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Should I Be Tested for Cancer?: Maybe Not and Here's Why

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For decades, the American Cancer Society and others have relentlessly campaigned for early cancer detection. And the campaign has been successful - the Journal of the American Medical Association recently reported that only 2% of Americans felt that there are too many cancer-screening tests. Despite this enthusiasm, expert panels of physicians and scientists, after careful reviews of the evidence, do not always endorse screening. Facing these conflicts can be distressing, particularly when confronting issues as serious as cancer.

This book offers insights that clarify the issues for patients and physicians alike. As the subtitle suggests, Welch is skeptical about screening, and his text challenges the establishment. However, Welch is not a medical outsider. He is a practicing physician, a Professor at the Dartmouth Medical School, the former editor of a medical journal, and a researcher who has helped reshape professional thinking in articles in the New England Journal of Medicine, Journal of the American Medical Association, Annals of Internal Medicine, and other key medical journals. Using the traditional medical literature, Welch raises some very challenging questions for anyone considering cancer screening.

Welch's book provides the reader with a new way to think about testing. He tells how cancer tests may identify disease for which there is no effective treatment, or for which the consequences of treatment are worse than the consequences of the disease. Welch explains why it may sometimes be better not to know you have cancer. In fact, many of us have conditions that will never affect us. In one section, he uses data from the pathology literature to demonstrate how fuzzy the definition of early cancer realy is - that different pathologists can examine the same specimens and come to different conclusions about whether cancer is present. Another section offers easy rules that clarify misleading reports of cancer rates. By walking us through the meaning of cancer statistics for individual patients, Welch clarifies what numbers should be important to individual patients.

The bottom line is that this book takes on a difficult topic with remarkable clarity. Dr. Welch provides tools that will help patients play a more active role in their own health care decision making.

Robert M. Kaplan is Professor and Chair of the Department of Family and Preventive Medicine at the University of California, San Diego School of Medicine.

H. Gilbert Welch, MD, MPH, has written an unusually understandable revelation of the folly of testing for cancer in people with no symptoms. He explains how only a few people will benefit from common tests such as PSA, fecal blood, mammograms and others. He is enough of an insider to be able to explain the flaws in clinical trials being used by "authorities" to recommend extensive testing, and the lack of trials in some cases. The unneccessary biopsies, surgeries, radiations, chemotherapies for slow-growing cancers or even non-malignant ones are presented bravely. The uncertainty of testing is exposed where a positive for cancer may be wrong 1/3 of the time. And it is up to the patient to get second opinions.
The financial and legal pressures on MDs to test excessively are brought out. There is advice on talking or writing to your MD to indicate your unwillingness to undergo too many tests, and not to hold your MD liable if a cancer was "missed" - that is the big thing.
The deaths caused by cancer treatment are aired. This is something very few people, even MDs, know. Even when a treatment can cut the deaths from a particular cancer in half, most current treatments create non-cancer deaths, many of which will be improperly reported.
Welch is a special expert on the misleading nature of 5-year survival rates how they can rise because of early detection, yet with no change in the cancer plus cancer treatment mortality rate.
There are good explanations of how 5-year survival rates are calculated, how age-adjustments are made, how randomization for trials is done, and other things not even taught in medical school, but reserved for medical researchers. And quite easy to comprehend with clear figures and tables.
No errors that I can find; a really excellent book.

Should I be Treated for Concer? Maybe Not and Here's Why, by H. Gilbert Welch

It is hard to put into words the importance of the book, Should I be Tested for Cancer? by Gilbert Welch, M.D., Professor of Medicine at Dartmouth Medical School. It is equally as hard to put into words the courage that it must have taken to write this book. The medical establishment does not look kindly on those who stray too far from the constraints of conventional wisdom. Those of us who seek only about the truth as it pertains to healthcare issues are greatly indebted to Dr. Welch for daring to do so.

I have been involved with health care issues for over 28 years. This book is a God-sent and is easily the most important book on this subject I've read in the last decade. Quite frankly, I couldn't put it down. It was given to me by one of my patients who, over the years, has known of my "healthy skepticism" towards many aspects of conventional medical practice, especially as it relates to cancer diagnosis and treatment. The book confirms many of the thoughts that I have shared with my "nontraditional" patients over the years.

