I have a few non-authoritative comments regarding recent and current medical developments. This concerns the flu (esp. the H1N1 Swine Pandemic Flu), and the two recent changes in screening recommendations, for breast and cervical cancer and related issues.
Regarding the flu, we are seeing more evidence that a peak has passed in the H1N1 outbreak. What you need to know if you are in the US is that as of today, the CDC has NOT declared that a peak has passed here. The number of states with "outbreak" level occurrences has dropped and the number of children who die per week has gone down a little, but it is too early to say if a peak has actually passed.
What you need to know is this: Starting over the next few days, Americans start to travel in large numbers. This is very likely to increase exposure and enhance the spread of H1N1 and any other respiratory viruses that happen to be hanging around. Perhaps we will start to see the appearance of seasonal flu, perhaps we will see an increase in H1N1 infection. If there is an increase in H1N1 infections over the last several days in November, we will be looking back at this month and we will be tempted to engage in a trivial debate as to whether or not there was a peak and then another peak, a non-peak with some variation, or a hump on a peak, or yada yada.
The point is that the immediate conditions under which the flu spreads are winter time conditions that are arriving as we speak, and the larger scale conditions under which it may spread ... increased travel ... will be a major factor over the next several days and again in late December and early January.
It would be very reasonable to assume that the highest rate of infection ... the tallest peak in the data across time ... will happen over the next month or two.
Now, on to mamograms and pap smears. I have not read the papers, I have not read much of my fellow science/medicine/public health fellow bloggers' commentary. I will, but to date I've been busy with other things. So, this comment is short and sweet and based entirely on what I've heard on the news, and is subject to revision:
It seems to me that we were making mistakes before based on the information that was gathered as part of frequent screening. We were finding indications of possible problems, then treating problems that really were not there.
It seems to me that the solution being recommended is this: Let's have less information at hand so that we don't fuck up our use of that information. If we don't have information that we can misuse, then we can't misuse it.
It seems to me that it would be better to use the information better than to reduce the amount of information.
It seems to me that these recommendations are the end result of a neocon-esque analytical approach that assumes that people learning and knowing and acting apropriately on scientific information is nil and can't be improved.
It seems to me that such an attitude totally sucks. Am I wrong?
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You do not appear to be wrong. The actual future data will show us the truth. They can not hide the deaths.
"It seems to me that it would be better to use the information better than to reduce the amount of information."
Exactly how would this be done given current technology?
DR: An indicator such as a small mass in a breast is said to lead to surgery, but the surgery is now believed to be often unnecessary. So, the new standards fix this by not k nowing about the lump. I'm simply suggesting when the mass is found, its meaning is assessed more intelligently and the action that is taken is more appropriate.
As you said yourself, you haven't read any of your fellow sciencebloggers posts on this yet. Do it and I am sure you will change your mind. If the data that we get at the moment is not good enough to guide our decisions in such a way, that we don't create more trouble than we actually help, then the data should not be collected. If medical scientist create better screening methods with higher sensitivity/specificity and/or better treatment-biopsy methods, then the guidelines will have to reassessed. Until then, it seems reasonable to go with the guidelines that just came out.
If anyone knew how to better distinguish a life threatening cancer from a tumor that would never have become clinically manifest, or worse, from something that is not even a cancer, then it would probably already be happening in the US, as you could probably charge more for it as well.
beeb: I dunno. I'm pretty sure I'm never going to change my mind about this ...
If the data that we get at the moment is not good enough to guide our decisions in such a way, that we don't create more trouble than we actually help, then the data should not be collected.
... beging the dumbest thing i've read all week. Since when is our inability to use data as well as we like a reason to do the three monkey thing?
Oh, wait, there's this:
If anyone knew how to better distinguish a life threatening cancer from a tumor that would never have become clinically manifest, or worse, from something that is not even a cancer, then it would probably already be happening in the US, as you could probably charge more for it as well.
Really? Does this apply to all research? If so, then the research is done, yes?
What we really have here is a case of me, the blogger, violating (on purpose, thoughtfully, but maybe regretfully) the Numbah One Roole of Blawging: Never indicate that there is something you don't know. Why? Because this will induce in others a feeling that somehow THEY know.
