
Why Some Doctors Hesitate to Screen Smokers for Lung Cancer (2015) - g3ph4z
https://www.npr.org/sections/health-shots/2015/04/13/398101515/why-some-doctors-are-hesitant-to-screen-smokers-for-lung-cancer?t=1554391785239
======
nimbius
I wonder if this is a "dont waste your time" issue coming from management?

As an anecdotal example, Im an engine mechanic who routinely sees older trucks
from the 80s and 90s. mostly idler/pitman arm replacements, tires, diff fluid,
etc... on these which is expected as many are pushing a million miles or more.
I had a 1981 International S1700 limp into my garage one day with a misfire
problem due to long, long overdue oil pressure problems. I fixed the oil pump
and was getting ready to hook up the diagnostic computer when my boss stopped
me and said "if you plug that thing in its going to light up like a christmas
tree. You aint telling the driver anything they care about anyway."

~~~
skullborg
Do share more stories on working on old trucks! I have a '99 Ford with a 7.3,
and everyone's saying it's not worth fixing, but I just like keeping it on the
road...

~~~
lilbobbytables
I thought the 7.3's were supposed to be super solid? How many miles does it
have, what's wrong with it?

My extremely limited knowledge of diesel engines is something like "they go a
ton of miles, then need a major overhaul, then go a ton more miles". If you're
at some kind of major overhaul milestone, then I could see the response you're
getting.

'99-ish Ford kicked off the Super Duty series, but it isn't sufficiently
interestingly old to a lot of people, so I can understand their the why-bother
attitude.

~~~
skullborg
It's nearing 400k miles. It's had service - new turbo and engine control
components, suspension and frontend, brakes, glow plugs, etc. Original
everything else though, nothing fancy, just a work truck. But anything
"newer", even 10 years old, is $25k minimum for any halfways decent duty
truck.

~~~
unchocked
Your 7.3 is gold, that engine will last till the heat death of the universe.
And you’re maintaining it. For some reason people think that a well maintained
vehicle is a grenade because it has service history, while one being run into
the ground is great because they haven’t paid for anything recently.

Newer trucks aren’t more reliable. They’re just newer. You won’t find a truck
cheaper to maintain than the one you’ve already got.

(The people who tell you your truck ain’t worth fixing sound like my mother in
law who traded in her car ‘cause the windshield wipers broke.)

~~~
tomcam
Please tell me the story about your mother-in-law is an exaggeration

~~~
unchocked
Nope, literal truth. Lovely lady, but some decisions...

------
linsomniac
I've watched my family go through smoking, and cancer hasn't been the issue. I
don't know how representative it is, but my experience definitely reflects the
premise of this article: cancer testing could have caused way more harm than
good.

Both my mother and her father were still smoking frequently when they were on
oxygen. In other words: When they should have known better. Her mother was
looking really bad at 50 and when the Dr told her "it's killing you, and not
in some abstract way", she cut it out cold turkey and pretty much instantly
looked 10 years younger.

Grandfather was struggling in general, but it was twisted up intestines that
did him in. My mom, one nurse told me, her lungs were "just shot". COPD. Funny
thing was that she was getting enough oxygen (with O2), she just couldn't get
rid of CO2. Basically took her outta the game 20 years early.

Hopefully, my kids who watched this, can use the experience to steer clear of
some things. If you can't set a good example, show what a bad example leads
to. :-)

~~~
elhudy
This could be the most controversial thing comment I've posted on here,
but...: Why are we even spending resources figuring out how to extend the
lives of people who have smoked a pack a day, for 30 years, and are currently
in old age? Even if we find cancer and save their lives now, will that prevent
then from picking up smoking again? Will it prevent the heart disease they're
going to encounter ten more years down the line? Dragging it out seems like a
massive burden on the rest of society. I'm unsure how these studies are being
funded but I just wonder if the money is better spent on helping people to
stop smoking.

