Differences over "policies" on screening only arise when the system is collectivistic. In an individualistically oriented world, each person can measure their own cost/benefit ratio. Benefits are entirely individualistic while collectivistic costs make it impossible to calculate a true cost/benefit analysis. The only certainty is that the costs will continue to rise up to the level of tolerance and acceptability set by the insurer or whatever organization is actually paying the bill.
Agreed. In terms of public health, no screening makes sense, personally, not so much. Death by cancer is a particularly horrible way to die. Give me a fatal MI/stroke/aneurysm/motor vehicle accident/asteroid strike. OK, if not immediately fatal, there can be long lingering but it's not clear to me that the pain (of surviving an ultimately fatal CV attack) comes anything close to that inflicted by cancer treatments and the cancer itself. I watched a dear neighbor stop colonoscopy in her 70s and then succumb to CRC. No thanks.
I’m still got screening, at least for people under 75 (I’m not a doctor but interested in health). Colon cancer is no fun, even if you survive it. The surgery is painful; you may need a colonoscopy bag for life (extremely life-limiting); or have to do chemotherapy. The three people I know who had colon cancer but survived (all had it at least 15 years ago and are still alive and cancer free) went through hell, despite beating the cancer. Colonoscopy removed the polyps, thereby preventing cancer in the first place and the treatment hell.
Mammography is a different story. I’m more sympathetic to choosing not to have a mammogram, as you could have a small cancer that’s slow growing and won’t kill you, but the treatment might.
Very good post. And when you factor in Lead time Bias and Length time bias, the screening of the well population makes no sense at all. But humans make decisions based on emotion, not reason or data, something I have learned trying to teach EBM to students over the years. In covid, our politicians and health bureaucrats spent Billions doing PCR tests on well patients for god's sake ! This alone convinced me that humans are just irrational and you are probably wasting your breath ( or typing hand , lol. )
With cologard style tests, why not just use them? If something hideous is found, then decide on next steps. Why subject everyone to a test that generally isn't adding to longevity in majority of people?Additionally, The public generally doesn't want to address stats on those topics. And even worse big pharma hides real data, skews it, then people get even more confused. A .05% difference between tested v. nontested isn't enough to make me risk a puncture from a colonoscopy, esp if I have zero family history of the disease. Not to mention the horrible consequenses from being sedated repeatedly. No one even mentioned your long term risks from sedations....
We are stuck in the early detection mentality of the 1970s and 80s, which was predicated on a belief that we could catch disease early in every patient and that cancer was a single disease. Now that we know better, we need personalized screening. Personalized means complicated which means one size does not fit all and that will be difficult. The other part about screening is that no one is in charge. It’s the same with cancer prevention. No primary care physician or even breast surgeon/gastroenterologist is paid for counseling and prevention of disease. It will require a reboot of the system to prioritize this prevention and early detection model.
You are correct that the perceived benefit of CRC screening is orders larger than the actual benefit, and we should modify public policy accordingly. But competing risks do not logically defeat screening, and one bad test may be insufficient evidence for stopping testing of asymptomatic people entirely. If the significant risk of death accumulates from additive, unrelated, statistically insignificant components, we ought to improve screening technologies such that they can reduce some of these component-risk-factors and ultimately reduce the significant death risk.
We shouldn't really conflate one test's merit with the entire screening enterprise. After all, today's paradigms are not tomorrow's, and it's not clear when these paradigms shift.
Isn’t the better conclusion that invasive, single-disease screening needs a very high evidentiary bar when the absolute cause-specific mortality risk is tiny?
The assessment is different when N=1 (you) vs N=100,000,000. “Sorry you’ve got colon cancer but most of the other people didn’t need screening” isn’t a very comforting support for withholding readily available testing. Same for PSA tests: I don’t really care about everybody else’s odds too much when it comes down to checking ME.
I had one parent die of it at 69. My old GE doctor said that made me high risk. He retired. My new GE doctor says no, to be considered high risk I need TWO family members to have died of it, even if they’ve died from all kinds of other cancer (breast, uterine, ovarian).
Is this rationing healthcare for old people or is it reasonable?
I see the point , but I don't want to die of something preventable because it costs money. I'm not willing to play the odds with health issues. As long as I can cover costs, I will practice preventive self care. BTW cash pay for colonoscopy is surprisingly inexpensive.
Keeping in mind also that most adenoma do not progress, and some regress. For example, at autopsy at least 30-40% of people have adenomas, and the adenoma detection rarte in 40 year olds is 30% or more, yet 30% of people do not get colon cancer, and that was true before colonoscopies.
The VA likely funded it based on the influence of a key UCSD-administrator (Vice-Chancellor for Health Sciences), probably as a bonus check for past service (is that about right, Dr Carethers).
The data highlight competing mortality risk, especially in older adults, but this should refine rather than dismiss screening. Evidence shows colorectal screening lowers cancer incidence and mortality, so decisions should be individualized based on age, comorbidity, and life expectancy rather than a single risk comparison.
A better heuristic is to ignore what tests are available in the marketplace and identify your own top tier health risks and address those through 1. Lifestyle 2. Medications (if needed) 3. Specific testing. With #1 separated by 10 miles from #2, which is a mile apart from #3.
