Virtually all deaths from solid cancers are preventable with routine scans to find tumors before they metastasize. Doctors have for decades refused to learn to use this technology.[1-4][5-9] *
Meanwhile, population studies like the one this article is based on[10] are horseshit because they are subject to unknown degrees of sampling bias, rely on enormous assumptions (such as linear relationships which may not hold at all being applied over many orders of magnitude), and cannot in any case establish causality.
* Compare the experience of getting an x-ray from a dentist to getting one from a doctor. Or getting an ultrasound from an OB to getting one from any other doctor.
Your first four links are just random ultrasound device companies. Doctors are very well-versed in ultrasound technology so your claim that doctors refuse to learn this is patently false.
Full-body scans have been marketed for years by companies looking to drum up business for their machines, but they mostly lead to false positives. Notice how your fifth link clearly says it has helped people find “warning signs of potential cancer” instead of that it helps people find cancer? These machines are basically false positive generators in most cases. If someone had effectively infinite time and money to dedicate to routine cancer screenings from these machines, they are more likely to end up harmed by unnecessary procedures stemming from false positive results than they are to catch and remove a specific cancer occurring randomly in their bodies.
Contrary to your claims, we do actually screen for certain cancers in cases where a clear net positive benefit can be demonstrated. Mammograms for breast cancer are one common example.
Doctors definitely aren’t just burying their heads in sand. These are common research topics and the tradeoffs of false positives are constantly being investigated. Full-body screenings aren’t necessarily a net benefit.
There's also a lot of politics and social psychology involved in these things. From the government side, it can be decades between arranging, deploying and evaluating large scale, population-wide cancer screenings. These are timescales on which scientific consensus can easily change. Mammograms in particular are a touchy subject, since newer metastudies only show a statistically significant reduction in mortality for women above the age of 50 and below the age of 74 [1]. However, many policy makers still offer screenings starting at the age of 40 with no upper limit, despite evidence that annual mammograms will result in a false positive result over 10 years with up to 61% probability [2]. Below the age of 50, regular mammograms may even increase the risk of dying from breast cancer [3]. Ultrasound screenings on the other hand would be much safer from a radiation-exposure point of view and metastudies suggest they can detect cancers under difficult conditions more reliably, but they also suffer from more false positives [4]. This is where the social aspect comes in, where many woman fear getting their breasts removed for no reason. This is especially concerning when more than 50% of positive results are found to be false positives [5]. To summarize: It's really hard to figure out what amounts to "net positive benefit" when it comes to general public screenings.
> Contrary to your claims, we do actually screen for certain cancers in cases where a clear net positive benefit can be demonstrated. Mammograms for breast cancer are one common example.
Not really; mammograms for breast cancer are commonly seen as an example of overscreening.
What is your medical background? I am a physician and do not agree with your thesis. Linking to ultrasound websites is not really evidence of anything.
There simply isn't good evidence that "all solid tumors caught early are curable." Some cancers, like localized breast cancers and certain renal cancers, are highly curable when caught early. Some other non-solid cancers like certain pediatric leukemias are also extremely responsive to therapy and highly curable. Conversely, some solid tumors, even when caught early, have dismal prognosis due to micrometastasis and the underlying biology of the tumor. I would recommend "The Hallmarks of Cancer" for a high level overview of the current understanding of what drives cancer: https://doi.org/10.1016/j.cell.2011.02.013
He has no actual clue, thats for sure. On top of all correct items you mention, some stuff is completely benign and should be left alone. Nobody will know that until operation or other, very invasive procedures are taken which have their own risks anf consequences.
Especially at older age, many things killing slowly are just too slow and other items will surpass them in achieving that kill, ie prostate cancer in basically all men (according to a close friend who is swiss urology surgeon its only question of time we all males get it, but most of the time you dont know about it and it progresses super slowly).
