While most people are unaffected by testing, a few will be helped, and some will be hurt. To be helped you must have a cancer you are destined to die from if not tested. Note that that sentence contains two requirements: (1) the cancer must be one that's destined to be lethal and (2) it must be treatable if found by the test but not treatable if found later.
It is a little harder to define who will be hurt. Two groups can be singled out: those who will die of cancer anyway with or without testing; and those not destined to die of cancer (that is, those destined to die of something else).
To be hurt, people from these groups must suffer a considerable loss attributable to the testing process: they may experience undue anxiety, or learn about their cancer years before it was destined to become a problem, or experience morbidity (and occasional mortality) from a treatment that wasn't needed.
So you might envision two strategies to improve the odds of "winning": increase the chances of being helped and decrease the chances of being hurt. In this gamble, we can identify groups of people who are more likely to come out on top:
People at high risk to die of the cancer being sought. If the combination of early detection and treatment works, it is most likely to work in high-risk people: those with strong family histories (genetic predisposition) or with substantial exposure to known carcinogens. Abnormal test results in this type of person more likely to be significant and much less probably be false positives.
This type of person more likely than most to have real disease not pseudodisease. In short, the greater your chances are to get the cancer, the much more likely the potential benefit from testing exceeds the potential harm, and the more reason there is to try to find cancer early. People in relatively good health. Remember, the whole idea of early detection is to try and get ahead of the cancer. Getting ahead is measured in terms of years. For any of this effort to be worth it, you should have a reasonable expectation that you will be alive in the next decade.
The careful reader may note a contradiction between these two groups of people. Because the risk of dying of cancer rises with age, the defining characteristic of the first group argues for screening the old. Yet because life expectancy decreases with age, the second argues for screening the young. As with many things, the ideal is somewhere in the centre. Testing for cancer is most likely to benefit those who have both a considerable risk for cancer and a considerable life expectancy that is, middleaged people, roughly age 50 to 70.
People who can be patient. The most important cancers tend to announce themselves clearly: the tests are unambiguously abnormal and all observers agree that it's cancer. But you need to be ready for small, questionable abnormalities as well. Probably the best way to minimize the harmful effects of screening is to be willing to snap time with these. Too often, big decisions are made based on a single observation, when it makes better sense to wait and take further readings.
The best response to an abnormal test, therefore, may be to check it again in a few months. When one pathologist says the abnormality is a small early cancer, it might be worthwhile to ask a second pathologist to take a look. And even when "cancer" is agreed on, it may make sense to wait and be sure the cancer is really growing. Watchful waiting can be hard. Patience takes courage. Moreover, it seems contrary to the conventional wisdom about cancer, which is that one must act fast. But patience is generally a virtue, also it can help save you from overtreatment.
People whose doctors understand that early detection is a two-edged sword. To be honest, watchful waiting is hard for doctors too. Think about it: I'm watching a patient's cancer.
While the semiannual scan has become routine for him, I feel like I am waiting to be proved wrong. I think I'm doing the right thing, but I'll never know for certain until he dies from something else. Had we decided to take the cancer out, I could never be proved wrong even if he died to undergo the knife. To avoid being proved wrong, it is always safer for the doctor to treat even if that is not the best course for the patient.
This kind of patience does not come easily for doctors. Many of us are from the "when in doubt, cut it out" school. Watching an early cancer entails a considerable paradigm shift. Because it is no fun to fight your doctor on this issue, you will want to make sure your doctor are able to see both sides. You want a doctor who can see beyond simply doing everything possible to avoid "missing cancer," who understands that acting on every abnormality is overreacting a prescription for overdiagnosis and overtreatment.
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