tag:blogger.com,1999:blog-1474751880645498536.post1162061779200295692..comments2023-10-10T10:14:36.340-04:00Comments on Medical Evidence Blog: Overediagnosis and Mitigated Overdiagnosis: Ongoing problems with Breast and Lung Cancer ScreeningScott K. Aberegg, M.D., M.P.H.http://www.blogger.com/profile/17564774546019869201noreply@blogger.comBlogger8125tag:blogger.com,1999:blog-1474751880645498536.post-57218894436409457992014-05-31T12:18:45.193-04:002014-05-31T12:18:45.193-04:00Alas, CMS has denied coverage for lung cancer scre...Alas, CMS has denied coverage for lung cancer screening - there's hope for reason after all....<br /><a href="http://pulmccm.org/main/2014/lung-cancer-review/medicare-bucks-uspstf-rations-lung-cancer-screening/" rel="nofollow">Medicare bucks USPSTF, denies coverage for lung cancer screening</a>Scott K. Aberegg, M.D., M.P.H.https://www.blogger.com/profile/17564774546019869201noreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-26495435880584182752014-03-04T19:10:43.054-05:002014-03-04T19:10:43.054-05:00In this post:
http://medicalevidence.blogspot.com...In this post:<br /><br />http://medicalevidence.blogspot.com/2013/12/billions-and-billions-of-people-taking.html<br /><br />I show some of the discrepancies I'm referring to above, and the kind of analysis based on absolute risk I'm advocating.<br /><br />If you wish to use relative risk, you are building in a bias to the decision making process that favors treatments with SMALLER EFFECTS! Why?<br /><br />Because as the mortality somebody is facing increases (making treatment all the more important) any absolute efffect is proportionally smaller than the relative effect.<br /><br />Likewise, as the mortality burden decreases (meaning that treatment is less important, you might well get by without it), a small absolute risk reduction has a correspondingly LARGE relative risk reduction.<br /><br />The use of Relative Risk Reduction biases the evaluation and has no role in rational decision making about these kinds of choices.Scott K. Aberegg, M.D., M.P.H.https://www.blogger.com/profile/17564774546019869201noreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-64978124423410648022014-03-04T19:03:44.219-05:002014-03-04T19:03:44.219-05:00The Absolute/Relative distinction is totally pivot...The Absolute/Relative distinction is totally pivotal. If one is to start at the position "we should screen" and then look for reasons that will convince people, relative risk is one way to do that, but it is not, in my opinion, an honest and transparent way.<br /><br />If instead we start from the position that we ought to decide for ourselves or to help others decide, based on a rational thought process, then absolute risk reduction is the critical metric to consider.<br /><br />It matters little if other preventative measures also have a small absolute reduction in risk, and that people won't do them if presented with absolute risk, because: 1.) autonomy gives them that right; 2.) autonomy is based on full knowledge and understanding. Unless we wish to paternalistically guide people to behaviors that WE think are good for them without real regard to THEIR values, absolute risks are what we must focus on.<br /><br />What we ought to do to resolve some of this is to look at "revealed preferences" and "willingness to pay" for certain risk reduction measures and then help people to compare them with other things that they're not doing, so that they can see any discrepancies if there are any.<br /><br />Moreover, if something is easy, or cheap, or without side effects, then small absolute risk reductions are still enough to motivate the behavior of the rational decision maker. The cost-benefit analysis is still favorable.<br /><br />But when things are not cheap or easy or benign, we have to look at trade-offs. Especially when society, not the individual is going to pay for them. Because society has to choose between competing alternatives for spending finite public resources.<br /><br />But you say you don't care about competing alternatives because you have a personal stake here, an emotional investment in lung cancer screening - so in some ways we realize we're speaking different languages. I the language of rational evidence appraisal, you the language of lobby for a cause.<br /><br />And it's fine that we disagree on those bases. I just want there to be no confusion about the facts.Scott K. Aberegg, M.D., M.P.H.https://www.blogger.com/profile/17564774546019869201noreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-6240950194214427542014-03-04T18:30:43.237-05:002014-03-04T18:30:43.237-05:00160,000 people a year die of lung cancer in the US...<br />160,000 people a year die of lung cancer in the US, 4x your comparison to 40,000 hwy deaths. As for absolute vs relative risk, I totally understand the difference (I am an engineer) Based on absolute risk nobody would ever get screened, adopt healthy behaviors or buy a lotto ticket; that's why we use relative risk. My goal is not to save maximum lives due to any cause. My goal is to advocate for fairness for lung cancer patients who have gotten the short end of the stick compared to other high burden (individually and to society) diseases due to the stigma associated with smoking. And before you lecture me on personal responsibility, 90% of all regular smokers start smoking before the age of 18 targeted by tobacco companies sucking them into a lifetime of addiction at an age when experimentation often trumps judgment. Smoking has been shown by epidemiological studies to be more addictive than heroin. So until we see 5 year survival rates over 50% for lung cancer, I will continue to advocate for lung cancer screening including research and modeling to better risk stratify the population to screen. I am back in school to get my MPH to make me more effective in my mission. <br />I also fully appreciate the QOL discussion. My 81 year old mom is days from death due to tongue cancer. She has huge metastasized tumors on her neck. She elected no treatment due to her comorbid conditions. But it was her decision. Her Doc wanted to treat her. He did not think her comorbidities were sufficient to withhold treatment. Age by itself should not be the final say. Screening and treatment should be a joint decision with patient and the Doc. <br />ps I'm not a spammer. No idea how to make link hot<br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-91489592743276412372014-03-03T20:08:11.394-05:002014-03-03T20:08:11.394-05:00You should make that link hot, if you can figure o...You should make that link hot, if you can figure out to like my spammers all have.