we are bombarded by news of cancer
epidemics many have cancer many know
someone who has been frozen in their
tracks by a cancer diagnosis but the
news is better than it seems and that’s
what I hope to explain to you today
since the 1950s many cancers have
increased breast brain kidney prostate
has tripled thyroid and melanoma skin
cancers have exploded and so like some
of these folks who are frozen among the
crowds rushing through New York’s Grand
Central more and more of us may also
become frozen in our tracks by cancer
that is a grim picture but there is good
news often these are harmless cancers
I’m a physician who would like to spare
you the harmful treatment of harmless
cancers okay as a radiologist and an
advocate I’d like to spare you the
anguish of my own family’s ordeal on
Memorial Day in 2016 my family gathered
in the Green Mountains we were
celebrating my daughter’s birthday
everyone was happy we were relaxing my
husband Bernie played some tennis and
then he developed back pain excruciating
back pain and literally overnight
unexplained paralysis now I’ve been an
army doctor a witness to mass casualty
I’ve seen tragedies I would rather
forget during my medical career but this
tragedy was unbearably brutal none of
the brilliant doctors at the best
hospitals knew what the heck was going
on and for five months in five hospitals
in three states I watched as Bernie
underwent
procedures often with utter disregard
for his dignity ravaging our finances
anguishing our adult children now
medicine can be brilliant it can be
miraculous but suffering can come even
from well-intentioned over treatment and
I hope that you and your loved ones will
never suffer unnecessarily the harm of
harmful treatment of harmless cancers is
common and it can cause psychological
distress unnecessary surgery the
complications from treatment
chemotherapy radiation therapy which may
outweigh the benefits and incredible
expense the over treatment of breast
cancer alone is estimated at four
billion dollars per year the human
genome project cost a mere 2.7 billion
now this too is a grim picture but there
is again good news
cancer mortality has dropped 20 percent
in the last 20 years how can that be
we’ve got rampant epidemics and
plummeting mortality well the
explanation is partially the substantial
improvement in cancer care and treatment
but it is largely the unearthing of
harmless cancers epidemics of things we
call cancer but which act benign the
best evidence for harmless cancer comes
from autopsy studies of people who have
died from other causes and the large
reservoirs of harmless cancers which
increase as we age and the classic case
is prostate
autopsy studies first demonstrate
harmless prostate cancers in men in
their 20s they’re more common in the 40s
and they are virtually a normal finding
in the elderly autopsy studies estimate
silent harmless cancers stowing away in
the prostate of more than 60% of men
over 70 in the breasts of up to 39
percent of women in the thyroid of
almost every adult and in the pancreas
because the harmless cancers identified
only at autopsy far outweigh your risk
of a harmful cancer that’s important
your lifetime risk of a harmful cancer
is far less than the certainty of a
silent harmless cancer because cancers
are not all alike cancers are a motley
crue some are like pirates deadly
unstoppable ravage the ship some are
like masked mutineers threatening
cancers the treatment may contain or
cure and most are like harmless
stowaways which hide silently and pose
no threat now this became personal for
me when two close friends developed the
same rare pancreatic islet cell tumor as
did Steve Jobs my friend Matt wrote
about his situation in Slate and he
explains that he had a large tumor
golf-ball-sized tumor found late by pure
luck on a cat scan for appendicitis now
in the ten years since matt has started
a family and a pancreatic cancer charity
with his surgeon John Cameron
Matt appears to have had a stowaway my
friend song music doctor’ll Canada had
no such luck son was entirely well at
our dinner June 2014 just before she
jetted home to Korea for the summer in
October I awoke to an email announcing
her untimely death
now I dearly miss sung who appears to
have had a pirate Steve Jobs who
reportedly deferred treatment may have
had a masked mutant ear that ignored
took his life but despite this motley
crue public health messages reinforce
our view that early detection is the key
to survival what I’m trying to explain
is that your survival may depend instead
on your tumors biology rather than the
why now why now have we unearthed
epidemics of harmless cancers screening
and scanning the signing of the National
Cancer Act by President Nixon in 1971
began the war against cancer and
organized screening radiologic scanning
continually improves and it has led to