Differences over "policies" on screening only arise when the system is collectivistic. In an individualistically oriented world, each person can measure their own cost/benefit ratio. Benefits are entirely individualistic while collectivistic costs make it impossible to calculate a true cost/benefit analysis. The only certainty is that the costs will continue to rise up to the level of tolerance and acceptability set by the insurer or whatever organization is actually paying the bill.
Agreed. In terms of public health, no screening makes sense, personally, not so much. Death by cancer is a particularly horrible way to die. Give me a fatal MI/stroke/aneurysm/motor vehicle accident/asteroid strike. OK, if not immediately fatal, there can be long lingering but it's not clear to me that the pain (of surviving an ultimately fatal CV attack) comes anything close to that inflicted by cancer treatments and the cancer itself. I watched a dear neighbor stop colonoscopy in her 70s and then succumb to CRC. No thanks.
I’m still got screening, at least for people under 75 (I’m not a doctor but interested in health). Colon cancer is no fun, even if you survive it. The surgery is painful; you may need a colonoscopy bag for life (extremely life-limiting); or have to do chemotherapy. The three people I know who had colon cancer but survived (all had it at least 15 years ago and are still alive and cancer free) went through hell, despite beating the cancer. Colonoscopy removed the polyps, thereby preventing cancer in the first place and the treatment hell.
Mammography is a different story. I’m more sympathetic to choosing not to have a mammogram, as you could have a small cancer that’s slow growing and won’t kill you, but the treatment might.
Very good post. And when you factor in Lead time Bias and Length time bias, the screening of the well population makes no sense at all. But humans make decisions based on emotion, not reason or data, something I have learned trying to teach EBM to students over the years. In covid, our politicians and health bureaucrats spent Billions doing PCR tests on well patients for god's sake ! This alone convinced me that humans are just irrational and you are probably wasting your breath ( or typing hand , lol. )
Having said that, I do applaud your efforts!
With cologard style tests, why not just use them? If something hideous is found, then decide on next steps. Why subject everyone to a test that generally isn't adding to longevity in majority of people?Additionally, The public generally doesn't want to address stats on those topics. And even worse big pharma hides real data, skews it, then people get even more confused. A .05% difference between tested v. nontested isn't enough to make me risk a puncture from a colonoscopy, esp if I have zero family history of the disease. Not to mention the horrible consequenses from being sedated repeatedly. No one even mentioned your long term risks from sedations....
We are stuck in the early detection mentality of the 1970s and 80s, which was predicated on a belief that we could catch disease early in every patient and that cancer was a single disease. Now that we know better, we need personalized screening. Personalized means complicated which means one size does not fit all and that will be difficult. The other part about screening is that no one is in charge. It’s the same with cancer prevention. No primary care physician or even breast surgeon/gastroenterologist is paid for counseling and prevention of disease. It will require a reboot of the system to prioritize this prevention and early detection model.
You are correct that the perceived benefit of CRC screening is orders larger than the actual benefit, and we should modify public policy accordingly. But competing risks do not logically defeat screening, and one bad test may be insufficient evidence for stopping testing of asymptomatic people entirely. If the significant risk of death accumulates from additive, unrelated, statistically insignificant components, we ought to improve screening technologies such that they can reduce some of these component-risk-factors and ultimately reduce the significant death risk.
We shouldn't really conflate one test's merit with the entire screening enterprise. After all, today's paradigms are not tomorrow's, and it's not clear when these paradigms shift.
Isn’t the better conclusion that invasive, single-disease screening needs a very high evidentiary bar when the absolute cause-specific mortality risk is tiny?
The assessment is different when N=1 (you) vs N=100,000,000. “Sorry you’ve got colon cancer but most of the other people didn’t need screening” isn’t a very comforting support for withholding readily available testing. Same for PSA tests: I don’t really care about everybody else’s odds too much when it comes down to checking ME.
I had one parent die of it at 69. My old GE doctor said that made me high risk. He retired. My new GE doctor says no, to be considered high risk I need TWO family members to have died of it, even if they’ve died from all kinds of other cancer (breast, uterine, ovarian).
Is this rationing healthcare for old people or is it reasonable?
I see the point , but I don't want to die of something preventable because it costs money. I'm not willing to play the odds with health issues. As long as I can cover costs, I will practice preventive self care. BTW cash pay for colonoscopy is surprisingly inexpensive.
We look because we can.
If anything, screening simply shifts the causes of death from one chapter of the ICD-11 to another.
Keeping in mind also that most adenoma do not progress, and some regress. For example, at autopsy at least 30-40% of people have adenomas, and the adenoma detection rarte in 40 year olds is 30% or more, yet 30% of people do not get colon cancer, and that was true before colonoscopies.
That study should have never been funded.
The VA likely funded it based on the influence of a key UCSD-administrator (Vice-Chancellor for Health Sciences), probably as a bonus check for past service (is that about right, Dr Carethers).
The data highlight competing mortality risk, especially in older adults, but this should refine rather than dismiss screening. Evidence shows colorectal screening lowers cancer incidence and mortality, so decisions should be individualized based on age, comorbidity, and life expectancy rather than a single risk comparison.
A better heuristic is to ignore what tests are available in the marketplace and identify your own top tier health risks and address those through 1. Lifestyle 2. Medications (if needed) 3. Specific testing. With #1 separated by 10 miles from #2, which is a mile apart from #3.