> Renaming the lowest-risk prostate cancer would cut down on overly aggressive treatment, some doctors say
I'm very skeptical. My father died from metasticized prostate cancer, and I'm now showing elevated PSA, though needle biopsy and MRI found no cancer.
It's true that prostate cancer is slow-growing, and it affects older men. So the theory is most men die of something else and it's not worth aggressive treatments.
That may be true--but there's no reason not to call a cancer "cancer."
65% of men are obese or overweight. So it follows that an obese 70 year old--and the majority of men--who are diagnosed with prostate cancer may die of something else first.
But it would be wrong--and unfair--if right-sized people were denied or discouraged from aggressive treatment because the population as a whole had other health issues.
The reason they are reluctant to aggressive treatment is because risk of side effects that affect quality of life, such as impotence and incontinence. Do you want to wear a diaper for the rest of your life or live with a relatively low risk of earlier death from cancer?
My point is that it isn't population considerations that make physicians reluctant to treat many cases of prostate cancer, but balancing relatively low risks of the cancer being aggressive against quite severe quality of life degradation for the individual patients. I really don't see how my post would be considered hostile.
The vast majority of radical prostatectomies don’t have incontinence (like 95%), and impotence isn’t common either. Furthermore, they’re usually in older men who are already impotent.
Many years ago incontinence was a side effect but it isn’t common any longer as surgery has gotten better.
The story of how they discovered the nerves they were cutting that causes impotence is kind of crazy, because for years it is basically like nobody even looked into it. Then one day someone decided to and they figured it out pretty quickly. That was in 1982.
I’m talking about long-term incontinence which is what people are most concerned about. You probably are reading about short-term incontinence. If you are having a radical prostatectomy done, you probably are hoping to live at least ten more years or even longer, so you’re basically saying you want short-term pain (surgery, pain, incontinence, etc) for long-term peace of mind (no metastases).
Population considerations are what make it low risk. If prostate cancer was most common in 10 year old boys, the risk tradeoffs for a slow cancer would be quite different.
>I really don't see how my post would be considered hostile.
To make a point, you are quite literally asking someone with elevated PSA, whos father died of prostate cancer, if they want to wear a diaper.
There is a solution for chronic cases like this: a manually operated valve that stands in for the sphincter. Some of the guys in my prostate cancer support group have described this as "life changing".
Yes! Also, most people will dribble a bit when they get old no matter what--with or without prostate cancer. I'm much more concerned about my mental health than having to wear incontinence pads in my 80s.
>But it would be wrong--and unfair--if right-sized people were denied or discouraged from aggressive treatment because the population as a whole had other health issues.
I agree. Public health professionals should not engage in deceit in the name of the public good. Utilitarian arguments may rationalize net benefit on average, but that comes with winners and losers. The goal should be clarity of communication, even if it is sub-optimal.
Is cervical dysplasia a deceptive term? CIN 3 dysplasia seems pretty close conceptually to grade 1 prostate cancer. There are doctors on HN, maybe one of them will set the record straight.
This doesn't seem like one of those things where public health officials are trying to mind control the public with terminology. There are precancerous neoplastic illnesses, and cancer is defined by the threat of metastasis, which is sort of exactly what you don't have with grade 1 prostate "cancer".
For when it metastasizes, aggressive treatment is to get rid of every trace of testosterone in your system. Prostate cells are regulated by it, so removing it is pretty effective… for a while…
Your analysis is contradicted by the evidence presented in the article.
> One study took 1,600 men with low-risk prostate cancer in the U.K. and randomly assigned them to get surgery, radiation or active surveillance. Fifteen years later, the researchers found that mortality rates for all the men were low, and similar for each group no matter which approach they took, according to the study which was published last year in the New England Journal of Medicine.
If aggressive treatment regularly saved lives the healthiest 35% of the population, one would probably see a noticeable difference in mortality between the randomized groups.
Maybe it would be possible to find flaws in the study, or an interpretation of the results that would align with your analysis, but it seems like you haven't engaged with the evidence at all.
> If aggressive treatment regularly saved lives the healthiest 35% of the population, one would probably see a noticeable difference in mortality between the randomized groups.
It isn’t different from no treatment according to that statistic, but it does save lives. Unfortunately, it also kills about the same number of men.
It also, for thousands, decreases quality of life. Unnecessary operations can have side effects and there are scares on early false positives. Even the visits for checkups decrease quality of life a bit, and you’ve to do millions of those to save a life.
The problem is that, once the word ‘cancer’ has fallen, people categorize dying and side effects such as erectile dysfunction as the cancer’s fault and surviving as being thanks to medicine. So, on parties, they’ll say “doctors saved my life” and “cancer killed my brother”
>But it would be wrong--and unfair--if right-sized people were denied or discouraged from aggressive treatment because the population as a whole had other health issues.
Everyone should be discouraged from choosing treatment that does more harm than good, which (unfortunately) is practically the norm for cancer treatment in the US. If a treatment is described as "aggressive", it is usually inappropriate - aggression is rarely motivated by a thoughtful and careful consideration of the facts. The fear of cancer is wholly understandable, but it often leads to avoidable harm.
