Author Topic: Episode #677  (Read 15056 times)

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Offline bachfiend

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Re: Episode #677
« Reply #30 on: July 02, 2018, 09:30:30 PM »

If an ‘abnormality’ is detected, what do you do?  Worry yourself sick?  Henry Marsh, a retired British neurosurgeon, recounted an example in his book ‘Do No Harm.’  A patient had tension headaches, so her GP ordered a CAT scan (which was inappropriate), which showed a very small berry aneurysm on one of her cerebral arteries.  The risk is that it might rupture causing death or a stroke.  The lifetime risk of either of these two occurring is around 2% for the size of the aneurysm.  The aneurysm could be surgically clipped, removing future risk, but with a 2% risk of an intraoperative stroke or death, which occurs immediately.  The rational decision would be to do nothing, besides ensuring that the blood pressure is normal and remains normal (since high blood pressure is a risk factor for rupture).  The patient opted for immediate operation so as to avoid a lifetime of worrying about a timebomb in her head that was unlikely ever to cause her harm otherwise.


My Medical Choice by Angelina Jolie - The New York Times

Quote
I carry a “faulty” gene, BRCA1, which sharply increases my risk of developing breast cancer and ovarian cancer.
My doctors estimated that I had an 87 percent risk of breast cancer and a 50 percent risk of ovarian cancer, although the risk is different in the case of each woman.
Only a fraction of breast cancers result from an inherited gene mutation. Those with a defect in BRCA1 have a 65 percent risk of getting it, on average.
Once I knew that this was my reality, I decided to be proactive and to minimize the risk as much I could. I made a decision to have a preventive double mastectomy. I started with the breasts, as my risk of breast cancer is higher than my risk of ovarian cancer, and the surgery is more complex.

You don’t need to do a whole genome sequencing to detect BRCA1 (and BRCA2) mutations.  They can be looked for specifically with a simple test, and they’re already strongly recommended if there’s a family history.  BRCA2 mutations are a risk factor for prostatic carcinoma with a moderate to high probability over the lifespan.  I think two of my brothers had prostatic cancer.  Should I be tested for BRCA2 mutations?  If it’s positive, what should I do?  Have a prophylactic prostatectomy (with all of its complications)?

Whole genome sequencing would just pick up numerous gene variants associated with a slightly increased lifetime risk of some diseases such as type 2 diabetes or coronary heart disease.  And how would knowing that you’ve got a slightly increased lifetime risk change what you would (or should) be doing anyway?
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Offline brilligtove

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Re: Episode #677
« Reply #31 on: July 02, 2018, 11:12:59 PM »
People tend to say - and think - that you can never have too much information. When they do I ask, "How's your email inbox looking? Also, would you like to hear about my flesh burning under the radiation gun? Wait, you mean those both represent too much information? Hey, where are you going?"

...I may not use this tactic on people who are not assholes. Or I might stop after the first question at least.:)
evidence trumps experience | performance over perfection | responsibility – authority = scapegoat | emotions motivate; data doesn't

Offline drmarkf

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Re: Episode #677
« Reply #32 on: July 03, 2018, 04:11:46 AM »
So many people assume all screening is good for you (“learning you’ve got cancer early is good, surely?), but Steve is correct that the medical issues in many cases are not at all clear, and we need to do more to educate the public about this. Harm most definitely does occur, and the pre and post test probabilities are but part of the necessary assessment. There also needs to be the necessary scientific data on what should be done after the result has been obtained, and in many cases (even for quite common diseases) we don’t yet have that data.

A simple example close to the hearts of many men in their 50/60s: prostatic specific antigen testing (PSA) which is included in many commercial health screens. Levels tend to be raised in many men with prostatic cancer, but not all, and it can be raised in some common non-cancerous conditions.

It is reasonable to do the test if you have relevant symptoms (like poor pee stream) but an isolated raised PSA level discovered in a ‘routine’ medical is more trouble than it is worth. Yes, a few cancers will be detected, but there is a significant rate of false positives, the adverse event rate associated with some of the necessary further investigations is high (eg a 1.5 - 2% rate of septicaemia after trans-rectal needle biopsy), and management of true asymptomatic prostatic cancer is far from yet being an exact science. A full prostatectomy is major surgery with significant associated risks, yet a significant proportion of prostate cancers discovered at that age will not kill their owners or even cause much in the way of debilitating symptoms.

Work is going on in several relevant areas, eg less invasive diagnostic techniques, genetics of different tumours and their associated risks of acting in benign or aggressive ways etc, but we are currently not yet there.

