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Dangers in Early Detection By H. Gilbert Welch

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General fitness, health and nutrition
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5 July 2004
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5 July 2004
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Bignascarfan
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  1. Here's an article by a doctor who is skeptical of the big
    medico consortium of test ordering providers, test producing
    diagnostic companies and labs, and big pharma.

    This is another physician that Doc Biggs will disparage. He
    is part of this consortium. I'm here for my HEALTH-he's here
    to justify his BUSINESS practices belittle skeptics of his
    ALMIGHTINESS.

    I just received my latest A1C-5.5 on a labnorm of 4.3 to
    5.9, guess I'm doing my part as a T1 after 42 years.

    2x Hypurin Lente mixed with Iletin II Regular.

    You feel well. You're only 60. Your PSA -- the blood test
    for prostate cancer -- is normal. Much to your chagrin, you
    learn of recent research that suggests you still might have
    prostate cancer. But the only way researchers know this is
    because they performed a more aggressive test -- placing a
    probe through the rectum of normal men and inserting a
    biopsy needle six, maybe 12 times to search for cancer in
    various parts of their prostate. Should this procedure be
    performed on you? Should it be performed on all healthy men?

    This is American medical care today -- care increasingly
    directed toward the well. Ironically, the primary service
    we offer them is relentless testing to establish whether
    they are, in fact, sick. We screen for early forms of
    diabetes, heart disease, osteoporosis, hepatitis, vascular
    disease and, of course, cancer. The conventional wisdom is
    that early detection improves health. But this assumption
    may be wrong.

    Why? Because early disease detection means more people
    become patients. Inevitably some will be treated needlessly
    and suffer as a result.

    To understand this, you need to understand that each of us
    harbors early forms of disease. Even in middle age, many of
    us who feel well have evidence of diabetes, heart disease,
    osteoporosis, hepatitis, vascular disease and cancer. Just
    because we harbor these early forms of disease doesn't mean
    that they will ever affect our health. Some diseases
    progress so slowly that people die of other causes long
    before the diseases generate symptoms. Other diseases may
    not progress at all. Unless we were tested, we'd never have
    known we were sick.

    Prostate cancer is the classic example. Among men age 60,
    around half have microscopic evidence of prostate cancer
    if we look hard enough. Yet only four in 1,000 will die
    from prostate cancer in the next 10 years. How can this
    be? Because prostate cancer isn't just one disease: It's a
    spectrum of disorders. Some forms of prostate cancer grow
    very rapidly and kill men. Some grow slowly and men die of
    something else before the cancer ever causes symptoms. And
    others look like cancer under the microscope but never
    grow at all.

    A little over a decade ago, doctors started looking hard for
    prostate cancer using the PSA and lots of needle biopsies.
    And we found a great deal: Roughly 2 million cases were
    diagnosed in this period -- almost a million more than would
    have been without the test.

    Did prostate cancer screening help men? To be honest, we
    aren't sure about the net effect. There has been a small
    decline in the death rate from prostate cancer, but this may
    simply reflect that our treatments are better. While
    screening probably has helped a few men live longer, it has
    also clearly hurt others. Millions have been biopsied who
    otherwise wouldn't have been. Many with nonprogressive
    disease have been turned into cancer patients unnecessarily.
    Most have been treated, and many have suffered ill effects.
    A few have even had their lives shortened by treatment.

    This is the reality of early detection. A few may be
    helped, because their disease is destined to cause problems
    and because early treatment is able to solve those problems
    in a way that later treatment cannot. But many simply are
    told earlier that they have a disease and gain nothing,
    because their disease could have been treated just as well
    later, when symptoms appeared. And others are hurt by
    treatment for a disease that would have otherwise never
    affected their health.