We're very good at identifying tumours and suspicious cells, but we're very bad at predicting which of those will actually develop into serious disease. As a result, far too many patients are being subjected to painful and risky treatments with life-altering side-effects for no clear clinical benefit.
But that’s how public healthcare works. You create a system based on population level evidence.
If regular mammograms don’t reduce cancer deaths, then you don’t pay for them. That might be some people get diagnosed later, have to undergo more aggressive treatment, but that added cost is more than offset by not paying for mammograms for the entire population.
Works great at the population level, but at the individual level it may mean some people “slip through the cracks”.
I don't disagree! But perhaps they should have two sets of "actuarial tables" -- one for the overweight/obese majority, and one for the right-sized miniority. When ever I see a study that doesn't talk about the "elephant in the room" I don't trust it.
There's a prostate cancer treatment algorithm that the Mayo Clinic uses that separates obese people from healthy-weight people. I trust that.
TL;DR Doctors consider renaming low-risk prostate cancer to something else, because calling it “cancer” prompts aggressive treatment that doesn’t improve the outcomes.
Since other low-risk cancers were already renamed, it does not seem controversial. Perhaps a more correct way forward is to stop assuming cancer = death, but that seems unlikely.
I wonder if the stress from knowing you have cancer contributes to stress, inflammation, and as a result worsens the illness or makes it less likely to resolve.
It's only years later, well into my adult life, that I learned that "melanoma" was actually skin cancer. I always thought it was just a nasty mole.
Various members in my family and circle has had a melanoma, my father had two in the last 10 years. It was only when a friend of mine was diagnosed very late, after the damn thing spread to his lymph system when I realized "holy shit this is actually cancer".
Another friend had a "cancer scare" and broke contact with all of us for months while she was dealing with the trauma and anxiety. Only much later did we learn she had a /possible/ melanoma. Most of us were kind of baffled by the reaction.
It's interesting how naming scary things sometimes greatly contributes to the actual scare-factor of the thing. Where if it's unnamed, or receives a benign name, then most ignore it.
It's certainly scary, but it's on the skin, so it's easy to spot, and when spotted early, it's easily cured. Lots of qualifiers there, so check those moles.
Other skin cancers have a low mortality and can mostly just be chopped out because they don't tend to invade other tissues and spread throughout the body. Most skin cancer deaths are from melanoma because it often invades and spreads. The mortality rate has gone down a lot for melanoma due to treatments, but it can't be caught too late and even then the treatments are much more intense than just an excision.
If your cells are not dividing correctly so much so that the skin cell replication is disrupted then your skin as one of the largest organs your body has will replicate the cancer very very fast. But lets call it what it really is in most cases, the protein of cells being replaced by glyphosphates. Your body not producing enough enzymes, chlorine dioxide, to replace the glypohsphate protein which is causing uncontrollable cell division with not enough healthy proteins through anaerobic means e.g exercise, replacing them fast enough. Usually hiding in fat or muscle cells. Your body is so fargone if you have melanoma even with strict diet change and a very careful and strict exercise regiment its already too late since your doctor will be pumping you full of chemotherapy/poison to kill the cancer, killing you in the process.
I wonder if "melanoma" is a catchall for all types of skin cancer in your family. Melanoma itself is one of three primary skin cancers, and the most lethal, while the other two are generally less threatening.
I can’t really speak to the subject, but I suspect that autocorrect changed what should be “glycosylation” into “glyphosate” (the active ingredient of roundup herbicide).
Is this because things like regular moles are also technically a form of cancer/tumor? And a melanoma is a mole that evolved into full malignant your-life-is-in-danger cancer?
When my wife was diagnosed with thyroid cancer our doctor said the same thing was being discussed about reclassifying her diagnosis as well. His assertion was that a lot of thyroid cancers aren’t even discovered until post mortem from another cause of death. Also that the standard treatments are so effective, and in some ways unique to thyroid cancer (radioactive iodine treatment specifically) that the cure rate was very high.
This was a decade ago and while I remember reading up on it at the time, I don’t have any primary research to back this up so take it with a grain of salt.
Depends on how advanced. I had a relatively fast growing papillary thyroid cancer that was already 3cm and spread to my lymph nodes. Still relatively "easy" to address, and I've been in remission for 10 years, but if my thyroid was not removed, and I didn't take the radiation treatment, I probably would have been toast long ago.
I would like to know whose stands to benefit from this the most. Is it about improving quality of life for patients? Or to save costs for health insurers who won't have to pay for treatment of the side effects of the more aggressive options?
The former. Something like 75% of men in their 80s probably have some sort of mild prostate cancer. It’s just extremely prevalent but most of the time they are rather non-aggressive so you will die of something else years before you’d even think of worrying about the cancer killing you.
In a competitive market, insurers don't really care one way or another whether something should be covered or not: they just adjust premiums accordingly.
(Ideally, as a customer you'd have a choice between plans that do and do not cover a particular treatment.)
Insurers are incentivized to set standards for spending as much money as possible on all health care.
