A happy and healthy new year…

Being the Jewish New year (5772 since the world was created, of course), although I am totally secular, I find myself taking a couple days off my “Denisovich” lifestyle to visit with family. It seems that one of the main wishes for new year, be it Jewish, Christian or other religions–at least those with which I have some vague familiarity–is for a “happy and healthy new year.”

We can all argue what “happy is about”–for some of us it’s getting off work and heading to the pub for some pints, for others, it’s family life, and for others still, taking work home and being “happy as a pig in sh*t.” But how do we define healthy? And more specifically, how do we stay healthy?

I think there is a lot to be said that the evidence is out there. Smokers can expect a 10 y average reduction in lifespan, not to mention life quality. The same goes for obesity, which dramatically increases the likelihood of succumbing to a variety of diseases that go well beyond diabetes and heart disease. Today good evidence exists for increased risk for a variety of GI-based and other cancers. Perhaps it’s not the obesity per se, but the tendency of obese people to eat certain foods that increase risk. The jury is still out on those issues, but the risks are fairly clear.

Well, what about preventive medicine? Here’s where I came across an article in Newsweek some time ago–the type of article that I don’t often have time to read. This one, entitled “No! The one word that can save your life” was written by Sharon Begley (Aug. 22/29 edition, 2011), whose articles about science and medicine I think are generally pretty good.

Not this one.

The underlying premise of this article is that there are too many medical tests being done–not just an issue of saving money, but rather tests that confuse and ultimately lead to more harm than help. The author takes as an example a Professor (Emeritus) of family medicine at Brown University who tells his own physician not to order PSA tests for prostate cancer screening or electrocardiograms for heart irregularities. She cites a Professor of Medicine, Dr. Redberg, at UCSF who maintains that mammograms are not worth doing because they detect too many false positives. The latter notes that “There are many areas of medicine where not testing, not imaging and not treating actually result in better health outcomes.”

Many of the examples given are of the anecdotal nature, about which much has been said in this blog on OT and others. The elderly woman who had her colon perforated by an unnecessary colonoscopy and died. But as distasteful as my hypochondriac nature views such a screening (recommended at age 50 in only a few years for me)–perhaps the little pill-camera gizmo will be in general use by then? Please!

http://www.youtube.com/watch?v=mQX2lbutli0

In any event, there is no arguing that colonoscopies are for the most part very benign procedures that have saved many lives by early detection of colorectal cancer.

But let’s return for a moment to PSA testing. Infallible, it certainly isn’t. It’s well documented that there are a lot of false positives. There is even evidence that recent male ejaculation may alter blood PSA levels. While randomized trials and calculating statistics are complicated by a large number of factors, gliding through PubMed as a scientist without medical training, I find the evidence fairly conclusive that PSA screening is worthwhile. Especially when combined with a yearly digital prostate exam. One of a number of articles noted: “Men in the screening group in the European Randomized Study of Screening for Prostate Cancer were 20% less likely than those in the control group to die from prostate cancer. The absolute difference was only 0.7/1000, implying that over 1400 men needed to be screened to prevent one prostate cancer death. Screening was also associated with a 70% increased risk for being diagnosed with prostate cancer.” Those may not be wonderful odds, but if I were that 1 person out of 1400, I’d take it. Especially when all that’s needed is a tick by my physician on a form when doing a blood test anyway.

In this article, a battery of anecdotal cases are described–the woman who did a cardio CT and had plaques show up, and the ensuing medical tests led to a torn artery and ultimately a heart transplant.

In my humble opinion, this type of article only serves as a “scare tactic,” and does a disservice to medicine by warning off the not-as-well-informed population–something that is reminiscent of the anti-vaccine proponents.

Don’t get me wrong; I have no doubt that there are risks involved and inherent false positives in many of today’s largely accepted medical screening tests. I have heard a first-hand account of someone who decided to do a full-body scan, which identified a shadow on the lung. The subsequent biopsy led to infection and a very long and slow recovery from–what was essentially nothing. These cases do occur (and I’m not sure that full-body scans are on any physicians regular screening tests in any case), but they are not representative of the numerous procedures that are done–many of which prove useful.

I would charge that science journalists–particularly those with a wide following who are–in a way–serving as interpreters for the general public, would be wise to carefully weigh any anecdotal and emotionally compelling stories with statistical evidence.

Wishing you all a happy and healthy Jewish New Year.

About Steve Caplan

I am a Professor of Biochemistry and Molecular Biology at the University of Nebraska Medical Center in Omaha, Nebraska where I mentor a group of about 10 students, postdoctoral fellows and researchers working on endocytic protein trafficking. My first lablit novel, "Matter Over Mind," is about a biomedical researcher seeking tenure and struggling to overcome the consequences of growing up with a parent suffering from bipolar disorder. Lablit novel #2, "Welcome Home, Sir," published by Anaphora Literary Press, deals with a hypochondriac principal investigator whose service in the army and post-traumatic stress disorder actually prepare him well for academic, but not personal success. Novel #3, "A Degree of Betrayal," is an academic murder mystery that is now in press! All views expressed are my own, of course--after all, I hate advertising. http://www.stevecaplan.net
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16 Responses to A happy and healthy new year…

  1. rpg says:

    I’m not going to talk about stats, because you’re right, but for me the problem is that the treatments often seem worse than the disease–particularly for prostate cancer. Now, you may treat 1400 men to save one life, but for those other 1399, it’s a pretty shitty few years of life that remains. And for those who are false positives, its even worse because they don’t even have a chance of being the 1 in 1400.

