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					                                                                                                                            today Wednesday october 12, 2011                          18

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   you have to gamble on your health                                                easy one — do it. Instead, both breast and                                       abnormalities, which leads to the two              is some debate about whether they really
                                                                                    prostate cancer screening are really dif-                                        basic harms of screening: False-positive           exist, my reading of the data is that they do,
                                                                                    ficult calls, and the statistical differences                                    tests and overdiagnoses.                           but they are few and far between — on the
                                                                                    between them are only of degrees.                                                     False positives are really common in          order of less than one breast or prostate can-
                                                 H GILbert WeLcH                         Personally, as a 56-year-old man, I                                         both breast and prostate cancer screening.         cer death averted per 1,000 people screened
                                                                                    choose not to be screened for prostate can-                                      Approximately 15 to 20 per cent of women           over 10 years. That’s less than 0.1 per cent.

E   arly October brought two developments
    in the world of cancer screening: The
beginning of Breast Cancer Awareness
                                                                                    cer (and, were I female, I believe I would
                                                                                    choose not to be screened for breast can-
                                                                                    cer). Some of my patients have made the
                                                                                                                                                                     and men who are screened annually over
                                                                                                                                                                     a 10-year period will have to undergo at
                                                                                                                                                                     least one biopsy because of a false-positive
                                                                                                                                                                                                                             Overall, in breast cancer screening, for
                                                                                                                                                                                                                        every big winner whose life is saved, there
                                                                                                                                                                                                                        are about five to 15 losers who are over-
Month, with its calls for regular mammo-                                            same choice, while others choose to be                                           mammogram or PSA — prostate-specific               diagnosed. In prostate cancer screening, for
grams for women, and a new recommen-                                                screened. That’s okay, because there is no                                       antigen — test.                                    every big winner there are about 30 to 100
dation from the United States Preventive                                            single right answer.                                                                  It’s a matter of opinion to what extent       losers. You may look at these numbers and
Services Task Force that healthy men not                                                 Screening is like gambling: There are                                       patients with false-positive tests are losers      decide that both tests are good gambles —
undergo screening for prostate cancer.                                              winners and there are losers. And while the                                      — the physical complications of biopsies           or that both are bad gambles.
     It’s a stark juxtaposition: Screening                                          few winners win big, there are a lot more                                        are generally short-lived. But they certainly           Or you might try to distinguish be-
is good for women and bad for men. But                                              losers. It’s easy to understand why.                                             don’t benefit from the procedures. And in          tween the two. Overdiagnosis is more com-
just how different are these two cancer                                                  When doctors screen for early can-                                          the interim, they’re made to worry that            mon following prostate cancer screening
screening tests?                                                                    cer, all the incentives — cultural, finan-                                       they have cancer.                                  and is arguably more consequential, as
     The answer is: Not very. Neither is like                                       cial, professional and legal — line up in                                             Overdiagnosis is less common, but             there is a higher risk of long-term compli-
the decision of whether or not to be treated                                        one direction: Don’t miss it. As a result,                                       much more consequential because it leads           cations from prostate cancer treatment. So
for really high blood pressure. That’s an                                           doctors overreact to even the tiniest                                            to unnecessary treatment. Screening finds          maybe mammography is the better gamble.
                                                                                                                                                                     abnormalities that meet the pathological                Or you might make a different calcula-




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                                                                                                                                                                     definition of cancer, yet will never go on         tion and consider what happens without


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                                                                                                                                                                     to grow or cause any symptoms, let alone           screening. For breast cancer the first sign
                                                                                                                                                                     death. Sometimes patients choose to wait           is typically a breast lump, which in most




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                                                                                                                                                                     and see if the cancer grows, but most opt to       cases can now be treated very successfully.


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                                                                                                                                                                     treat it; once you’re told you have cancer, it’s   (The real success in the war against breast
                                                                                                                                                                     difficult to wait and see what happens next.       cancer has been improved treatment, not
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                                                                                                                                                                          Patients who are overdiagnosed are
                                                                                                                                                                     the big losers here. They undergo surgery,
                                                                                                                                                                                                                        screening.) But the first sign of prostate
                                                                                                                                                                                                                        cancer typically occurs too late for the dis-
   during this
      session                                                                                                                                                        radiation and chemotherapy unneces-                ease to be treated successfully. So maybe
                                                                                                                                                                     sarily. And then there are the associated          PSA testing is the gamble to take.
                                                                                                                                                                     complications: Chemotherapy can cause                   The truth is that neither test works
                                                                                                                                                                     nausea and radiation can burn normal tis-          that well. Even with screening, most people
                                                                                                                                                                     sue; breast surgery can be disfiguring, and        destined to develop deadly, untreatable
                                                                                                                                                                     prostate surgery can lead to bladder and           cancers will still do so. When it comes to
                                                                                                                                                                     sexual dysfunction.                                breast and prostate cancer screening, there
                                                                                                                                                                          Doctors don’t know which patients             are no right answers, just trade-offs.
                                                                                                                                                                     they are treating unnecessarily, but they          ¢ tHe neW york tImes


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                                                                                                                                                                     know how the unnecessarily treated pa-
                                                                                                                                                                     tients got there in the first place — because      H Gilbert Welch, a professor of medicine at
                                                                                                                                                                     they were screened for cancer.                     the Dartmouth Institute for Health Policy
                                     “Kishore M have helped thousands of                                                           “I turned $1,000                       Now let’s consider the winners — those          and Clinical Practice, is a co-author of
                                                                                                                                   into $78,000
                                     people to live the life they want by                                                          in 2 months.”                     who have avoided dying from breast or pros-           Overdiagnosed: Making People Sick
                                     teaching them how to trade. If you are                                                          Mona Mhd - mother of 8 kids     tate cancer by getting screened. While there                 in the Pursuit of Health.
                                     determined to take an active role in                                               “I turned $750 into
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