Assume that you are a 40-year-old man. What do you think the chances are that you will die of a heart attack or stroke in the next 10 years? (Please forgive the morbidity of the question; there is a purpose to this pop-quiz.) The answer: just 4 out of 10,000 according to Drs. Steve Woloshin and Lisa Schwartz, authors of Know Your Chances. The odds that you will die in an accident before reaching your 50th birthday are 50 percent higher: 6 out of 10,000.
Nevertheless, many men remain convinced that they are at great risk of dying from vascular disease, particularly as they get older. In truth, even at age 60, the odds that a heart attack or stroke will end your life over the next decade are only 37 out of 10,000. Over that span, you are three times as likely to die of another cause—with the chance of a fatal accident (5 out of 10,000 ) just as high as the chance of a stroke.
Moreover, for reasons we do not fully understand, the incidence of heart attacks is declining. “Fifty hears ago, heart attacks were a scourge. Everyone knew a working-age man who’d dropped dead from one,” writes Dr. Nortin Hadler in his new book, Worried Sick. Today “the decline in mortality from coronary artery disease is well documented.”
There is one exception: If you are a 60-year-old smoker, the chance of a fatal heart attack or stroke in the next ten years climbs to 67 out of 10,000, and your chance of dying of lung disease rises to 59 out of 10,000.
The moral? The average man should probably worry less about his cholesterol levels, and more about driving safely and avoiding tobacco.
For many women, breast cancer is the great fear. Again, let’s look at the numbers. If you are a 35-year-old woman, what do you think the chances are that you will die of breast cancer before you turn 45? Just 1 out of 10,000 according to Woloshin and Schwartz. The chances that you will die in an accident over the next decade are twice as high: 2 out of 10,000.
Granted, as you grow older, your chances of dying from breast cancer rise, but so do your chances of dying from other causes. When you are 60, the odds that breast cancer will kill you over the next ten years are 7 out of 10,000. Slim odds. The chances you will die of a heart attack are twice as high: 14 out of 10,000. Maybe you shouldn’t worry quite so much about breast cancer.
I was surprised by these numbers because I thought breast cancer was a leading cause of death among women. This is because I have heard that 1 in 9 women will “get” breast cancer if they live to 85. But as Woloshin and Schwartz point out , this is one of those health messages that is “intended to be scary, warning us that we are surrounded by danger and hinting that everything we do or neglect to do brings us one step closer to cancer, heart-disease, and death.”
As a result, Americans are Worried Sick writes Dr. Hadler. A professor of medicine and micro-biology/immunology at the University of North Carolina, Chapel Hill , Hadler points out that “far less than 1 in 9 women will die of breast cancer, or even know that they “have” it when they die.
Unless they had a mammogram. Then they would probably find out and be treated—whether or not they need treatment. It turns out that two-thirds of women over 55 who have breast cancer will die of something else. Here are the numbers: In order to prevent one cancer death among women over 55, 250 women have to be screened annually, beginning at age 55. But mammograms will also detect two other women with breast cancer who would not have died of the cancer and would never have known that they had breast cancer.. “In other words” Hadler points out, “the screening will lead to the treatment of three women, for two of whom the treatment is unnecessary.” In some cases, "treatment" means that they lose a breast.
This is the best-case scenario for screening post-menopausal women,” Hadler explains. One out of 250 will be saved, and two out of 250 will be exposed to the risk and worry of treatment—without deriving any benefit. Hadler sums up the findings: “Early detection [via a mammogram] makes less sense the older the woman, or the more morbidities [potentially fatal diseases] that she suffers. In such a circumstance breast cancer is but one of the processes vying for the proximate cause of death, and not the most likely to win.”
Moreover, there is no “best-case scenario” for screening younger women unless they have a family history of early death from breast cancer. This, Hadler notes, is why “the American College of Physicians believes that the risks of unnecessary biopsies far outweighs the likelihood of saving a life and therefore does not recommend mammography before age 50 and suggests that women do not need to be screened after age 74." Similarly, the U.S. Preventive Services Task Force recommends mammography screening only every 1-2 years for women age 50 -69.
