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Redefining cancer

Blogging is a rather immediate endeavor. Over the last nine years (nearly), I’ve lost track of how many times I saw something that I wanted to blog about but by the time I got around to it, it was no longer topical. Usually what happens is that my Dug the Dog tendencies take over, as I’m distracted by yet another squirrel, although sometimes there are just too many targets topics and too little time. Fortunately, however, sometimes the issue is resurrected, sometimes in a really dumb way, such that I have an excuse to correct my previous oversight. This is just such a time, and the manner in which the topic has been resurrected is every bit as dumb as the rant by the Food Babe that Mark Crislip so delightfully deconstructed last Friday. Unfortunately, for purposes of snark, I’m not Mark Crislip—but, then, who is?—but fortunately I am known elsewhere (and sometimes here) for being a bit “insolent.” So let’s dig in. We’ll start with the idiocy and then use that as a “teachable moment” about cancer biology. Funny how I manage to do that sort of thing so often.

Abuse of cancer science for political purposes

I realize that we at SBM are supposed to stay, for the most part, apolitical, but the idiocy that’s leading me to revisit a topic is unavoidably political because it involves using a profound misunderstanding of science for political ends. Specifically, I’m referring to the misuse of a legitimate scientific debate about cancer screening and diagnosis for purely political ends. First, however, for those not living in the US or my fellow citizens who might be blissfully unaware (in this case) of recent events, during the first half of October, our nation underwent what can only be described as a self-inflicted crisis that could have caused worldwide economic turmoil if it hadn’t been (sort of) resolved at the last minute. The reason for the crisis boiled down to the extreme resistance of some of our more radically conservative Representatives to the Patient Protection and Affordable Care Act, usually referred to as just the Affordable Care Act (ACA) or, colloquially, Obamacare. Normally when we write about Obamacare here on SBM, it’s to complain about how advocates of unscientific medicine and outright quackery have tried to piggyback their advocacy on the ACA in order to have health insurance plans sold through government exchanges cover modalities like naturopathy, chiropractic, and other so-called “complementary and alternative medicine” (CAM) or “integrative medicine.” In related posts, I’ve examined the evidence with respect to the relationship between health insurance and mortality and whether attacks on Medicaid as not improving the health of patients insured by it have any validity. (Let’s just say they are oversimplifications and distortions.)

The claims I’m about to address come from a place every bit as brain dead as the Food Babe in its own way and seem to have originated from an article on Forbes by someone named Paul Hsieh, who claims to “cover health care and economics from a free-market perspective.” Imagine my relief, because he sure doesn’t seem able to cover them from a science-based prospective. Behold his op-ed, Why The Federal Government Wants To Redefine The Word ‘Cancer’. The insinuation (although Hsieh is quick to deny that that’s what he’s really saying) is that the government wants to redefine cancer so that fewer patients will be diagnosed with cancer and qualify for treatment under Obamacare:

With respect to the definition of “cancer,” downgrading some conditions as no longer being “cancer” can and will used to justify reducing “unnecessary” screening tests (e.g., mammograms for women between ages 40-49). Mammograms can now detect the condition known as “ductal carcinoma in situ” (DCIS), which would no longer be called a cancer under the new proposal.

And, later:

I don’t believe the individual scientists arguing for a redefinition of cancer are driven by inappropriate political motives. But government will soon account for 66% of health spending and is aggressively seeking to limit health expenditures. Hence, the government may have a vested interest in definitions that err towards undertreatment, rather than overtreatment. We must remain vigilant against any attempts by the government to use language as a tool of covert rationing.

Imagine my further relief that Hsieh doesn’t think those of us who are interested in reducing overtreatment are twirling our moustaches and rubbing our hands with glee as we plot on “death panels” how to deny mom and grandma her mammograms to save money, all in the service of Obamacare. Not that I actually believe him. Or maybe he doesn’t believe that, but knows that the rubes who read his column do.

What Hsieh is referring to is an article published online in JAMA in July, and in the dead tree edition, by Laura J. Esserman, Ian M. Thompson, Jr., and Brian Reed entitled Overdiagnosis and Overtreatment in Cancer: An Opportunity for Improvement, a viewpoint report that was reported fairly widely in the media in Medscape, the New York Times, and NPR. The article, as I will discuss shortly, should not have been a surprise to anyone who regularly reads this blog or my writings at my not-so-super-secret other blog about overdiagnosis and overtreatment of cancer and the complexities of screening asymptomatic populations for cancers. As I’ve said time and time again, the relationship between early diagnosis and improvements in survival is complex and not nearly as clear-cut as most people, even most physicians, think. What Esserman et al. discussed as part of their summary of recommendations of a working group at the National Cancer Institute was simply the next logical step, recommending possible strategies to reign in overdiagnosis without compromising treatment of potentially life-threatening cancers. Their recommendations are reasonable and science-based, although likely to be at least somewhat controversial. Near the end of his piece, Hsieh quotes Dr. Milton Wolf, who says something that is so wrong on so many levels that one wishes it were possible to strip doctors of their medical licenses for spreading medical misinformation:

Health care rationing takes many insidious forms but perhaps the most immoral is for the government to wage a public relations campaign designed specifically to dissuade patients and doctors from seeking available cures for cancer. They scheme to rename cancer, not to cure it, but to deny it exists. These government rationers have calculated that rather than actually treat patients with cancer, it’s cheaper to simply keep them as calm as Hindu cows right up to the very end.

I’ve noticed that radiologists (for example, Dr. Daniel Kopans) seem to be the ones most opposed to any recommendation that involves decreasing screening intensity or frequency. One notes that Wolf is also a conservative Republican running for the Senate in Kansas who is in favor of defunding or repealing Obamacare. Ironically, he is also Barack Obama’s second cousin, who proudly proclaims, “I may not be the first doctor to oppose ObamaCare, but I am the first doctor from Barack Obama’s own family to oppose ObamaCare” and has even written an e-book entitled First, Do No Harm: The President’s Cousin Explains Why His Hippocratic Oath Requires Him to Oppose ObamaCare (Voices of the Tea Party). He’s also written articles with titles like The FDA’s one-man death panel and Tyranny in our time, criticizing his cousin and Obamacare. You get the idea.

Well, maybe you don’t. Hsieh and Dr. Wolf are downright reasonable in comparison to how the right wing blogosphere ran with this story. Here’s a sampling:

  • “It is plain and simply rationing of health care. And, at some point, rationing becomes a death sentence. So, in the opinion of your humble observer of the asylum we all have to live in, the House Republicans should go back to their original proposal to defund ObamaCare and each time the Senate sends the bill back to the House, they should just change the date and return it to the Senate. Keeping the government in partial shut-down may be a godsend.” – Asylum Watch.
  • “And why would the Obama administration want to re-define cancer? Because starting tomorrow, Obamacare will begin subsidizing millions of Americans’ health insurance, and cancer tests and treatments are expensive. This is nothing more than a back-door, roundabout form of rationing. It has nothing to do with improving health care or saving lives and everything to do with bureaucrats picking and choosing who gets what tests and treatments.” – Poor Richard’s News.
  • “Aren’t we glad that crazy Sarah Palin lady with her death panel rants didn’t get elected. And instead we live with a wise and sane government that fights new wars while renaming them as interventions and cures cancer by renaming it and denying coverage? Hope. Change. Death.” – Daniel Greenfield, Frontpage Mag.
  • “Cancer tests and treatment are expensive, and the government doesn’t want to foot the chemotherapy bill for lesions that don’t have a ‘reasonable likelihood of killing the patient.’ This redefining of the word cancer has absolutely nothing to do with improving healthcare, with saving lives, or with saving patients unnecessary anxiety; it is no more than an underhanded and surreptitious attempt at rationing. It is a cloak-and-dagger attempt to restrict who can benefit from healthcare system overpromised to us by Obama himself.’ – Crissy Brown, Thoughts on Liberty.
  • “One of the great problems in allowing the government– especially one proven to be untrustworthy by a number of recent high-profile scandals– to run health care and judiciously dole treatments with an idea toward cost-saving, is that the truth becomes completely lost. Any sort of trust that is supposed to exist between patient and doctor is lost as doctors are required to redefine, to the point of untruth, diagnoses, treatment options, and future prognosis due to the federal legal requirements. It’s Orwellian and wrong. And it’s guaranteed by ObamaCare.” – Yukio Ngaby at the very much misnamed Critical Narrative.
  • “The government wants to redefine the word “cancer” in order to have fewer conditions that can be classified as actual cancer. I’m going to go out on a limb here and ask…..do they really believe changing a couple of definitions is really going to help lessen the lives taken by cancer? I mean, if you paint a coconut pink it is still a coconut isn’t it?” – The Black Sheep Conservative.

I’m going to go out on a limb here (actually, no I’m not) and say bluntly that all of these criticisms demonstrate an astronomical level of ignorance about cancer that at its heart boils down to a conspiracy-minded belief that the government (via the NCI) wants to redefine cancer in order to not have to treat people with cancer and save money, no matter how many lives this costs. Of course, it never occurred to them that, given by definition overdiagnosis and overtreatment mean diagnosing cancer that will never threaten the life of the patient and treating such cancers unnecessarily, reducing overdiagnosis and overtreatment is a desirable goal, both from the standpoint of improving patient care (overtreatment is all risk, no benefit, after all) and decreasing costs. This is the problem with science-based guidelines rooted in new understandings of cancer biology. Reasonable recommendations about how to decrease the rate of overdiagnosis and overtreatment are immediately seized upon by activists. Unfortunately, as can be seen from Dr. Wolf’s likening of such recommendations to slaughtering cattle, a lot of physicians share in this ignorance. With that in mind, let’s look at what Esserman et al. actually wrote and recommended.

