Early detection can be good, but beware the scares
Should I Be Tested for Cancer?
Maybe Not and Here’s Why
H. Gilbert Welch
University of California Press;
226 pp.; $19.95
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A disturbing thought among many in H. Gilbert Welch’s “Should I Be Tested for Cancer?†is that all of us walk around with cancer inside us. But “cancer†is a broader term than might be supposed, applying to a growth that never spreads and to damaged cells destroyed by the body’s defenses before they can multiply.
Such growths and cells, Welch says, fall under the term “pseudodisease†(because they aren’t lethal) that most of us are thankfully oblivious to in our daily lives. As the medical establishment pushes for early screening, and with the advent of body scans and other tests, doctors are finding more cases of pseudodisease than ever before.
That’s a good thing, right? Better safe than sorry, yes? Welch, a cancer detection specialist, isn’t so sure.
For starters, Welch isn’t convinced that “early detection, faster cure†is always true. What he has found, drawing on a wide range of stories from patients and doctors, is that the number of cancer scares is on the rise.
“You might think I am trying to persuade you not to have a mammogram or not to undergo fecal occult blood testing. I’m not.... ,†he writes. “But I object to the emerging mind-set that patients should be persuaded, frightened, and coerced into undergoing these tests.â€
There’s a gap, he says, between the concept of early detection and what medical technology actually accomplishes. Falling into that gap every year are people subjected to unnecessary tests, biopsies and uncomfortable scans, not to mention terror, all because a cancer screening found “something.â€
Welch describes pathologists dueling over biopsy results and people trapped in endless cycles of testing because of inconclusive results. Where’s the problem? According to Welch, it has to do with the word “early†in “early screening.†Screenings are intended to detect cancer -- if it really is cancer -- long before it turns into a recognizable, invasive disease (and it doesn’t always do that, he says). That injects more subjectivity into the pathologist’s job.
“Pathologists do agree about big, obvious cancers. They also agree on what is normal tissue,†Welch explains. “But there is a fair amount in between.... Disagreement [between pathologists] is information: it tells you that the abnormality you have is subtle. That means that the chances are good that it’s not a lethal cancer.â€
And if this is true, what next?
“Maybe,†Welch says, “it is an abnormality that should simply be watched.â€
Easy to suggest if it isn’t you. Welch understands the terror of cancer that makes most of us willing to endure the discomforts of testing. If you’re given a routine test that finds “something†and you decide for more testing, he recommends that you ask your physician three questions: Why are you suggesting this test? Has there been a randomized trial of screening for this cancer? What will we do if my test is positive?
The first and third questions seem obvious; the middle one is meant to provide information that isn’t misleading. Take five-year survival rates, for instance, which are used as a sign of a test’s effectiveness. Such rates can be skewed if they’re based on a selective sample of patients that includes people detected earlier than usual (and who may in fact have pseudodisease) -- naturally these people live longer and will boost survival rates. So be a little skeptical about the figures presented to you, Welch advises, and if your doctor can’t answer this question, at least it will signal that you want to be as clearly informed as possible.
Often we surrender our judgment to a doctor, trusting in his or her skills. “Should I Be Tested for Cancer?†argues to the contrary. It is not a book for sick people -- Welch is emphatic that people who have clear symptoms should see a doctor -- and it might be an especially difficult book for the hypochondriacs among us. But sometimes the most important lessons are the hardest to hear, even when they promise to make us all better informed consumers in the medical marketplace.