So, the UK NHS line is do have a proper work-up if you have symptoms, and this will include a PSA, but screening is not medically advised for asymptomatic men generally.

A final point on the unexpected side effects of genetic profiling, relevant to those of us in nationally funded healthcare systems: obviously the wealthy are welcome to give their money to anyone for almost anything, but the guy before me in the waiting room to see my GP had just spent £3500 on what was described as a full screen by a private laboratory, including some genetic tests. Various ‘positives’ had turned up, and he was advised to take these to his healthcare provider. He then had an extremely long consultation with the GP who had to reassure him and explain all the issues.

So, this delayed the clinic by around half an hour, and potentially the NHS would have had to have picked up the cost of the fallout from this guy’s ‘worried well’ personal decision to waste his own money.
« Last Edit: July 03, 2018, 04:14:12 AM by drmarkf »
Regards,

Mark

Offline bachfiend

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Re: Episode #677
« Reply #33 on: July 03, 2018, 10:46:46 PM »
So many people assume all screening is good for you (“learning you’ve got cancer early is good, surely?), but Steve is correct that the medical issues in many cases are not at all clear, and we need to do more to educate the public about this. Harm most definitely does occur, and the pre and post test probabilities are but part of the necessary assessment. There also needs to be the necessary scientific data on what should be done after the result has been obtained, and in many cases (even for quite common diseases) we don’t yet have that data.

A simple example close to the hearts of many men in their 50/60s: prostatic specific antigen testing (PSA) which is included in many commercial health screens. Levels tend to be raised in many men with prostatic cancer, but not all, and it can be raised in some common non-cancerous conditions.

It is reasonable to do the test if you have relevant symptoms (like poor pee stream) but an isolated raised PSA level discovered in a ‘routine’ medical is more trouble than it is worth. Yes, a few cancers will be detected, but there is a significant rate of false positives, the adverse event rate associated with some of the necessary further investigations is high (eg a 1.5 - 2% rate of septicaemia after trans-rectal needle biopsy), and management of true asymptomatic prostatic cancer is far from yet being an exact science. A full prostatectomy is major surgery with significant associated risks, yet a significant proportion of prostate cancers discovered at that age will not kill their owners or even cause much in the way of debilitating symptoms.

Work is going on in several relevant areas, eg less invasive diagnostic techniques, genetics of different tumours and their associated risks of acting in benign or aggressive ways etc, but we are currently not yet there.

So, the UK NHS line is do have a proper work-up if you have symptoms, and this will include a PSA, but screening is not medically advised for asymptomatic men generally.

A final point on the unexpected side effects of genetic profiling, relevant to those of us in nationally funded healthcare systems: obviously the wealthy are welcome to give their money to anyone for almost anything, but the guy before me in the waiting room to see my GP had just spent £3500 on what was described as a full screen by a private laboratory, including some genetic tests. Various ‘positives’ had turned up, and he was advised to take these to his healthcare provider. He then had an extremely long consultation with the GP who had to reassure him and explain all the issues.

So, this delayed the clinic by around half an hour, and potentially the NHS would have had to have picked up the cost of the fallout from this guy’s ‘worried well’ personal decision to waste his own money.

I agree with what you’re saying about PSA screening for prostatic carcinoma.  It’s complementary to what I wrote about BRCA2 testing.

It should be noted though that most prostatic carcinomas are located peripherally in the prostatic gland and only produce urinary obstruction late (benign prostatic hyperplasia is usually the cause of a poor pee) usually after they’ve spread elsewhere and are no longer curable (in which case a PSA level is likely to be diagnostic, but alas, not a screening test).

The best screening test for prostatic carcinoma is the finger of an experienced doctor.  If you can afford it, the next best one is periodic prostatic MRI scans (and it’s a long way behind).  My GP insists on doing yearly PSAs - if they ever increase, then I’ll insist on an MRI scan instead of a biopsy to exclude a false positive.
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Offline drmarkf

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Re: Episode #677
« Reply #34 on: July 04, 2018, 04:02:40 AM »
>> It should be noted though that most prostatic carcinomas are located peripherally in the prostatic gland and only produce urinary obstruction late (benign prostatic hyperplasia is usually the cause of a poor pee) usually after they’ve spread elsewhere and are no longer curable (in which case a PSA level is likely to be diagnostic, but alas, not a screening test).

