11 ms·

Why Some Doctors Hesitate to Screen Smokers for Lung Cancer (2015)

91 points by g3ph4z 8y ago

wyldfire 8y ago
> That's because some cancers grow slowly and never become dangerous...These false-positive tests led to more follow-up testing, including risky procedures like a biopsy, which inserts a needle into the lung. > "Not surprisingly," Welch says, "sometimes that creates problems like causing someone's lung to collapse." These outcomes should inform whether or not the biopsy needs to take place or whether they should instead follow up with further screens to monitor whether the cancer progresses. Of course, the major downside of my suggestion is that patients are extremely reluctant to hear "cancer" without a plan to rapidly classify it as malignant or benign.
woliveirajr 8y ago
> "but [can also] find cancers that were never going to matter." I'm not sure, but isn't better to know that you have it and then investigate further, do more tests, perhaps do some period follow-up with a shorter interval? Otherwise it's just betting: I bet that I don't have a lung cancer that will be agressive....
- hackeraccount 8y ago
  "investigate further" is the sticking point. You're swimming in the ocean and notice something beneath you. Is it a friendly dolphin or a dangerous shark? Do you hold your breath and do a deep dive to figure out which it is? Keep in mind the deeper you go the greater the chance that you'll drown. It's a strained analogy but I think it gets at the problem. What if you dive a little bit deep - some minor test - and still aren't sure? Go deeper - a more invasive dangerous test - or go back to the surface? And what if you dive and are pretty sure it's a shark? Swimming all the way to shore (i.e. cancer treatment) is very risky but the shark will almost certainly kill you. How sure are you, really?
  - maxxxxx 8y ago
    “You're swimming in the ocean and notice something beneath you. Is it a friendly dolphin or a dangerous shark? Do you hold your breath and do a deep dive to figure out which it is? Keep in mind the deeper you go the greater the chance that you'll drown.” Does it really make a difference what it is? Will you do anything differently?
    - RyJones 8y ago
      I ask this question about metrics constantly. "If you had this information a year ago, what decisions would have been different?" It usually ends in dropping the request for another metric
    - plink 8y ago
      Absolutely. So called "friendly" dolphins are often very sexually aggressive. With knowledge of what aquatic beast lurked in the depths below, I could tailor my preparedness to either be on guard against unwelcome mammalian advances, or remain blithely unconcerned over some incurious, nimrod fish.
  - nradov 8y ago
    I understand your point, but let's dispel the myth of dangerous sharks. The vast majority of shark species never attack humans at all and it's totally safe to swim near them.
- MereInterest 8y ago
  * Choice A: X% chance of aggressive cancer, which worsens as it is left untreated. * Choice B: X% chance of finding and treating aggressive cancer. Y% chance of false positive leading to significant side effects. If Y is zero, then the choice to do further testing is obvious. If Y is large, then it depends on how large the side effects are, and what the chance of running into them is. You have risk in either case, and you will never reduce risk to zero. The question is how much risk you have, and what cost there is to mitigate that risk.
- thebeefytaco 8y ago
  Nope. When it comes to tumors, doctors always play 'better safe than sorry', but the treatments available for cancer are so detrimental that it's going to do way more harm than good to receive treatment for something that was benign. A little bit of information can be a dangerous thing.
- rurp 8y ago
  The issue is that testing often comes with its own health costs and many tests return a fairly high rate of false positives, which in turn leads to surgeries that can take a high toll on the body. Related to this, I recall reading about a study of elderly men with slow growing prostate cancer. Having surgery to remove the cancer did decrease the chance of dying from prostate cancer, but actually reduced their overall life expectancy. Prostate cancer surgery is hard on the body and an older person with a slow moving cancer has a pretty good chance of dying from some other cause before the cancer gets them.
sampleinajar 8y ago
Anecdotally, as an ex-smoker who quit after my mother died from lung cancer, I spoke to my doctor about screening. He did a lot of dismissing and hand waving about it. It upset me greatly at the time. This article explains it all well enough. Doctor/patient communication is very important.
- toomuchtodo 8y ago
  If you don't feel like you doctor is addressing your concerns, seek a second opinion. You are your own best patient advocate.
- 52-6F-62 8y ago
  How long did you smoke? My own anecdote: I was athletic when I was younger, but I was a regular smoker through most of my twenties. I quit a few years back. My doctor would check my breathing, etc, with everything I'd told him about my habit. He gave me the surprising news that my lungs would be virtually back to virgin health in 4-5 years (after nearly 10 years of smoking). And to get back to exercising more.
  - sampleinajar 8y ago
    I smoked for 7 years, the quit, then picked it back up 4 years later for 5 more years. I didn't really meet the criteria outlined in this article of x "pack years and over 55". I have read that quitting before 40 reduces your chances of lung cancer to that of the general population. Honestly within two years it was stark how much a difference there was.
maxxxxx 8y ago
This sounds familiar. I have watched now quite a few people go through serious diseases. One pattern I saw was tests, tests and more tests. A lot of them very expensive, time consuming and painful. But when you ask what they will do with the test results there often is silence. To me it looks like they are doing something because “we need to do something”. Reminds me a little of data collection practices at companies. Sucking up more data feels like you are doing something. But using the data is much more difficult and often doesn’t happen.
- thebeefytaco 8y ago
