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Most cancer screenings don’t extend life, study finds

69 点作者 geeB超过 1 年前

26 条评论

kccqzy超过 1 年前
This is the pertinent quote:<p>&gt; “Cancer screening was never really designed to increase longevity. Screenings are really designed to decrease premature deaths from cancer.” Explained another way, Dahut said, if a person’s life expectancy at birth was 80, a cancer screening may prevent their premature death at 65, but it wouldn’t necessarily mean they’d live to be 90 instead of the predicted 80.<p>Personally I think this is just a matter of terminology in public health not necessarily aligning with our intuitive understanding. I presume most people would think that preventing a shortening of lifespan <i>is</i> prolonging your life, but the article makes clear that they are different.
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twoodfin超过 1 年前
I am skeptical of the implied lesson of this analysis—and it is a meta-analysis of other research, not an original study.<p>Just take as given that the analysis is correct, and screening for rare Disease A on net has no effect on life expectancy. Almost no one actually gets Disease A, but everyone is screened for it, and that has some diffuse cost to life expectancy: Screen enough people enough times and <i>someone</i> will die in a car accident on the way to or from the doctor&#x27;s office. More likely the screening crowds out other more net-beneficial medical testing or is taken as some false comfort to continue an unhealthy lifestyle.<p>Modern cancer treatment, especially for the most common types (i.e. the most likely to be screened for) is very good, even if the cancer is caught later due to lack of screening. So even the folks who catch it early due to screening don&#x27;t incur a benefit in many cases, further pushing down the life-expectancy win on average.<p>Still: This is like saying home insurance is a bad deal because on average the insurance companies make money. Screening is an insurance policy (not a free one, to be sure) against a catastrophic outcome.<p>If you&#x27;re a public health authority in a utilitarian and budget-constrained mindset, sure, don&#x27;t encourage screenings by the logic and findings of this analysis. But I don&#x27;t think individuals should consider on-average-LE-negative screenings as something to avoid.
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porcoda超过 1 年前
(Note: very US centric comment here) I’ve become skeptical of the motives behind any article that seems to seed some level of doubt about health screenings and any preventative or treatment measure that involves the healthcare system itself. They always stink of the insurance and for-profit healthcare system and their aversion to paying anything out beyond the absolute bare minimum to get people the care they need. I often wonder how different public attitudes would be towards treatment and prevention if the US healthcare system wasn’t profit driven.
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monero-xmr超过 1 年前
An excellent episode of EconTalk came out today on this very subject:<p>Open: <a href="https:&#x2F;&#x2F;simplecast.econtalk.org&#x2F;episodes&#x2F;vinay-prasad-on-cancer-screening" rel="nofollow noreferrer">https:&#x2F;&#x2F;simplecast.econtalk.org&#x2F;episodes&#x2F;vinay-prasad-on-can...</a><p>Apple: <a href="https:&#x2F;&#x2F;podcasts.apple.com&#x2F;us&#x2F;podcast&#x2F;econtalk&#x2F;id135066958?i=1000625920965" rel="nofollow noreferrer">https:&#x2F;&#x2F;podcasts.apple.com&#x2F;us&#x2F;podcast&#x2F;econtalk&#x2F;id135066958?i...</a><p>Highly recommend the episode and show. The gist is that cancer is only 4% of deaths, and screening only reduces those 4% by 20% (so it does not help whatsoever 80% of cancers). But there is a lot more to the episode.<p>The most important thing you need to do to prevent early death is reduce heart attack and stroke, and that requires better diet and exercise. Really the best drug of all is diet and exercise.
