Thank you for this series of posts. Can one or more of you write or do a podcast on the use of breast cancer models to guide individual screening decisionmaking in BRCA negative women? Do you have an opinion on models that incorporate extended panel test results and PRS? Is there any hope for an assist from AI soon?
I’m a woman who got caught by this before age 40 (false positive, biopsy, surgery to remove a rare incidentaloma that wasn't even of breast cell origin, life insurance headaches because underwriters have no idea what to do with the sh*t you guys found, whopping bills from my high deductible plan.).
Read afterward that these models perform slightly better than a coin flip at discriminating between women who will & wont get cancer, and as you say, the cost/benefit for breast screening in BRCA negative women is not as positive as the pink ribbon industrial complex suggests..
Recently read that 45% of women are classified as high risk by at least one of 3 leading risk models.
At the end of my saga my doctor
offered me a dose of Xanax to get through the screening mammograms, ultrasounds, and MRIs. I honestly paused and looked around expecting some TV personality to pop out from behind a curtain to finally reveal that I was the object of some kind of reality TV show prank. It didn’t happen, but hey, I get to participate in a new episode every year for the rest of my life, so perhaps it’s still coming?
Thanks for the follow up post. I am more on the "screening should be a choice" not a metric.
However, viven consolidation in healthcare, large organizations will push for more screening via advertising--essentially controlling the narrative.
Examples include:
- In October there is huge push to get mammograms. There are organizations that hold "parties" where women can get mammogram, Hors d'oeuvre and wine.
- Employers and payers will pay people to get their cancer screening tests (and more egregiously will mail FIT test if they don't have colon cancer screening data)
- Several life insurance policies still require PSA testing and will require further diagnostics before covering people.
All of these send a message to the masses that screening is beneficial, otherwise why is everyone doing it!
1. What is purpose of just changing what people die from rather than when people die. It makes no sense. If you make it to your life expectancy at birth - you've won the lottery.
2. Big quibble and pushback with one word in one sentence: "... but do we really need to stress test the overworked, underpaid primary care physician?" Quit the complaining about allegedly being "underpaid". There is no primary care physician that is poor. I don't even think there is a primary care physician whose household is below either the median or mean household income. 75th percentile: $244,500 annually; Average: $217,445; 25th percentile: $190,000. (I think lowest is 120K.)
If you entered the medical profession to be a 1%er , or even a 5%er - you became a doctor for the wrong reason.
Yes, mammograms can cause cancer and are not a good marker for cancer, PSA is not indicative of prostate cancer, chemo and radiation do not kill cancer stem cells. Hmmm... what is stored in the thyroid, salivary glands, breasts, pancreas, ovaries and prostate? Iodine. Maybe the lack of iodine is a vector for cancer.
GREAT commentary Adam! The reality is that we just don't know the "best answer" — therefore, the "ideal" would be for each patient to make an informed consent decision for themself — but —realistically, this is not something many patients feel comfortable doing (or want to do) — therefore, what "gets done" ends up being heavily infuenced by the way in which each patient's clinician practices (which may or may not be a good thing, depending .... ). But as the "2nd-smartest doctor" in your household — your write-up is SUPERB! Thank you — :)
In Switzerland, where I live, women without a family history of breast cancer are offered mammograms every other year between the ages of 50 and 70. This is in contrast with the US, where women without a family history start receiving annual mammograms at age 40 and continue well into their 80s. Even though Switzerland does much less screening for breast cancer than the US does, the death rate from breast cancer here is about the same as it is in the US.
Similarly, asymptomatic people without a family history of colon cancer are not offered colonoscopy. Instead, beginning at age 50, we are offered annual FIT tests. Again, the colon cancer death rate in Switzerland is comparable to that of the US.
It seems obvious to me that the costs of all this extra testing in the US—not just financial, but also the waste of time and needless stress, inconvenience, and pain—is not worth the benefits.
The cancer screening data is outside of my expertise, so I have much to learn about those, for personal interest (since I have a wife and 2 daughters, and am proud owner of a prostate and a colon).
But the CV and PVD cases from last week were egregious, and I hope they weren’t “real patients”.
