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.

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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.

 

 

Quick hits (part II)

1) Totally agree with Mark Joseph Stern that Democratic politicians need to get out in front on marijuana legalization:

The lack of mobilization from lawmakers is especially puzzling given how neatly marijuana legalization aligns with the goals of the self-styled resistance to Trump. Progressive Trump opponents not only tend to favor legalization on its own, they also broadly support the goals behind legalization. It’s true that the Trump era has reinvigorated liberals’ support for federalism, mostly out of necessity as blue states band together to protect sanctuary cities and fight Trump’s travel ban. But it has also intensified liberals’ opposition to mass incarceration and racial bias in the criminal justice system. Concerns about overpolicing and racism in law enforcement are what animate progressive support for legalization, along with a healthy respect for states’ rights and personal liberty.

And yet, on pot as on so many other issues, Democratic politicians are failing to respond to their base’s stated preferences.

2) Damn the militarization of the police and all the needless no-knock warrants.  And shame on our judicial system for making them way to easy to get.  People die and lives are ruined over these.  And, because, some police departments think it is a good idea to break into a house at 5am, basically unannounced, over a few ounces of marijuana.  Ugh.

3) Basically 75% of my twitter feed yesterday was about the NYT’s big Comey story. Many, many tweets mentioned the fact that the story completely ignores the role of the media in all this.  Relatedly, Drum lays out the clear case for why Comey’s letter was the decisive factor.  I agree.

4) Jacob Levy on Kushner and the problem of nepotism in a democracy.

5) I came across this latest example of classic interest group politics via a FB ad.  I’m 100% convinced that NC ophthalmologists are only interested in the welfare of their patients in attempting to stop optometrists from performing four types of simple surgery that they have been doing successfully in three other states.  I’m sure it has nothing at all to do with protecting their turf and their incomes.  My favorite is their “poll” stating, ” Almost nine out of 10 North Carolina voters oppose legislation that would allow eye-care providers who have not been to medical school to perform eye surgery, a new statewide public opinion poll found.”  As if 1 in 100 NC voters actually has any idea what this legislation is actually about.

6) Ben Mathis-Lilley, “There’s No News Right Now Because Trump Doesn’t Actually Do Anything.”

None of this is really surprising. As has been well-documented, Trump—though he claims to be a “builder”—actually made most of his hay in the private sector by licensing his name. He’s the guy who makes big promises at the ribbon-cutting and gets the name of the project in the newspaper, not the guy who gets the permits and arranges the funding and hires the subcontractors. He doesn’t make things; he talks. (When he does try to make things, they go bankrupt.)

7) While everybody was focused on Betsy DeVos and K-12 education, those in the know were aware that her real damage would be to higher education and college students.  When it comes to student loans, she’s already at it.

8) The saga of North Carolina’s contaminated water gets a nice feature in the Atlantic.  Thanks, NC Republicans!

9) Somehow I missed that prostate cancer screening is back in the news.  Good take on the latest from doctor/blogger Kenny Lin, whom I am now going to start following.  Short version: official take is now that you should at least discuss PSA test with your doctor.  Ongoing reality.  Getting a PSA test makes it about 10 times more likely you will end up incontinent or with sexual dysfunction than the likelihood it will save your life.  No thanks to that trade.

10) Great EJ Dionne column on Trump:

Two issues are paramount in American politics. The first is whether President Trump will get away with his arrogant dismissal of the public’s right to a transparent government free of corrupting conflicts of interest. The second is whether those who would hold him to account remain focused, mobilized and determined.

They are related. There are many reasons to stand against Trump, but the one that should take precedence — because it is foundational for decent governance — is his autocratic assumption that he is above the expectations that apply to us normal humans.

Should Trump separate himself completely from his business interests, as presidents had been doing for more than four decades? His implicit message is always: No, I can do what I want.

11) The political impact of helicopter parents.  Really.

Using a survey conducted at multiple universities in the U.S., we find that helicopter parenting has a significant impact on the policy attitudes of college students. Specifically, students with helicopter parents are more likely to express support for both government surveillance and social welfare policies than are students without helicopter parents. Given the growing trend of helicopter parenting, these findings will likely have substantial implications for both the political science classroom and public opinion in the near future.