  Cancer runs pretty deeply in my family, and I had read the same about breast cancer screenings years ago, re: false positives causing more harm than good, so it'd make sense to see the same trends for other cancers as well.
  - astura 8y ago
    As far as breast cancer screening goes, the recommendations are for the general population; woman with a family history or other specific risk factors may benefit much more from screening than the general population and/or have different intervals than the general population. This is why communication with physicians is so important.
- athenot 8y ago
  As a patient (or a patient advocate for a loved-one), anytime a test is proposed it is important to ask what actionable information can come out of it. Basically look 2 steps ahead. Some tests will help confirm a course of treatment, or propose a new one. But what if that treatment is something you've already decided you won't do? For example in an older patient too old for a surgery or a baby that you've already decided you'll keep. But you are right, some tests are ordered out of a desire to show that "something is being done". It's important to talk with the doctor about the cost (not just money but pain & recovery) and benefit. Everything is a tradeoff.
  - maxxxxx 8y ago
ams6110 8y ago
tl; dr: the false positive rate is too high.
nimbius 8y ago
I wonder if this is a "dont waste your time" issue coming from management? As an anecdotal example, Im an engine mechanic who routinely sees older trucks from the 80s and 90s. mostly idler/pitman arm replacements, tires, diff fluid, etc... on these which is expected as many are pushing a million miles or more. I had a 1981 International S1700 limp into my garage one day with a misfire problem due to long, long overdue oil pressure problems. I fixed the oil pump and was getting ready to hook up the diagnostic computer when my boss stopped me and said "if you plug that thing in its going to light up like a christmas tree. You aint telling the driver anything they care about anyway."
- oarabbus_ 8y ago
  I mean the overall incidence of lung cancer is too low for this to be the case, even in smokers. It's around 5-6 percent.
- mistrial9 8y ago
  thank you for saying this ! The environmental "externalities" world is exactly like this! Saving generations of [insert-charismatic-species] from extinction in the wild is NOT PROFITABLE and will, in certain cases, be HIDDEN from investors and regulators.
  - crooked-v 8y ago
    Well, yes, paying for externalities is not profitable. That's the whole reason that people have to be forced to pay for them.
- skullborg 8y ago
  Do share more stories on working on old trucks! I have a '99 Ford with a 7.3, and everyone's saying it's not worth fixing, but I just like keeping it on the road...
  - WhompingWindows 8y ago
    What kind of MPG does that get?
KingMachiavelli 8y ago
Classic base rate problem, the rate of lung cancer rate is low compared to the false positive rate. It seems that one option is to follow up with a second scan 3-6 months latter and see if the tumor has increased in size. However there probably serious liability issues with this approach even if it means you're still catching the cancer earlier on average compared to waiting for physical symptoms. I'm curious how counties like France, where smoking rates are high yet have high life expectancies, deal with screening for lung cancer currently.
- VikingCoder 8y ago
  Also, detection only really matters if the treatments are effective. If you can detect Stage 4 lung cancer one week earlier, it probably does very little to improve the quality of life. :(
scottlegrand2 8y ago
What this and many other similar situations argue for IMO are better blood screens for cancer biomarkers. For it turns out even with early detection, metastasis has already happened. It's just that those metastasized cancer cells take a long time to grow. I mean the doctor is right, but it sure sucks to be one of the people who really has cancer and you skipped the screening, no? https://www.sciencedaily.com/releases/2016/12/161214145615.htm https://www.sciencedaily.com/releases/2016/12/161214145615.h...
aitchnyu 8y ago
What does a false positive look like to a doctor, and how will it not harm the organism? I can't imagine a cancer that can be ignored safely, nor an early stage treatment that is counterproductive.
- VikingCoder 8y ago
  Lots of things look like cancer and can be ignored, and there are benign cancers. Every treatment has risks. That's the cruddy math.
- astura 8y ago
  So the old thought about cancer was "every cancer will grow and kill the patient so we always want to find the cancer early and treat it before it spreads" Turns out that's not accurate, and its complicated, and we are still learning. There's three types of cancer, birds, turtles, and rabbits. (I didn't make up this terminology, see links) The birds have already flown away and left the barnyard, early detection isn't going to help. The rabbits need to be contained before they hop away, if we shut the barnyard gate early enough we can prevent their escape. These are the cancers where early detection is useful and saves lives. The turtles just chill out, moving so slow that they never escape. These cancers cause no symptoms and will not go on to ever harm the patient and may even resolve themselves over time. Finding turtles is bad, treating turtles causes very serious side effects (cancer treatment isn't exactly benign), wastes time and money, causes anxiety, and doesn't reduce mortality one bit. We've discovered there's a lot of turtles out there. Of course, once we find early stage cancer we usually treat it like its a rabbit, even if its destined to be a turtle, because a lot of the time we can't tell the difference. South Korea is finding this out the hard way, aggressive screening for thyroid cancer has produced a TON of thyroid cancer patients (15-fold increase (!) over the past 20 years) but ZERO reduction in thyroid cancer mortality. https://sciencebasedmedicine.org/a-skeptical-look-at-screening-tests/ https://sciencebasedmedicine.org/a-skeptical-look-at-screeni... https://fivethirtyeight.com/features/the-case-against-early-cancer-detection/ https://fivethirtyeight.com/features/the-case-against-early-... https://www.skepdoc.info/a-skeptical-look-at-screening-tests-2/ https://www.skepdoc.info/a-skeptical-look-at-screening-tests...
