Why Some Doctors Hesitate to Screen Smokers for Lung Cancer (2015)

I wonder if this is a &quot;dont waste your time&quot; issue coming from management?<p>As an anecdotal example, Im an engine mechanic who routinely sees older trucks from the 80s and 90s. mostly idler&#x2F;pitman arm replacements, tires, diff fluid, etc... on these which is expected as many are pushing a million miles or more. I had a 1981 International S1700 limp into my garage one day with a misfire problem due to long, long overdue oil pressure problems. I fixed the oil pump and was getting ready to hook up the diagnostic computer when my boss stopped me and said &quot;if you plug that thing in its going to light up like a christmas tree. You aint telling the driver anything they care about anyway.&quot;

I&#x27;ve watched my family go through smoking, and cancer hasn&#x27;t been the issue. I don&#x27;t know how representative it is, but my experience definitely reflects the premise of this article: cancer testing could have caused way more harm than good.<p>Both my mother and her father were still smoking frequently when they were on oxygen. In other words: When they should have known better. Her mother was looking really bad at 50 and when the Dr told her &quot;it&#x27;s killing you, and not in some abstract way&quot;, she cut it out cold turkey and pretty much instantly looked 10 years younger.<p>Grandfather was struggling in general, but it was twisted up intestines that did him in. My mom, one nurse told me, her lungs were &quot;just shot&quot;. COPD. Funny thing was that she was getting enough oxygen (with O2), she just couldn&#x27;t get rid of CO2. Basically took her outta the game 20 years early.<p>Hopefully, my kids who watched this, can use the experience to steer clear of some things. If you can&#x27;t set a good example, show what a bad example leads to. :-)

False positives will be much more rare in practice with the new guidelines used (Lung RADS) which cut false positives by 50% or more while mostly preserving sensitivity.<p>That doctor should really update his diagram to reflect the current standard of care for lung cancer screening. Using the false positive rate from the 2011 study is intellectually dishonest!<p>In addition the amount of lung cancer deaths prevented was doubled (!!) in a recent European study by tracking patients for 5 years instead of 3 years.

This sounds familiar. I have watched now quite a few people go through serious diseases. One pattern I saw was tests, tests and more tests. A lot of them very expensive, time consuming and painful. But when you ask what they will do with the test results there often is silence. To me it looks like they are doing something because “we need to do something”.<p>Reminds me a little of data collection practices at companies. Sucking up more data feels like you are doing something. But using the data is much more difficult and often doesn’t happen.

&gt; That&#x27;s because some cancers grow slowly and never become dangerous...These false-positive tests led to more follow-up testing, including risky procedures like a biopsy, which inserts a needle into the lung.<p>&gt; &quot;Not surprisingly,&quot; Welch says, &quot;sometimes that creates problems like causing someone&#x27;s lung to collapse.&quot;<p>These outcomes should inform whether or not the biopsy needs to take place or whether they should instead follow up with further screens to monitor whether the cancer progresses. Of course, the major downside of my suggestion is that patients are extremely reluctant to hear &quot;cancer&quot; without a plan to rapidly classify it as malignant or benign.

Classic base rate problem, the rate of lung cancer rate is low compared to the false positive rate. It seems that one option is to follow up with a second scan 3-6 months latter and see if the tumor has increased in size. However there probably serious liability issues with this approach even if it means you&#x27;re still catching the cancer earlier on average compared to waiting for physical symptoms. I&#x27;m curious how counties like France, where smoking rates are high yet have high life expectancies, deal with screening for lung cancer currently.

Anecdotally, as an ex-smoker who quit after my mother died from lung cancer, I spoke to my doctor about screening. He did a lot of dismissing and hand waving about it. It upset me greatly at the time. This article explains it all well enough. Doctor&#x2F;patient communication is very important.

VOMIT, Victim Of Modern Imaging Technology, is a term among doctors for a reason.<p>Generally the more you know the better, but sometimes things can be stumbled upon that might otherwise be irrelevant yet the intervention can then introduce new risk or some other unique problem or undesired side effect. There aren&#x27;t always easy answers.

&gt; &quot;but [can also] find cancers that were never going to matter.&quot;<p>I&#x27;m not sure, but isn&#x27;t better to know that you have it and then investigate further, do more tests, perhaps do some period follow-up with a shorter interval?<p>Otherwise it&#x27;s just betting: I bet that I don&#x27;t have a lung cancer that will be agressive....

