Wednesday, October 21, 2009

American Cancer Society Now Going My Way: "Overdiagnosis is pure, unadulterated harm"

The NYT is reporting on an impending important change, one with which I am quite sympathetic: see In Shift, Cancer Society Has Concerns on Screenings. It is worth a read. The single most interesting part to me is the finale:

“The issue here is, as we look at cancer medicine over the last 35 or 40 years, we have always worked to treat cancer or to find cancer early,” Dr. Brawley said. “And we never sat back and actually thought, ‘Are we treating the cancers that need to be treated?’ ” (Ed: She also obviously means, "Are we finding the cancers that we need to find?")

The very idea that some cancers are not dangerous and some might actually go away on their own can be hard to swallow, researchers say.

“It is so counterintuitive that it raises debate every time it comes up and every time it has been observed,” said Dr. Barnett Kramer, associate director for disease prevention at the National Institutes of Health.
It was first raised as a theoretical possibility in the 1970s, Dr. Kramer said. Then it was documented in a rare pediatric cancer, but was dismissed as something peculiar to that cancer. Then it was discovered in common cancers as well, but it is still not always accepted or appreciated, he said.

But finding those insignificant cancers is the reason the breast and prostate cancer rates soared when screening was introduced, Dr. Kramer said. And those cancers, he said, are the reason screening has the problem called overdiagnosis — labeling innocuous tumors cancer and treating them as though they could be lethal when in fact they are not dangerous.

“Overdiagnosis is pure, unadulterated harm,” he said.

I had a patient in the 1990s who was competing for the Nobel Prize with his research into breast cancer and other topics. His publications filled a number of large books. He refused to be tested for prostate cancer for the above reasons. He felt that cancers are always forming and being killed by the body's natural defences.

On behalf of "doing healthcare", the President has argued that more preventative medicine would save money. In this blog, I pointed out that the medical data did not support this claim. Presidents can talk all they want, but talking can't make it so.

Here's a true, tragic example that from a doctor's standpoint tells the inside story of much of cancer screening.

A young man saw multiple family members die young of colon cancer. He became a gastroenterologist in response. At a very young age, he began to have yearly colonoscopies performed on himself. All were normal. One day, he woke up and noticed that his liver was enlarged. He had cancer that had spread to the liver. A biopsy showed it was colon cancer. How could that be? Well, his number had been called. He had a primary tumor in the only part of the colon that cannot be screened by colonoscopy. He had primary cancer of the appendix--invisible to the colonoscope--which silently spread to the liver and killed him soon after.

Don't smoke, get enough sleep, exercise, eat a balanced diet free of the bad stuff, don't be fat, have good genes, have a happy committed relationship, and be lucky. Those are the sorts of things that doctors know are the secrets to having the best shot at a long healthy life. And laugh a lot.

Regarding screening, nothing here is a recommendation for therapeutic nihilism. But low-risk, asymptomatic people should discuss the risks and benefits of screenings with a medical professional and do that screening, if any, with which they are comfortable. People should be aware that there truly is a huge industry making a huge income from screening low-risk people for cancer, sometimes with little or no evidence of benefit.

For example, women under age 50 should ask their doctors for any evidence that routine mammograms are of any known health value in the absence of risk factors such as fibrocystic disease, family history etc. Click HERE for a reference on this topic.

In my prior practice of clinical cardiology, in my later years I almost completely stopped giving people screening stress tests. I knew without a computer-generated risk profile if they needed a statin, other medication, or testing if asymptomatic. When I retired, I heard from patient after patient who felt well that they had been shot up with some radioactive scanning agent to find out if they had a problem. Invariably, this test was a highly reimbursed one that the doctor did in his private office. Cancer screening is too often analogous, in my view.

It's about time that the ACS calmed down. We need more data before we create or perpetuate large medical-industrial complexes and scare people unnecessarily about something as terrifying as cancer.

Copyright (C) Long Lake LLC 2009

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