There are many things like this. That doesnt mean there isnt a room for improvement. I have some bad experiences too, but my wife is a doctor and medicine is HARD, every case properly unique. IT and stuff google et al do is trivial and deterministic by comparison.
We all would like this idea that medicine can cure it all, but we are far, far from it. But some folks apparently just love reading "10 things THEY don't want you to know about XYZ" articles and actually believe them.
Does a physician have a globally optimal understanding?
Do you actively read medical journals? Developments in biochemistry? Even amongst the best read physicians and researchers, I would bet my life that we're doing a lot of things suboptimally or have improper understanding of many diseases.
I'm not trying to belittle your understanding or your credentials, which I understand to be far better than untrained laymen.
The current state of medical care leaves a lot to be desired. We have a long way to go to detect and cure every disease state.
If more money is spent on developing better tooling, assays, imaging, etc. we will undoubtedly improve patient outcomes.
> Does a physician have a globally optimal understanding?
I’m far more inclined to trust a trained physician than a random HN commenter whose first four citations are just random ultrasound device manufacturer websites. The parent comment makes bold claims and tries to overwhelm the reader with non sequitur citations, but it’s clear they don’t actually understand the subject matter.
While I agree with your premise, how the hell do we know the parent is a trained physician? This is an anonymous forum. Without a long, elaborate history on HN or public credentials, to be of meaningful value in terms of trust (in the context we're discussing) the reply needs to bring a lot more to the conversation than a one line statement and claim of being a doctor. Maybe they are a doctor, great: they can add a lot more to the counter reply if so, information that they are in theory particularly equipped to discuss.
> While I agree with your premise, how the hell do we know the parent is a trained physician?
We don't know, but it doesn't matter. We can go to websites like the BMJ and see trained physicians and researchers saying the same thing across a range of different articles.
We can go to research organisations like NICE, or Cochrane, or the UK National Screening Committee to see doctors and researchers saying the same thing. For mass screening, the harm often outweighs the benefits.
A globally optimal understanding would involve far more than biochemistry and medical journals - population analysis, behavioral economics, regular economics, risk analysis, and a crystal ball would all be needed to avoid "doing a lot of things suboptimally". The fact that you haven't even mentioned those fields of study makes it clear you're not familiar with even the scope of the problem, let alone how to solve it.
Hell, we could improve patient outcomes enormously by paying for everyone to receive basic dental care, today.
Routinely scanning people without symptom or otherwise cause for concern is not a good idea. The human body is very messy and variable, and it's hard for anyone or anything to reliably spot thing that are actually worth acting on. If the doctor spots a vague blob - how can they know what it is without any symptoms? The course of action is then "come back in three months for another scan."
Subjecting a population to unnecessary routine full body scans, especially with radiation, will cause harm statistically. There are also countless examples of people undergoing unnecessary operation and suffering complications, like losing a perfectly fine healthy heart and requiring transplant.
We need yearly scans or even monthly scans (MRI) for everyone. Privacy concerns aside, I think we would learn an awesome lot. We could then monitor changes over time and machine-learning could probably get really good at recognizing what changes are harmless and which are harmful and need a doctor to look into.
It's a dream scenario, but maybe some day it will be like that. Or it will be like that and be dystopia. :)
That's not really going to help. For an MRI, you have to lay there being still, and for some you have to hold your breath, all while in a loud little tube. I have to get a couple every year, and I*m lucky not to find them too uncomfortable. Some folks, though, would have serious issues with the cage over your head when you get your brain scanned: Your brain and spinal column will take 45 minutes, as will other areas. You will need to be repositioned often, adding and removing things to get the pictures of all the areas.
In other words, you'll need an entire day off to do this if it is even possible for you to lay there for so long in one event, even if you get breaks. And for some folks it is going to be hours of torture.
Well, I wouldn't call them "fun tests" but otherwise that's true.