explosions of harmless cancers on scans
order for other reasons and we see this
in the thyroid of 67 percent of adults
in the lungs of 50 percent of smokers in
high percentages of the adult kidney
liver and pancreas the harder you look
by scanning and screening the more
harmless cancers you find and there’s
more evidence take a look at this
National Cancer Institute data from 1975
to 2005
that’s the first 30 years the data was
available thyroid cancer incidents in
yellow more than doubled death rates in
red are stable because these are largely
incidental and harmless thyroid cancers
on scans ordered for other reasons and
we see the same trend for melanoma for
kidney cancer during that 30 year period
increase incidence stable death rates
now this is mind-blowing
the thyroid cancer experience in Korea
shows that the incidence increased 15
fold during the interval between 1999
and 2011 after the initiation of
screening but the death rates in red are
stable so what I am trying to show you
is that the incidental cancers in the US
and the screen detected lesions in Korea
are the mildest forms of disease and
they are the source of the epidemics of
harmless cancers but this is poorly
understood by the public by policymakers
by physicians and it drives over
treatment also poorly understood our
medical or medical probabilities what
I’ve called statistical magic tricks
which also drive this culture of testing
more finding more treating more now I’ve
summarized three examples hang in few
stats the first is false positives a
false positive test says you have a
disease when you don’t test yourself how
likely is breast cancer in a 40 year old
with a positive mammogram only 8.3
percent how can that be well of 10,000
40 year olds 100
have breast cancer the remainder will
not okay
of those with breast cancer 90 percent
or 90 women will have a true positive
mammogram 10 percent of those without
breast cancer 990 women will have a
false positive mammogram you see where
this is going of 1080 positive tests 990
will be false positive and they will
lead to additional imaging biopsies
surgery
perhaps the harmful treatment of a
harmless cancer because a 40 year old
woman with a positive mammogram has a
92% chance of not having breast cancer
if the disease is rare most positive
screening tests will be false positive
it’s counterintuitive and it is true
okay the second poorly understood
statistical magic trick is relative risk
this exaggerate the effect of a test or
treatment and it is reported as a
percentage for example cat scan
screening of lung cancers decreases
deaths in smokers by 16% which in
absolute terms is 0.05 live saved per
thousand screened let me walk you
through that cat scan screening will
decrease deaths from 21 per thousand to
18 per thousand three fewer deaths which
is a 16% relative risk reduction because
three is 16% of 21 but in absolute terms
that is three live saved per thousand
over six years point oh
I’ve live saved four thousand per year
so relative relative risk will
exaggerate the benefit and it under
reports the harms biopsies surgeries
which may outweigh the benefit again it
is counterintuitive but it is true okay
one more sorry five year survival
creates the false impression that lives
have been saved take two patients whose
cancer starts in 2008 okay one patient
is diagnosed when he developed symptoms
in 2016
he lives for two years our second
patient is diagnosed when screened in
2010 okay and he lives for eight years
with the awareness the questionable gift
of awareness of a terminal illness he
has an improved 5-year survival
although screening has made no
difference in the length of his life
it’s counterintuitive but it is true so
my objective is clear to make you aware
of the evolution in our understanding of
cancer statistics of cancer
these statistical magic trix false
positive relative risk five-year
survival and the motley crue of cancers
though counterintuitive are true and
because they are poorly understood they
contribute to the well-intentioned but
harmful treatment of harmless cancers
okay
so in summary if you are faced with the
shattering news of cancer diagnosis I
hope that you now can take an emotional
step back ask for the facts in absolute
terms review a decision aid which
outlines the harms and benefits such as
this or a decision aid a graphical
decision aid which explains that for a
per one life saved
perhaps 436 will be harmed by a
complication from the treatment in this
way you can make an objective choice
based upon your own values as my husband
Bernie and I did you may choose to wait
and see you may seek personalized cancer
care you may opt to undergo modified
screening or participate in a research
protocol I hope that you will now find
yourself back among the ordinary folks
no longer frozen in your tracks and
getting back to living thank you [Applause]
