the modest benefit.

“I’d like to think cost doesn’t need to come up when it’s a slam dunk,” said H. Gilbert Welch of the Dartmouth Institute for Health Policy and Clinical Practice. “But when it’s a close call like this, it certainly has to be a factor. That’s $100,000 Medicare can’t spend elsewhere.”

Either you are going to draw some lines based on price, or your not.  If your not willing to, we are quite simply going to bankrupt this county on health care spending.   And, if we are going to draw some lines, this one seems pretty good to me.

 

 

Who gets the money vs. who needs it

Love this infographic via Vox:

donating v death

Wow.  Would be nice to put some of that breast cancer and prostate cancer money (let’s be honest, cancer simply scares people disproportionately) into heart disease, COPD, and diabetes.

Mammograms and the c word

Okay, maybe you’ve had enough of the topic, but I think 1) the ideological commitment to universal mammogram despite evidence and 2) the treatment of any disease labeled “cancer” no matter it’s likelihood of actually leading to mortality, are emblematic of so much of what is wrong with how we approach medical care in this country.  Best piece I’ve read on the matter is from Christie Aschwanden in Slate.

The Rosenbaum commentary explores a phenomenon that Cass Sunstein dubbed “misfearing”—our human nature to fear instinctively, rather than factually. Rosenbaum’s patient’s first answer is correct—heart disease kills more women than all cancers combined, yet breast cancer seems to invoke far more fear among most women. “What is it about being at risk for heart disease that is emotionally dissonant for women?” Rosenbaum asks. “Might we view heart disease as the consequence of having done something bad, whereas to get breast cancer is to have something bad happen to you?”

I don’t know the answer to this question, but I suspect that Rosenbaum is onto something. Studies show that women—and doctors—grossly overestimate their risk of developing breast cancer and dying from it. One study published in the Journal of the National Cancer Institute found that women in their 40s overestimated, by a factor of 20, their risk of dying from breast cancer during the next decade. I have to think that the media is partly to blame…

 The way to prevent such a fate [an early death from breast cancer], most of these stories will tell you, is obvious—screen early and often.

This solution is the only reasonable option if you think of breast cancer as a relentlessly progressive disease that will inevitably kill you if you don’t remove it in time. That story about breast cancer—I call it the “relentless progression” model—has truthiness on its side. It makes common sense and offers a measure of comfort: Every cancer can be cured if you just catch it in time.

There’s just one problem, as I’ve written herenumeroustimesbefore—research has shown that the relentless progression model is wrong. Despite the one-size-fits-all name, breast cancer is not a single disease, and as the science of tumor biology has advanced, researchers have come to understand that not every breast-cancer cell is destined to become one of the life-threatening varieties. It’s only when cancer spreads to other parts of the body—a process called metastasis—that it becomes deadly, and it’s now clear that not every breast cancer is fated to leave the breast. If you detect an indolent cancer early, there’s no life to save.

Now, breast cancer is obviously much more lethal than prostate cancer and it certainly strikes many more young women than prostate cancer strikes young men, but there’s little doubt that both of these diseases are over-treated and thousands upon thousands are submitted to misery-inducing treatment they didn’t really need because people have a hard time thinking rationally about “cancer.”

The BMJ study published this week adds another large mass of evidence to an already rather large pile suggesting that most of what mammography has done is turn healthy people into sick but grateful cancer survivors. The Canadian study followed nearly 90,000 women across several decades and found that those who received screening mammograms were no less likely to die of breast cancer than the women in the study randomly assigned to skip the tests, but they were prone to getting treated for breast cancers that would have never harmed them. (The problem, of course, is that we can’t yet distinguish the bad ones from the harmless ones, so once a cancer is detected, we must assume it’s the worst kind, lest we undertreat it.)

The BMJ study calculated that 22 percent—more than 1 in 5—breast cancers diagnosed by a screening mammogram represented an overdiagnosis. These were breast cancers that did not need treatment, and the women who received these diagnoses needlessly underwent treatments that could damage their hearts, spur endometrial cancer, or cause long-lasting pain and swelling.

