The worst thing can be, not knowing what to be afraid of

The word “cancer” is terrifying for most people who hear it. When the general public is informed of the risks of heart disease and diabetes, most stay indifferent. But the moment you speak of even a minimal increase in the risk of cancer from any source, people are up in arms.

This is a classic example of why it is so important for a physician to be up-to-date not just on the physiology of the human body and the pathology of a disease, but also on the statistics of various illnesses. The doctor needs to be able to calm a patient when the patient has a phobia about certain medical risks, and the same doctor needs to warn the patient when that patient fails to appreciate the risk in their behavior.

The statistics about diseases are coming more and more from larger and larger centralized collections of patient data. The more data you have, along with the software to analyze it, the better you can advise a patient on the options available for staying healthy and/or curing a new disease and/or screening the general population for this disease.

A graph that I saw on Twitter speaks of the statistics of overdiagnosis of cancer. Of course, the initial reaction of many to such a statement is that “how can there be over diagnosis of such a dangerous disease?”. Many will say that even if there is the slightest chance of a cancer, then it is worth being as aggressive as possible in removing it, and treating it with additional therapies.

The flaw in this mindset is that it assumes that a full diagnostic workup, and then aggressive treatment, have no negative side effects. A classic example for this is prostate cancer. Screening for prostate cancer became the standard of care about 20 years ago when a blood test called PSA became available. This blood test highly correlated with the presence of prostate cancer, and thus was thought to be the magic bullet for identifying prostate cancer before it caused any harm.

It took 15 to 20 years to complete major .studies that truly assessed the benefit of using PSA to screen for cancer. Unfortunately, even after all this work and all this time, there still remains controversy as to the value of PSA in screening for cancer. However, the general sense from all of the research is that screening actually has minimal [if any] benefit. Therefore, I personally would choose NOT to screen myself nor my patients for prostate cancer using PSA.

When a man does have a high PSA, the next step still often is an invasive biopsy of the prostate, which is far from a comfortable procedure. Then, if according to the biopsy, there appears to be significant cancer, the patient may very well be subjected to aggressive surgery or radiation.

Both of these treatments, while effective against cancer, have very serious side effects. There are of course the basic risks that come with any major surgery: bleeding, infection, damage to other healthy organs and so on. In the case of prostate cancer treatment, many patients are left impotent and a significant number are left with difficulty in controlling their urinary flow [which is called incontinence]. While these last two complications might seem like a small price to pay for sparing oneself metastatic disease, these new problems can be life-changing and cause depression and lead to loss of work and marital strife.

The big issue with prostate cancer is that despite the finding of cancer cells on the biopsy, it still may be that doing nothing would be sufficient. It could very well be that this particular cancer is very slow growing and thus would not harm the patients before he passes away from natural causes or from other diseases that he may have [like heart disease, diabetes, emphysema and so on]. There are estimates that 60% of the patients who are treated for prostate cancer could have been left alone without any negative effects. This is the kind of information that people must have when they are deciding on the next step in their assessment/treatment [or lack thereof.]

Breast cancer is also still a highly controversial topic. There are some large studies that would argue that screening adds little to the lifespan of the patients, while subjecting many women to disfiguring surgery and/or radiation therapy and/or chemotherapy.

While there are standard recommendations for the management of prostate and breast cancer and many other cancers, these recommendations will likely change as more and more data is collected on outcomes from treatment versus lack of treatment (which is also called “watchful waiting”). Watchful waiting means that you regularly call the patient in for general exams and even do follow up x-rays and CT’s and blood tests. But until you see some dramatic change in some test, you only continue to watch.

As I just noted, recommendations for the management of cancer, and for all diseases, will change as we collect more and more data. The kind of data that we collect might initially seem unrelated. For example, regularly measuring a person’s blood pressure does not intuitively help in predicting cancer. But if we were to have the data from the constant monitoring of blood pressure [via smart watches, for example] from millions (or billions?) of people, we might in fact discover that there is a correlation between developing cancer and blood pressure.

It is not beyond imagination that a cancer could release factors into the bloodstream that have an effect on blood pressure, either raising it or lowering it. And it might very well be that blood pressure does correlate with some cancers but not with others. In other words, we just don’t know. What would be ideal at this point is to collect as much data as possible about as many different parameters as possible and then have all of this data analyzed by really smart people using really smart software.

In the world where new sensor devices are being released to the public on a very frequent basis, it would really seem that privacy is a lost cause. And I do actually believe that. I personally am willing to forgo some of my privacy (actually, alot of my privacy), if there is a chance that the data collected from me, will help in finding the correlations that will predict disease.

When people say that they want to contribute  to curing a disease, sometimes the best contribution is their personal data. If, for example, we are tracking vital signs on every child and adult in the United States, then when any one of these individuals becomes ill, we will have the data to look back at and see if there were any warning signs within old vital signs. The discoveries that are waiting to be found are likely very many in number. The more data we collect, the greater the likelihood of uncovering critical medical information.

I personally believe that we are on the cusp of a whole new medical world when cancer will no longer be the fear inducing term that it is today. When that day comes, that we can detect all cancers earlier on and know which ones will require treatment and which ones can be left alone, then we will have succeeded in sparing millions of people unnecessary pain and suffering, while treating only those people who really need it. And when the next stage after this comes, that all cancers are curable, my only regret will be that my own brother was born too early to benefit from these treatments.

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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