The best screening test for prostatic carcinoma is the finger of an experienced doctor.  If you can afford it, the next best one is periodic prostatic MRI scans (and it’s a long way behind).  My GP insists on doing yearly PSAs - if they ever increase, then I’ll insist on an MRI scan instead of a biopsy to exclude a false positive. <<

Yes, serial PSAs make sense logically, but to the best of my knowledge when I last looked this area up (a few years ago and, yes, I am a man in my 50/60s!) there was no evidence I could find it was better. I can't help thinking about serial MRIs that even for a billionaire your time and money would be better spent elsewhere. Think of all that mercury leaking from your fillings, for example!

Maybe there should be a separate board on here for us blokes of a Certain Age? Steve would be a member...

(Since this is a US site I'd better note that, yes, I am a retired medic who no longer has a license to practice clinically and is certainly not a urologist, so none of this constitutes medical advice  8)  )
Regards,

Mark

Offline CarbShark

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Re: Episode #677
« Reply #35 on: July 04, 2018, 11:11:35 AM »

You don’t need to do a whole genome sequencing to detect BRCA1 (and BRCA2) mutations. 

Right. I wonder if 23&Me or any of these other services look for that among the other genetic disease risks they look for.






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Offline CarbShark

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Episode #677
« Reply #36 on: July 04, 2018, 11:16:47 AM »
http://docs.wixstatic.com/ugd/c621e5_421837f94d654e7784af18d98b5fc4d9.pdf

This is a sample report from one company. They claim they detect risks for over 100 diseases. (Including breast cancer)




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Offline Friendly Angel

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Re: Episode #677
« Reply #37 on: July 04, 2018, 12:23:19 PM »
You don’t need to do a whole genome sequencing to detect BRCA1 (and BRCA2) mutations. 


Right. I wonder if 23&Me or any of these other services look for that among the other genetic disease risks they look for.


I don't know if it's the BRCA gene they're looking at, but my 23andMe report does list my relative risk for prostate cancer


Amend and resubmit.

Offline bachfiend

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Re: Episode #677
« Reply #38 on: July 04, 2018, 06:05:22 PM »
>> It should be noted though that most prostatic carcinomas are located peripherally in the prostatic gland and only produce urinary obstruction late (benign prostatic hyperplasia is usually the cause of a poor pee) usually after they’ve spread elsewhere and are no longer curable (in which case a PSA level is likely to be diagnostic, but alas, not a screening test).

The best screening test for prostatic carcinoma is the finger of an experienced doctor.  If you can afford it, the next best one is periodic prostatic MRI scans (and it’s a long way behind).  My GP insists on doing yearly PSAs - if they ever increase, then I’ll insist on an MRI scan instead of a biopsy to exclude a false positive. <<

Yes, serial PSAs make sense logically, but to the best of my knowledge when I last looked this area up (a few years ago and, yes, I am a man in my 50/60s!) there was no evidence I could find it was better. I can't help thinking about serial MRIs that even for a billionaire your time and money would be better spent elsewhere. Think of all that mercury leaking from your fillings, for example!

Maybe there should be a separate board on here for us blokes of a Certain Age? Steve would be a member...

(Since this is a US site I'd better note that, yes, I am a retired medic who no longer has a license to practice clinically and is certainly not a urologist, so none of this constitutes medical advice  8)  )

The comment about periodic prostatic MRIs as a screening test for prostatic carcinoma was more tongue-in-cheek.  I don’t think anyone would seriously consider doing it.  In Australia it’s said to cost around $400 so you wouldn’t need to be a billionaire to afford it.  I’m sceptical about PSAs as a screening test.  PSA is prostate specific, not cancer specific.  There are other causes of an elevated PSA, besides prostatic carcinoma, such as a long bike ride.
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Offline Dangbh

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Re: Episode #677
« Reply #39 on: July 06, 2018, 08:06:49 AM »
On behalf of every British listener I am utterly utterly offended, nay, disgusted.

BENNY HILL????

You think that BENNY HILL is representative of British Humour? Dear God. I mean, there is a truth to the idea that he is representative of a certain kind of British humour in the same way that 'Beautiful Like My Mom (Support The Troops)' is representative of a certain type of American music. But look, this is like if a Brit said to you 'I like American music', and you're wondering 'Nirvana? Billie Holliday? The Velvet Underground?' and then they turn around and say 'Billie Ray Cyrus'.

Offline seamas

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Re: Episode #677
« Reply #40 on: July 06, 2018, 09:37:47 AM »
On behalf of every British listener I am utterly utterly offended, nay, disgusted.

BENNY HILL????