<br /><br />I appreciate your interest in these topics. There are several things to say about risk and its reduction, and points to clarify.<br /><br />Firstly, we should NOT ever talk about relative risk reduction. It inflates the perceived benefit. A person should be concerned with ABSOLUTE risk. The 20% RRR in the NLST exaggerates the MINISCULE absolute risk reduction which is more on the order of 0.5%.<br /><br />Next, I have to thank you for discovering a semantic error in my choice of words for the number needed to scan. What I meant to say is the number of scans needed (let's call it NSN). You had to screen 320 people, but you had to do 3 scans each. So, if we're interested in discussing radiation exposure (something elected to ignore), the NSN is a more valid metric than the NNT converted to NNS (which distinction recognizes that we're not "treating" but rather "scanning" or "screening".<br /><br />As regards age, I defer a full discussion to a pending post on Status Iatrogenicus I've been pondering for some time that will be entitled "Age Matters" or some variation thereof. I will simply say that age does matter, and if you're going to die of a heart attack at the end of hte year, you would not want to spend the beginning of the year getting testing and treatment for lung cancer which may extend you life only long enough to die of the heart attack. Since you're asymptomatic, it might be better to remain asymptomatic for the rest of the year, have no biopsies, no surgery, no radiation, no chemo, and then die suddenly, one month early. Trade-offs are important. In the end of the paragraph about age, you highlight that the USPSTF, like I, recognizes that age matters.<br /><br />Your patient discussion differs from mine. In yours, you are "selling" lung cancer screening. In mine, I'm saying "it's for sale" but giving actual statistics about the possible outcomes in different scenarios. I didn't state this, but the statistics I give are actually the conditional probabilities (given X, probability of Y). These are the actual statistics that are necessary for a rational decision maker to make a decision.<br /><br />I'm sorry that your husband fell victim to lung cancer. Lung cancer sucks. I deal with it all the time and I truly am sorry and sympathize with you.<br /><br />But my blog has a stated purpose to rationally search for the truth.<br /><br />At the end of the day, this MASSIVE screening experiment, enrolling 50,000 patients and following them for 6.5 years, costing untold millions of dollars, saved perhaps 120 lives. That, I'm sorry to point out, is a drop in the bucket, but the expense is not.<br /><br />If our goal is to save lives, not just save lives from a particular disease because it is has afflicted someone who is dear to us [aside: in a different life, for different people, in other realities, a different disease may have afflicted our loved one] 40,000 people die needlessly on American roadways each year. We could reduce the speed limit; raise the minimum or make a maximum driving age; enact universal helmet laws; etc, and save, at MUCH lower cost, FAR more lives than by scanning everybody for lung cancer.Scott K. Aberegg, M.D., M.P.H.https://www.blogger.com/profile/17564774546019869201noreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-85163608800526064762014-03-03T18:59:02.763-05:002014-03-03T18:59:02.763-05:00Dr. Aberegg,
I have written a response to address...Dr. Aberegg, <br />I have written a response to address the many misconceptions in your post about screening. I address both the Canadian National Breast Screening Trial and the National Lung Screening Trial. Please see my response in <br />Guest Post: Does Cancer Screening Cause “Overdiagnosis”?<br /><br />http://grayconnections.wordpress.com/2014/03/03/guest-post-does-cancer-screening-cause-overdiagnosis<br /><br />Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-88377879430093996172014-03-02T08:28:43.082-05:002014-03-02T08:28:43.082-05:00We are implementing a lung cancer screening progra...We are implementing a lung cancer screening program in our hospital, but my concern is that our population is different to NSLT, we are in the Ohio Valley and I see lots of farmers (histoplamosis), factory workers, poor people on Medicaid. The participants in the NSLT were healthier and probably more educated. We can potentially, have more false positives, more overdiagnosis, worse mortality (all cause deaths). I wonder what could happen in places where whites are a minority. Latinos or asians with h/o TB, poor african americans, etc. I think than more than 90% of subjects in the NSLT where white.<br />Anonymoushttps://www.blogger.com/profile/09035516480362712595noreply@blogger.comtag:blogger.com,1999:blog-1474751880645498536.post-9333427498626322362014-03-01T21:51:38.165-05:002014-03-01T21:51:38.165-05:00Well put Scott. I appreciate your ability to disti...Well put Scott. I appreciate your ability to distill the relevant statistics and subsequently articulate them in a manner that non-MD's can grasp.Lewhnhhttps://www.blogger.com/profile/16195216638214407050noreply@blogger.com