Seriously, you have told me that if I read XYZ I'd change my mind. Citations please?
I really am interested in changing my mind if appropriate. But I need something quantitatively more and qualitatively different than you are giving me in this comment.
Looking forward to your response.
I'm simply suggesting when the mass is found, its meaning is assessed more intelligently and the action that is taken is more appropriate.
That'd be great, but it's not clear that we have the capability to better assess things at the moment. That's the big problem. Whenever we get good biomarkers, or whatever, then I'm sure the recommendations will change drastically to screening at younger ages.
What articles?
It's easy to imagine situations in which less screening can be recommended and without an increase in adverse outcomes. For example, paranoia or self-promotion may have lead to too frequent a screening and the historical information shows that it is not necessary. You do need to be extremely careful about medical claims though; there are people out there who might have something valuable to sell but rather than sell it honestly they'll make claims which simply are not true. Far more common are people with something of almost no value to sell and who make insinuations that their product is valuable. If you see any article which mentions "epidemiological studies" you can safely dismiss it as nonsense; first of all such studies only suggest a correlation - to which any decent scientists will shrug and say "so what?" Epidemiological studies are also used almost extensively for 'data mining' to support false assertions; the technique seems to be: (1) get a lot of worthless data, (2) ignore most of that worthless data to find a few bits that you can use to con the unwary into believing your claims.
You asked for articles by others. So there's Orac:
"Obama's fixin' death panels for your mama": The USPSTF recommendations for mammography used as a political weapon
"Obama's fixin' death panels for your mama," the misogyny gambit, and other idiotic responses to the updated USPSTF mammography recommendations
Really rethinking breast cancer screening
MarkCC also talked a bit about the thought matrix behind coming up with these decisions:
The Balance of Screening Tests
Over at sciencebasedmedicine, David Gorski also discussed the topic:
The USPSTF recommendations for breast cancer screening: Not the final word
Those are the ones I've seen off-hand, I'm sure there are others. Recommendations like this are always a bit subjective; it's never entirely clear how much risk is reasonable to suggest people take, so it's unsurprising that there are disagreements.
Based on the research I've been doing lately about cervical cancer, the rate of progression of the disease does seem to warrant a recommendation for less frequent screenings. In the early stages, the treatment is generally watch and wait anyway.
However, this is only the case if people are actually compliant with the new recommendations. My one concern with this change is that many people will stretch the timing out even further given that the recommendation is now for less-frequent screening.
The big medical cost for this is indeed people simply seeing their OBGYN (or whomever) often enough. PAP smears were to doctor visits what daylight savings time is to the batteries in the smoke detectors.
âAm I wrong?â
Well for a start it might be more appropriate to blame socialism rather than neoconservatism for the analytical (aka science/evidence based) approach to medical screening: http://www.cancerscreening.nhs.uk/index.html ;-)
Paul: You are conflating and confusing several issues. Like the difference between recommendations and policies.
No Greg, I am not. It seems to me that I've seen a little more of the information relevant to deciding what constitutes good medical screening practise than you have. Then again, I'm not an expert in the field and don't feel qualified to point out what I believe to be the stupendous irony of your position. So I'll leave it at that. :)
DR: There is also the piece by Revere, came out today or yesterday. The more I look into it the more I feel confident in my position that while the recommendations may make sense in a certain analytical world, at even the most basic meta level it sucks to say that we will solve our inability to use the knowledge we have by avoiding the knowledge rather than increasing our ability to use it.
Paul: You are not making any sense but you have become the current canonical example of Greg's Blogging Rule Number One. I appreciate that!
The more I look into it the more I feel confident in my position that while the recommendations may make sense in a certain analytical world, at even the most basic meta level it sucks to say that we will solve our inability to use the knowledge we have by avoiding the knowledge rather than increasing our ability to use it.
I don't think anyone disagrees that it sucks to say that, but it is the way it is. I'm not sure what you're suggesting as an alternative. We have to work with what we have now, not what we might have someday. It's not like changing recommendations will stop people from trying to improve techniques and usage.