~~~
aladoc99
One of the truisms of medicine is that ultimately every disease and every
treatment has a 100% mortality, so we can never truly save a life. What we can
do is promote the quality and quantity of life. In the US, the rule of thumb
is that it's worth spending $50,000 to keep someone alive for a year, with
that being the approximate cost of dialysis therapy. So, to save 10 years of
life would be expected to be worth spending a half a million bucks. Which is
all to say that an additional 10 years of reasonable quality of life is worth
a lot, both to society and to most individuals. The other strain in your
comment suggests that people who are presumably in some way responsible for
their disease are less worthy of care. This opens up a giant slippery slope.
Start with drug use, smoking, alcohol use, being overweight, eating meat,
drinking coffee, working too many hours a week... Ultimately only celibate
teetotalling vegans are worthy of medical care.

~~~
elhudy
>The other strain in your comment suggests that people who are presumably in
some way responsible for their disease are less worthy of care

I am stating that people who are presumably in some way responsible for their
disease are not MORE worthy of care. It is only these people who are receiving
free screenings - as per the article.

~~~
Aloha
Where do you draw that line? - I mean no person who understand the addictive
power of nicotine would make this kind of statement.

------
dontreact
False positives will be much more rare in practice with the new guidelines
used (Lung RADS) which cut false positives by 50% or more while mostly
preserving sensitivity.

That doctor should really update his diagram to reflect the current standard
of care for lung cancer screening. Using the false positive rate from the 2011
study is intellectually dishonest!

In addition the amount of lung cancer deaths prevented was doubled (!!) in a
recent European study by tracking patients for 5 years instead of 3 years.

~~~
wswope
Honestly curious: are most radiologists actually following guidelines like
Lung RADS in practice, especially just after publication? Is it part of any
standardized CME?

It's my impression that there's often a big gap between ACR best practices and
what's happening on the ground in most places, which was a key point the
doctor in the article was making.

~~~
riahi
Adoption of Lung-Rads is essentially required to be designated as an ACR
screening center. To be reimbursed for Lung Cancer Screening, you must provide
registry data to CMS (the registry is run by the ACR).

It's not codified into Federal Law, but if reimbursement requires a Lung-Rads
code, then it's more or less mandated.

I'd argue out of all the fields of medicine, Radiology is pretty quick to
adopt new technology or reporting schemes "on the ground". See the
proliferation of Lung-Rads, TI-Rads, Cad-Rads, LI-Rads, PI-Rads, etc.

~~~
wswope
That's good to know, thank you for the response!

------
maxxxxx
This sounds familiar. I have watched now quite a few people go through serious
diseases. One pattern I saw was tests, tests and more tests. A lot of them
very expensive, time consuming and painful. But when you ask what they will do
with the test results there often is silence. To me it looks like they are
doing something because “we need to do something”.

Reminds me a little of data collection practices at companies. Sucking up more
data feels like you are doing something. But using the data is much more
difficult and often doesn’t happen.

~~~
athenot
As a patient (or a patient advocate for a loved-one), anytime a test is
proposed it is important to ask what actionable information can come out of
it. Basically look 2 steps ahead.

Some tests will help confirm a course of treatment, or propose a new one. But
what if that treatment is something you've already decided you won't do? For
example in an older patient too old for a surgery or a baby that you've
already decided you'll keep.

But you are right, some tests are ordered out of a desire to show that
"something is being done". It's important to talk with the doctor about the
cost (not just money but pain & recovery) and benefit. Everything is a
tradeoff.

~~~
maxxxxx
"Some tests will help confirm a course of treatment, or propose a new one. But
what if that treatment is something you've already decided you won't do? For
example in an older patient too old for a surgery or a baby that you've
already decided you'll keep.

"

I had the impression that a lot of doctors go through the same test protocols
independent of patient situation. They are more deliberate with the actual
treatment but there seems less thought about the necessity of testing.

~~~
athenot
It also varies by doctor. Some like to order more tests than their peers.
That's why it's important to have a doctor with whom you can openly discuss
these tradeoffs. The vast majority are open to that, but some will give you
the stink eye if they interpret that as you questionning their algorithm.

------
wyldfire
> That's because some cancers grow slowly and never become dangerous...These
> false-positive tests led to more follow-up testing, including risky
> procedures like a biopsy, which inserts a needle into the lung.

> "Not surprisingly," Welch says, "sometimes that creates problems like
> causing someone's lung to collapse."

These outcomes should inform whether or not the biopsy needs to take place or
whether they should instead follow up with further screens to monitor whether
the cancer progresses. Of course, the major downside of my suggestion is that
patients are extremely reluctant to hear "cancer" without a plan to rapidly
classify it as malignant or benign.

