81 Comments

i am 53 and done with screening mammogram and not doing colonoscopies.. my question is why is the slogan “early detection saves lives” ? where did this come from?

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You're only evaluating the test's benefit for pancreatic cancer? It tests more than 50 cancer types, many of which are more common than pancreatic cancer, so the benefit is much much greater than you're presenting. Also, if this test can replace existing costly cancer screening procedures, several of which expose patients to ionizing radiation, it seems like a win both for patients and for insurance.

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Just ran across this article, and really appreciate your POV, particularly this: “I am also afraid of how this type of screening will affect medicine. Although I don’t like it, I feel a necessary part of the practice of medicine is counseling people on the inevitability of our decline and death. Like all of us, I would love to have treatments for more of the diseases that shorten our lives. But tests and treatments that promise to protect us from the inevitable, diseases that seem part and parcel of the human condition, trouble me. This is why hope that early detection and cure of late-life cancer or dementia seem empty to me. Call me defeatist, a pessimist, an old doctor who cannot dream of a better future for medicine. I’d rather say I am a realist, both as a doctor and a human.” Thank you.

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I have had my share of mammograms at age 68. I have to unabashedly admit that I went 8 years without one because it seemed like I had “just had one.” Saved myself from some radiation.

What I would have benefited from is a DEXA.

A little background: I’m a 68 y/o female physician and an aging jock. Grew up with no one but brothers and male cousins, meaning I played baseball, football, climbed trees and rode horses. I had an extremely active child and young adulthood, running track and playing lots of weight bearing sports. In my mid twenties I began running 20 to 30 miles a week and trained for several marathons.

Never smoked, rarely drank ETOH, didn’t drink soda and had all sorts of dairy all along. Tool calcium and vitamin D3.

My 92 y/o mother broke her ankle and her surgeon was amazed at how healthy her bones were.

You can probably see where this is going. I knew I needed a bone scan at some point, but only had one fracture as an 11 y/o when a rope swing I was on broke and I plowed into the ground. I spent some weeks wearing a foam brace for my fractured collarbone.

Wait, I forgot the violent mountain bike crash I had 5 years ago. I went over the handlebars going about 15 mph and dropping 8 feet before landing on granite. I fractured my pelvis in two places. After three weeks on crutches it was like it never happened. Healed great and went on my merry way. Surely if I had osteoporosis my pelvis would’ve shattered, right? And what about the many times being bucked off horses? A horse fell on me, pinning my left leg between his body and a paved road. I had some nice bruises but that was it.

So when I went skiing 4 weeks ago, fractures were not on my radar. On my first run, I got caught on my outside ski and simply sat down. It didn’t hurt and I got up and skied off. Something didn’t seem right as I continued. My legs felt weak and my skin boots seemed too big. I was having trouble controlling my skis so I went to the lodge and was knitting until my husband was done.

The next week was normal. I was due to go on vacation and was going to ski more. But the first day off my back felt tight. Then it settled into spasms so bad it felt like a bear trap was clamping onto my spine. I spent the week with an ice pack and was unable to lie down without pain and spasms that would make me cry out. Sleep was impossible.

Luckily, a colleague at work saw me and ordered an X-ray. Nice compression fracture in L1, confirmed with an MRI. Three days ago I had a bone scan. Osteoporosis in the whole spine, T-score -2.7 and osteoporosis in left femur. Osteopenia elsewhere.

I can’t begin to express my disbelief at this turn of events. My whole sense of self has flown out the window. My back still aches sullenly every day, and I am fucking furious! What do I do now? Who am I, even?

Adding to my fury is the fact that nobody has ever suggested that I, a slender blonde, should get a DEXA.

And of course, once the Women’s Health Initiative served us all a bullshit sandwich, every menopausal female got yanked off estrogen. If only we’d known to wave goodbye to our skeletons! Even if HRT caused breast cancer, 90% of those cancers are cured nowadays. If a person breaks a hip, there’s a 50% mortality rate within the next year.

True story: I had a Pap smear last summer from my current ObGYN; a nice guy in his late 30s, I’d say, and I told him I had recently put myself on a wee dose of estradiol and progesterone because my libido was starting to wane. He was strongly against it, saying he had seen several malignancies and thought it wasn’t worth the risk. He suggested (this is the funny part) that I get counseling from a sex therapist. What? I’ve been sleeping with the same guy for 40 years, and we’ve basically gotten things in the bedroom handled just fine. It’s the dry vagina that’s holding me back now. Feeling like you’ve been abraded by a Brillo pad after sex isn’t conducive to fun in bed.

