[yashap]

I do think AI has a chance to make healthcare, for cancer and other diseases, a lot more proactive.

Even though we know prognosis is much better for cancer, and many other diseases, if you catch it early, we do essentially nothing to catch it early. My understanding is that this is because:

1. Administering regular MRIs, blood panels, etc. is expensive, in terms of the initial data collection

2. It’s also expensive, in terms of getting healthcare professionals to analyze the results

3. People often get the analysis wrong, in terms of both false negatives and false positives

4. False positives can lead to even more scans, analysis, etc., costing even more money

It does seem possible to me that specialized AI could get much better than humans at interpreting this data, doing it very cheaply (solving problem 2) with far fewer false negatives and false positives (solving 3 and 4). And it’s even possible that AI powered robotics gets great at collecting data in the first place, bringing down the cost of problem 1.

Basically, “AI invents cures for different types of cancer” seems like a moonshot, but “AI makes proactive medical scanning cheap and effective, thus greatly improving cancer outcomes” seems like a real possibility.

While we have some proactive screening for some types of cancer, the status quo for many types of cancer/patients is “wait until the cancer has spread enough that the patient is experiencing significant symptoms, with no systematic way to detect cancer early.” This is clearly not great. We’re accepting this for practical reasons today, but I do think AI has a significant chance to greatly improve the status quo here.

[pheewma]

There are also downstream consequences of ordering tests aside from cost; not all tests are harmless. As an example, regular screening for prostate cancer isn't recommended as much. Partially because it is often so slow-growing that people often die of other causes before the cancer even begins to cancer, and because the definitive test is a biopsy which is somewhat invasive. Rates of complications are relatively low, but it becomes a cost-benefit consideration (again, irrespective of cost) of if those risks are worth catching something that you may not even want to bother treating.

[yashap]

Sure, of course you would make practical decisions about what kinds of tests to administer, and not proactively administer the tests that have significant negative side effects.

For the other point, personally I don’t really buy the argument of “it’s better not to know you have cancer X, because it might end up being low impact.” If we had excellent regular screening, yes detection of low impact cancers would become a lot more common, but I think people’s perception of them would change too. If it became a common thing for cancers to be detected, but the detection could reliably say “this is likely low impact, we should just keep an eye on it but not treat it”, this would be a lot less scary. It would become normalized IMO. Cancer diagnoses are partly so scary right now because we’re often mostly catching cancers that have progressed and are causing symptoms, so the public perception is rightly “cancer diagnosis = very scary.”

[haldujai]

> Sure, of course you would make practical decisions about what kinds of tests to administer, and not proactively administer the tests that have significant negative side effects.

The harm is from investigating the screening test result and not the test itself.

> If it became a common thing for cancers to be detected, but the detection could reliably say “this is likely low impact, we should just keep an eye on it but not treat it”, this would be a lot less scary

This is already the case for some like prostate cancer and certain lymphomas.

> Cancer diagnoses are partly so scary right now because we’re often mostly catching cancers that have progressed and are causing symptoms

The most aggressive cancers are also the least likely ones to be diagnosed by screening due to growth rates, screening intervals and diagnostic test limitations.

[vidarh]

The harm can be from the initial screening too. The lifetime risk for complications from routine colonoscopy is around 1.6%. The lifetime risk of colo-rectal cancer is 4-5%.

So already before investigating the result, there's a very real consideration whether increasing the number of colonoscopies is likely to be a net benefit.

[haldujai]

Colonoscopy is confusing because it is both screening and diagnostic/investigating.

Most if not all of the complication/risk (perforation and major bleeding being the ones of note) is from the polypectomy / biopsy part of the colonoscopy.

[RandomLensman]

The path to being able to say "low impact, don't worry" will be quite rocky and possibly involve a lot of painful treatment for patients. If you have a very different detection surface, you would not initially know what is all low impact, for example.