Precancers
Too often, Hadler warns,"early detection" means that mammograms discover ductal carcinoma in situ (DCIS). “In situ” suggests that there is no discernible evidence that the cancer is spreading. By the 1970s, he explains, physicians were finding more and more cases of DCIS.
“It’s about this time that the notion of a ‘precancer’ really took hold,” Hadler observes. “Powerful surgeons writing in powerful journals were advocating mastectomy to expunge the risk, whatever its magnitude.” DCIS can “become invasive,” he acknowledges, “but low-grade tiny DCIS lesions take their time to become invasive and even more time to become metastatic. It is defensible to excise DCIS if it is discovered in a younger patient,” he adds. “That’s not the issue. The issues are what are the yield and iatrogenicity [danger of inadvertenly harming the patient] when trying [so] hard to discover DCIS in the first place?”
Today, “we are witnessing an epidemic of DCIS,” says Hadler. “In 1980 DCIS accounted for only 2 percent of breast cancers. Between 1973 and 1992, the age-adjusted incidence rate of DCIS increased nearly six-fold.” Meanwhile, the age-adjusted rise in the incidence of invasive breast cancer was only 34 percent. "Women are not getting more cancers," says Hadler. "Rather, U.S. women are gettjng more breast biopsies thanks to mammography.” And once diagnosed “local excision is always recommended, often with some radiation therapy, chemotherapy, or surgical exploration of the nodules. And ‘local excision’ can be extensive, to assure clean margins.’ Often women then opt for painful, expensive breast reconstruction.
How many of these women would have been better off if they had never known about the lesion? As Hadler points out, older women ,in particular, are likely to die of something else before this type of cancer becomes invasive.
Nevertheless, Americans have been sold on the idea that “early detection” is always best. As Hadler puts it: “the public-awareness program for cancer has been far more successful in promoting enthusiasm than reason.” Research shows that “Americans are willing to undergo screening without regard to the efficacy of the tests or the likelihood that they will lead to unnecessary treatment.”
Hadler and Popper
Who is Nortin Hadler, and why he is saying these terrible things about screening and early detection? Hadler is both a scientist and a physician. He started his career as a geneticist, moved on to study immunochemistry and spent his first decade on faculty as a physical biochemistry. Today, he is a professor of medicine and an attending rheumatologist at UNC hospitals. He has closed his laboratory but he retains “a keen appreciation for the scientific method at its most rigorous.”
At the same time Hadler knows how fallible medical science is. A student of Karl Popper, the philosopher of science who taught that “truth is only the hypothesis that is yet to be disproved,” Hadler knows that today’s received wisdom may be replaced tomorrow.
Not long ago, he points out “tonsils were removed because they were swollen and uteruses because they were lumpy.” We were wrong. Throughout the 1990s oncologists thought that bone-marrow transplants would help breast cancer patients—and thousands of women suffered needlessly. More recently, we are realizing that when you consider the risks as well as the benefits, we may have been overly optimistic about mammograms as the answer to breast cancer. A few women are saved; many others are hurt. Or as an Australian study declared not long ago: “Benefits and harms of screening mammography are relatively finely balanced.”
Until quite recently the National Cancer Institute and the American Cancer Society recommended PSA testing for early-stage prostate cancer for average-risk men over 50. Now, they don’t.
In medicine, scientific progress is not simply a matter of accumulating knowledge. Often, advances mean unlearning what we thought we knew—and replacing that knowledge with a new, temporary truth. Sometimes the new truth is misleading; sometimes it will apply only to some patients. Always, we have to be ready to see it replaced.
Hadler explains that he wrote Worried Sick, not for people who are seriously ill, but for the “worried well.” He wants to help us cope with knowing that we are mortal without letting the fear of death shadow our lives as we fret over each and every symptom –be it “heartburn, a peculiar sensation, or a realization of our physical limits.”