However, there is also a chance to save a lot of money by recognizing illnesses early. Sometimes it's possible to prevent a life-long need to take expensive medicamentation or it allows to detect cancer and allow for easy surgery in an early stage allowing for complete cure instead of requiring expensive chemotherapy AND surgery for a long time with a worse outcome. It might also very well prevent people from being unable to work due to illnesses if they are detected early enough.
And that all isn't even considering the changes in quality of life of course.
Yeah I think my last MRI was $800, with insurance. And they didn't find anything. I'm not exactly champing at the bit to spend the money to do that every year.
I've had like 4 MRI's total. The most recent one was I had a scare about a possible aneurism, which is what they didn't find anything for, and then had a couple for looking at my neck and back, where they found two bulging disks, one in the middle of my back and one in my lower back. And they had to check my leg for something once, maybe blood clots? I haven't needed to get one for several years now.
MRI's don't seem that great for an annual preventative check, since they are usually checking a pretty small area (or at least mine were). Like those were 4 different MRI's to check me from head to one of my calves. Getting 4+ of those a year would add up quick. And that's not even taking into account any of a myriad of other tests that could be done every year. I'm sure I could probably take a different test every week of the year, but I'd be bankrupt quick.
Why would you jump to an absurd scenario like one every week?
It would be an enormous benefit to do one MRI a year, rotating between areas of interest, at a relatively negligible cost ($500-1k or so per year - about what it costs for an annual physical).
It's extremely cheap compared to your Dr's hourly billable rate and would get cheaper at scale.
"20% of americans havent even seen a doctor in the last year"
And 80% have. The needs of the 80% are not determined by the behavior of the bottom 20%
Rich people get better everything, including better medical care. The upper 30% or so can afford better diagnostics and they should be getting those better diagnostics.
Many of us in the software industry could afford a few extra thousand a year for preventative care -- but it is very difficult to obtain care commensurate with one's ability to pay. This is a real problem.
> especially with radiation, will cause harm statistically.
Ultrasound is not radiation (as in photons). To the best of our understanding (from a physics/engg perspective) ultrasound imaging capped by appropriate energy/etc limits is expected to be perfectly safe. Likewise with MRI. If we want more pointed study to be sure of this, that's fair, but let's be clear & specific about it and commit to figuring it out one way or another so we don't repeat the same discussion a couple of decades down the line. (We have to think of moving the state of the art forward, instead of festering in unresolved disagreements)
Further, if you're concerned about under-studied possible side-effects of radiation from occasional diagnostic testing, what do you plan to do about being blanketed by mm waves once 5G gets deployed more ubiquitously?
> There are also countless examples of people undergoing unnecessary operation and suffering complications
This sounds far more serious (and fixable) compared to the physics/biology interaction of diagnostic testing. Why do we continue to bury our heads in the sand collectively, instead of trying to fix this with better decision-making tools?
MRI isn't radiation, but is sometimes used with contrast dye. People can be allergic to the dye. For one person this is a small risk. Across a population we'd be causing harm. We'd balance the risks of harm against the benefits, and so far no-one can find a benefit to routine whole body MRI scans. And if the benefit was there the MRI machine companies probably would have found it by now because it'd massively increase the numbers of machines they could sell.
MRI uses electromagnetic radiation. MRI uses a magnetic field with a radio-frequency pulse and then the protons emit a radio-frequency response - that response location is used to synthetically generate the image. MRI does not use ionising radiation. Nice overview here: https://www.nibib.nih.gov/science-education/science-topics/m...
You've misread their reply. MRI's sometimes use contrast dye. I've personally had these sorts of dyes, both on brain and spinal cord scans (I have MS and get these regularly) and for the first scan of my pancreas (non-symptomatic cyst they are watching to be cautious).
Wouldn’t the skill of analyzing scans improve if they were done more frequently?
It seems like you’re promoting a self fulfilling prophecy. Doctors aren’t good at reading scans, so scans will cause false positives.
