Thursday, April 17, 2014

No PSA, please...

I have tried to avoid difficult conversations with friends and family about my conviction we are over-screening for cancer, especially breast and prostate. While I have numbers on my side, people do not want rational discussions - they want to live, and almost always at any cost (which they do not know) or any effort or even if the odds of successful treatment are small.

Mostly they embrace the idea that more screening can only be a good thing. The "Save Just One Life Standard" is a powerful calculus and frankly exploited by our medical industry. What is not understood is that to save that one life other lives are damaged or even sacrificed due to false positives, treatment consequences, and other unadvertised complications.

More evidence continues to pile up to illustrate how unreasonable our expectations from screening are.


The bottom half of this pic shows the actual effect of mammography. If we take 1000 women age 50 and watch them for 10 years, and don’t screen them, 5 will die of breast cancer, 44 will die of other causes, and 951 will be fine. If we do screen them, then 4 women die of breast cancer, 44 or 45 die of other causes, and 951 or 952 are fine. This is why the effects seem to be negligible.But if you ask women to estimate how well mammography works, then you’re in for a whole different ballgame. They think that without screening, of those 1000 women, 160 are going to die from breast cancer in the next 10 years. They way, way, way overestimate the danger. They also overestimate the effectiveness of mammography. They think that it will halve the rate of death, so that only 80 of the 1000 women will die from breast cancer.Therein lies the problem. If you think that breast cancer is going to kill 16% of all 50-year-old women in the next 10 years and that mammography makes a huge difference in the mortality rate, then you’re going to demand a universal screening program. Hell, I’d demand it if that were the case. Until we can change the perception of the public to more closely match reality, and make them realize that the harms may outweigh the benefits, we’re going to get nowhere in trying to make changes. [More]

Along those same lines, someone I know recently was diagnosed with prostate cancer, and promptly underwent a prostatectomy. After the operation, he was told his prostate and the lymph nodes removed showed no trace of cancer. His original biopsy was mixed up with another patient at the lab. While he did have symptoms it could have been benign BPH. I do not know all the facts, but often in these cases the urge to "cut that cancer out of me" is overwhelming and surgeons rarely suggest watchful waiting. (My physician brother always considered a surgeon as a doctor who believed there was nothing wrong with you that an expensive operation couldn't prolong.)

Many things went wrong - no second opinion and biopsy is one obvious fault. But our system refuses to accept that aggressive treatment is not always the answer, so there was no established procedure to slow the rush to surgery. Nor does a hyperactive litigation system offer real compensatory relief, IMHO.

I have always expected to talk a good game, but in the end melt down to a passive victim should I face such a diagnosis. But after simply telling my doctor to not check my PSA because I'm over 60 and have no risk factors or symptoms, I think I will be able to deal with the next level of decisions should the occasion present. Multiple experiences of friends and family with difficult treatments and dubious benefits reinforces my inclinations. Getting older also helps anchor our cost/benefit calculations, I think.

There is something about the process of learning and taking small steps that enables us to gain control of our lives. And we will never control health care costs until we control our own health care.

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