Re: Healthcare: 38% Favor, 56% Opposed

El Castor wrote:
On Thu, 26 Nov 2009 10:35:52 -0500, Josh <user@xxxxxxxxxxx> wrote:

Glenn wrote:
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El Castor wrote:
On Wed, 25 Nov 2009 10:59:06 -0500, lieselottea@xxxxxxxxx (Olly
Mensch) wrote:

Josh - -I have been following your discussion with El Castor, regading
PSA screening. I must admit, I cannot understand your obvious lack of
logic. It is that "lack' which just might some day endanger your good
health; don't you realize that??
What Jeff argues is so basic, so logical, that it escapes me why you
disagree???
Olly
Olly, Josh would disagree, but I think I understand. Many of us have a
need to believe in something.
My belief is grounded in science, math and logic.

http://content.nejm.org/cgi/content/full/NEJMe0901166
http://www.bmj.com/cgi/content/full/339/sep24_1/b3537

What exactly is Jeff's supposedly unassailable "basic" logic? How does it address the arguments raised in my links?


Hang in there Josh, you need to add game theory (a descendent of operational analysis) and reasoning. What Olly and Jeff are getting at is found in game theory.
I don't think so, but by all means detail where I am wrong.

Sorry Josh but I'm not a teacher, there are many books available on game theory at your local Barns and Noble. It's about making decisions, I'm sure you will enjoy reading about it, after-all it was operational analysis that was decisive in our victory in ww2.
Let me get this straight. You claim there is a flaw in my logic explained by game theory, but that flaw can only be understood if I read some Barnes and Noble books about game theory (**). How can you possibly know all that if you haven't read those books? But if you have read them and know the flaw, how come you won't explain it?

Josh Rosenbluth

(**) I have a BS/MS in Operations Research and 25+ years at Bell Laboratories. I've done a bit more than just read a few Barnes and Noble books about game theory.

I claim no logical flaw as you have made no logical statements, you are being deceptive and I won't go along with your childishness. You have no standing to criticize Jeff and Olly. In plain English, you are a fraud.
Since it looks like you missed it, here is my logic (the supporting data are contained in the above links):

1) PSA screenings either only barely improve mortality rates or do not improve them at all.

2) It is true that the higher your PSA readings, the higher chance you will get prostate cancer.

3) The reason #1 and #2 are both true is:

A) Most people who have PSA levels above the threshold of 4 ng/ml never get prostate cancer.

B) Most of the people who do get prostate cancer would not have died from that cancer even if they never had a PSA test (very slow growing cancers).

C) Some of the people in A and B will die as a result of the unnecessary diagnostic and treatment actions taken in response to a PSA test.

D) Other people who do get prostate cancer will die from it with or without a PSA test (very fast growing cancers)

E) Yet other people will be saved by PSA tests.

4) The empirical data suggest the effects of C, D and E counter-balance, resulting in no overall improvement in mortality.

Conclusion: PSA screenings are not presently useful as a tool to guide further actions.

Strange you should present this, as the doctor first uses the person's age to determine if treatment, operation, is advisable. If one is aware, one is asked for permission to continue with treatment. If one is old, usually one declines, if one is young, odds favor the operation. Regardless, the patient is presented with the odds and makes the choice when it is about to become a matter of life or death, not ahead of time to make sure the decision conforms to your above logic. Without the test, no choice would be offered and and I don't find that that any more acceptable than someone doing what they think is best for me without asking.
Firstly, can you provide a link that gives the odds (both for the treatment will save you, and the treatment will kill you) as a function of age?

Secondly, I have no objection to you having the test. I do question the public policy that says all should have the test based on the data I have seen. Maybe you can persuade me otherwise for a particular age group based on the data requested above.

I got the information from old people that have been diagnosed with this cancer, some live with it, some had the operation. They get their information from the nurses and doctors. I'm sure there is a better reference, you can search if you care to, I don't have a need. I didn't mention what the odds are, again I don't care.
Since I'm attempting to arrive at a fact-based conclusion, I do. I have searched. I have found nothing that suggests the age effect you talk about.

