As a nation and profession, we have agreed that cancer screening is a worthy place to spend healthcare dollars. However, for screening to be successful, physicians and guideline producing societies should speak with one voice.
Can you clarify what you mean by, "We would suggest that there should be agreement that harms of screening are unlikely to prevent overall mortality benefits." Are you stating that because screening can cause harms (including mortality), we should not expect lower overall mortality from screening? That seems a point of contention for most screening programs: many decrease disease-specific mortality, but increase other harms due to overscreening/overtreatment.
Saving hundreds of thousands with screenings? Meanwhile, over 600,000 people die from cancer every year. Looks to me that if you get a positive screening for cancer, your survival rates aren't that great.
There are always safer alternatives for cancer treatment in many cases outside of the mainstream cancer mafia...which is extremely close minded and arrogant. Chemo is not anything I would ever try. I have known only one or two people that survived cancer and chemo over the last 55 years out of dozens of cases. No thanks...I do not trust the medical system.
So-called cancer screening is a scam intended to promote more health expenditures at the expense of actual health. When it is examined objectively, there is a strong argument to be made against prostate, breast and colorectal cancer screening. But it is rarely examined objectively and almost everything issued on the subject is propaganda.
The issue of false positives, the extreme costs of these, and over—treatment, is rarely addressed anywhere. Often the NNT is over 1000, and the costs to patient health is too high.
For prostate cancer, there has developed a regime of “active surveillance” aka “watchful waiting” which is a fancy term for doing nothing — and it has been shown to be effective. 24% of tumors disappeared in one study I read. The data was there but the study authors dared not even remark on this.
In fact cancers routinely disappear on their own, but this is never studied and never remarked upon.
In the face of such murkiness, as someone said upthread, it comes down to an informed discussion between a patient and their doctor. The challenge arises when doctors are pressed to have all of their patients get screened as a matter of course. Where I live, we have an entire provincial program for breast cancer screening. And by the way, you haven't lived until you've had a mammogram on a bus :-).
I also understand why you'd want to use all cause mortality as an end point in evaluating the impact of screening. However, I wonder how you'd evaluate quality of life. So my cancer is dealt with early but I'll be taken out by heart disease or detentia because I live longer? And maybe I will have long term side effects from my cancer treatment.
So in the end, I have a good doctor who is willing to make decisions with me. But I am a relatively informed patient and not every one is.
Thank you for a very nice summary of this issue from a medical perspective. Another perspective that deserves greater attention is the psychological impact of screening, which identifies many people as having cancer who would never have experienced symptoms, much less died, from this cancer. As Gilbert Welch has noted, cancer screening often identifies "turtles", or cancers that may be very small and slow growing, and without screening people would have died "with" rather than "from" the cancer. Cancer screening has generated an army of people who view themselves as "cancer survivors". This is lifelong label as being a patient, one who has presumably been "saved" from death by cancer screening. CDC statistics show 239,612 breast cancer survivors and 42,273 breast cancer deaths in 2020. How many of these people who now have a life-long self image, and image by their families, employers, etc., as a cancer survivor had a cancer that was identified by screening that identified a cancer that would have been asymptomatic and not affected their longevity? https://www.cdc.gov/cancer/uscs/about/stat-bites/stat-bite-breast.htm
If providers are so cowed politically and economically NOT to tell you the truth about the real hazards of the vaccine then how would you come to believe anything they say now days. The medical profession now has a huge yellow streak up their backs now....and Big Pharma control their voices and their ethics...shameful at best and potentially lethal to us as patients.
I can definitely understand and appreciate the general idea of this but in practice, the single voice really falls apart for certain illnesses. As a cancer patient who speaks with many patients, the concept of every patient being unique is abundantly clear. SOC May work for a broken arm or a bad ticker, but it’s been a nightmare for the vast majority of cancer patients I know. I also think there are inherent issues in the equation like patients overly deferring to physicians or not sharing all details or doctors making assumptions or just not having time due to the constraints of being part of a business. And that’s even everything that comes to mind as someone who isn’t a medical professional. At least 4 doctors dissuaded me from getting tests that might’ve helped me avoid many serious issues because I was such an unlikely candidate for the scary stuff. And I wasn’t told either that I wasn’t even told about certain tests because the doctors knew insurance would decline covering the tests assuming I wouldn’t pay out of pocket (I would). I would love the idea of a single voice but that also assumes all docs are equal in quality and patients will react the same to certain situations. Neither is true. I applaud the intention of this post but I think it’s way more complicated.
Fantastic article wrt laying out the potential criteria/endpoints that a cancer screening program ought to address.
I think the NordICC study was an important and enlightening addition to the evidence landscape. I think pragmatic trials of “strategies “ can be hard to do well; so well done by the authors.
