Headlines That Confuse and Medical Trials That Prove Nothing

Two large trials looking at prostate cancer screening were published in The New England Journal of Medicine on March 26, 2009. Summary: the US trial showed no benefit to screening. The European study showed a 20% reduction in mortality among the screened group.

Net effect on medical mandates from government: stop looking for prostate cancer as it doesn’t kill that many people and finding it doesn’t make any difference.  The European study looked at screening every four years. The US study looked at 6 PSA tests and 4 digital rectal exams (DRE) in 10 years vs. ‘usual care’; whatever that means and however that is done in the community. No thoughtful doctor would willingly meet such low standards unless his HMO told him to and he didn’t have any high-tech imaging and diagnostic options. Junk science yields junk. Be sure you are in the hands of a doctor who knows how to think as well as how to do well in school.

Many newspapers had articles outlining the cost of ‘false positive’ tests in terms of money and, frankly, suffering and loss.  What no one mentioned, in the studies or the editorials, is the well described, clear, and beneficial path of the proper use of PSA studies, the optimal type of imaging that reduces and nearly eliminates seemingly random testing and surgery associated with a low-tech approach to positive PSA results and the known and published morbidity and mortality advantages to such a careful, high-tech diagnostic and therapeutic pathway.  Get your PSA done very regularly and make sure you don’t submit to random punch biopsies is the only direct take-home from these studies. But I have a broader point to make.

About twenty years ago medical science turned from discovering the optimal diagnostic and therapeutic approach to disease and began instead to structure and interpret ‘scientific studies’ in the utilitarian and feeble light of ‘cost-benefit analysis.’  Whose cost and whose benefit soon became a quest for an equation focused on social costs rather than individual benefit. I won’t rehearse for you how fungible, how malleable the definition of ‘social cost’ can be and in fact is for various medical and governmental bureaucrats.  I personally know people, I bet some of you do too, who have died of prostate cancer in their 50’s and colon cancer in their 40’s. They very likely would still be alive today had statistically meaningful screening studies been done. Colon cancer occurs in about 1 in every 250 people in their 40’s: no one looks.

The same crazy numbers hold for prostate cancer.  Push back.

The End of Medicine is here! The apotheosis of everything modern pharmaceutical medicine has been striving for has arrived: The Polypill. You surely saw the headlines: “miracle pill prevents heart disease.”A pill guaranteed to cause fat weight gain, induce diabetes in about 10% of users, increase the incidence of impotence, insomnia, depression, fatigue and in rare cases cause kidney failure and death has now been used in human studies in India.

If you lay down, eat bad food and only bad food, never sleep well, worry constantly, and have no hope of every being any better; if you do not ‘rage against the dying of the light’ if you have given up, want everyone you know to give up, think the entire human population aspires to nothing other than some version of becoming vegetation then The Polypill is for you and in fact may soon be available at your local pharmacy.  When you are playing chess and see your opponent make a fatal mistake in what has already evolved as an end-game you sometimes smile to yourself. The Polypill makes me smile just so.

Have a heart attack, you already feel bad, take the first pill or two, and then month by month take more pills you think the fatigue is just your disease and no more or less than you deserve. But go to the doc feeling generally well, have a relative who had a heart attack, and then your doc gives you The Polypill and a few weeks later you feel like your 90 then people will start to connect the dots and say ‘no’ to poor medicine.

Again I say: Push back.

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