12) Excellent Isaac Chotiner piece on how Bill O’Reilly was very much the proto-Trump:

But the aspect of The O’Reilly Factor that always shocked me was a different kind of resentment, which took the form of the anchor’s unrepentant solipsism. It’s simply impossible to overstate how much of each night’s show was consumed by O’Reilly’s own grievances. He skirmished with everyone from Matt Lauer to Rosie O’Donnell to Al Franken, and those fights would invariably become the topic of the day on his show. He spent countless hours talking about himself—usually as the victim of various conspiracies. (Frequently, George Soros was the conspiracy’s prime mover.) He would drone on about the New York Times and how it was out to make him look bad. It was endless, and it was exceptionally boring—to everyone except his legions of viewers and fans.

I never really had a theory for how this supposed man of the people got away with talking about nothing but himself. Then Donald Trump came along. Here was another rich guy who built a following speaking up for the working man. Like O’Reilly he seemed entirely driven by resentment: at President Obama, at the media, at the people who doubted him. And like O’Reilly, he spoke almost entirely of himself. His stump speeches were shocking, in part, because they were rarely about anything other than Donald Trump.

13) Interesting Rebecca Traister piece on the role of women’s reproductive rights within the Democratic party.  That said, I’m tired of throw-away lines like this:

For some time now, Sanders — who, it should be noted, has an extremely strong legislative record on reproductive rights — has spoken somewhat carelessly about a populist strategy that exchanges some core Democratic beliefs for the set of issues that are most important to him. “Once you get off the social issues — abortion, gay rights, guns — and into the economic issues, there is a lot more agreement than the pundits understand,” he said in 2015. In January of this year, at a CNN Town Hall, he reiterated, “Yes, of course, there are differences on issues like choice or on gay rights … But on many economic issues, you would be surprised at how many Americans hold the same views.”

Sanders is wrong that reproductive rights (or gay rights, for that matter) are separate from economic issues. The ability to control reproduction is central to women’s social, professional, and economic stability, and the women most likely to require abortion services and to be negatively affected by restrictions on access to reproductive health care are poor and low-income women, disproportionately women of color.

Really, I get it.  But still, let’s just not pretend people think about and conceptualize these issues the way they do matters like taxes, jobs, minimum wage, etc.  Oh, heck, as long as I’m letting Traister annoy me:

The deprioritization of reproductive rights was part of the strategy that helped Rahm Emanuel, chair of the DCCC, win the House for Democrats in 2006. But Ilyse Hogue, head of NARAL Pro-Choice America, argues that we should evaluate that strategy now with an understanding of its longer-term implications: “It did not result in more progressive legislation or in a durable governing coalition,” she says. “It depressed the base and predicated the rise of the Tea Party.”

Right.  That’s what led to the rise of the Tea Party.  Dumbest, most obviously self-serving political analysis ever?

14) The many forces pulling Trump in a more conventionally conservative direction.

15) Love Josh Marshall’s post on Trump’s “militant ignorance.”

What is endearing, terrifying and hilarious about Trump is not simply his ignorance, really his militant ignorance, but his complete lack of self-awareness about his ignorance. Trump told a reporter for The Wall Street Journal that his understanding of the problem of North Korea changed dramatically after hearing ten minutes of history from the President of China. Needless to say, Trump didn’t need to admit this. But neither was it candor.

So far the Trump Presidency has been a sort of Mr Magoo performance art in which the comically ignorant Trump learns elemental or basic things that virtually everyone in the world of politics or government already knew – things that the majority of adults probably know. Health Care: “Nobody knew health care could be so complicated.” North Korea: “I felt pretty strongly that they had tremendous power. But it’s not what you think.” There are perhaps half a dozen examples equally stark.

In other words, President Trump is open about his discoveries and even eager to share them but universally projects his previous state of comical ignorance onto the general public or whomever he is talking to. In other cases, this would make sense. If Trump discovered that humans could fly if they hold their nose, close one eye and say “Shazam!” I’d want to know. Because that’s awesome. And I wouldn’t think worse of Trump for not knowing it before. Because this is new and amazing information. But learning that health care policy is complicated is a different kind of discovery.

 

 

Bonus quick hits!

Read a lot of good stuff this weekend and didn’t want my list to grow too big for next week, so…

1) It’s not easy being in solitary confinement, especially if you are already mentally ill.  The good news is the NC is cutting back on it’s over-use of solitary.

2) The reality of prostate cancer is finally making it through to many men as “active surveillance” has finally (and quite appropriately) caught up with aggressive treatment.