Redefining cancer: What it really means

I’ve discussed ductal carcinoma in situ (DCIS) before on multiple occasions. To recap, DCIS is a condition in which malignant-appearing ductal cells are observed in the milk ducts of the breast but have not yet invaded through the membrane surrounding the duct to get into the tissue outside of the duct. To put it simply, that’s basically what “in situ” means, that the cancerous cells have not yet invaded the basement membrane. There are quite a few epithelial cancers that have a carcinoma in situ stage: breast, colon, bladder, prostate, and others. In the breast, DCIS is generally considered “stage 0″ cancer, and treatment has a very high success rate. The reason for this success is likely because a lot of DCIS, possibly even most DCIS, never progresses to invasive cancer or progresses so slowly that the women who have it die of something else (such as old age) before it ever causes a problem. Indeed, it is estimated that low grade DCIS, if it progresses, does so within a time frame of 5 to 40 years and possibly in only 20% of DCIS cases, while high grade DCIS is more likely to progress. The same sort of behavior occurs with a lot of early stage prostate cancer in men. Since I’m a breast cancer surgeon, most of my examples will come from breast cancer. In other words, premalignant lesions are not one disease, and many of them will never cause harm within the remaining lifetime of the person harboring them.

The fact is that before the advent of widespread mammographic screening, DCIS was a relatively uncommon diagnosis. Now, thirty years or so after mass mammographic screening programs became widespread, DCIS is common. Indeed, approximately 40% of breast cancer diagnoses are in fact DCIS. A recent study found that DCIS incidence rose from 1.87 per 100,000 in the mid-1970s to 32.5 in 2004. That’s a more than 16-fold increase over 30 years, and it’s pretty much all due to the introduction of mammographic screening of asymptomatic women. One potential reason is that by the time DCIS progresses to the point of being detectable by means other than mammography (such as feeling a breast mass), it has usually progressed to invasive ductal cancer. Another potential reason is that much of the DCIS we detect by mammography doesn’t progress to become symptomatic and threaten the life of the woman. Probably both mechanisms are in play. Either way, we don’t know for sure what percentage of DCIS lesions progress to cancer, and, in fact, we don’t know for sure whether the progression from normal ductal cells to cancer necessarily goes through DCIS. (Yes, I am a co-author on this paper and helped with much of the clinical discussion.) Indeed, there are currently three main models, all of which might contribute in different specific cases of DCIS, for how infiltrating ductal cancer (IDC) arises:

DCIS

Supporting the hypothesis that something more than just a straight linear model of breast cancer progression is most in line with how breast cancer develops is the observation that, although the diagnosis of breast cancer has very much slanted much more towards DCIS and early stage (stage I and II) cancers over the last 30 years, detecting and treating these cancers aggressively has not resulted in a proportionate decrease in metastatic and locally advanced cancers. This was reported in the New England Journal of Medicine last December and is in line with other studies that I’ve mentioned finding that one in three breast cancers diagnosed by mammographic screening could be overdiagnosed and that one in five might spontaneously regress without treatment. Indeed, it’s becoming increasingly apparent that even a subset of frankly invasive cancers either don’t progress, progress so slowly that they won’t cause harm, or even regress. Treating these lesions provides no benefit to women, but does produce risk. In other words, these lesions (in this case, DCIS) that we refer to as “cancer” might better be considered something else, as many of them might not behave like cancer at all, at least not if defined as if untreated, inevitably progressing into a cancer that will threaten a woman’s life within her natural lifespan. Some are likely to be very indolent; some might even regress.

Who wouldn’t want to reduce the number of patients who are overtreated, and who wouldn’t want to name these premalignant, possibly malignant, conditions more accurately? Although part of this debate does have something to do with decreasing costs, contrary to what the fractally wrong quotes above more than insinuate, the primary reason is to decrease the number of patients subjected to potentially toxic therapies like radiation, surgery, and even chemotherapy for lesions that would cause no harm in their lifetime. The problem, as I’ve pointed out time and time again, is that we don’t yet know how to distinguish the in situ and early invasive cancers that are harmless from the ones that will progress. Until we can do that, we as physicians feel obligated to treat all of them aggressively.

With this background in mind, the recommendations by Esserman et al. seem downright reasonable, mainly because they are downright reasonable, beginning with the introduction:

Over the past 30 years, awareness and screening have led to an emphasis on early diagnosis of cancer. Although the goals of these efforts were to reduce the rate of late-stage disease and decrease cancer mortality, secular trends and clinical trials suggest that these goals have not been met; national data demonstrate significant increases in early-stage disease, without a proportional decline in later-stage disease. What has emerged has been an appreciation of the complexity of the pathologic condition called cancer. The word “cancer” often invokes the specter of an inexorably lethal process; however, cancers are heterogeneous and can follow multiple paths, not all of which progress to metastases and death, and include indolent disease that causes no harm during the patient’s lifetime. Better biology alone can explain better outcomes. Although this complexity complicates the goal of early diagnosis, its recognition provides an opportunity to adapt cancer screening with a focus on identifying and treating those conditions most likely associated with morbidity and mortality.

Changes in cancer incidence and mortality reveal three patterns that emerged after inception of screening (Table). Screening for breast cancer and prostate cancer appears to detect more cancers that are potentially clinically insignificant. Lung cancer may follow this pattern if high-risk screening is adopted. Barrett esophagus and ductal carcinoma of the breast are examples for which the detection and removal of lesions considered precancerous have not led to lower incidence of invasive cancer. In contrast, colon and cervical cancer are examples of effective screening programs in which early detection and removal of precancerous lesions have reduced incidence as well as late-stage disease. Thyroid cancers and melanoma are examples for which screening has expanded and, along with it, the detection of indolent disease.

All of which is basically what I’ve been saying, with the addition of the examples of cervical and colorectal cancer, which do appear to behave in a manner consistent with a more linear progression model, which means that removing early stage disease does effectively prevent the appearance of late stage disease. Based on these observations, here is what the NCI recommends, with my comment afterward

  • Physicians, patients, and the general public must recognize that overdiagnosis is common and occurs more frequently with cancer screening. [Note: This is nothing that I haven't been saying for at least four years now, ever since I started to appreciate the complexities of screening for cancer.]
  • Change cancer terminology based on companion diagnostics. Use of the term “cancer” should be reserved for describing lesions with a reasonable likelihood of lethal progression if left untreated. There are two opportunities for change. First, premalignant conditions (eg, ductal carcinoma in situ or high-grade prostatic intraepithelial neoplasia) should not be labeled as cancers or neoplasia, nor should the word “cancer” be in the name. Second, molecular diagnostic tools that identify indolent or low-risk lesions need to be adopted and validated. Another step is to reclassify such cancers as IDLE (indolent lesions of epithelial origin) conditions. [Note: Again, if you understand the more recent data with respect to screening certain cancers, none of this is an attempt by the evil government to withhold vital care from cancer patients. It is actually an attempt to improve the care of cancer patients by decreasing overdiagnosis and more carefully "personalizing"—if you'll excuse the use of this overused term—care to the patient's tumor.]
  • Create observational registries for low malignant potential lesions. Providing patients and clinicians with pathologic diagnosis and information related to disease prognosis is crucial to informed decision making, including comfort with alternate treatment strategies such as active surveillance. [Note: Again, if we are truly going to "personalize" the treatment of lesions of low malignant potential, we need better information about what percentage of them progress into life-threatening malignancy and over what time frame they do so in order to facilitate shared decision-making between physician and patient. Again, this is not withholding treatment; this is empowering patients based on scientific findings to make decisions regarding their care with which they are comfortable.]
  • Mitigate overdiagnosis. Strategies to reduce detection of indolent disease include reducing low-yield diagnostic evaluations appropriately, reducing frequency of screening examinations, focusing screening on high-risk populations, raising thresholds for recall and biopsy, and testing the safety and efficacy of risk-based screening approaches to improve selection of patients for cancer screening. [Note: Again, this is nothing that I haven't discussed in depth many times, beginning with the USPSTF recommendations for mammography. Unfortunately, any attempt to decrease screening inevitably runs into criticism that we'll be "killing patients," because the idea that premalignant diseases inevitably progress to life-threatening cancer is deeply embedded not only in the popular concept of cancer, but in the medical profession itself. Indeed, physicians even go so far as to erroneously blame the New York Times for killing patients by publicizing the problems with screening tests for cancer, like PSA testing.]
  • Expand the concept of how to approach cancer progression. Future research should include controlling the environment in which precancerous and cancerous conditions arise, as an alternative to surgical excision. [Note: I must admit that this one left me scratching my head a bit. What, specifically, does this mean in practice? I must admit that I don't know.]

Esserman et al. conclude by pointing out that much of this is an issue of communication as much as it is of science. After all, for the last 30-40 years, the medical profession and public health officials have been drumming it into our heads that we have to catch cancer early and that screening tests are the best way to do it, without also pointing out that every medical tests have risks and benefits. Yes, catching cancer early tends to be better in many ways. Treatment is more likely to be successful (or at least appear so) and, in the case of many cancers, can be achieved with much less aggressive and disfiguring surgeries. In my field, the example of doing a lumpectomy compared to being forced to do a mastectomy comes to mind. However, much more difficult is explaining how much of that improved survival is due to lead time bias and how much is due to treatment and early detection (as I’ve discussed here, here, here, and here). It’s also hard to include in such discussions the concept of length bias, in which most cancer screening tests are biased towards detecting slower-growing, more indolent disease. As I’ve discussed before as well, to avert one death from breast cancer with mammographic screening for women between the ages of 50-70, 838 women need to be screened over 6 years for a total of 5,866 screening visits, to detect 18 invasive cancers and 6 instances of DCIS. The additional price of this was estimated to be 90 biopsies and 535 recalls for additional imaging, as well as many cancers treated as if they were life threatening when they are not. To prevent one death from prostate cancer, 1,410 men need to be screened over 9 years, for a total of 2,397 screening visits and 48 cancers detected. In other words, screening takes a lot of effort for, on an absolute basis, not as many lives saved as most people, even doctors, believe.

