Overdiagnosis?


In my last post I left you hanging with suspense! Well, in this post I have a couple of issues to raise that should quell any after effects of inordinate suspense left behind from reading my last post. One is about overdiagnosis, which I promised to raise again, and the other is about cancer itself and what would happen if it didn’t exist.

So, in her book Natural Causes, Barbara Ehrenreich addresses what she calls overdiagnosis. This is a situation wherein currently powerful imaging techniques can, for example, ‘see’ many more, and smaller, lumps in a person’s neck than was previously possible. The question is then put to the patient: “We’ve found a lump in your neck. What would you like us to do?” Patient, very concerned: “Is it cancer?” Doctor: “We don’t know, but we can always remove it.” Patient: “Well, let’s not take any chances. Let’s get rid of it.” Ehrenreich claims that in seventy to eighty percent of these cases in the US the surgery was unnecessary.

I have my own example of overdiagnosis. I had a parotid gland removed from the left side of my face years ago. There was evidence that it was enlarged, but nothing to say it was malignant. I had a choice to make and opted to have it removed. It was unnecessary surgery. Because of it I was left with insensitivity on the left side of my face and a scar leading from my ear down the side of my neck. It’s a crapshoot. How many people do you think would turn down the surgery?

Recently, Dr. Brian Goldman of the CBC’s program White Coat, Black Art, wrote in his blog about overdiagnosis. He writes that overdiagnosis “means identifying problems that weren’t causing symptoms and were never going to cause the patient harm.” The source for most of his information is a study led by Prof. Paul Glasziou, director of the Institute for Evidence-Based Healthcare at Bond University in Australia. It used data collected over a thirty year period by the Australian Institute of Health and Welfare. The results are quite astounding. Goldman writes:

The researchers found that, in men, 42 per cent of prostate cancers, 42 per cent of kidney cancers and 58 per cent of melanomas were overdiagnosed. In women, 22 per cent of breast cancers, 58 per cent of kidney cancers and 54 per cent of melanomas were overdiagnosed.

Overdiagnosis can arise from overly prescribed testing including screening tests like mammography. Increasingly sensitive imaging equipment can detect smaller and smaller lesions and tumours, benign or malignant. It’s often difficult to tell whether a tumour is benign or malignant. In the case of kidney cancers, invasive biopsies are not often carried out for fear of spreading cancer cells to adjacent lymph glands. So, surgery is a crapshoot. Do we operate or not? The default position is surgery because few people would be willing to take the risk of leaving a possibly benign tumour in their bodies.

To take this even further, Goldman’s blog post argues that even “incidental abnormalities” or cancers that would never have caused symptoms or led to full-blown rapid onset pathological mitosis are being surgically extirpated. We probably all have asymptomatic cancer cells in our bodies that may never result in any health threat because of them.

In the September 11, 2017 issue of The New Yorker Siddhartha Mukherjee is back at it with a thoroughly provocative article entitled: Cancer’s Invasion Equation: We can detect tumors earlier than ever before. Can we predict whether they’re going to be dangerous?

Good question. The gist of Mukherjee’s argument in this article is that two things are required for a full-blown cancer to make itself known which he metaphorically refers to as the seed and the soil. This metaphor he borrowed from a 19th Century English doctor interested in cancer research, Stephen Paget. His idea was that a cancer cell (the seed) would grow only if the local bodily ecosystem (the soil) was conducive to that growth. It could happen that the cancer cell falls on barren ‘soil’ and does not grow and divide. On top of that, on close examination cancer cells could be found that would never produce any symptoms. Some cancer researchers were now becoming human ecologists. Some even began to ask why people don’t get cancer and not just why they do when they do.

In my case, I may have carried the myeloma ‘oncogene’ for a long time but my ‘soil’ wasn’t yet ready to receive it. It may be that it was just a matter of time in my case, age being a big factor, but there may have been others that contributed too to creating the right conditions for my myeloma to go from dormant (smoldering) to active. Now, there’s no turning back for me. The seed has been planted and the hemoglobin garden in my bones is turning into an oncological garden.

There’s a final note towards the latter part of Mukherjee’s book The Emperor of all Maladies that makes me realize how little we know about cancer at this stage and about the process of dying and what that entails. Mukherjee writes:

“Taken to its logical extreme, the cancer cell’s capacity to consistently imitate, corrupt, and pervert normal physiology thus raises the ominous question of what “normalcy” is. “Cancer,” Carla said, “is my new normal,” and quite possibly cancer is our normalcy as well, that we are inherently destined to slouch towards a malignant end. Indeed, as the fraction of those affected by cancer creeps inexorably in some nations from one in four to one in three to one in two, cancer will, indeed, be the new normal—an inevitability. The question then will not be if we will encounter this immortal illness in our lives, but when.” (from “The Emperor of All Maladies: A Biography of Cancer” by Siddhartha Mukherjee)

So, how exactly does the body shut down as it’s dying? Cancer may very well be one (a very important one) of the mechanisms that is ‘natural’ in its role in having us die. Maybe cancer is not the pathological evil that it’s made out to be. What would happen if cancer did not exist? How would we die then? What does it mean to die of natural causes? How can we figure that out? Stay tuned. I think science and medicine have a lot to learn about us yet.