Alright, I’ve quoted a lot, but I think this paragraph really sums it up great:

No one wants to get diagnosed with cancer. You only benefit from a cancer diagnosis if that cancer is destined to kill you and the diagnosis allows you to treat it in a way that prevents you from getting sick and dying. And that’s where things get complicated, because treatment for cancer makes most people feel pretty lousy. It disrupts their lives in a major way. Even a relatively early stage breast cancer can cost you your hair, part or even all of your breast or breasts, and months of treatments that make you feel tired and sick. These treatments are totally worth it if it means that you avoid dying from the cancer. But if they’re aimed at curing a cancer that was never going to become deadly, then what early diagnosis has actually done is made a healthy person sick.

In no way do I want to be glib or suggest this is a simple issue.  But the evidence on the matter is pretty clear.  And that’s what we should be following.  Yeah, it’s great to be a breast cancer “survivor”but if all you’ve really “survived” is months of misery at the hands of a treatment that didn’t actually save your life, what have we accomplished?

Too many mammograms?

I’ve written plenty about our excess of prostate cancer screening, but I find the issue of mammograms even more fascinating (and I’ve written about a few times, too).  Sadly, because unlike prostate cancer, which is rarely lethal, breast cancer sadly does strike down thousands of relatively young women in the prime of their lives every year.  But, does increased mammogram screening actually do anything to prevent this?  Best answer says no.  Nice summary by Jon Cohn of a really important study new study:

On Wednesday, the British Medical Journal published one of the largest, most rigorous studies of mammography to date. If that study is right, the experts on USPSTF deserve some kind of apology.

The study followed almost 90,000 women (that’s a lot of people) over the course of 25 years (that’s a long time). And it was as close to a perfectly scientific study as you’ll find in this field. Researchers assigned women into two groups randomly. Women in one group got regular mammograms starting at 40. Women in the other group got only physical exams. Mammograms can pick up growths before it’s possible to feel them, so it was a good test of whether detecting those small growths translates to significantly more women surviving breast cancer…

The answer, according to the researchers, is a pretty definitive “no.” In fact, the researchers found, the primary consequence of such widespread screening was over-diagnosis, which led to procedures and treatments that were uncomfortable and costly and, occasionally, harmful. 

Cohn than quotes from this Austin Carroll post on the topic:

Of the 44,925 women in the mammogram group, 500 died of breast cancer. Of the 44,910 in the no mammogram group, 505 died of breast cancer. This was not a significant difference. There wasn’t a significant difference if you looked at only older women (50-59) or younger women (40-49). There wasn’t a difference if you lengthened the screening period to seven years.

Mammograms did not affect mortality at all.

However, they did affect diagnosis. During the screening period, 666 cases of cancer were diagnosed in the mammography group versus 524 in the no mammography group. This meant an excess of 143 breast cancers were diagnosed with screening. Fifteen years later, the excess settled in at 106 cases of cancer.

More than 20% of the cancers detected by mammography were over-diagnosed. This means that mammography over-diagnosed one case of breast cancer for every 424 women screened with mammography. Do you know how many women we screen a year here?

This study is going to make a whole lot of people upset. It’s a large, well designed randomized control trial with a really long follow-up period. The people in the mammogram groups actually complied with screening in surprisingly high numbers. It’s hard to find fault with much of this. The data make a really good case that universal screening with mammograms does almost no good, and likely does harm.  [emphasis mine]

Well, this should settle things– right?  As if.  Back to Cohn:

As Ezekiel Emanuel, the oncologist and former Obama Administration advisor, explained to the New Republic, studies like this are a “Rorschach test” for researchers. While people who tend to be skeptical of medical intervention will see evidence that we screen too much, people who tend err on the side of early, aggressive action will find flaws with the study. Among other things, they will point out, the study is based on screenings that took place 25 years ago—when the technology itself was less sophisticated.