When taken in this context, all Esserman et al. are saying is that we need to screen smarter, not more, and that we need to adjust our terminology and treatments to be more in line with our more recent understanding of biology. As Dr. Otis Brawley, chief medical officer of the American Cancer Society, put it so aptly, “We need a 21st-century definition of cancer instead of a 19th-century definition of cancer, which is what we’ve been using.” He’s right. Most of our definitions of carcinoma, carcinoma in situ, and premalignant conditions date back over 100 years and were based largely on what could be observed about tumors under the microscope. In 2013, we now have the tools to probe the molecular pathways that define and drive the progression of cancer.

Conclusions

There is actually one point that the cranks attacking the recommendations of the NCI panel make that has some validity, just not in the way that they think it does. That point is that words have power, and the word “cancer” has particular power. Of course, the cranks think that the reason the NCI is suggesting ceasing to use the word “cancer” to describe conditions that appear cancerous using old criteria but are not likely to harm patients who have them, is to deceive patients and doctors into accepting less care in order to save money. In reality, it is a plea to bring language more into line with new science, based on concern among doctors that “hundreds of thousands of men and women are undergoing needless and sometimes disfiguring and harmful treatments for premalignant and cancerous lesions that are so slow growing they are unlikely to ever cause harm.” At the same time, we do not want to go too far in the opposite direction and err on the side of undertreatment.

Frequently referenced in discussions of the NCI recommendations is another study that I had meant to blog about when it first came out but got distracted by my Dug the Dog tendencies. (It came out about the same time the NCI recommendations saw print.) This study by Omer et al. examined the effect of how DCIS is described on the treatment choices of women. In the study, 394 women without a history of breast cancer were presented with three scenarios that described ductal carcinoma in situ (DCIS) as noninvasive breast cancer, breast lesion, or abnormal cells. They were then asked to choose among three treatment options: surgery, medication, or active surveillance. When DCIS was described as noninvasive cancer, 53% favored nonsurgical options. However, 63% chose nonsurgical options when the term used was breast lesion, a number that rose to 69% when the term used was abnormal cells. The authors concluded:

We conclude that the terminology used to describe DCIS has a significant and important impact on patients’ perceptions of treatment alternatives. Health care providers who use ‘cancer’ to describe DCIS must be particularly assiduous in ensuring that patients understand the important distinctions between DCIS and invasive cancer.

Or, as Ian Thompson put it:

“That is the real world of this when you include the word ‘cancer,’” Dr. Thompson said. “Because the word ‘cancer’ has a connotation that is profoundly bad.” The word “precancerous” has that same connotation. “That means the shoe is going to drop sometime down the road and that you are irresponsible if you don’t do anything about it,” he continued.

The consequences of the use of the word “cancer” to describe conditions that are only somewhat likely to progress can be seen all around us. For instance, the NPR article on the NCI recommendations tells the story of a 42-year-old woman who was diagnosed with DCIS and decided that she wanted a double mastectomy. In fact, I was shocked to learn that 6% of women with DCIS opt to undergo double mastectomy, which is massive overkill for such lesions that will not decrease the risk of dying of breast cancer. The consequences are found in women with DCIS being pressured by well-meaning doctors to have surgery right away, as if DCIS will turn into cancer overnight if they don’t act. It won’t.

In the end, dealing with premalignant lesions comes down to three things. First, we desperately need more accurate methods of risk assessment that allow us to accurately predict the likelihood that a given lesion will progress into cancer. Second, we have to get rid of the mindset that all precancerous lesions will inevitably “turn into” cancer. They won’t, and which ones are dangerous depends on the cancer type, observable characteristics such as nuclear grade, and molecular characteristics that we haven’t dissected yet. Finally, it’s a matter of communication. Telling people that finding cancer early is always better, that precancerous lesions found by screening will inevitably kill them if they don’t act, is based on an understanding of cancer progression that is decades old and no longer appropriate given the knowledge accumulated over the last two decades. It might be a cliché, but we need to screen smarter, not more, and we need to be able to explain that not all premalignant lesions require aggressive treatment.

It’s not going to be easy to change this culture and mindset, though, not the least of which because cynical pundits like Paul Hsieh and Mark Wolf are trying to convince people for their own political purposes that any effort to decrease screening, or more accurately describe premalignant lesions that are unlikely to cause harm, is somehow wanting to let cancer patients die in order to save money.

Posted in: Cancer, Politics and Regulation, Science and the Media, Surgical Procedures

Leave a Comment (58) ↓

58 thoughts on “Redefining cancer

  1. Hsieh acknowledged there are legit medical reasons to redefine what cancer is – you could even make a case to remove the word entirely from medical lexicon, and use the specific names instead – plasmocytoma, glioblastoma, etc.. the generic “You have cancer” is just as useful as “You have disease” – not very useful!

    The issue is not a medical one, but the use of medical terminology for political gain, propaganda, and relentless push by the Federal Death Authority to strip decision making from patients and their physicians.

    1. David Gorski says:

      You’re a very silly person.

      1. Said by someone who injects himself with thimerosal for fear of catching the flu.

        1. WilliamLawrenceUtridge says:

          Said by someone who may inject themselves with a rapidly excreted form of mercury that doesn’t accumulate in the body and therefore there isn’t anything to worry about. Thiomersal gets pissed out, and quickly, so why worry about it? Why not worry about the chance of influenza killing you by drowning your lungs, or thickening your blood to the point that it causes you to stroke out?

          The devil is in the details, you should learn what they are.

          1. David Gorski says:

            Of course, FBA always finds a way to bring up vaccines. This is not a post about vaccines. Vaccines are off topic for this particular post.

        2. Sawyer says:

          I have to admit, I’m always impressed at how much insanity FBA is able to pack into such a small space. Non-sequiter, false premise, poisoning the well fallacy, tu-quoque fallacy, naturalistic fallacy, flawed biochemistry, flawed immunology, and a blatant lie all packed into 15 words.

          No SBM contributer or commenter will ever match his talents.

          1. Carl says:

            FBA is a homeopath. Crazy don’t get crazier than that.

  2. Stephen H says:

    Note to Doctors Wolf and Gorski: Hindu practice does not involve the slaughtering of any cows. Cows are not exactly sacred, but they are definitely revered – and taboo.

    And of course, one wonders whether the male commentators will jump to have surgery if/when they are advised of an enlarged prostate. (Bugger – I still have to check that word every time, to make sure I’m not using prostrate instead!)

  3. goodnightirene says:

    Thanks for this. I was aware of the study as reported in the NY Times, but not aware of the right wing blogosphere response–or of President Obama’s cousin! I guess we all have cousins we’d rather not be related to.

    I wonder if any of this will be sorted out in my lifetime? Having fairly recently had a (probably) unnecessary breast biopsy, I really didn’t feel I could refuse with the argument, “well, you see, I read this blog, and…”

  4. Ed Whitney says:

    If someone with a little spare time and a high tolerance for pain chooses to do so, it would be possible to look at these right wing websites and see how many of them also deny evolution, deny climate change, think that Pres. Obama was born in Kenya, and think that Pres. Kennedy’s assassination was done by a conspiracy. These beliefs tend to cluster together.

  5. Harriet Hall says:

    Just try telling patients they have a plasmacytoma or a glioblastoma. They will ask “Is it cancer?” and demand an answer. Even if we tried to remove it from the medical lexicon, it has been too well-established in the public lexicon. Patients demand simple diagnoses they can understand, and the concepts of pre-malignant and indolent lesions are complicated.

    1. If they ask is plasmacytoma cancer, you can say it is a tumor of plasma cells that grows in the soft tissues of the skeleton. More specific and more useful and keeps the person listening. You say cancer and the patient is in shock for the next 10 minutes not hearing the rest of what you had to say like treatment options.

      1. NorrisL says:

        There was a case here in Queensland, Australia in which a lady patient was told she had cancer. Her brain stopped working right at that point. She knew she had cancer and she knew that cancer kills people. She went home and told her husband and the details blur at some point here, but the end result was a double suicide caused by a perfectly treatable illness.

  6. Rick says:

    Quacks are presents on both ends of the political spectrum. I’ve spent hours debunking anti-vaccine, anti-fluoride, and harmless marijuana claims on many left wing sites.

    1. Ed Whitney says:

      True as far as it goes, but do these lefties run for the US Senate and other high office with the support of a left-wing Tea Party faction? The right wing actually nominates these clowns for Congress and elects them in numbers sufficient to influence government policies regarding scientific issues.

      1. Windriven says:

        Ed, distasteful as it may be, I think that’s how our system is intended to work. They run. People vote. If enough vote for them they win.

        I can easily name Reps and Senators on both sides of the political divide who make my skin crawl. Sadly, politics in this country have long since stopped being a search for common ground. I don’t think that either party can claim the high ground in this regard.

        1. Ed Whitney says:

          Well, there is a tendency in many media toward being “fair” and saying that “the blame game” is happening with both sides equally to blame. This works to the advantage of Tea Party types, who can go as far to one extreme as they please, and still the “fairness” doctrine requires that the centrists be equally blamed for holding the center.