They have maximum profit rates, as a percentage of revenue. So the two ways to grow the revenue, and therefore profit, are to 1) capture a larger percentage of patients, and 2) make sure that all patients, including competitors, start using more expensive care options all together.
System-wide cost savings do not increase insurance company profits. This could be considered a good thing or a bad thing, depending on your point of view, I guess.
I had always considered it a bad thing, but given the thrust of your comment, perhaps it's good that there's no incentive for health care companies to push cost-savings measures as an industry.
This isn’t true. Insurers are incentivized by lowering healthcare costs as well. All you have to do is look at all the preventative care that they pay for - often with smaller or no copay (although no copay was mandated by Obamacare).
You’re missing the part where insurers have to big for coverage. Companies will say “we want a plan that includes X” then get a bunch of proposals from insurers.
Cost is a big factor in which one you go with. So while insurers do make more money by paying higher and more claims, that’s offset by customers wanting a low price.
I was talking about standard changes to what is deemed medically necessary, and the best medical course of action.
Individual companies wanting particular things covered is quite different. And the topic of this thread is why is the entire field shifting in their care in terms of what's thought to be medically best.
The standard treatment of cancer forty years ago meant very aggressive chemotherapy, radiation, and radical surgery. Many have reduced quality of life afterwards, think having to walk with help or having brain fog for the rest of your life when for all intents and purposes, you were okay a few months before. Not being able to do strenuous chores like lifting a box off the floor. That is the nature of treatment after early detection, usually when cancer is discovered during an infection or with symptoms, it's too late. In the cases discussed above, early detection of mild cancers usually don't mean the patient has a poor quality of life at that time and would actually experience a drop in their QoL from the treatment itself.
Cancer treatment to this day is not magic, it's not like taking a pill other than in extremely rare cases. You should spend time looking at cancer statistics, the oft mentioned statistics state death rates are a result of "cancer or cancer treatments" because the treatments take a toll on your body and leave you disabled or infirmed for the rest of your life. Until we have better treatments, which are coming, yes if a tumor will go away on its own you best believe it this is better for the quality of life for patients. In fact, the people who stand to lose the most from such a re-diagnosis would be drug manufacturers or even hospitals who can charge a lot for radical surgery and hospices who care for patients undergoing chemo.
For unfortunate personal reasons I have been reading studies on rectal cancer. Rectal cancer is terminal if untreated and curable if treated, but still 20-30% of patients don't even complete radiation and chemo treatment. Standard of care is localized radiation, poison in pill and IV form, and hope the cancer dies before the patient. At 40, this is rough. At 80, I might decide to call it game over. Only in the last decade, they have downplayed surgery with ~40% dodging it altogether when chemo-radiation provides total response. Surgery typically means at least a temporary colostomy and is high risk for older patients so the incentive was there to avoid it. Modern medicine is very pro-treatment and it takes a lot of 5 year studies to get them to dial things back.
I had colorectal surgery for a 5cm tumor at 41. I had two very young kids and wife, so opting out wasn't really a serious option. I'm pretty glad how things turned out, all things considered but knowing how tough those years of treatment and surgery were, there's no chance in hell I'd go through it at 80. I lost my father to lung cancer at 85, and his last year of fighting it really hit hard on his quality of life. He thought he was going to beat it though.
One big problem today is, that professionals have voted to reduce screening because of the side-effects of treatment. Especially on those, non-threatening, low risk cancers, which would (likely) never have posted a risk.
If removing the cancer label on those, and thus remove most of the useless treatment, this would be a net positive for all men. As we could start to role out society-wide screening. And really catch the problematic cases. Like men in their 40s or 50s getting prostate cancer.
Today we have voted (in most western countries) to not screen at all because the cost (in human suffering, not money, although that’s surely also a problem) of over-treatment is higher than the cost for those who die early because their cancer wasn’t found early enough. Which basically means we let people die, because we are not able to manage low risk cancer cases correctly.
Source: I’ve once been the tech part of a prostate cancer patient network startup for seven years. Turns out it’s hard to make it cash positive.
E.g. PSA (a blood value, easy to measure), if increasing very slowly over a long timeframe, is a good indicator that you may have cancer but that it is growing really slow, aka unlikely to be aggressive and to be an immediate problem. While a quick increase tells you the opposite.
Then there is DNA sequencing of cancer samples from a Biopsy. Which is evolving rapidly and should be soon cheap enough to be available at scale.
AFAIK there is currently know way to reliably tell from DNA sequencing data whether a prostate cancer will become dangerous. That may change, but I suspect there may be some inherent stochasticity in the transition of a cancer from benign to dangerous that will make a perfect classification possible. I would guess some form of monitoring may be required for all the currently non-dangerous cancers.
Yes, I had a glimpse at current research, it’s being worked on, but it’s not yet there. Also sequencing is still too expensive for more general application.
Genotyping assays for single nucleotide polymorphisms (SNPs) are relatively cheaper (I may not be up to date). In the space of 'polygenic risk score' of these genomice variants it is still a bit of debate how useful it is for screening.
The article addresses this. There's some risk of misclassification, but the answer is the same either way: you monitor the condition carefully to see how it behaves.
