R
Robert A. Fink
Guest
From the Washington Post:
------------------------------------------------------------
------------
washingtonpost.com Dangers in Early Detection
By H. Gilbert Welch
Thursday, July 1, 2004; Page A23
You feel well. You're only 60. Your PSA -- the blood test
for prostate cancer -- is normal. Much to your chagrin, you
learn of recent research that suggests you still might have
prostate cancer. But the only way researchers know this is
because they performed a more aggressive test
--
placing a probe through the rectum of normal men and inserting a
biopsy
needle six, maybe 12 times to search for cancer in various parts of
their
prostate. Should this procedure be performed on you? Should it be
performed on all healthy men?
This is American medical care today -- care increasingly directed
toward
the well. Ironically, the primary service we offer them is relentless
testing to establish whether they are, in fact, sick. We screen for
early
forms of diabetes, heart disease, osteoporosis, hepatitis, vascular
disease and, of course, cancer. The conventional wisdom is that early
detection improves health. But this assumption may be wrong.
Why? Because early disease detection means more people become
patients.
Inevitably some will be treated needlessly and suffer as a result.
To understand this, you need to understand that each of us harbors
early
forms of disease. Even in middle age, many of us who feel well have
evidence of diabetes, heart disease, osteoporosis, hepatitis, vascular
disease and cancer. Just because we harbor these early forms of
disease
doesn't mean that they will ever affect our health. Some diseases
progress
so slowly that people die of other causes long before the diseases
generate symptoms. Other diseases may not progress at all. Unless we
were
tested, we'd never have known we were sick.
Prostate cancer is the classic example. Among men age 60, around half
have
microscopic evidence of prostate cancer if we look hard enough. Yet
only
four in 1,000 will die from prostate cancer in the next 10 years. How
can
this be? Because prostate cancer isn't just one disease: It's a
spectrum
of disorders. Some forms of prostate cancer grow very rapidly and kill
men. Some grow slowly and men die of something else before the cancer
ever
causes symptoms. And others look like cancer under the microscope but
never grow at all.
A little over a decade ago, doctors started looking hard for prostate
cancer using the PSA and lots of needle biopsies. And we found a great
deal: Roughly 2 million cases were diagnosed in this period -- almost
a
million more than would have been without the test.
Did prostate cancer screening help men? To be honest, we aren't sure
about
the net effect. There has been a small decline in the death rate from
prostate cancer, but this may simply reflect that our treatments are
better. While screening probably has helped a few men live longer, it
has
also clearly hurt others. Millions have been biopsied who otherwise
wouldn't have been. Many with nonprogressive disease have been turned
into
cancer patients unnecessarily. Most have been treated, and many have
suffered ill effects. A few have even had their lives shortened by
treatment.
This is the reality of early detection. A few may be helped, because
their
disease is destined to cause problems and because early treatment is
able
to solve those problems in a way that later treatment cannot. But many
simply are told earlier that they have a disease and gain nothing,
because
their disease could have been treated just as well later, when
symptoms
appeared. And others are hurt by treatment for a disease that would
have
otherwise never affected their health.
What's next? Consider CAT scans of the chest to look for lung cancer.
During mass screenings in one region of Japan, CAT scans found 10
times as
many patients with lung cancer as had been found a few years earlier
using
chest X-rays. Incredibly, nonsmokers were almost as likely to have
lung
cancer as smokers. Is smoking getting safer? Of course not. Everyone
agrees that smoking is far and away the most important cause of lung
cancer. The CAT scans were simply labeling some people as lung cancer
patients who otherwise would never be affected by a few abnormal
cells.
Why not treat these patients -- just to be safe? Because some people
die
from treatment. In the Mayo Clinic study comparing lung cancer
screening
(using chest X-rays) to standard care, more people in the screening
group
were told that they had lung cancer. It didn't help them live longer;
in
fact, slightly more people in that group died.
And some think we should scan the whole body. But the harder we look,
the
more we find. CAT scans of the chest lead more people to be told they
have
lung cancer, and there are even more abnormalities to find in the
abdomen.
As one radiologist who has read thousands of these scans put it, "With
this level of information, I have yet to see a normal patient."
Millions of healthy Americans are being told that they are sick (or
"at
risk"). More are undergoing invasive evaluations with needles,
flexible
scopes and catheters. And more are taking drugs for early forms of
diabetes, heart disease, osteoporosis, hepatitis, vascular disease and
cancer.
We need to start asking hard questions about whose interests are
served by
the relentless pursuit of disease in people who are well. Clearly it's
good business -- for test manufacturers, hospitals, pharmaceutical
companies. And it's good for some doctors.
But is it in society's interest? Many suggest that it saves money by
lowering the cost per patient. But the savings per patient (if they
exist)
are overwhelmed by the increased expense of having so many more to
treat.
Is it in the interest of sick patients? Absolutely not, as caring for
the
well increasingly distracts doctors from caring for the truly sick.
And
what about the well? Is it in their interest? Only they can decide --
after they have been informed that early detection is a double-edged
sword.
The writer is a professor of medicine in the Department of Veterans
Affairs and Dartmouth Medical School. He is the author of "Should I Be
Tested for Cancer? Maybe Not and Here's Why."
© 2004 The Washington Post Company
===================================
Best,
Bob
Robert A. Fink, M. D.
Neurological Surgery
2500 Milvia Street Suite 222
Berkeley, CA 94704-2636 USA
510-849-2555
**********************************
NOTE: The material above is not "medical
advice". Medical advice can only be
given after an in-person contact between
doctor and patient.
