Should I Be Tested for Cancer?: Maybe Not and Here's Why
by: H. Gilbert Welch
Topics include:
From the New England Journal of Medicine, January 27, 2005
In the absence of well-reasoned skepticism, medical practice can become enraptured with the potential of new technological advances. In this insightful how-to book on health care, Welch provides a comprehensive overview of current challenges in cancer screening. He draws from published literature, case histories, and his own medical practice in discussing the risks and benefits of screening, thereby exposing the true limits of current technology and of our knowledge as to how and when to intervene against early neoplasia. This comprehensive book has two parts, "Problems You Should Know About" and "Becoming a Better-Educated Consumer." Part I lays out the premise for early detection and gauges the risks and benefits that most people might derive from screening, given their susceptibility to cancer and the competing causes of illness and death. Part II details the practice of early detection and instances in which nonmedical factors -- such as human vulnerability, social forces, and fear of litigation -- have sometimes led to overzealous adoption of unevenly effective techniques for cancer screening. A comprehensive index accompanies the text, along with useful commentary that expands on and qualifies selected excerpts. Welch's lucid presentation of complex and timely issues is an achievement in itself, but even more, this is an eminently readable book that is bound to inform and complement the ongoing debate about screening. The author maintains that cancer screening may have been oversold to the public and health care practitioners alike. By challenging commonly held assumptions, Welch stimulates a critical dialogue between patients and providers regarding the effect of screening on cancer-associated morbidity and mortality, the sequelae of false positive results, and the slippery slope of diagnosing and managing incidentally detected cancers, many of which may pose no immediate health threat. To balance this cautious approach to cancer screening, the author acknowledges the successes of rigorously proven screening methods and weighs them against the high costs that invasive cancer imposes. Indeed, leading health economists recently estimated that as little as a 10 percent reduction in cancer would translate into a savings of $4.4 trillion to society. This book, which offers a sobering view of the status of cancer screening today, deserves to be widely used by patients and providers as they navigate an expanding and often bewildering array of screening options. Nevertheless, improvements in our understanding of carcinogenesis, enhanced performance characteristics of early-detection technology, and noninvasive approaches to diagnosing early neoplasia are likely to narrow the gap between the detection of disease and its appropriate medical management. These advances are likely to recalibrate the risk-benefit ratio of cancer screening. Indeed, transient uncertainties and potential harm should serve as an impetus for scientific advancement, rather than as evidence of conceptual failure. In an evolutionary sense, the dilemmas so well detailed in this book may be viewed as natural preconditions for continued progress. Jaye L. Viner, M.D., M.P.H.
Copyright 2005 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
From Booklist
The cost of medical malpractice soars as patient lawsuits proliferate, and healthcare providers react with rounds of "defensive testing" that boost insurance costs. Add to those trends "early detection" as the watch(buzz)word associated with the most dreaded of diseases, cancer, and you have Americans possessing health coverage routinely undergoing test after test. What of the downside of testing healthy people? Welch, a specialist in cancer detection, challenges common knowledge about everyday screenings, such as mammograms and PSA (prostate specific antigen) tests, citing patient anecdotes and research data on the most commonly diagnosed cancers in this readable, thought-provoking book. He argues that of the two basic cancer-prevention strategies--health promotion (diet, exercise, etc.) and early detection--the latter is the easier sell, and he notes that most tested people never develop cancer; screenings tend to miss the fastest-growing, most deadly cancers; and cancer-free patients with abnormal screenings often endure seemingly endless, sometimes risky testing that leads to unnecessary treatment. Accessibly written, Welch's perspective provides needed balance to current emphasis on testing. Whitney Scott
Copyright American Library Association. All rights reserved
Book Description
Getting tested to detect cancer early is one of the best ways to stay healthy--or is it? In this lively, carefully researched book, a nationally recognized expert on early cancer detection challenges one of medicine's most widely accepted beliefs: that the best defense against cancer is to always try to catch it early. Read this book and you will think twice about common cancer screening tests such as total body scans, mammograms, and prostate-specific antigen (PSA) tests.
