Tuesday, November 29, 2016


That is the question...

An argument ensues and the voices get louder. The points of view are bandied about and the loudest voice has the sway. Today the voice with the most promoted resonance is one that deems that “Less is More” and is couched in the premise that doing more, causes “harm.” Harm is defined as potential risks related to interventional therapy, be it surgery, radiation therapy or drug therapy. Citing examples of prostatic infections from biopsies in establishing diagnosis of prostate cancer to emotional stress and in some cases establishing PTSD as a causation of diagnostic and treatment intervention.

What is even more striking is that physicians not wanting to standout against the zeitgeist and be ridiculed are following the piper in lockstep and agreeing with the “Rationing “ concept of healthcare(1).

Allow me to dissect this new frame of reference.

Let us start with a malignancy such as Ductal Carcinoma in Situ (DCIS). Some ivory wall experts believe that DCIS is not even a malignancy. They harp at the 98% survival rate at 10 years for such a diagnosis. But clearly there is more than meets the non-discerning eye.

The difference between the DCIS and invasive cancer is the breach of the basement membrane (a membrane that keeps the contents of the duct within the duct). So a breach indicates that the cancer cell has transmigrated to the tissues outside the duct. But here is a path less travelled in their minds. 

A duct is a convoluted path of continuity (seen in these radiology duct images), not a straight line as represented on the cartoon above and pathology slides are cut in a linear razor sharp format, so the duct can from the pathologist point of view present with multiple views in the specimens but not all. 

Hence where a breach might have happened might not be represented in the pathologist’s slide at all. And no two are the same

Arrows point to cancer outside the duct

On the other hand, sitting out the DCIS for months in a “Less is More” policy the cancer cells continue to, as is their wont, acquire more DNA mutation and ultimately seek the outside the duct environment to flourish. As this article suggests that radiation therapy benefits patients with DCIS versus Observation, further negates the argument of “sitting on one’s hands” (2).

Look no further than  the Prostate Cancer scenario, where a “low risk” defined prostate cancer relegated to the “observation deck or watchful waiting” policy has led to an increased risk of more aggressive prostate cancer diagnoses. Again one shouldn’t be mystified as the experts are and try to rationalize in pretzel fashion the reasoning behind that transgression (4).

Clearly in the legal circles, “delay in diagnosis” is a big money maker for the plaintiffs and their legal eagles. The lawyers dressed up in pin-striped suits and charming ties make pitches to the jury by using terms like “negligence and such” to get a better pay day. And most such large verdicts are clearly in their favor and against the physicians. And yet the ivory walled tower consultants seem uninterested in that aspect of the disproportionately weighted coin (3). For individual cases of such “malpractice” are the domain of the doctor and their insurer not the matters for the policy experts.

What to do?

Clearly, the answer lies in the physician’s personal judgment. Unfortunately the drumbeat in the medical literature by the experts, who use statistical graphics of “waterfalls” and “forest plots” constantly hammering the ear drums holds a sway to some physicians (Nowadays, it appears the majority 53.1%). Bombarded by the constant level of rhetoric from the “Choosing Wisely” crowd and the “Less is More” cost container segment of the experts the mistruths seem to be gaining ground and impacting patient care (1).

Isn't it ironic that causation is definitely implied through correlation in most of the “studies.” Isn't it further sad that the belief in such idiocy continues to gain ground and the vast conspiratorial impact of the probability function of p-value through tortuous mathematical indiscretion has become the mainstay of medical science. Using the p-value one can create any scenario to befit any belief , thought or nuance. There are legions of “P-Hackers” among us (6, 7)!

Pushing the needle further a study suggests that metastatic renal cell cancer should be placed on the observation deck also since many survive longer than anticipated (5). Assuming that DNA mutations are a function of biology and thus can happen anytime as Immune surveillance can be overwhelmed anytime, the logic in this “study” escapes, especially when there are newer therapies available for care of these patients. The thought comes to mind that it is all about costs at this point and time. The administrators and Managers point the finger of fault while they collect handsome bonuses. The average hospital cost devoted to administrative serves was 24.3% in 2015 (8). And that my friends is in the Billions.

The irony of it all in costs and purported care

So what do we do? If you still believe in the coffee enemas, then all hope is lost. Barring that, a self imposed moratorium in instant belief of the “studies” should be the way to go. The ability to understand, the ability to reason, the ability to weigh the consequences and the ability to define the world according to those fundamental principles of reality and not some hogwash pseudo-science.

If we only had a bulletproof mechanism to establish the indolent versus the aggressive, things could be different. But we don’t. Even Genome Assays are a point in time and do not presage further change in the genetic structure. So we remain in the dark and in so doing we stretch the limits of our understanding into policy mistakes that harm our patients in the end.

1. http://link.springer.com/article/10.1007/s11606-016-3756-5

7. http://fivethirtyeight.com/features/science-isnt-broken/#part1

8. http://www.nejm.org/doi/full/10.1056/NEJMsa022033#t=article