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Comment by bricemo | Hacker News Reader

This is a complicated space to get right. Prostate cancer is the opposite: The government used to screen for it (PSA blood test) and so people would see their doctor at stage 1 or 2 cancer, when it can be easily tested. But the problem was that the positivity rate was about 45:1, and the test is too expensive at that scale. So now PSA tests are not routine. As a result, people are now coming in to their doctors with prostate cancer at stage 3 or 4. Might be the right choice for society, but the wrong choice for the individual.

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It's definitely complicated because most of these older men with stage 1/2 prostate cancer will not actually die from it since it's so slow. However, getting the treatment for it leaves a huge number with erectile dysfunction or other issues.

Is it really worth screening/treating a disease with a small chance to kill you if that treatment has a huge chance to make you impotent?

Depends on your values. Some people may think it's worth it for them, and that's valid.

I don't think it's as easy as "let the patient decide". First, probabilities are very abstract concepts for people, that's why people respond very differently to the dangers of things when given the probability. Some people are scared if there is a 1:1000 chance of something happening, others are reassured, but both might have very similar reactions if they actually get hit by the chance event.

Secondly, also there is significant evidence of high incidence of depression for people with side effects, such as incontinence and impotence. I don't think people have the ability to assess that effect based on their values. To use an extreme example, should we operate something that has a 1:1000 change of killing you before something else, if it increases your suicide risk to 1:500? Should we allow patient to make that decision?

Yes, patients should be making all decisions regarding their own health. Am I misreading you? Are you really suggesting they shouldn’t have these options because they might make a bad decision?

This article is about screening which is a public health policy. Policies shouldn't promote things that are not effective.

Anyway, patients can't make all decisions regarding their own health since most drugs need a medical prescription. And doctors won't just do any procedure that you ask them to.

Yes, the unwashed masses can't handle abstract concepts like 1:1000 being smaller than 1:500. We certainly know better than them the value of years with the kids versus a physically satisfying romantic life, and if they think differently they are clearly just irrational plebs who should be hoodwinked for their own protection. We can't let a lifetime of unique experience and perspective stand in the way of a good one-size fits all system that produces better (for our definition of better) results on average.

The problem is that when handed numbers by a professional with years of training in an emotionally vulnerable state many people err on the side of being conservative on the issue at hand to avoid feeling like they may be judged.

This is further encouraged by modern western medicine being highly compartmentalised - to oversimplify, the cancer doctor has succeeded if you don't get cancer, but will probably never even find out if you get severe depression as a side effect of a side effect and certainly won't have to deal with it. Specialists also have their own professional and personal bias when they deliver their options, which is not apparent when presenting as a patient.

Is a scenario where the patient and the doctor are both acting based on short term benefit, rather than a holistic view, good for either party?

There is a role for large scale public health policy in my opinion, as morally complicated as it is.

I would not call general statistical data which takes no accounting of the details of the actual circumstances "holistic"

The fact is there are tons of people for whom the side effects are a non-issue, and many for whom they would be far worse than the disease, and the statistics give no indication as to who is in which category.

The role of public health is to provide information so that doctors and patients can make better informed decisions. But the idea that decisions should be made by some third party that "knows better" is predicated entirely on the false belief that such an entity exists.

I'm not sure how looking at large scale trends and scenarios experienced by thousands/millions is anything but holistic, especially when talking about individual patients with individual specialists dealing with individual .

> Holism (from Greek ὅλος holos "all, whole, entire") is the idea that various systems (e.g. physical, biological, social) should be viewed as wholes, not merely as a collection of parts.

Of course it would be best if there was a universal language which everyone was proficient in, every patient had unlimited healthcare resources, had a strong understanding of medicine and every doctor was an excellent communicator, was under no personal/professional pressure to deliver specific outcomes, always took all the time a patient needed to understand every aspect of their case and care in the present and into the future and personally consulted with every possible specialist that may be involved with the potential outcomes.

Putting aside the strawman, there are significant compromises with the highly personalised approach you suggest (some of which I tried to outline, but have not been responded to), just as there are with national level approaches (which are self evident). I feel that there are applications for both.

Complicated indeed. For prostate cancer, the pendulum really seems to have swung in the direction of underdiagnosing. My dad was doctoring for several months with urinary tract systems. The doctor flat out told him "you don't have prostate cancer". It wasn't until he sought out a second opinion several months later that he was diagnosed with stage 4 prostate cancer.

I would like to share my personal view on prostate cancer screening : my father was found 'positive' at around ~61 yrs. He evaluated the offered treatments and opted for 'internal radiation' : a bunch of radio-active pellets are implanted in the prostate.

I heard from him one of the pellets went 'missing' and was assumed to be 'wandering'.

At 63 yrs, he developed acute leukemia and basically died within a week.

I am not going to research and pursue this, but I am very bitter.

> As a result, people are now coming in to their doctors with prostate cancer at stage 3 or 4. Might be the right choice for society, but the wrong choice for the individual.

Hypothetical Bob is going to die when he's 78. We can tell Bob he has prostate cancer when he's 76, or when he's 70. Telling him does not make him live longer. But telling him does mean he may undergo treatment that degrades his quality of life, or even shortens his life.

How can we justify telling him when he's 70, when that won't make him live longer but could well make his life worse?

The reason they quit screening for it is that prostate cancer screening was found to have zero benefit on the number that really matters: how many die.

The thing is prostate cancer is usually a very slow cancer. Very often the proper response to a diagnosis of prostate cancer is keep an eye on it. Being aggressive about going after prostate cancer means more patients harmed by treatment (can you say "erectile dysfunction") but no lives saved. The few saved from cancer are offset by those who die from treatment.

There are basically three types of cancers and note that other than by observing what happens over time the doctors can't tell them apart:

Aggressive cancers. You're dead. The doctors putting you through hell might buy you a bit more time, but that's it.

Slow cancers. In most patients you'll die with the cancer, not of it. Prostate cancer tends to fall into this category.

Middle of the road cancers. These are the only ones where treatment is actually of much benefit to the patient. Found early enough you might even get a cure.

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