It is never easy to be perceived as going against the grain of conventional wisdom in any discipline, especially one as emotionally charged as cancer. The author has performed an invaluable service to the many concerned people who dare to think for themselves "outside of the box." A simple perusal of some of the chapter headings reveals all you need to know about where the book is headed: "It is unlikely that you will benefit." "You may have a `cancer scare' and face and endless cycle of testing." "You may receive unnecessary treatment." "You may find a cancer you would rather not know about." "Your pathologist may say it's cancer, while others say it's not." "Your doctor may get distracted from other issues that are more important to you."

In Dr. Welch unemotional, factual writing style, we learn about such concepts as "false positives," "pseudo disease," the fallacy of "early detection," suspicious and unreliable "cure rates." We are introduced to the rarely recommended but legitimate treatment option of "watchful waiting" which, for many patients and some forms of cancer, may be the best course of action. We are told that how hard doctors look for prostate cancer affects how much they find. Did you know that there is a saying among doctors about prostate cancer: more men die with it than die from it? There are similar nuggets of wisdom about breast cancer, cervical cancer, and lung cancer. And did you know that you could easily become a victim of a deadly form of medical "political correctness"?

Here are a few snippets from the book well worth quoting:

"Tests can be wrong, people are made to worry unnecessarily, some are treated unnecessarily, and some are even harmed by treatment."

"I will argue that a decision to forgo cancer treatment can be a reasonable option."

"If the behavior of doctors and the public continues unabated, eventually every well person will be labeled as sick."

"Some believe that anyone who dies of cancer and wasn't screened would have been saved had they had a test. But that's not true."

"I object to the emerging mindset that patients should be persuaded, frightened, and coerced into undergoing [mammography, PSA tests, fecal occult blood testing]. There is today a certain "medical correctness" about screening - making patients feel guilty if they choose not to pursue testing. This is wrong." [emphasis added]

As Dr. Welch makes abundantly clear, this book is not for everyone. It is not for people for have a need for simple answers. We all know friends and relatives who, if told they have a "lump" somewhere on their body, need to "have it out" as soon as possible in order to restore a certain peace of mind. This book is definitely not for them. Rather, it is for those thinking individuals who are open to questioning the wisdom of traditional medical practices, especially as they pertain to cancer testing and conventional treatment modalities. For them this book is a definite eye-opener and may someday become a life-saver. Again, one can only admire the courage that it took to write a book of this magnitude.

I enjoy the give-and-take of discussing health issue with my patients. While I refrain from offering specific medical advice outside of my field of dentistry, I readily discuss health issues on a general level with selected patients. What I always suggest is that it is extremely important that they educate themselves in all aspects of healthcare - including cancer diagnosis and treatment - now, when they are healthy, so that when the day comes when they or a loved one are confronted with an important health issue, they can make an intelligent , informed, and unemotional decision. This book has greatly assured me that this is a sound, reasonable philosophy, and as such, I will be highly recommending this book to all those who want to be actively involved in their own healthcare decision-making process.

Dr. Welch: I'm 40 years old. I'm tired of people saying "you haven't had a mammogram?" with the same disbelief and insulting tone that would be appropriate for asking "you've never been vaccinated?" I'm tired of my female friends emailing me cancer scare emails and obsessing over their breasts as though their entire existence is as a life support system for breasts. ESPECIALLY given that I had, by age 25, a will, living will, and medical and legal powers of attorney filed in my file drawer and update them every year, despite being completely healthy. But that's morbid. Oh, but obsessing over cancer isn't.

I read about your book, bought it, read it in one sitting, annoyed the daylights out of my friends forcing them to listen to excerpts, and badgered my doc at length when he started on the bullying tactics. Confronting him with the accusation that he gets a free toaster if I get a mammogram got his attention. He's backed off now. I've changed physicians anyway and found one who doesn't subscribe to the routine prescreening hysteria.

I recommend your book more than any other I own. A close second is one dealing with the realities of crime... contrary to TV or media hysteria, most women are NOT beat up, raped, or killed by complete strangers. Similar goal to yours in effect. Putting things in perspective and getting them away from the realm of urban legend.

This is one woman who spends not one second a day worrying that I might have something. There is a 100% chance, as you say, that I'm going to die of something someday and I've come to terms with that. I keep my papers in order and I live like I won't be around forever. Wednesday I head on vacation to Italy. I don't worry too much about terrorism either.