As for this week’s screening “wins”….those are sure to occur ….if one (or society) does enough screening. The counterfactual is how much harm, or waste, is incurred in securing those “wins”.
In that sense, although I find studies of “screening” more difficult to parse than studies of therapy, the bottom line should be the same. Among all the screening tests under the Sun that we “could” do, we need RCT to determine which screening tests we “should” do. And we need cost effectiveness analyses to further determine which tests are worth doing, or that society can afford doing. We get nowhere based on anecdotes (of wins, or otherwise).
On the one hand last week's post felt like something was missing. On the other hand, it seemed like that missing piece reflected the subject matter....we don't and can't know the counterfactuals in each case.
I go back n forth on this. My daughter was saved by a routine mammogram that discovered melanoma. She’s currently cancer free but went through surgery, radiation, and immunotherapy. She likely would not have survived had it not been caught. I have had colonoscopy and crohns was discovered (we had all continued to think it was lingering effects from CDIFF). I still though, subscribe to the statement that “nothing is more dangerous to health than an over care of it.”
Wow. I don't know what to think. I REALLY liked last week's post. Maybe the "literary" format was too alien for folks expecting exposition more in line with peer-reviewed medical literature? It was thought-provoking, caused the reader to reflect. "To screen, or not to screen, that is the question." I think there is some prominent figure in English Literature who receive much acclaim for writing a piece very similar in tone.
"What gets measured gets managed." -- Peter Drucker
Humans have an action bias (DO something!). So we should work hard to improve the validity of our measurement tools, diagnostic and otherwise, so the actions they trigger are as beneficial as possible. Science, even with its imperfections, is the best validity judge.
Thank you for this series of posts. Can one or more of you write or do a podcast on the use of breast cancer models to guide individual screening decisionmaking in BRCA negative women? Do you have an opinion on models that incorporate extended panel test results and PRS? Is there any hope for an assist from AI soon?
I’m a woman who got caught by this before age 40 (false positive, biopsy, surgery to remove a rare incidentaloma that wasn't even of breast cell origin, life insurance headaches because underwriters have no idea what to do with the sh*t you guys found, whopping bills from my high deductible plan.).
Read afterward that these models perform slightly better than a coin flip at discriminating between women who will & wont get cancer, and as you say, the cost/benefit for breast screening in BRCA negative women is not as positive as the pink ribbon industrial complex suggests..
Recently read that 45% of women are classified as high risk by at least one of 3 leading risk models.
At the end of my saga my doctor
offered me a dose of Xanax to get through the screening mammograms, ultrasounds, and MRIs. I honestly paused and looked around expecting some TV personality to pop out from behind a curtain to finally reveal that I was the object of some kind of reality TV show prank. It didn’t happen, but hey, I get to participate in a new episode every year for the rest of my life, so perhaps it’s still coming?
Thanks for the follow up post. I am more on the "screening should be a choice" not a metric.
However, viven consolidation in healthcare, large organizations will push for more screening via advertising--essentially controlling the narrative.
Examples include:
- In October there is huge push to get mammograms. There are organizations that hold "parties" where women can get mammogram, Hors d'oeuvre and wine.
- Employers and payers will pay people to get their cancer screening tests (and more egregiously will mail FIT test if they don't have colon cancer screening data)
- Several life insurance policies still require PSA testing and will require further diagnostics before covering people.
All of these send a message to the masses that screening is beneficial, otherwise why is everyone doing it!
Thank you for thoughtful follow-up essay.
1. What is purpose of just changing what people die from rather than when people die. It makes no sense. If you make it to your life expectancy at birth - you've won the lottery.
2. Big quibble and pushback with one word in one sentence: "... but do we really need to stress test the overworked, underpaid primary care physician?" Quit the complaining about allegedly being "underpaid". There is no primary care physician that is poor. I don't even think there is a primary care physician whose household is below either the median or mean household income. 75th percentile: $244,500 annually; Average: $217,445; 25th percentile: $190,000. (I think lowest is 120K.)
If you entered the medical profession to be a 1%er , or even a 5%er - you became a doctor for the wrong reason.