The problem then is, if you rename the "grade 1" condition "prostate dysplasia", some fraction of patients don't do the follow-ups, and then those misclassifications are a big deal. But if you don't rename it, some fraction of patients get unnecessary treatment that lowers their quality of life.
If the population who do _not_ actually have serious cancer is orders of magnitudes larger than those who do then there will be far more people in the false positive group than the true positive group and thus the vast majority of operations will be unnecessary.
The key here is how we manage the positive ones. And this is where the current system fails. We have yet to find a good way to manage them without doing unnecessary treatments causing more harm than good.
But instead of fixing this problem, we opted to stop screening. Which, for me, sounds stupid. But it sure is easier to do.
With all due respect to 3Blue1Brown, there are limits to wjat you can explain with statistics. Medicine applied on the individual pevel is one of those cases, because its purpose is to optimize the outcome for the individual.
A pandemic is different, there the goal is to optimize the outcome for the population.
Applying the latter to the former is at the very least cynical. The opposite is what got us anti-mask and anti-vaxxers.
Also, especially with cancer, people tend to be so affraid of the diagnosis, they look for excuses to not be examined. As if cancer onpy pops up when it is found or something. Which is stupid, if ypu have cancer you want to know as early as possible.
> Applying the latter to the former is at the very least cynical. The opposite is what got us anti-mask and anti-vaxxers.
I have no idea where you're going here. Wearing masks and getting vaccinated benefit both the individual and the population. (That actually contributed to it being politicized -- your choices affect my chances of getting a nasty disease).
At the individual level, you wear a mask when appropriate and get vaccinated, then you're less likely to get the disease and it's likely to be less severe if you do. Likewise, the population benefits from less disease spread, and less strain on the healthcare system as many of these cases become outpatient "take some Paxlovid" type deals.
Where is there any sort of basis for anti-mask and anti-vax theology here?
For the very same reason, breast cancer screening is under discussion.
We treat false-positives and low-risk patients that actually don't need treatment. As any treatment, at scale, invariably results in (averse) side-effects, that's a problem.
And the easiest way to get rid of false-positives is to not screen in the first place.
For breast cancer the statistics are the same as for prostate cancer, there is no society net-benefit to screening, as false-positive side effects are equal or worse to the benefits of the screening.
But, women are way better in handling (their) health than men, the public outcry over removing breast cancer screening would be load.
In other words, men are not load enough when it comes to (their) health. Which is no surprise I guess.
Not ony do treatments have risks, but so do tests! It doesn't take all that lopsided a ratio where if the odds of cancer are low, you have greater lifetime cancer risk from the additional xrays.
There's no hard facts separating a 3+3 from a 3+4, just one (or two if you're lucky) overworked pathologists and their subjective opinion on what they see on their slides.
Hey friend, I'm so sorry you're going through that and I wish you the best of luck in your journey.
I would argue though that it's not rocket science...currently, it's a lot harder with many more unknowns. Some of the issues we face are:
- Imperfect screening tests: the (very real) risk of both false positives and false negatives
- Lack of great prognostic models: if we think a certain cancer has a 25% chance of metastasizing within 5 years and I have 4 patients in front of me, how do I know which is the one?
- How do we identify if we're actually changing the trajectory of cancer with certain treatments? If a treatment fails, is it because we didn't choose the right treatment or is it reflective of underlying aggressive disease biology?
- Mass amounts of data from new technologies: this is obviously great and has allowed us to become granular with cancer in a way we haven't been able to before. It's important to recognize that widespread next generation sequencing is something we've had for less than a decade, and we have identified a lot of risk factors with this BUT it's also raised many questions (e.g. what mutations are actually significant?).
- Being human: every individual has their own values. Some patients will hear that it's a 1% chance this will become cancer and be okay with monitoring it. Some patients hear 1% and think it's too much of a risk and want intervention.
I think, with time and more data, we will become a lot better at this. But it's really not easy.
The testing itself is an issue as well. Most people think that you put a blood sample in a machine and it spits out "yes you have cancer" or "no you don't", but in reality in the earliest stages it's more akin to reading tea leaves. The chances of false positives are high, and can be equally or more harmful to the patient than false negatives.
This is also why doctors are increasingly recommending that young, healthy people not get routine annual checkups and blood work done unless they have any specific problems.
The general public definitely doesn't have a great understanding of the word "cancer." Patients often don't know that prostate cancer is not the same as lung cancer is not the same as colon cancer, etc.
And unfortunately, cancer is a lot more nuanced than that with a lot of heterogeneity even within a cancer type, e.g. an 80 year old male incidentally found to have an elevated PSA and subsequent low grade prostate cancer has a biologically different disease than a 35 year old who comes in with de novo metastatic prostate cancer.
I wish we had better ways of predicting what a patient's life will look 1 or 5 or 10 years down the line. We're developing the tools to do that, but there is still a significant amount of uncertainty and we can't eliminate that anxiety for patients. I don't know if re-naming low risk prostate cancer will do that either, but I can't say I feel strongly about it one way or another.