10 thoughts on “Overdiagnosis?

  1. It reminds me of something that my mother, who is 28 years into her Parkinson’s disease (now nearly blind, nearly deaf, difficult to understand speaking, and unable to walk unassisted) said: “be careful what you save me from.”

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  2. But sometimes I wonder just how much science and medicine has learned about us? Often, it seems as though the very nature of science is to medicalize bodies without even acknowledging souls. At least, Western science. Probably most of the medical practitioners I know would reject the notion of cancer as normal being firm believers in the if-thine-eye-offends-thee-pluck-it-out school. This does not mean, of course, that doctors lack souls but that they keep them as a kind of last resort for themselves as well as their patients? When medicine has to call it quits only then can all concerned get down to the real business of dying, and it seems to be very busy indeed1

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    1. It’s clear that modern medicine considers death and disease the twin ‘evils’ of life. It’s the old trope that life is good, death is bad. However, death is necessary for life and is entirely ‘normal’ in that nothing alive escapes it. Modern medicine is pretty good with hammers and saws, but not so good when considering dying…and that’s simply following broader cultural norms. Physicians are in a tough spot. They can’t defeat their ultimate enemy, death. They may win the odd battle, but they always lose the war. That has to be disheartening after a time. I find the whole idea of saving lives quite funny. Life is never saved, death is simply postponed. In oncology, the postponing of death is the general rule. Oncologists don’t generally talk about saving lives. Postponing death, even for a few months, is considered a victory. In my case, victory might mean a few months more of life. The older we are, of course, the less we can expect in terms of longevity.

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  3. My friend was talking about a friend of hers who was in a car accident and ended up needing numerous surgeries, not long after he developed cancer in the same area. I know a surgery for uterine fibroids has been cancelled for fear it may spread unknown cancer cells. Here is a good writeup about the complexities trying to determine the best way to proceed with treatment. I had this new surgery, so new the surgeon was training others how to do it. I am very grateful to have found someone online from a different area and surgeon to compare notes and allay my nerves.

    FDA Advisors Debate Ban, Black Box
    And Status Quo of Power Morcellators, 2014

    http://med.stanford.edu/content/dam/sm/cancer/documents/pdfs/TCL072514.pdf

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  4. My friend was talking about a friend of hers who was in a car accident and ended up needing numerous surgeries, not long after he developed cancer in the same area. I know a surgery for uterine fibroids has been cancelled for fear it may spread unknown cancer cells. Here is a good writeup about the complexities trying to determine the best way to proceed with treatment. I had this new surgery, so new the surgeon was training others how to do it. I am very grateful to have found someone online from a different area and surgeon to compare notes and allay my nerves. After my surgery, I was shocked when my now trained surgeon told me it was better than what he had originally proposed for me.

    FDA Advisors Debate Ban, Black Box
    And Status Quo of Power Morcellators, 2014

    http://med.stanford.edu/content/dam/sm/cancer/documents/pdfs/TCL072514.pdf

    Like

  5. My friend told me about a friend of hers who was in a car accident and ended up needing numerous surgeries, not long after he developed cancer in the same area. I know a surgery for uterine fibroids has been cancelled for fear it may spread unknown cancer cells. Here is a good write up about it and the complexities trying to determine the best way to proceed with treatment. I had this new surgery, so new the surgeon was training others how to do it. I am very grateful to have found someone online from a different area and surgeon to compare notes and allay my nerves. After my surgery, I was shocked when my now trained surgeon told me it was better than what he had originally proposed for me.

    FDA Advisors Debate Ban, Black Box
    And Status Quo of Power Morcellators, 2014

    http://med.stanford.edu/content/dam/sm/cancer/documents/pdfs/TCL072514.pdf

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    1. Hi Mama. So, I read the Cancer Letter piece on morcellation. That was from 2014. I wonder what the state of the technology is now from the FDA’s point of view. The article focussed on fibroids but I think that power morcellation, or at least morcellation, was rejected for my kidney cell cancer in 2002 for fear that it might spread the cancer. My surgeon opted for surgery that basically cut me in half so that my left kidney could be gently lifted out of my body while leaving the entire kidney intact. I expect that’s why I’m still alive. In any case, treatment options are very difficult to determine, that’s certainly true. In my case, with multiple myeloma, there are many options but a few favoured ones for initial therapy. I’m on one of those favoured ones and it seems to be working very well. I may get to live a few more years yet although I fear that my quality of life will be diminished substantially. That’s what my oncologist told me during our last ‘visit’. Oh well. Upward and onward. I can still write and I’m thinking I may be able to do other things, even woodworking, on a moderate scale. That would be fine. Take care.

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      1. I don’t know how individuals find all the treatments available to them, determine which ones are best for their circumstances, learn about up and coming new treatments, find a doctor that does the procedure, and learn about all the potential risks. I hope you are around for many, many years, I love how you share your experiences and wisdom. Doug Linker might offer something for your woodworking interests.

        https://www.youtube.com/channel/UC-eOXKXJ2GQ1gewivwNxYKQ

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      2. Hi Mama, thanks for your interest. We’ve done a lot of research and have assessed the options, of which there are not a lot! And thanks for the Doug Linker reference. He’s pretty entertaining and I like that style of videography.

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