The Problem With Early Cancer Detection
Tuesday, May 21, 2019
Cancer and diet from NIH (Photo credit: Wikipedia)
Early cancer detection was what piqued my interest in magnetic resonance imaging (MRI) technology even before it won FDA approval.
While helping introduce it into mainstream medical practice, however, I learned of the downsides to increasingly sensitive imaging technologies like MRI.
Yes, they enable physicians to detect disease earlier in its progression. But they also detect other benign abnormalities – and the adult human body is often riddled with various lesions and other abnormalities that never pose a threat. The problem occurs in determining which are benign and which are not – and the current state of the science in this regard is far less precise than is generally understood.
Since the early days of CT and MRI in the 70’s and 80’s, imaging technologies have grown even more sensitive – perhaps even hyper-sensitive – in their ability to detect all manner of both disease, including cancer, and benign abnormalities.
But since the distinction between the two isn’t always black-and-white – and the rate at which a suspect abnormality may, or may not, develop into a pre-cancerous or cancerous condition is generally unknown – doctors generally opt for a “conservative” strategy of removing all suspect abnormalities.
But is this aggressiveness really conservative? Isn’t so-called “watchful waiting” to monitor the suspect abnormality rather than subject patients to invasive follow-up tests and toxic treatments actually far more conservative? (See “Angelina Jolie’s Brave Example – and the Other Side of the Story” for more on this).
This is a subject I also discuss in Our Healthcare Sucks in relation to its impact in promoting unnecessary follow-up tests and invasive biopsies and surgeries. But given our collective terror of “The Big C”, it’s fair to ask…
Is It Time to Redefine Cancer?
The National Cancer Institute (NCI) has finally taken the lead by recommending sweeping changes to the nation’s approach to cancer detection and treatment. This includes no longer calling pre-cancerous conditions “cancer”.
In a study published this week in The Journal of the American Medical Association (JAMA), a study of screening program effectiveness found three categories of screenings based on their relative effectiveness. Breast and prostate screening – perhaps primary in the public consciousness – were found to be largely ineffective:
“Screening for breast cancer and prostate cancer appears to detect more cancers that are potentially clinically insignificant.”
Another study published a day later confirmed that watchful waiting of patients with abnormal lobular breast tissue – with properly coordinated imaging and laboratory analyses – would have avoided 3 out of 4 follow-up surgeries.
It’s likely, however, that these suggestions for greater moderation in our approach to cancer will fall on deaf ears – both in the medical and patient communities. Doctors will fear lawsuits if they aren’t aggressive enough and patients will fear having a “cancer” growing in their bodies. And fear is a prime motivator for much of our healthcare (See “America’s Health Scare System“).
Patients can’t generally be expected to understand that whatever abnormality – pre-cancerous or not – that may have been detected by one screening exam or another, there are likely dozens more lurking elsewhere in their bodies (see “Navigating Medical Uncertainty – Disease, Un-ease & Uncertainty“).
Doctors, however, can be expected to understand this – to put suspect abnormalities into a broader clinical perspective that might suggest more caution than is currently the norm. Their willingness to subject patients to unneeded tests and procedures – with their own risks of infection and other complications – reflects their abandonment of the “Do no harm” foundation of medical care.
And then, of course, there’s the ever-prevalent reality of money in medicine. I’ve written previously about the lengths to which many oncologists have been willing to go to preserve and enhance their incomes. This includes increasing toxic chemotherapy dosages to offset reductions in their chemo payments ( see “Got Cancer? Too Bad“).
It’s no overstatement to suggest that Hippocrates would roll over in his grave…
Selling Cancer Screenings
I have no doubt this latest NCI initiative will precipitate a salvo of defensive outbursts from the medical establishment. Wrapped tightly in their concern for patient quality (yada, yada, yada…), expect to hear how our doctors have only their patients’ best interests at heart and how our better cancer results demonstrate that cancer screenings work and work well.
As the JAMA study suggests, however, this is more true for colon and cervical cancer screenings than it is for breast and prostate cancer screenings. It’s no surprise that some cancer screenings are more effective than others. Our willingness to fund them – and make no mistake that cancer screening is a huge industry (see “Selling Cancer Screenings With Meaningless Survival Rates“) – and to endure their follow-up interventions as patients should reflect this clinical reality.
Instead, we’ll continue to be bombarded with broad-brushed promotion of cancer screenings that may have little merit. The importance of diet, however, as evidenced by the graph at the start of this post, will continue to be given short shrift.
The JAMA study suggests that…
“The term ‘cancer’ should be reserved for lesions with a high likelihood of lethal progression if left untreated”.
But that would pull the rug out from one of healthcare’s strongest growth engines of profitability. And as demonstrated by the example of oncologists ramping up their toxic chemotherapy regimens to preserve their profits – at the expense of their patients’ shortened lives – that is simply not how American healthcare works.