
Theranos and the Blood-Testing Delusion - tokenadult
http://www.bloombergview.com/articles/2016-04-27/theranos-and-the-blood-testing-delusion
======
entee
This article points out the major issue in blood testing: it's not a panacea.
So often, particularly outside the life-sciences press, the idea that we'll be
able to test for everything and that it will be useful gets shouted from the
rafters.

The problem is, it's not that simple. Biological variation and lab procedure
variation and just plain dumb bad luck makes it so that any lab test should
only be considered a single datapoint. To be taken seriously, but not to be
taken as "the answer" in and of itself.

Technology can solve the lab procedure variation issue, but can't solve
biological variation. Maybe it can alleviate the biological variation problem
by making it feasible to test more frequently. However as you multiply the
things you're measuring and multiply the frequency of testing you might end up
testing too many hypotheses too frequently for your statistics to be reliable.

I'd love to have more tests more frequently. I work in medical informatics
after all. But We need to be cautious about what will come out of it and not
over-promise.

Much as we'd like it to be true, big squishy bags of water with bits of
hardened calcium in them are not computers. Anything biological is hugely more
noisy and far less deeply understood than anything we deal with in information
technology.

~~~
DanBC
> The problem is, it's not that simple. Biological variation and lab procedure
> variation and just plain dumb bad luck makes it so that any lab test should
> only be considered a single datapoint. To be taken seriously, but not to be
> taken as "the answer" in and of itself.

And even if the results are accurate it's often not useful. See the amount of
over-diagnosis and over-treatment that results from too much testing.

~~~
entee
Indeed, and never forget the false positive paradox:

[https://en.wikipedia.org/wiki/False_positive_paradox](https://en.wikipedia.org/wiki/False_positive_paradox)

------
bsirkia
I'm consistently surprised at the low bar for due diligence in startup
funding. In my personal experience, it goes something like "send us a business
plan, pitch deck, three customers (that you handpick) for us to talk to, the
legal paperwork, and maybe some bank records but not usually". I always
assumed investors required credentials to Google Analytics or Mixpanel or
iTunes analytics or whatever to actually verify that the usage numbers are
what founders say they are, yet I've never had an investor do that or even
heard of it being done. It's completely baffling to me that Theranos can raise
~$700M w/o any third party testing or diligence.

This article suggest it's because Holmes is "enthralling" and investors had an
"exaggerated faith in the power of medical testing". Faith and charisma are
very abstract concepts, but data and testing aren't, so why rely on the former
instead of the latter? As Deming said, "In God we trust; all others must bring
data."

~~~
mbesto
I do diligence for a living. It's just not economical to do a full diligence
on every investment when you're investment thesis is a portfolio approach.

~~~
aclements18
Agreed. Also there are typically legal repercussions for misrepresenting your
business that are outlined in deal terms.

~~~
azinman2
Exactly. If things go south, legal can uncover and if lies were presented then
things can turn criminal as theranos now knows.

~~~
jacquesm
But that will not recover your investment.

~~~
azinman2
It can depending on how much capital or assets are still around.

Jail is also a pretty decent incentive to make people avoid overtly lying.
Unfortunately its disproportional used on the poor and minorities instead of
on professionals.

------
petra
>> That way she could see how many diseases were caught early, how many
diseases were missed, and how many times false positives occurred

I don't understand why this article continually mixes one thing tests
do(measuring physical quantities) with another(predicting disease) ? The way
to evaluate theranos is whether they measure the physical quantities
correctly(and it appears they are not), not with the complexity of predicting
disease from those numbers. That's a job for other parts of the medical
establishment.

~~~
imaginenore
You can catch many things early, if you test your blood often. Cancer is the
big one.

~~~
nommm-nommm
Assuming this is true (which is a stretch) this is tricky business - you are
assuming detecting all types of cancer in asymptomatic individuals has no
downsides. In reality it has major downsides, this is the reason why the the
U.S. Preventive Services Task Force no longer recommends the PSA antigen test
be used for routine population wide screening.

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

~~~
hga
That's _early_ testing, specifically " _average-risk men aged 55 to 69 years
"_.

E.g. my 82 year old father would be dead or severely suffering today if his
routine, over 69 years of age PSA tests hadn't prompted his doctor to order a
biopsy 5 years ago.

~~~
javadocmd
Your father _might_ be dead or suffering today. It is impossible to be certain
about the natural course of a disease after you intervene. I'm glad your
father is doing well, of course, but we should be cautious: stories like this
one tend to bias people towards treatment with what is technically a false
representation of facts. I hate to seem pedantic, but accuracy is crucial in
discussions like this.

~~~
hga
Given the Gleason score, let's just say would/might -> most likely.

~~~
javadocmd
I don't doubt that you (or whoever) had additional information and made a
sound decision.

Point being simply that someone reading your original comment (or such
comments generally) doesn't have the full context and might not realize it.
I'm not making a point about your situation, but about how the internet is
often misused by people seeking to make their own decisions. A subject that
fascinates me.

~~~
hga
Well, all that's after the fact 20/20 hindsight.

Initially, all he and his doctor knew was that he was 77 years old and his
routine, approved by the powers that be, PSA test results took a worrisome
turn, bad enough that a biopsy was indicated.