epidemics many have cancer many know
someone who has been frozen in their
tracks by a cancer diagnosis but the
news is better than it seems and that’s
what I hope to explain to you today
since the 1950s many cancers have
increased breast brain kidney prostate
has tripled thyroid and melanoma skin
cancers have exploded and so like some
of these folks who are frozen among the
crowds rushing through New York’s Grand
Central more and more of us may also
become frozen in our tracks by cancer
that is a grim picture but there is good
news often these are harmless cancers
I’m a physician who would like to spare
you the harmful treatment of harmless
cancers okay as a radiologist and an
advocate I’d like to spare you the
anguish of my own family’s ordeal on
Memorial Day in 2016 my family gathered
in the Green Mountains we were
celebrating my daughter’s birthday
everyone was happy we were relaxing my
husband Bernie played some tennis and
then he developed back pain excruciating
back pain and literally overnight
unexplained paralysis now I’ve been an
army doctor a witness to mass casualty
I’ve seen tragedies I would rather
forget during my medical career but this
tragedy was unbearably brutal none of
the brilliant doctors at the best
hospitals knew what the heck was going
on and for five months in five hospitals
in three states I watched as Bernie
underwent
procedures often with utter disregard
for his dignity ravaging our finances
anguishing our adult children now
medicine can be brilliant it can be
miraculous but suffering can come even
from well-intentioned over treatment and
I hope that you and your loved ones will
never suffer unnecessarily the harm of
harmful treatment of harmless cancers is
common and it can cause psychological
distress unnecessary surgery the
complications from treatment
chemotherapy radiation therapy which may
outweigh the benefits and incredible
expense the over treatment of breast
cancer alone is estimated at four
billion dollars per year the human
genome project cost a mere 2.7 billion
now this too is a grim picture but there
is again good news
cancer mortality has dropped 20 percent
in the last 20 years how can that be
we’ve got rampant epidemics and
plummeting mortality well the
explanation is partially the substantial
improvement in cancer care and treatment
but it is largely the unearthing of
harmless cancers epidemics of things we
call cancer but which act benign the
best evidence for harmless cancer comes
from autopsy studies of people who have
died from other causes and the large
reservoirs of harmless cancers which
increase as we age and the classic case
is prostate
autopsy studies first demonstrate
harmless prostate cancers in men in
their 20s they’re more common in the 40s
and they are virtually a normal finding
in the elderly autopsy studies estimate
silent harmless cancers stowing away in
the prostate of more than 60% of men
over 70 in the breasts of up to 39
percent of women in the thyroid of
almost every adult and in the pancreas
because the harmless cancers identified
only at autopsy far outweigh your risk
of a harmful cancer that’s important
your lifetime risk of a harmful cancer
is far less than the certainty of a
silent harmless cancer because cancers
are not all alike cancers are a motley
crue some are like pirates deadly
unstoppable ravage the ship some are
like masked mutineers threatening
cancers the treatment may contain or
cure and most are like harmless
stowaways which hide silently and pose
no threat now this became personal for
me when two close friends developed the
same rare pancreatic islet cell tumor as
did Steve Jobs my friend Matt wrote
about his situation in Slate and he
explains that he had a large tumor
golf-ball-sized tumor found late by pure
luck on a cat scan for appendicitis now
in the ten years since matt has started
a family and a pancreatic cancer charity
with his surgeon John Cameron
Matt appears to have had a stowaway my
friend song music doctor’ll Canada had
no such luck son was entirely well at
our dinner June 2014 just before she
jetted home to Korea for the summer in
October I awoke to an email announcing
her untimely death
now I dearly miss sung who appears to
have had a pirate Steve Jobs who
reportedly deferred treatment may have
had a masked mutant ear that ignored
took his life but despite this motley
crue public health messages reinforce
our view that early detection is the key
to survival what I’m trying to explain
is that your survival may depend instead
on your tumors biology rather than the
why now why now have we unearthed
epidemics of harmless cancers screening
and scanning the signing of the National
Cancer Act by President Nixon in 1971
began the war against cancer and
organized screening radiologic scanning
continually improves and it has led to
explosions of harmless cancers on scans
order for other reasons and we see this