Thanks for helping me sleep well. I think you're awesome. Now write something else!

Jan

As we enter the 21st century everyone wants to be tested. My clients want career tests. Patients want health tests. We're trained to believe that tests of any kind are infallible and anyway, "What harm can they do?"

Thankfully, Welch's book sets the record straight. Like many care avoiders, I've been challenged by well-meaning friends and even acquaintances. They insist that certain procedures could help me live longer.

I say, "When I die you can shake your finger at my urn and say, 'I told you so.'"

In truth, once you get on the medical merry-go-round of tests, x-rays, biopsies and more, it's hard to get off. You submit to all sorts of horrible procedures only to find nothing's changed.

One gap in the book: Many of us worry about stroke and disability more than death. Welch's book just looks at the way tests fail to extend life. But what about quality of life? I suspect the answer's the same but it would be helpful to have that point covered as well.

A must-read for everyone who's healthy and wants to stay that way.

This is a very well written short book on the excessive use of cancer testing. The book is divided in two parts. The first part explains the problems associated with the inaccuracy of cancer screening and its implications: painful over treatment including surgery. The second part educates one on how to interpret cancer statistics so as not to be vulnerable to the positive media spin. It also educates as to the limit of research findings. The benefits of cancer screening are often statistically unfounded. This part also educates on how to manage your doctor so you don't get over tested.

If you combine the most technology and profit driven medical establishment with the most litigious society, you get a Perfect Storm for excessive cancer testing. That is what we got in the U.S. No doctor will ever get sued because he ordered a cancer test. But, he will if his patients get cancer, and he had not actively recommended a test. As a result, doctors don't take any chances and they scear us in taking many cancer screening test.

Cancer tests are deemed to be good for us. Supposedly, the earlier you catch cancer the greater the survival rate. Per the author that is nothing but a simple statistical flaw. We are now tested earlier, and our cancers are detected many years earlier. If you test a population of 50 year olds for prostate cancer, you get a higher survival rate at 5 years, then if you test a population of 70 year olds. Thus, the increase in 5 year survival rate means nothing. The author further adds that mortality rates (of cancer or other causes) has really not changed whether you get tested for cancer or not. Thus, PSA tests and mammograms really don't save lives. Also, cancer incidence has risen to supposedly epidemic levels. But, again this is just due to increase testing.

The standard path is to first take a really benign test whose result is more often than not inconclusive (radiologists often disagree). This leads to biopsies that often are inconclusive (pathologists often disagree too). But to remove the uncertainty, radical surgeries are often the next step. The intervention escalated from one level to the next in part because of the perceived threat of malpractice suit.

The author advances an excellent argument that the healthy would be better off without that much cancer screening. A lot of cancers that are now uncovered such as prostate cancers are benign and would not affect health or lifespan. Many more men die with prostate cancer than from prostate cancer. He calls those benign cancers a "cancer reservoir." The increasing sensitivity of tests uncovers more and more benign growth from our cancer reservoir. And, that really does not do anyone healthy any good. It leads to overly aggressive painful over treatment. At this pace, the entire male American population will have their prostate removed without gaining a day in lifespan, but with a marked increase in incontinence and impotence. This paragraph could be rewritten very much the same way for women regarding ductal carcinoma in situ, a most common but benign form of breast cancer (DCIS). These certainly don't warrant breast removal, but that's often what doctors do.

To become a well educated customer of medical services, I also strongly recommend two other excellent books. One is "The Last Well Person" by Nortin Hadler. This book extends the critique of the medical establishment not just to cancer screening, but to the treatment of cardiovascular disease, and everything else. The other is "Calculated Risks: How to know when numbers deceive you" by Gerd Gigerenzer. This book explains in detail the logic and implication of Baye's Theorem. By doing so, it explains why PSA tests and mammograms are so inaccurate.

This book has helped restore some sanity (namely, my own). After reading extensively about the value of mammograms and other widely used cancer screenings, I concluded that the benefit to myself as an individual was probably minuscule -- or perhaps even negative. But I seemed to be the only one who thought so. It all left me wondering: Am I missing something? Are my math skills really that bad? (Hey, I checked the numbers with my RPN calculator!) Am I just loony?

After reading this book, I was relieved to discover that the answer to these questions is no. Well, OK, maybe there are other grounds for answering yes to the last one, but never mind that.

