health care issues

Today we read in the NY Times, "Mammologists wanted" that delayed diagnosis of breast cancer is the most common and second most costly claim against American doctors. And therein lies a big problem. First of all, I disagree with the consensus that early diagnosis improves survival in breast cancer (or almost any cancer for that matter). Although it sounds plausible enough, this idea is based on a faulty hypothesis about the way cancer develops, spreads and kills. It is also caused by warped statistics and the fact that we do not know the natural history of malignant looking lesions.

So here is the first issue. American doctors, eager to help patients, and esp. militant patients as one finds in breast cancer, have popularized the notion that early detection is key. That it saves lives. Several agencies and scientific bodies have lent credibility to this nonsense and it is now generally accepted that early detection is necessary.

The second issue is even more daunting. And once again it rests on a faulty assumption. And that assumption is that cancer grows locally until it hits a certain size, at which point it will start spreading. But many cancers do not evolve that way. In many cases, finding the early lesion is not trivial. But it is rather easy to go back (hindsight is 20/20 as they say) and "find" the earlier lesion that -now by definition- someone must have "overlooked." I.e. a vague shadow may not be identifiable when you look but when you come back months later and know it is there, well that is a different story. Now that you know the right answer, interpretation is easy.

Can you see where this is going? We treat too many people who then survive, but would have survived anyways. These people add to the statistics and make it more plausible that we should think early detection is key. Now lots of women whose cancers are found "late" start complaining that their lesions were overlooked and go see "legal help." Enter the lawyers, another highly paid profession that has no business in medicine or healthcare. Someone has to pay these lawyers, and the exorbitant fees they charge and the even more ridiculous and exorbitant "settlements" they get.

Once the lawyers are in, the docs start practicing more "defensive medicine," doing even more tests and more procedures so as to make sure nobody can come after them later. Before you know it the whole system is dangerously and expensively out of whack. Ironically enough nobody benefits from this, certainly not the patients. Many more of them suffer complications, while others are told they have "cancer" and need expensive treatment and lots of anxiety for lesions that would regress naturally if left alone. These people not only suffer tremendous mental anguish, they also undergo needless chemo -and some die or get very ill- and they no longer qualify for most healthcare after that. Not to mention all the extra economic hardship they suffer.

And who pays for all this? Your healthcare system. Your premiums.
You pay for unnecessary treatment, for longer than necessary treatment, for high malpractice insurance fees, for experts and more experts to read and re-read xrays, etc. etc.

And what does it buy you? Has survival improved? Except for a few cases, it hasn't. If you include the iatrogenic morbidity the end result is probably zero. That is the long and short of it.