But doctors are capable of learning and improving their skills. They will surely rapidly learn to screen a lot of false positives, thereby saving lives.
You seem to assume that radiologists currently see patient scans too rarely to deliver accurate diagnosis. That seems very unfounded to me.
"More frequent scans per patient" != "More scans seen per clinician". You would just end up having to hire more clinicians.
(Yes, your family doctor might end up seeing more scans in this scheme, but it is implausible that they would be better at evaluating them than a trained radiologist, which is who this would almost surely be deferred to anyway.)
Is the argument then that scans are intrinsically error prone, as in the noise level is so high that even a team of highly trained radiologists can’t accurately determine if cancer is present from a scan?
It's not the quality of the scan (although that can certainly be a factor). It's that there is a lot of variation in human anatomy, and "these pixels are brighter than the rest" can mean any of many things.
Relatedly, for many types of brain tumors, you simply don't know what exact kind of tumor it is until you actually do a biopsy (= you undergo surgery). This can be important information ("how aggressive is it?"), so in some hospitals it is common practice to send a tissue sample for identification and get back the result while the surgery is still going on.
This is a very naive argument, it assumes the entire problem is lack of skill and that early intervention on positive diagnosis is always a good thing.
Mammography is a really good candidate for random screening and it's still debated because of false positives and the impacts of misdiagnosis.
the screening guidelines take into account those risks and it's still deemed worthwhile because cancer can grow and become lethal despite being asymptomatic. colon cancer is the mid-life killer...plenty of ppl in their 50s or even 40s get it despite no risk factors. Screening is the only option to catch it early.
This is just silly. You are never disadvantaged by knowing more about what's inside your body. What you don't know can easily kill you, though.
Hopefully in the long term future we will have extremely cheap & frequent MRI and blood testing so you can assemble a high resolution digital history of your body. Doctors are generally not very innovative people though and they will probably resist it to the end.
It's not silly. Look at how the mammogram guidelines are set. If the scans are too frequent, the harm done from false positives (unnecessary surgeries and risks from those surgeries) can become too great. The standards were relaxed to include fewer scans in the last few years because of this.
Apply this to more invasive exploratory surgeries, and you see people dying from internal surgery complications for benign cysts and lumps.
That's because single datapoints are used to trigger intervention. We should be intervening based on growth trends from time-series data. Time-series data which can only be collected by... frequent scans.
Don't discount psychological stress. "You have something growing in your breast which might be cancer, just wait a few months and we'll scan again" is not something that gives people a good nights sleep.
So don't tell them. Like I said, a single datapoint by itself is meaningless — so you wouldn't bring it to the patient's attention. Heck, the software shouldn't flag it for the doctor's attention. (Think: metrics-based alerting thresholds in software systems.)
We do have time series data for mammograms. You may think it doesn't meet whatever standard you are setting, but it is objectively false to say it isn't there.
My standard is "doing it for everything, rather than for one thing"; and more importantly, not acting upon data about chronic disease progression, if it isn't a time-series.
In science, you don't call one datapoint "data." You call it an anecdote. Outside of emergency medicine/urgent care, medical practice should be the same.
I honestly can't imagine how you believe breast cancer is diagnosed and treated, but it's clearly inaccurate. So is the cute phrase about "in science".
You didn't understand what I said. Breast cancer screening is the "one thing" I referred to that we're doing right. But who cares if we're doing one thing right? We're doing screening for literally every other cancer wrong. And not getting any less wrong over time.
We — the medical profession in general — are aware of the proven effectiveness of time-series analysis of regular mammograms as a screening technique. However, we have failed utterly to spread this "obvious" knowledge out from the specialty that understands it and has proven its effectiveness, to literally anywhere else. We've been doing regular mammograms for decades now, but that hasn't sparked (wide) adoption of regular scans + time-series-based screening for any other cancer.