His goal is to “bolster the personal resources that facilitate coping” with the ills that flesh is heir to. “And our coping is in dreadful need of bolstering,” he adds. “The wealth of information disseminated by all sorts of health-care vendors, including those in the medical profession, may be intended as helpful but often is not. Much of this information does violence to our sense of invincibility without doing equivalent good for our health or longevity…
“Your sense of well-being requires conviction to withstand the badgering assaults of health-promotion programs,” Hadler adds. “Yes, we will all die. The issue for me is not so much how or why we die, but when and how we lived.” But in our health care system, and in the mind of the laymen, “the proximate cause of death is foremost, so that great energy and great wealth is expended trying to spare you death from a particular cause without considering whether you will die at the same [age] from some other cause. "
A man may spend his fifties checking his blood pressure and cholesterol, levels, taking Lipitor and worrying about chest pains He may even undergo angioplasty for temporary relief from angina. And he still may be hit and killed by a car when he is 59. This isn't to say that he shoudln't check his blood pressure, but if he finds himself obsessing over the possibilty of a heart attack or stroke, he might want to remember Hadler's words.
And before undergoing the angioplasty, he should consider this fact: every treatment carries risks and the possibily of side effects. Hadler's aim is to help his reader avoid medical interventions that cause harm. "Armed with sketpicism and a critical intellect, it is possible to safely and effectively benefit from modern medicine without being harmed in the process," he writes. "Armed with informed skepticism, it is possible to design a rational health-delivery system, It is not my intent to speak ill of your doctor, or even of doctors generally. I am examining the institution of medicine that molds the behavior of physicians.. .."
Ultimately, Hadler wants to help us cope with not being perfectly well—and the knowledge that we are mortal –without being “worried sick" about dying. “No one should be as concerned about the proximate cause of their demise as they are about the likelihood their course in life will be satisfying. It matters little what carries one off, as long as it was her or his time and the journey was gratifying.”
In part 2 of this post, I will talk more about heart attacks, angioplasty, bypass surgery, and why the incidence of heart attacks is declining.
Thanks Maggie!
I’ve know Nortin Hadler for decades. He is telling us what we need to hear.
He does impeccable and thorough research homework and writes scientifically on a values and common sense platform.
Crisis circumstances we are now in will lead to many more taking a carefull look at his writings.
I believe his time may have arrived.
Recently following a review in JAMA of his latest book-“Worried Sick” I have declared myself a “Hadlerian”
I hope other providers, health care planners, health economists and patients join me in that declaration.
Dr. Rick Lippin
Southampton, Pa
Thanks Dr. Rick.
I found Worried Sick eye-opening. To my mind it’s up there with Don Berwick’s Escape Fire,
and Atul Gawande’s Complications in changing the way that a reader thinks about medicine.
In particular, I liked the section at the back of the book that gives sources (usually articles from medical journals) backing up what he says.
PS from Rick Lippin
“Give me a doctor-short and stout- who, with warm hands, rosy cheeks and a twinkle in his eye – tells me, with kindness, it is my time to die”
It concerns me that Dr. Hadler is against screening colonoscopies, which have been shown to save lives.
I agree with the general point that there is a lot of overtreatment in the American health care system.
Marilyn-
I don’t think I said anything about colonoscopies in the post.
Hadler’s book is at home, I’ll have to look up what he says.
But I know that, in general, many people worried about overtreatment are concerned that some patients are having colonscopies too often (the guidelines say once every year) because this is a very lucrative procedure.
And of course, as with any test, there are risks (in this case, puncturing the colon.)
“many people worried about overtreatment are concerned that some patients are having colonscopies too often (the guidelines say once every year)”
I think you mean once every 10 years.
“A man may spend his fifties checking his blood pressure and cholesterol, levels, taking Lipitor and worrying about chest pains. He may even undergo angioplasty for temporary relief from angina. And he still may be hit and killed by a car when he is 59. This isn’t to say that he shoudln’t check his blood pressure, but if he finds himself obsessing over the possibilty of a heart attack or stroke, he might want to remember Hadler’s words.”
If someone has angina, that means they are at high risk of a heart attack. They *should* be worrying about their risk factors, and they definitely should be on a statin. Does Hadler say something different?
What matters to an individual is their own risk, not population-wide statistics. Treating someone with angina is secondary prevention, and the evidence for that is very, very good.
