3 ms·

Treatment != Outcome. Until an RCT is completed, we won't actually know if such diagnostic devices are a net good or harm. You are ignoring the very real effect

Treatment != Outcome. Until an RCT is completed, we won't actually know if such diagnostic devices are a net good or harm. You are ignoring the very real effects of iatrogenic harms and the psychological harms of giving people alerts that "cancer is detected!!!" when in actuality they would've been fine and never noticed any symptoms whatsoever. Not to mention the associated medical costs, tests done, time wasted, etc. This is why mammograms are so controversial: they might save you from dying of cancer, but they don't actually reduce your overall mortality. Screening doesn't always save lives by default. It's complicated. https://www.bmj.com/content/352/bmj.h6080 https://www.bmj.com/content/352/bmj.h6080

dontreact 6y ago
I honestly think the aversion to screening has more to do with other political and economic factors. For example, lung cancer screening has been shown to clearly reduce all-cause mortality in an extremely comprehensive study with 7 years of followup (NLST). These results are also replicated in studies around the world. The problem is, how do you properly incentivize patients, providers and payers to actually implement this? The payoffs are not immediate but are rather long term for everyone involved: it takes 6+ years to clearly see the significant mortality reduction payoff actually show up in the data. The downsides, on the other hand, are immediate (another trip to the hospital/imaging center, deaths due to false positives, increased costs, more work for clinicians).
- toast0 6y ago
  Incentivising patients should be the easiest part. People, generally, would like to live longer, and if you make imaging convenient and work on the messaging, you can get good compliance, at least for the screening part; compliance for interventions would still be an issue, I presume. For providers, provide the studies and incentives. Bonuses for lung cancer screening work, or % of patients screened (of eligible patients seen above age X, who haven't been screened, don't have a counter indication to screening, etc). For payers, I think there's two classes of payers; long term payers like national health services; and short term payers like US health insurance where people can change insurance every year. Long term insurers can (and should) be looking at their budgets and data (their own, but also studies like you mention) to find out what things to prioritize. Depening on your perspective, goals could be to maximize good years of life given the budget or to minimize future budget needs given the current budget. Short term payers are going to have a hard time prioritizing long term issues. Reducing future costs for your insurance pool doesn't help you much when your pool can change every year. To incentivize this through economics, we would need to somehow increase the time exposure of the provider. Something along the lines of the insurance carried for a given year has partial responsibility for future years. Of course, that would be an administrative nightmare.
  - dontreact 6y ago
    So Medicare already fully reimburses screening and yet only 3% of the eligible population gets screened. Imaging convenience is a bit chicken and egg. Not sure how you get the bonuses you are describing to happen. It seems to me like no one really is caring enough to make it happen.
dontreact 6y ago
I don't know the literature as well for Breast Cancer, but at least as implemented in the UK there seems to be clear evidence for reduction in all-cause mortality. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121088/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121088/ Edit: hastily posted an article without reading it... this is not correct.
- TaupeRanger 6y ago
  This study demonstrates what would be necessary to show a possible reduction - it doesn't show an actual reduction. But it would be encouraging to see such a study at some point.
  - dontreact 6y ago
    Yeah I messed this one up. Thanks. I think my point about Lung Cancer in the other thread. still stands. There are no RCTs, but at this point it seems not likely to happen for mammography. Perhaps for DBT though. I am optimistic that DBT + AI assistance will produce significantly different results than screening using a single reader on mammography.
  - dontreact 6y ago
    Also I think you are painting an ongoing disagreement in the medical community (do we need to measure all-cause, or just breast cancer related mortality) as settled. There are good arguments on both sides, but I think that we have a much better shot at turning the breast-cancer specific mortality boost into all-cause mortality boost by continuing to improve treatment, biopsy, screening etc.
sfink 6y ago
Sure. I'm aware of the difficult tradeoffs of screening. But the fact that screening tests X and Y are not worth doing isn't really adequate to write off a whole new world of additional screening tests, many of which would have very different tradeoffs. (Olfactory tests are far less invasive, for one.) It's also something of a UX issue. Nobody is going to write an app that rings the cancer alarm after one positive. People might write an app that sends raw results to your doctor or medical monitoring service, and you get an email requesting an appointment to discuss your latest status. And if your breath results say that you're gonna die in the next 10 days and there's nothing to be done (exaggerated for effect), well then... maybe it won't send an email after all.

