The plural of anecdote is not data. The plural of anecdote is not data. The plural of anecdote is not data.

Please write that on the board 300 times.

You’re also acting out the interesting psychodynamics of loss aversion – we pay far over the odds to avoid a loss, whether its for insurance or taking on the risk of medical procedures.

Good doctors want you to understand that all procedures have risks, even minor, routine ones. Which is why I had a sit down with a doc over whether I wanted a CT given the cancer risk – I really, really wanted a CT and wasn’t in the right state of mind to give informed consent anyways (extreme acute pain that we were trying to nail down), but CTs are bog standard these days. I also almost died 1 day after having an abscessed ingrown hair treated, which is one of the most minor things a doctor will do to you with a knife.

To the patient (especially one with the big C), you’re going to die if this thing isn’t removed, and the low risks are meaningless. But you really aren’t going to die – great new research came out last week highlighting tumors that spontaneously shrivel away (study focused on testicular cancer). Plus, as you mentioned, the findings that nearly everyone dies with cancer, but not of cancer. Our screening ability has raced ahead of our ability to make predictions. We are very, very close to the line of killing more people with excessive treatment than we are saving with screenings. This is even more so in Breast Cancer thanks to increased radiation doses.

The worst thing to do to health care and intelligent, personal decisions is to let the government have a monopoly on it. Monday had The Globe and Mail highlighting women who’d been condemned to death thanks to the revocation of coverage of multiple drug therapies by the Ontario Government http://www.theglobeandmail.com/news/national/mds-press-ontario-to-fund-rare-disease-therapy/article1347770/

Because the math you’re using is incomplete. Screening doesn’t just catch people with disease; it also tells some people they have disease when they don’t. These people then get painful, dangerous (not very dangerous, but not as safe as not having it done) and expensive additional testing, for no good reason. Some of these people who did not need to be screened will have complications, and some will, die when they need not have.

And furthermore, screening misses some people who have disease, but the screening isn’t good enough to tell them they have it. These people go along with their lives, possibly deferring further screening (because hey, they got screened once and it was fine, right?), until they get symptoms, and are then blindsided by a diagnosis they thought they had dodged.

Screening tests need to be *really, really good*, and the outcome of screening needs to be *very* much better than not screening. And the science on PSA testing is that it just isn’t good enough. It misses too many people who have cancer, and tells too many people they have cancer when they don’t. And (as you accurately note), the consequences of missing some of these cancers are not particularly high, since most men will die *with* these cancers, rather than *of* them.

So again-I’m glad you had a good outcome. A relative recently told me his PSA was rising; I told him to get the ultrasound, but to think hard about whether to have biopsies or surgery (he is quite a bit older than you, to be fair), as his outcome with and without surgery is probably similar (he’s much more likely to die of something else). He hasn’t decided what to do yet. For myself-I am not having my PSA screened. I’ll keep an eye on the science, and if it gets better I will have whatever screening is better, but PSA is not ready for prime time.

And speaking of the plain patient and his ability to have the knowledge that gives him choice, would you tell us what the total cost of the surgery was?

When you say the “insurance company will probably pay $25k,” one is left wondering what was left unsaid. Those of us who pay our own way would very much appreciate knowing the rest of the story. That type of information is not easy to obtain online.

Thanks in advance!

I did give it a moment’s thought. Amortized over my expected life span with surgery, it comes out to about $100 per month. Scratch one dinner out at a nice restaurant.

Something has been nagging at me about your argument for a couple of days. I think it is this…

… this discussion is really about playing the odds with my life – and who gets to roll those dice. I want to be the one who makes this bet.

I understand your point that its is only screening that alerts you to the fact that a bet has to be made (and you want to make sure you make that bet not your insurance company). But how did you know what the odds were? Surely, the only way you knew was thanks to public health epidemiologists. They did the research in blind randomized tests to find out what the risks and benefits of treatment are for various PSA levels for men of various ages.

Those blind randomized tests must have been conducted by using the very protocols that you condemn: by taking the choice away from individual men over whether to have surgery; assigning some to choice A and others to choice B; and then tracking their long-term prognoses.

So your ability — and mine too — to “roll those dice,” as you put it, stands on the shoulders of men who had scientists roll the dice for them. Your attempt to draw the bright line between “me and my cancer” on the one hand and “statistics and money” on the other does not stand scrutiny. If you do not know the statistics, then you cannot place the wager.

Fair enough.

Of course, that means that you’ll have no objection to giving every dime that you have to pay for someone’s medical care.

Yes, your money. After all, “invaluable” is your opinion.

Of course, that does mean that you’ll probably be unable to pay for certain care that you might like, but that’s how these things go. (There’s always someone who is unable to do something for themselves because their money was taken to provide that same thing for someone else.)

Jarvis, you are way off on your odds here. Not only would a patient be ill advised to undergo such major surgery if there were 99% odds that it was unnecessary to save his life. No surgeon could conscientiously perform the surgery. It would be a gross violation of the Hippocratic Oath to do the “harm” of surgery on 99 non-terminal men in the hope of saving the life of the hundredth.

I was told, as I am sure you were, that a prostate cancer discovered in a man under 60 indicates surgery for two reasons. First, his life expectancy is otherwise long enough that the tumor would have time to kill him; second, that tumors in younger men grow more quickly than those in older men. I was told that the odds of the tumor killing me untreated were very short indeed, nowhere near 1 in 100, considerably greater than 50%.

Someone who had the same PSA levels at the age of 80 would never be a candidate for surgery.

The point is that any screening is only appropriate if its results are actionable. The worry at the American Cancer Society is that doctors and patients are being misled into believing that action is warranted in response to a positive PSA test merely by virtue of the results being available. The contemporary fee-for-service healthcare industry has a built-in incentive for tests to be performed and for procedures to be followed as a consequence. The ACS is wise to warn that the benefits of PSA screening are exaggerated.

Anyway, this is how the network nightly newscasts — ABC here and NBC here — covered the fallout from the Times coverage.

Recently I’ve been listening to the debate in US, wondering what the perfect health care system would look like. I’m quite certain that a completely free market approach will never work properly, since the health of oneself and his loved ones is not something one can do without.

All in all, I think most health care is a form of disaster relief and should be run by the government.

My question is not “is the $25k spent on your surgery worth it?”

It is, would it be worth it to you (Jeff) if you had to write the check yourself? Would you weigh the choices (surgery vs. watchful weighting) differently? I ask it because it’s an interesting amount. I presume Jeff could afford it, but it would be an actual financial sacrifice.

At least that would roughly be my situation, if I had to make that choice. And it makes the expense more “real” if you have to think about paying it directly, and not through an insurance proxy.