“Early detection saves lives!”
This is perhaps one of today’s most oft chanted medical maxims, but is it true? According to H. Gilbert Welch, M.D., M.P.H., medical professor at Dartmouth Medical School and co-director of the VA Outcomes Group in the Department of Veterans Affairs, the issue is far more nuanced than the hype would suggest. His book, Should I Be Tested for Cancer?, is unique and important because it gives readers what they don’t usually want: no easy answers. What he does provide is valuable, rarely heard information, much of which would indicate that testing can bring serious problems and may not produce intended benefits.
To be clear, we’re talking about routine screening for healthy people (e.g., mammograms, PSA, pap smears, etc.) not tests for those with specific symptoms (another discussion, but also with many shades of gray…).
Dr. Welsh does not propose that early testing shouldn’t be done, but he does tell another side: “Tests can be wrong, people are made to worry unnecessarily, some are treated unnecessarily, and some are even harmed by treatment.” False-positives, he explains, are rife, due in part to today’s hi-tech equipment able to detect the most minute abnormalities to the point where something aberrant can be found in just about anybody! How to interpret this is far from exact science. While pathologists can easily distinguish big invasive cancers from normal tissue, they, often disagree about whether small deviations will ever become a problem. Faced with ambiguous reports, many doctors tend to err on the side of “problem,” perhaps out of fear of lawsuit. Dr. Welch says: “Most of us think of it [cancer] as a deadly disease if left untreated. But there are also microscopic cancers that will never cause problems. We all have abnormal cells, but most of us will not die from cancer.” He posits that a disagreement among pathologists is actually a good thing, indicating something so small, so slow growing, that “watchful waiting,” rather than heading down the treatment path might be the safest, most reasonable response.
Another myth-buster: there really is no scientific proof that treating “cancer” early does save lives. Welch says that the conclusive randomized studies simply have not been done. Early detection, however, does enhance the 5-Year Survival rate which doctors tout to persuade patients of the efficacy of treatment. But that’s only because the timing starts earlier on more questionable “cancers.” The facts are that mortality rates have not substantially decreased. This implies that early intervention may simply prolong anxiety more than improve overall survival.
Though conventionally-oriented, Dr. Welch freely acknowledges the limits and dangers of standard treatments and he sees that there’s a whole lot the medical establishment does not understand about cancer and its progression. His comments about the dubious value of genetic testing are also refreshingly outsidè the orthodox box.
So, to screen or not to screen? The bottom line is it’s a choice that depends on an individual’s philosophy of life more than any quantifiable scientific evidence. Dr. Welch urges each of us to ask ourselves : do I want to spend my life pursuing disease or pursuing health? This is something doctors cannot decide. It’s important to understand the culture of doctors, Welsh counsels. They can’t go wrong calling for more tests or be sued for recommending aggressive treatment. Most doctors assume patients seek absolute certainty and expect everything to be checked out. Patience is not always an M.D.’s strongest suit (“When in doubt, cut it out.”). Find a doctor willing to dialogue and let him/ her know you understand there are downsides to testing and do not want unnecessary exams. Ask the doctor why he thinks the test is necessary, what are the risks, what course of action would follow if positive? Take time to think through decisions; acting quickly is overrated.
For all those befuddled about how much they need to know about what’s going on inside their bodies (and that’s a lot of people today), Should I Be Tested for Cancer? is a smorgasbord for thought. It’s also an exceptional volume because it respects the reader’s ability to accept and handle uncertainty. After all, doctors are only humans and, even in this highly complex, specialized age, each of us is still responsible for what we do with our body and how we choose to live our life.
Should I Be Tested for Cancer? Maybe Not and Here’s Why by H. Gilbert Welch, M.D., M.P.H. (University of California Press, 2006, 234 pp.).