There is a certain moral culpability in that. A certain negligence of duty / not seeing the forest for the trees in what it means to be saving lives. (I hypothesize that doctors in at least some specialties, could save more lives over the course of their career by dropping their practice and instead turning into advocates for wide adoption of periodic-scans + time-series-analysis-based screens. Somewhat like would have been true of a doctor in the 1800s quitting doctoring to instead become an advocate for hand-washing before surgery.)
You're right, I had absolutely no idea that you thought we were doing breast cancer screening right. And I don't know if you're now failing to communicate your awareness of regular screening for prostate and cervical cancer, or skin cancer in higher risk locations, or if that doesn't count somehow, or what. I also don't know if you have any evidence for the existence of these other tests that we could be doing on everyone and the risk-benefit profile that shows we should be doing them, or if you're assuming such tests and evidence exists, or complaining that we haven't invented the tests that must be theoretically possible.
It can be hard to predict how aggressive a tumor will be. It isn't uncommon for people to obtain cancers that they "die with" instead of "die of". In those cases, treatment can be worse for the patient than the cancer. But since you don't know which it'll be, people get the treatment and sometimes wind up worse off than they otherwise would have.
And as the GP post cites, the scans themselves can cause health problems down the road. Performing them on massive scale will increase the occurrences of those side effects.
Knowing that there is something weird in your body sets off a cascade of medical care that easily escalates to surgery, anesthesia, medication to manage complications, side effects of that medication, time in the hospital being at risk for infection, etc. These things absolutely can kill you, or at least put you through hell. When there was actually nothing wrong with you in the first place. That is why the medical establishment is so conservative about it.
Isn't the danger of knowing there's something weird there caused by the rarity of knowing anything at all?
I'd imagine that if there was consistent, good information available, we'd figure out how and when to act on it. The real issue is the massive cost of performing any given scanning procedure to everyone alive.
The question is not even what doctors think warrants a follow up. The question is what a malpractice attorney could construe as warranting a follow up, if it turns out later to have been real.
Once a scan exists, doctors are essentially forced to act on it. If an algorithm for deciding which scan results to pay attention to were so solid that it would hold up in court, that might make more scanning reasonable on the margin? I dunno though.
I think modern medical ethics demands a physical treatment for literally everything and anything that's discovered, including quite a few that either aren't physically dangerous (e.g. atypical brains) or are inevitable (a 90+ year old with a laundry list of conditions). And, as other comments have pointed out, a panicked surgical response to a mammogram isn't based on time series data.
I totally understand and agree with trusting that medical professionals "know better", but I also would not conflate current practices with absolute perfection. It's clearly not a perfect profession or practice.
You don't have to conflate current practice with perfection. You just have to bother learning what the current practice is and why - and "it's just so rare to know anything" is not the correct answer. Just to start with basics: yes, actually mammograms are analyzed using time series data of a patients previous scans!
Full body scans, as they currently exist, are not recommended for routine-usage. These scans use large amounts of radiation. This can increase your risk of cancer. If you have more tests, your risk increases.
Further, they are costly, and often times insurance does not reimburse or cover it. They can cost anywhere from $500-1000.
Unless you find a way to make this viable for the general population and lower the radiation exposure, this will never become viable for use.
I'm a physician that uses ultrasound every shift, and I'm pretty darn good at it. I've even used one of the specific devices you linked to.
Virtually every physician I know is foaming at the mouth to learn more ultrasound and to apply it to new indications and with new approaches. Inappropriate use of ultrasound for harebrained indications (for which we have far superior alternatives) is on of my pet peeves.
I am not a cancer doc, but I am drawing a blank as to what solid tumors you could possibly be referring to for which ultrasound is the preferred screening or diagnostic technique, or what kind of conspiracy you're vaguely implying that prevents its use. IME, virtually everyone is (over?) eager to use ultrasound for every condition under the sun, and I am sincerely perplexed as to what experiences have led you to form your opinion on this matter.