Marilyn
Marilyn–
We know that statins are useful only in secondary prevention–preventing a second heart attack. If the man in his fifties has not had a heart attack, there is no reason for him to be on statins. (See Hayward, et. al.,Ann Int Med, 2006, Manuel et.al.(BMJ) 2006, Abramson and Wright, Lancet, 2007.
Steinbrook NEJM< (2007) discloses how virtually all of the reserachers involved in trials which promoted statins had very lucrative arrangements with pharmaceutical companies. Meanwhile, a class-action suit was filed against Pfizer in 2005 in Mass. regarding deceptive advertising regarding Lipitor. The suit charges that Pfizer is marketing Lipitor "for indications for which there is no scientific support." Within medical academia (Harvard and elsewhere) many are outraged by the "cholesterol con" that I've written about on HealthBeat. Business Week even did a major cover story questioning cholesterol-lowering drugs within the past year. The news is now in the mainstream press . . . As for whether a man suffering from angina should be on statins,we now know that statins are useful only for middle-aged men who have had one heart attack. For this group, statins will redue the chance of a second attack--though the drug does not reduce mortalities (the number of men who actually die.) Here, the NYT sums up the evidence in "Science Times: " a 2006 study in The Archives of Internal Medicine tlooked at seven trials of statin use in nearly 43,000 patients, mostly middle-aged men without heart disease. In that review, statins didn’t lower mortality. Nor did they in a study called Prosper, published in The Lancet in 2002, which studied statin use in people 70 and older. Nor did they in a 2004 review in The Journal of the American Medical Association, which looked at 13 studies of nearly 20,000 women, both healthy and with established heart disease." If the patient with angina has not had a heart attack there is no evidencce of any benefit if you put him on statins. If he has had one heart attack, ststins will make a second attack less likely--but won't prolong his life. Bottom line: what we thought was true 3 or 4 years ago often turns out to be untrue. It is just a hypothesis that has not yet been disproved. As for individual risk vs. population-wide statistics--more and more 21st century physicians are looking at public health (population-wide( statistics, because they know that if the "number you need to treat" to save one life is high--then a large number of people are being subjected to risk for no reason. For example, if you need to treat 250 to save one life, then 249 individuals are subjected to the risks, side-effects and stress of the treatment for no reason. Depending on how severe those risks and side-effects are (death folowing a surgery you didn't need, loss of a healthy breast, permanent impotence or incontinence . . . we decide whether it is worth putting so many people at risk. Certainly, the patients should know the odds when deciding whether or not they want to be tested or treated. And number need to treat helps the Natoinal Task Force on PReventive Services decide that the number need to threat--and risk of harm for the vast majority --is too high for women under 50 to have mammograms.
“If the patient with angina has not had a heart attack there is no evidencce of any benefit if you put him on statins. If he has had one heart attack, ststins will make a second attack less likely–but won’t prolong his life.”
I disagree.
And, by the way, I looked into Quackwatch and have been receiving their newsletter. I consider your comment that I am similar to Quackwatch to be quite a compliment. They are doing an excellent job.
Marilyn
BTW, have you actually read that article by Rod Hayward? Because it does not support your position at all.
Treating someone with angina is secondary prevention, whether or not they have had a heart attack.
Marilyn
“For adults aged between 30 and 80 years old who already have occlusive vascular disease, statins confer a total and cardiovascular mortality benefit and are not controversial.”
Wright and Abramson, Are lipid lowering guidelines evidence-based?, The Lancet (2007)
http://www.lancet.com/journals/lancet/article/PIIS0140-6736(07)60084-1/fulltext
Even John Abramson admits that there is a total mortality benefit from statin therapy in people who already have heart disease. This includes people with angina.
Marilyn
Marilyn:
This is what you quote from Wright & Abramson:
“For adults aged between 30 and 80 years old who already have occlusive vascular disease, statins confer a total and cardiovascular mortality benefit and are not controversial.”
This is what you convenintly left out:
While the group already suffering from heart disease showed a benefit,
their analysis that included healthy but high-risk people without heart disease showed that statins should not be prescribed to women of any age who do not have heart disease or diabetes, or to men older than 69 years who do not have heart disease or diabetes because no benefit was shown for them.