astura 8y ago
>Lazris says he shows the theater diagrams to many of his patients and gets a wide range of responses. Some patients, he says, point at one of the three blackened seats and say, " 'That's probably me. I'm not taking any chances, I'm getting this test.' " >"Other people," he says, "will see [the same diagram] and will say, 'Are you kidding me? I'm not going for that; that's not worth it.'" >But in either scenario, Lazris says, he has done his job — he has helped his patients understand the odds and then let them make the choice. This is wonderful!! Good on him!! This is how medicine should always be practiced. Much too often a doctor/PA just orders a bunch of tests with ZERO discussion (other than maybe "we'll screen you for XYZ"). No discussion of risks. No discussion of the upsides of testing. No discussion of individual risk factors. No discussion about how the results will be actionable. Sometimes they order tests before even meeting a patient for the first time or even telling you what they are testing you for. My last primary care doctor did just that, I made an initial appointment with him for a routine physical (I need referrals for my health insurance) and someone from his office calls before the appointment and says "Dr So and So has ordered some blood tests for you, please go to the lab and get then done before the appointment." Didn't think telling me any other information was important, like, uh, what I'm being tested for and why. Of course, at least some of the tests he ordered were not evidence based. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5638475/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5638475/ On top of that, I have untreatable anemia due to a genetic condition. His first tests found the anemia and he ordered follow up tests. Mind you, this is before I ever met him or even spoke to him. If he had a conversation with me, the followup tests would have been completely and totally unnecessary. A different doctor did that to my husband recently as well ("we've ordered some tests for you" before even meeting him nor telling him which tests were ordered.) I looked at the lab work afterwards and turns out PSA was one of the tests they ordered, which has shown to cause more harm than good. ZERO discussion about risks vs benefits. No discussion of benefits of testing at your age vs an advanced age. No theater diagrams. https://www.medicalnewstoday.com/articles/260087.php https://www.medicalnewstoday.com/articles/260087.php https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prostate-cancer-screening https://www.uspreventiveservicestaskforce.org/Page/Document/... I read a story about an elderly woman in good health with no symptoms who went to the doctor for a routine physical. The doctor ordered a bunch of blood tests and a urine test, turns out she had an asymptomatic urinary track infection. She was given ciprofloxacin and had a bad reaction to it. Turns out: A quarter of elderly women have asymptomatic urinary track infections. Detecting and treating them have not shown to have any benefit. Ciprofloxacin is an inappropriate treatment for uncomplicated urinary track infections in the elderly due to the high risks of serious side effects. https://www.nytimes.com/2019/03/15/health/antibiotics-elderly-risks.html https://www.nytimes.com/2019/03/15/health/antibiotics-elderl... The story doesn't say if the doctor discussed benefits and risks of doing those blood and urine tests, but I'm doubting they did (considering both the testing and the treatment was against recommendations). I'm not, as a rule, against screening tests. I'm against doctors not explaining the risks vs benefits of screening tests. I'm also against doctors ordering screening tests that have shown to have no benefit.
linsomniac 8y ago
I've watched my family go through smoking, and cancer hasn't been the issue. I don't know how representative it is, but my experience definitely reflects the premise of this article: cancer testing could have caused way more harm than good. Both my mother and her father were still smoking frequently when they were on oxygen. In other words: When they should have known better. Her mother was looking really bad at 50 and when the Dr told her "it's killing you, and not in some abstract way", she cut it out cold turkey and pretty much instantly looked 10 years younger. Grandfather was struggling in general, but it was twisted up intestines that did him in. My mom, one nurse told me, her lungs were "just shot". COPD. Funny thing was that she was getting enough oxygen (with O2), she just couldn't get rid of CO2. Basically took her outta the game 20 years early. Hopefully, my kids who watched this, can use the experience to steer clear of some things. If you can't set a good example, show what a bad example leads to. :-)
- elhudy 8y ago
  This could be the most controversial thing comment I've posted on here, but...: Why are we even spending resources figuring out how to extend the lives of people who have smoked a pack a day, for 30 years, and are currently in old age? Even if we find cancer and save their lives now, will that prevent then from picking up smoking again? Will it prevent the heart disease they're going to encounter ten more years down the line? Dragging it out seems like a massive burden on the rest of society. I'm unsure how these studies are being funded but I just wonder if the money is better spent on helping people to stop smoking.
  - moftz 8y ago
    Those people (or their insurance) are willing to pay for treatment. If the market is there, why not fund some new research into treating lung cancer? Not every incidence of lung cancer is from smoking two packs a day, sometimes it just happens although its more rare. It's the idiots smoking two packs a day that are helping subsidize the research that can help save the person who just gets lung cancer randomly. I think it's a hard choice between allowing for personal freedoms and improving society for the better by outlawing dangerous drugs like smoking and alcohol. I think there can be a balance by allowing everyone the same level of access to healthcare but increasing taxes on dangerous recreational drugs to subsidize the healthcare system. You can eat fast food and smoke all you want but it's going to cost you heavily financially.