**********************************
------------------------------------------------------------
------------
washingtonpost.com Dangers in Early Detection
By H. Gilbert Welch
Thursday, July 1, 2004; Page A23
You feel well. You're only 60. Your PSA -- the blood test
for prostate cancer -- is normal. Much to your chagrin, you
learn of recent research that suggests you still might have
prostate cancer. But the only way researchers know this is
because they performed a more aggressive test
--
placing a probe through the rectum of normal men and inserting a
biopsy
needle six, maybe 12 times to search for cancer in various parts of
their
prostate. Should this procedure be performed on you? Should it be
performed on all healthy men?
This is American medical care today -- care increasingly directed
toward
the well. Ironically, the primary service we offer them is relentless
testing to establish whether they are, in fact, sick. We screen for
early
forms of diabetes, heart disease, osteoporosis, hepatitis, vascular
disease and, of course, cancer. The conventional wisdom is that early
detection improves health. But this assumption may be wrong.
Why? Because early disease detection means more people become
patients.
Inevitably some will be treated needlessly and suffer as a result.
To understand this, you need to understand that each of us harbors
early
forms of disease. Even in middle age, many of us who feel well have
evidence of diabetes, heart disease, osteoporosis, hepatitis, vascular
disease and cancer. Just because we harbor these early forms of
disease
doesn't mean that they will ever affect our health. Some diseases
progress
so slowly that people die of other causes long before the diseases
generate symptoms. Other diseases may not progress at all. Unless we
were
tested, we'd never have known we were sick.
Prostate cancer is the classic example. Among men age 60, around half
have
microscopic evidence of prostate cancer if we look hard enough. Yet
only
four in 1,000 will die from prostate cancer in the next 10 years. How
can
this be? Because prostate cancer isn't just one disease: It's a
spectrum
of disorders. Some forms of prostate cancer grow very rapidly and kill
men. Some grow slowly and men die of something else before the cancer
ever
causes symptoms. And others look like cancer under the microscope but
never grow at all.
A little over a decade ago, doctors started looking hard for prostate
cancer using the PSA and lots of needle biopsies. And we found a great
deal: Roughly 2 million cases were diagnosed in this period -- almost
a
million more than would have been without the test.
Did prostate cancer screening help men? To be honest, we aren't sure
about
the net effect. There has been a small decline in the death rate from
prostate cancer, but this may simply reflect that our treatments are
better. While screening probably has helped a few men live longer, it
has
also clearly hurt others. Millions have been biopsied who otherwise
wouldn't have been. Many with nonprogressive disease have been turned
into
cancer patients unnecessarily. Most have been treated, and many have
suffered ill effects. A few have even had their lives shortened by
treatment.
This is the reality of early detection. A few may be helped, because
their
disease is destined to cause problems and because early treatment is
able
to solve those problems in a way that later treatment cannot. But many
simply are told earlier that they have a disease and gain nothing,
because
their disease could have been treated just as well later, when
symptoms
appeared. And others are hurt by treatment for a disease that would
have
otherwise never affected their health.
What's next? Consider CAT scans of the chest to look for lung cancer.
During mass screenings in one region of Japan, CAT scans found 10
times as
many patients with lung cancer as had been found a few years earlier
using
chest X-rays. Incredibly, nonsmokers were almost as likely to have
lung
cancer as smokers. Is smoking getting safer? Of course not. Everyone
agrees that smoking is far and away the most important cause of lung
cancer. The CAT scans were simply labeling some people as lung cancer
patients who otherwise would never be affected by a few abnormal
cells.
Why not treat these patients -- just to be safe? Because some people
die
from treatment. In the Mayo Clinic study comparing lung cancer
screening
(using chest X-rays) to standard care, more people in the screening
group
were told that they had lung cancer. It didn't help them live longer;
in
fact, slightly more people in that group died.
And some think we should scan the whole body. But the harder we look,
the
more we find. CAT scans of the chest lead more people to be told they
have
lung cancer, and there are even more abnormalities to find in the
abdomen.
As one radiologist who has read thousands of these scans put it, "With
this level of information, I have yet to see a normal patient."
Millions of healthy Americans are being told that they are sick (or
"at
risk"). More are undergoing invasive evaluations with needles,
flexible
scopes and catheters. And more are taking drugs for early forms of
diabetes, heart disease, osteoporosis, hepatitis, vascular disease and
cancer.
We need to start asking hard questions about whose interests are
served by
the relentless pursuit of disease in people who are well. Clearly it's
good business -- for test manufacturers, hospitals, pharmaceutical
companies. And it's good for some doctors.
But is it in society's interest? Many suggest that it saves money by
lowering the cost per patient. But the savings per patient (if they
exist)
are overwhelmed by the increased expense of having so many more to
treat.
Is it in the interest of sick patients? Absolutely not, as caring for
the
well increasingly distracts doctors from caring for the truly sick.
And
what about the well? Is it in their interest? Only they can decide --
after they have been informed that early detection is a double-edged
sword.
The writer is a professor of medicine in the Department of Veterans
Affairs and Dartmouth Medical School. He is the author of "Should I Be
Tested for Cancer? Maybe Not and Here's Why."
© 2004 The Washington Post Company
===================================
Best,
Bob
Robert A. Fink, M. D.
Neurological Surgery
2500 Milvia Street Suite 222
Berkeley, CA 94704-2636 USA
510-849-2555
**********************************
NOTE: The material above is not "medical
advice". Medical advice can only be
given after an in-person contact between
doctor and patient.
**********************************