This highlights what to do from a population standpoint, but of course there are individual values and preferences. As others have commented, there are intermediate endpoints btw “cancer diagnosis “ and “cancer specific mortality” that may be of importance to Individual pts, like extent of required therapy and avoidance of things like total colectomy. I know those considerations factored in heavily for me. The $64,000 question was of course whether removal of a benign polyp today changes the aformentioned downstream outcomes, and nobody knows….nor would there seem to be any easy way to study that. That introduces an even broader policy question of at what point society should pay for something, vs it being a personal cost for a personal choice.
So, to be clear, terminology wise, screening (a one-step test) is what healthy people would receive to know the potential, the existence of cancer? Testing (a multiple set of specific tests for a specific type cancer) is given to people who have had a positive screening? What about those people who never get tested because they would not accept the treatments for cancer? When those people come in because they have their yearly physical or they aren't feeling "right" and the doctor suspects cancer, what then? Should there be a document similar to a POLST, or a living will where it's agreed that the doctor won't test nor discuss a professional opinion of the probability of existing cancer with that person? With what Dr. Chow and Dr. Cifu have written and with what I just wrote it seems like the waters are murky at best.
An argument against using reduction in all-cause mortality as an end point in evaluating screening, from a patient's point of view, is that screening may identify a cancer at an earlier stage requiring less radical treatment. As a patient, I would prefer living the rest of my life without, for example, a colonostomy if the colonoscopy can identify a cancer or pre-cancer before extensive surgery is required. Avoiding extensive cancer treatment, including radiation and chemo, would be a persuasive argument for cancer screening for me.
The various treatments for advanced cancer can have serious side effects, some permanent, such as neurological problems, impotence, need for a colostomy, missing a spleen, a kidney, or a limb, and so on. An asymptomatic cancer detected by screening at the earliest stage can often be treated and “cured” with surgery only, avoiding the most toxic treatments and their after effects.
My rational side agrees with this article completely, while my emotional side says early colonoscopy probably would have saved the life of my father and also a good friend, both of whom died of colon cancer at age 56. Given my family history and personal history of colon adenomas, I will continue to get colonoscopies, although I'm unsure when I'll stop. I hope research focuses on safer screening measures with non-invasive variables to help guide who would most benefit from a colonoscopy. Perhaps a risk score could be derived based on age, family history, biomarkers (link #1) and gut microbiome (link #2).
I am one who got the routine at age 54. Polyps. lots of them were found. Come back in six months - more polyps; let's try three months, indeed fewer but still polyps. Reworked diet a lot and the exams relaxed to every six months. GI suggested colon removal which after checking several other doctors, I rejected and got a new GI doc. (At the time laparoscopic surgery was fairly new). Even got down to a yearly exam and even a genetic test but always a few to many polyps found. Then one day when I was ~ 70, the exam found a mass, a rapidly growing one unusual for colon cancer. Few days later the colon removed by laparoscopic surgery, a sub-total so no stoma. Did a bit of chemo as prophylactic, no fun at all, debilitating. I await my maker at 83. My Onco follow ons have been routine but watchful. Asked if I would repeat chemo should something happen and I noted doubtful given my current frailty. No more partner to help me with the struggle.
But the screenings were preventive in the end. No apparent spread despite seven lymph nodes involved.
You have been through a lot and are still here to share your story, and I thank you so much for doing so. I will always remember it. I wish you the best!
There is a fundamental problem with labeling tests as "negative" and "positive" when in fact the diagnostic uncertainty is on a continuum. Binary test classification also invites group rather than individual-patient decision making, going against a professed belief in personalized medicine. One of the beauties of continuous risk-based decision making, besides doing away with arbitrary notions of "false negative" and "false positive" is that intermediate risk estimates mean what they say, providing a gray zone indicating "we don't know enough" and that perhaps intensified monitoring or another test is in order.
You mention that physicians are no longer permitted to accept gifts from pharmaceutical companies, I assume in the US. But the CMS database records what physicians are paid each year for dinners, vacations (miscellaneous), consulting, and promotional speaking. And these are on top of research grants.
For example, an oncologist who treated a close friend for head and neck cancer this year took in $700,000+ over the years 2018-2022 for consulting, promotional speaking, travel etc. That's on top of several million for research. Most of that was from Merck, who make the immunotherapy drug that this doctor is a big believer in. It's hard to see how he could be objective about its benefits/harms.
Wouldn't this relationship also exist between doctors and the companies involved in screening technologies? Because of this question and others I avoid cancer screening, especially colonoscopy and mammography.
Can you clarify what you mean by, "We would suggest that there should be agreement that harms of screening are unlikely to prevent overall mortality benefits." Are you stating that because screening can cause harms (including mortality), we should not expect lower overall mortality from screening? That seems a point of contention for most screening programs: many decrease disease-specific mortality, but increase other harms due to overscreening/overtreatment.