Sorry for the rant, but the WRONG things are being screened for. I can live without my breasts, but not my damned skeleton.

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Whether or not a few people may benefit from this test, it holds the potential to inaugurate a new era of iatrogenic injuries.

To be honest, even if it is tested in RCTs, all I can think about is that quote from the book ‘Malignant’:

“One only has to review the graveyard of discarded therapies to discover how many patients have benefited from being randomly assigned to a control group”

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Many MDs don't know how to use the PSA. Get a baseline at a young age then follow the trend. It is simply calculus--the rate of change, not the change itself.

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No mammograms for me. QT Imaging is my go to for screening . Non invasive, no radiation, affordable. Lie on stomach, breast submerged in warm water for a few minutes. Incredible imaging and information. https://www.qtimaging.com/

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I’d say Dr. Cifu’s fears are well founded. It will be a lot of healthcare $ devoted to this test, as well as all the downstream testing and treatment (much of it likely unnecessary and useless) that will surely arise from the results of this screening test.

If it takes 10 years to prove this test is worth something….so be it. That is a burden for the proponents to bear. This is how the scientific method works, or should work.

I’d still be amused to see the cost benefit on this, as in cost of screening to save one life. I say “amused” cuz ridiculously large numbers are funny.

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The other issue not raised is that ot all cancer screening is created equal. For example, let us say one screened for multiple myeloma and picked up cases of smoldering myeloma. Would that be useful. I would say no because there is no evidence that treating smoldering myeloma prolongs life of enhances quality of life (in fact possibly quite the reverse with regard to quality). On the other hand, if one picks up a breat cancer that is less than a cubic centimeter in volume, and has not spread, then removal will prevent death from breast cancer arising from that specific tumor. Of course that doesn't mean that one won't develop other breast tumors. The same argument applies to colonoscopies, for example.

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About 8 years ago my primary doc noticed I got had a small goiter, and modestly elevated TSH. She ordered an expensive imaging test in the local hospital and then a referral to a local ENT for biopsy. Biopsy negative for cancer. The ENT, an experienced older man, sat with me in his office and explained that some people's TSH just runs a bit high, and that's not anything to freak out over, even when it's accompanied by a goiter (an aside here, "goiter" has to be one of the ugliest sounding words in English). In other words, my primary doc in trying to rule out any malignancy cost me a lot of money, pain and fear. The ENT doc, I thought, had real wisdom. And that wisdom is something other than relying simply on guidelines and screening tests. So I lean the way you do on this, Dr Cifu.

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You are (as usual) correct in your assessment of the real wisdom shown by the older and experienced ENT doctor. Many people think that the wisdom that comes with age is due to the collection of more knowledge. Although there is some truth in that I have found that much of real wisdom is knowing what you don't know.

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Isn't that because the ENT really knows what he/she is talking about whereas the primary care physician, while knowledgeable, doesn't have that level of detailed knowledge regarding specific conditions.

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The primary was young, and struck me as a by-the-book type. She meant well. Because I was so ignorant I wasn't about to question her guidance.

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I think the truth is that one has to use such tests sensibly and then make personal decisions based on one's own assessment of the risk/benefit ratio.

The truth is that we are all going to die. The question, however, is when and how. Personally I would prefer to die in my sleep of some coronary event than of cancer where I might have to suffer a prolonged painful death due to either the cancer or the treatment.

The second issue is that even though one is going to die at some point, ideally one would like to live as long as one is fit of body and sound of mind. In other words, one doesn't want to die prematurely, even if that prematurely means dying at say the age of 89 versus 92 if one had been treated.

With regard to cancer screening I'm really not sure of the validity of RCTs. The reason for this is that the analysis is invariably too coarse. For example, it may well be the case that at a. population level PSA screening does not result in any significant prolongation of life. But that's perhaps not too surprising given that the incidence of aggressive prostate cancer is probably rather low. i.e. many men may well die with incidental prostate cancer present, for example. But at an individual level, especially where a family history is present, cancer screening may well result in prevention of premature death. And that's especially so if the cancer is caught before the horse has bolted the barn. And in essence that's the real key. Detection at a time where surgery is curative.

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The only relevant question for me is whether early detection leads to meaningful interventions—specifically those which could with reasonable confidence mitigate/delay/cure an early cancer in an effective way without unacceptable side effects. If early detection leads to better treatment, I'm on board. If early detection just gives us more to worry about, then I think I'll pass.

