Cancer Screening: Changing Hype To Hope
    By Hank Campbell | November 27th 2011 09:00 AM | 2 comments | Print | E-mail | Track Comments
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    A problem began to come into existence a few decades ago and in the polarized climate enabled by instant access to partisan spin, it's only going to get worse.

    The problem isn't always that people are anti-science, though documenting the numerous instances of global warming deniers on one side and anti-science hippies on the other is always fun, it may be that people accept science too much - and there is a backlash on the way because people don't always understand that accepting science isn't always going to mean things don't change when new information comes to light.

    For most aspects of science, that works out okay. It makes no difference in the lives of people if they are right or wrong for accepting the latest research on how eyes evolved, yet in medicine, an evidence basis for public statements is vital because people can die.  Thus, the risk of being wrong can often be subordinate to being conservative - there are multi-billion dollar companies in the business of creating marketing campaigns against smoking cigarettes, for example, and it turns out smoking is overhyped, it doesn't cause every ailment and disease like some have claimed it does for decades, but you aren't more likely to get lung cancer if you don't smoke. (1) You may still get lung cancer but 50% of lung cancer victims never smoke so they can't blame smoking.  The conservative money bets on not smoking regardless if whether or not people were bandwagoning and lumping in more diseases to attribute to smoking.

    Conservative thinking has always bet on cancer screenings also - and anyone with common sense accepted the science basis for it.  It turns out the odds of there being no risk are not as clear as we thought. Like I said, in most cases it isn't a problem because people with knowledge of science understand science is not perfect, but when scientists speak with authority (and in modern times, even derision about skepticism or caution) and end up being wrong, it has cultural reverberations.  The modern plague of well-educated progressives who don't believe in vaccines is because they are jaded by claims that scientists are to be trusted on global warming but out to kill us when it comes to food - and there are lots of other examples you can pick favored by the left and the right.  Science then becomes a la carte and a world view issue rather than facts.  It's the last laugh of postmodernism and people across the cultural and political spectrum are guilty of it. 

    Navigating cancer screening is tough. If the National Cancer Institute said various people should be screened, who could argue?  But what they seem to have left out were the risks and benefits of screening and that is a worry to some in medicine now.

    It's easy to understand why this can be an issue on many levels.  If you've seen the concern over personal genetics services, you know why problems happen and politicians take occasionally misguided action; people do not properly understand risk factors nor how to calibrate them but they will blame the science or medical community regardless.  So the NCI debated screening guidelines instead of arguing about who should be screened - that meant everyone should be screened, to doctors who are trying to keep up with the latest recommendations.

    Now the U.S. Preventative Task Force (USPTS) has found that the difference in mortality rates for breast cancer among women who had mammograms and who did not is insignificant, ditto for PSA's and male prostate cancer.  The conservative money says get them anyway, right?  The screenings do not cause cancer, after all.  Well, it is more complicated than that.  The harm from false positives, false negatives, over treatment, and under treatment turns out to be rather substantial.

    A commentary by Michael Edward Stefanek, Ph.D., associate vice president of collaborative research in the office of the vice president at Indiana University, in the Journal of the National Cancer Institute says we should educate the public about cancer screening and engage patients in shared decision making. Imagine the difficulties for most patients if they now have to think about the risks and perils of even getting a cancer screening; imagine the lawsuits when people are tracked by who got cancer after being screened or not. What if insurance companies decide that they are no longer covered?

    "If we agree on the premise that individuals are supposed to be informed before making medical decisions, including decisions about cancer screening, then the time and talent of such groups could be much better spent educating the public on the harms and benefits of cancer screening," Stefanek writes. "Screening can be very beneficial (or not), and screening messages should reflect the complexity of this decision."

    Which sounds very reasonable - but discussions about cancer are not always reasonable(2) and telling people after decades that screening may be doing harm or good, and no one can be sure, is going to polarize anti-science beliefs even more.


    (1) Witness this ridiculous bit of invented economic fluff. The Cap And Trade industry is loving examples of $86 billion 'money saved' as it is used here. Using their math, if people stop smoking every economy in the world is running a financial surplus just on the health care costs they saved. When I went to find this commercial, TobaccoFreeCA was buying the top spot on Google.  They ain't poor.

    (2) Apparently it is taboo to even say the word 'cancer' in a song.  Brad Paisley says so.


    I see what you are saying.  As one comment on a thread of mine mentioned the "harm" that even scientific musings could have I have been thinking about this.   Trusting the numbers you gave, if getting screened only hasa a 50/50 chance of extending you life then it effectively does nothing.  On the other hand what if I was one of the 50% that were helped by it?  The conservative money has to be on cancer screening.
    As for informed consent, one has to wonder about that.  I am no MD and to be honest they know way more than I ever ever could about these issues.  To some extent, we all end up trusting the doctors.  

    It's like this.  Recently a good friend died, she was HIV+.  Yet she did not die of AIDS, something else got her.  Did getting an HIV test really help her?  She was one of many people I know who are HIV+ but don't develop disease to a point where any medication is given, not even anti-retrovirals. 

    I wonder how many people are saved by their seatbelt VS trapped and die because of their seatbelt. Hmm

    Good post, it's one to think on. 
    Science advances as much by mistakes as by plans.
    Nice article, Hank.As a prostate cancer survivor (see my post here as today is my 2 year anniversary of cancer surgery), and as someone whose cancer was detected totally out of the blue at the unexpected age of 42 via PSA screening, it is hard for me to be impartial about PSA screening. I really think it made a difference in my life by allowing me to get my cancer removed probably 8 years earlier than it would have been otherwise, but there are good reasons to think I may be the exception when I think about it with my lab coat on as cancer scientist that I am.

    I am in favor of PSA screening, but not the way we do it now and I have proposed a new plan. In a nutshell, PSA screening the way it is done now will almost always detect cancers for which the detection will have little or no meaningful impact. Why? 3 reasons.

        1) It is a fact that most prostate cancers are not going to kill men so their detection can have no benefit and their detection can only cause harm via stress, prostate biopsies that are literally human torture (they are not done with anesthesia if you can believe it), and unnecessary surgeries and radiation therapy treatments.
        2) The vast majority of men who could be helped most by PSA tests are young men, but paradoxically men are not advised to get PSA tested until age 50 or older. What's a smarter plan? Starting PSA testing at age 40 with an educated rather than arbitrary cutoff for what is considered abnormal and with an interval plan. For example, the lower your PSA, the longer between future tests (e.g. low PSA at age 40, no test again until age 45 or even 50; normal PSA at age 50, no test until age 55 or 60, etc).
        3) The truly dangerous, deadly prostate cancers are sadly those that are the type that like to rapidly spread. The types of prostate cancers that most often will kill you are also the ones that at diagnosis may have already spread beyond the prostate. Tragically, what this means is that all the expense, suffering, and side effects of surgery, radiation, etc., which all target the prostate, may do no good for a lot of patients whose prostate cancer is the deadly type because that cancer has already moved away from the prostate.

    So unfortunately global PSA screening done the way it is today (e.g. defining an abnormal PSA level for a 40 year old and a 70 year old as the same, which is truly crazy) may very well do little good overall as suggested by recent papers. Logically, we need to move to smarter types of cancer screening programs that include more scientifically-based screening still based on mammograms and PSA tests, which still have a powerful place to help people if they are used in a logical way. This is the way to move away from hype and towards hope when it comes to cancer screening. 
    Paul S. Knoepfler, Ph.D. Associate Professor UC Davis School of Medicine