Combining patient stories and solid data on common cancers, Dr. H. Gilbert Welch makes the case that testing healthy people for cancer is really a double-edged sword: while these tests may help, they often have surprisingly little effect and are sometimes even harmful. Bringing together a body of little-known medical research in an engaging and accessible style, he discusses in detail the pitfalls of screening tests, showing how they can miss some cancers, how they can lead to invasive, unnecessary treatments, and how they can distract doctors from other important issues. Welch's conclusions are powerful, counterintuitive, and disturbing: the early detection of cancer does not always save lives, it can be hard to know who really has early cancer, and there are some cancers better left undiscovered.
Should I Be Tested for Cancer? is the only book to clearly and simply lay out the pros and cons of cancer testing for the general public. It is indispensable reading for the millions of Americans who repeatedly face screening tests and who want to make better-informed decisions about their own health care.
From the Inside Flap
"I have long been a fan of Dr. Welch's research and his considerable insight into the dilemma of disease screening. I'm profoundly grateful that he has now made this information available to everyone in an easy-to-read, practical book. Should I Be Tested for Cancer? is a must-read for every doctor and patient in this country."Christiane Northrup, M.D., author of Women's Bodies, Women's Wisdom
"I did not think it possible to bring such a dry topic to life, but Dr. Welch has done it. He writes wonderfully well. For anyone interested in cancer screening or preventive medicine, this book is a page-turner. It will be a rare personlayperson or health professionalwhose perspective is not changed by reading this provocative book." Alfred Berg, M.D., M.P.H., Chair of the U.S. Preventive Services Task Force
"Dr. Welch has performed an invaluable public service. Whatever the successes of the nation's 'war on cancer,' too many people now believe it's always in their best interest to detect the disease early and rout it, regardless of the costs. This book will inject reason and good sense into an arena of medical decision making often dominated by hype and fear."Susan Dentzer, Health Correspondent, The NewsHour with Jim Lehrer
From the Back Cover
"I have long been a fan of Dr. Welch's research and his considerable insight into the dilemma of disease screening. I'm profoundly grateful that he has now made this information available to everyone in an easy-to-read, practical book. Should I Be Tested for Cancer? is a must-read for every doctor and patient in this country."--Christiane Northrup, M.D., author of Women's Bodies, Women's Wisdom
"I did not think it possible to bring such a dry topic to life, but Dr. Welch has done it. He writes wonderfully well. For anyone interested in cancer screening or preventive medicine, this book is a page-turner. It will be a rare person--layperson or health professional--whose perspective is not changed by reading this provocative book." Alfred Berg, M.D., M.P.H., Chair of the U.S. Preventive Services Task Force
"Dr. Welch has performed an invaluable public service. Whatever the successes of the nation's 'war on cancer,' too many people now believe it's always in their best interest to detect the disease early and rout it, regardless of the costs. This book will inject reason and good sense into an arena of medical decision making often dominated by hype and fear."--Susan Dentzer, Health Correspondent, The NewsHour with Jim Lehrer
About the Author
H. Gilbert Welch, M.D., M.P.H., is Professor in the Departments of Medicine and Community and Family Medicine at Dartmouth Medical School and Codirector of the VA Outcomes Group in the Department of Veterans Affairs, White River Junction, Vermont.
Reviews:
No study has confirmed that cancer screening extend lives:
This is a very well written short book on the excessive use of cancer testing. The book is divided in two parts. The first part explains the problems associated with the inaccuracy of cancer screening and its implications: painful over treatment including surgery. The second part educates one on how to interpret cancer statistics so as not to be vulnerable to the positive media spin. It also educates as to the limit of research findings. The benefits of cancer screening are often statistically unfounded. This part also educates on how to manage your doctor so you don't get over tested.
If you combine the most technology and profit driven medical establishment with the most litigious society, you get a Perfect Storm for excessive cancer testing. That is what we got in the U.S. No doctor will ever get sued because he ordered a cancer test. But, he will if his patients get cancer, and he had not actively recommended a test. As a result, doctors don't take any chances and they scear us in taking many cancer screening test.