in the thyroid of 67 percent of adults
in the lungs of 50 percent of smokers in
high percentages of the adult kidney
liver and pancreas the harder you look
by scanning and screening the more
harmless cancers you find and there’s
more evidence take a look at this
National Cancer Institute data from 1975
to 2005
that’s the first 30 years the data was
available thyroid cancer incidents in
yellow more than doubled death rates in
red are stable because these are largely
incidental and harmless thyroid cancers
on scans ordered for other reasons and
we see the same trend for melanoma for
kidney cancer during that 30 year period
increase incidence stable death rates
now this is mind-blowing
the thyroid cancer experience in Korea
shows that the incidence increased 15
fold during the interval between 1999
and 2011 after the initiation of
screening but the death rates in red are
stable so what I am trying to show you
is that the incidental cancers in the US
and the screen detected lesions in Korea
are the mildest forms of disease and
they are the source of the epidemics of
harmless cancers but this is poorly
understood by the public by policymakers
by physicians and it drives over
treatment also poorly understood our
medical or medical probabilities what
I’ve called statistical magic tricks
which also drive this culture of testing
more finding more treating more now I’ve
summarized three examples hang in few
stats the first is false positives a
false positive test says you have a
disease when you don’t test yourself how
likely is breast cancer in a 40 year old
with a positive mammogram only 8.3
percent how can that be well of 10,000
40 year olds 100
have breast cancer the remainder will
not okay
of those with breast cancer 90 percent
or 90 women will have a true positive
mammogram 10 percent of those without
breast cancer 990 women will have a
false positive mammogram you see where
this is going of 1080 positive tests 990
will be false positive and they will
lead to additional imaging biopsies
surgery
perhaps the harmful treatment of a
harmless cancer because a 40 year old
woman with a positive mammogram has a
92% chance of not having breast cancer
if the disease is rare most positive
screening tests will be false positive
it’s counterintuitive and it is true
okay the second poorly understood
statistical magic trick is relative risk
this exaggerate the effect of a test or
treatment and it is reported as a
percentage for example cat scan
screening of lung cancers decreases
deaths in smokers by 16% which in
absolute terms is 0.05 live saved per
thousand screened let me walk you
through that cat scan screening will
decrease deaths from 21 per thousand to
18 per thousand three fewer deaths which
is a 16% relative risk reduction because
three is 16% of 21 but in absolute terms
that is three live saved per thousand
over six years point oh
I’ve live saved four thousand per year
so relative relative risk will
exaggerate the benefit and it under
reports the harms biopsies surgeries
which may outweigh the benefit again it
is counterintuitive but it is true okay
one more sorry five year survival
creates the false impression that lives
have been saved take two patients whose
cancer starts in 2008 okay one patient
is diagnosed when he developed symptoms
in 2016
he lives for two years our second
patient is diagnosed when screened in
2010 okay and he lives for eight years
with the awareness the questionable gift
of awareness of a terminal illness he
has an improved 5-year survival
although screening has made no
difference in the length of his life
it’s counterintuitive but it is true so
my objective is clear to make you aware
of the evolution in our understanding of
cancer statistics of cancer
these statistical magic trix false
positive relative risk five-year
survival and the motley crue of cancers
though counterintuitive are true and
because they are poorly understood they
contribute to the well-intentioned but
harmful treatment of harmless cancers
okay
so in summary if you are faced with the
shattering news of cancer diagnosis I
hope that you now can take an emotional
step back ask for the facts in absolute
terms review a decision aid which
outlines the harms and benefits such as
this or a decision aid a graphical
decision aid which explains that for a
per one life saved
perhaps 436 will be harmed by a
complication from the treatment in this
way you can make an objective choice
based upon your own values as my husband
Bernie and I did you may choose to wait
and see you may seek personalized cancer
care you may opt to undergo modified
screening or participate in a research
protocol I hope that you will now find
yourself back among the ordinary folks
no longer frozen in your tracks and
getting back to living thank you [Applause]
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