You think that BENNY HILL is representative of British Humour? Dear God. I mean, there is a truth to the idea that he is representative of a certain kind of British humour in the same way that 'Beautiful Like My Mom (Support The Troops)' is representative of a certain type of American music. But look, this is like if a Brit said to you 'I like American music', and you're wondering 'Nirvana? Billie Holliday? The Velvet Underground?' and then they turn around and say 'Billie Ray Cyrus'.

So Keeping Up with Appearances* it is!

One funny thing about American opinion of "British Humor" is how generational it is.
I grew up watching Monty Python's Flying Circus when it was on PBS (as well as some Benny Hill), and would regard that as British Humor.

I recall using the phrase "British humor" in front of my mother and she was a bit confused, as people of her generation  (growing up in the 1940s) used the term "british humor" as a euphemism for "not funny at all" or "dull" humor.

Offline bachfiend

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Re: Episode #677
« Reply #41 on: July 06, 2018, 07:47:48 PM »
On behalf of every British listener I am utterly utterly offended, nay, disgusted.

BENNY HILL????

You think that BENNY HILL is representative of British Humour? Dear God. I mean, there is a truth to the idea that he is representative of a certain kind of British humour in the same way that 'Beautiful Like My Mom (Support The Troops)' is representative of a certain type of American music. But look, this is like if a Brit said to you 'I like American music', and you're wondering 'Nirvana? Billie Holliday? The Velvet Underground?' and then they turn around and say 'Billie Ray Cyrus'.

So Keeping Up with Appearances* it is!

One funny thing about American opinion of "British Humor" is how generational it is.
I grew up watching Monty Python's Flying Circus when it was on PBS (as well as some Benny Hill), and would regard that as British Humor.

I recall using the phrase "British humor" in front of my mother and she was a bit confused, as people of her generation  (growing up in the 1940s) used the term "british humor" as a euphemism for "not funny at all" or "dull" humor.

I wonder if your mother’s generation thought British humour was dull or not funny at all was because it was too subtle and understated, unlike slapstick comedy? 

Your reference to Monty Python reminds me that I have the complete collection of the episodes released for the American market.  In the ‘summarise Proust in 30 seconds’ segment, one of the contestants announced that his hobbies were golf, strangling small animals and masturbation.  It went over in dead quiet.  The MC noted that the contestant had let himself badly - golf isn’t popular around here.  And masturbation was censored from the American version, which somehow ruins the joke.
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Offline DevoutCatalyst

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Re: Episode #677
« Reply #42 on: July 06, 2018, 07:53:40 PM »
Regarding WTN, there are of course women rail workers. Jay's comment reminded me of a fascinating book about life on the Southern Pacific from the vantage point of one of the first women brakemen, and probably the only one with a PhD. Linda's description of some of her male co-workers is pretty disturbing, the job itself is dangerous and physically demanding. Paraphrasing Smithsonian "A sometimes crude, always vivid book".


Offline arthwollipot

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Re: Episode #677
« Reply #43 on: July 08, 2018, 06:37:45 PM »
Benny Hill hasn't aged well.
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Offline seamas

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Re: Episode #677
« Reply #44 on: July 08, 2018, 11:25:33 PM »
On behalf of every British listener I am utterly utterly offended, nay, disgusted.

BENNY HILL????

You think that BENNY HILL is representative of British Humour? Dear God. I mean, there is a truth to the idea that he is representative of a certain kind of British humour in the same way that 'Beautiful Like My Mom (Support The Troops)' is representative of a certain type of American music. But look, this is like if a Brit said to you 'I like American music', and you're wondering 'Nirvana? Billie Holliday? The Velvet Underground?' and then they turn around and say 'Billie Ray Cyrus'.

So Keeping Up with Appearances* it is!

One funny thing about American opinion of "British Humor" is how generational it is.
I grew up watching Monty Python's Flying Circus when it was on PBS (as well as some Benny Hill), and would regard that as British Humor.

I recall using the phrase "British humor" in front of my mother and she was a bit confused, as people of her generation  (growing up in the 1940s) used the term "british humor" as a euphemism for "not funny at all" or "dull" humor.

I wonder if your mother’s generation thought British humour was dull or not funny at all was because it was too subtle and understated, unlike slapstick comedy? 

No. I think Americans of that area were exposed to  a pretty broad array of comedy back then --not all of it was slapstick. I don't think the perception was some dullard inability to get understated humor, just the little exposure Americans had of British humor --either in film or in personal experience wasn't all that funny.

That said, two icons of American humor--Charlie Chaplin and Bob Hope were actually English--but few people perceived them that way.

 

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