My father's case only supports the Official Word, that starting at age 70 you
should get PSA tests. WRT to people making their own decisions, I highly
advise that, if you're 70 or older, to get regular PSA tests!

~~~
nommm-nommm
>My father's case only supports the Official Word, that starting at age 70 you
should get PSA tests. WRT to people making their own decisions, I highly
advise that, if you're 70 or older, to get regular PSA tests!

I highly advise you don't take medical advice from hga on Hacker News based on
one anecdote. The Official Word from the U.S. Preventive Services Task Force
is "The U.S. Preventive Services Task Force (USPSTF) recommends against
prostate-specific antigen (PSA)-based screening for prostate cancer."

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

[https://www.sciencebasedmedicine.org/screening-for-
disease-i...](https://www.sciencebasedmedicine.org/screening-for-disease-in-
people-without-symptoms-the-reality/)

Surgery for prostate cancer has some very serious side effects...

------
epistasis
I think a lot of the blame falls on the hype machine from Silicon Valley these
days. SV has mastered manipulation of the press, and that's a power that can
be used just as much for bad as it can for good. The drive to have the next
celebrity CEO as well as being the talk of the town has driven this media
craze. Relying on the media to drive celebrity rather than accomplishments and
engineering chops is what changes SV back into any other mundane cronyistic
industry.

Looking back at the Theranos hype, it was exactly the phrases that SV loves to
hear, but without any of the data to back it up. That can work in software to
some degree, where you can just build what you need, and it's just an
engineering problem. You can't do that with science; nature is not as
malleable as code.

~~~
adrenalinelol
One thing about Theranos that seems different from most SV hype stories is the
insane level of focus on the founder. Every piece that reports on Theranos
spends more time on her than it does the product. I'm speaking from minimal
experience here (my start-up credentials right now extend to one short-lived
company), but I think normally VCs aren't willing to "fund the founder" vs.
"fund the product" outside of the very early stages of a start-up. Theranos
has been around for a decade and the fact Mrs. Holmes is a Stanford dropout is
still nearly in every single article about the company. Contrast this to Mark
Zuckerberg and his former association with Harvard is nearly never mentioned
anymore (In articles dealing with Facebook).

~~~
pinewurst
That is an interesting call-out. I think originally, that it was a deliberate
part of the Theranos story, trying to piggyback on the life stories of the
likes of Gates, Jobs and Zuckerberg. Now it's beginning to backfire.

Facebook never had such a personality centric story past the panache of coming
out of Harvard and the Ivy League.

------
musesum
I wonder how this bodes for paper diagnostics?
[http://www2.technologyreview.com/news/412187/tr10-paper-
diag...](http://www2.technologyreview.com/news/412187/tr10-paper-diagnostics/)

Maybe the solution isn't higher one-shot accuracy, as with nanotainers(tm).
Maybe it is higher frequency? The idea of creating blood diagnostics for
pennies is so compelling.

Hate to see diagnostic research suffer from one bad investment. Am reminded
how Minsky-Papert's book on Perceptrons created a winter for neural net
research.

------
wonnage
Theranos has a really curious set of investors and board members:
[http://www.techinsider.io/theranos-board-of-
directors-2015-1...](http://www.techinsider.io/theranos-board-of-
directors-2015-10)

Maybe it didn't matter that much whether the tests actually worked.

------
hga
If you want frequent testing, and this is not my idea, but that of someone
who's been doing serious biology for decades, the most obvious was is to see
what we excrete, something that's part of a toilet.

Needless to say, this won't make for a glamorous startup....

~~~
TheEzEzz
Interesting. Any links to diagnostics that can be run from fecal samples
compared to blood samples?

~~~
hga
Don't forget urine, the kidneys give quite a view into one's bloodstream.

Don't have any links, it's just something that is said to likely be fruitful.

------
zmanian
The thesis here is that having a personalized healthy baseline for many
bookmakers will be far more powerful than comparing a diagnostic against
population based averages.

Also that higher time frequency I the data will also be revealing.

There is some research in support of this idea[1] but it remains highly
speculative.

[1][http://med.stanford.edu/news/all-news/2012/03/revolution-
in-...](http://med.stanford.edu/news/all-news/2012/03/revolution-in-
personalized-medicine-first-ever-integrative-omics-profile-lets-scientist-
discover-track-his-diabetes-onset.html)

------
gumby
The thing that amazes me is that Theramnos was valued at 9M. Tabcorp's market
cap is $13B on revenues of $6B; Quest is $11B on revenues of $7.6B.

With a $9B market cap already, even if Theramnos were able to take 100% of the
market and have a higher margin product it would be at best a 2.5X return for
its investors -- hardly a "10 bagger"!

I never "got" it because of those economics and the crazy science of tiny
samples.

------
hmahncke
>> He used his sister’s breast-cancer markers as an example... her risk may
not have changed at all, the variation being the result of natural biological
fluctuations and inherent uncertainty in the measurement. >>

That natural biological fluctuation is exactly what pinprick blood testing
could help with, because (in concept) the blood test could be delivered much
more frequently, and measure the true variability.

~~~
gumby
I don't see why pinprick testing would help; it's not like a regular draw is
that unpleasant (I went through a period of my life where I had two cylinders
drawn every week).

The opposite problem exists with the tiny samples: blood like any other fluid,
is not at all points identical at all times. You can easily demonstrate this
for yourself: go to the drug store and buy a cheap glucose meter and take a
bunch of samples just around the same finger, much less different fingers.
You'll see a surprising level of variation. The larger samples of a
conventional draw are shown to vary less.

They still vary (as the line you quote says) but less than the highly local
samples.