          The core of Obamacare was, after all, a Republican idea back in 1993, when an individual mandate for universal coverage was proposed by the conservative Heritage Foundation. But now Newt Gingrich can call it socialized medicine and Sarah Palin can say that it has death panels, and Heritage Action can denounce it as a government takeover of health care, and still it is considered liberally biased to report that one side has gone off the rails to the right and sabotaged the meanings of words so that reasoned discourse is made impossible; we must still say that no one is blameless and that each side is pointing its fingers at the other, as if they were equally petulant children.

          The GOP has members in its ranks who say that evolution is a lie and climate change is a hoax, but they suffer no loss of standing or esteem. There is good evidence to reject the idea of equal blame, and I reject it.

    2. Windriven says:

      I’d be interested in a link to a debunk of safe marijuana. I don’t have a particular axe to grind either way*. But accurate or not I am inclined to believe that casual use of marijuana is harmless, at least in comparison to alcohol and other drugs. If you have scientifically compelling information to the contrary I’d like to see it. We recently passed a recreational MJ law here in WA. I voted for it. I’d hate to think I screwed up.

      *Mediocre MJ makes me cough and not much else. Really fine MJ makes me cough, then go to sleep. I settled on Scotch many years ago as my drug of choice.

    3. Sawyer says:

      I’ll give you the pot correlation and maybe fluoride, but I think we’ve seen enough evidence at this point that anti-vaccination nonsense is just as common among fringe conservatives as it is among the left. I’m struggling to locate the post, but I know Dr. Gorski talked about the Lewandowski study before.

      And while I don’t have a tally in front of me, the most rabid anti-vax comments on this site do not appear to be coming from card carrying Democrats.

      1. windriven says:

        “I think we’ve seen enough evidence at this point that anti-vaccination nonsense is just as common among fringe conservatives as it is among the left.”

        No arguments from me. I’m sick to death of nut jobs at both political extremes. At the moment the right seems to have more than its fair share. But these things ebb and flow. Far too many people let others do their thinking for them. Apparently it is much easier for them to simply sign on to some political party than to think through the difficult public policy issues facing our nation for themselves. All that thinking would interfere with American Idol.

        “[T]he most rabid anti-vax comments on this site do not appear to be coming from card carrying Democrats”

        FBA and stanmrak leap immediately to mind.

    4. David Gorski says:

      Quacks are presents on both ends of the political spectrum. I’ve spent hours debunking anti-vaccine, anti-fluoride, and harmless marijuana claims on many left wing sites.

      No one ever said otherwise, particularly not here. In fact, the myth that I’m usually debunking here is that quackery and antivaccinationism are primarily left wing phenomena.

      1. JAK-STAT says:

        My experience in primary care on the East Coast has been that the vast majority of anti-vaccine patients were left leaning. The only patients I had with conspiratorial views about OBGYNs and who gave goats milk and rice milk to their infants were left leaning as well.

        My right leaning patients had conspiracies about the Fed, the president’s birthplace and religion, probably were way off on a few other things, yet they seemed to exhibit higher trust in the medical profession. but they were much more consistent with flu shots and did not perceive ACIP to be a bankster plot.

        Both sides were roughly equally accepting of the 2008 data on prostate cancer screening and extant uncertainty vis the Swedish data. I think I’ve only ordered one PSA for screening purposes and that was for an AAM with +FHx, significant concern and an unknown prior PSA measurement that he aimed to follow-up.

        In any case I saw a lot of ignorance on both sides.

        These observations may reflect mere correlation and there are many potential confounders. This is an observation from my personal experience and may but more likely may not reflect some causal link; it suffers from the problem of inductive logic Popper warned us about as well as 3rd variable problems and multiple probable biases. I would caution others to exhibit like suspension in reflecting upon their own observations. The same goes when perusing a few sites and comments from same and calling that the ‘right wing blogosphere’.

        The conservative weltanschauung is different. The way Inuit, Icelandic and Jainist cultures are different, so too are the US left and right. You would not quote some foreign culture out of hand / context and use these things to impugn the whole worldview – you would try to understand it first, no? Anyway that’s the usual approach when diplomacy across national / cultural boundaries are sought. It seems neither side is really interested in understanding what makes the other tick. Why do we suppose these folks deny global warming? Brainwashing isn’t an answer. There is some criterion for knowledge that you need – it isn’t the same when the idea presented to you opposes your current biases. What are those biases and how does that epistemological rigor become more or less stringent across subjects? If you accept that your ideologic opponents are ‘brainwashed’ and read only what the straw-man least equipped ignoramus among them has to say, then you are actively choosing to continue this circling of the drain that we currently have going on in the US.

        I suppose it’s no coincidence that the era of trolling is also an era in which elevated conversation to achieve mutual understanding just does not happen.

  7. Windriven says:

    Where to start?

    First, there is something troublingly Orwellian about calling a carcinoma something other than a carcinoma. Clearly, the label leads to overtreatment in cases such as DCIS. But that strikes me as an issue of education rather than nomenclature.

    Second, I detest the term ‘precancerous’ as a relatively meaningless ‘scare’ word.

    “The word “precancerous” has that same connotation [very bad]. That means the shoe is going to drop sometime down the road and that you are irresponsible if you don’t do anything about it,” as Dr. Gorski quoted Ian Thompson.

    Why not simply note an unusual cell morphology and move on. If there is a high likelihood of the unusual morphology leading to invasive cancer, then that is a point to be covered.

    But most troubling to me is this: “Health care rationing takes many insidious forms.” It is troubling because it is true, though not, I think, in the way that Hsieh suggests.

    Health care is what economists refer to as a scarce commodity. That simply means that the demand for health care exceeds the supply. This is true for many reasons, some perfectly practical and some rather less savory. It guarantees that health care is rationed by one means or another. It is true in the US. It is true in Canada. It is true in every nation with whose health care system I have familiarity. There simply are not enough health care resources for everyone to get unlimited access to health care.

    From a public policy perspective one of the most intelligent ways to ration is to be sure that resources are expended on those who actually need them and will meaningfully benefit from them. This, I believe, is central to Dr. Gorski’s argument here. Fear of a 6 letter word is not a good reason to spend resources willy-nilly.

    But this also gives rise to fears of ‘death panels’ because if a resource is rationed, somebody gets to pick the winners and the losers. I think it is a generally fair characterization of the political right that it distrusts the federal government’s ability to administer rationing in a way that it would perceive as equitable.

    One might also make the observation that the political right would prefer a more darwinian rationing system similar to that which exists today: the golden rule; he who has the gold gets the care. Perhaps Senator Cruz will explain why this characterization is unfair.

    In any event, healthcare will continue to be a battleground issue until we find ways to have honest discussions about it. We spend too much in the US. We get too little. And we attempt to balance the books by denying care to some of our neighbors. Obamacare attempts to address this last bit by bringing everyone into the insurance system. But it does so without funding new residencies for primary care and it does so without addressing many of the idiocies that push health care costs so high in the US. So the books are likely to wander farther out of balance.

    This is unsustainable. It drains productivity. It puts us at a competitive disadvantage to our trading partners who spend less. And it is a lousy deal for everyone save those few who benefit by running up health care costs.

    1. CannotSay2013 says:

      “One might also make the observation that the political right would prefer a more darwinian rationing system similar to that which exists today: the golden rule; he who has the gold gets the care. Perhaps Senator Cruz will explain why this characterization is unfair.”

      I think that you correctly described the problem here. As somebody who is a right winger, I have to say that the reason many of us are opposed to Obamacare is precisely because of the rationing aspect. That is not to say that what existed before was perfect, but what existed before let a big chunk of the population (an overwhelming majority of the 85% who currently have health care) to make their own choices when it came to the treatments he/she wanted to follow without having to follow the guidelines of “death panels”, all that at a reasonable cost. The big problem with Obamacare is that it is going to dismantle this system and replace it with another which, overtime, will evolve to something like a three tier system,

      - 20-25% of the population will be on Medicaid.

      - 10-20 % of the population will have a system like the one enjoyed by the majority of the population today: freedom of choosing doctors and patients. The “Darwinian system” if you will. These 10-20% will be people who pay out of their pockets all the healthcare expenses or who work in areas where generous health benefits are the norm (lawyers, doctors, highly educated professionals, etc.)

      - 55-70% of the population (and this would include those who will get their insurance through the exchanges as well as those who will get the minimum coverage required by law from their employers) who will get to live by the “rationing rules” and pay a lot of money for their care.

      How do we know this? Because it is the case in every single country that has socialized medicine (which Obamacare is only a step away from) that a two tier system develops: the single payer system for a majority of the population -which is rationed-, and the private healthcare system for the top earners which is basically what those insured today in the US have. The Obamacare system will not be there yet, but it will eventually go there if Obamacare is not repealed in the next 10 year. And when it happens, we will have the 3 tier system above morph into a 2 tier system: Medicaid (or Medicaid-like) for 80-90% of the people, private insurance for the 10-20% remaining. In a country as large as the US, those two systems will be able to co-exist because 20 % of the people (especially high earners) is like having a wealthy country of 60 million people, each of which will be happy to pay the higher premiums (or their employers will pay the premiums) to have good healthcare. And of course, no there will be no support from the left or the right to repeal the system of the 20% since it is the system that will produce the top notch treatments and medical breakthroughs.

      1. windriven says:

        @CannotSay2013

        “I think that you correctly described the problem here. As somebody who is a right winger, I have to say that the reason many of us are opposed to Obamacare is precisely because of the rationing aspect.

        But health care is already rationed in the US. Those who can afford first tier health insurance get first tier health care. Those who cannot afford insurance get either Medicaid or, if the fall in the gap, incur unsustainable medical bills that in the worst case scenarios end in bankruptcy.