Cancer tests are deemed to be good for us. Supposedly, the earlier you catch cancer the greater the survival rate. Per the author that is nothing but a simple statistical flaw. We are now tested earlier, and our cancers are detected many years earlier. If you test a population of 50 year olds for prostate cancer, you get a higher survival rate at 5 years, then if you test a population of 70 year olds. Thus, the increase in 5 year survival rate means nothing. The author further adds that mortality rates (of cancer or other causes) has really not changed whether you get tested for cancer or not. Thus, PSA tests and mammograms really don't save lives. Also, cancer incidence has risen to supposedly epidemic levels. But, again this is just due to increase testing.
The standard path is to first take a really benign test whose result is more often than not inconclusive (radiologists often disagree). This leads to biopsies that often are inconclusive (pathologists often disagree too). But to remove the uncertainty, radical surgeries are often the next step. The intervention escalated from one level to the next in part because of the perceived threat of malpractice suit.
The author advances an excellent argument that the healthy would be better off without that much cancer screening. A lot of cancers that are now uncovered such as prostate cancers are benign and would not affect health or lifespan. Many more men die with prostate cancer than from prostate cancer. He calls those benign cancers a "cancer reservoir." The increasing sensitivity of tests uncovers more and more benign growth from our cancer reservoir. And, that really does not do anyone healthy any good. It leads to overly aggressive painful over treatment. At this pace, the entire male American population will have their prostate removed without gaining a day in lifespan, but with a marked increase in incontinence and impotence. This paragraph could be rewritten very much the same way for women regarding ductal carcinoma in situ, a most common but benign form of breast cancer (DCIS). These certainly don't warrant breast removal, but that's often what doctors do.
To become a well educated customer of medical services, I also strongly recommend two other excellent books. One is "The Last Well Person" by Nortin Hadler. This book extends the critique of the medical establishment not just to cancer screening, but to the treatment of cardiovascular disease, and everything else. The other is "Calculated Risks: How to know when numbers deceive you" by Gerd Gigerenzer. This book explains in detail the logic and implication of Baye's Theorem. By doing so, it explains why PSA tests and mammograms are so inaccurate.
Clear Expose of The Cancer Industry
H. Gilbert Welch, MD, MPH, has written an unusually understandable revelation of the folly of testing for cancer in people with no symptoms. He explains how only a few people will benefit from common tests such as PSA, fecal blood, mammograms and others. He is enough of an insider to be able to explain the flaws in clinical trials being used by "authorities" to recommend extensive testing, and the lack of trials in some cases. The unneccessary biopsies, surgeries, radiations, chemotherapies for slow-growing cancers or even non-malignant ones are presented bravely. The uncertainty of testing is exposed where a positive for cancer may be wrong 1/3 of the time. And it is up to the patient to get second opinions.
The financial and legal pressures on MDs to test excessively are brought out. There is advice on talking or writing to your MD to indicate your unwillingness to undergo too many tests, and not to hold your MD liable if a cancer was "missed" - that is the big thing.
The deaths caused by cancer treatment are aired. This is something very few people, even MDs, know. Even when a treatment can cut the deaths from a particular cancer in half, most current treatments create non-cancer deaths, many of which will be improperly reported.
Welch is a special expert on the misleading nature of 5-year survival rates how they can rise because of early detection, yet with no change in the cancer plus cancer treatment mortality rate.
There are good explanations of how 5-year survival rates are calculated, how age-adjustments are made, how randomization for trials is done, and other things not even taught in medical school, but reserved for medical researchers. And quite easy to comprehend with clear figures and tables.
No errors that I can find; a really excellent book.
Learn how to escape from the drawbacks linked to cancer fear: People interested in taking care of their own health should read the book. It is the next best thing to consulting Dr Welch. It liberates then from the drawbacks linked to cancer fear. It is also a remarkable training course for medical doctors. As an epidemiologist, I understood why cancer research is flawed : pseudo-cancers detected by screening preclude any improvement in cancer understanding. I also discovered why cancer screening leads to useless treatments. Current cancer health policy appears here as a religion based on a technical illusion. It reveals the folly of mankind when having to face disease and death.