If there's information available about me, I want to know. I know of no doctor that will force an old person to have any test, but most want to know. I had a relative that died in his forties from diabetes complications. He refused to treat it. It take all kinds, but he and you are part of a small minority (some people refuse fluoride toothpaste but there's only one non-fluoride toothpaste available at Wal-Mart).
I'm with you when it comes to diabetes treatments and fluoride because the data support them.

Josh Rosenbluth

Interesting discussion. As someone who suffers from BPH, I have PSA
scores persistently above 4, so it's a subject that interests me.

First, with regard to the European study, here is a synopsis of the
results from the March 26, 2009 New England Journal of Medicine:

"PSA-based screening reduced the rate of death from prostate cancer by
20% but was associated with a high risk of overdiagnosis."
http://content.nejm.org/cgi/content/full/NEJMoa0810084

But, is the 20% number really accurate? "In the screening group, 82%
of men accepted at least one offer of screening". The study lasted
nine years, and to be a valid member of the screened group only one
test was required, and a second test was not given until four years
later. This is not comparable to annual testing, particularly in view
of the fact that aggressive cancers with a high Gleason score will
metastasize very quickly.

Here is a comment on the study from a US News article, also from March
of this year:

"The European results show that picking up cancers before they produce
symptoms brings a 20 percent improvement in mortality, and if the
analysis is done including only those people who actually got screened
(some signed on but did not get tested), the benefit was 28 percent.
Based on bone scans, the screened group was 40 percent less likely to
have cancer that spread to bone, the favored site for prostate cancer
metastasis."
http://health.usnews.com/blogs/heart-to-heart/2009/03/23/what-to-make-of-the-prostate-cancer-screening-studies.html

In the wake of this discussion I am more aware than ever that PSA
screening is controversial. In my case, when my PSA scores went from
2.X to 4.X, I had a negative biopsy. My scores remain in the 4.X
region, and I have not had another biopsy, nor do I want one. On the
other hand, if next year I am tested and it goes to 10, I am sure my
urologist would recommend a biopsy, and I would concur.

So, Josh, I intend to continue with annual testing. You, on the other
hand, should request that your doctor omit the PSA screening from your
annual blood test. Will you do that?

I am glad to see your discussion is much more measured than your earlier posts, and seems reasonable to me.

Some additional thoughts:

1) A threshold of 10 maybe useful for proceeding to biopsy (haven't seen mortality rates at that level), but isn't worth much as a policy measure because too few test that high, and many will develop prostate cancer who test below that figure.

2) As you probably can guess, I don't think biopsies are called for at a threshold of 4, but at least the data say you are doing no harm (probabilistically speaking).

3) My level has always been below 1. I ought not get tested anymore, but my insurance pays for it and they are going to draw blood anyway for other purposes. So, I can't see not doing it. But once the insurance rules change, then yes I am done with it.

Josh Rosenbluth

3) Fortunately
.

Relevant Pages

  • Re: Healthcare: 38% Favor, 56% Opposed
    ... PSA screenings either only barely improve mortality rates or do ... ng/ml never get prostate cancer. ... "PSA-based screening reduced the rate of death from prostate cancer by ...
    (soc.retirement)
  • Re: Healthcare: 38% Favor, 56% Opposed
    ... Olly, Josh would disagree, but I think I understand. ... PSA screenings either only barely improve mortality rates or do not improve them at all. ... It is true that the higher your PSA readings, the higher chance you will get prostate cancer. ... Most of the people who do get prostate cancer would not have died from that cancer even if they never had a PSA test. ...
    (soc.retirement)
  • Prostate (PSA) Test Found to Save Few Lives two large studies have found.
    ... The PSA blood test, used to screen for prostate cancer, saves few lives ... Screening and Prostate-Cancer Mortality in a Randomized European Study ... that, in 2019 or later, he will be spared death from a cancer that would ...
    (sci.med.diseases.cancer)
  • Re: OT: Update on my Prostate Cancer
    ... of misunderstanding regarding the PSA screening. ... Just as a high PSA ... individual is prostate cancer free. ... support group with men who have advanced Pca. ...
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  • Study dents confidence in prostate cancer tests
    ... Men who have been screened for prostate cancer by the most commonly used ... The value of the screening has long been a matter of debate. ... A PSA level ... physician is obligated to clarify all the issues for patients. ...
    (sci.med.diseases.cancer)