[jcims]

We found out about my daughter's type 1 diabetes purely by accident. I found a blood glucose test kit doing some spring cleaning and asked the family to gather around to check our sugar. It was really just a joke but I thought it would be fun. Queue three results around 100 and one at 270. We tested again the next day and it was 290.

Finding type 1 diabetes this way in a young teenager was so absolutely out of the norm that a major children's hospital had no idea what to do with her. They admitted her because it was protocol but it was completely unnecessary and we had to explain how it happened at least ten times while we were there.

It was an eye opening experience.

[yashap]

Yeah that’s wild! I do think proactive medical screening is something most medical systems have mostly given up on, other than in very targeted ways, for very specific diseases in very specific high risk populations. But I don’t think this is because it’s a fundamentally bad idea, I think it’s more that it’s impractical right now. It does seem to me that AI has a chance to make it practical.

[RandomLensman]

If you screen a lot of people for a lot of things, you will find a lot of things, but not all the findings will mean something or require action. The initial ramp up of huge "unwarranted" screenings will create a lot of pain until we/AI figures out when something warrants attention.

[dale_glass]

Can't we intelligently limit that to things with essentially no risk of false positive?

[vidarh]

The problem with that is that even "essentially no risk of false positives" starts adding up when you do millions of tests every year.

If those tests are done on demographics where the chance of a true positive is also very low and the difference in risk profile between catching it during such screening vs. waiting until the patient discovers it is not very significant, it can take a very low rate of complications before it becomes a problem.

But, yes, we do limit that, and that is a major reason there are very few mass screening programs.

[RandomLensman]

Then the selection of tests might get very small and we simply don't even know what all might be relevant if doing billions and billions of tests on a lot things - a lot of possible weird things to trip us up.

[vidarh]

It is a fundamentally bad idea to do without very specific understanding of the risks. E.g. many programs intended to expand mass screening for breast cancer were reconsidered after it became clear that it was not a given that they would provide a net benefit, because it takes a very low level of risk from screenings and subsequent follow-ups before mass screening becomes harmful when applied to groups where it is likely to save many lives.

[kvhdude]

years ago doing similar thing found out my type2 diabetes when i was 24. It has been a life saver since i am able to manage it before any complication.

[mlyle]

> Even though we know prognosis is much better for cancer, and many other diseases, if you catch it early

This is, to some extent, misleading.

I mean, earlier treatment is beneficial, but there's a significant confound. All else being equal, if a cancer is less aggressive and slowly growing it is more likely to be detected early.

Put in other terms, the cancers detected earlier by screening are a very different population of cancers detected late and with progression.

[Nowado]

There is even more fun aspect.

'Survival' for cancer tends to be defined as surviving 5 years. The earlier you catch, the more patient had left to live anyway.

[MyFirstSass]

Probably hyperbole but a colleague told me about a 80/20 distribution, that a decreasing amounts are spent on substantial life extension or quality of life improvement in the west as the pop ages.

The basic good old medical care invented 100 years ago, while dizzying amounts are spent on prolonging lives for very, very few years, often very late in life - efforts that are very close to - in effect to have done nothing, ie. almost performative.

Is this true?

[haldujai]

I don’t know about that, speaking to oncology as I work in a NCI designated cancer center (i.e. somewhere that spends dizzying amounts) and it skews younger than you might think these days.

I’m not sure what you mean by “very, very few years”. As a hypothetical would prolonging life for ~3-7 years in a 40-50 year old be considered “almost performative” to you?

“Good old medical care” often means 3-6 month survival for these patients.

[mixdup]

yes. the amount we spend to keep people alive who have little to no hope of ever recovering is immense. of course it is cruel and leads to myriad bad outcomes if you were to even attempt to have a discussion about trying to change that (it is the slippery-est of slippery slopes)

there's probably no way to actually do anything concerted about it without turning society into Logan's Run but having gone through it with a grandparent and a parent, it is clear something is broken at the end of life

[jedberg]

Spending on Medicare beneficiaries in their last year of life accounts for about 25% of total Medicare spending on beneficiaries age 65 or older.