        That is not to say that what existed before was perfect, but what existed before let a big chunk of the population (an overwhelming majority of the 85% who currently have health care) to make their own choices when it came to the treatments he/she wanted to follow without having to follow the guidelines of “death panels”, all that at a reasonable cost.”

        One man’s ‘death panel’ is another man’s ‘best practices.’ But where you and I really part company is: “all that at a reasonable cost.” As an employer I can tell you that the cost does not strike me as at all reasonable. The United States spends a little less than 18% of GDP on health care. Sweden spends, about half that and achieves better outcomes using WHO rankings. That isn’t reasonable in my estimation.

        “Because it is the case in every single country that has socialized medicine (which Obamacare is only a step away from) that a two tier system develops: the single payer system for a majority of the population -which is rationed-, and the private healthcare system for the top earners which is basically what those insured today in the US have.”

        I can’t speak for every single country that has socialized medicine. But I can speak with some authority on two: Sweden and Canada. I think you would find the vast majority of Swedes extremely satisfied with their health care; Swedes from the highest and the lowest quintiles of income. The Canadian system varies a bit from province to province but in the west satisfaction with their system seems to be very high. Canadians of my acquaintance in Ontario though seem not as universally happy but I will leave it to some of our Canadian friends to weigh in here.

        Regular readers here know that I am not at all a knee-jerk liberal. I am a businessman in a tough business – manufacturing. I have strong libertarian tendencies. But I also recognize the social and economic realities of health care.

        Again, health care is a scarce commodity. It will be rationed. It is already rationed. I personally find something along the lines of best practices as a first cut to be perfectly supportable. I don’t choke on a single payer socialized system because I’ve seen it work quite well in Sweden, Denmark and Canada.

        But if you have some better way to manage health care rationing while getting our expenditures down to something closer to 10% of GDP – something that ACA doesn’t even pretend to do – America waits with bated breath!

        1. CannotSay2013 says:

          Sure there was rationing before, but more people had bargaining power (by way of switching providers) before Obamacare than will have once Obamacare is fully settled. The point is that Obamacare will shrink the percentage of the population able to bargain, that cannot be denied.

          You speak of Sweden and Canada as “models” but I see both countries as anything but. I know very well the system of the European country where I was born and three more, which are none of the two you have mentioned. People in my former country as in others are “happy” because most don’t know any alternative to socialized medicine. But even in those two, the higher earners don’t play by the same rules as everybody else. There are no waiting times for those willing to pay cash in Canada or Sweden.

          It is best to illustrate the situation by way of an example. I still hadn’t moved to the US when HAART was introduced in the US as an effective way to keeping HIV infection under control circa 1995. Guess what, the socialized system of my former country didn’t make those treatments available to all who needed them until 1 or 2 years after 1995. During this time many people died of something they should not have if they had had access to HAART. Of course, those with HIV infection and with means ran to the US to get HAART. So this is a clear example of thousands of Europeans – and probably hundreds of Canadians- killed by socialized medicine between 1995 and 1997 (when HAART became available everywhere in Europe). While this example is dramatic, it illustrates what happens when people get their healthcare rationed. Of course, if you haven’t known an alternative to socialized medicine during your entire life (as it is the case of the majority of Europeans) you cannot complain about what you don’t have.

          The well to do in the US will continue to have access to the best healthcare possible without rationing. Somebody like Bill Gates could afford to build his own hospital and hire the best doctors if he needed to. Steve Jobs for instance, was able to live a couple of years more than a regular guy would because of his billions. The problem with Obamacare is that it will shrink the share of the population that can have access to this level of care.

          With respect to alternatives, what about eliminating the oligopolistic practices of the health insurance companies by enabling nationwide competition? Or what about decoupling health insurance from employers so that the tax deduction goes to the individual regardless of the employer he/she works for? I am afraid that not too many businessmen would be happy with eliminating a very effective way of slaving employees.

          Obamacare passed with the support of a few lobbies: the AMA, the insurance company lobby and the drug companies. That should tell you who are going to be the main beneficiaries of the reform. I blame the doctors lobby, ie the AMA, as much as the rest. They keep the costs of healthcare high by limiting the supply of doctors, which is a real shame.
          I also blame Big Pharma, big supporters of Obamacare, for doing the same.

          1. windriven says:

            “but more people had bargaining power (by way of switching providers) ”

            Somehow I don’t think that BlueCross will lose sleep if I move my policy to another carrier. Health care premiums are ridiculously high. If this were something like a free market I might agree with you. But health care is anything but a free market.

            “You speak of Sweden and Canada as “models” but I see both countries as anything but.”

            Both countries spend much less on health care and both deliver better outcomes. That sounds like a model to me.

            “But even in [Sweden and Canada], the higher earners don’t play by the same rules as everybody else.”

            Are you seriously arguing that high earners play by the same rules as the bottom quintile in the US? That just isn’t so.

            “the socialized system of my former country didn’t make [HAART] available to all who needed them until 1 or 2 years after 1995.”

            You don’t name your former country and I have no data close at hand about the availability of HAART. But I would be very surprised to see hard evidence that Canada – or Sweden for that matter – lagged far behind the US in providing HAART to AIDS patients.

            “The problem with Obamacare is that it will shrink the share of the population that can have access to this level of care.”

            How? There is nothing in ACA that prevents you from purchasing health insurance from whomever you please … or simply writing a check if you have that kind of money. What ACA does do is force everyone to participate. This should appeal to a conservative like you. We don’t let people die in the street in this country. A young healthy woman might eschew health insurance in favor of paying off student loans or saving for a house. If she presents with acute appendicitis, somebody is going to take it out whether she can pay for it or not. That sort of free ride is largely eliminated by ACA.

          2. CannotSay2013 says:

            “Both countries spend much less on health care and both deliver better outcomes. That sounds like a model to me.”

            Mmmm. I think that there is a lot of misconception about what a “better outcome” is. Life expectancy alone, for instance is not a good one given the high rate of violent crime in the US when compared with other countries. Regardless of the real reason for the crime rates, it has nothing to do with healthcare. In fact people have gone through the trouble of eliminating this factor from the calculation of life expectancy, and when that is done, the US comes out on top http://b-i.forbesimg.com/theapothecary/files/2011/11/National-Life-Expectancy1.png . The Concord study also found that in the US 5 year survival rates to the most common types of cancer beats countries with socialized medicine http://b-i.forbesimg.com/theapothecary/files/2011/11/CONCORD-table1.jpg . When it comes to spending in medical R&D, the US is second to none. We Americans subsidize the research that benefits those other countries.

            “Are you seriously arguing that high earners play by the same rules as the bottom quintile in the US? That just isn’t so. ”

            No, but the type of care that is available to the high earners is now available in the US to 60-70% of the people. Obamacare will change that. There is simply no workaround with that.

            ” But I would be very surprised to see hard evidence that Canada – or Sweden for that matter – lagged far behind the US in providing HAART to AIDS patients. ”

            This study focused on Sweden and Denmark will help you understand reality (look at the figures of percentage of people on HAART between 1995 and 1997),

            http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0072257

            Also your comment misses the reality that HAART was developed in the US, not in Western Europe because the lack of incentives in the latter to do top notch research.

            “How? There is nothing in ACA that prevents you from purchasing health insurance from whomever you please … or simply writing a check if you have that kind of money. What ACA does do is force everyone to participate. ”

            Obamacare does more than that. It forces you to buy a product that has a minimum of specs, such as maternity coverage that people might not need. Before Obamacare you could select a plan that covered only the issues you were interested. A couple who is in their 30s who has decided to not have more children doesn’t need such coverage for instance (let alone a couple in their fifties with adult children). Because Obamacare forces you to buy a plan with “essential coverage” it makes all plans more expensive than what they were previously. There is no magic here. Either the premium will cost more, or the deductible will be higher or both.

            ” A young healthy woman might eschew health insurance in favor of paying off student loans or saving for a house. If she presents with acute appendicitis, somebody is going to take it out whether she can pay for it or not. That sort of free ride is largely eliminated by ACA.”

            Sure, but said young woman will also be forced to pay for a lot of things that do not concern her. Let’s not fool anybody. The young people of today are getting the worst deal of all. Not only they are paying into two programs that will be extinct by the time they need them (Social Security and Medicare), but now they are also forced to buy a product that offers a lot of things they don’t need so the seniors get a better deal. Obamacare makes the problem of intergenerational theft even worse. I can only imagine that you are part of the band of thieves who is happy to steal from young people. That would explain why you defend Obamacare so enthusiastically.

          3. Young CC Prof says:

            @Cannotsay13: Since different countries have different screening policies, 5-year survival rates for cancer make a poor international comparison, due to things like lead time bias. It’s been written about here before.

          4. CannotSay2013 says:

            YCCP,

            Despite its problems, the Concord study surely is a better indicator of healthcare quality than the travesty put forward by the World Health Organization in 2000 which was designed to make socialized medicine look good. In addition, The Lancet has a definite left editorial stance when they do commentary on current issues so you can hardly claim that the study was published to make the US look good. Seriously, anybody here has the guts to say that in the case of a life/death condition he/she rather go to get his/her care to any of the countries that ranked higher than the US in that WHO study? Like let’s say… Malta, which ranked near the top. Get real! There is no such thing as a free lunch.

          5. windriven says:

            @CannotSay2013

            “Seriously, anybody here has the guts to say that in the case of a life/death condition he/she rather go to get his/her care to any of the countries that ranked higher than the US in that WHO study?”

            I have received outstanding care in China and Germany. Prompt. Inexpensive. I wouldn’t go to China for something major but primarily for reasons of language. I’d happily go to Germany, Denmark, Sweden or France. I’ve worked with doctors and hospitals in these countries (France excepted) and they are every bit as good as those I’ve worked with in the US.