It is hard to put into words the importance of the book, Should I be Tested for Cancer? by Gilbert Welch, M.D., Professor of Medicine at Dartmouth Medical School. It is equally as hard to put into words the courage that it must have taken to write this book. The medical establishment does not look kindly on those who stray too far from the constraints of conventional wisdom. Those of us who seek only about the truth as it pertains to healthcare issues are greatly indebted to Dr. Welch for daring to do so.
I have been involved with health care issues for over 28 years. This book is a God-sent and is easily the most important book on this subject I've read in the last decade. Quite frankly, I couldn't put it down. It was given to me by one of my patients who, over the years, has known of my "healthy skepticism" towards many aspects of conventional medical practice, especially as it relates to cancer diagnosis and treatment. The book confirms many of the thoughts that I have shared with my "nontraditional" patients over the years.
It is never easy to be perceived as going against the grain of conventional wisdom in any discipline, especially one as emotionally charged as cancer. The author has performed an invaluable service to the many concerned people who dare to think for themselves "outside of the box." A simple perusal of some of the chapter headings reveals all you need to know about where the book is headed: "It is unlikely that you will benefit." "You may have a `cancer scare' and face and endless cycle of testing." "You may receive unnecessary treatment." "You may find a cancer you would rather not know about." "Your pathologist may say it's cancer, while others say it's not." "Your doctor may get distracted from other issues that are more important to you."
In Dr. Welch unemotional, factual writing style, we learn about such concepts as "false positives," "pseudo disease," the fallacy of "early detection," suspicious and unreliable "cure rates." We are introduced to the rarely recommended but legitimate treatment option of "watchful waiting" which, for many patients and some forms of cancer, may be the best course of action. We are told that how hard doctors look for prostate cancer affects how much they find. Did you know that there is a saying among doctors about prostate cancer: more men die with it than die from it? There are similar nuggets of wisdom about breast cancer, cervical cancer, and lung cancer. And did you know that you could easily become a victim of a deadly form of medical "political correctness"?
Here are a few snippets from the book well worth quoting:
"Tests can be wrong, people are made to worry unnecessarily, some are treated unnecessarily, and some are even harmed by treatment."
"I will argue that a decision to forgo cancer treatment can be a reasonable option."
"If the behavior of doctors and the public continues unabated, eventually every well person will be labeled as sick."
"Some believe that anyone who dies of cancer and wasn't screened would have been saved had they had a test. But that's not true."
"I object to the emerging mindset that patients should be persuaded, frightened, and coerced into undergoing [mammography, PSA tests, fecal occult blood testing]. There is today a certain "medical correctness" about screening - making patients feel guilty if they choose not to pursue testing. This is wrong." [emphasis added]
As Dr. Welch makes abundantly clear, this book is not for everyone. It is not for people for have a need for simple answers. We all know friends and relatives who, if told they have a "lump" somewhere on their body, need to "have it out" as soon as possible in order to restore a certain peace of mind. This book is definitely not for them. Rather, it is for those thinking individuals who are open to questioning the wisdom of traditional medical practices, especially as they pertain to cancer testing and conventional treatment modalities. For them this book is a definite eye-opener and may someday become a life-saver. Again, one can only admire the courage that it took to write a book of this magnitude.
I enjoy the give-and-take of discussing health issue with my patients. While I refrain from offering specific medical advice outside of my field of dentistry, I readily discuss health issues on a general level with selected patients. What I always suggest is that it is extremely important that they educate themselves in all aspects of healthcare - including cancer diagnosis and treatment - now, when they are healthy, so that when the day comes when they or a loved one are confronted with an important health issue, they can make an intelligent , informed, and unemotional decision. This book has greatly assured me that this is a sound, reasonable philosophy, and as such, I will be highly recommending this book to all those who want to be actively involved in their own healthcare decision-making process.