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Blood test that finds 50 types of cancer is accurate enough to be rolled out

theguardian.com

341–350 of 389 posts

Re: Blood test that finds 50 types of cancer is accurate enough to be rolled out

#341

For those interested in reading the actual paper, this appears to be it (open access too): https://www.annalsofoncology.org/article/S0923-7534(21)02046... I’ve only skimmed it, but seen quite a few limitations, notably those with “non-malignant conditions at enrolment” (it would be nice to know more what that means), previous cancer or recent corticosteroids use were excluded. Additionally, it’s a case controlled tri…

>“non-malignant conditions at enrolment” (it would be nice to know more what that means)

My guess is they're referring to the neoplasm behavior codes defined by the WHO in the International Classification of Diseases for Oncology (see article's references for info). Which means "malignant" is a neoplasm which has begun spreading beyond the tissue it appeared in. Non-malignant neoplasms are either benign (not likely to ever spread), borderline (could go either way), or in situ (still in the original tissue, but it will spread).

North American cancer registries typically don't even bother collecting records of benign or borderline tumors. The only exceptions are brain tumors, which can be deadly without metastasizing. Registries also don't collect cervical cancer in situ records because there are so many and a lot of physicians never bothered reporting them. And finally, oncologists and epidemiologists classify urinary bladder cancer in situ as malignant because it's really hard for physicians to differentiate. Better safe than sorry, in case.

Re: Blood test that finds 50 types of cancer is accurate enough to be rolled out

#342
post #304

Earlier quoted context omitted.

The argument you’re making has always bothered me because it’s hiding the ball. If finding something that otherwise carries no symptoms is best left untreated, then the fact that you found it should make no difference to the decision. The doctor should say that the best course of action is to do nothing. More information can never be harmful. If you know information is best not acted on in the abstract, then you also…

"More information can never be harmful." In my particular field of biomedical research, there has recently been a push for "Diagnostic Stewardship" because more information has demonstrably been harmful to patient well-being.

I believe that's what the data says, but I have a really hard time reconciling it with common sense. More information is strictly better than less information, because you can always choose to ignore the extra information.

I would say most medical decisions are made either due to statistics, or due to experience. What treatment has the highest chance of making the patient better, extending their life, or giving the best quality of life? You'd "just" have to adjust the tables for the new test.

I mean in a contrived example, you could have the lab technician themself look up the numerical result (xyz > 100, abc conditionally to improve my treatment if possible.

Re: Blood test that finds 50 types of cancer is accurate enough to be rolled out

#343

Earlier quoted context omitted.

Your point across this thread is weird because it's not the testing itself which is an issue (if we assume the testing has a negligible cost economically and is comfortable/easy for the subject). We just need to improve the decision making after getting test results (one of these decisions is to decide to not do anything), and more data make improving it easier.

But tests do not have a negligible cost, have other costs besides the pure monetary value (such as occupying valuable lab time that could be spent on symptomatic patients instead), are typically not at all comfortable and easy because you'll be looking at a biopsy at a minimum (which again takes away valuable resources from symptomatic patients) and so on. My argument is not about particular individuals, but about po…

My lay understanding of the current standard of care is very roughly speaking something like:

Patient exhibits symptom => perform a not-especially-invasive test Positive test result => invasive test like a biopsy Positive biopsy result => heavy-duty intervention (although I'm not focusing on this part of the chain in what follows)

Both testing and (certain) symptoms have predictive value, and don't completely overlap. So there's something like this going on:

P(actual problem|no additional information) = really really low, which is why they don't scoop out chunks of every organ to test "just in case" every time you go to the doctor

P(actual problem | [symptom AND positive test result]) = generally high enough in at least some cases to justify the risk of the biopsy, which is why it's the standard of care

P(actual problem | just symptom) = probably not super high, which is why the tests are developed

P(actual problem | just a positive test result) = substantially lower than P(actual problem | [symptom AND positive test result]), so in the general case the balance of risk no longer favors the biopsy

In the broadest of strokes, is there anything I've just said that you substantially disagree with?

Re: Blood test that finds 50 types of cancer is accurate enough to be rolled out

#344

Earlier quoted context omitted.

Actually you don't want this, and you are describing a nightmare scenario that everyone who studies health policy understands all too well. Mass screening of healthy people will result in extreme iatrogenics and unnecessary psychological damage and stress (which leads to physical effects as well), not to mention overwhelming the medical system. The fact is that many things that could be detected will never result in…

> so by detecting it early you are just reducing the amount of life they have left without worrying about their disease I wonder if people would rather continue to live care free, spending most of their waking hours commuting and at work, or if they'd rather learn the truth and face the harsh reality that their time is about up and adjust their priorities accordingly?

Nobody knows when his time is up. You could be hit by a truck on your commute to work.

I would rather live my life as it comes, for whatever length of time fate has given me.