            But look, I don’t have to have a single payer socialized system to be happy. Propose an alternative system that reduces health care as a percentage of GDP and extends quality basic healthcare to everyone.

            It is easy to bitch, not so easy to offer a constructive alternative.

          6. CannotSay2013 says:

            “I’d happily go to Germany, Denmark, Sweden or France.”

            I can assure you that if you had had terminal AIDS in 1995, you would not be making the same statement. Or if you had today a disease that required the latest medical breakthroughs, you wouldn’t go there.

            You, and those who think “socialism” like you seem to be unable to understand that top not medical research is incompatible with socialized medicine. For those countries to deliver healthcare somebody has to innovate. If the US healthcare system were to fall victim of the same forces that dominate those countries’ healthcare systems, it would be a tragedy not only for Americans but for the rest of the world. This fact also applies to other areas of innovation. When was the last time that any of those countries produced something as revolutionary as Google? The only thing that comes to mind remotely close is the Concorde, which is from the seventies. Luc Montagnier might have gotten the Nobel for the discovery of the HIV virus but nobody in his right mind would suggest that his contribution mattered in anyway in the chain of events that led to the development of HAART.

            Then you say,

            “But look, I don’t have to have a single payer socialized system to be happy. Propose an alternative system that reduces health care as a percentage of GDP and extends quality basic healthcare to everyone.”

            I already have, but you seem to have problems reading English:

            - Remove the restrictions that prevent companies from competing nationally.

            - Remove the notion of “employer provided healthcare”. Attach the tax deduction to the employee, so it goes with him/her when he/she changes jobs. That would mean the elimination of the concept of Group Insurance as we know it today. There would be a national market of insurance where individuals could apply regardless of “group”.

            - Remove “for profit insurance”. In higher education, the best universities are non profit and pay very well their professors. Making insurance “non profit” would not affect the quality.

            - Remove the concept of “essential coverage”. Let the market work.

            These measures would be enough to contain costs by way of competition. Obamacare, takes the worst of the current system and puts it on steroids.

          7. windriven says:

            “- Remove the restrictions that prevent companies from competing nationally.”

            Insurance companies? Like Blue Cross/Blue Shield? The one that I have in Washington that is just like the one I had in New Orleans and the one that I had in Cleveland?

            “- Remove the notion of “employer provided healthcare”. Attach the tax deduction to the employee, so it goes with him/her when he/she changes jobs. That would mean the elimination of the concept of Group Insurance as we know it today. There would be a national market of insurance where individuals could apply regardless of “group”.”

            Fine and dandy. No arguments from me. I think labor unions are going to give you a bit of trouble on this but that is between you and them and their political toadies.

            But what about those who cannot afford insurance, group or otherwise? I’m not speaking of the indigent now, I’m talking about the working poor.

            “- Remove “for profit insurance”. In higher education, the best universities are non profit and pay very well their professors. Making insurance “non profit” would not affect the quality.”

            Is that before or after we let them compete nationally? You know, it sounds just like a single payer system – Obamacare on steroids ;-) I’m OK with that if you are!

            “- Remove the concept of “essential coverage”. Let the market work.”

            Ah, you mean let shysters sell meaningless insurance to rubes who can’t tell meaningful coverage from bullshit. Most states have insurance commissions because letting the market work had some unpleasant side effects.

            Look, after working through this all I hear is wind. Your proposals are just a twist on ACA. They do nothing to attack the burgeoning costs of health care other than cutting some of the profits out of health insurance. I thought you didn’t like Obamacare. Your ‘proposal’ is just Obamacare with lipstick.

          8. Ed Whitney says:

            CannotSay2013 links to a table of national life expectancies with and without fatal injuries, showing that when injuries are excluded, the US has the highest standardized mean life expectancy of the listed OECD nations, increasing from 75.3 to 76.9. However, excluding injuries for Japan and the other highest ranking countries has the effect of lowering life expectancy (Japan goes from 78.7 down to 76.0). How does it happen that excluding a category of causes of death occurring mainly in young persons decreases life expectancy? There are big problems with this table. Anyone have any ideas here?

          9. windriven says:

            @Ed Whitney

            “CannotSay2013 links to a table of national life expectancies with and without fatal injuries, showing that when injuries are excluded, the US has the highest standardized mean life expectancy of the listed OECD nations, increasing from 75.3 to 76.9.”

            I’m not quite sure how to take that. It suggests that the US lags in trauma care but that doesn’t make much sense given our experience in war zones.

            I didn’t catch that link and I can’t seem to find it in his comments. If you’ll reply with the URL I’ll dig into it.

          10. windriven says:

            @Ed Whitney

            I found it. That chart is from Forbes Magazine and there is no citation for the source of information. The chart is pretty. But without more information it is hard to take it seriously.

            This looks to me like an exercise in cherry picking at best and an attempt at baffling with bullshit at worst.

          11. Stella B says:

            CannotSay: Your four point plan though is far from adequate for making a health care system work. The middle two points – non-profit insurance and the separation of employment from insurance – are points that any liberal would agree with. The ACA is headed in those directions, if not quite all the way there. Your other two points are less successful. There is no reason to think that selling insurance across state lines (federalizing a privilege formerly reserved for the states!) would decrease costs. It’s more likely that it would lead to a race to the unregulated bottom as happened with credit cards. Ditto “essential coverage”. The markets don’t work now and it’s unlikely that decreasing regulation is going to help. I’m not planning to ever have a child with autism, so why should I pay for insurance that covers autism? Oops.

            Your other point, that US care is better than Western European or Canadian care, is equally shaky. We don’t keep statistics on US access times, but all conservatives just know that those access times are better than Canada. Never mind people with poor insurance or no insurance, they probably deserve what they get.

            I don’t believe that conservatives are heartless, but I have noticed that they have constructed an elaborate framework to justify why some people can’t get insurance and access to heal care. Unhappily, that elaborate framework is not based on reality. There really is no free car available from ERs, most uninsured want insurance, most uninsured are legal residents, many people with pre-existing conditions have healthy lifestyles, tort reform hasn’t lowered health care costs in the states that have tried it, etc.

            Oh, and as a note for future purposes, everybody here can read. Most of us have advanced degrees.

          12. windriven says:

            “http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0072257″

            OK, CannotSay2013, what exactly is this supposed to mean? It says nothing about the rate of HAART implementation in the US during the same period. And the implementation curve for Denmark looks terrific! Do you know what you’re talking about?

          13. WilliamLawrenceUtridge says:

            Your other point, that US care is better than Western European or Canadian care, is equally shaky. We don’t keep statistics on US access times, but all conservatives just know that those access times are better than Canada. Never mind people with poor insurance or no insurance, they probably deserve what they get.

            I remember seeing a series of posts over at scienceblogs (not RI) that gave a comparison between different countries (Canada, France, Germany, the Netherlands?) regards health care. I believe that the poster said you couldn’t conduct a similar comparison of the US because there was no system. But because of source confusion, I could be mixing that up with a friend of mine who did a Masters in public health.

            Point still stands.

          14. Ed Whitney says:

            @ Windriven and CannotSay again:

            Of course, the largest contributions to life expectancy over the past century or so can be credited to plumbers, not doctors. Separating the sewage from the drinking water was due to their efforts. Health care systems add some years too, but basic advances in standards of living take the lion’s share of these increases.

        2. lap says:

          Well yes, but america is not Sweden, Denmark or Canada. Those nations have better debt to GDP ratios as well as a government that took some spending cuts before having their systems. The opposition to the ACA is a financial one. We already have entitlements that are far more expensive than out very own GDP, it would seem irrational to spend extra money we simply don’t have. And the bill is (thank god) not single payer, rather a mandate which was supported by most health insurance companies. Granted, they had to accept certain regulations on how they manage their profits and revenues but the fact remains that after the ACA, they will have more opportunity to insure everyone or else the dissident will have a (proverbial) gun to his head.

          As for Sweden, Denmark and Canada
          Sweden has already took strides to privatize some of their systems, as well as lower some government spending. They also have a younger and smaller population.

          Canada only has 32,000,000 people. and has better fiscal outcomes. Quebec had a small constitutional ordeal (Chouli v Quebec, 2005) on the law. I would understand Saskatchewan and Alberta having better care due to less dense population and more per capita income. But the problems of the systems in the east is a political factor.

          Denmark sources their hospitals to private management, but i have no authority.

          As for the WHO reports, the report was not soley on healthcare and pnalized the united states on having HSA’s.
          However, WHO also acknowledged that Wait times for elective surgeries is not a policy problem. In fact, they rated us highly on access to care (lower wait times) and patient privacy.

          However, i do agree, american healthcare is not good. But this stems from perverse incentives and state monopoly. If you want to solve this crises we can take 2 measures: decrease entitlement cost and deregulate certain sectors.

          1. Windriven says:

            “Those nations have better debt to GDP ratios as well as a government that took some spending cuts before having their systems. ”

            First, debt to GDP is an important ratio in many ways but as a primary factor in health care reform, not so much.

            Second, Canada has a higher debt to GDP (84.1%) than the US (73.6%)*.

            Third, Sweden and Denmark have lower debt to GDP because they tax more aggressively that either the US or Canada. Put another way, they pay their bills out of cash flow rather than with debt. That is commendable. Following your logic we should dramatically increase income taxes in the US so that we can provide basic health care services to our population without borrowing. I’m good with that. But I’d rather do it by getting our health care expenditures down in line with other major industrialized nations.

            “We already have entitlements that are far more expensive than out very own GDP”

            We spend roughly $2 trillion on entitlements versus a GDP of roughly $16 trillion. How is that more than our GDP?