I hope that the population starts to get a better understanding of what "cancer" really is (i.e. a very wide spectrum of diseases), the inherent uncertainty associated with the diagnosis, and that we continue to get better predictive tools in the meantime.
> The brand is beneficial to the medical system, which about managing disease for profit, rather than making people well.
This is a very American point of view, other places in the world do not have this issue but cancer is still a serious disease. Not every disease is an invention of the for-profit medical system of the USA.
Intel's Andy Grove in the mid '90s was particularly candid about his experiences and I think his willingness to discuss his experiences with the then state of the art advanced the public discussion in a healthy way.
Wrote Hacking Healthcare, managed hospital systems, blah, blah... I remember first learning about cancer treatment and encology in detail when we took over management of a health system with a large set of encology centers. It was very eye opening to understand that one word, "cancer", is really an inappropriate blanket term for hundreds of more or less distinct diseases. Yes, they share a base element of disease mechanism but in terms of diagnosis, prognosis, treatment and morbidity, they are wildly different.
Regarding the posted article, there are two big related factors that the average patient has a difficult time appreciating. First is that "doing nothing and or waiting & seeing", even in 2024, is still the best course of treatment for a huge array of situations. The second related factor, is that the rate of preventable medical errors is absolutely staggering. In my multi-decade experience it typically hovers over 20%. As a patient myself I have been the victim of three near fatal preventable medical errors. So 1/5 of the time doctors are creating new problems and complications that are preventable if all of the known best practices at the time are employed, while attempting to resolve whatever is wrong with you. A troubling amount of the time the treatment can be worse than the disease.
I’ve been quite curious about Cancer since losing my mom to it two years ago. I’m currently infatuated with the idea that Cancer my well be parasites reaching various stages of killing the host.
Parasites, their preferred habitats, diet, chemical excretions, breeding and life cycles in general has been enlightening. Could some seasonal allergies or colds be the Jarisch-Herxheimer reaction to parasites… these are the kind of questions I find when not looking.
I guess the biggest question I have is, why if after countless autopsies that confirm the deceased had parasites do we not investigate this subject more? Humans are one of the rare species that don’t receive preventive treatment or screenings for parasites. Cattle, fish, birds, pets, all manner of zoo animals… but not humans?
Because cancer isn't a parasite. They are your own cells, just with various mutations. A parasite is a foreign living organism that lives off of another, for example, a parasitic worm. Anyone can easily confirm cancer cells are genetic mutations to your own by doing a genetic test - and in fact this is done regularly, it's called a germline and somatic genetic test, which can help identify if certain drugs would work well on the cancer. This is a form of personalized medicine.
My description that “Cancer my well be parasites reaching various stages of killing the host” wasn’t great.
> They are your own cells, just with various mutations.
Could parasite eggs lodged deep inside tissue for a long time (a fusion or sorts) not produce similar results? Have any studies along those lines been done?
EDIT: Could the chemical signal they excrete to keep the eggs dormant or the chemicals they excrete at time of death cause a mutation or other illnesses?
Any reason why we don’t treat humans with preventives or do screenings for parasites? I remember reading that it’s estimated that 80% of the population likely has some kind of parasite. I not trying to drift off subject. It just seems to be a gaping hole that the medical industry has no interest in.
A lot of things can cause cancer. For example, prostatitis and inflammation likely cause cancer, and likely are also correlated with it metastasizing. (I'm not claiming it's the cause or a sole reason but the evidence suggests it increases the risks.) I've never looked into parasites but it's possible parasites are associated with an increased relative risk of cancer, and the mechanism of action would probably be inflammation.
My guess is people are in effect checked for parasites by way of annual bloodwork and annual checkups. If someone started losing weight, for example, they'd go see a doctor who might investigate for parasites if the symptoms point to it. There is probably not much reason to do an annual parasite-specific test in people. Livestock cannot talk to us about their symptoms, and eat all sorts of crap, so there's some important difference there.
> Livestock cannot talk to us about their symptoms, and eat all sorts of crap, so there's some important difference there.
My understanding is that parasite eggs can live outside the host for months if not longer (surviving long winters, etc) and can be smaller than the eye can see. They’re effectively unavoidable and that a healthy immune system keeps them in check.
> they'd go see a doctor who might investigate for parasites if the symptoms point to it.
I am really struggling to see any interest in the subject and very little data. From what I’ve seen doctors are fairly dismissive even when the patient brings it up (although this appears to be mostly hearsay but again to little data on what would seem to be a fascinating subject for researchers).
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[ 3.9 ms ] story [ 159 ms ] threadI'm very skeptical. My father died from metasticized prostate cancer, and I'm now showing elevated PSA, though needle biopsy and MRI found no cancer.
It's true that prostate cancer is slow-growing, and it affects older men. So the theory is most men die of something else and it's not worth aggressive treatments.
That may be true--but there's no reason not to call a cancer "cancer."
65% of men are obese or overweight. So it follows that an obese 70 year old--and the majority of men--who are diagnosed with prostate cancer may die of something else first.
But it would be wrong--and unfair--if right-sized people were denied or discouraged from aggressive treatment because the population as a whole had other health issues.
