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Getting At Cancer Before Cancer Gets Us
It was hard to believe Cathy Seipp, who joked about cancer putting a crimp in her "usual Nietzschean sense of physical superiority" would get struck down by the disease. I asked a question in the comments of one of my favorite blogs, cancer surgeon Orac's Respectful Insolence.

As for so many cancers -- can you talk about why they get as far as they do? Are there any advances being made in detection?

I was kind of dejected when nobody -- none of his doctor or researcher readers -- posted any comments in response. Then, one deadline day, I woke up to find this -- Early detection of cancer, part 1: More complex than you think. It's an extraordinarily detailed answer Orac gives, and you should read the whole thing, but here are a few essential points:

It's a common assumption (indeed, a seemingly common sense assumption) that detecting cancer early is always a good thing. Why wouldn't it always be a good thing, after all? It turns out that this is a more complicated question than you probably think, a question that even many doctors have trouble with, and in this post and a followup, I'll try to explain why.

...The bottom line is that the ever-earlier detection of many diseases, particularly cancer, is not necessarily an unalloyed good. As the detection threshold moves ever earlier in the course of a disease or abnormality, the apparent prevalence of the disease increases, and abnormalities that may never turn into the disease start to be detected at an increasing frequency. In other words, the signal-to-noise ratio falls precipitously. This has consequences. It leads, at the very minimum, to more testing and may lead us to treating abnormalities that may never result in disease that affects the patient, which at the very minimum leads to patient anxiety and at the very worst leads to treatments that put the patient at risk of complications and do the patient no good.

...In other words, early detection makes it appear that fewer people die of the disease, even if treatment has no effect on the progression of the disease. It will also make new treatments introduced after the lower detection threshold takes hold appear more effective.

...Does all of this mean that we're fooling ourselves that we're doing better in treating cancer? Not at all. It simply means that the question of sorting out "real" effects from new treatments from spurious effects due to these biases is more complicated than it at first seems.

...Unfortunately, it is very difficult to convince patients and even most physicians that, if we can detect disease at ever lower thresholds that we shouldn't and that if we can treat cancer at ever earlier time points or ever smaller sizes that we shouldn't. For some tumors, clearly we need to do better at early detection, but for others spending ever more money and effort to find disease at an earlier time point will yield ever decreasing returns and may even lead to patient harm. It is likely that each individual tumor will have a different "sweet spot," where the benefits of detection most outweigh the risks of excessive intervention.

Posted by aalkon at April 4, 2007 12:20 PM

Comments

I understand what Orac is getting at, but as a guy who lost his mom to 15 years of back and forth with the "Big C", I cannot completely concur. Even if at the time of detection there is little that can effectively be done, you know where it is. You can monitor it and hit it when the time is right.

Posted by: André-Tascha at April 4, 2007 5:29 AM

Sure, Andre, fight like hell. Seipp sure did! But never forget that the outcome is not in doubt.

I just googled this from St. Augustine: "Inter faeces et urinam nascimur."

Posted by: Crid at April 4, 2007 7:15 AM

The thing that drove my family nuts where doctors who came from the standpoint that information should be doled out to patients and their families in spoonfuls.

One of my fondest memories as a child is my 5 foot 1 inch mom standing in a big lobby at Stanford's cancer center and telling her doctor (in a very loud voice) that she was not a moron and that he could go "fuck himself", whereupon she continued her treatments with a physician/hospital (Marin General) where she actually was provided all the information she asked for.

Posted by: André-Tascha at April 4, 2007 7:31 AM

Autopsy studies of the bodies of people who died well into their 90s (of non-cancer-related causes) have found reservoirs of cancer that never caused any symptoms or showed any signs while these people were living. It's possible that a substantial proportion of cancer that is detected through screening and then "successfully" treated may actually be pseudo-disease that would have never become apparent or caused any problem.

Highly recommended: "Should I Be Tested for Cancer? Maybe Not and Here's Why" by H. Gilbert Welch (a professor of medicine at Dartmouth)

"The thing that drove my family nuts where doctors who came from the standpoint that information should be doled out to patients and their families in spoonfuls."

That's changed a lot in recent years, Andre, due to the increasingly litigation-happy approach of American patients. Full-disclosure is now the medical malpractice insurance of choice for many physicians. I'm surprised we haven't been yet had the pleasure of seeing televised illustrations of Tony Snow's colon -- or perhaps we have, and I just missed it? I'm still trying to erase all that prime-time imagery of Reagan's colon from the early 80s. I'm not terribly fond of Republican rectum, thank you very much.


