A few days ago, there was news that former YouTube CEO Susan Wojcicki died at 56 after battling cancer for a year. This reinforces my belief that even powerful people can't escape death from cancer. Reflecting on my previous post, modern medicine seems helpless against cancer, often leading to over-treatment. Over-treatment is ingrained in the medical system as doctors strictly adhere to clinical guidelines, especially for influential patients. These guidelines, representing mainstream medical research, are essentially just product lists for pharmaceutical companies. In the realm of cancer, I believe that clinical guidelines often do more harm than good to patients. The more influential the patient, the greater the harm they might suffer.
The Chaos of Overtreatment
In China, there is a saying: "Of those who die from cancer, one-third are scared to death, one-third are treated to death, and only the remaining third actually die from the cancer itself." This proverb highlights the dangers of overtreatment.
Currently, clinical cancer treatment relies heavily on three pillars: cancer staging, standardized treatment, and evidence-based medicine. These collectively form the entire cancer treatment system. Cancer staging is used to determine the severity of each patient's condition and to design a "standard treatment" plan for each stage. These treatment plans are based on the results of evidence-based medicine, verified through clinical trials to assess the effectiveness of a treatment method on a group of patients. If a treatment method proves effective or superior for a specific stage in trials, it is recommended for other patients with the same stage. These recommended protocols are submitted to the medical field in the form of expert consensus, known as guidelines. Once published, every doctor is expected to follow the treatment plans described in these guidelines, down to every detail.
However, the reality is that even patients with the same stage of cancer do not always achieve similar results after receiving the same guideline-based treatment. Doctors often attribute these differences to individual variability. This raises a question: knowing that patients differ, why use the same treatment plan for all? Currently, there is no satisfactory explanation. Logically, it doesn't make sense to subject hundreds of thousands of patients to the same treatment plan when many other options are available, as most may not benefit from it.
The full name of the "guidelines" is the "NCCN Clinical Practice Guidelines in Oncology," written and published by the National Comprehensive Cancer Network (NCCN) and updated annually. These guidelines specify detailed treatment methods for each type of cancer and aim to standardize and regulate cancer treatment to improve outcomes and quality. The intent behind the guidelines was to address the chaos in cancer treatment, primarily due to its challenging nature. Given the stakes, it was believed that treatment should be determined by recognized authorities, not left to the discretion of general practitioners. Thus, these guiding documents were created from the collective wisdom and judgment of the most authoritative experts.
Initially, tumor assessment involved merely measuring the size of the primary tumor. It was later found that the number and location of metastases were more crucial for prognosis. Even a small primary tumor can be classified as stage IV if there are multiple distant metastases, indicating a bleak prognosis. Although the primary tumor might be easily removable, guidelines often prohibit surgery if distant metastases are present. However, extensive clinical observations have shown that not all stage IV cancer patients are incurable by surgery; some can be cured. The dilemma is that some people are saved by surgery, while others fare worse, with shortened survival times. Doctors are unclear who will benefit from surgery and who will suffer, so avoiding surgery for all stage IV patients might seem the safest approach. Similarly, outcomes can vary for early-stage patients after the removal of the primary tumor. Although most are cured by surgery, a significant number (10-50%) experience relapse and die.
Once diagnosed with cancer, patients enter a "conveyor belt" of treatment guided by these guidelines. First, the stage of cancer is determined based on tumor size and distribution. If it is early-stage and operable, surgery is performed first, with recurrence dealt with later. For late-stage patients who cannot undergo surgery, radiation, chemotherapy, or targeted therapy is administered until options are exhausted. This "conveyor belt" approach has been in place for decades, based on the logic of evidence-based medicine, which includes: (1) Selecting the best treatment option from past similar cases; (2) Continuing a treatment as long as it works, until it fails; (3) Avoiding unproven treatments. This approach inevitably harms some patients, even if the chosen treatment has a relatively high success rate, as a significant portion may not benefit.
As treatment guidelines have become widespread, the overall level of cancer treatment has improved in the short term due to greater uniformity. However, in the long run, these standardized guidelines have not significantly enhanced treatment levels. Instead, they have simplified cancer treatment to some extent. While standardization has reduced errors and benefited some patients, it has also harmed those not suited for guideline-based treatment.
For example, guidelines might recommend a specific chemotherapy drug as first-line treatment for a certain tumor. Clinical trial data show that this drug is effective for about 70% of patients, which seems reasonable. But why force the remaining 30% to undergo this treatment? The only reason is the lack of alternatives. Because it is impossible to know in advance whether the drug will work for a specific individual, it must be tried to find out. In reality, the greatest benefit of following guidelines is not patient welfare but protection for doctors: even if the world's most authoritative treatment fails, the doctor cannot be blamed.
In today's increasingly tense doctor-patient environment, doctors strictly adhere to guidelines partly to avoid liability. Even high-ranking officials and celebrities may only receive standard treatment because doctors prefer to follow guidelines to reduce liability risks. In such cases, patient outcomes are often less than ideal.