            *CIA World Factbook

        3. Ed Whitney says:

          @ Windriven and CannotSay2013:
          I did find a link to the Forbes article at http://www.forbes.com/sites/theapothecary/2011/11/23/the-myth-of-americans-poor-life-expectancy/

          It appears that Avik Roy, the author, did acknowledge some feedback about the effects of excluding fatal injuries from life tables, but then appears to be confused about the expected direction of the confounding. Removing fatal injuries should increase life expectancy in all countries in the developed world. The Roy column goes on to say that the “adjustment factor was based on fatal injury rates relative to the average.” The average what? It is not that difficult to recalculate life tables with injury deaths excluded, and to make direct calculations of life expectancy with all other causes of death.

          It is true to say that the adequacy of a health care system is only partially related to life expectancy at birth; the numbers presented by Mr. Roy are not credible and add little to this discussion.

  8. Marion says:

    So, FastBuckArtist:
    why aren’t all you conservatives out rallying in support of Julian Assange and Bradley Manning and opposing the FEDERAL GOVERNMENT (army, NSA) invading citizens’ privacy at worst, wasting TRILLIONS of dollars, torturing /burning cats in labs?

    Where are all the fiscally-minded conservatives out rallying to shut down financial terrorist organizations like Goldman Sachs, JP Morgan, Wall Street, HSBC and put the conspirators into prison, and to pay back all the multitrillion dollar bailouts they were given?

    Where are all the fiscally-minded conservatives out demanding radical restructuring of society off fossil fuels onto a sustainable energy system, to manmade climate change that will destroy the economy and preventing running into the brick wall of depleted oil reserves?

    1. CannotSay2013 says:

      Who says we are not? You see, conservatives are not monolithic. Suffice it to say that the House measure that was narrowly defeated in the House had strong conservative support or that Rand Paul filibustered the senate until he got assurances from the White House that it didn’t have the legal authority to use drones inside the US. Remember that “mistrust of government” is a core conservative value.

      When it comes to Assange, etc, ultra liberal Dianne Feinstein is more your enemy than me or those with my worldview. She has been a very staunch defender of all the NSA spying programs.

    2. Marion: for the record I am not a member of the republican party or the tea party. With that in mind, I can give some answers to what you ask:

      why aren’t all conservatives out rallying in support of Julian Assange and Bradley Manning

      To put it bluntly they dont care about military crimes committed overseas. It’s some faraway land full of weird-talking brown people to them. There is much more opposition to federal tyranny at home (NSA spying, drones) in the ranks of the conservatives.

      Where are all the fiscally-minded conservatives out rallying to shut down financial terrorist organizations like Goldman Sachs, JP Morgan, Wall Street, HSBC and put the conspirators into prison, and to pay back all the multitrillion dollar bailouts they were given?

      In the ranks of the Tea Party. The Tea Party was created as a public outrage reaction to the federal bailouts of private banks. It evolved as a libertarian wing of the republican party but the origin of the movement was a direct reaction to the bailouts.

    3. windriven says:

      @Marion

      FBA is full of crap as usual. The Tea Party was founded to oppose what it sees as excessive taxation, hence the reference to the Boston Tea Party of 1773. Some in the Tea Party also decry the bailouts but bailouts were not the precipitating issue. The Occupy Movement, radically different from the Tea Party, arose in response to bailouts for the financial industry.

  9. Marion says:

    c0nc0rdance’s YouTube channel has an excellent video on the exaggerations about the harmlessness of marijuana. He gives as fair and objective and scientific an analysis of the effects of smoking marijuana as one can give. As usual, the extremes from the pro-pot and anti-pot sides jump in with rage and insults against c0nc0rdance.

  10. Marion says:

    I and my family (siblings and their spouses) have been vegan since the 1970s for animal rights, not false exaggerated claims that veganism cures or prevents cancer.

    I’ve been enraged and sickened by my local vegetarian society inviting chiropractors and other antiscience types to speak at their dinners. That’s why I had to pass on attending these recent events. And, yes – I have made my objections know to the leaders of the vegetarian society, but I don’t think they “get it”.

    However, I think the leader of the society is sympathetic to the cause of growing cultured meat in the laboratory, which groups like New Harvest support. She understands the need to feed protein to millions of pet dogs & cats who have no choice where to get their protein, and to prevent breeding billions of chickens & cows who have every right and desire to live as much as cats & dogs do.

  11. Frederick says:

    Good article! I live In the Province of Québec, I’m always fascinated by your health care debate and how ridiculous some arguments are. With have free health care, and there no ‘death panel’. those saying that always forgot the fact that it is the insurance company that will most likely try ‘not to pay for a treatment’ to increase profit. In fact i remember seeing a a documentary about how some doctor work hard for insurance company to find reason for them not to pay.

    Anyway, great Vulgarization of Cancer. And i think that those recommendation are good for all health care system. More accurate vocabulary and technical term is always good. over-treatment is as bad a non treatment.
    There is always some learning to do in here.
    Thank Dr. Gorski

    1. WilliamLawrenceUtridge says:

      One of the big advantages of a universal health care system is that everyone pays a bit, so nobody pays a lot, and everyone gets care. It’s totally imperfect (find me a system that is) particularly when you are the one who has to wait. But overall nobody goes bankrupt because of health care costs.

      I’m torn on whether “two-tier care” is a feature or a bug. On one hand, it offends my sense of fairness. On the other hand – if everyone is paying for health care through taxes, two-tier care means those with enough money can go elsewhere, which reduces the load on the system overall.

      Canada’s health care system is also rational. Many of the complaints are about what I would term “lifestyle” issues. Urgent care is well-done, with triage and whatnot. Screening for cancer, and treatment for cancer is top-notch. Complaints are found around things like joint replacement, lap band surgery and related issues that pose little risk of immediate death, but do make lives less pleasant. Hip pain and immobility sucks – but if it breaks you are treated right away and if you’ve got cancer the system manages you pretty well.

      Frankly, Americans should reject Obamacare in favour of a genuine health care system, not merely the bandage that is the insurance and reimbursement process. Obamacare is better than what existed before, but it’s still a far, far cry from a humane and reasonable genuine, federally-funded, universal system.

      1. Frederick says:

        I agree with you on some point, but I don’t think US should reject this, because, right now, that’s you ‘best’ option. I’m pretty sure a lot of people will want to build a universal health base on example like Canada or Europe. And with all the money spend on the military or money that the GOV could get by a small increase of corporate taxes, you could have the best universal health care of the world. You have top Doctors, top universities. I might insult people so i’m sorry, but i always found it stupid, and totally insane that you don’t have that already.
        Anyway, just look how much ideological opposition just a small change stir up. Sorry but somehow and unfortunately you country is not ready for this.

        Personally, i will never want to change my universal health care ( and almost free education, except for university) over US system. I’m proud to pay my taxes for that. of course we could debate for day about imperfection.

        For the two tiers system. it won’t work. because a health care for rich will attract the best Med, best resources, etc. Because they could overprice there service and the rich will still be able to pay them. And the rich system will pay their doctors more. In the long run this will drain the public one. Wwe have this problem hear because of the US, and because of the Ontario paying more is doctors. So even between province with free health cares, those problem appears. This could be worst if people could ‘opt out’ of paying their part.
        I’m not against .some private clinic, for some specific things. but they must be part of the whole system. It is like this here. youre private care are paid by the system. we always have debate about our system every year. Some issues come and go. we always want to find how to make it better.

        they are Some blinded right wing person who think that every thing should be private. but they are really few of them.

  12. CannotSay2013 says:

    To my critics on my insurance plan,

    Windriven, apparently you are unaware that the market of health insurance today in the US is state based, even with Obamcare. Since Stella B seems to know better I let her explain that matter to you.

    With respect of nationalizing healthcare, and fears that it will drive a race to the bottom, I think that the example that I have cited, higher education, shows that it will not. What it will do is to create a series of options that will appeal to some people more than others. Given that we are 300 million people here, even if an option appeals to 1% of the population, that’s still 3 million people. In higher education, there is a market for those who want to go the Ivies, but there is also a market for those who don’t want to go there for whatever reason. The free market works wonders there. and it would do the same to a national healthcare marketplace. The quality of European universities, compared to the American ones, is a joke. In Europe, cheap access to higher education has resulted in more people having access to mediocre higher ed (and a selected few having access to Oxford, Cambridge and the like). The American system makes it possible for anybody who deserves it to go to Harvard. This is what happens in Europe with healthcare too. The majority have access to the socialized, mediocre system (with state imposed rationing), and a selected few have access to whatever they want.

    Finally, for those who cannot afford health insurance, I suggest a system like medicaid: something that makes sure that nobody is left out or required care, but that doesn’t encourage government dependency. It should cover a bare minimum (particularly catastrophic, chronic situations) but it should not be a “Cadillac plan” by any means.

    The biggest obstacles for a plan like the one I propose are the special interests who benefit from the current system: insurers, the AMA and Big Pharma. These will continue to benefit under Obamacare. Big Tobacco was defeated and I believe that these three can also be defeated if enough pressure is put on them.

  13. Flower says:

    I’m all for health screening and prevention. However, according to recent reports in the medical literature the rate of overdiagnosis of cancer and subsequent overtreatment, not to mention the unnecessary traumatic experience for women who do not actually have cancer must be avoided. Any solutions?

    It’s also now known that pre-malignant lesions, as well as breast cancer often regresses spontaneously without any treatment.

    This should be taken into account, especially since chemotherapy and radiation actually increase the number of malignant cancer stem cells over the relatively non-malignant daughter cells within the tumor colony.

    Another serious aspect that needs to be looked at is the carcinogenicity of the x-rays of the mammography technology itself.

    The 30 kVp radiation, known as “low energy” x-rays, are between 300-400% more carcinogenic than the “higher energy” radiation given off by atomic bomb blasts (200 kVp or higher).