Saving hundreds of thousands with screenings? Meanwhile, over 600,000 people die from cancer every year. Looks to me that if you get a positive screening for cancer, your survival rates aren't that great.
There are always safer alternatives for cancer treatment in many cases outside of the mainstream cancer mafia...which is extremely close minded and arrogant. Chemo is not anything I would ever try. I have known only one or two people that survived cancer and chemo over the last 55 years out of dozens of cases. No thanks...I do not trust the medical system.
So-called cancer screening is a scam intended to promote more health expenditures at the expense of actual health. When it is examined objectively, there is a strong argument to be made against prostate, breast and colorectal cancer screening. But it is rarely examined objectively and almost everything issued on the subject is propaganda.
The issue of false positives, the extreme costs of these, and over—treatment, is rarely addressed anywhere. Often the NNT is over 1000, and the costs to patient health is too high.
For prostate cancer, there has developed a regime of “active surveillance” aka “watchful waiting” which is a fancy term for doing nothing — and it has been shown to be effective. 24% of tumors disappeared in one study I read. The data was there but the study authors dared not even remark on this.
In fact cancers routinely disappear on their own, but this is never studied and never remarked upon.
In the face of such murkiness, as someone said upthread, it comes down to an informed discussion between a patient and their doctor. The challenge arises when doctors are pressed to have all of their patients get screened as a matter of course. Where I live, we have an entire provincial program for breast cancer screening. And by the way, you haven't lived until you've had a mammogram on a bus :-).
I also understand why you'd want to use all cause mortality as an end point in evaluating the impact of screening. However, I wonder how you'd evaluate quality of life. So my cancer is dealt with early but I'll be taken out by heart disease or detentia because I live longer? And maybe I will have long term side effects from my cancer treatment.
So in the end, I have a good doctor who is willing to make decisions with me. But I am a relatively informed patient and not every one is.
Thank you for a very nice summary of this issue from a medical perspective. Another perspective that deserves greater attention is the psychological impact of screening, which identifies many people as having cancer who would never have experienced symptoms, much less died, from this cancer. As Gilbert Welch has noted, cancer screening often identifies "turtles", or cancers that may be very small and slow growing, and without screening people would have died "with" rather than "from" the cancer. Cancer screening has generated an army of people who view themselves as "cancer survivors". This is lifelong label as being a patient, one who has presumably been "saved" from death by cancer screening. CDC statistics show 239,612 breast cancer survivors and 42,273 breast cancer deaths in 2020. How many of these people who now have a life-long self image, and image by their families, employers, etc., as a cancer survivor had a cancer that was identified by screening that identified a cancer that would have been asymptomatic and not affected their longevity? https://www.cdc.gov/cancer/uscs/about/stat-bites/stat-bite-breast.htm
If providers are so cowed politically and economically NOT to tell you the truth about the real hazards of the vaccine then how would you come to believe anything they say now days. The medical profession now has a huge yellow streak up their backs now....and Big Pharma control their voices and their ethics...shameful at best and potentially lethal to us as patients.
I can definitely understand and appreciate the general idea of this but in practice, the single voice really falls apart for certain illnesses. As a cancer patient who speaks with many patients, the concept of every patient being unique is abundantly clear. SOC May work for a broken arm or a bad ticker, but it’s been a nightmare for the vast majority of cancer patients I know. I also think there are inherent issues in the equation like patients overly deferring to physicians or not sharing all details or doctors making assumptions or just not having time due to the constraints of being part of a business. And that’s even everything that comes to mind as someone who isn’t a medical professional. At least 4 doctors dissuaded me from getting tests that might’ve helped me avoid many serious issues because I was such an unlikely candidate for the scary stuff. And I wasn’t told either that I wasn’t even told about certain tests because the doctors knew insurance would decline covering the tests assuming I wouldn’t pay out of pocket (I would). I would love the idea of a single voice but that also assumes all docs are equal in quality and patients will react the same to certain situations. Neither is true. I applaud the intention of this post but I think it’s way more complicated.
It astounds me that in 2023 this even needs to be said but thank you for saying it.
Mostly cancer screening still involves an awful lot of magical thinking in my opinion.
Fantastic article wrt laying out the potential criteria/endpoints that a cancer screening program ought to address.
I think the NordICC study was an important and enlightening addition to the evidence landscape. I think pragmatic trials of “strategies “ can be hard to do well; so well done by the authors.
This highlights what to do from a population standpoint, but of course there are individual values and preferences. As others have commented, there are intermediate endpoints btw “cancer diagnosis “ and “cancer specific mortality” that may be of importance to Individual pts, like extent of required therapy and avoidance of things like total colectomy. I know those considerations factored in heavily for me. The $64,000 question was of course whether removal of a benign polyp today changes the aformentioned downstream outcomes, and nobody knows….nor would there seem to be any easy way to study that. That introduces an even broader policy question of at what point society should pay for something, vs it being a personal cost for a personal choice.