For cancer treatment, both doctors and patients tend to choose the newest, most expensive methods, believing them to be the most effective. However, the approval of new therapies or drugs is often based only on short-term effects in a selected group of people. Therefore, cancer patients should carefully consider the long-term effectiveness and suitability of treatments.
Debunking the Myth of "Early Detection, Early Treatment" in Cancer
In the medical field, the widely accepted notion is that early detection of cancer is often considered key to improving cure rates and survival. The National Comprehensive Cancer Network (NCCN) vigorously promotes the concept of early cancer screening and treatment. This organization provides up-to-date guidelines for cancer diagnosis and treatment, aimed at helping doctors and patients detect and treat cancer earlier to enhance treatment outcomes and survival rates. Indeed, for cancers like breast cancer and skin cancer, early detection and treatment often lead to better treatment outcomes and relatively higher survival rates. This is because cancer is generally easier to manage in its early stages, and the treatment methods are relatively simpler.
However, this widespread promotion of early screening and treatment also brings some problems, particularly the issues of overdiagnosis and overtreatment. Overdiagnosis refers to the detection through screening of cancers that would not impact the patient's health or lifespan even if left untreated. These cancers may never show any symptoms and might not become life-threatening. However, once diagnosed, patients and doctors usually opt for treatment, leading to the problem of overtreatment. Overtreatment means aggressively treating these essentially non-dangerous cancers with surgery, radiation, chemotherapy, and other methods, which can themselves cause severe side effects and complications. For example, chemotherapy can lead to nausea, hair loss, and suppression of the immune system, while surgery can cause infections and long-term pain. Additionally, the mental stress, time commitment, and financial burden of treatment are significant burdens that patients must bear.
Overtreatment is one issue, but a bigger problem is that the logic of improving patient survival through early detection and treatment does not always hold up, especially when cancer treatment methods generally have low efficacy. It may only increase the survival period during the early detection and treatment phase, with almost no difference in overall quality of life and final outcomes for the patient. When examining existing cancer treatments, there are virtually no therapies without side effects.
If a cancer patient recovers after treatment, it is impossible to prove that they would not have recovered without treatment; it is generally assumed that it was because the cancer was detected relatively early. If a cancer patient does not respond to treatment, even if the cancer was detected when it was very small, it is often assumed that it was not detected early enough; in medical practice, it is also not feasible to divide cancer patients into groups for controlled studies of treated versus untreated. However, we can still gain considerable insights through the following three approaches.
A. Analyzing the impact of early detection, diagnosis, and treatment on cancer outcomes involves looking at changes in cancer incidence, 5-year survival rates, and mortality in a country or region, especially before and after emphasizing these early interventions.
One clinical investigation that highlights this issue began in 1993 in South Korea, where thyroid ultrasound screenings became widespread among the healthy population. This led to a fifteenfold increase in diagnosed thyroid cancer cases by 2011. Regions that conducted more screenings also diagnosed more thyroid cancer cases. However, despite this sharp increase in diagnoses, the mortality rate from thyroid cancer remained unchanged over these 18 years, sparking widespread attention and discussion.
Additionally, a comparative analysis of cancer statistics between the United States and China reveals intriguing phenomena and provides insights. In 2014, major Chinese media outlets reported a striking statistic on the front pages: the 5-year survival rate for cancer in the U.S. was 68%, while in China, it was only 31%. Many naturally assumed this was due to the more advanced medical technology and better medical conditions in the U.S., particularly in terms of early detection, diagnosis, and treatment. However, a deeper look into the specific data revealed some very interesting facts.
Particularly noteworthy are the cases of breast cancer and prostate cancer. These cancers show a significant difference in incidence rates between the two countries: in China, the incidence rate of breast cancer is 22.1 per 100,000, compared to 92.9 per 100,000 in the U.S.; prostate cancer has an incidence rate of 5.3 per 100,000 in China versus 98.2 per 100,000 in the U.S. Since the 5-year survival rates for these cancers are much higher than for other types, this discrepancy significantly widens the gap in the 5-year survival rates between the two countries.
Excluding these two cancers from the comparison, the 5-year survival rates for cancer in China and the U.S. are 25% and 33%, respectively, significantly narrowing the gap. Moreover, when comparing the mortality rates of these cancers, it is found that China's rates are notably lower than those in the U.S., with breast cancer mortality rates of 5.4 per 100,000 in China and 14.9 per 100,000 in the U.S.; prostate cancer mortality rates are 2.5 per 100,000 in China and 9.8 per 100,000 in the U.S. These results suggest that early detection, diagnosis, and treatment of breast and prostate cancer have not significantly improved outcomes.
B. Conducting prospective cohort studies to compare the incidence and mortality rates of cancer between screened and unscreened populations provides valuable insights.