------
KingMachiavelli
Classic base rate problem, the rate of lung cancer rate is low compared to the
false positive rate. It seems that one option is to follow up with a second
scan 3-6 months latter and see if the tumor has increased in size. However
there probably serious liability issues with this approach even if it means
you're still catching the cancer earlier on average compared to waiting for
physical symptoms. I'm curious how counties like France, where smoking rates
are high yet have high life expectancies, deal with screening for lung cancer
currently.

~~~
VikingCoder
Also, detection only really matters if the treatments are effective.

If you can detect Stage 4 lung cancer one week earlier, it probably does very
little to improve the quality of life.

:(

------
sampleinajar
Anecdotally, as an ex-smoker who quit after my mother died from lung cancer, I
spoke to my doctor about screening. He did a lot of dismissing and hand waving
about it. It upset me greatly at the time. This article explains it all well
enough. Doctor/patient communication is very important.

~~~
52-6F-62
How long did you smoke?

My own anecdote:

I was athletic when I was younger, but I was a regular smoker through most of
my twenties.

I quit a few years back. My doctor would check my breathing, etc, with
everything I'd told him about my habit. He gave me the surprising news that my
lungs would be virtually back to virgin health in 4-5 years (after nearly 10
years of smoking). And to get back to exercising more.

~~~
sampleinajar
I smoked for 7 years, the quit, then picked it back up 4 years later for 5
more years. I didn't really meet the criteria outlined in this article of x
"pack years and over 55". I have read that quitting before 40 reduces your
chances of lung cancer to that of the general population. Honestly within two
years it was stark how much a difference there was.

------
babyslothzoo
VOMIT, Victim Of Modern Imaging Technology, is a term among doctors for a
reason.

Generally the more you know the better, but sometimes things can be stumbled
upon that might otherwise be irrelevant yet the intervention can then
introduce new risk or some other unique problem or undesired side effect.
There aren't always easy answers.

------
woliveirajr
> "but [can also] find cancers that were never going to matter."

I'm not sure, but isn't better to know that you have it and then investigate
further, do more tests, perhaps do some period follow-up with a shorter
interval?

Otherwise it's just betting: I bet that I don't have a lung cancer that will
be agressive....

~~~
hackeraccount
"investigate further" is the sticking point.

You're swimming in the ocean and notice something beneath you. Is it a
friendly dolphin or a dangerous shark? Do you hold your breath and do a deep
dive to figure out which it is? Keep in mind the deeper you go the greater the
chance that you'll drown.

It's a strained analogy but I think it gets at the problem. What if you dive a
little bit deep - some minor test - and still aren't sure? Go deeper - a more
invasive dangerous test - or go back to the surface?

And what if you dive and are pretty sure it's a shark? Swimming all the way to
shore (i.e. cancer treatment) is very risky but the shark will almost
certainly kill you. How sure are you, really?

~~~
maxxxxx
“You're swimming in the ocean and notice something beneath you. Is it a
friendly dolphin or a dangerous shark? Do you hold your breath and do a deep
dive to figure out which it is? Keep in mind the deeper you go the greater the
chance that you'll drown.”

Does it really make a difference what it is? Will you do anything differently?

~~~
plink
Absolutely. So called "friendly" dolphins are often very sexually aggressive.
With knowledge of what aquatic beast lurked in the depths below, I could
tailor my preparedness to either be on guard against unwelcome mammalian
advances, or remain blithely unconcerned over some incurious, nimrod fish.

------
1e-9
I believe this is indicative of a frustrating phenomenon in the U.S.
healthcare/legal system where many doctors are prone to being overly cautious
due to the threat of malpractice litigation. You rarely hear of doctors being
sued for unnecessary testing. They are much more likely to be sued for missing
a cancer. This happens even when it was reasonable to miss a cancer. A doctor
who is overly concerned about litigation can thus cause harm through the
patient stress and physical effects of unnecessary followup testing when it is
not justified. Rather than sticking our heads in the sand by not screening
because we are worried that some doctors will have a harmful false positive
rate, we should be addressing the root causes of the high false positive rate.

------
pytyper2
I periodically smoke, yet I don't call myself a smoker. Yet when I buy
insurance I buy the smokers plan, the idea being that if I do need to use the
insurance I expect the Insurance company to use any information necessary to
deny my claim. Should I be worried about this?

~~~
NullPrefix
Have fun getting any physical activity injury claim denied. Smokers aren't
expected to do sports.

/s

~~~
pytyper2
What does '/s' indicate?