So, to be clear, terminology wise, screening (a one-step test) is what healthy people would receive to know the potential, the existence of cancer? Testing (a multiple set of specific tests for a specific type cancer) is given to people who have had a positive screening? What about those people who never get tested because they would not accept the treatments for cancer? When those people come in because they have their yearly physical or they aren't feeling "right" and the doctor suspects cancer, what then? Should there be a document similar to a POLST, or a living will where it's agreed that the doctor won't test nor discuss a professional opinion of the probability of existing cancer with that person? With what Dr. Chow and Dr. Cifu have written and with what I just wrote it seems like the waters are murky at best.
An argument against using reduction in all-cause mortality as an end point in evaluating screening, from a patient's point of view, is that screening may identify a cancer at an earlier stage requiring less radical treatment. As a patient, I would prefer living the rest of my life without, for example, a colonostomy if the colonoscopy can identify a cancer or pre-cancer before extensive surgery is required. Avoiding extensive cancer treatment, including radiation and chemo, would be a persuasive argument for cancer screening for me.
Of course the corollary of this is that much of this perceived benefit is simply living with the diagnosis longer.
The various treatments for advanced cancer can have serious side effects, some permanent, such as neurological problems, impotence, need for a colostomy, missing a spleen, a kidney, or a limb, and so on. An asymptomatic cancer detected by screening at the earliest stage can often be treated and “cured” with surgery only, avoiding the most toxic treatments and their after effects.
Sure.and those same surgeries can lead to iatrogenic complications including death.
My rational side agrees with this article completely, while my emotional side says early colonoscopy probably would have saved the life of my father and also a good friend, both of whom died of colon cancer at age 56. Given my family history and personal history of colon adenomas, I will continue to get colonoscopies, although I'm unsure when I'll stop. I hope research focuses on safer screening measures with non-invasive variables to help guide who would most benefit from a colonoscopy. Perhaps a risk score could be derived based on age, family history, biomarkers (link #1) and gut microbiome (link #2).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7432436/
https://www.sciencedirect.com/science/article/pii/S2590097822000039
I am one who got the routine at age 54. Polyps. lots of them were found. Come back in six months - more polyps; let's try three months, indeed fewer but still polyps. Reworked diet a lot and the exams relaxed to every six months. GI suggested colon removal which after checking several other doctors, I rejected and got a new GI doc. (At the time laparoscopic surgery was fairly new). Even got down to a yearly exam and even a genetic test but always a few to many polyps found. Then one day when I was ~ 70, the exam found a mass, a rapidly growing one unusual for colon cancer. Few days later the colon removed by laparoscopic surgery, a sub-total so no stoma. Did a bit of chemo as prophylactic, no fun at all, debilitating. I await my maker at 83. My Onco follow ons have been routine but watchful. Asked if I would repeat chemo should something happen and I noted doubtful given my current frailty. No more partner to help me with the struggle.
But the screenings were preventive in the end. No apparent spread despite seven lymph nodes involved.
You have been through a lot and are still here to share your story, and I thank you so much for doing so. I will always remember it. I wish you the best!
There is a fundamental problem with labeling tests as "negative" and "positive" when in fact the diagnostic uncertainty is on a continuum. Binary test classification also invites group rather than individual-patient decision making, going against a professed belief in personalized medicine. One of the beauties of continuous risk-based decision making, besides doing away with arbitrary notions of "false negative" and "false positive" is that intermediate risk estimates mean what they say, providing a gray zone indicating "we don't know enough" and that perhaps intensified monitoring or another test is in order.
I am having a very hard time understanding how that approach could be scalable.
One patient one doctor one condition. Maybe.
Show us as proof of concept how it would work with 10 PCPs, their patient load and 4 or 5 conditions. Surely you could find 10 PCPs to sign on.
Do you think you'd make it through a year?
Go ahead, we await results. You'll be first to win Nobel both in Medicine and Economics.
You mention that physicians are no longer permitted to accept gifts from pharmaceutical companies, I assume in the US. But the CMS database records what physicians are paid each year for dinners, vacations (miscellaneous), consulting, and promotional speaking. And these are on top of research grants.
For example, an oncologist who treated a close friend for head and neck cancer this year took in $700,000+ over the years 2018-2022 for consulting, promotional speaking, travel etc. That's on top of several million for research. Most of that was from Merck, who make the immunotherapy drug that this doctor is a big believer in. It's hard to see how he could be objective about its benefits/harms.
Wouldn't this relationship also exist between doctors and the companies involved in screening technologies? Because of this question and others I avoid cancer screening, especially colonoscopy and mammography.