In the United States, a research study involved men aged 55 to 74 undergoing prostate cancer screening. The study included 38,340 men in the screening group who received annual PSA tests, and 38,345 men in the control group who did not undergo PSA testing. After a 10-year follow-up, 92% of participants completed the study, and 57% completed a 13-year follow-up. The results showed that the incidence of prostate cancer in the screening group was 108.4 cases per 100,000 person-years, compared to 97.1 cases per 100,000 person-years in the control group, an increase of 12%. However, the mortality rates from prostate cancer were 3.7 per 100,000 person-years in the screening group and 3.4 per 100,000 person-years in the control group, showing no significant difference between the two groups.
Another study, known as the ERSPC, was conducted across seven European countries involving 182,000 men aged 50 to 74, with 162,243 men aged between 59 and 69. In this study, 72,890 men underwent PSA screening every four years, while the rest did not. After a 9-year follow-up, the cumulative incidence of prostate cancer was 8.2% in the screening group and 4.8% in the non-screening group, a significant difference. However, the screening group saw a 20% reduction in the rate of death from prostate cancer compared to the control group. Despite this, the actual difference in mortality rates over the 9 years was only 0.071%, suggesting that the real-world impact of early diagnosis and treatment might be limited.
These studies provide important information about prostate cancer screening, especially valuable in assessing the necessity and effectiveness of screening. The findings indicate that while screening may increase the rate of diagnosed cases, its impact on reducing mortality is not significant, suggesting a need for cautious promotion of prostate cancer screening.
C. Examining non-cancer deceased individuals or general medical patients for cancerous lesions reveals significant findings.
In pathological examinations of thyroid tissue from individuals who died from non-thyroid cancer causes, 36% were found to have cancerous lesions. This percentage increases when tissue sections are cut thinner, to 0.5mm. Furthermore, pathological examinations of breast tissue from deceased women aged 40 to 50 who did not die from cancer showed that 40% had breast cancer lesions. In Japan, prostate tissue examinations of 525 men who died accidentally revealed that 82% of those aged 70 and above had prostate cancer, with a detection rate of 46% among those aged 50 to 59, and even an 8% detection rate in men as young as 20.
These data suggest that with advancements in diagnostic technologies, more examinations are likely to detect more cases of cancer. For instance, lung CT scans in a smoking population aged 50 reveal pulmonary nodules in 50% of the cases, yet based on a 10-year mortality risk, 96.4% of these nodules are not fatal; similarly, in non-smokers, 15% are likely to show pulmonary nodules on CT scans, with 99.3% being non-fatal. Similar findings are reported with CT scans of the kidneys and liver. Ultrasound screenings of the thyroid in the same demographic reveal suspected cancerous lesions in two-thirds of individuals. Generally, these incidental findings, known as incidentalomas, indicate a less than 1% ten-year mortality rate for the 50-year-old demographic, excluding smokers.
Therefore, there are grounds to question the positive impact of early detection and treatment on the prognosis of cancer patients, especially in the context of prevalent overtreatment in cancer care. Early detection and treatment do not necessarily improve survival rates and may instead reduce quality of life due to the side effects of treatment.
Patients' Tendency to Not Participate in Decision-Making During Treatment
In the current medical system, many patients tend to remain passive during their treatment process, often relying entirely on their doctor's recommendations without asking questions. Due to time constraints or communication styles, doctors may not fully explain all treatment options, or may not present the information in a way that's easily understandable for patients. In some cultural contexts, patients might refrain from expressing their views or doubts out of high respect for medical professionals. Additionally, patients with limited education or health literacy may find it challenging to understand complex medical information, which can deter them from participating in decision-making. Economic status and insurance limitations can also influence treatment choices. Without support from family or other advocates, patients might not realize that they can or should have a say in their treatment decisions.
This phenomenon of patient non-participation is even more pronounced in the field of cancer treatment. Cancer treatment often involves complex medical procedures and multiple treatment options, making it particularly difficult for patients to understand and evaluate all available choices. Furthermore, the severity of cancer can induce fear and uncertainty, leading patients to rely more on the professional judgment of their doctors rather than actively engaging in decision-making.
Indeed, the lack of patient involvement in cancer treatment decisions can have long-term consequences. The problem of overtreatment in cancer is difficult to address, and the healthcare system does not seem to encourage active patient participation. Although doctors' concerns about over-intervention are understandable, even the NCCN guidelines recommend that patients communicate with their treatment teams and consider their advice. Additionally, in pharmaceutical development, patient perspectives are often overlooked, especially evident in the marketing of prescription drugs where pharmaceutical companies view doctors as their primary customers, despite the medications being intended for patients.
This book(myxcancer.com) aims to change this status quo by encouraging and guiding cancer patients to actively participate in their treatment decisions. By providing necessary information and tools, this book helps patients gain a basic understanding of cancer treatments, comprehend the pros and cons of various options, and thus communicate more effectively with their doctors to make decisions that better suit their individual health conditions and long-term interests.
Patients should have the right and opportunity to understand all viable treatment options, including the potential risks and benefits of each. Active participation not only helps patients make choices that better meet their individual needs but also enhances overall satisfaction and effectiveness of the treatment. Therefore, having a voice in cancer treatment is not only a patient's right but also a critical factor in improving treatment outcomes.
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