robotrout 8y ago
Welch says, "but [can also] find cancers that were never going to matter." That's because some cancers grow slowly and never become dangerous, he says. This exact same phenomenon is already occurring with breast cancer. Everybody is a "breast cancer survivor" these days, because they keep finding these turtle tumors that were never going to be a problem. If you look at mortality rates between those who screen early and those who don't, they are the same. https://link.springer.com/article/10.1007/s10549-018-4691-4 https://link.springer.com/article/10.1007/s10549-018-4691-4
- 1e-9 8y ago
  While it is true that there is plenty of uncertainty regarding the value of finding DCIS, it is well established that there is significant benefit to finding small invasive breast cancers such as invasive lobular carcinoma and invasive ductal carcinoma. The value is particularly significant if the lesions are found before exceeding 1 cm in size, which they often are nowadays. The paper sited refers to one study focused on DCIS and another Canadian study on breast cancer screening during the 1980's and 1990's before there were good mammography screening standards. The Canadian study essentially just showed that poor screening is of limited value.
dontreact 8y ago
False positives will be much more rare in practice with the new guidelines used (Lung RADS) which cut false positives by 50% or more while mostly preserving sensitivity. That doctor should really update his diagram to reflect the current standard of care for lung cancer screening. Using the false positive rate from the 2011 study is intellectually dishonest! In addition the amount of lung cancer deaths prevented was doubled (!!) in a recent European study by tracking patients for 5 years instead of 3 years.
- wswope 8y ago
  Honestly curious: are most radiologists actually following guidelines like Lung RADS in practice, especially just after publication? Is it part of any standardized CME? It's my impression that there's often a big gap between ACR best practices and what's happening on the ground in most places, which was a key point the doctor in the article was making.
  - riahi 8y ago
    Adoption of Lung-Rads is essentially required to be designated as an ACR screening center. To be reimbursed for Lung Cancer Screening, you must provide registry data to CMS (the registry is run by the ACR). It's not codified into Federal Law, but if reimbursement requires a Lung-Rads code, then it's more or less mandated. I'd argue out of all the fields of medicine, Radiology is pretty quick to adopt new technology or reporting schemes "on the ground". See the proliferation of Lung-Rads, TI-Rads, Cad-Rads, LI-Rads, PI-Rads, etc.
    - wswope 8y ago
      That's good to know, thank you for the response!
- caycep 8y ago
  yeah, the cost benefit ratio of scans probably would improve significantly w/ less misinterpretation of scans...radiologists tend to notoriously over-call findings for liability reasons, and most MD's don't look at the images, they just read what the radiologist wrote.
djsumdog 8y ago
Didn't we see the exact same thing a decade ago with mammograms and breast cancer? I remember there being two issues, one being computer aided detection in mammograms at the time was terrible for false positives compared to an experienced doctor (the the computer-aided was a selling/marketing point so people tended to opt for it). The second was mammograms no longer being recommended for certain age groups, as they were shown in studies to just be ineffective. There was a backlash against such recommendations, under a kind of 'better safe than sorry' argument.
pytyper2 8y ago
I periodically smoke, yet I don't call myself a smoker. Yet when I buy insurance I buy the smokers plan, the idea being that if I do need to use the insurance I expect the Insurance company to use any information necessary to deny my claim. Should I be worried about this?
- NullPrefix 8y ago
  Have fun getting any physical activity injury claim denied. Smokers aren't expected to do sports. /s
  - pytyper2 8y ago
    What does '/s' indicate?
djtriptych 8y ago
a.k.a. every layman's writeup of bayesian reasoning ever.
babyslothzoo 8y ago
VOMIT, Victim Of Modern Imaging Technology, is a term among doctors for a reason. Generally the more you know the better, but sometimes things can be stumbled upon that might otherwise be irrelevant yet the intervention can then introduce new risk or some other unique problem or undesired side effect. There aren't always easy answers.
1e-9 8y ago
I believe this is indicative of a frustrating phenomenon in the U.S. healthcare/legal system where many doctors are prone to being overly cautious due to the threat of malpractice litigation. You rarely hear of doctors being sued for unnecessary testing. They are much more likely to be sued for missing a cancer. This happens even when it was reasonable to miss a cancer. A doctor who is overly concerned about litigation can thus cause harm through the patient stress and physical effects of unnecessary followup testing when it is not justified. Rather than sticking our heads in the sand by not screening because we are worried that some doctors will have a harmful false positive rate, we should be addressing the root causes of the high false positive rate.
JonesWilly 8y ago
A great and seemingly minimally biased resource for this type of preventative care(mentioned in the article): https://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations https://www.uspreventiveservicestaskforce.org/BrowseRec/Inde... It presents an evidence based pros v cons listing on screening and tries to present a informed approach, with less financial bias. The most toxic component of this entire issues also has to do with a form of defensive medicine that physicians engage in. Basically if you don't want problems don't look for them, not to say all physicians engage in this type of behavior. This mentality is very common amongst the older generations of physicians who fear the repercussion associated with minor mistakes.. Ie. doctor sends patient for CT suspicious finding are noted, doctor forgets to order future followup or some other variety of mistake... Patient ends up having cancer and the physician is slapped with a malpractice suit.
deleted 8y ago
[deleted]