------
JonesWilly
A great and seemingly minimally biased resource for this type of preventative
care(mentioned in the article):

[https://www.uspreventiveservicestaskforce.org/BrowseRec/Inde...](https://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-
recommendations)

It presents an evidence based pros v cons listing on screening and tries to
present a informed approach, with less financial bias. The most toxic
component of this entire issues also has to do with a form of defensive
medicine that physicians engage in. Basically if you don't want problems don't
look for them, not to say all physicians engage in this type of behavior. This
mentality is very common amongst the older generations of physicians who fear
the repercussion associated with minor mistakes.. Ie. doctor sends patient for
CT suspicious finding are noted, doctor forgets to order future followup or
some other variety of mistake... Patient ends up having cancer and the
physician is slapped with a malpractice suit.

------
astura
>Lazris says he shows the theater diagrams to many of his patients and gets a
wide range of responses. Some patients, he says, point at one of the three
blackened seats and say, " 'That's probably me. I'm not taking any chances,
I'm getting this test.' "

>"Other people," he says, "will see [the same diagram] and will say, 'Are you
kidding me? I'm not going for that; that's not worth it.'"

>But in either scenario, Lazris says, he has done his job — he has helped his
patients understand the odds and then let them make the choice.

This is wonderful!! Good on him!!

This is how medicine should always be practiced. Much too often a doctor/PA
just orders a bunch of tests with ZERO discussion (other than maybe "we'll
screen you for XYZ"). No discussion of risks. No discussion of the upsides of
testing. No discussion of individual risk factors. No discussion about how the
results will be actionable.

Sometimes they order tests _before even meeting a patient for the first time_
or even _telling you what they are testing you for_. My last primary care
doctor did just that, I made an initial appointment with him for a routine
physical (I need referrals for my health insurance) and someone from his
office calls before the appointment and says "Dr So and So has ordered some
blood tests for you, please go to the lab and get then done before the
appointment." Didn't think telling me any other information was important,
like, uh, what I'm being tested for and why.

Of course, at least some of the tests he ordered were not evidence based.

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5638475/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5638475/)

On top of that, I have untreatable anemia due to a genetic condition. His
first tests found the anemia and he ordered follow up tests. Mind you, this is
_before I ever met him or even spoke to him_. If he had a conversation with
me, the followup tests would have been completely and totally unnecessary.

A different doctor did that to my husband recently as well ("we've ordered
some tests for you" before even meeting him nor telling him which tests were
ordered.) I looked at the lab work afterwards and turns out PSA was one of the
tests they ordered, which has shown to cause more harm than good. ZERO
discussion about risks vs benefits. No discussion of benefits of testing at
your age vs an advanced age. No theater diagrams.

[https://www.medicalnewstoday.com/articles/260087.php](https://www.medicalnewstoday.com/articles/260087.php)

[https://www.uspreventiveservicestaskforce.org/Page/Document/...](https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prostate-
cancer-screening)

I read a story about an elderly woman in good health with no symptoms who went
to the doctor for a routine physical. The doctor ordered a bunch of blood
tests and a urine test, turns out she had an asymptomatic urinary track
infection. She was given ciprofloxacin and had a bad reaction to it.

Turns out:

A quarter of elderly women have asymptomatic urinary track infections.
Detecting and treating them have not shown to have any benefit.

Ciprofloxacin is an inappropriate treatment for uncomplicated urinary track
infections in the elderly due to the high risks of serious side effects.

[https://www.nytimes.com/2019/03/15/health/antibiotics-
elderl...](https://www.nytimes.com/2019/03/15/health/antibiotics-elderly-
risks.html)

The story doesn't say if the doctor discussed benefits and risks of doing
those blood and urine tests, but I'm doubting they did (considering both the
testing and the treatment was against recommendations).