“There will never be a truly definitive mammogram study,” says Emanuel, who was longtime head of the National Institutes of Health Bioethics Department and is now a vice provost at the University of Pennsylvania. “You’re in this circle where you will never resolve the issue. You need a long timeline to get the best results, but in that time span the technology always improves—and people will always say, well, this is based on old technology so it’s not so relevant anymore.”

This may be a Rorschach test but this study truly makes it hard to argue that there’s evidence for mammograms providing a net benefit.  Unlike the studies that find in their favor, this was a randomized, controlled trial– the gold standard.  Of course, doctors being doctors, I don’t actually expect anything to change any time soon, but I’m definitely not encouraging my wife to get a mammogram (though, of course that’s her call).  That said, it’s also important to note that the non-mammogram group had annual breast exams.  That’s important and should not be ignored.  It’s just the the results suggest there’s no mammogram benefit above and beyond the breast exam.  

Death by accident and mendacious health care claims

Avik Roy abuses the data (if you torture the data enough, it will confess) to argue that the US really does have a great health care system and that Obamacare will ruin it.

First, though, this chart is just plain fascinating.  If you factor out fatal accidents, the US relative life expectancy improves a bunch.  I would love to know more about why Americans are more prone to fatal accidents.

But, or course, no serious person uses life expectancy to judge health care in the first place.  Roy admits as much, but then lies horribly:

If you really want to measure health outcomes, the best way to do it is at the point of medical intervention. If you have a heart attack, how long do you live in the U.S. vs. another country? If you’re diagnosed with breast cancer? In 2008, a group of investigators conducted a worldwide study of cancer survival rates, called CONCORD. They looked at 5-year survival rates for breast cancer, colon and rectal cancer, and prostate cancer. I compiled their data for the U.S., Canada, Australia, Japan, and western Europe. Guess who came out number one?

[I didn't copy the chart in the middle]

U-S-A! U-S-A!

This is absurd.  No serious scholar of health policy would argue: “If you really want to measure health outcomes, the best way to do it is at the point of medical intervention.”  Half the damn problem with American health care is that people who need medical intervention never get it!!  Rather, the actual best way to measure health outcomes is mortality amenable to health care.  And guess what, here the US is not so great:

The statistic known as “mortality amenable to health care” or “amenable mortality” measures deaths from certain causes before age 75 that are potentially preventable with timely and effective health care. Researchers have used it to assess the performance of health systems of industrialized nations and to track changes over time. Previous studies have shown that the U.S. has failed to keep pace with rates of decline in amenable mortality in other countries. As of 2002–2003, the U.S. fell to last place out of 19 industrialized countries.

Best health care in the world?  Only for the hopeless blinded and hopelessly dishonest (I’m putting Roy in the last category).

Did I just put my health at risk?

So, as mentioned, in not the most astute bit of scheduling, I had a physical this morning on the heels of a three (really four) day weekend.  And man oh man did I have a pile of emails to get through this afternoon.  Finally a few minutes to blog…

And what I cannot resist on this day of my annual checkup (though, not quite annual in my case) is this recent Brian Palmer story in Slate that argues going to the doctor when you are not sick does more harm than good:

here are two kinds of arguments against the adult annual health checkup. The first has to do with the health care system overall, and the second has to do with you personally.

Annual checkups account for more than 8 percent of doctor visits and cost the health care system $8 billion annually—more than the total health care spending of several states. Each visit takes around 23 minutes, which means doctors in the United States spend approximately 17 million hours each year running their stethoscopes over 45 million completely healthy people.

It’s important to separate preventive care from annual checkups. Only one-half of annual checkups actually include a preventive health procedure such as a mammogram, cholesterol testing, or a check for prostate cancer. (Annual gynecological visits are excluded from these numbers, although the evidence supporting those is not particularly overwhelming either.) More importantly, only 20 percent of the preventive health services provided in the United States are delivered at annual checkups…

Many primary-care doctors order totally unnecessary procedures during annual exams, squandering patients’ time and our health care dollars. Perhaps they just want to make patients feel like they’re doing something. Here’s where this stops being about the efficiency of the health care system and starts being about you: unnecessary screenings can be hazardous to your health.