POCUS is used commonly in my experience and there are large amounts of curriculum devoted to it. We haven't had affordable access to POCUS for decades so I don't see how doctors have refused to learn it for decades.
Probably not. Costs have come down immensely, most HN users could afford a butterfly if they wanted to play around with it.
Ultrasound has limited penetration for deeper tissues so you aren't going to see lung cancer with it (especially behind ribs), and overweight patients don't image as well, again because of limitations in imaging depth. Regardless of uptake it's not going to solve all our diagnostic challenges.
It also takes skill to know what you are seeing and to know how to find what you're looking for. Anyone could learn, but it's a time investment and physicians have limited time as is.
Still, it is becoming more popular and soon it won't be uncommon for your primary care doc to pull out the probe and see if your gallbladder is inflammed or if that abscess is going to be amenable to in office drainage.
"Doctors have for decades refused to learn to use this technology"
In Sweden this is actually standard practice. It's used for patients who have syndromes that guarantee them to get cancer several times over in their lifetime. IIRC some get an MRI every 6 months. The reason it's not done to a wider population.. well you can't justify the cost in a state funded healthcare system. The health benefit just isn't justifiable when MRIs are so scarce and expensive to run.
> Virtually all deaths from solid cancers are preventable with routine scans to find tumors before they metastasize.
Fantastic. I take it from those links this would be detectable with a full body MRI? I already wanted an excuse to start getting those regularly.
> Compare the experience of getting an x-ray from a dentist to getting one from a doctor. Or getting an ultrasound from an OB to getting one from any other doctor.
Can you expand on this? It sounds like you're implying something (I might agree with), but am not sure.
> Fantastic. I take it from those links this would be detectable with a full body MRI? I already wanted an excuse to start getting those regularly.
There is a lot of research on the topic but it doesn’t agree with the OP’s thesis. Full body scans can be purchased if you have the funds, but you are far more likely to get false positives than to actually catch a cancer this way. The ensuing medical costs and possibly even unnecessary surgeries are statistically likely to cause you more detriment than any benefit you might receive. This is counterintuitive to many, but the truth is that it’s not actually easy to spot nascent pre-symptomatic cancers from full body scans without incurring a massive number of false positives along the way. Something like 1 in 8 people will end up getting flagged for “warning signs of potential cancer” during these scans that turns out to be nothing upon further investigation. Few people continue to get the tests for this reason.
If you're looking for a hobby, it's 2022 and you can buy better-than-a-potato ultrasound gear on eBay for less than $1000. Also, cheap ECG amplifiers are quite available these days.
I think the difference is that ultrasound/imaging is routine annual from dentist and monthly or whatever from OB during pregnancy, but otherwise requires a specialist referral for a specific injury or complaint.
It's also the case that a pregnancy is a hugely obvious invisible but major health situation, and teeth are expected to rot frequently.
There is a fair amount of scientific study that has linked diet to some cancers. Those same diet attributes that can make one obese also lead to higher rates of cancer.
Wait, so I've been avoiding McDonalds all this time for no reason? I literally lost a GF because I decided to skip eating one afternoon when the only place close to us was McDonalds!
Meanwhile, population studies like the one this article is based on[10] are horseshit because they are subject to unknown degrees of sampling bias, rely on enormous assumptions (such as linear relationships which may not hold at all being applied over many orders of magnitude), and cannot in any case establish causality.
[1] https://www.pocus.org/ [2] https://www.butterflynetwork.com/ [3] https://www.exo.inc/ [4] https://vavehealth.com/
[5] https://ezra.com/ [6] https://www.halodx.com/ [7] https://www.prenuvo.com/ [8] https://www.simonone.com/ [9] https://www.lifeimagingfla.com/
* Compare the experience of getting an x-ray from a dentist to getting one from a doctor. Or getting an ultrasound from an OB to getting one from any other doctor.
[10] https://pubmed.ncbi.nlm.nih.gov/35988567/