There is a MODEST BENEFIT for men aged 30-69 years who are at high risk of developing heart disease. Out of 50 high-risk men taking a statin every day for five years, only one avoids a “cardiac event” —that is, a heart attack or heart-related death. Put another way, out of every 50 men who stay on statins for five years, 49 risk an adverse drug reaction for no benefit.
“In our experience,” wrote Drs. Abramson and Wright, “many men presented with this evidence do not choose to take a statin, especially when informed of the potential benefits of lifestyle modification on cardiovascular risk and overall benefit health.”
As to whether patients suffering from Angina should be on statins . . .
The MayoClinic.com offers a long list of durgs that, in combination with lifestyle changes, should be used to treat angina.
Aspirin is at the top of the list, followed by nitrates. Statins are much further down on the list, and the risks are listed. . .
“This is what you convenintly left out”
I left that out because I was not talking about primary prevention. I was talking about secondary prevention. You seem to think I am some kind of rabid statin booster, someone who wants to put statins in the water supply. That is not the case.
“Assume that you are a 40-year-old man. What do you think the chances are that you will die of a heart attack or stroke in the next 10 years? . . . The answer: just 4 out of 10,000 according to Drs. Steve Woloshin and Lisa Schwartz, authors of Know Your Chances.”
According to the Risk Chart for Men on page 128 of Know Your Chances (H. Gilbert Welch is also an author), the risk of dying of a heart attack or stroke over the next 10 years for a 40-year-old man who has never smoked is 4 out of 1,000, not 4 out of 10,000. For a 40-year-old male smoker, the risk of dying of heart attack or stroke over the next 10 years is 16 out of 1,000. The average risk for a 40-year-old man is not given (at least in that chart; I haven’t read the whole book).
You might want to check the other statistics you quote to see if “10,000” should be “1,000” in the other cases as well.
Best, Marilyn
“As for individual risk vs. population-wide statistics–more and more 21st century physicians are looking at public health (population-wide) statistics, because they know that if the ‘number you need to treat’ to save one life is high–then a large number of people are being subjected to risk for no reason.”
I was simply making the point that a physician talking to a particular patient needs to focus on that patient’s risk. Let’s say that patient’s risk of a heart attack over the next 10 years is 15% and that it can be lowered to 10% by taking a statin. Many people would think that reduction in risk was worthwhile. Some would not.
The fact that the NNT for, say, all 50-year-old men who do not have known vascular disease is very high is relevant if your risk is similar to the average 50-year-old man. If your risk is higher or lower, the NNT will vary as well.
Similarly, women with BRCA mutations are at high risk of breast cancer, and population wide statistics on breast cancer risk are of no use to them.
Smokers are at much higher risk of lung cancer (and other diseases) than nonsmokers. That’s why they would be well-advised to quit smoking.
If you break your leg, do you expect the doctor to tell you not to worry because the average person does not have a broken leg? After all, the NNT for broken legs would be very high if it we put everyone’s leg in a cast.
You yourself are citing statistics based on age, gender, presence or absence of vascular disease, and so forth. Thankfully, those aren’t the only tools we have for calculating risk.
Marilyn
Marilyn—
I’m actually looking at this from the point of view of public policy–and waht we shoudl pay for– which means stepping back and looking at “number needed to treat”
Also, I’m curious. . . Are you an M.D. You speak as if you are (talking about what a doctor would say to a patient), but when I tried to Google you
the only Marilyn Mann I found was an attorney with the investment division of the SEC.
Is that (or was that at one time)you?
If so, the investment division of the SEC needs your help!!
Marilyn—
I’m actually looking at this from the point of view of public policy–and waht we shoudl pay for– which means stepping back and looking at “number needed to treat”
Also, I’m curious. . . Are you an M.D. You speak as if you are (talking about what a doctor would say to a patient), but when I tried to Google you
the only Marilyn Mann I found was an attorney with the investment division of the SEC.
Is that (or was that at one time)you?
If so, the investment division of the SEC needs your help!!
No, I am not an M.D. I am an attorney in the Division of Investment Management at the SEC. I have an interest in cardiology because of family members who have a genetic disease called heterozygous familial hypercholesterolemia. I also blog on Gooznews (see the “About” page for more info).