People have a hard time viewing screenings as dangerous. Take, for example, the “hands off my mammogram” uprising that followed a 2009 government recommendation that mammograms be started later in life and conducted less frequently. Reactions of this kind appear to be based on two misunderstandings. First, many people overestimate the accuracy of screening exams. The false positive rate for a single screening exam is usually low, but when you take them year after year, it becomes very likely that a healthy patient will receive a false positive. A 2009 study showed that, for many cancer screening tests, a patient who undergoes 14 screenings has more than a 50 percent chance of a false positive…

There’s also the risk of unnecessarily “medical-izing” minor illness. People who go for annual checkups typically report symptoms that they would have otherwise ignored. In some cases, that’s a good thing—some patients minimize their symptoms and ignore the warning signs of serious illness. Most of the time, however, it forces the physician to investigate and treat a problem that would have gone away on its own.

Okay, so my report.  Well, I did get a cholesterol screen (no results yet).  Hooray, “preventative medicine.”  I also had a nice discussion with my doctor about the folly of PSA tests.   Got a prescription for some nasty plantar’s warts on my foot (TMI?), Over-medicalizing a minor problem?  Maybe, but they’ve been there over five years– definitely not going away on their own.  And, hey my propecia prescription requires I see a doctor every now and then (no shame, it’s no secret that my hair is pretty damn thin on top and that propecia is the difference between me not having a nasty sunburn this past weekend).  We also had a nice talk about my ongoing sore tricep (ever since I threw a boomerang toy about 100 times on Memorial day) and how getting PT at this point would be premature.

Anyway, so there you go.  I’d like to think given my lack of unnecessary screenings, Palmer would not be too unhappy with me.  Of course, your typical medical consumer does not blog about PSA tests and look up articles in PubMed.

The c word

Interesting article in the NYT a couple weeks ago about how doctors are looking to redefine when we actually use the word “cancer.”  This sounds like a great idea to me.  I think it is fairly safe to say that once many people hear the word “cancer” all ability for rational weighing off possible health outcomes goes out the window (i.e., the huge over-treatment of Prostate cancer).  To wit:

A group of experts advising the nation’s premier cancer research institution has recommended changing the definition of cancer and eliminating the word from some common diagnoses as part of sweeping changes in the nation’s approach to cancer detection and treatment.

The recommendations, from a working group of the National Cancer Institutewere published on Monday in The Journal of the American Medical Association. They say, for instance, that some premalignant conditions, like one that affects the breast called ductal carcinoma in situ, which many doctors agree is not cancer, should be renamed to exclude the word carcinoma so that patients are less frightened and less likely to seek what may be unneeded and potentially harmful treatments that can include the surgical removal of the breast.

The group, which includes some of the top scientists in cancer research, also suggested that many lesions detected during breast, prostate, thyroid, lung and other cancer screenings should not be called cancer at all but should instead be reclassified as IDLE conditions, which stands for “indolent lesions of epithelial origin.” …

The concern, however, is that since doctors do not yet have a clear way to tell the difference between benign or slow-growing tumors and aggressive diseases with many of these conditions, they treat everything as if it might become aggressive. As a result, doctors are finding and treating scores of seemingly precancerous lesions and early-stage cancers — like ductal carcinoma in situ, a condition called Barrett’s esophagus, small thyroid tumors and early prostate cancer. But even after aggressively treating those conditions for years, there has not been a commensurate reduction in invasive cancer, suggesting that overdiagnosis and overtreatment are occurring on a large scale.

Now, nobody’s about to start calling lung cancer or brain cancer something else.   But it’s also pretty clear that “cancer” covers an array of vastly different diseases and that, in some cases, it probably does more harm than good to use the word cancer.

Stop taking a multi-vitamin?