    What's next? Consider CAT scans of the chest to look for
    lung cancer. During mass screenings in one region of Japan,
    CAT scans found 10 times as many patients with lung cancer
    as had been found a few years earlier using chest X-rays.
    Incredibly, nonsmokers were almost as likely to have lung
    cancer as smokers. Is smoking getting safer? Of course not.
    Everyone agrees that smoking is far and away the most
    important cause of lung cancer. The CAT scans were simply
    labeling some people as lung cancer patients who otherwise
    would never be affected by a few abnormal cells.

    Why not treat these patients -- just to be safe? Because
    some people die from treatment. In the Mayo Clinic study
    comparing lung cancer screening (using chest X-rays) to
    standard care, more people in the screening group were told
    that they had lung cancer. It didn't help them live longer;
    in fact, slightly more people in that group died.

    And some think we should scan the whole body. But the
    harder we look, the more we find. CAT scans of the chest
    lead more people to be told they have lung cancer, and
    there are even more abnormalities to find in the abdomen.
    As one radiologist who has read thousands of these scans
    put it, "With this level of information, I have yet to see
    a normal patient."

    Millions of healthy Americans are being told that they are
    sick (or "at risk"😉. More are undergoing invasive
    evaluations with needles, flexible scopes and catheters.
    And more are taking drugs for early forms of diabetes,
    heart disease, osteoporosis, hepatitis, vascular disease
    and cancer.

    We need to start asking hard questions about whose interests
    are served by the relentless pursuit of disease in people
    who are well. Clearly it's good business -- for test
    manufacturers, hospitals, pharmaceutical companies. And it's
    good for some doctors.

    But is it in society's interest? Many suggest that it saves
    money by lowering the cost per patient. But the savings per
    patient (if they exist) are overwhelmed by the increased
    expense of having so many more to treat. Is it in the
    interest of sick patients? Absolutely not, as caring for the
    well increasingly distracts doctors from caring for the
    truly sick. And what about the well? Is it in their
    interest? Only they can decide -- after they have been
    informed that early detection is a double-edged sword.

    The writer is a professor of medicine in the Department of
    Veterans Affairs and Dartmouth Medical School. He is the
    author of "Should I Be Tested for Cancer? Maybe Not and
    Here's Why." washingtonpost.comA19323
    2004Jun30.html

  2. BigNascarFan said:

    Here's an article by a doctor who is skeptical of the big
    medico consortium of test ordering providers, test
    producing diagnostic companies and labs, and big pharma.

    This is another physician that Doc Biggs will disparage.
    He is part of this consortium. I'm here for my HEALTH-he's
    here to justify his BUSINESS practices belittle skeptics
    of his ALMIGHTINESS.

    I just received my latest A1C-5.5 on a labnorm of 4.3 to
    5.9, guess I'm doing my part as a T1 after 42 years.

    2x Hypurin Lente mixed with Iletin II Regular.

    You feel well. You're only 60. Your PSA -- the blood test
    for prostate cancer -- is normal. Much to your chagrin,
    you learn of recent research that suggests you still might
    have prostate cancer. But the only way researchers know
    this is because they performed a more aggressive test --
    placing a probe through the rectum of normal men and
    inserting a biopsy needle six, maybe 12 times to search
    for cancer in various parts of their prostate. Should this
    procedure be performed on you? Should it be performed on
    all healthy men?

    This is American medical care today -- care increasingly
    directed toward the well. Ironically, the primary service
    we offer them is relentless testing to establish whether
    they are, in fact, sick. We screen for early forms of
    diabetes, heart disease, osteoporosis, hepatitis, vascular
    disease and, of course, cancer. The conventional wisdom is
    that early detection improves health. But this assumption
    may be wrong.

    Why? Because early disease detection means more people
    become patients. Inevitably some will be treated
    needlessly and suffer as a result.

    To understand this, you need to understand that each of us
    harbors early forms of disease. Even in middle age, many
    of us who feel well have evidence of diabetes, heart
    disease, osteoporosis, hepatitis, vascular disease and
    cancer. Just because we harbor these early forms of
    disease doesn't mean that they will ever affect our
    health. Some diseases progress so slowly that people die
    of other causes long before the diseases generate
    symptoms. Other diseases may not progress at all. Unless
    we were tested, we'd never have known we were sick.