Re: Blood test that finds 50 types of cancer is accurate enough to be rolled out

#345

Earlier quoted context omitted.

I detest this mindset. It is incredibly counter productive. "Our tests are bad, so lets not test" is not a thought worthy of respect. This states that you know about a problem but want to continue to ignore that problem. Reprehensible. No, we should take the exact opposite approach. Test everyone constantly until such methods become both cheap and powerful. So yeah we all have some cancer load but if the diagnostic o…

This is not a question of mindset, it's a question of statistics when you're trying to identify anything that is rare. Take prostate cancer as an example. It's a relatively common cancer, with an incidence of .1% [0]. If you have an _incredible_ screening test with a 99% specificity (ie, 1% false positive rate), then: If you test 100,000 people, you will correctly identify 100 people with cancer, and misdiagnose one…

But the tests are not binary sick or healty. If your test gets more sensitive, then you have to shift the, say, PSA value that you use for a diagnosis.

I really hope that false positives become a regular thing. For one it shows that the tests are working according to statistics.

Second, getting comfortable with false positives means that you can more easily hold off treatment, if in your specific scenario the treatment is not beneficial - think an old test that doesn't find the cancer plus a new test that does; and the new test is shown to lead to overtreatment. We need to learn when to hold on and not to treat.

And third, if testing for 10 things will find something that you don't want to know and harm your psyche, when you test for 100 things you will have almost certainty that there is a false positive and this can give you back some of the "blissfull ignorance" I believe (while the doctor can still give you the statistically best treatment).

Re: Blood test that finds 50 types of cancer is accurate enough to be rolled out

#346

Earlier quoted context omitted.

Actually you don't want this, and you are describing a nightmare scenario that everyone who studies health policy understands all too well. Mass screening of healthy people will result in extreme iatrogenics and unnecessary psychological damage and stress (which leads to physical effects as well), not to mention overwhelming the medical system. The fact is that many things that could be detected will never result in…

Utterly wrong. You are conflating current technology like MRIs and CT scans that only detect lumps, to blood tests that detect CANCER. Yes, if every lump were treated and excised then it would be problematic. But CANCER is different. The only cancer that you might be able to leave alone is prostate because it grows so slowly. Everything else is a risk. And if we can treat cancer at early stage 1, then maybe people wo…

> ke MRIs and CT scans that only detect lumps, to blood tests that detect CANCER.

You mean like the PSA test? It's pretty bad, in the scale of these things. It's used because there isn't a better screen, not because it is more specific.

Re: Blood test that finds 50 types of cancer is accurate enough to be rolled out

#347

Earlier quoted context omitted.

But tests do not have a negligible cost, have other costs besides the pure monetary value (such as occupying valuable lab time that could be spent on symptomatic patients instead), are typically not at all comfortable and easy because you'll be looking at a biopsy at a minimum (which again takes away valuable resources from symptomatic patients) and so on. My argument is not about particular individuals, but about po…

My lay understanding of the current standard of care is very roughly speaking something like: Patient exhibits symptom => perform a not-especially-invasive test Positive test result => invasive test like a biopsy Positive biopsy result => heavy-duty intervention (although I'm not focusing on this part of the chain in what follows) Both testing and (certain) symptoms have predictive value, and don't completely overlap…

No, there isn't, though it is probably important to point out that age, genetic disposition and gender are a big factor in selecting what kind of test and if positive what kind of treatment - if any - will be administered and that this is as you correctly identify on symptomatic patients only which raises the base rate in that population (the population of symptomatic patients) tremendously.

And that's exactly where the issue with indiscriminate asymptomatic testing lies, that requires much higher quality tests than the ones that can be used in a diagnostic setting once a patient is symptomatic.

To add one more unpopular bit of data to all this: there is some evidence that the indiscriminate testing for certain cancers has gone too far and that it no longer is a net positive. But in the presence of certain mutations those tests are extremely valuable.

https://www.statnews.com/2018/01/01/cancer-screening-misled-...

Biology is messy, and it is quite hard to state up front whether or not a test or a treatment - even if in an experimental setting it is working - will still be a gain if rolled out in a different setting or application. Hence all the trials and studies, that's the only way to really get a grip on this.

I'm quite curious what the outcome of the large scale test the article refers to will be.

Re: Blood test that finds 50 types of cancer is accurate enough to be rolled out

#348

Earlier quoted context omitted.

Actually you don't want this, and you are describing a nightmare scenario that everyone who studies health policy understands all too well. Mass screening of healthy people will result in extreme iatrogenics and unnecessary psychological damage and stress (which leads to physical effects as well), not to mention overwhelming the medical system. The fact is that many things that could be detected will never result in…

The argument you’re making has always bothered me because it’s hiding the ball. If finding something that otherwise carries no symptoms is best left untreated, then the fact that you found it should make no difference to the decision. The doctor should say that the best course of action is to do nothing. More information can never be harmful. If you know information is best not acted on in the abstract, then you also…

If I can step in with a personal anecdote: I was diagnosed in my late 20s with papillary thyroid cancer.