dontreact 6y ago

I honestly think the aversion to screening has more to do with other political and economic factors. For example, lung cancer screening has been shown to clearly reduce all-cause mortality in an extremely comprehensive study with 7 years of followup (NLST). These results are also replicated in studies around the world. The problem is, how do you properly incentivize patients, providers and payers to actually implement this? The payoffs are not immediate but are rather long term for everyone involved: it takes 6+ years to clearly see the significant mortality reduction payoff actually show up in the data. The downsides, on the other hand, are immediate (another trip to the hospital/imaging center, deaths due to false positives, increased costs, more work for clinicians).

toast0 6y ago
Incentivising patients should be the easiest part. People, generally, would like to live longer, and if you make imaging convenient and work on the messaging, you can get good compliance, at least for the screening part; compliance for interventions would still be an issue, I presume. For providers, provide the studies and incentives. Bonuses for lung cancer screening work, or % of patients screened (of eligible patients seen above age X, who haven't been screened, don't have a counter indication to screening, etc). For payers, I think there's two classes of payers; long term payers like national health services; and short term payers like US health insurance where people can change insurance every year. Long term insurers can (and should) be looking at their budgets and data (their own, but also studies like you mention) to find out what things to prioritize. Depening on your perspective, goals could be to maximize good years of life given the budget or to minimize future budget needs given the current budget. Short term payers are going to have a hard time prioritizing long term issues. Reducing future costs for your insurance pool doesn't help you much when your pool can change every year. To incentivize this through economics, we would need to somehow increase the time exposure of the provider. Something along the lines of the insurance carried for a given year has partial responsibility for future years. Of course, that would be an administrative nightmare.
- dontreact 6y ago
  So Medicare already fully reimburses screening and yet only 3% of the eligible population gets screened. Imaging convenience is a bit chicken and egg. Not sure how you get the bonuses you are describing to happen. It seems to me like no one really is caring enough to make it happen.

dontreact 6y ago

I don't know the literature as well for Breast Cancer, but at least as implemented in the UK there seems to be clear evidence for reduction in all-cause mortality. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121088/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121088/ Edit: hastily posted an article without reading it... this is not correct.

TaupeRanger 6y ago
This study demonstrates what would be necessary to show a possible reduction - it doesn't show an actual reduction. But it would be encouraging to see such a study at some point.
- dontreact 6y ago
  Yeah I messed this one up. Thanks. I think my point about Lung Cancer in the other thread. still stands. There are no RCTs, but at this point it seems not likely to happen for mammography. Perhaps for DBT though. I am optimistic that DBT + AI assistance will produce significantly different results than screening using a single reader on mammography.
- dontreact 6y ago
  Also I think you are painting an ongoing disagreement in the medical community (do we need to measure all-cause, or just breast cancer related mortality) as settled. There are good arguments on both sides, but I think that we have a much better shot at turning the breast-cancer specific mortality boost into all-cause mortality boost by continuing to improve treatment, biopsy, screening etc.

sfink 6y ago

Sure. I'm aware of the difficult tradeoffs of screening. But the fact that screening tests X and Y are not worth doing isn't really adequate to write off a whole new world of additional screening tests, many of which would have very different tradeoffs. (Olfactory tests are far less invasive, for one.) It's also something of a UX issue. Nobody is going to write an app that rings the cancer alarm after one positive. People might write an app that sends raw results to your doctor or medical monitoring service, and you get an email requesting an appointment to discuss your latest status. And if your breath results say that you're gonna die in the next 10 days and there's nothing to be done (exaggerated for effect), well then... maybe it won't send an email after all.