[throwway120385]

Life expectancy is really only one dimension of "health," and it's probably the most shallow dimension. If I'm quadriplegic and confined to a ventilator but I live to 80, that's the same in this metric as if I'm not paralyzed and able to breathe on my own until I die.

What if some people in the group that didn't get screening had fewer high-quality years? It might simply be that the last 5 years of life for people who are screened positive early on and who subsequently receive treatment is a better 5 years than the last 5 years of life for people who aren't screened positive early on and who subsequently have to undergo brutal hail mary treatments at the last minute.

[pessimizer]

> Life expectancy is really only one dimension of "health," and it's probably the most shallow dimension. If I'm quadriplegic and confined to a ventilator but I live to 80, that's the same in this metric as if I'm not paralyzed and able to breathe on my own until I die.

Claiming that there are missing elements that could possibly turn the equation in favor of screening is cause for further research and analysis. You can't just claim that they fall in your favor; some diagnostic and exploratory processes due to false positives are painful and/or dangerous in and of themselves.

> What if

"What if" is right. You can't just conjure these people into existence to justify current policies, you have to find them and do the statistics.

[throwway120385]

Given that screening is arguably benign for most people, you could argue that we continue screening while we gather more information. But you do whatever you want to do. I'm just pointing out that it's really premature to cancel all of your screenings based on the idea that it doesn't add any years to your life. That may be true, but there's more to a life than how long you live.

[idopmstuff]

> Given that screening is arguably benign for most people

You're 100% wrong here, this is not a given. Prostate cancer screenings, which are very common, can have both false positives as well as findings of cancer that is and would remain completely benign. These can both lead to unnecessary treatments that cause serious negative health effects, including incontinence and erectile dysfunction.

https://www.cdc.gov/cancer/prostate/basic_info/benefits-harm...

[Gibbon1]

Also read that death rates from thyroid cancer hasn't changed in 50 years. Despite huge numbers of thyroid screenings and treatment.

An ultrasound of the thyroid often leads to finding a nodule. Which leads to a biopsy. Which comes out indeterminate. Which leads to a thyroidectomy and life long dependence on thyroid hormones.

Another one is ductal carcinoma in situ. Read somewhere there is a 1% chance that will evolve into cancer. And yet you have women having double mastectomies and chemo for it.

[haldujai]

Absolutely no one is getting a bilateral mastectomy or chemotherapy for DCIS.

This is by far the most inaccurate medical claim I've ever seen on HN. Where on earth did you get this from?

The whole point of diagnosing DCIS on screening mammography is that it avoids systemic therapy and mastectomy. It also wouldn't be bilateral.

[vc8f6vVV]

Yes, they do. I have a friend who did just that. Was it justified? I don't know, but it's very real.

[DennisP]

So work the numbers. Put together the chance of false positives, false negatives, rate of negative effects from treatment, and rate of death with and without treatment. Tell the patient the risk of each outcome.

The math is easy. If we don't have the numbers for it, then get them. Plenty of people get prostate cancer and some of them choose to just monitor. We should have plenty of information to make a rational decision. This seems preferable to blinding ourselves out of fear that we'll do something stupid with the information we might get.

[idopmstuff]

> Tell the patient the risk of each outcome.

This isn't a simple problem of calculating EV. Telling somebody that there's a 40% chance that the positive test is actually wrong and in the 60% case that it's right, 40% of the time it's going to be benign, but if it's not benign it might kill them but if it is benign and they do surgery they might be left wearing diapers is not a simple thing for a person to evaluate. Add to that the fact that people have a bias towards action, so doctors tend to overindex on treatment vs. just ignoring something, and you have an incredibly complex problem.

> The math is easy.

No, it's not. It's a series of probabilities combined with extremely subjective outcomes (getting erectile dysfunction may have a very different impact on your life if you're 40 vs. 80).

> If we don't have the numbers for it, then get them.

You're just trivializing medicine and medical research here. Why don't you just go ahead and build some AI that'll solve this whole problem by diagnosing cancers based on a blood sample? That seems easy enough.

> This seems preferable to blinding ourselves out of fear that we'll do something stupid with the information we might get.

Ironically what you're describing here is the opposite of everything you've just talked about. If we understand the numbers well, and from those we can conclude that tests are highly prone to false positives and thus that treatment based on positive results is more likely to be harmful than helpful, then we shouldn't take those tests. That's not blinding ourselves, it's acting appropriately based on understanding the math.

[DennisP]

No, I mean you take the test and if it's positive then present options like this:

Risk of death: X% with treatment, Y% without treatment.

Risk of side effect A: X% with treatment, Y% without treatment.

Those numbers take into account the rate of false positives and false negatives. They are clear and understandable.

There are definitely situations in which you shouldn't test: where the rate of the cancer is low, the false positive rate is high, and the risk of treatment is high. In that case, the numbers can show that risk of death is higher with treatment than without, so while (noninvasive) testing doesn't make things worse if we're giving clear numbers, it doesn't help either; we might as well not test at all. But that's not true for everything. As for side effects, we should give patients clear numbers like this so they can make informed decisions.

Adding up the number of false positives and negatives, and the number of patients with various outcomes, is not comparable to using AI.

[pintxo]

It’s important to note that it’s not the screening causing those issues. It’s the fact that our health care systems are rather inadequate in properly handling those screening results at the margin.

[vc8f6vVV]

There is another consideration:

1. You have an aggressive (i.e. non-treatable) cancer, maybe you feel slightly off, but you go on with your life, until you finally got worse and die. Or you performed screening, focus on treatment, bankrupt your family and ... die anyway,

2. You have a slow growing cancer (e.g. prostate), live your life and die of some other causes. Or you performed screening, got surgery, got tons of problems and die of myocardial infarction (yes, that's one of complications after prostate surgery).

If you read the original JAMA publication you would notice that there is a research on quality of life metric. That metric for breast cancer is higher among non-screened women.

[kirkni]

There are attempts to address this, “The quality-adjusted life year (QALY) is a generic measure of disease burden, including both the quality and the quantity of life lived. It is used in economic evaluation to assess the value of medical interventions.” See: https://en.m.wikipedia.org/wiki/Quality-adjusted_life_year

[dudeofea]

I'm going to start with one assumption that I believe is true: higher mental and physical stress will kill you faster.

If two statistical people both get cancer, one gets screened and potentially treated, and the other doesn't and they both live to 80, I would rather be the person that doesn't get treated.

A regular schedule of treatments is only better than a hail mary if you actually get more longevity from it, otherwise it's just more pain for the patient. At least with the hail mary, I only spend a short time feeling horrible before dying. This is most likely why doctors don't opt for treatment more than the average.

https://slatestarcodex.com/2013/07/17/who-by-very-slow-decay...