Posted by: Lena at April 4, 2007 8:20 AM

Great comment, Lena

The 80's were the golden era for shitty TV news animation

Posted by: Crid at April 4, 2007 8:35 AM

I was diagnosed with Chonic Lymphocytic Leukemia a few months ago. I am what is called "asymptomatic". My Oncologist was mystified as to how my doctor figured out I had it. It was only because I have bloodwork done every year, and by comparing it over the years that a pattern showed up.

My family doctor told me he had a patient who had the disease for 30 years, and it never manifested itself; she died from some other sort of cancer.

I didn't freak out when I learned I had it, because my mother and her sister both died of cancer, so I expect I will, too; but I go to the doctor and have tests, and don't put off the things that will help to find it earlier, and give me a chance, if there is one.

"Forewarned is forearmed", they say.

Posted by: Mary Jane at April 4, 2007 8:45 AM

A family member was diagnosed early with melanoma. It was surgically removed and treatment was assumed to have worked because, "It as caught early." Needless to say, it spread throughout the lymph system and a short time later the battle was lost.

Posted by: CJ at April 4, 2007 9:34 AM

"It was only because I have bloodwork done every year, and by comparing it over the years that a pattern showed up."

That's why I have a PSA done every year, even though it could lead to some unnecessary and potentially harmful biopies down the line. Some researchers think that "PSA velocity" (ie, the rate of PSA change over time) is a better indicator of disease process than a PSA measurement at one point in time. Some of us just start out with higher levels.

I wish you the very best with your health, Mary Jane. I'm sure that Chronic Lymphocytic Leukemia is no party.

Posted by: Lena at April 4, 2007 10:19 AM

Eesh. My sympathies go out to everyone here who is dealing with, or has a loved one dealing with, cancer or a similar disease. Remember, everyone, get your colonoscopies once you reach the appropriate age - that's one disease where early detection is incredibly vital.

One thing Orac's post didn't really touch on was this issue of limited resources. Theoretically, every single person in the U.S. could have a CAT scan of his/her lungs once a year in order to check for lung cancer. That would probably catch some cancers very early...but the cost would be horrendous. And yes, theoretically, no cost is too much to pay if it saves someone's life...but, on the other hand, we need adequate resources for research that can come up with new treatments to save lives, and funds for testing and then administering those treatments. And I do think that Orac's right that "watchful waiting" just wouldn't work in most cases. Rationally, I know that watchful waiting could be the best idea in certain cases. Emotionally, if I were told that I were at serious risk of breast cancer/had an inert form of the disease, I'd want a mastectomy tomorrow. (Of course, being rather flat-chested, I've never had a huge emotional attachment to my breasts. You'll note that I'm not also adding that I'd want my ovaries removed.)

I'd say the ultimate answer is twofold: better testing for diseases in which early detection is incredibly vital (colon cancer, ovarian cancer, etc.), and gene therapy that can reprogram the body to get rid of the cancer (etc.) on its own. The latter is obviously a long way off. For now, we're fighting a very sophisticated, persistent enemy with extremely crude tools...and no, I don't think the war metaphor is inappropriate here. Cancer doesn't have a brain, but I do consider it an enemy, and I'd like it gone, please.

Posted by: marion at April 4, 2007 11:44 AM

I went down a guy last week who'd been treated for testicular cancer a few years ago. It was weird to know that those things in my mouth were prosthetics.

Posted by: Lena at April 4, 2007 11:57 AM

yes that's right

Posted by: Frank at April 4, 2007 2:08 PM

And then I bent him over and plowed his ass.

Posted by: Lena at April 4, 2007 3:35 PM

Did they taste like plastic? Enquiring minds want to know.

Posted by: deja pseu at April 4, 2007 6:35 PM

The prosthetics were inside a normal scrotum, so they tasted like good old sweaty balls. This guy has done a good bit of TV acting, and for a while he was one of the Power Rangers on the Saturday morning kids TV show. Let it be known: Lena has licked the prosthetic balls of a Power Ranger.

I love LA.

Posted by: Lena at April 4, 2007 9:28 PM

I'd much rather catch a cancerous mass at stage 1 than stage 3.

Posted by: kanani at April 4, 2007 10:37 PM

And I'd rather be waited on hand and foot at a beachside resort than catch a cancerous mass at stage 1.

Posted by: Lena at April 5, 2007 10:21 AM

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