    Prostate cancer is the classic example. Among men age 60,
    around half have microscopic evidence of prostate cancer
    if we look hard enough. Yet only four in 1,000 will die
    from prostate cancer in the next 10 years. How can this
    be? Because prostate cancer isn't just one disease: It's a
    spectrum of disorders. Some forms of prostate cancer grow
    very rapidly and kill men. Some grow slowly and men die of
    something else before the cancer ever causes symptoms. And
    others look like cancer under the microscope but never
    grow at all.

    A little over a decade ago, doctors started looking hard
    for prostate cancer using the PSA and lots of needle
    biopsies. And we found a great deal: Roughly 2 million
    cases were diagnosed in this period -- almost a million
    more than would have been without the test.

    Did prostate cancer screening help men? To be honest, we
    aren't sure about the net effect. There has been a small
    decline in the death rate from prostate cancer, but this
    may simply reflect that our treatments are better. While
    screening probably has helped a few men live longer, it
    has also clearly hurt others. Millions have been biopsied
    who otherwise wouldn't have been. Many with nonprogressive
    disease have been turned into cancer patients
    unnecessarily. Most have been treated, and many have
    suffered ill effects. A few have even had their lives
    shortened by treatment.

    This is the reality of early detection. A few may be
    helped, because their disease is destined to cause
    problems and because early treatment is able to solve
    those problems in a way that later treatment cannot. But
    many simply are told earlier that they have a disease and
    gain nothing, because their disease could have been
    treated just as well later, when symptoms appeared. And
    others are hurt by treatment for a disease that would have
    otherwise never affected their health.

    What's next? Consider CAT scans of the chest to look for
    lung cancer. During mass screenings in one region of
    Japan, CAT scans found 10 times as many patients with
    lung cancer as had been found a few years earlier using
    chest X-rays. Incredibly, nonsmokers were almost as
    likely to have lung cancer as smokers. Is smoking getting
    safer? Of course not. Everyone agrees that smoking is far
    and away the most important cause of lung cancer. The CAT
    scans were simply labeling some people as lung cancer
    patients who otherwise would never be affected by a few
    abnormal cells.

    Why not treat these patients -- just to be safe? Because
    some people die from treatment. In the Mayo Clinic study
    comparing lung cancer screening (using chest X-rays) to
    standard care, more people in the screening group were
    told that they had lung cancer. It didn't help them live
    longer; in fact, slightly more people in that group died.

    And some think we should scan the whole body. But the
    harder we look, the more we find. CAT scans of the chest
    lead more people to be told they have lung cancer, and
    there are even more abnormalities to find in the abdomen.
    As one radiologist who has read thousands of these scans
    put it, "With this level of information, I have yet to see
    a normal patient."

    Millions of healthy Americans are being told that they are
    sick (or "at risk"😉. More are undergoing invasive
    evaluations with needles, flexible scopes and catheters.
    And more are taking drugs for early forms of diabetes,
    heart disease, osteoporosis, hepatitis, vascular disease
    and cancer.

    We need to start asking hard questions about whose
    interests are served by the relentless pursuit of disease
    in people who are well. Clearly it's good business -- for
    test manufacturers, hospitals, pharmaceutical companies.
    And it's good for some doctors.

    But is it in society's interest? Many suggest that it
    saves money by lowering the cost per patient. But the
    savings per patient (if they exist) are overwhelmed by
    the increased expense of having so many more to treat.
    Is it in the interest of sick patients? Absolutely not,
    as caring for the well increasingly distracts doctors
    from caring for the truly sick. And what about the well?
    Is it in their interest? Only they can decide -- after
    they have been informed that early detection is a double-
    edged sword.