    Which makes me ask: is the quality of life (the ‘happy’ portion of your greeting) less important than its length?

    If we had effective treatment, the case might be different. I’d be interested in your thoughts.

    • Steve Caplan says:

      No, no. My take was NOT treating 1400 to save 1, but identifying by screening 1 patient at earlier enough stage out of 1400 screened (the others either healthy or, on the contrary, ill beyond repair) to treat and save.

      I’m not a prostate expert, but I have a number of colleagues heavily into such research and my take is that IF you catch the disease at an early level of staging–before it goes from “androgen-dependent” to “androgen-independent,” it is definitely possible to save/seriously prolong lives with good quality.

      Having said that, I agree that there are cases where nothing can be done, if diagnosis is too late. Pancreatic cancer is a classic example, with any intervention being essentially useless by the time this awful disease usually presents. However, experts tell me that IF coincidentally discovered at an early stage (ie., seen during an appendectomy or GI surgery for other reasons), it is resectable with excellent chances for 100% recovery.

      • rpg says:

        Sorry, you’re right: 1 in 1400 screened. But you still have to wonder how many of those 1399 are false +ve.

        Still, the treatment is pretty terrible, even at an early stage. Treating “androgen-dependent” prostate cancer still involves chemical castration, and it always progresses to androgen-independence.

        • Steve Caplan says:

          With regard to false/pos, I think prior to even considering biopsy, physicians usually do 2-3 more PSA tests over a 6 week period to see if the level is consistently high, or if that was just a quirky result. Only then would they consider a biopsy.

          Yeah, chemical castration is pretty awful, I’m sure. While I don’t have handy papers to back up the following comment (too lazy to look right now), sitting in on a load of prostate cancer seminars, my understanding is that if caught early enough, the switch from androgen-dependence to independence (which is when things really go into metastatic and chemotherapy/unresponsive mode) can be prevented by early enough intervention. Again, PSA is certain not the perfect “biomarker” for early detection (and thus a lot of researchers are trying to find alternatives), but it still generally serves to save and improve life quality.

          So perhaps PSA testing and prostate cancer isn’t as clear-cut (although I do think the evidence is still strong) as colonoscopy for early colorectal cancer detection, but blanket statements of “hands off” because we’ll all die anyway are pretty misleading to the general public.

          For those who use financial calculations as a reason to deny testing–my answer is: life is expensive. It’s cheaper for all involved to just die–or better yet, not to have even been born.

          • rpg says:

            The general public is constantly mislead. I think there is a healthy debate to be had. I think blanket statements of “get tested because we’ll save your life” are equally misleading.

  2. cromercrox says:

    I’m with Ben Goldacre who advocates (in Bad Science) the use of real numbers rather than statistics in the reporting of medical stories. If the death rate from Big Rock Candy Mountain Spotted Fever goes up from 5771 to 5772 in a year (not significant), that’s an annual rise of 100 per cent (a headline in the Daily Nimbyist Bungaloid Curtain-Twitcher).

    I close with a verse I heard at a medical students’ revue (sung to the sound of Cliff Richard’s Summer Holiday)

    We’re all going on a sigmoidoscopy
    Up your anus for a foot or two
    Fun and laughter on our sigmoidoscopy
    Bet you wouldn’t want two…

  3. Steve Caplan says:

    @steve and @austin: Steve, you’ve been scooped by Austin! I hadn’t seen that video, but it’s great. Is the “Daily Fail” a Murdoch enterprise?

    • stephenemoss says:

      Whoops – I didn’t check the link on Austin’s comment. Oddly enough, the Fail is not one of the Murdoch stable.

  4. Cath@VWXYNot? says:

    Shana Tova!

    BTW, you’re neglecting another benefit of prostate screening (not the PSA kind): women who’ve been getting pap tests for years get to laugh at their male partners and friends freaking out about it. This sense of schadenfreude lasts until our mammograms start in another few years.

    • Steve Caplan says:

      @Cath–Shana Tova! Thank you! Well said!

      Great Quip! “Even more fun than this?!” If you can think up a line like that during a test like that, you should be doing stand-up comedy! Maybe I’ll try that line with my physician next year. He has a healthy sense of humor.

      Kidding aside, the non-PSA prostate screening has to be among the most uncomfortable tests done while a person is not sedated. I can’t imagine it’s much fun for the physician either! All this reminds me of plumbing, which brings up a story..

      A surgeon goes to bed and can’t fall asleep because the faucet in his bathroom is dripping. Finally he gives in, picks up the phone and calls his plumber. The plumber arrives at 3 a.ma, fixes the drip in 10 min., and the next day the doctor gets a bill for $800 in the mail.

      He calls the plumber angrily and says: “$800?! For 10 min. of work? That’s like $5000 an hour. Even I don’t make that in the operating room!”

      The plumber says: “I didn’t either when I was a surgeon.”

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