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Sunday, November 10, 2013

The origins of irrational exuberance for cancer screening

Every day I wake and I am here, wherever I might be. I operate using a set of assumptions, most of which I do not think to question. While we constantly exclaim that the pace of change is scary, on a day to day basis we perceive very little change. Given that background, I read articles like the one that appeared in the Health section of the New York Times on October 17th which remind me that the world that we presently experience is not the world that has existed for time in memorial (NYT- Bowery study).

The article is by Gina Kolata, one of my favorite writers for the Times and her piece was about a study done more than 50 years ago by Dr. Perry Hudson, a urologist who was a researcher working out of Columbia University.  For those of you who follow my blog, you realize I have more than a little skepticism when it comes to cancer screening programs. In the present time, I am the outlier, expressing essentially little or no faith in the ability of our tools to accurately predict who will die from malignancies. I was intrigued to read in Dr. Arnowitz's piece (Aronowitz)  that early in Dr. Hudson's career, the position that I currently hold was more the norm for the medical profession.
At mid-century, there was also a backlash to the optimism-promoting “do not delay” public health campaign in other cancers. Physicians were increasingly skeptical that existing means of prevention and treatment were effective because the mortality from most site-specific cancers had not improved. This skepticism led to a group of self-identified physician “predeterminists” who argued that at the time of a cancer diagnosis the fate of most individuals was outside of medical care, determined by the poorly understood tumor characteristics and the individual patient’s immune status.
Enter Dr. Hudson. He was motivated to dispel the cancer fatalism which permeated the medical community and it only made sense to him that early detection and treatment was a promising approach.  He begins to test his ideas on homeless men living in flop houses in the Bowery of New York City. He provided inducements to coax them into participation in gruesome diagnostic and "therapeutic" interventions, inflicting untold harm upon ill informed subjects. His work was accepted by the medical powers that were at the time, passing peer review and receiving funding from NIH.

The damage is not limited to the poor souls from the Bowery, but extends to to current times. As Dr. Aronowitz  states in words that I cannot improve upon:
There has been a disturbing continuity between the Bowery series and our current paradigm. The Bowery studies were prematurely deployed, crude technopractices that anticipated and followed a similar logic undergirding many subsequent incremental developments in prostate cancer. These studies, forgotten perhaps because they reminded later practitioners of the violence and dubious ethics of subjecting men to invasive procedures without good evidence of benefit, are a window into the long halting history of how we have come to accept as efficacious a set of very invasive prostate cancer practices, developments that are themselves part of an ever larger quest to control cancer and our fears of cancer and that have brought millions of American men into state of prostate cancer risk.
The message is clear. We tend to be blind to the very things that the future will be appalled by. The medical profession has a long history of caring for the sick and relieving suffering. However, it also has a long history of doing terrible things to other people with inadequate disclosure and without their consent, often justified by lofty goals for humanity in general. We cannot forget specific humans in particular.

1 comment:

  1. It makes one wonder what Dr. Cutler, an esteemed economist at Harvard, was thinking when he became the president's point man on selling ObamaCare, knowing that the man he was working for at the time had no substantive executive experience at all. How does one delude themselves that an individual who has never had responsibility for implementing, directing or delegating the tasks necessary to manage anything could do so in an enterprise to manage one-sixth of the economy.