Groopman discusses the role of “managed care,” and the use of decision-trees, etc. as additional contributors to a lack of critical thinking by physicians. He also suggests what kinds of questions patients can raise to essentially help their doctors avoid some of those errors. Although these questions won’t “cure” the problem, they are a beginning – and Groopman urges patients who don’t receive satisfying answers from their doctors to seek another physician.

What would be the characteristics of the individuals in a career entity that you admire?

i think that there was a time when doctors, especially those working in prestigious places, were amongst the top 1% of 1% of intelligent people. i see an overall slippage of education, and all sorts of perverse motivations have cropped up due to economic factors.

most doctors are people who want three things 1) money, 2) prestige, 3) a feeling of being altruistic. they are willing to put up with a tremendous amount of “work” and dedicate years of their lives to pursuit of their MD, but that education has mainly deteriorated into a signalling mechanism.

so i am not surprised to hear you relate this story. maybe your generous interpretation is the right one, but i feel like it is not.

@T Savehn: You can guess the current status of the story by the use of the past tense in the preceding paragraph.

DeVita’s 6th edition on Oncology was published in 2001. It is a volume with multiple authors, each of whom was assigned his/her chapter(-s) about three years prior to publication. Most of what they write that is not based on personal studies is from citations that are 3 to 10+ years old at the time, plus the 3 years it takes to compile and publish the edition. For instance, there could be no knowledge in that tome of the long-term outcome of Lance Armstrong (treatment 1996) and others like him with non-seminoma germ cell testicular cancer. Check the 8th edition. In a dynamic field like chemotherapy trials, all current info is from researcher-to-researcher communication, and presentation of current papers. Text books are always obsolete at the time of publication.

@T Savehn: (I) object to the “bits of cancer” nonsense set out by some above.

The problem here is discussing mutations from various cell lines as if they were the same actors. Seminomatous testicular cancers are exquiisitely sensitive to radiation, while radiation has no beneficial effect on testicular choriocarcinoma at all; yet both may arise from the same testicle. Consequently, one observer might say that radiation is a great way to treat testicular cancer, while another might say that it is a terrible treatment; both would be correct, just as both would be incorrect. In the original post, the cell-type of the cancer in question was not revealed; the discussion became more meaningful once the discussants knew that it was endometrial carcinoma, for which there is no known benefit of chemotherapy beyond normalization of tests (complete response).

Lastly, Balin’s actual point was that there is a major difference between the position, “There is no evidence that further chemo helps, but that is because we haven’t run the clinical trials yet”, and the position, “There is no evidence that further chemo helps, because double-blind propsective studies have shown this result.”

One of the best works on cancer is DeVita’s “Cancer: Principles & Practice of Oncology”. Chapter 17, 6th Ed. p. 291 addresses the issue. Under “Adjuvant Chemotherapy” the authors write:

“There was initially great excitement with the concept of using chemotherapy as an adjunct to local treatment. The rationale for adjuvant chemotherapy was to treat micrometastic disease at a time when tumor bulk would be at a minimum, thereby enhancing the potential efficacy of drug treatment. It was assumed that drug therapy, at this stage, would result in a much higher cure rate.”

You can guess the current status of the story by the use of the past tense in the preceding paragraph.

Here is a tiny part of the problem. p53 is responsible, at least in part, for causing defective cells to self destruct. It turns out that like little M-Class starfreighter Nostromos the cells in your body each have self-destruct mechanisms that are executed (apoptosis) when the proper command signal (cytokine key) is received from Warrant Officer Ripley (your immune system). But what if the system loses the ability to receive or understand the command? And what if that system isn’t just a stupid computer but instead is a pluripotent stem cell (queen) that is churning out huge numbers of immature, useless (to you) and ultimately destructive (i.e. cancerous) daughter cells?

And what if those daughter cells are susceptible to chemo but the queen is not?

In that case the chemo (which is designed to destroy the bulk of the tumor) will set the clock back to a pre-clinical point by debulking the tumor but not killing the queen. For a slow-growing cancer that takes decades to manifest you’ve rolled back the odometer and may have another 40 years; for an aggressive one you’ve got months.

So you say “hey, but I’ll keep the cancer at bay by taking chemo as a prophylactic”. Evolution answers that question. The malignant queen isn’t happy to just churn out identical copies of partially differentiated daughters who get blasted to pieces by Ripley. Oh no. She continues accumulate mutations as she rapidly produces offspring; and from time to time she produces sisters whom she sends out into the unhappy world to do the same.

Eventually one of those mutations leads to offspring immune to the chemo. That’s why first remissions are generally followed by much shorter second remissions (if at all) which are followed by salvage regimins (experimental Hail Marys) which are followed by palliative care. (Hairy cell leukemia being an exception).

So what then is the point of using a weapon to which both the queen and her brood are immune? Especially if that weapon damages the user and is itself a potent carcinogen quite capable of inducing a high grade cancer like acute myelogenous leukemia in the case of alkylating chemo drugs?

I understand that there are healthy women having mastectomies and hysterectomies because they are more afraid of dying of say uterine cancer (low risk) than they are of dying of diabetes – after multiple amputations – (high risk). And I’m ok with grown ups doing whatever they want with their own bodies. I’m just pointing out the bias at work here described by others that make some people take risks that are, from a Bayesian perspective, foolish.

You are quite welcome. I’m very sorry for the situation that made it necessary.

@you have a special voice and you should find a way to get it out into the universe.

Thank you for such kind remarks. I have two ex-wives who might wish to debate you. I have a lot of spare time on my hands; following HA’s recommendation, my new Blog is here. If any readers would like to have a discussion, or educate me on any aspect of transhumanism or extended life, or request an opinion about medical *issues* (not recommendations for medical therapy or suggestions of diagnoses), please make a comment on my blog, which currently contains only the inaugural post.

@ Is that right?

I *think* that it is, but you have educated me about thinking as much as I have educated you about medical issues. As to *right*, if you know what that is, tell Mr. Yudkowsky so that he can incorporate it into his fAI and get it built. If there really is such a thing as “time”, mine is running out.

Best wishes.

You are right that my relative did have metastatic disease, and you are also right that by all accounts she has had a very unusually good outcome, far better than I would have dared expect a few years ago.

As for the substance, here is my current best understanding of what’s going on: (i) there *is* in fact some at least some merit to the general “common sense” notion that additional chemo beyond clean scans can have additional cancer fighting effects; (ii) there is no evidence of this for endometrial cancer, but mostly because no one has really looked–the second kind of “no evidence”; and (iii) despite this, the right answer, given that the scans have been coming back clean for a while and all other relevant considerations, is still probably in favor of discontinuing. Is that right?

Thank you again. You have been enormously helpful.
Dave