So yes, it's true (although that includes the cost of hospital stays which is where a lot of people end their life).

[Spooky23]

Probably. Look at the people in the hospital - they’re old. Inpatient costs are astronomical, and seniors with poor social supports end up hospitalized at great expense with issues where root cause are easily prevented… like dehydration.

[inglor_cz]

Being old is a fairly long part of life nowadays. Old is not the same as hopeless or almost dying.

My grandma had a melanoma at the age of 74, which is "old" by most human standards. It was located on her earlobe and an operation helped her get rid of it.

She then lived to be 90, most of that extra time either fully or partially self-sufficient. Only in the last months in her life she really deteriorated.

Basically, she gained almost a fifth of her life by that single operation performed when she was already old.

[Spooky23]

That’s awesome. I’m not suggesting that older folks not get care.

But because of way our system works, we’ll happily pay $300k to hospitalize an otherwise healthy 70 year old who is dehydrated and develops serious problems that could be solved by an aide or helper that would cost $20-30k.

[CamelCaseName]

> I mean, earlier treatment is beneficial, but there's a significant confound. All else being equal, if a cancer is less aggressive and slowly growing it is more likely to be detected early.

Wow! That makes so much sense! I had never considered this!

[yashap]

Sure, but my understanding is that for many types of cancer, detecting that specific cancer early does make a big difference. It can be the difference between a single, minimally invasive surgery to remove a tiny rumour that hasn’t spread, that can be effective even without chemo/radiation/etc., and stage 4 cancer that has spread a tonne where even with extensive chemo/radiation/etc., your chances aren’t good.

[mlyle]

> Sure, but my understanding is that for many types of cancer, detecting that specific cancer early does make a big difference.

The problem is, this is hard to measure. We know that "detected early" correlates with better long term outcomes. But "early" means "smaller and with less spread" which in turn is strongly correlated with "growing slower and spreading less".

We've had unpleasant surprises where e.g. extending screening to earlier ages detects more cancers but doesn't decrease the number of people dying from that type of cancer because of these confounds.

[RandomLensman]

How frequently do you want to screen? Monthly? Weekly? Some also have no known effective treatment - maybe some super early detection helps, but maybe not.

[unsupp0rted]

Annual full body MRI would be good

[Spooky23]

Cancer isn’t one thing and AI is an important tool that will accelerate treatment and drug development.

My late wife detected a mole that was melanoma in 2019. She was within months of being cleared for observation in 2023 when two brain tumors were detected. Despite the best of care, she was gone in 6 months.

If her initial treatment had been in 2024 instead of 2019, it’s 80% likely she would be around for another decade or more. That’s how fast new treatment options are coming to market, and data analysis with AI and other tech is improving it. New trials are using platforms like Moderna to provide custom vaccines that should reduce treatment side effects.

While the hyperbole of the media is annoying, the impacts of new tech to identify genetic vulnerabilities in cancers is near miraculous.

[mlyle]

I'm sorry for your loss.

I was speaking specifically towards screening more and detecting earlier. They have utility, but recent evidence seems to indicate that it's not nearly as much as the public assumes.

[Spooky23]

No worries. I share it frequently here because I think the personal connection underscores the import, which sometimes gets lost. It's easy to think about "cancer" in the abstract, and sometimes we miss that it's a mother, a wife, a friend -- I know that I did.

And at the end of the day "cancer" is a category, not a thing. Sometimes (prostate cancer) early detection and intervention is bad, as the cure is worse than the disease! Other times (ovarian cancer), accidental early detection while looking for something else entirely, as symptoms don't present until you've hit Stage 4 typically.

[daniel_reetz]

Can you elaborate a little on what's new? Someone close to me had a melanoma scare on almost the same time frame, and had a lot of difficulty finding doctors who would take her seriously.

[Spooky23]

In the case of my wife, she would have been given a round of nivolumab or keytruda. These are immunotherapies that enable your immune system to kill the cancer cells.