    The writer is a professor of medicine in the Department of
    Veterans Affairs and Dartmouth Medical School. He is the
    author of "Should I Be Tested for Cancer? Maybe Not and
    Here's Why." washingtonpost.comA19323
    2004Jun30.html

    SOME of the points outlined have some validity, BUT I sure
    as hell wished my DM was caught MANY years before I was
    diagnosed. I'd love to jump into a time machine and go back
    several years BEFORE my '78 diagnosis and DEMAND a
    definitive test for DM. I had all the classic symptoms for
    so long before my diagnosis, it's a wonder I didn't
    completely fall apart.

    Society is a group who's members have individual interests
    that others would just as soon not cater to. When you talk
    about society, don't confuse that concept with the
    individual members who make up "society". Look at the cost
    of socialized medicine, ala the UK or some European
    countries. The level of care is often inadequate, and S-L-O-
    W, even for life threatening illnesses. "Society", being the
    group, may have everyone "covered" by the program, but
    individuals die each day, waiting for treatment.

    dave

  3. On Fri, 02 Jul 2004 22:02:52 GMT, BigNascarFan
    <[email hidden]> wrote: <snip>

    Quoted message said:

    This is the reality of early detection. A few may be
    helped, because their disease is destined to cause problems
    and because early treatment is able to solve those problems
    in a way that later treatment cannot. But many simply are
    told earlier that they have a disease and gain nothing,
    because their disease could have been treated just as well
    later, when symptoms appeared. And others are hurt by
    treatment for a disease that would have otherwise never
    affected their health.


    <snip>

    I don't doubt that there is sometimes an excessive over-
    reaction, both by the medical fraternity and some
    hypochondriac patients. These are valid comments if they
    force critical review of the medical need (NOT the financial
    implications) for accurate diagnostic criteria.

    However, I see this sort of generalised comment also as an
    over-reaction. The comments this author makes about the
    "others that are hurt by the treatment" in no way balance
    the "few" that may be helped. However, it may mean that the
    methods and intervention points of treatment need review
    rather than the criteria for diagnosis.

    This sort of statement instantly brings to mind the comments
    and resistance we get from some sectors of the medical
    fraternity concerned about the "obsession" that some of us
    have with "self-testing" and how harmful this "excessive"
    testing is to our psyches.

    It is likely that I would not have been diagnosed, with
    either leukaemia or diabetes, under the old standards in
    place ten years ago. But the tighter standards used today
    led to my diagnosis in early '02. The diagnosis did lead to
    depression, but I survived that. If I hadn't been diagnosed
    I would now be 25 Kg (55 lbs) heavier, have soaring
    triglycerides and constant hyperglycemia; although that's
    probably false because it's more likely I'd be dead.

    The spiteful remarks on another poster are not worthy
    of rebuttal.

    Cheers, Alan, T2 d&e, Australia. Remove weight and
    carbs to email.
    --
    Everything in Moderation - Except Laughter.

  4. BNF,

    So who *is* the author ? Apparently that part got
    chopped off.

    Send me the name & address on that consortium. I must have
    misplaced it. 😉

    Cheers,

    William C Biggs, MD

  5. BigNascarFan said:

    This is American medical care today -- care increasingly
    directed toward the well. Ironically, the primary service
    we offer them is relentless testing to establish whether
    they are, in fact, sick. We screen for early forms of
    diabetes, heart disease, osteoporosis, hepatitis, vascular
    disease and, of course, cancer. The conventional wisdom is
    that early detection improves health. But this assumption
    may be wrong.

    <snip>

    Very interesting BigFan, I think there is definitely
    something to what you have posted. From a psychological
    point of view it can be difficult to separate things in our
    minds especially in new or unfamiliar situations so that we
    have to relay on preconceptions somewhat, or taking things
    at face value. So we know: workers go to work, pupils go to
    school, sick people go to the hospital- You go to the hospital-
    therefore you must be sick.

    Personally I think- Hospitals are full of people who are
    brimming with nasty germs I have a below average immune
    system hospitals should be avoided whenever possible.