Yes, mammograms can cause cancer and are not a good marker for cancer, PSA is not indicative of prostate cancer, chemo and radiation do not kill cancer stem cells. Hmmm... what is stored in the thyroid, salivary glands, breasts, pancreas, ovaries and prostate? Iodine. Maybe the lack of iodine is a vector for cancer.
GREAT commentary Adam! The reality is that we just don't know the "best answer" — therefore, the "ideal" would be for each patient to make an informed consent decision for themself — but —realistically, this is not something many patients feel comfortable doing (or want to do) — therefore, what "gets done" ends up being heavily infuenced by the way in which each patient's clinician practices (which may or may not be a good thing, depending .... ). But as the "2nd-smartest doctor" in your household — your write-up is SUPERB! Thank you — :)
In Switzerland, where I live, women without a family history of breast cancer are offered mammograms every other year between the ages of 50 and 70. This is in contrast with the US, where women without a family history start receiving annual mammograms at age 40 and continue well into their 80s. Even though Switzerland does much less screening for breast cancer than the US does, the death rate from breast cancer here is about the same as it is in the US.
Similarly, asymptomatic people without a family history of colon cancer are not offered colonoscopy. Instead, beginning at age 50, we are offered annual FIT tests. Again, the colon cancer death rate in Switzerland is comparable to that of the US.
It seems obvious to me that the costs of all this extra testing in the US—not just financial, but also the waste of time and needless stress, inconvenience, and pain—is not worth the benefits.
Still think you are pretty darned good, even if you are not the smartest doctor in your household!
The cancer screening data is outside of my expertise, so I have much to learn about those, for personal interest (since I have a wife and 2 daughters, and am proud owner of a prostate and a colon).
But the CV and PVD cases from last week were egregious, and I hope they weren’t “real patients”.
As for this week’s screening “wins”….those are sure to occur ….if one (or society) does enough screening. The counterfactual is how much harm, or waste, is incurred in securing those “wins”.
In that sense, although I find studies of “screening” more difficult to parse than studies of therapy, the bottom line should be the same. Among all the screening tests under the Sun that we “could” do, we need RCT to determine which screening tests we “should” do. And we need cost effectiveness analyses to further determine which tests are worth doing, or that society can afford doing. We get nowhere based on anecdotes (of wins, or otherwise).
On the one hand last week's post felt like something was missing. On the other hand, it seemed like that missing piece reflected the subject matter....we don't and can't know the counterfactuals in each case.
So well said.
I go back n forth on this. My daughter was saved by a routine mammogram that discovered melanoma. She’s currently cancer free but went through surgery, radiation, and immunotherapy. She likely would not have survived had it not been caught. I have had colonoscopy and crohns was discovered (we had all continued to think it was lingering effects from CDIFF). I still though, subscribe to the statement that “nothing is more dangerous to health than an over care of it.”
Excellent points Jim.
Thanks Dr. Cifu!
"..Many men with an elevated PSA can now be monitored.."
Since there is no correlation between elevated PSA for anything good/bad...what are they monitored for other than potential $..?
The Great prostate Hoax by Ablin covers this subject in depth..
Over diagnosis + capitalism + third party payor + anxiety= $$$$$$
Or, in one word, screening.
Sorry guys, i woke up on the cynical side of the bed today.
It’s from 2012, but the book “How We Do Harm” by Dr. Otis Webb Brawley delves into these issues and is eye opening.
"I am pretty sure we save thousands of people each year with screening tests"
do you mean on balance? Can you show us back of the envelope for that?
Wow. I don't know what to think. I REALLY liked last week's post. Maybe the "literary" format was too alien for folks expecting exposition more in line with peer-reviewed medical literature? It was thought-provoking, caused the reader to reflect. "To screen, or not to screen, that is the question." I think there is some prominent figure in English Literature who receive much acclaim for writing a piece very similar in tone.
"What gets measured gets managed." -- Peter Drucker
Humans have an action bias (DO something!). So we should work hard to improve the validity of our measurement tools, diagnostic and otherwise, so the actions they trigger are as beneficial as possible. Science, even with its imperfections, is the best validity judge.