The reason they are reluctant to aggressive treatment is because risk of side effects that affect quality of life, such as impotence and incontinence. Do you want to wear a diaper for the rest of your life or live with a relatively low risk of earlier death from cancer?
Many years ago incontinence was a side effect but it isn’t common any longer as surgery has gotten better.
The story of how they discovered the nerves they were cutting that causes impotence is kind of crazy, because for years it is basically like nobody even looked into it. Then one day someone decided to and they figured it out pretty quickly. That was in 1982.
>I really don't see how my post would be considered hostile.
To make a point, you are quite literally asking someone with elevated PSA, whos father died of prostate cancer, if they want to wear a diaper.
I agree. Public health professionals should not engage in deceit in the name of the public good. Utilitarian arguments may rationalize net benefit on average, but that comes with winners and losers. The goal should be clarity of communication, even if it is sub-optimal.
This doesn't seem like one of those things where public health officials are trying to mind control the public with terminology. There are precancerous neoplastic illnesses, and cancer is defined by the threat of metastasis, which is sort of exactly what you don't have with grade 1 prostate "cancer".
[1] https://www.who.int/news-room/fact-sheets/detail/obesity-and...
CDC says 73.6% of adults are overweight or obese (https://www.cdc.gov/nchs/fastats/obesity-overweight.htm)
> One study took 1,600 men with low-risk prostate cancer in the U.K. and randomly assigned them to get surgery, radiation or active surveillance. Fifteen years later, the researchers found that mortality rates for all the men were low, and similar for each group no matter which approach they took, according to the study which was published last year in the New England Journal of Medicine.
If aggressive treatment regularly saved lives the healthiest 35% of the population, one would probably see a noticeable difference in mortality between the randomized groups.
Maybe it would be possible to find flaws in the study, or an interpretation of the results that would align with your analysis, but it seems like you haven't engaged with the evidence at all.
It isn’t different from no treatment according to that statistic, but it does save lives. Unfortunately, it also kills about the same number of men.
It also, for thousands, decreases quality of life. Unnecessary operations can have side effects and there are scares on early false positives. Even the visits for checkups decrease quality of life a bit, and you’ve to do millions of those to save a life.
The problem is that, once the word ‘cancer’ has fallen, people categorize dying and side effects such as erectile dysfunction as the cancer’s fault and surviving as being thanks to medicine. So, on parties, they’ll say “doctors saved my life” and “cancer killed my brother”
Everyone should be discouraged from choosing treatment that does more harm than good, which (unfortunately) is practically the norm for cancer treatment in the US. If a treatment is described as "aggressive", it is usually inappropriate - aggression is rarely motivated by a thoughtful and careful consideration of the facts. The fear of cancer is wholly understandable, but it often leads to avoidable harm.
We're very good at identifying tumours and suspicious cells, but we're very bad at predicting which of those will actually develop into serious disease. As a result, far too many patients are being subjected to painful and risky treatments with life-altering side-effects for no clear clinical benefit.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4322920/
If regular mammograms don’t reduce cancer deaths, then you don’t pay for them. That might be some people get diagnosed later, have to undergo more aggressive treatment, but that added cost is more than offset by not paying for mammograms for the entire population.
Works great at the population level, but at the individual level it may mean some people “slip through the cracks”.
There's a prostate cancer treatment algorithm that the Mayo Clinic uses that separates obese people from healthy-weight people. I trust that.
Since other low-risk cancers were already renamed, it does not seem controversial. Perhaps a more correct way forward is to stop assuming cancer = death, but that seems unlikely.
I wonder if the stress from knowing you have cancer contributes to stress, inflammation, and as a result worsens the illness or makes it less likely to resolve.
Various members in my family and circle has had a melanoma, my father had two in the last 10 years. It was only when a friend of mine was diagnosed very late, after the damn thing spread to his lymph system when I realized "holy shit this is actually cancer".
Another friend had a "cancer scare" and broke contact with all of us for months while she was dealing with the trauma and anxiety. Only much later did we learn she had a /possible/ melanoma. Most of us were kind of baffled by the reaction.
It's interesting how naming scary things sometimes greatly contributes to the actual scare-factor of the thing. Where if it's unnamed, or receives a benign name, then most ignore it.
For the unitiated: Why?
In most of the cases I have direct experience with, the melanoma is "simply" removed, and /maybe/ some local radiotherapy in extreme cases.
No-one I know of received chemo. Nor was bad diet or unhealthy lifestyle blamed for the appearance of the melanoma.
https://en.m.wikipedia.org/wiki/Glycosylation
Ask me how I know, and I'll tell you about a nine-fingered person.
This was a decade ago and while I remember reading up on it at the time, I don’t have any primary research to back this up so take it with a grain of salt.
Iodized?
(Ideally, as a customer you'd have a choice between plans that do and do not cover a particular treatment.)
They have maximum profit rates, as a percentage of revenue. So the two ways to grow the revenue, and therefore profit, are to 1) capture a larger percentage of patients, and 2) make sure that all patients, including competitors, start using more expensive care options all together.
