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Early Detection Prevents All Bad Outcomes

On the Prevention page, I showed how many common preventive medical interventions don’t save money, even if pretty much everyone agrees that the interventions extend lives and improve health. To explain this concept, first an analogy:

THE TALE OF TWO SEEDS

It is true people whose cancers are detected at a small size are more likely to be cured than those whose cancers are detected at a larger size. Many people then conclude early detection is extremely important to prevent deaths from cancer. Unfortunately, reality is not so simple.

To illustrate this point, imagine you have prize rose bushes and two birds drop two different seeds at the base of two different rose bushes at the same time. One seed is a fast-growing vine, the other a slow-growing shrub like a holly. If left alone, both invading plants will take over and overwhelm the rose bushes. The vine will ultimately kill the rose bush by enveloping it. The holly will kill the rose bush by growing larger than the rose bush and covering it up. Each can damage or kill the rose bush if not removed before it reaches a critical size.

Now imagine you were away from your garden for many weeks. While you were gone, both seeds germinated at about the same time and started growing. When you return home, you go outside to inspect your prize flowers and you see the vine growing halfway into one of the rose bushes. The holly by another rose bush is less than a foot tall.

The vine is impossible to remove without damaging the rose bush, because it grew so fast and is so intertwined in the branches. The holly is much easier to remove. It barely reaches the lower branches. The damage caused by the invading plants was caused by the speed and nature of their growth, not when they were detected.

The same reality exists in cancer detection. People assume the small cancer is more curable because it was caught early. A more accurate understanding is a less aggressive cancer not only grows slower, but is less likely to invade the surrounding normal tissue or break apart and spread all over the body (metastasize). The small cancer’s slow growth and lack of aggressiveness is the reason it’s detected at an earlier size and simultaneously allows the treatment to be more successful. The timing of cancer detection has little to do with it.

LUNG CANCER

There is actually proof early detection of lung cancer doesn’t save lives. Several clinical trials performed in the 1960s tested different strategies to prevent lung cancer deaths in heavy smokers. The researchers checked chest x-rays and looked for cancer cells in patients’ sputum samples. In those patients whom lung cancer was detected, the lumps in their chest were smaller. However, the people whose cancer was detected early died at the same rate as the people left alone. Early results of lung CAT scan screening in heavy smokers find the same thing.

THE GIMeC INFLUENCE

To make one more point that the value of prevention is overstated, let’s look at other cancers. There are only three cancers for which nearly all doctors agree that early detection saves lives: breast, cervical, and colon. For other cancers, there is a range of speculation about how effective early detection might be, though clearly GIMeC has convinced the American people early detection is crucial for all cancer care.

A recent national study found 87% of adults believe routine cancer screening is almost always a good idea and 74% say finding cancer early saves lives.4 Two-thirds said they would want to be tested for cancer, even if nothing could be done. 56% said they would want to be tested for pseudo-disease: cancers growing so slowly they would never cause problems during the person’s lifetime even if untreated. Clearly, the GIMeC assumptions have penetrated the American psyche.

3 Responses to Early Detection Prevents All Bad Outcomes

  1. Mara on November 14, 2010 at 11:11 am

    All the walk-a-thons and century rides and tv shows like “House” have given Americans the wrong idea that all we need to do is to diagnose some disease early enough, and we can fix it. Also, nobody ever thinks that their parent or grandparent is old enough to die no matter how old they are.

    As a nurse in ICU I hear these kinds of stories from patients and families all the time. They feel that if only their condition had been detected earlier, they would not have wound up in such dire straits. Oftentimes the patient is in his or her 80’s or older and would not have benefited from any sort of aggressive treatment anyway.

    I recently read this story, posted to a nursing forum, about a hospital that was trying to revoke the power of attorney a woman had for her 84-year old mother because the daughter is refusing to allow her mother to be transferred to a more appropriate level of care. One of the daughter’s arguments, and the one that seems to most excite public sympathy, is that she claims that the hospital did not inform the patient of a pancreatic tumor seen on CT several months ago. Apparently, an earlier diagnosis of this cancer would have changed everything?

    http://www.chicagotribune.com/health/ct-met-power-of-attorney-20101108,0,5423469.story

  2. bryce on May 28, 2012 at 12:01 pm

    Maybe early detection isn’t saving every single life but its better to catch it before it envelopes you whole body. I know what you are saying about lung cancer we found my dads when it was small but it was so intertwined in there that if they would have removed it he would have died instantly. He was given 4 months to live and died 9 years later.

    At least people are more aware about cancers and their bodies and are getting checked and living healthier now.

    • Richard Young MD on May 28, 2012 at 9:02 pm

      Bryce,

      For many cancers and other diseases, there is ample proof that early detection makes no difference changing the ultimate outcome. For other cancers, early detection helps, but it costs a ton of money and doesn’t change the outcome even for most people who have the disease. For example, mammograms make the difference in dying of breast cancer or not in only of 13% of women with breast cancer, and roughly 1% of all women overall over a lifetime of regular mammograms. There’s even some observational evidence that this figure is generous.

      “Getting checked” makes a lot less difference than you’ve been led to believe.

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