3) Elizabeth Warren knows how to take on Donald Trump.  Indeed.

Observe, then, the felicity with which this sense of purpose allows her to tear into Trump as she did at a gala Tuesday night.

“Donald Trump was drooling over the idea of a housing meltdown because it meant he could buy up more property on the cheap,” Warren said, touching on one of the more meaningful Trump opposition sound bites to emerge recently.

“What kind of a man does that? What kind of a man roots for people to get thrown out of their house? What kind of a man roots for people to get thrown out of their jobs? To root for people to lose their pensions? To root for two little girls in Clark County, Nevada, to end up living out of a van?

“What kind of a man does that? I’ll tell you exactly what kind of a man does that: It is a man who cares about no one but himself. A small, insecure moneygrubber who doesn’t care who gets hurt so long as he makes a profit off it. What kind of man does that? A man who will never be president of the United States.”

She then lit into him for wanting to eliminate the Dodd–Frank financial reform law,something he has always said he would do but which the political world has only recently seemed to notice: “Donald Trump is worried about helping poor little Wall Street? Let me find the world’s smallest violin to play a sad, sad song.”

4) Addicted to a treatment for addiction?  Sadly, many person seem to develop an addiction for Suboxone.  That said, way better than being addicted to heroin.

5) Normally, after a recession we invest in our infrastructure.  This time– not at all so (and, yes, the GOP Congress is to blame).

6) Tyler Cowen on Donald Trump’s appeal to “brutes.”

The contemporary world is not very well built for a large chunk of males.  The nature of current service jobs, coddled class time and homework-intensive schooling, a feminized culture allergic to most forms of violence, post-feminist gender relations, and egalitarian semi-cosmopolitanism just don’t sit well with many…what shall I call them?  Brutes?

Quite simply, there are many people who don’t like it when the world becomes nicer.  They do less well with nice.  And they respond by in turn behaving less nicely, if only in their voting behavior and perhaps their internet harassment as well…

Trump’s support is overwhelming male, his modes are extremely male, no one talks about the “Bernie sisters,” and male voters also supported the Austrian neo-Nazi party by a clear majority.  Aren’t (some) men the basic problem here?  And if you think, as I do, that the incidence of rape is fairly high, perhaps this shouldn’t surprise you.

The sad news is that making the world nicer yet won’t necessarily solve this problem.  It might even make it worse.

Again, we don’t know this is true.  But it does help explain that men seem to be leading this “populist” charge, and that these bizarre reactions are occurring across a number of countries, not just one or two.  It also avoids the weaknesses of purely economic explanations, because right now the labor market in America just isn’t that terrible.  Nor did the bad economic times of the late 1970s occasion a similar counter-reaction.

One response would be to double down on feminizing the men, as arguably some of the Nordic countries have done.  But America may be too big and diverse for that really to stick.  Another option would be to bring back some of the older, more masculine world in a relatively harmless manner, the proverbial sop to Cerberus.  But how to do that?  That world went away for some good reasons.

If this is indeed the problem, our culture is remarkably ill-suited to talking about it.  It is hard for us to admit that “all good things” can be bad for anyone, including brutes.  It is hard to talk about what we might have to do to accommodate brutes, and that more niceness isn’t always a cure.  And it is hard to admit that history might not be so progressive after all.

7) Why Greek statues of men have small penises.  Actually, quite interesting.

8) Loved this essay on why you have married the wrong person.  I don’t actually think I have, but this strikes me as pretty spot-on:

The good news is that it doesn’t matter if we find we have married the wrong person.

We mustn’t abandon him or her, only the founding Romantic idea upon which the Western understanding of marriage has been based the last 250 years: that a perfect being exists who can meet all our needs and satisfy our every yearning.

WE need to swap the Romantic view for a tragic (and at points comedic) awareness that every human will frustrate, anger, annoy, madden and disappoint us — and we will (without any malice) do the same to them. There can be no end to our sense of emptiness and incompleteness. But none of this is unusual or grounds for divorce. Choosing whom to commit ourselves to is merely a case of identifying which particular variety of suffering we would most like to sacrifice ourselves for.

This philosophy of pessimism offers a solution to a lot of distress and agitation around marriage. It might sound odd, but pessimism relieves the excessive imaginative pressure that our romantic culture places upon marriage. The failure of one particular partner to save us from our grief and melancholy is not an argument against that person and no sign that a union deserves to fail or be upgraded.