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amluto超过 1 年前
The actual study is (after some URL sanitization):<p><a href="https:&#x2F;&#x2F;jamanetwork.com&#x2F;journals&#x2F;jamainternalmedicine&#x2F;fullarticle&#x2F;2808648" rel="nofollow noreferrer">https:&#x2F;&#x2F;jamanetwork.com&#x2F;journals&#x2F;jamainternalmedicine&#x2F;fullar...</a><p>and I do <i>not</i> like it. It suffers from what I consider an extremely common problem in statistics: if you define the question poorly, then your output is garbage no matter how fancy or careful your analysis is.<p>We can start with the beginning of the abstract:<p>&gt; Importance Cancer screening tests are promoted to save life by increasing longevity, but it is unknown whether people will live longer with commonly used cancer screening tests.<p>I have never heard of a doctor suggesting a cancer screening by saying &quot;this might save your life by increasing your longevity.&quot; What does that even mean?<p>So let&#x27;s try to figure it out. The paper uses the terms &quot;lifetime&quot; and &quot;longevity&quot; somewhat interchangeably, and it does not define either term. The best I can figure out is that, <i>for an individual deceased person</i>, they have a certain lifetime in days from when they were screened to when they because deceased. (Or a certain lifetime in days from birth to death, and I&#x27;m not sure this distinction matters.)<p>Great, but this is only for one patient. What about for a sample of patients or for a population in general or for the probability distribution of lifetimes of a given patient conditioned on whether they do or do not get screened? The article <i>does not say</i>, and a single &quot;lifetime&quot; number is not a probability distribution. Is it an expected value or a mean? A median? A mode? No comment.<p>One of the headline conclusions is:<p>&gt; Based on the observed relative risks for all-cause mortality and the reported follow-up time in the trials, the only screening test that significantly increased longevity was sigmoidoscopy, by 110 days (95% CI, 0-274 days) (Table 2, Figure 2)<p>Figure 2 is useless. Table 2 is somewhat informative, and it has a column for relative risk of all-cause mortality and a column for lifetime gained and its 95% CI. But WAIT A MOMENT! The only way you can know the lifetime of an individual patient is if they&#x27;re dead. If they&#x27;re dead, their risk of all-cause mortality by the time they died is 100%. That&#x27;s not 100% plus or minus something with some relative risk thrown in -- they are dead enough to have a date of death so that someone could compute their lifetime! Or maybe &quot;lifetime&quot; means something else, and the authors didn&#x27;t bother to figure it out and say what they meant. So what exactly is this paper even analyzing?<p>So I suspect this is a meta-analysis of studies, of which some may or may not have been high enough quality to define their terms, and probably several of which used &quot;lifetime&quot; to mean some estimated property of a distribution, and this meta-analysis completely failed to figure out what the included studies were talking about.<p>So I rate this meta-analysis as almost entirely useless, on account of it failing to actually analyze anything that makes sense.<p>So I don&#x27;t think any conclusions can be drawn. Although... ACS puts the lifetime risk of colorectal cancer at 1:25 or so. So one might naively translate a 110-day lifetime extension for everyone to a 110 day · 25 = 2750 day = ~7.5 year expected lifetime extension for people who actually get colorectal cancer. Sign me up -- 7.5 more expected years of life and presumably more than that of quality life years in the event I contract a not-particularly-rare disease sounds like a pretty good deal. (Colorectal cancer screening is not all that unpleasant, and I apparently only have a 96% chance of the screening being unnecessary.)
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aydyn超过 1 年前
&gt; explained that if breast cancer caused 3% of all female deaths and screenings reduced these deaths by 35%, that’s a good result on its own. But screenings may change mortality overall by only about 1%<p>This statement makes it clear what&#x27;s going on. In ML terms: class imbalance. 99.9% of people won&#x27;t ever get colon cancer, and therefore won&#x27;t ever benefit from a colonoscopy. It won&#x27;t make any statistical difference in overall population survival. But for the 0.1%? It will save their lives.
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xp84超过 1 年前
I am still disturbed by this though. The alternative I see to &quot;get screenings&quot; is &quot;get no screenings.&quot; If you&#x27;re one of the ones who actually do have an aggressive cancer, and you don&#x27;t find out about it until it&#x27;s like Stage Four, then you just definitely die, badly and soon. You, specifically, might have been helped if screened when you had a little baby tumor.<p>So, while I see the &quot;statistically&quot; part, asking everyone to get zero screenings until you start coughing up blood (or whatever happens when the cancer starts showing very obvious signs)... it just seems weird on the individual level. <i>Nobody knows (nor can they know) if you&#x27;re the person who would be cured with treatment, or if you&#x27;re the person whose outcome wouldn&#x27;t have changed a bit with treatment (for better or for worse).</i> That question matters <i>individually,</i> and while &quot;statistically you&#x27;re slightly more likely to be in the second group&quot; according to these studies, that doesn&#x27;t make me feel great about just declining all screenings.
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jbandela1超过 1 年前
What surprising to me is that sigmoidoscopy shows a benefit but colonoscopy doesn’t.<p>In colonoscopy, the entire colon is examined by using a long flexible tube. In sigmoidoscopy, only the lower portion of the colon is checked, again by using a flexible tube.<p>The things that come to mind is that sigmoidoscopy may be better tolerated by patients or have fewer complications.
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hedora超过 1 年前
This article uses extremely contorted logic. Pretty much all health care has some cost, and hopefully some benefit in terms of life expectancy and&#x2F;or quality-of-life-adjusted life expectancy.<p>If you assume all the costs are fungible, then the analysis is straightforward (the costs are not actually fungible -- some things cost money, other things cost patient time, or use resources that are in finite supply -- so it turns into a linear programming problem, and we&#x27;ve been able to solve those since before computers existed).<p>With fungible costs, for each of the available health care services, you the expected increase of life expectancy and divide it by the cost, and prioritize the things that have the highest benefit&#x2F;cost ratio.<p>The article doesn&#x27;t talk at all about the cost of the screens, which is fairly low (vs. spending time exercising, or a year of exotic chemo). It also doesn&#x27;t look at patient quality of life.
retrocryptid超过 1 年前
Wow. People really are bad at reasoning about probabilities. A more important question might be &quot;does not getting cancer treatments lead to a shortened lifespan?&quot; And that is exactly the question they did not ask in that study.