System-wide cost savings do not increase insurance company profits. This could be considered a good thing or a bad thing, depending on your point of view, I guess.
I had always considered it a bad thing, but given the thrust of your comment, perhaps it's good that there's no incentive for health care companies to push cost-savings measures as an industry.
For the government the only thing that matters is net tax revenue. Healthy people pay more taxes and unhealthy people cost money.
So the solution is obvious: invest in effective low cost preventative treatments and cures. That maximizes net tax revenue.
Meanwhile private insurers only care about your health to the extent that they get paid. Healthy people bring in less money than the chronically ill.
Cost is a big factor in which one you go with. So while insurers do make more money by paying higher and more claims, that’s offset by customers wanting a low price.
[1] https://www.ama-assn.org/delivering-care/patient-support-adv...
[2] https://www.ama-assn.org/delivering-care/patient-support-adv...
Individual companies wanting particular things covered is quite different. And the topic of this thread is why is the entire field shifting in their care in terms of what's thought to be medically best.
Cancer treatment to this day is not magic, it's not like taking a pill other than in extremely rare cases. You should spend time looking at cancer statistics, the oft mentioned statistics state death rates are a result of "cancer or cancer treatments" because the treatments take a toll on your body and leave you disabled or infirmed for the rest of your life. Until we have better treatments, which are coming, yes if a tumor will go away on its own you best believe it this is better for the quality of life for patients. In fact, the people who stand to lose the most from such a re-diagnosis would be drug manufacturers or even hospitals who can charge a lot for radical surgery and hospices who care for patients undergoing chemo.
If removing the cancer label on those, and thus remove most of the useless treatment, this would be a net positive for all men. As we could start to role out society-wide screening. And really catch the problematic cases. Like men in their 40s or 50s getting prostate cancer.
Today we have voted (in most western countries) to not screen at all because the cost (in human suffering, not money, although that’s surely also a problem) of over-treatment is higher than the cost for those who die early because their cancer wasn’t found early enough. Which basically means we let people die, because we are not able to manage low risk cancer cases correctly.
Source: I’ve once been the tech part of a prostate cancer patient network startup for seven years. Turns out it’s hard to make it cash positive.
E.g. PSA (a blood value, easy to measure), if increasing very slowly over a long timeframe, is a good indicator that you may have cancer but that it is growing really slow, aka unlikely to be aggressive and to be an immediate problem. While a quick increase tells you the opposite.
Then there is DNA sequencing of cancer samples from a Biopsy. Which is evolving rapidly and should be soon cheap enough to be available at scale.
The problem then is, if you rename the "grade 1" condition "prostate dysplasia", some fraction of patients don't do the follow-ups, and then those misclassifications are a big deal. But if you don't rename it, some fraction of patients get unnecessary treatment that lowers their quality of life.
So it's an interesting dilemma.
If the population who do _not_ actually have serious cancer is orders of magnitudes larger than those who do then there will be far more people in the false positive group than the true positive group and thus the vast majority of operations will be unnecessary.
The key here is how we manage the positive ones. And this is where the current system fails. We have yet to find a good way to manage them without doing unnecessary treatments causing more harm than good.
But instead of fixing this problem, we opted to stop screening. Which, for me, sounds stupid. But it sure is easier to do.
A pandemic is different, there the goal is to optimize the outcome for the population.
Applying the latter to the former is at the very least cynical. The opposite is what got us anti-mask and anti-vaxxers.
Also, especially with cancer, people tend to be so affraid of the diagnosis, they look for excuses to not be examined. As if cancer onpy pops up when it is found or something. Which is stupid, if ypu have cancer you want to know as early as possible.
I have no idea where you're going here. Wearing masks and getting vaccinated benefit both the individual and the population. (That actually contributed to it being politicized -- your choices affect my chances of getting a nasty disease).
At the individual level, you wear a mask when appropriate and get vaccinated, then you're less likely to get the disease and it's likely to be less severe if you do. Likewise, the population benefits from less disease spread, and less strain on the healthcare system as many of these cases become outpatient "take some Paxlovid" type deals.
Where is there any sort of basis for anti-mask and anti-vax theology here?
We treat false-positives and low-risk patients that actually don't need treatment. As any treatment, at scale, invariably results in (averse) side-effects, that's a problem.
And the easiest way to get rid of false-positives is to not screen in the first place.
For breast cancer the statistics are the same as for prostate cancer, there is no society net-benefit to screening, as false-positive side effects are equal or worse to the benefits of the screening.
But, women are way better in handling (their) health than men, the public outcry over removing breast cancer screening would be load.
In other words, men are not load enough when it comes to (their) health. Which is no surprise I guess.
Also I feel like it's actually getting worse, sometimes I am wondering if this is a covid side-effect thing.
Due to late/lazy screening, my cancer was caught late and now I'm fighting an uphill battle.
It doesn't seem like rocket science to screen early but also not over-treat.
I would argue though that it's not rocket science...currently, it's a lot harder with many more unknowns. Some of the issues we face are:
- Imperfect screening tests: the (very real) risk of both false positives and false negatives
- Lack of great prognostic models: if we think a certain cancer has a 25% chance of metastasizing within 5 years and I have 4 patients in front of me, how do I know which is the one?