I'm not, as a rule, against screening tests. I'm against doctors not
explaining the risks vs benefits of screening tests. I'm also against doctors
ordering screening tests that have shown to have no benefit.

~~~
frontloadpro
Start calling them Physicians.

It's important to break up the medical field by service.

Physicians are drug dealers and the literal key to getting insurance paid for.

Doctors of Physical Therapy do not perscribe medication, but are the experts
in muscle and skeletal matters.

Primary Care Physicians are this weird beaurcratic step in our healthcare
process.

------
djsumdog
Didn't we see the exact same thing a decade ago with mammograms and breast
cancer?

I remember there being two issues, one being computer aided detection in
mammograms at the time was terrible for false positives compared to an
experienced doctor (the the computer-aided was a selling/marketing point so
people tended to opt for it).

The second was mammograms no longer being recommended for certain age groups,
as they were shown in studies to just be ineffective. There was a backlash
against such recommendations, under a kind of 'better safe than sorry'
argument.

------
scottlegrand2
What this and many other similar situations argue for IMO are better blood
screens for cancer biomarkers.

For it turns out even with early detection, metastasis has already happened.
It's just that those metastasized cancer cells take a long time to grow.

I mean the doctor is right, but it sure sucks to be one of the people who
really has cancer and you skipped the screening, no?

[https://www.sciencedaily.com/releases/2016/12/161214145615.h...](https://www.sciencedaily.com/releases/2016/12/161214145615.htm)

------
ams6110
tl; dr: the false positive rate is too high.

------
aitchnyu
What does a false positive look like to a doctor, and how will it not harm the
organism? I can't imagine a cancer that can be ignored safely, nor an early
stage treatment that is counterproductive.

~~~
astura
So the old thought about cancer was "every cancer will grow and kill the
patient so we always want to find the cancer early and treat it before it
spreads"

Turns out that's not accurate, and its complicated, and we are still learning.

There's three types of cancer, birds, turtles, and rabbits. (I didn't make up
this terminology, see links)

The birds have already flown away and left the barnyard, early detection isn't
going to help.

The rabbits need to be contained before they hop away, if we shut the barnyard
gate early enough we can prevent their escape. These are the cancers where
early detection is useful and saves lives.

The turtles just chill out, moving so slow that they never escape. These
cancers cause no symptoms and will not go on to ever harm the patient and may
even resolve themselves over time. Finding turtles is bad, treating turtles
causes very serious side effects (cancer treatment isn't exactly benign),
wastes time and money, causes anxiety, and doesn't reduce mortality one bit.

We've discovered there's a lot of turtles out there.

Of course, once we find early stage cancer we usually treat it like its a
rabbit, even if its destined to be a turtle, because a lot of the time we
can't tell the difference.

South Korea is finding this out the hard way, aggressive screening for thyroid
cancer has produced a TON of thyroid cancer patients (15-fold increase (!)
over the past 20 years) but ZERO reduction in thyroid cancer mortality.

[https://sciencebasedmedicine.org/a-skeptical-look-at-
screeni...](https://sciencebasedmedicine.org/a-skeptical-look-at-screening-
tests/)

[https://fivethirtyeight.com/features/the-case-against-
early-...](https://fivethirtyeight.com/features/the-case-against-early-cancer-
detection/)

[https://www.skepdoc.info/a-skeptical-look-at-screening-
tests...](https://www.skepdoc.info/a-skeptical-look-at-screening-tests-2/)

------
robotrout

        Welch says, "but [can also] find cancers that were never 
        going to matter."  That's because some cancers grow 
        slowly and never become dangerous, he says. 
    

This exact same phenomenon is already occurring with breast cancer. Everybody
is a "breast cancer survivor" these days, because they keep finding these
turtle tumors that were never going to be a problem. If you look at mortality
rates between those who screen early and those who don't, they are the same.

[https://link.springer.com/article/10.1007/s10549-018-4691-4](https://link.springer.com/article/10.1007/s10549-018-4691-4)

~~~
1e-9
While it is true that there is plenty of uncertainty regarding the value of
finding DCIS, it is well established that there is significant benefit to
finding small invasive breast cancers such as invasive lobular carcinoma and
invasive ductal carcinoma. The value is particularly significant if the
lesions are found before exceeding 1 cm in size, which they often are
nowadays. The paper sited refers to one study focused on DCIS and another
Canadian study on breast cancer screening during the 1980's and 1990's before
there were good mammography screening standards. The Canadian study
essentially just showed that poor screening is of limited value.

------
djtriptych
a.k.a. every layman's writeup of bayesian reasoning ever.