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Thanks so much for these thoughtful comments. I am a psychologist, and I am concerned about the consequences for people who are screened for cancer, and subsequently diagnosed with cancer and treated, who would not have had any symptoms or impact on their longevity. These people become cancer survivors. They go on to have an identity that may affect many aspects of their lives as having been someone who "beat" cancer. They also share their stories with others and credit the health care professionals and cancer treatment centers where they received this treatment, and believe that their lives were saved. All of this adds to a narrative that we are ticking time bombs, saved only by the marvels of medical testing and scientifically sound treatments. One step further, these cancer survivors have family caregivers who also often sacrifice tremendously in order to get their loved ones to treatment, manage the side effects of chemotherapy and other treatments, and who may make major changes in their lives (such as stopping employment). Both the cancer survivor and caregiver can experience serious psychological, career, and economic consequences. I would be very interested in seeing a calculation of how many such people are affected, and the consequences for these people who become patients and caregivers only because of screening. There are already very good methods used to study the impact of serious illness on both patients and their families, and this should be done to look at the consequences of screening.

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This is a very insightful comment. As a gynecologist focusing on women's health in midlife and beyond, I see this frequently in my patients with DCIS. Most of them are told that they actually have breast cancer, and are treated for up to a decade with profound hormonal blockade (in case of postmenopausal women with aromatase inhibitors), resulting in significant side effects affecting not just daily quality of life, but bearing significant mental health, bone, sexual and metabolic effects. These women often live in fear of cancer forever, side effects are ignored, and they shame themselves or are shamed for wanting to address said side effects (because after all they "beat" cancer and that's the most important thing), and have their lives turned upside down forever.

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Thanks so much for this response based in your clinical experience. We have to find a middle ground here, both men and women are bullied and shamed by their physicians, advertisements, or well-meaning family members, into thinking they have no choice in deciding whether cancer screening is the right choice for them. That first step is one down a very long road. Your patients are fortunate to have a physician who cares about these issues.

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very true

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Thank you Adam for taking up this important and often counterintuitive subject.

I agree with everything you write, except for your decision to volunteer that you had both a PSA and a colonoscopy done without explaining your rationale.

If you have a much higher baseline risk that justifies both of these, why not clearly say so?

If you are at average risk of cancer and know all of the potential harms and benefits of screening and decided to go ahead anyway, fine. Why not say so?

If you do not want to reveal your rationale, why confuse us by telling us that you had the tests done at all?

These are not easy choices, and real life models of decision-making can be useful. I am a healthy 60 year old retired family physician. My age alone gives me a greater than 1 in 3 chance of having incidental prostate cancer and I choose not to get a PSA. In contrast, I had a significant pulmonary embolism last year and in this case chose to get a fecal immunochemical test to screen for colon cancer as a potential cause of clotting. It was negative.

Life is full of uncertainties. There is wisdom and sanity in accepting this fact, and in being wary of those who would sell reassurance without adding up both sides of the ledger.

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Read How to Starve Cancer by Jane McLelland and the blog Mycancerstory.rocks. Follow people like Chris Beat Cancer and Kris Carr. Learn about less toxic, more natural treatment options. Strengthen the microbiome and support the immune system. Perhaps, then your fear of cancer will ebb.

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Feb 22·edited Feb 22

I'd rather take this $1K test than have a colonoscopy or a mammogram. Why? Because it's less invasive. The biggest problem with cancer screening, in my opinion, is how invasive it is.

But Adam, what you fear is the second biggest problem - that you're pressured to act - whether it's a mammogram or your yearly flu/covid/etc. shot or being forced to dive into chemotherapy instead of taking a wait-and-see attitude. Isn't that what you're really afraid of - not the test itself? Unfortunately, that's the benefit and curse of universally available, government funded health care. When someone else is paying the bill, you *must* take the test or do the intervention because you'd be crazy not to. Which leads to your third complaint - this isn't a bottomless cup of money, but people treat it like it is.

The pressure to take an intervention is a VERY serious problem - and it's extremely pervasive. And I think this is what you're truly worried about. And I absolutely agree. Which is why I don't get these tests in the first place and then people think I'm crazy. But once that test comes back positive, you *have to act*. From the stories of other commenters here being pressured to remove their thyroid to people refusing vaccines and being denied organ transplants, the system will pressure you to do it's will.

And this was especially rampant during Covid:

https://www.npr.org/2022/01/26/1076004339/heart-transplant-patient-unvaccinated

https://arstechnica.com/science/2021/10/unvaccinated-patients-are-getting-kicked-off-organ-transplant-waitlists/

And here's one where the PARENTS weren't vaccinated and the child was denied heart surgery:

https://www.newsweek.com/3-year-old-reportedly-denied-heart-treatment-because-parents-were-unvaccinated-1674707

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