The person who is best suited to us is not the person who shares our every taste (he or she doesn’t exist), but the person who can negotiate differences in taste intelligently — the person who is good at disagreement. Rather than some notional idea of perfect complementarity, it is the capacity to tolerate differences with generosity that is the true marker of the “not overly wrong” person. Compatibility is an achievement of love; it must not be its precondition.

9) Drum’s liberal heresy– campaign finance reform really isn’t suck a big deal.  I think he’s more right than wrong.

10) Nick Kristoff on the liberal blind spot.  After reading some of the comments, I’d have to say (noted Libertarian) Mike Munger’s take is spot-on, “It is remarkable that so many commenters insist of proving Kristoff’s claims to be correct.”

11) China’s aging population represents a huge problem for their future global competitiveness.  In the US, much less so.  Why?  In a word– immigration.

12) Love this story about White House photographer Pete Souza featuring tons of great photos of Obama.

Too much health care

I have no idea how in the world I missed this terrific Atul Gawande New Yorker piece back when it came out in May, but at least I read it now.  And it’s going into my Public Policy syllabus on health care.  Basic premise, we waste so much medical care on overtreatment.  (A subject long near and dear to my heart).  There’s so much good here (and it’s a typical lengthy New Yorker article, so there’s only so much I can excerpt), but this conceptualization of disease, I really, really liked:

H. Gilbert Welch, a Dartmouth Medical School professor, is an expert on overdiagnosis, and in his excellent new book, “Less Medicine, More Health,” he explains the phenomenon this way: we’ve assumed, he says, that cancers are all like rabbits that you want to catch before they escape the barnyard pen. But some are more like birds—the most aggressive cancers have already taken flight before you can discover them, which is why some people still die from cancer, despite early detection. And lots are more like turtles. They aren’t going anywhere. Removing them won’t make any difference.
We’ve learned these lessons the hard way. Over the past two decades, we’ve tripled the number of thyroid cancers we detect and remove in the United States, but we haven’t reduced the death rate at all. In South Korea, widespread ultrasound screening has led to a fifteen-fold increase in detection of small thyroid cancers. Thyroid cancer is now the No. 1 cancer diagnosed and treated in that country. But, as Welch points out, the death rate hasn’t dropped one iota there, either. (Meanwhile, the number of people with permanent complications from thyroid surgery has skyrocketed.) It’s all over-diagnosis. We’re just catching turtles.

Every cancer has a different ratio of rabbits, turtles, and birds, which makes the story enormously complicated. A recent review concludes that, depending on the organ involved, anywhere from fifteen to seventy-five per cent of cancers found are indolent tumors—turtles—that have stopped growing or are growing too slowly to be life-threatening. Cervical and colon cancers are rarely indolent; screening and early treatment have been associated with a notable reduction in deaths from those cancers. Prostate and breast cancers are more like thyroid cancers. Imaging tends to uncover a substantial reservoir of indolent disease and relatively few rabbit-like cancers that are life-threatening but treatable.

We now have a vast and costly health-care industry devoted to finding and responding to turtles. Our ever more sensitive technologies turn up more and more abnormalities—cancers, clogged arteries, damaged-looking knees and backs—that aren’t actually causing problems and never will. And then we doctors try to fix them, even though the result is often more harm than good. [emphasis mine]

For whatever reason, the piece is currently not behind the New Yorker paywall.  Do yourself a favor and read it.

Quick hits (part I)

Didn’t blog much at the beach, but still read lots of good stuff.  Many quick hits coming at you.

1) Really liked this perspective on Galileo— he was not as right as you think nor his critics as wrong.

2) Nice N&O Editorial on the latest example of NC Republicans deciding that local government is best– except when it is electing Democrats.  When Jesse Helm’s chief adviser says you’ve gone too far, you’ve probably gone too far.   And Thomas Mills on the travesty that is the NC Senate:

House Speaker Tim Moore came to power promising to show that the GOP could govern. Unfortunately, it’s not to be. The ideologues in the Senate are too busy micromanaging local governments and sticking square pegs into round, free-market holes to pay attention to what’s working and what’s not. They don’t seem to care whether policies are good for the people or the state. They only care that they fit into their narrow ideological box.

3) On the science behind “Inside Out.”  And seriously, if you haven’t yet, see this movie.