- How do we identify if we're actually changing the trajectory of cancer with certain treatments? If a treatment fails, is it because we didn't choose the right treatment or is it reflective of underlying aggressive disease biology?
- Mass amounts of data from new technologies: this is obviously great and has allowed us to become granular with cancer in a way we haven't been able to before. It's important to recognize that widespread next generation sequencing is something we've had for less than a decade, and we have identified a lot of risk factors with this BUT it's also raised many questions (e.g. what mutations are actually significant?).
- Being human: every individual has their own values. Some patients will hear that it's a 1% chance this will become cancer and be okay with monitoring it. Some patients hear 1% and think it's too much of a risk and want intervention.
I think, with time and more data, we will become a lot better at this. But it's really not easy.
This is also why doctors are increasingly recommending that young, healthy people not get routine annual checkups and blood work done unless they have any specific problems.
And unfortunately, cancer is a lot more nuanced than that with a lot of heterogeneity even within a cancer type, e.g. an 80 year old male incidentally found to have an elevated PSA and subsequent low grade prostate cancer has a biologically different disease than a 35 year old who comes in with de novo metastatic prostate cancer.
I wish we had better ways of predicting what a patient's life will look 1 or 5 or 10 years down the line. We're developing the tools to do that, but there is still a significant amount of uncertainty and we can't eliminate that anxiety for patients. I don't know if re-naming low risk prostate cancer will do that either, but I can't say I feel strongly about it one way or another.
I hope that the population starts to get a better understanding of what "cancer" really is (i.e. a very wide spectrum of diseases), the inherent uncertainty associated with the diagnosis, and that we continue to get better predictive tools in the meantime.
The brand is beneficial to the medical system, which about managing disease for profit, rather than making people well.
This is a very American point of view, other places in the world do not have this issue but cancer is still a serious disease. Not every disease is an invention of the for-profit medical system of the USA.
https://fortune.com/1996/05/13/andy-grove-prostate-cancer-co...
https://www.forbes.com/forbes/2008/0128/070.html
I think the HN crowd may be interested in learning more about TNM staging (https://en.wikipedia.org/wiki/TNM_staging_system) and the staging process in detail (https://www.facs.org/media/j30havyf/ajcc_7thed_cancer_stagin... pg 457 for prostate) . This was once "open source" but is now locked behind a proprietary API of sorts (https://drive.google.com/file/d/1sa2Qlv03-E-nBJuUynZuFxIaMsO...)
These are US oriented resource links.
Regarding the posted article, there are two big related factors that the average patient has a difficult time appreciating. First is that "doing nothing and or waiting & seeing", even in 2024, is still the best course of treatment for a huge array of situations. The second related factor, is that the rate of preventable medical errors is absolutely staggering. In my multi-decade experience it typically hovers over 20%. As a patient myself I have been the victim of three near fatal preventable medical errors. So 1/5 of the time doctors are creating new problems and complications that are preventable if all of the known best practices at the time are employed, while attempting to resolve whatever is wrong with you. A troubling amount of the time the treatment can be worse than the disease.
Parasites, their preferred habitats, diet, chemical excretions, breeding and life cycles in general has been enlightening. Could some seasonal allergies or colds be the Jarisch-Herxheimer reaction to parasites… these are the kind of questions I find when not looking.
I guess the biggest question I have is, why if after countless autopsies that confirm the deceased had parasites do we not investigate this subject more? Humans are one of the rare species that don’t receive preventive treatment or screenings for parasites. Cattle, fish, birds, pets, all manner of zoo animals… but not humans?
> They are your own cells, just with various mutations.
Could parasite eggs lodged deep inside tissue for a long time (a fusion or sorts) not produce similar results? Have any studies along those lines been done?
EDIT: Could the chemical signal they excrete to keep the eggs dormant or the chemicals they excrete at time of death cause a mutation or other illnesses?
Any reason why we don’t treat humans with preventives or do screenings for parasites? I remember reading that it’s estimated that 80% of the population likely has some kind of parasite. I not trying to drift off subject. It just seems to be a gaping hole that the medical industry has no interest in.
My guess is people are in effect checked for parasites by way of annual bloodwork and annual checkups. If someone started losing weight, for example, they'd go see a doctor who might investigate for parasites if the symptoms point to it. There is probably not much reason to do an annual parasite-specific test in people. Livestock cannot talk to us about their symptoms, and eat all sorts of crap, so there's some important difference there.
My understanding is that parasite eggs can live outside the host for months if not longer (surviving long winters, etc) and can be smaller than the eye can see. They’re effectively unavoidable and that a healthy immune system keeps them in check.
> they'd go see a doctor who might investigate for parasites if the symptoms point to it.
I am really struggling to see any interest in the subject and very little data. From what I’ve seen doctors are fairly dismissive even when the patient brings it up (although this appears to be mostly hearsay but again to little data on what would seem to be a fascinating subject for researchers).
Anyway, thanks for your time.