I believe this is indicative of a frustrating phenomenon in the U.S. healthcare&#x2F;legal system where many doctors are prone to being overly cautious due to the threat of malpractice litigation. You rarely hear of doctors being sued for unnecessary testing. They are much more likely to be sued for missing a cancer. This happens even when it was reasonable to miss a cancer. A doctor who is overly concerned about litigation can thus cause harm through the patient stress and physical effects of unnecessary followup testing when it is not justified. Rather than sticking our heads in the sand by not screening because we are worried that some doctors will have a harmful false positive rate, we should be addressing the root causes of the high false positive rate.

I periodically smoke, yet I don&#x27;t call myself a smoker. Yet when I buy insurance I buy the smokers plan, the idea being that if I do need to use the insurance I expect the Insurance company to use any information necessary to deny my claim. Should I be worried about this?

A great and seemingly minimally biased resource for this type of preventative care(mentioned in the article):<p><a href="https:&#x2F;&#x2F;www.uspreventiveservicestaskforce.org&#x2F;BrowseRec&#x2F;Index&#x2F;browse-recommendations" rel="nofollow">https:&#x2F;&#x2F;www.uspreventiveservicestaskforce.org&#x2F;BrowseRec&#x2F;Inde...</a><p>It presents an evidence based pros v cons listing on screening and tries to present a informed approach, with less financial bias. The most toxic component of this entire issues also has to do with a form of defensive medicine that physicians engage in. Basically if you don&#x27;t want problems don&#x27;t look for them, not to say all physicians engage in this type of behavior. This mentality is very common amongst the older generations of physicians who fear the repercussion associated with minor mistakes.. Ie. doctor sends patient for CT suspicious finding are noted, doctor forgets to order future followup or some other variety of mistake... Patient ends up having cancer and the physician is slapped with a malpractice suit.

&gt;Lazris says he shows the theater diagrams to many of his patients and gets a wide range of responses. Some patients, he says, point at one of the three blackened seats and say, &quot; &#x27;That&#x27;s probably me. I&#x27;m not taking any chances, I&#x27;m getting this test.&#x27; &quot;<p>&gt;&quot;Other people,&quot; he says, &quot;will see [the same diagram] and will say, &#x27;Are you kidding me? I&#x27;m not going for that; that&#x27;s not worth it.&#x27;&quot;<p>&gt;But in either scenario, Lazris says, he has done his job — he has helped his patients understand the odds and then let them make the choice.<p>This is wonderful!! Good on him!!<p>This is how medicine should always be practiced. Much too often a doctor&#x2F;PA just orders a bunch of tests with ZERO discussion (other than maybe &quot;we&#x27;ll screen you for XYZ&quot;). No discussion of risks. No discussion of the upsides of testing. No discussion of individual risk factors. No discussion about how the results will be actionable.<p>Sometimes they order tests <i>before even meeting a patient for the first time</i> or even <i>telling you what they are testing you for</i>. My last primary care doctor did just that, I made an initial appointment with him for a routine physical (I need referrals for my health insurance) and someone from his office calls before the appointment and says &quot;Dr So and So has ordered some blood tests for you, please go to the lab and get then done before the appointment.&quot; Didn&#x27;t think telling me any other information was important, like, uh, what I&#x27;m being tested for and why.<p>Of course, at least some of the tests he ordered were not evidence based.<p><a href="https:&#x2F;&#x2F;www.ncbi.nlm.nih.gov&#x2F;pmc&#x2F;articles&#x2F;PMC5638475&#x2F;" rel="nofollow">https:&#x2F;&#x2F;www.ncbi.nlm.nih.gov&#x2F;pmc&#x2F;articles&#x2F;PMC5638475&#x2F;</a><p>On top of that, I have untreatable anemia due to a genetic condition. His first tests found the anemia and he ordered follow up tests. Mind you, this is <i>before I ever met him or even spoke to him</i>. If he had a conversation with me, the followup tests would have been completely and totally unnecessary.<p>A different doctor did that to my husband recently as well (&quot;we&#x27;ve ordered some tests for you&quot; before even meeting him nor telling him which tests were ordered.) I looked at the lab work afterwards and turns out PSA was one of the tests they ordered, which has shown to cause more harm than good. ZERO discussion about risks vs benefits. No discussion of benefits of testing at your age vs an advanced age. No theater diagrams.<p><a href="https:&#x2F;&#x2F;www.medicalnewstoday.com&#x2F;articles&#x2F;260087.php" rel="nofollow">https:&#x2F;&#x2F;www.medicalnewstoday.com&#x2F;articles&#x2F;260087.php</a><p><a href="https:&#x2F;&#x2F;www.uspreventiveservicestaskforce.org&#x2F;Page&#x2F;Document&#x2F;UpdateSummaryFinal&#x2F;prostate-cancer-screening" rel="nofollow">https:&#x2F;&#x2F;www.uspreventiveservicestaskforce.org&#x2F;Page&#x2F;Document&#x2F;...</a><p>I read a story about an elderly woman in good health with no symptoms who went to the doctor for a routine physical. The doctor ordered a bunch of blood tests and a urine test, turns out she had an asymptomatic urinary track infection. She was given ciprofloxacin and had a bad reaction to it.<p>Turns out:<p>A quarter of elderly women have asymptomatic urinary track infections. Detecting and treating them have not shown to have any benefit.<p>Ciprofloxacin is an inappropriate treatment for uncomplicated urinary track infections in the elderly due to the high risks of serious side effects.<p><a href="https:&#x2F;&#x2F;www.nytimes.com&#x2F;2019&#x2F;03&#x2F;15&#x2F;health&#x2F;antibiotics-elderly-risks.html" rel="nofollow">https:&#x2F;&#x2F;www.nytimes.com&#x2F;2019&#x2F;03&#x2F;15&#x2F;health&#x2F;antibiotics-elderl...</a><p>The story doesn&#x27;t say if the doctor discussed benefits and risks of doing those blood and urine tests, but I&#x27;m doubting they did (considering both the testing and the treatment was against recommendations).<p>I&#x27;m not, as a rule, against screening tests. I&#x27;m against doctors not explaining the risks vs benefits of screening tests. I&#x27;m also against doctors ordering screening tests that have shown to have no benefit.