0cf8612b2e1e超过 1 年前
&gt; In this systematic review and meta-analysis of 18 long-term randomized clinical trials involving 2.1 million individuals, colorectal cancer screening with sigmoidoscopy prolonged lifetime by 110 days, while fecal testing and mammography screening did not prolong life…<p>That is shockingly bad. An extra three months of life is not nothing, but not exactly a clear win to push people towards the added stress and effort to be screened.
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kwhitefoot超过 1 年前
The patient is not interested in the effect on the average life expectancy of all people in society, they are only interested in their own case when they are diagnosed early enough to have treatment that will extend their life if they have cancer. This is a different sub-population.
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dang超过 1 年前
Recent and related:<p><i>The real cost of a preventive health scan goes well beyond the price tag</i> - <a href="https:&#x2F;&#x2F;news.ycombinator.com&#x2F;item?id=37266189">https:&#x2F;&#x2F;news.ycombinator.com&#x2F;item?id=37266189</a> - Aug 2023 (254 comments)
freedude超过 1 年前
My wife&#x27;s grandpa was diagnosed with prostate cancer. He was 82 and had been a natural food store owner for over 30 years. He said the side effects to the treatment and the surgery was too great for him to endure and would impede his quality of life. He passed away 4 years later from pneumonia unrelated to the cancer. The cancer wasn&#x27;t easy to deal with in those four years. He wasn&#x27;t cut up and on chemo or radiation either. I agree with him in that too much can be &quot;done&quot;
arisAlexis超过 1 年前
There is a really weird connotation with this: if when malignancy is found and then actions are taken and when it&#x27;s found earlier actions are taken earlier but they still don&#x27;t survive means that when you treat a cancer early is the same as treating it late. But that is contrary to all studies ever done. So either there is some mistake or stage I with stage 3 cancer have the same survival. Look like someone fucked up some math imo.
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kazinator超过 1 年前
&gt; <i>But experts say this doesn’t mean you should cancel that colonoscopy or mammogram appointment.</i><p>That can only be that these experts disagree with the study, because if it were properly conducted such that its findings are true, then in fact its conclusions do add up to skipping colonoscopies and mammograms.<p>The study is saying that the diagnostic procedures have no effect on outcome. You should not waste time on procedures that don&#x27;t change outcome.
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stevehawk超过 1 年前
Is this study just proving that other things kill you while you&#x27;re being or after you&#x27;ve been treated for cancer?
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psychphysic超过 1 年前
This is not an unexpected result. Last I checked breast self examination also does not reduce deaths from breast cancer, nor testicular self examination.<p>If anyone&#x27;s interested the &quot;Wilson criteria&quot; is the basis of decisions about screening programmes and many run programmes fail it.
neongodzilla超过 1 年前
Sounds like a talking point one would use if you no longer wanted to provide coverage for preventive care.
michael1999超过 1 年前
discussed here - <a href="https:&#x2F;&#x2F;news.ycombinator.com&#x2F;item?id=37296122">https:&#x2F;&#x2F;news.ycombinator.com&#x2F;item?id=37296122</a><p>I found this comment useful: - <a href="https:&#x2F;&#x2F;news.ycombinator.com&#x2F;item?id=37297963">https:&#x2F;&#x2F;news.ycombinator.com&#x2F;item?id=37297963</a><p>Several comments noted that a 4 month improvement in life expectancy (for sigmoidoscopy) over the whole population is actually pretty good for a low-incidence cancer. That&#x27;s several years for the people who actually get it.<p>But the comments seem naive about the downsides of broad screening: over-treatment, iatrogenic disease, false positives, opportunity cost, etc.
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bironran超过 1 年前
Does that mean early cancer treatments don&#x27;t prolong life?<p>Positive screening result usually leads to treatment of one kind or another. Without screening, treatment would start later, if at all. Is that a corollary of this study?
memonkey超过 1 年前
What&#x27;s the next question then? Curious to know if any of these screening caught cancers at various stages and if there is a correlation to better long term prognosis.
arisAlexis超过 1 年前
These articles are dangerous for the public. They may not go to have their regular checkups that will make them die younger and thus ironically yeah their life would not be extended any more.
wkat4242超过 1 年前
Still it&#x27;s nice to be the one outlier. For those with higher risk it would still be a good idea. Smokers, people who work with chemicals etc.
Flatcircle超过 1 年前
Breast cancer screens def save lives. Can&#x27;t speak to all screenings but some def work.
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apsec112超过 1 年前
Me before reading: &quot;this study, like ~every study, will detect no effect on all-cause mortality because that needs a crazy big sample size&quot;<p>After reading: &quot;this study, like ~every study, detected no effect on all-cause mortality because that needs a crazy big sample size&quot;<p>A three-year study where one group magically had zero car crashes would need a sample size of 5,000,000 to detect a difference in all-cause mortality. It&#x27;s really hard. (80% chance of p &lt; 0.05)
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