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Are we screening too much for skin cancer? It's complicated

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Re: Are we screening too much for skin cancer? It's complicated

#61

Post by jjk166 »

cycomanic wrote: post #24
im3w1l wrote: post #5

Earlier quoted context omitted.

Depends on your values. Some people may think it's worth it for them, and that's valid.

I don't think it's as easy as "let the patient decide". First, probabilities are very abstract concepts for people, that's why people respond very differently to the dangers of things when given the probability. Some people are scared if there is a 1:1000 chance of something happening, others are reassured, but both might have very similar reactions if they actually get hit by the chance event. Secondly, also there i…

Yes, the unwashed masses can't handle abstract concepts like 1:1000 being smaller than 1:500. We certainly know better than them the value of years with the kids versus a physically satisfying romantic life, and if they think differently they are clearly just irrational plebs who should be hoodwinked for their own protection. We can't let a lifetime of unique experience and perspective stand in the way of a good one-size fits all system that produces better (for our definition of better) results on average.

Re: Are we screening too much for skin cancer? It's complicated

#62

Post by taneq »

rscho wrote: post #51
taneq wrote: post #28

Earlier quoted context omitted.

I'm surprised he only took a sample. Where I live, anything suspected of being melanoma gets removed immediately, it's still sent off for testing to see whether it was cancerous or not but if you're taking a biopsy might as well just take it out entirely.

> I'm surprised he only took a sample. The lesion was likely too big to comfortably remove in-office.

Yikes, if so then it's incredibly lucky that it wasn't melanoma, that would likely have been too late.

Re: Are we screening too much for skin cancer? It's complicated

#63

Post by allturtles »

aeternum wrote: post #58
allturtles wrote: post #57

Earlier quoted context omitted.

Unfortunately you can't know the benefit in advance. It's not generally possible to tell from a MRI/CT that detects a tumor if it will kill you soon if not treated, if it will kill you no matter what you do, or if it will just sit there for a decade and do nothing.

The only way we will figure that out is to collect lots of data on it. Perhaps there are correlations in the MRI/CT that determine lethality/malignancy. Even if we perform zero treatment, this data argument should be sufficient reason to increase rather than decrease the number of MRIs we do. CT is different since there is some radiation exposure risk that must be considered.

I'm not sure how this would work. Doctors start ordering lots of MRIs that wouldn't have been ordered before, and some percentage of those that wouldn't have been ordered before show tumors. Now what to do you do? If you are just doing it to gather data, you don't tell the patients the results, I guess? This seems unethical.

If you do disclose the results and proceed with a normal patient relationship, you are in the same dilemma as above. You don't know if the tumor is dangerous or not, so the safe course is to do a biopsy, which is itself often invasive. Depending on the results that may lead larger surgeries to exicse large parts of organs and/or the starting of chemotherapy.

Also MRIs are expensive, and in the U.S. a significant amount of that cost (usually hundreds of dollars) is borne by the patient, even if they are insured.

But I don't think we lack for MRI or CT data, there are lots ordered every year. The biggest problem with gathering your data set would be medical privacy regulations. I would guess that medical researchers have already tried longitudinal studies on this to see if different imaging characteristics lead to different outcomes. It's a hard problem, the only data you really get from scans is tissue density, which can probably never tell you what you need to know.

Re: Are we screening too much for skin cancer? It's complicated

#64

Post by jvidalv »

jazoom wrote: post #43
jvidalv wrote: post #20

I think people overblowns it. I live in a rural town in Spain where most people are still farmers ( wineries, olives ). It means most of the men can take up to 6-7 hours, at minimum, of sun their entire life each day. Its a small town so we know whenever someone dies. In my 27 years never heard or someone died from skin cancer. There have been many lung cancers from smoking, prostata, belly... I dont know where this…

I'm a skin cancer doctor in Queensland. I find skin cancers in patients almost every day. In fact, I think there have only been a few days of working this year where I didn't find one. This is from screening. People in Australia generally understand the importance of skin cancer screening because most people know of someone who's had skin cancer.

Im not saying that skin cancer is not a thing, but that from my position seems overblown.

The fact that seems that if you take sun without sunbathe you could likely get skin cancer is crazy.

As I said, I live in a rural place where most people gets lots and lots of sun and I still have to know a single old man having it.

And old mans that have taken +8 hours of sun since they are 12.

Just my two cents

Re: Are we screening too much for skin cancer? It's complicated

#65

Post by tweetle_beetle »

jjk166 wrote: post #61
cycomanic wrote: post #24

Earlier quoted context omitted.

I don't think it's as easy as "let the patient decide". First, probabilities are very abstract concepts for people, that's why people respond very differently to the dangers of things when given the probability. Some people are scared if there is a 1:1000 chance of something happening, others are reassured, but both might have very similar reactions if they actually get hit by the chance event. Secondly, also there i…

Yes, the unwashed masses can't handle abstract concepts like 1:1000 being smaller than 1:500. We certainly know better than them the value of years with the kids versus a physically satisfying romantic life, and if they think differently they are clearly just irrational plebs who should be hoodwinked for their own protection. We can't let a lifetime of unique experience and perspective stand in the way of a good one-…

The problem is that when handed numbers by a professional with years of training in an emotionally vulnerable state many people err on the side of being conservative on the issue at hand to avoid feeling like they may be judged.