91 points by g3ph4z 8y ago

> That's because some cancers grow slowly and never become dangerous...These false-positive tests led to more follow-up testing, including risky procedures like a biopsy, which inserts a needle into the lung. > "Not surprisingly," Welch says, "sometimes that creates problems like causing someone's lung to collapse." These outcomes should inform whether or not the biopsy needs to take place or whether they should instead follow up with further screens to monitor whether the cancer progresses. Of course, the major downside of my suggestion is that patients are extremely reluctant to hear "cancer" without a plan to rapidly classify it as malignant or benign.

woliveirajr 8y ago

> "but [can also] find cancers that were never going to matter." I'm not sure, but isn't better to know that you have it and then investigate further, do more tests, perhaps do some period follow-up with a shorter interval? Otherwise it's just betting: I bet that I don't have a lung cancer that will be agressive....

hackeraccount 8y ago
"investigate further" is the sticking point. You're swimming in the ocean and notice something beneath you. Is it a friendly dolphin or a dangerous shark? Do you hold your breath and do a deep dive to figure out which it is? Keep in mind the deeper you go the greater the chance that you'll drown. It's a strained analogy but I think it gets at the problem. What if you dive a little bit deep - some minor test - and still aren't sure? Go deeper - a more invasive dangerous test - or go back to the surface? And what if you dive and are pretty sure it's a shark? Swimming all the way to shore (i.e. cancer treatment) is very risky but the shark will almost certainly kill you. How sure are you, really?
- maxxxxx 8y ago
  “You're swimming in the ocean and notice something beneath you. Is it a friendly dolphin or a dangerous shark? Do you hold your breath and do a deep dive to figure out which it is? Keep in mind the deeper you go the greater the chance that you'll drown.” Does it really make a difference what it is? Will you do anything differently?
  - RyJones 8y ago
    I ask this question about metrics constantly. "If you had this information a year ago, what decisions would have been different?" It usually ends in dropping the request for another metric
  - plink 8y ago
    Absolutely. So called "friendly" dolphins are often very sexually aggressive. With knowledge of what aquatic beast lurked in the depths below, I could tailor my preparedness to either be on guard against unwelcome mammalian advances, or remain blithely unconcerned over some incurious, nimrod fish.
- nradov 8y ago
  I understand your point, but let's dispel the myth of dangerous sharks. The vast majority of shark species never attack humans at all and it's totally safe to swim near them.
MereInterest 8y ago
* Choice A: X% chance of aggressive cancer, which worsens as it is left untreated. * Choice B: X% chance of finding and treating aggressive cancer. Y% chance of false positive leading to significant side effects. If Y is zero, then the choice to do further testing is obvious. If Y is large, then it depends on how large the side effects are, and what the chance of running into them is. You have risk in either case, and you will never reduce risk to zero. The question is how much risk you have, and what cost there is to mitigate that risk.
thebeefytaco 8y ago
Nope. When it comes to tumors, doctors always play 'better safe than sorry', but the treatments available for cancer are so detrimental that it's going to do way more harm than good to receive treatment for something that was benign. A little bit of information can be a dangerous thing.
rurp 8y ago
The issue is that testing often comes with its own health costs and many tests return a fairly high rate of false positives, which in turn leads to surgeries that can take a high toll on the body. Related to this, I recall reading about a study of elderly men with slow growing prostate cancer. Having surgery to remove the cancer did decrease the chance of dying from prostate cancer, but actually reduced their overall life expectancy. Prostate cancer surgery is hard on the body and an older person with a slow moving cancer has a pretty good chance of dying from some other cause before the cancer gets them.

sampleinajar 8y ago

Anecdotally, as an ex-smoker who quit after my mother died from lung cancer, I spoke to my doctor about screening. He did a lot of dismissing and hand waving about it. It upset me greatly at the time. This article explains it all well enough. Doctor/patient communication is very important.

toomuchtodo 8y ago
If you don't feel like you doctor is addressing your concerns, seek a second opinion. You are your own best patient advocate.
52-6F-62 8y ago
How long did you smoke? My own anecdote: I was athletic when I was younger, but I was a regular smoker through most of my twenties. I quit a few years back. My doctor would check my breathing, etc, with everything I'd told him about my habit. He gave me the surprising news that my lungs would be virtually back to virgin health in 4-5 years (after nearly 10 years of smoking). And to get back to exercising more.
- sampleinajar 8y ago
  I smoked for 7 years, the quit, then picked it back up 4 years later for 5 more years. I didn't really meet the criteria outlined in this article of x "pack years and over 55". I have read that quitting before 40 reduces your chances of lung cancer to that of the general population. Honestly within two years it was stark how much a difference there was.

maxxxxx 8y ago

This sounds familiar. I have watched now quite a few people go through serious diseases. One pattern I saw was tests, tests and more tests. A lot of them very expensive, time consuming and painful. But when you ask what they will do with the test results there often is silence. To me it looks like they are doing something because “we need to do something”. Reminds me a little of data collection practices at companies. Sucking up more data feels like you are doing something. But using the data is much more difficult and often doesn’t happen.