So, when I was a kid, my mom was way convinced by Linus Pauling of the importance of large doses of Vitamin C– especially for fighting off colds.  Turns out they were both wrong.  That said, given my poor diet for most of my childhood, I truly think I might have gotten scurvy if not for the vitamin C supplementation.   At some point as a young adult, I realized that I was surely missing plenty more nutrients due to my picky eating and started taking a daily multivitamin, which I’ve been doing for at least 20 years or so.

Turns out, I may be increasing risks to my health as a result.  At minimum, there’s basically no evidence that multi-vitamins lead to improved health.  Paul Offit summarized the evidence in the Atlantic:

Studies have shown that people who eat more fruits and vegetables have a lower incidence of cancer and heart disease and live longer. The logic is obvious: if fruits and vegetables contain antioxidants — and people who eat lots of fruits and vegetables are healthier — then people who take supplemental antioxidants should also be healthier.

In fact, they’re less healthy.

Offit then provides brief summaries of about a dozen or so studies– here’s two particularly compelling ones:

In 2007, researchers from the National Cancer Institute examined 11,000 men who did or didn’t take multivitamins. Those who took multivitamins were twice as likely to die from advanced prostate cancer.

In 2008, a review of all existing studies involving more than 230,000 people who did or did not receive supplemental antioxidants found that vitamins increased the risk of cancer and heart disease.

So, what’s going on?  Scientists aren’t sure, but here’s the main idea:

How could this be? Given that free radicals clearly damage cells — and given that people who eat diets rich in substances that neutralize free radicals are healthier — why did studies of supplemental antioxidants show they were harmful? The most likely explanation is that free radicals aren’t as evil as advertised. Although it’s clear that free radicals can damage DNA and disrupt cell membranes, that’s not always a bad thing. People need free radicals to kill bacteria and eliminate new cancer cells. But when people take large doses of antioxidants, the balance between free radical production and destruction might tip too much in one direction, causing an unnatural state in which the immune system is less able to kill harmful invaders. Researchers have called this “the antioxidant paradox.” Whatever the reason, the data are clear: high doses of vitamins and supplements increase the risk of heart disease and cancer; for this reason, not a single national or international organization responsible for the public’s health recommends them.

At this point, I think I’ll finish my current bottle of Target multi-vitamins, but then I’m done.  Also, I eat way healthier than I used to and am not so worried about meeting basic nutritional needs.  I used to have almost now fruits and vegetables, but now I have pretty much 5-6 servings a day (yay for me).  At least for the time being, though, I’m going to keep the kids on the multi-vitamin.  Yes, I know I need to try harder to get them to eat healthy, but until we make more progress there I think they need the multis just to meet basic dietary needs.

Anyway, as much as part of me wants to keep taking the vitamins, I very much consider myself an “evidence-based person” and I just cannot deny the weight of the evidence on this.

US Health Care: worse than you think

Nice post from Aaron Carroll yesterday on a study pointing out just how sorry US health care is.  Here’s the nickel summary:

I’m a health services researcher, and I’m obsessed with outcomes. One of the first major projects of this blog was a two-week series on quality in the US health care system. I’ve written numerous times about what kills us. This study specifically looked at the burden of disease, injuries, and risk factors in the US versus other countries. The methods are amazingly detailed.

So how did we do compared to other countries? Not well. Between 1990 and 2010, among the 34 countries in the OECD, the US dropped from 18th to 27th in age-standardized death rate. The US dropped from 23rd to 28th for age-standardized years of life lost. It dropped from 20th to 27th in life expectancy at birth. It dropped from 14th to 26th for healthy life expectancy. The only bit of good news was that the US only dropped from 5th to 6th in years lived with disability.

Anybody who says we have the best health care in the world is absolutely, shamelessly, clueless on the matter.  Anyway, I found his take at the end quite interesting:

What we have here is a prioritization issue. We spend a lot of time worrying about colon cancer. It’s ranked 11th in 2010. We spend a lot of time worrying about breast cancer. We have walks, and ribbons, and whole months dedicated to it. It’s ranked 13th. Prostate Cancer? Men are obsessed with it. It’s ranked 27th. But more years of life are lost to lung cancer than to prostate cancer, colon cancer, and breast cancer combined. Ischemic heart disease causes four times as many years of life to be lost each year as prostate cancer, colon cancer, and breast cancer combined. Stroke is 3rd. COPD is 4th. Traffic accidents are 5th. Suicide is 6th. None of these things get the national attention, or resources, that they deserve.