PTC is a very survivable cancer, with a near-100% survival rate (death usually only occurs in rare cases where the disease is diagnosed very late, the progession is atypical, or there are comorbidities at play). It is very easy to screen for and diagnose: a neck ultrasound identifies thyroid nodules, and if the nodules look suspicous they are biopsied in a 20 minute procedure performed under local anaesthetic.

Treating papillary thyroid cancer is also relatively straightforward, as far as cancer goes: depending on the size of the lesion and the features, either half or all of the thyroid gland is removed surgically. In cases where the whole gland is removed (which is the majority), the patient is given a course or two of radioiodine therapy to nuke anything left over, and in many/most cases, it's a done deal.

The vast majority of thyroid cancer survivors have to take thyroid replacement hormones (all patients who had the whole gland removed have to do this, and about half of patients who only had half the gland removed still need a small dose to keep up). I'm relatively lucky: the oral hormone seems to work just fine for me. I take a pill every morning and then go about my day. I will need to do this for the rest of my life, but hey, that's life.

However, there's a substantial minority of patients who aren't so lucky: even with oral hormone replacement, they suffer from long-term sequelae including weight gain, low energy, brain fog, hair loss, and other hypothyroid symptoms.

And there lies the crux of the issue: it turns out that even with increased diagnostic capability (thanks to the ubiquity of relatively cheap ultrasound exams in clinical practice), the number of people dying from thyroid cancer has stayed pretty much flat for decades (mostly due to more aggressive types than papillary, such as medullary or anaplastic). Yet, we take out a lot more thyroids now.

The reason this happens is pretty simple: if you see something, you have to do something about it. So you're removing thyroid glands from people where the cancer might never have actually grown big enough to be a problem, and then subjecting those people to a lifetime of hormone replacement therapy. Something like 10% of all cadavers at autopsy have thyroid cancer: it's a cancer that very commonly develops, but only becomes a concern in a few patients. As of now, we don't have a good way to differentiate between "thyroid cancer that's a problem" and "thyroid cancer that'll be fine."

The clinical guidelines have changed a bit in recent years: if the cancerous nodule is really small, they'll now do "watchful waiting" and monitor the nodule to see if it grows. But you're still subjecting a patient to potentially many years of worry and regular testing. And good luck getting life insurance if you have a microcarcinoma! Yeah, it's highly unlikely to kill you (especially when monitored), but try telling an insurer that.

The medical profession is well aware of these concerns. That's why they avoid testing for thyroid cancer unless there are symptoms, such as thyroid hormone disturbances or a lump in the neck. If you were to make a thyroid ultrasound a regular test, you'd quickly overwhelm the system with cancer patients who probably never needed to be treated in the first place, and who may now have to get their thyroids removed and be dependent on pills for the rest of their lives.

Re: Blood test that finds 50 types of cancer is accurate enough to be rolled out

#349

Earlier quoted context omitted.

Same vibe as "I would just simply..." What do you think the entire medical, pharmaceutical, bioinformatic, etc. industries have been doing for decades? Are you really so arrogant to think that other people are too lazy and stupid to think of your brilliant idea and that you are simply more intelligent than everybody else? Do you really think people haven't been trying?

> What do you think the entire medical, pharmaceutical, bioinformatic, etc. industries have been doing for decades? Well, let's remember that the AlphaFold team at Google solved the protein folding problem with a relatively small team in a relatively small number of years after extremely large, well funded companies whose primary business was drug development failed to do so for decades. So yeah, it's been demonstrat…

> let's remember that the AlphaFold team at Google solved the protein folding problem with a relatively small team in a relatively small number of years after extremely large, well funded companies whose primary business was drug development failed to do so for decades

Did they though? They did extremely well at CASP14, and much better than competing groups. But does this solve protein folding? Deepmind's marketing department would have you think so, but for those of us that work in the field we know that this is not the case.

Furthermore, does protein folding solve the relevant problems of drug design? It solve the forward problem, given an amino acid sequence predict its 3d structure. But for drug design we need the inverse problem, given a specified structure predict an amino acid sequence that produces that structure.

Re: Blood test that finds 50 types of cancer is accurate enough to be rolled out

#350

Earlier quoted context omitted.

Actually you don't want this, and you are describing a nightmare scenario that everyone who studies health policy understands all too well. Mass screening of healthy people will result in extreme iatrogenics and unnecessary psychological damage and stress (which leads to physical effects as well), not to mention overwhelming the medical system. The fact is that many things that could be detected will never result in…

The argument you’re making has always bothered me because it’s hiding the ball. If finding something that otherwise carries no symptoms is best left untreated, then the fact that you found it should make no difference to the decision. The doctor should say that the best course of action is to do nothing. More information can never be harmful. If you know information is best not acted on in the abstract, then you also…

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