thebeefytaco 8y ago
Cancer runs pretty deeply in my family, and I had read the same about breast cancer screenings years ago, re: false positives causing more harm than good, so it'd make sense to see the same trends for other cancers as well.
- astura 8y ago
  As far as breast cancer screening goes, the recommendations are for the general population; woman with a family history or other specific risk factors may benefit much more from screening than the general population and/or have different intervals than the general population. This is why communication with physicians is so important.
athenot 8y ago
As a patient (or a patient advocate for a loved-one), anytime a test is proposed it is important to ask what actionable information can come out of it. Basically look 2 steps ahead. Some tests will help confirm a course of treatment, or propose a new one. But what if that treatment is something you've already decided you won't do? For example in an older patient too old for a surgery or a baby that you've already decided you'll keep. But you are right, some tests are ordered out of a desire to show that "something is being done". It's important to talk with the doctor about the cost (not just money but pain & recovery) and benefit. Everything is a tradeoff.
- maxxxxx 8y ago

ams6110 8y ago

tl; dr: the false positive rate is too high.

nimbius 8y ago

I wonder if this is a "dont waste your time" issue coming from management? As an anecdotal example, Im an engine mechanic who routinely sees older trucks from the 80s and 90s. mostly idler/pitman arm replacements, tires, diff fluid, etc... on these which is expected as many are pushing a million miles or more. I had a 1981 International S1700 limp into my garage one day with a misfire problem due to long, long overdue oil pressure problems. I fixed the oil pump and was getting ready to hook up the diagnostic computer when my boss stopped me and said "if you plug that thing in its going to light up like a christmas tree. You aint telling the driver anything they care about anyway."

oarabbus_ 8y ago
I mean the overall incidence of lung cancer is too low for this to be the case, even in smokers. It's around 5-6 percent.
mistrial9 8y ago
thank you for saying this ! The environmental "externalities" world is exactly like this! Saving generations of [insert-charismatic-species] from extinction in the wild is NOT PROFITABLE and will, in certain cases, be HIDDEN from investors and regulators.
- crooked-v 8y ago
  Well, yes, paying for externalities is not profitable. That's the whole reason that people have to be forced to pay for them.
skullborg 8y ago
Do share more stories on working on old trucks! I have a '99 Ford with a 7.3, and everyone's saying it's not worth fixing, but I just like keeping it on the road...
- WhompingWindows 8y ago
  What kind of MPG does that get?

KingMachiavelli 8y ago

Classic base rate problem, the rate of lung cancer rate is low compared to the false positive rate. It seems that one option is to follow up with a second scan 3-6 months latter and see if the tumor has increased in size. However there probably serious liability issues with this approach even if it means you're still catching the cancer earlier on average compared to waiting for physical symptoms. I'm curious how counties like France, where smoking rates are high yet have high life expectancies, deal with screening for lung cancer currently.

VikingCoder 8y ago
Also, detection only really matters if the treatments are effective. If you can detect Stage 4 lung cancer one week earlier, it probably does very little to improve the quality of life. :(

scottlegrand2 8y ago

What this and many other similar situations argue for IMO are better blood screens for cancer biomarkers. For it turns out even with early detection, metastasis has already happened. It's just that those metastasized cancer cells take a long time to grow. I mean the doctor is right, but it sure sucks to be one of the people who really has cancer and you skipped the screening, no? https://www.sciencedaily.com/releases/2016/12/161214145615.htm https://www.sciencedaily.com/releases/2016/12/161214145615.h...

aitchnyu 8y ago

What does a false positive look like to a doctor, and how will it not harm the organism? I can't imagine a cancer that can be ignored safely, nor an early stage treatment that is counterproductive.

VikingCoder 8y ago
Lots of things look like cancer and can be ignored, and there are benign cancers. Every treatment has risks. That's the cruddy math.
astura 8y ago
So the old thought about cancer was "every cancer will grow and kill the patient so we always want to find the cancer early and treat it before it spreads" Turns out that's not accurate, and its complicated, and we are still learning. There's three types of cancer, birds, turtles, and rabbits. (I didn't make up this terminology, see links) The birds have already flown away and left the barnyard, early detection isn't going to help. The rabbits need to be contained before they hop away, if we shut the barnyard gate early enough we can prevent their escape. These are the cancers where early detection is useful and saves lives. The turtles just chill out, moving so slow that they never escape. These cancers cause no symptoms and will not go on to ever harm the patient and may even resolve themselves over time. Finding turtles is bad, treating turtles causes very serious side effects (cancer treatment isn't exactly benign), wastes time and money, causes anxiety, and doesn't reduce mortality one bit. We've discovered there's a lot of turtles out there. Of course, once we find early stage cancer we usually treat it like its a rabbit, even if its destined to be a turtle, because a lot of the time we can't tell the difference. South Korea is finding this out the hard way, aggressive screening for thyroid cancer has produced a TON of thyroid cancer patients (15-fold increase (!) over the past 20 years) but ZERO reduction in thyroid cancer mortality. https://sciencebasedmedicine.org/a-skeptical-look-at-screening-tests/ https://sciencebasedmedicine.org/a-skeptical-look-at-screeni... https://fivethirtyeight.com/features/the-case-against-early-cancer-detection/ https://fivethirtyeight.com/features/the-case-against-early-... https://www.skepdoc.info/a-skeptical-look-at-screening-tests-2/ https://www.skepdoc.info/a-skeptical-look-at-screening-tests...