    Citizen D_M

  6. Quoted message said:

    Society is a group who's members have individual interests
    that others would just as soon not cater to. When you talk
    about society, don't confuse that concept with the
    individual members who make up "society". Look at the cost
    of socialized medicine, ala the UK or some European
    countries. The level of care is often inadequate, and S-L-O-
    W, even for life threatening illnesses. "Society", being
    the group, may have everyone "covered" by the program, but
    individuals die each day, waiting for treatment.

    dave

    Living in a country where health care is free I must agree
    with free=poor, inaccurate, downright lousy.

    Allthough I could get free health care I sure as hell steer
    clear from the "free" service lest I want to wait in line
    for five hours get to see someone who is way underqualified
    to do anything. The sad thing about free health service that
    it actually costs a helluva lot more than "commercial"
    health care. The free health care sector is very, very
    inefficient and rife with corruption and whatnot. Oh, and
    free means you still have to pay! The free part has been
    eroding year after year and now you have to pay all sorts
    cost to get the "free" service.

    I know many health care people and they are wonderful,
    caring people. It's just that the system is corrupt.

  7. On Sat, 3 Jul 2004 22:49:05 +0100, "Citizen DM"
    <[email hidden]> wrote: <snip>

    Quoted message said:

    Personally I think- Hospitals are full of people who are
    brimming with nasty germs I have a below average immune
    system hospitals should be avoided whenever possible.

    Citizen D_M

    That's an opinion I thoroughly endorse. With Igs in the
    toilet it's one reason I do everything I can to stay out of
    hospitals.

    And I don't wait in "waiting rooms". I've trained my various
    doc's receptionists that I will be outside in the lobby or
    car-park when my appointment time comes, not sitting beside
    all the sniffles and sneezes or thumbing through old
    magazines just put down by diseased hands.

    It took a while and development of some rapport, but my
    local doc's surgery is five minutes drive; the receptionist
    now rings me at home when the patient before me goes in.

    Cheers, Alan, T2 d&e, Australia. Remove weight and
    carbs to email.
    --
    Everything in Moderation - Except Laughter.

  8. Total [censored]

    In the US, health care spending per capita is over 6 times
    what it is in the UK, in fact, the FEDERAL government alones
    spending on healthcare, which is only government employee,
    military, veterans, Medicare, and a tiny portion of title
    19, when divided by all US residents is STILL more per
    capita than the UK spends for full health care.

    This provides, by far, the worst mortality and morbidity
    rates of any developed country.

    As to waiting, the portion of the country which is fortunate
    enough to have insurance has to wait many hours for service,
    then get a bunch of expensive tests and 30 seconds with a
    doctor. Do to the increasing medical costs, 75% of people
    who are unable to pay their medical bills are INSURED.
    Copays deductibles and corridor fees are rising even faster
    than insurance rates..

    As for the rest, well, 20% of all Americans can not get
    health coverage at all, not Medicare, not medicaid, NOTHING.
    They are mainly untreated. If it gets bad enough, they come
    into an emergency room under a false name. ER waits here,
    for walk ins, are over 12 hours!

    In addition to the rising number of uninsured, another 31
    million Americans were temporarily without insurance during
    the last two years. Mainly due to being laid off, or
    changing job. "Temporarily" means no less than one month, no
    more than 23 months. Average around 8 months.

    ppp said:
    Quoted message said:

    Society is a group who's members have individual interests
    that others would just as soon not cater to. When you talk
    about society, don't confuse that concept with the
    individual members who make up "society". Look at the cost
    of socialized medicine, ala the UK or some European
    countries. The level of care is often inadequate, and S-L-O-
    W, even for life threatening illnesses. "Society", being
    the group, may have everyone "covered" by the program, but
    individuals die each day, waiting for treatment.

    dave

    Living in a country where health care is free I must agree
    with free=poor, inaccurate, downright lousy.

