Wow, that was an amazing article! Thanks very much!
The mammography and PSA sections were very eye-opening. I did know that most men die with prostate cancer, but I didn't know that treatment often leads to impotence and incontinence. That's very scary.
> He was diagnosed with low-grade localized cancer, the kind that can be observed without treating. But he couldn’t face living with the knowledge that he was harboring an untreated cancer. He was afraid of surgery and opted for radiation treatment. He developed radiation proctitis and had rectal pain and bleeding for years.
I can understand the anxiety of living with an untreated cancer, and I'm starting to see why this might be a bad idea for the general population as a whole. "A person is smart. People are dumb, panicky, dangerous animals."
It doesn't change anything for me personally, and I would prefer to have more tests and more information. If the doctor says that I don't need to worry about it, then I'm not going to insist on surgery or radiation treatment. It's hard to know what it would feel like in the moment, but I don't think I would struggle with too much anxiety. I have already accepted that I probably have a lot of benign lumps and cancers in my body, because I know this is very normal. On the other hand, you also have to be careful about the other extreme, where you delay surgery or try to treat it with natural remedies.
> If a prostate cancer is localized and low grade, it is reasonable to observe the patient and not treat unless he develops signs of progression.
This is what I have been suggesting, but on a larger scale. People will just need to control their anxiety and realize that these cancers are normal, and they usually don't cause any harm. This is a tough problem, but we need to start educating people better.
They also talked about whole body CT scans, which is similar to what I am suggesting:
> Whole body CT scans were popular for a while; they were offered in free-standing CT facilities on request, without a doctor’s orders. They exposed patients to the same amount of radiation as 923 chest x-rays. They found abnormalities in 37-86% of patients, creating anxiety and leading to unnecessary follow-up tests that were sometimes invasive and potentially life-threatening. Fortunately they seem to have gone out of style.
Regular MRIs would be much better than CT scans. I think it would also be much better to have a series of scans, where you can look at the differences over time (and even use machine learning for this), instead of just having a single snapshot. I think this is similar to the blood test for PSA, where you look at the rate of rise over time. If these scans are leading to unnecessary follow-up tests, then the problem isn't the scans - the problem is the unnecessary tests. If this became a common practice, then it would be much easier to figure out the correct frequency of tests. It seems very foolish to throw away all the data instead of solving this problem.
I find it interesting that the USPSTF recommends against regular EKGs. I've heard lots of stories about the Apple Watch detecting AFib [1] [2]. I also read some articles that talk about the risks [3] [4]. My conclusion is that I'm going to buy an Apple Watch 4.
The "What makes a good screening test?" section was very helpful. Instead of using this list as a filter, I like to see this as a list of problems to solve:
1. Disease has serious consequences
Yes, 609,640 people die from cancer every year.
2. Screening population has high prevalence of the condition
Yes, and it would make sense to screen for the most common types of cancer. Melanoma screening can already be done with a phone camera and machine learning [5].
3. Not too many false positive or false negative results
I believe the results can be vastly improved with more data and better machine learning algorithms.
4. Test detects disease before critical point
Yes.
5. Test is safe – causes little morbidity
Yes, this would just be an MRI scan.
6. Test is affordable and available
This is the main problem that needs to be solved. This might be more feasible in a country with universal healthcare, so that the government can fund this program.
7. Treatment exists and is not too risky or toxic
No, surgery and radiation treatment is often very risky and toxic. I think this is most difficult part to get right. The general population will need to have a mental shift, where we understand that it can be ok to live with an untreated cancer. Especially for prostate cancer, since it's extremely common. Another solution might be to keep people ignorant and just send the data through a black-box machine learning algorithm.
8. Treatment is more effective when started earlier
Yes.
[1] https://9to5mac.com/2018/12/11/apple-watch-ecg-saves-life-a-...
[2] https://appleinsider.com/articles/19/04/02/apple-watch-credi...
[3] https://www.statnews.com/2019/03/15/apple-watch-atrial-fibri...
[4] https://www.biospace.com/article/apple-watch-atrial-fibrilla...
[5] https://cs.stanford.edu/people/esteva/nature/