We could have the best health care system in the world. We’ve got the money and the necessary pieces to get really, really good outcomes. But we need to be much smarter about it if we’re going to do so.

Indeed.  Our health care “system” is just massively, massively inefficient.  And there’s no evidence whatsoever that greater reliance on the marketplace will make it more so.

On cancer “survivors”

Not to belittle for a moment anybody who’s had cancer and successfully gone through treatment, but the seeming overuse of the term “survivor” has always bothered me.  The other day I was watching a college basketball game and the announcers mentioned all the men they knew that were prostate cancer “survivors.”  Now, as I’ve written about many times, whether you have treatment or not, the substantial majority of men with a prostate cancer diagnosis would not die of the disease even if they received no treatment.  Now, how exactly do you survive something that wouldn’t have killed you anyway?  I was looking for another article on Slate– which I’ll save for a future post– and I came across this excellent piece on the trouble with “survivor” from a couple years back.  It’s by an oncologist who is a breast cancer “survivor.”

The National Cancer Institute defines a “cancer survivor” as someone who’s had a malignant tumor and remains alive. This holds whether you’re thriving after a single intervention, like surgical excision of a small tumor, or struggling for years with metastatic illness. The American Cancer Societyreports that nearly 12 million Americans are living today after a cancer diagnosis; each of us is a “survivor.”…

I can’t help but wrestle with the expression. The Latin roots—super and vīvere—support a straightforward meaning: that a person has outlived another. As an oncologist, I’m not convinced of this label’s accuracy, at least as it applies to a woman living after breast cancer; this, like some lymphomas and other tumors, can recur years, even decades after treatment ends. What’s more, I worry the “survivor” lingo might cause harm: Just as the term can support or reflect upon a patient’s courage and tenacity, it might alienate or wound someone who knows she can’t alter the course of her disease…

At a deeper level, what’s wrong is that the expression connotes strength or heroism. Today, survivor feeds into the concept of cancer as some sort of contest of harsh ordeals. Best sellers like Dr. David Servan-Schreiber’s Anticancer: A New Way of Life push the impression that survival implies you’ve done something right. The fault’s in the converse: If you don’t lick your tumor, you’ve failed. Maybe you chose the wrong treatment plan, ate the wrong foods, exercised too little or too much, or weren’t sufficiently optimistic. But cancer is not a mystic life challenge or game. It’s a disease, or really a set of complex diseases, that’s common, feared, and widely misunderstood…

Only a cynic would dismiss all the tangible, big-money support for research and the information and practical assistance offered by the survivor community’s enthusiasm. But the true heroes in this—those deserving of pink ribbons and medals, if they’re to be given—are those who struggle longest and hardest, who will never truly be “survivors” in the commonly accepted sense of the word.

It’s not the same for people like me, who move on with their lives after a discrete, albeit sometimes harrowing episode of illness. I’m an oncologist; I know I’ve done nothing in particular to deserve these eight years since my diagnosis. I lucked out, nothing more. And sure, I’m uncertain about my future. But who isn’t?

Good stuff.  I think on some level these issues bothered me (in addition to what I raised above) without me really realizing what it is about the term that’s always rubbed me wrong.  And for those who have survived an ordeal with cancer– good for you, most definitely.  I just think there are some real downsides to the term and that, in some case, it paints a false picture as well.

Cancer and optimism bias

Read a really interesting piece about stage IV cancer in the Times earlier this week.  Basic gist: (sadly) a huge number of patients really don’t appreciate how bad or how incurable their cancer is.  Very much hit home with my mom’s stage IV diagnosis over 3 years ago.  The essay is specifically about a study of lung and colon cancers, but I’m sure much of it applied to these advanced cancers more broadly:

 Most patients with these so-called stage 4 cancers who choose to undergo chemotherapy seem to believe, incorrectly, that the drugs could render them cancer-free.