    Allthough I could get free health care I sure as hell
    steer clear from the "free" service lest I want to wait in
    line for five hours get to see someone who is way
    underqualified to do anything. The sad thing about free
    health service that it actually costs a helluva lot more
    than "commercial" health care. The free health care sector
    is very, very inefficient and rife with corruption and
    whatnot. Oh, and free means you still have to pay! The
    free part has been eroding year after year and now you
    have to pay all sorts cost to get the "free" service.

    I know many health care people and they are wonderful,
    caring people. It's just that the system is corrupt.

    --
    "...in addition to being foreign territory the past is, as
    history, a hall of mirrors that reflect the needs of souls
    observing from the present" Glen Cook

  9. ppp said:
    Quoted message said:


    Society is a group who's members have individual interests
    that others would just as soon not cater to. When you talk
    about society, don't confuse that concept with the
    individual members who make up "society". Look at the cost
    of socialized medicine, ala the UK or some European
    countries. The level of care is often inadequate, and S-L-O-
    W, even for life threatening illnesses. "Society", being
    the group, may have everyone "covered" by the program, but
    individuals die each day, waiting for treatment.

    dave

    Living in a country where health care is free I must agree
    with free=poor, inaccurate, downright lousy.

    Allthough I could get free health care I sure as hell steer
    clear from the "free" service lest I want to wait in line
    for five hours get to see someone who is way underqualified
    to do anything. The sad thing about free health service
    that it actually costs a helluva lot more than "commercial"
    health care. The free health care sector is very, very
    inefficient and rife with corruption and whatnot. Oh, and
    free means you still have to pay! The free part has been
    eroding year after year and now you have to pay all sorts
    cost to get the "free" service.

    I know many health care people and they are wonderful,
    caring people. It's just that the system is corrupt.

    You are either a shill or extremely brainwashed by the
    greedy part of the health care BUSINESS.

    I have experienced every item you quote as problems with any
    other system plus gross excess cost.

    So many good docs, but the other aggressive bums are
    creating a real dissatisfaction

    Diabetes is one of many diseases that requires a lot of
    time. We are here because we must depend on ourselves.. One
    minute at $1000 per hour is not bearable. But the result has
    been a very big negative for me. These groups were a life
    saver for me. LITERALLY. Take your line to the local club
    house were the fees are about $50K per year. That is where
    it belongs.

    There. is free medicine. I know as many wealthy people on
    that teat as there are very poor people using it, I can
    observe it without leaving my porch. That is a separate
    issue. A universal system would be a great equalizer where
    every one paying a fair share..But I must admit the hustlers
    would find some way.

    We now have so many going to the docs office for a hobby.
    The answer is not to make the docs office a luxury
    environment. with music and art. Now those that demand that
    should pay out of pocket for that service.

    Health care as always been a problem. Now we have a
    situation in the US that is gross. The fools have a good
    deal but demand more and more. for less and less.

    And too many cases finding a disease where it is better to
    not treat it.

  10. ppp said:

    Living in a country where health care is free I must agree
    with free=poor, inaccurate, downright lousy.

    Which country?

    Cheers, Alan, T2 d&e, Australia. Remove weight and
    carbs to email.
    --
    Everything in Moderation - Except Laughter.

  11. This is a big YMMV subject. I pay about $600 a year for
    Medicare. My work place pays about $6000 s year for Blue
    Cross. Of course I have to earn the income which pays Blue
    Cross, but the office gets to deduct it, too. (And anti-
    capitalists please note that a little personal service
    corporation has a 35% tax rate! So we grab any valid
    deductions we can get!). I picked my own doctors.
    Occasionally I have to wait an hour but they also spend an
    hour on me. Pay maybe $200 a year in "extras" (Wierd that
    neither insurance pays for annual physicals.) Bypass surgery
    several years ago cost nearly $100,000 of which I paid
    NOTHING. Drug costs are somewhat painful but on the whole,
    no complaints. Nan, Type 2, age 76

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