You have to advocate very heavily. With melanoma, I wouldn’t mess around and seek at a minimum second opinions from the nearest major cancer center.

[Engineering-MD]

False positive and negatives are unlikely to be improved by AI significantly. They are mostly based on a trade off between catching more, and making sure those you catch are accurate, and a limitation of the test itself. Sure, AI might marginally make some tests better by interpreting more variables more reliably, but it’s going to be marginal rather than solved. For example, for PSA a blood test for prostate cancer, it doesn’t matter how much AI you through at it, it’s just not a great test. It’s elevated outside cancer commonly, and is normal in a significant percentage of prostate cancers. Just have to deal with its limitations.

[zcw100]

“AI invents cures for different types of cancer” seems like a moonshot

What about AlphaFold? It’s just one piece of a very large puzzle but it’s not like AI needs to do it all.

I don’t think AI will be a complete solution for much of anything but I do think that it will be a part of the solution for just about everything.

[haldujai]

> Even though we know prognosis is much better for cancer, and many other diseases, if you catch it early,

5. Diagnosing cancer/disease early does not necessarily improve outcomes.

https://en.wikipedia.org/wiki/Lead_time_bias

https://en.wikipedia.org/wiki/Length_time_bias

> we do essentially nothing to catch it early.

Huh? That’s the whole point of cancer screening which we do a lot of in the West. The benefit of which remain hotly debated. New tests are also constantly being researched.

[yashap]

That initial statement may have been a bit too strong, but I did clarify it later in the same comment:

> While we have some proactive screening for some types of cancer, the status quo for many types of cancer/patients is “wait until the cancer has spread enough that the patient is experiencing significant symptoms, with no systematic way to detect cancer early.”

Maybe it depends on where you are, but where I am (Vancouver BC, Canada), the above is true. Proactive cancer screening is quite limited here. I believe it's limited to screening for cervical, breast, colon and prostate cancer, plus lung cancer for 55+ year old smokers who smoked for at least 20 years. And for even those specific cancers that are screened for, availability is limited by risk factors like age, e.g. you can't get screened for colon cancer until you're 50, that sort of thing.

There are so, so many other types of cancer and non-cancer diseases/conditions that we do not screen for at all. Plus, even for the cancers we do have screening for, it's often not frequent enough to catch more aggressive variants early - a lot of these screenings are only once every ~2-5 years. The idea of, say, proactively taking MRIs, blood panels, etc. on people, looking for early stage cancer (and other conditions) throughout the body is not something that's available. You can't even get an annual physical with a family doctor anymore, there's only screening for a handful of specific diseases, and only once you reach certain ages/risk factors.

Cancer screening starts a bit earlier for women, due to higher risk of breast and cervical cancer, but if you're a man under 50 in BC, you're really never getting any sort of medical test done ever (even simple things like blood panels) unless you go in to a doctor's office for a specific condition. I have MANY friends and family members who've been diagnosed with cancer in Canada, and almost none of it has been caught in regular screening, because the screening is so limited, its almost always been caught by the cancer spreading enough that the person goes to their doctor due to symptoms.

[haldujai]

> Plus, even for the cancers we do have screening for, it's often not frequent enough to catch more aggressive variants early - a lot of these screenings are only once every ~2-5 years.

Screening intervals are based on doubling time.

> The idea of, say, proactively taking MRIs, blood panels, etc. on people, looking for early stage cancer (and other conditions) throughout the body is not something that's available.

You can pay out of pocket for a “screening MRI” in BC but from my clinical practice the yield is dubious.

> You can't even get an annual physical with a family doctor anymore,

Evidence has shown the physical is useless.

> there's only screening for a handful of specific diseases, and only once you reach certain ages/risk factors

Screening needs pretest probability and a diagnostic test with sufficient accuracy. It simply does not exist for most cancers. Trials are underway for new tests like cfDNA but in 2024 there aren’t any validated options.