Didn&#x27;t we see the exact same thing a decade ago with mammograms and breast cancer?<p>I remember there being two issues, one being computer aided detection in mammograms at the time was terrible for false positives compared to an experienced doctor (the the computer-aided was a selling&#x2F;marketing point so people tended to opt for it).<p>The second was mammograms no longer being recommended for certain age groups, as they were shown in studies to just be ineffective. There was a backlash against such recommendations, under a kind of &#x27;better safe than sorry&#x27; argument.

What this and many other similar situations argue for IMO are better blood screens for cancer biomarkers.<p>For it turns out even with early detection, metastasis has already happened. It&#x27;s just that those metastasized cancer cells take a long time to grow.<p>I mean the doctor is right, but it sure sucks to be one of the people who really has cancer and you skipped the screening, no?<p><a href="https:&#x2F;&#x2F;www.sciencedaily.com&#x2F;releases&#x2F;2016&#x2F;12&#x2F;161214145615.htm" rel="nofollow">https:&#x2F;&#x2F;www.sciencedaily.com&#x2F;releases&#x2F;2016&#x2F;12&#x2F;161214145615.h...</a>

tl; dr: the false positive rate is too high.

What does a false positive look like to a doctor, and how will it not harm the organism? I can&#x27;t imagine a cancer that can be ignored safely, nor an early stage treatment that is counterproductive.

<p><pre><code> Welch says, &quot;but [can also] find cancers that were never going to matter.&quot; That&#x27;s because some cancers grow slowly and never become dangerous, he says. </code></pre> This exact same phenomenon is already occurring with breast cancer. Everybody is a &quot;breast cancer survivor&quot; these days, because they keep finding these turtle tumors that were never going to be a problem. If you look at mortality rates between those who screen early and those who don&#x27;t, they are the same.<p><a href="https:&#x2F;&#x2F;link.springer.com&#x2F;article&#x2F;10.1007&#x2F;s10549-018-4691-4" rel="nofollow">https:&#x2F;&#x2F;link.springer.com&#x2F;article&#x2F;10.1007&#x2F;s10549-018-4691-4</a>

a.k.a. every layman&#x27;s writeup of bayesian reasoning ever.