That is the finding of a recent national study of nearly 1,200 patients with advanced cancers of the lung or colon. Overall, 69 percent of those with stage 4 lung cancer and 81 percent of those with stage 4 colon cancer failed to understand “that chemotherapy was not at all likely to cure their cancer,” Dr. Jane C. Weeks, an oncology researcher at the Dana-Farber Cancer Institute in Boston, and colleagues reported in The New England Journal of Medicine.

When patients do not understand the limitations of such treatment, their consent to undergo it is not truly informed, the authors concluded.

This is not to say that chemotherapy is pointless when cancer is far advanced. Various drugs, some with limited toxicity, can be used as palliatives, perhaps shrinking tumors temporarily to relieve symptoms, slowing the cancer’s growth and prolonging the lives of some patients.

But aggressive chemotherapy when death is but weeks or months in the offing can seriously compromise the quality of patients’ remaining time and may delay their preparations for the end of life, to the detriment of both patients and their families.

“If you think chemotherapy will cure you, you’re less open to end-of-life discussions,” Dr. Weeks said in an interview.

Yep, yep, yep.  And definitely part of the problem is oncologists who just want to treat, treat, treat.  Now, in my mom’s case the chemo really helped in some ways as the cancer had spread to her spine and was causing great pain, but it certainly seemed to me that she had a way over-optimistic sense of being “cured.”  Now, in truth, my mom was easily among the most optimistic people I’ve ever known (definitely to a flaw), but I also feel like the medical professionals could have certainly done a better job here.

Anyway, just a couple of days later, there was a very interesting piece about the huge overdiagnosis of breast cancer.  The latest study is just strong confirmation, but the basic point that breast cancer screening leads to many, many diagnoses that actually do nothing to save women’s lives.  Ironically, my mom was well aware of the futility of breast cancer screening which led her to be skeptical of the annual pap smear which probably would have saved her life.  Anyway, on the breast cancer issue:

After correcting for underlying trends and the use of hormone replacement therapy, we found that the introduction of screening has been associated with about 1.5 million additional women receiving a diagnosis of early stage breast cancer.

That would be a good thing if it meant that 1.5 million fewer women had gotten a diagnosis of late-stage breast cancer. Then we could say that screening had advanced the time of diagnosis and provided the opportunity of reduced mortality for 1.5 million women.

But instead, we found that there were only around 0.1 million fewer women with a diagnosis of late-stage breast cancer. This discrepancy means there was a lot of overdiagnosis: more than a million women who were told they had early stage cancer — most of whom underwent surgery, chemotherapy or radiation — for a “cancer” that was never going to make them sick. Although it’s impossible to know which women these are, that’s some pretty serious harm.

But even more damaging is what these data suggest about the benefit of screening. If it does not advance the time of diagnosis of late-stage cancer, it won’t reduce mortality. In fact, we found no change in the number of women with life-threatening metastatic breast cancer.

Wow.  That’s a lot of needlessly diagnosed breast cancer and a lot of harm.  What do to differently?

What should be done? First and foremost, tell the truth: woman really do have a choice. While no one can dismiss the possibility that screening may help a tiny number of women, there’s no doubt that it leads many, many more to be treated for breast cancer unnecessarily. Women have to decide for themselves about the benefit and harms.

But health care providers can also do better. They can look less hard for tiny cancers and precancers and put more effort into differentiating between consequential and inconsequential cancers. We must redesign screening protocols to reduce overdiagnosis or stop population-wide screening completely. Screening could be targeted instead to those at the highest risk of dying from breast cancer — women with strong family histories or genetic predispositions to the disease. These are the women who are most likely to benefit and least likely to be overdiagnosed.

The more we learn, the more it seems that breast cancer resembles the over-diagnosed and over-treated prostate cancer (though, clearly, it is on average a much more serious disease).  Clearly, our medical system needs to do much better.  And it can, if we get smarter about it.

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