I would recommend this book highly. It is exceptionally enlightening and useful, and very clearly written. It's also much needed now, with the drumbeat for testing growing louder every day. An ad in my local paper recently tried to terrorize women into getting mammograms by saying, "You may be dying and not know it." Subtle, eh?

People interested in taking care of their own health should read the book. It is the next best thing to consulting Dr Welch. It liberates then from the drawbacks linked to cancer fear. It is also a remarkable training course for medical doctors. As an epidemiologist, I understood why cancer research is flawed : pseudo-cancers detected by screening preclude any improvement in cancer understanding. I also discovered why cancer screening leads to useless treatments. Current cancer health policy appears here as a religion based on a technical illusion. It reveals the folly of mankind when having to face disease and death.

Dr. Welch has performed a great public service by writing this book. In response to the pervasive message that testing for cancer is always good for patients, Dr. Welch explains that the truth is not so simple. In fact, most people will not benefit from cancer testing, and there are serious risks of over-diagnosis and over-treatment associated our most common cancer screening tests. This book is clear, well written, and eye-opening. For anyone who wants to make an informed decision about getting a mammogram, or a PSA test, this book is a must-read.

This book is truly an eye opener. Millions of people are being screened for cancer every year, but is it really necessary? Is it really making a difference? Are people harmed by these tests in anyway?

Dr. Welch explains brilliantly, in my opinion, what these cancer screenings really mean. He argues that we are taking healthy symptom-free individuals and looking for cancer.

What most people do not know and I did not before reading his book is that:

1-There is no evidence that these screenings have actually saved lives. In fact despite increased detection of early stages of prostate cancer and breast cancer, the death rate for prostate cancer has stayed the same and the rate of late stage breast cancer has increased over a 25 year period.

2-Autopsies of people who have NOT died from cancer have shown cancer in the lungs, thyroid, kidney, etc. This means millions of people are living with cancer and die of other causes and not even know they had cancer.

3-If the screening finds cancer, it does not necessarily mean that it is the type that will grow rapidly.
a-It could regress on its own as our immune system eliminated abnormal cells, including cancers regularly.
b-It may stay the same for many years and never cause a problem
c-It may grow so slowly that cause no health problems and the person dies of something else before it does

4-Studies conducted by John Hopkins, Harvard, and others have shown that different pathologist give different diagnosis for the same tissues. They may look at the same tissue and some think it is cancer while others think it is not. Especially when it comes to the a few abnormal tissues found from screening a healthy individual.

5-Also between screenings it is possible to develop a fast growing cancer. So how often do we need to do mammograms and colonoscopies?

6-The statistics, such as the five year survival rate, are not always reliable and maybe calculated in a misleading manner.

So you have a mammogram, PSA test, colonoscopy, fecal occult test, etc done. This is what may happen:

1-You end up with a false positive, depending on the test, 10 percent false positive is the average.
2-You get the cancer scare unnecessarily.
3-This can begin a cycle of retesting, biopsies and other tests. Some can be very unpleasant and have side effects.
4-If they find an abnormal tissue, what does it mean it mean? May the pathologist made a mistake; maybe it has been there for many years; maybe it is a slow growing one; maybe it will go away on its own; maybe it is a fast growing one! Of course, your doctor can't take a chance with your health, and also does not want to get sued for malpractice, so most likely she recommends the most safest (which could be the most aggressive) course of action!

Here you were living a relatively healthy symptom-free life and now you are told you need surgery, radiation, and/or chemotherapy.

BUT once you or I know about they have found cancer, it is hard to know what to do, not to speak of the emotional toll. That's why Dr. Welch believes sometimes it is better not to know. However, as Dr. Welch cautions: If you have any unusual symptoms and your doctor recommends screening for cancer, make sure you are screened.

After reading the book I decided I do not need any screening. As long as I am symptom free and healthy, why put myself through tests that may or may not extend or save my life. I think as long as we don't do anything to harm our immune system, such as smoking, and do the things that enhance the immune system, such as exercise, there is no need to become a patient.

We all need to make the decision for cancer screening based on our priorities, family history of cancer, and other factors. Perhaps a good course of action is to read the book and consult your doctor for best options.

Thank you Dr.Welch for an excellent expose: Well researched and well written.