The author of this remarkable book discusses the issue of whether healthy (non-sick) people should be screened (tested) for cancer, e.g., mammography, PSA test, PAP smears, colonoscopy, etc. As it turns out, this matter does not involve a simple yes or no answer - something that may surprise many people. The author guides the reader through issues that may not be well-known to the average individual, e.g., benefits and harms of the testing processes, of early detection, of subsequent tests, of various treatment options, the misleading nature of various quantities such as the "five-year survival rate", etc. All issues are presented in a very level-headed, objective yet compassionate way. In order to support his view that being screened for cancer is often not the ideal thing to do, he discusses many studies with lots of real data throughout the book. The author does an excellent job of conveying to the reader that any potential benefits of cancer screening can often be considerably outweighed by associated risks. With this information as well as with certain recommended guidelines, the reader is encouraged to decide for him/herself - the subject of the last chapter. The writing style is clear, immensely accessible, authoritative, jargon-free and quite engaging. This is a book that should be of interest to everyone.
on May 24, 2004
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.
on April 10, 2004
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.
on March 6, 2004
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.