Re: "Screening" tests
From: George Conklin (nilknoc_at_earthlink.net)
Date: 07/03/04
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Date: Sat, 03 Jul 2004 12:47:56 GMT
"Robert A. Fink, M. D." <lynxer@comcast.net> wrote in message
news:h4rbe0908t4rii0h6knd65ilhr6kbj56sn@4ax.com...
> 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.
> **********************************
Well, this is going against the cultural bias of more, more and more
health care. Patients seem to demand it, and think that if some test
somehow discovers even one cancer cell, or something which might be one,
they need immediate aggrressive therapy or they are doomed. Culture, not
science, is the issue here.
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