This is further encouraged by modern western medicine being highly compartmentalised - to oversimplify, the cancer doctor has succeeded if you don't get cancer, but will probably never even find out if you get severe depression as a side effect of a side effect and certainly won't have to deal with it. Specialists also have their own professional and personal bias when they deliver their options, which is not apparent when presenting as a patient.

Is a scenario where the patient and the doctor are both acting based on short term benefit, rather than a holistic view, good for either party?

There is a role for large scale public health policy in my opinion, as morally complicated as it is.

Re: Are we screening too much for skin cancer? It's complicated

#66

Post by throwlotterywon »

rscho wrote: post #27
throwlotterywon wrote: post #13

Recently, I had a mole on the top of my foot about an inch or two from my toes that grew from a normal size small dot to bigger than a pencil eraser in the span of two months. I went to the doctor, not suspecting any cancer, but because it was ANNOYINGLY itchy and started to grow a red ring around it. For context, I'm a nerdy software engineer who RARELY ventures outside of an air conditioned room, obviously no tanni…

Statistically speaking, your individual story says next to nothing about what we should do regarding screening. And screening strategies are all about statistical analysis.

What's the downside to screening more?

Re: Are we screening too much for skin cancer? It's complicated

#67

Post by throwlotterywon »

rscho wrote: post #51
taneq wrote: post #28

Earlier quoted context omitted.

I'm surprised he only took a sample. Where I live, anything suspected of being melanoma gets removed immediately, it's still sent off for testing to see whether it was cancerous or not but if you're taking a biopsy might as well just take it out entirely.

> I'm surprised he only took a sample. The lesion was likely too big to comfortably remove in-office.

Right.

Re: Are we screening too much for skin cancer? It's complicated

#68

Post by throwlotterywon »

elric wrote: post #30
throwlotterywon wrote: post #13

Recently, I had a mole on the top of my foot about an inch or two from my toes that grew from a normal size small dot to bigger than a pencil eraser in the span of two months. I went to the doctor, not suspecting any cancer, but because it was ANNOYINGLY itchy and started to grow a red ring around it. For context, I'm a nerdy software engineer who RARELY ventures outside of an air conditioned room, obviously no tanni…

Well done on spotting it! I have hundreds of moles. I can't even imagine how I'd be able to keep track of any increases in size, there are more than I can remember.

It was large and visible and itchy enough that you couldn't miss it.

Re: Are we screening too much for skin cancer? It's complicated

#69

Post by jjk166 »

tweetle_beetle wrote: post #65
jjk166 wrote: post #61

Earlier quoted context omitted.

Yes, the unwashed masses can't handle abstract concepts like 1:1000 being smaller than 1:500. We certainly know better than them the value of years with the kids versus a physically satisfying romantic life, and if they think differently they are clearly just irrational plebs who should be hoodwinked for their own protection. We can't let a lifetime of unique experience and perspective stand in the way of a good one-…

The problem is that when handed numbers by a professional with years of training in an emotionally vulnerable state many people err on the side of being conservative on the issue at hand to avoid feeling like they may be judged. This is further encouraged by modern western medicine being highly compartmentalised - to oversimplify, the cancer doctor has succeeded if you don't get cancer, but will probably never even f…

I would not call general statistical data which takes no accounting of the details of the actual circumstances "holistic"

The fact is there are tons of people for whom the side effects are a non-issue, and many for whom they would be far worse than the disease, and the statistics give no indication as to who is in which category.

The role of public health is to provide information so that doctors and patients can make better informed decisions. But the idea that decisions should be made by some third party that "knows better" is predicated entirely on the false belief that such an entity exists.

Re: Are we screening too much for skin cancer? It's complicated

#70

Post by tweetle_beetle »

jjk166 wrote: post #69
tweetle_beetle wrote: post #65

Earlier quoted context omitted.

The problem is that when handed numbers by a professional with years of training in an emotionally vulnerable state many people err on the side of being conservative on the issue at hand to avoid feeling like they may be judged. This is further encouraged by modern western medicine being highly compartmentalised - to oversimplify, the cancer doctor has succeeded if you don't get cancer, but will probably never even f…

I would not call general statistical data which takes no accounting of the details of the actual circumstances "holistic" The fact is there are tons of people for whom the side effects are a non-issue, and many for whom they would be far worse than the disease, and the statistics give no indication as to who is in which category. The role of public health is to provide information so that doctors and patients can mak…

I'm not sure how looking at large scale trends and scenarios experienced by thousands/millions is anything but holistic, especially when talking about individual patients with individual specialists dealing with individual .

> Holism (from Greek ὅλος holos "all, whole, entire") is the idea that various systems (e.g. physical, biological, social) should be viewed as wholes, not merely as a collection of parts.

Of course it would be best if there was a universal language which everyone was proficient in, every patient had unlimited healthcare resources, had a strong understanding of medicine and every doctor was an excellent communicator, was under no personal/professional pressure to deliver specific outcomes, always took all the time a patient needed to understand every aspect of their case and care in the present and into the future and personally consulted with every possible specialist that may be involved with the potential outcomes.

Putting aside the strawman, there are significant compromises with the highly personalised approach you suggest (some of which I tried to outline, but have not been responded to), just as there are with national level approaches (which are self evident). I feel that there are applications for both.

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