4) Nice piece from Bill Ayers on using the language of religious rights to deny rights:

As one lawmaker put it in North Carolina, “Just because someone takes a job with the government does not mean they give up their First Amendment rights.” A cake baker has apparently also decided to take his case to court, lest he be sanctioned for discriminating against gay couples in the making of wedding cakes.

I find this argument deeply troubling on many fronts. It strikes me as a species of other arguments people make which use the trappings of commonly-held values (in this case, the language about rights and freedom) to advance the opposite

5) Enjoyed this Slate piece on how Carli Lloyd and other US women soccer stars were rejected from youth teams and how that helped lead to their greatness.

6) I hate felony murder charges.  No, you should not rob somebody trying to sell you marijuana.  But when that goes wrong and the marijuana dealer falls off the truck and dies as it pulls away (and you are sitting in the back seat!) in no way are you a murderer at all.  Except, of course, under felony murder laws.  If I were on a jury for this case there would damn well be some juror nullification.  (Interesting that it happened at the park I visit every week with Sarah while Evan has his piano lessons).

7) A urologist argues in NYT that we need to bring back more prostate screenings.  This was a great example of smart commenters that you actually see in the NYT as they were all over the problems in this argument.

8) Apparently Amy Schumer’s jokes really are racist.  I, however, am not persuaded.

9) The best stuff I read on Germany and Greek debt last week.  Thomas Piketty on how the Germans are hypocrites. NYT’s Eduardo Porter makes a similar point.   And Harold Myerson.  Not like Greece doesn’t have plenty of blame to go around, of course.  For example, their crazy pension system.

10) I hate the tendency towards over air-conditioning in the summer.  I’ve been known to run my space heater in my office in the summer.  What a waste of energy.

11) I think I’m going to have to read this book on how over-parenting is ruining our kids.  I’m definitely no helicopter parent, but I fear I am not doing enough to make my kids learn tough life lessons on their own.

When parents have tended to do the stuff of life for kids—the waking up, the transporting, the reminding about deadlines and obligations, the bill-paying, the question-asking, the decision-making, the responsibility-taking, the talking to strangers, and the confronting of authorities, kids may be in for quite a shock when parents turn them loose in the world of college or work. They will experience setbacks, which will feel to them like failure. Lurking beneath the problem of whatever thing needs to be handled is the student’s inability to differentiate the self from the parent.

12) I’m glad I don’t have to rely on public schools in Texas to teach my kids history:

THIS FALL, Texas schools will teach students that Moses played a bigger role in inspiring the Constitution than slavery did in starting the Civil War. The Lone Star State’s new social studies textbooks, deliberately written to play down slavery’s role in Southern history, do not threaten only Texans — they pose a danger to schoolchildren all over the country.

On a related note, here’s some excerpts from a 1970’s Alabama history text.

13) Maybe autism is so more prevalent now because earlier clinicians actively worked to not diagnose it.

14) John Oliver on bail is, of course, excellent.

15) The most common reasons behind unfriending on FB:

In a 2014 study, Christopher Sibona, a researcher at the University of Colorado at Denver, actually pinpointed the four types of content that are most likely to prompt an unfriend:

  1. Frequent/unimportant posts
  2. Polarizing posts (politics and religion; liberals are, for what it’s worth,more likely to unfriend over political views)
  3. Inappropriate posts (sexist, racist remarks)
  4. Everyday life posts (child, spouse, eating habits, etc.)

Also, HS friends are most likely to get unfriended.

16) Iron Giant is going to be re-released on the big screen.  So going to take all the family to that.

17) I’m sure I’ve mentioned it before, but it never hurts to mention how near-useless the BMI is for addressing the health of individuals (there is some value as a population statistic).

18) A nearby public library that is actually inside a local HS is set to close.  Why?  People are worried about security:

The school system and Wake County partnered in the early 1980s so the Athens Drive High School library served students while also doubling as a public library.

But times have changed in terms of security at schools, said Ann Burlingame, assistant library director in Wake. High schools need to monitor who comes on their campuses, she said.

“We need to have a regard for the children and their safety,” Burlingame said…

No major security issues have been reported at the west Raleigh school. But Simmons said some parents have complained that it’s easy for library visitors to access the main part of the building.

Got that?  No actual issues in decades of use, but parents are worried.  So frustrating when the overly-fearful get to make public policy.

19) I had no idea about putative father registries.  Pretty interesting account of the laws and one disturbing case in South Carolina–yes, there are racial overtones (and the author was a friend of mine back at Duke).

 

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.

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