    So, by screening for a health problem we are actually creating a problem! That can’t be right.

    1. WilliamLawrenceUtridge says:

      I’m all for health screening and prevention. However, according to recent reports in the medical literature the rate of overdiagnosis of cancer and subsequent overtreatment, not to mention the unnecessary traumatic experience for women who do not actually have cancer must be avoided. Any solutions?

      Um…Dr. Gorski kinda discusses this. You might try reading his other posts as well. The solution is more research on the molecular and genetic mechanisms of cancer, and long-term follow-up to distinguish what lesions are likely to be precancerous, and which are likely to resorb or cause no symptoms. Science discovered a new way of identifying precancerous cells. Turns out it doesn’t work very well. Science is now correcting that process and looking for new avenues.

      This should be taken into account, especially since chemotherapy and radiation actually increase the number of malignant cancer stem cells over the relatively non-malignant daughter cells within the tumor colony

      Another serious aspect that needs to be looked at is the carcinogenicity of the x-rays of the mammography technology itself.

      The 30 kVp radiation, known as “low energy” x-rays, are between 300-400% more carcinogenic than the “higher energy” radiation given off by atomic bomb blasts (200 kVp or higher).

      So, by screening for a health problem we are actually creating a problem! That can’t be right.

      Seriously, did you read the article? You are repeating what oncologists already know, what is being turned into continuing medical education and in-school training. Screening is a battle between false positives, false negatives, true positives and true negatives, and the risks of screening itself. This is known, it’s why imaging technicians wear lead aprons and why screening itself is being revisited.

      I think what irks me most about you quacks is how you take an issue already known to doctors, researchers and regulators, and you trumpet it as if you had discovered it, as if you weren’t merely parasitic on knowledge already in circulation.

  14. Kiiri says:

    I just have to weigh in here. I will disclose my biases up front, I am politically liberal, work in public health, and supported the ACA though I had really hoped for rational single payer. In reference to comments above, most are talking about rationing in single-payer systems. This is a more nuanced topic. First, Europe does exercise control over one thing in particular and that is drugs. All drugs used in the NHS must be approved by NICE. But lets back up. Say you are a drug company and you just invented a drug for cancer. FDA will make you do studies to show that the drug isn’t harmful (doesn’t just kill people) and that it actually works. But showing it works means showing that it works against doing nothing. So most drugs can clear that low bar. But lets say there is another drug for this cancer. It also works. It costs half as much. NICE will make your new drug compete against the old drug. Does it work better than the old drug? If this answer is no, NICE sticks with the cheaper just as effective drug. If the answer is yes, then the decision can be more nuanced, how much better does it work? If the answer is a lot then it is going to get approval no matter the cost. If it works just a tiny bit better, or just for a small segment, then it may not. In the US we don’t compare the new drug against the old drug. We say new=good and new must be better than old, so give me the new one. Never asking the question does it work better, or could we get the same result and pay half as much. This is why there has been a big push recently to pit these drugs head to head and answer the question are they just as effective or not so that doctors can have the information to make a valid decision.
    I would personally take a single payer system any day. I don’t think insurance companies should make profit off a people’s misery. I support a minimum service plan because otherwise the insurance companies will cheat to make more money. By spreading the risk around then everyone benefits.
    I agree with other posters that healthcare is already rationed in the US. Those with deep pockets can get the best care fastest. Those without don’t. I think those right-wing posters who have advocated total free market and let the poor fend for themselves should think about that more. Free market rarely works to anyones advantage except the corporations and uber wealthy who are free to do whatever they want to make a buck. Everyone else pays the price for institutional greed. In order to have a society that operates like a society rather than anarchy government is a must and regulation is a must.

    1. WilliamLawrenceUtridge says:

      Have you read Bad Pharma? Dr. Goldacre discusses the kind of head-to-head, and above all pragmatic real-world trials you describe.

      I had thought the ACA included a mandate and funding for head-to-head trials. I hadn’t heard about it in a while, am I delusional or was it later dropped? Or merely no longer discussed in favour of the more press-worthy death panels?

    2. JAK-STAT says:

      1) Government’s Right -You have to believe that health care is the proper role of government. Some people don’t believe that – and it’s a metaphysical claim. If you’re going to say look at outcomes, you’re ignoring the role of deontology. Thoughts on the proper role of government and beliefs about a person’s freedom to gamble himself to ruin or buy lousy health insurance (caveat emptor / personal responsibility) outweigh concerns about a particular outcome for many people. Whether this is ‘good’ or ‘bad’ or ‘pleasing’ is a metaphysical question.

      2) Economization of Resources – Some believe that health care being undertaken by the state (medicare, medicaid, subsidized exchange plans) is an improper economization of national resources. There is no RCT or Hills criteria as regards this topic and the criterion for knowledge is very much pent up in the dogmas of the observer. In terms of cost savings, many look at Ontario’s 7.4% annual increase in OHIP costs over the past 8-9 years as validation of this concern about cost. Given that nobel laureates are referring to QE as ‘a nothing event’, leaving lesser ‘experts’ stunned, I can only imagine that the vast majority of us are completely unequipped to make coherent economic arguments (though many on both sides presume expertise).

      3) Caring for the Neediest in Society – Many conservatives believe that in concert with a federal healthcare system being a poor economization of resources, it is also a violation of moral agency. To them, it’s up to citizens to take care of the poor, not the government. This is commonly equated with leaving people to ‘fend for themselves’, when it really is an objection to so-called ‘forced-charity’. Whether this is merely bald idealism or the ultimate communitarianism, who knows? (If you’re tempted to object that there’s some historical comparison I’d ask you to count the number of confounding variables in your comparison to the present circumstance)

      4) Outcomes Data – it is very hard to know if US outcomes data are attributable to our health care antisystem or related more to income inequality, poorer diet, less physical activity, gun and gang violence, or 12-20 million undocumented folks who have had a lifetime of no medical access affecting overall numbers etc. If you have data that controls for such factors I’d very much like to see it.

      5) Name Calling – ‘You right wingers’, ‘ideological’ etc. Recognize that you too are making fundamental metaphysical claims which imply that utilitarian outcomes supersede individual liberty and moral agency. Further, the chance that your economic argument is as comprehensive and authoritative as you think it is is very low. If you think you have a good argument, please incorporate your projection using growth of M2-M3 over income, the effect of the baby boom, interplay of state medicaid obligations with burgeoning state debts in certain parts of the country, possible changes in reserve currency choices given Chinese resource utilization, comparisons the the NHS, provincial systems in Canada and the effect of Scandinavian style taxation on US investment and GDP over the next 50 years. There’re probably more things in play that I’ve failed to mention…

      Bottom line, we all want the sick and poor to be cared for. We all want health care waste to be minimized and to ensure that we’re not just spending profligately now at the cost of massive debt and inability to finance like services in future generations. I think many conservatives are beginning to come to grips with the fact that most Americans do think that healthcare is the domain of government and it is how they’d like to economize their resources. A lingering question, though, is that if Americans truly believe that – why didn’t the Democrats use their mandate 2008-2010 to offer a single-payer system? If you’re going to force me to pay for someone else’s healthcare by either buying a different plan or inflating my dollars – why make it a payout to insurance companies and drug companies?

  15. Mark says:

    Dr Gorski;

    Aren’t you being a bit hard on civilians and their response? This is your profession, your area of expertise but it’s only been the last 5 years or so that you’ve been saying these things: “[Note: This is nothing that I haven't been saying for at least four years now, ever since I started to appreciate the complexities of screening for cancer.]” And we peons are still often subjected to (huckster voice), “Screen early. Screen often. ACT NOW!”

    As for those who believe the change is a money saving trick, might I suggest the history of this administration has some bearing on their conclusions? Remember these hits:

    If you like your insurance you can keep it.
    You can keep your doctor. (How many of your acquaintances have or are considering quitting?)
    Not one penny in new taxes for anybody making less than $250,000.
    Don’t forget they imprisoned a man while the president falsely claimed his tape was responsible for the murders in Benghazi

  16. Fiona says:

    Sometimes I feel that what gets underestimated in this type of discussion is the tremendous variety in the way patients hear, understand, and evaluate information. There is never going to be one way to explain screening or treatment options to patients, because each patient is coming to the process with background biases and a whole host of considerations that the doctor may or may not be aware of. I’ve certainly been present during consults where the patient understood something very different from what the physician was attempting to explain. I can think of many instances when it does matter whether something is called abnormal, precancerous, potentially cancerous, or cancer.

    I wouldn’t mention my own experience if it wasn’t relevant. Dr. Esserman was my surgeon back in 1999 and treated my DCIS with a mastectomy. I was offered the option of chemo, but it was expected to confer only a 5% survival benefit (I considered it). Tamoxifen was also on offer, but I was E- so, again, the potential benefit didn’t seem worth the side effects. Would she now consider this overtreatment? I doubt it, because, as Dr. Gorski says, there’s DCIS and then there’s multi-focal, high-grade DCIS that has started to become invasive. (Added to this the fact that my mother, an early breast-cancer survivor, had just died of pancreatic cancer at the age of 61.) I’ve been asked lately if I’m angry that I lost my breast to something that “wasn’t even cancer”. You can imagine what I thought of that question. Nobody could have explained my options to me better than Dr. Esserman, and I trusted her judgement completely. I’m glad to see her research continue in the direction of greater clarity of language and communication.

    As the great screening/overdiagnosis/overtreatment debates move forward, I hope we see more of an emphasis on accurate terminology that reflects our ongoing understanding of this disease, not less. This matters to patients. So keep it up, Dr. G.; nothing to do with politics.

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