astura 8y ago

>Lazris says he shows the theater diagrams to many of his patients and gets a wide range of responses. Some patients, he says, point at one of the three blackened seats and say, " 'That's probably me. I'm not taking any chances, I'm getting this test.' " >"Other people," he says, "will see [the same diagram] and will say, 'Are you kidding me? I'm not going for that; that's not worth it.'" >But in either scenario, Lazris says, he has done his job — he has helped his patients understand the odds and then let them make the choice. This is wonderful!! Good on him!! This is how medicine should always be practiced. Much too often a doctor/PA just orders a bunch of tests with ZERO discussion (other than maybe "we'll screen you for XYZ"). No discussion of risks. No discussion of the upsides of testing. No discussion of individual risk factors. No discussion about how the results will be actionable. Sometimes they order tests before even meeting a patient for the first time or even telling you what they are testing you for. My last primary care doctor did just that, I made an initial appointment with him for a routine physical (I need referrals for my health insurance) and someone from his office calls before the appointment and says "Dr So and So has ordered some blood tests for you, please go to the lab and get then done before the appointment." Didn't think telling me any other information was important, like, uh, what I'm being tested for and why. Of course, at least some of the tests he ordered were not evidence based. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5638475/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5638475/ On top of that, I have untreatable anemia due to a genetic condition. His first tests found the anemia and he ordered follow up tests. Mind you, this is before I ever met him or even spoke to him. If he had a conversation with me, the followup tests would have been completely and totally unnecessary. A different doctor did that to my husband recently as well ("we've ordered some tests for you" before even meeting him nor telling him which tests were ordered.) I looked at the lab work afterwards and turns out PSA was one of the tests they ordered, which has shown to cause more harm than good. ZERO discussion about risks vs benefits. No discussion of benefits of testing at your age vs an advanced age. No theater diagrams. https://www.medicalnewstoday.com/articles/260087.php https://www.medicalnewstoday.com/articles/260087.php https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prostate-cancer-screening https://www.uspreventiveservicestaskforce.org/Page/Document/... I read a story about an elderly woman in good health with no symptoms who went to the doctor for a routine physical. The doctor ordered a bunch of blood tests and a urine test, turns out she had an asymptomatic urinary track infection. She was given ciprofloxacin and had a bad reaction to it. Turns out: A quarter of elderly women have asymptomatic urinary track infections. Detecting and treating them have not shown to have any benefit. Ciprofloxacin is an inappropriate treatment for uncomplicated urinary track infections in the elderly due to the high risks of serious side effects. https://www.nytimes.com/2019/03/15/health/antibiotics-elderly-risks.html https://www.nytimes.com/2019/03/15/health/antibiotics-elderl... The story doesn't say if the doctor discussed benefits and risks of doing those blood and urine tests, but I'm doubting they did (considering both the testing and the treatment was against recommendations). I'm not, as a rule, against screening tests. I'm against doctors not explaining the risks vs benefits of screening tests. I'm also against doctors ordering screening tests that have shown to have no benefit.

linsomniac 8y ago

I've watched my family go through smoking, and cancer hasn't been the issue. I don't know how representative it is, but my experience definitely reflects the premise of this article: cancer testing could have caused way more harm than good. Both my mother and her father were still smoking frequently when they were on oxygen. In other words: When they should have known better. Her mother was looking really bad at 50 and when the Dr told her "it's killing you, and not in some abstract way", she cut it out cold turkey and pretty much instantly looked 10 years younger. Grandfather was struggling in general, but it was twisted up intestines that did him in. My mom, one nurse told me, her lungs were "just shot". COPD. Funny thing was that she was getting enough oxygen (with O2), she just couldn't get rid of CO2. Basically took her outta the game 20 years early. Hopefully, my kids who watched this, can use the experience to steer clear of some things. If you can't set a good example, show what a bad example leads to. :-)

elhudy 8y ago
This could be the most controversial thing comment I've posted on here, but...: Why are we even spending resources figuring out how to extend the lives of people who have smoked a pack a day, for 30 years, and are currently in old age? Even if we find cancer and save their lives now, will that prevent then from picking up smoking again? Will it prevent the heart disease they're going to encounter ten more years down the line? Dragging it out seems like a massive burden on the rest of society. I'm unsure how these studies are being funded but I just wonder if the money is better spent on helping people to stop smoking.
- moftz 8y ago
  Those people (or their insurance) are willing to pay for treatment. If the market is there, why not fund some new research into treating lung cancer? Not every incidence of lung cancer is from smoking two packs a day, sometimes it just happens although its more rare. It's the idiots smoking two packs a day that are helping subsidize the research that can help save the person who just gets lung cancer randomly. I think it's a hard choice between allowing for personal freedoms and improving society for the better by outlawing dangerous drugs like smoking and alcohol. I think there can be a balance by allowing everyone the same level of access to healthcare but increasing taxes on dangerous recreational drugs to subsidize the healthcare system. You can eat fast food and smoke all you want but it's going to cost you heavily financially.

