“Jeopardy!” host Alex Trebek’s announcement that he has stage 4 pancreatic cancer has once again turned the spotlight on this cancer, much as Steve Jobs did in 2004. Make no mistake about it: Pancreatic cancer is a bad disease. More than 40,000 Americans die from it each year — more than from breast, prostate, or ovarian cancer. Only lung and colorectal cancer cause more deaths.
In a perspective article in the New York Times, Dr. Diane M. Simeone, who directs the Pancreatic Cancer Center at New York University Langone Health, suggested that early detection is a solution. But just because a disease is bad doesn’t mean early detection will make things better. In fact, by casting a net that pulls in more people, early detection can make a bad disease worse.
That’s what happened in randomized trials of ovarian cancer screening. (Screening means checking seemingly healthy people for signs of hidden disease.) Screening led more women to have surgery to remove their ovaries, and more women to experience complications from that surgery, but it did not change the risk of dying from ovarian cancer.
Early detection efforts always have the downside of turning more people into patients. Whenever doctors look for early forms of disease, they regularly find more people with it than they would have otherwise. In some, the detected disease is destined to intensify and cause symptoms, or even death. Earlier treatment may help them — or it may not. Others are overdiagnosed, told they have the disease yet it is not destined to ever bother them. Many more have findings that falsely suggest disease and require a battery of tests to attest to their health.
Screening must involve many to potentially help a few.
Anatomy is relevant when talking about treatment for pancreatic cancer. While the ovaries are relatively accessible, the pancreas is not. It sits deep in the abdomen — just getting there is a challenge. Removing a cancerous part of the organ is more challenging still. Surgeons must work around blood vessels that are tightly connected to the pancreas. Injuries to them can be difficult to repair and can lead to catastrophic bleeding.
The pancreas contains ducts that deliver to the intestines digestive fluids from both the liver and the pancreas. So this operation has the additional challenge of preserving and re-plumbing these ducts, which are essential for digestive function. Leaks are common and digestive fluids can wreak havoc on surrounding tissues.
There are few operations more dangerous than pancreatic surgery. Within a month of it, somewhere between 4 percent and 11 percent of patients die (the variability reflects both surgeon and hospital expertise). The risk of dying climbs even higher three months after surgery. Complications are the norm — roughly one-third of people undergoing pancreatic surgery experience a major surgery-related complication.
It is definitely not a good thing to subject more people to pancreatic surgery. But that’s what will happen if screening for this type of cancer takes off.
To be fair, relatively few extra individuals will undergo surgery. But less-consequential harms will accrue to many more, who will be subjected to more scans, more tests, and more biopsies. Some will have complications from the extra investigation. All will be made to worry — as will their families.
People will also be made poorer in the process. A few will be bankrupted by it.
It’s easy to think that early detection is the solution to every disease. But that’s not true. What is true is that early detection has become a great way to drum up more business for medical centers, physicians, test manufacturers, and the pharmaceutical industry.
It’s tempting to want to do something, particularly when a celebrity develops a bad disease. But don’t call for early detection, call for better treatment. And call for more acceptance: recognizing that good people — doing all the right things — can nevertheless develop bad diseases.
H. Gilbert Welch, M.D., is a general internist in Thetford, Vermont, and was a professor of medicine at Dartmouth for 28 years. He is the author of “Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care” (Beacon Press, 2015).