robotrout 8y ago

Welch says, "but [can also] find cancers that were never going to matter." That's because some cancers grow slowly and never become dangerous, he says. This exact same phenomenon is already occurring with breast cancer. Everybody is a "breast cancer survivor" these days, because they keep finding these turtle tumors that were never going to be a problem. If you look at mortality rates between those who screen early and those who don't, they are the same. https://link.springer.com/article/10.1007/s10549-018-4691-4 https://link.springer.com/article/10.1007/s10549-018-4691-4

1e-9 8y ago
While it is true that there is plenty of uncertainty regarding the value of finding DCIS, it is well established that there is significant benefit to finding small invasive breast cancers such as invasive lobular carcinoma and invasive ductal carcinoma. The value is particularly significant if the lesions are found before exceeding 1 cm in size, which they often are nowadays. The paper sited refers to one study focused on DCIS and another Canadian study on breast cancer screening during the 1980's and 1990's before there were good mammography screening standards. The Canadian study essentially just showed that poor screening is of limited value.

dontreact 8y ago

False positives will be much more rare in practice with the new guidelines used (Lung RADS) which cut false positives by 50% or more while mostly preserving sensitivity. That doctor should really update his diagram to reflect the current standard of care for lung cancer screening. Using the false positive rate from the 2011 study is intellectually dishonest! In addition the amount of lung cancer deaths prevented was doubled (!!) in a recent European study by tracking patients for 5 years instead of 3 years.

wswope 8y ago
Honestly curious: are most radiologists actually following guidelines like Lung RADS in practice, especially just after publication? Is it part of any standardized CME? It's my impression that there's often a big gap between ACR best practices and what's happening on the ground in most places, which was a key point the doctor in the article was making.
- riahi 8y ago
  Adoption of Lung-Rads is essentially required to be designated as an ACR screening center. To be reimbursed for Lung Cancer Screening, you must provide registry data to CMS (the registry is run by the ACR). It's not codified into Federal Law, but if reimbursement requires a Lung-Rads code, then it's more or less mandated. I'd argue out of all the fields of medicine, Radiology is pretty quick to adopt new technology or reporting schemes "on the ground". See the proliferation of Lung-Rads, TI-Rads, Cad-Rads, LI-Rads, PI-Rads, etc.
  - wswope 8y ago
    That's good to know, thank you for the response!
caycep 8y ago
yeah, the cost benefit ratio of scans probably would improve significantly w/ less misinterpretation of scans...radiologists tend to notoriously over-call findings for liability reasons, and most MD's don't look at the images, they just read what the radiologist wrote.

djsumdog 8y ago

Didn't we see the exact same thing a decade ago with mammograms and breast cancer? I remember there being two issues, one being computer aided detection in mammograms at the time was terrible for false positives compared to an experienced doctor (the the computer-aided was a selling/marketing point so people tended to opt for it). The second was mammograms no longer being recommended for certain age groups, as they were shown in studies to just be ineffective. There was a backlash against such recommendations, under a kind of 'better safe than sorry' argument.

pytyper2 8y ago

I periodically smoke, yet I don't call myself a smoker. Yet when I buy insurance I buy the smokers plan, the idea being that if I do need to use the insurance I expect the Insurance company to use any information necessary to deny my claim. Should I be worried about this?

NullPrefix 8y ago
Have fun getting any physical activity injury claim denied. Smokers aren't expected to do sports. /s
- pytyper2 8y ago
  What does '/s' indicate?

djtriptych 8y ago

a.k.a. every layman's writeup of bayesian reasoning ever.

babyslothzoo 8y ago

VOMIT, Victim Of Modern Imaging Technology, is a term among doctors for a reason. Generally the more you know the better, but sometimes things can be stumbled upon that might otherwise be irrelevant yet the intervention can then introduce new risk or some other unique problem or undesired side effect. There aren't always easy answers.

1e-9 8y ago

I believe this is indicative of a frustrating phenomenon in the U.S. healthcare/legal system where many doctors are prone to being overly cautious due to the threat of malpractice litigation. You rarely hear of doctors being sued for unnecessary testing. They are much more likely to be sued for missing a cancer. This happens even when it was reasonable to miss a cancer. A doctor who is overly concerned about litigation can thus cause harm through the patient stress and physical effects of unnecessary followup testing when it is not justified. Rather than sticking our heads in the sand by not screening because we are worried that some doctors will have a harmful false positive rate, we should be addressing the root causes of the high false positive rate.

JonesWilly 8y ago

A great and seemingly minimally biased resource for this type of preventative care(mentioned in the article): https://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations https://www.uspreventiveservicestaskforce.org/BrowseRec/Inde... It presents an evidence based pros v cons listing on screening and tries to present a informed approach, with less financial bias. The most toxic component of this entire issues also has to do with a form of defensive medicine that physicians engage in. Basically if you don't want problems don't look for them, not to say all physicians engage in this type of behavior. This mentality is very common amongst the older generations of physicians who fear the repercussion associated with minor mistakes.. Ie. doctor sends patient for CT suspicious finding are noted, doctor forgets to order future followup or some other variety of mistake... Patient ends up having cancer and the physician is slapped with a malpractice suit.

deleted 8y ago

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