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“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Tuesday, June 07, 2022

    Testing, Testing

    Today while going through Twitter I ran across a tweet written by a woman mourning a friend who died of colon cancer at age 39. Her post states the friend's father died "young" (she does not say how young) of colon cancer, and therefore the friend requested a colonoscopy. According to the post, the screening was denied; insurance wouldn't pay for it. The friend was not diagnosed until her cancer had metastasized. The tweet has attracted thousands of retweets and hundreds of comments, many of which give other examples of friends and family members dying early of colon and other cancers. The responders' chorus: "Why wouldn't insurance pay for this? Why! This could have been avoided!" as well as the mandatory curses thrown at the US health system and insurance companies.

    Make no mistake, this is a tragedy. Unfortunately there isn't enough information given in the tweet to fully critique what happened. My first question, however, was: was this person offered a FIT test? FIT is an abbreviation for fecal immunochemical test and is a test to check for blood in the stool. More recently, a more sensitive test called Cologuard has become available (it checks for DNA markers in the stool which are compatible with colon cancer or certain types of polyps). It is more expensive than the FIT test and many insurances do not cover it; however, it is still a lot cheaper than a colonoscopy. Either of these tests could have helped diagnose the woman at an earlier stage. If these tests came back positive, it would definitely have influenced the decision to proceed with colonoscopy.

    Second: the current standards for colonoscopy in the US are that you begin screening at age 45 or, if there is a family history of colon cancer in a near relative, when the patient's age is ten years younger than the relative's at time of diagnosis - whichever is sooner. "Screening" here refers to colonoscopy, although many people decline them, in which case they can choose to be screened annually with a FIT test or with Cologuard every three years. The US screening recommendations have evolved over the years to become more aggressive, as I will discuss further.

    As always, the benefits of the UK health system are being talked up. For comparison I will present the NHS testing policy for colon cancer, as follows: FIT screening every other year, not annually, and screening is recommended between the ages of 60 and 74 (it can be extended beyond age 74 upon request by the patient). The NHS is considering extending screening back to age 50 but this has not yet taken place. Colonoscopy is not part of routine screening. 

    When I began my training, screening for colon cancer consisted of sigmoidoscopies rather than full colonoscopies and screening began at age 50. The sigmoid colon is the last 40 cm of the colon, about 25 percent of the entire colon. Initially it was thought that the majority of colon cancers originated in the sigmoid colon, but we now know this is no longer true. Full colonoscopies became the norm after the well-publicized death of Jay Monahan in 1998. He was the husband of a journalist named Katie Couric, and had been screened with sigmoidoscopy but not full colonoscopy; Ms. Couric made it her cause to urge more aggressive screening techniques and this was changed. More recently, the age to begin colon cancer screening has been pushed back to age 45, as noted above. This is due to colon cancers trending at a younger age. 

    "Why not sooner?" - in general, colon cancer is not a young person's illness. There are very specific exceptions to this, involving genetic syndromes such as familial adenomatous polyposis, but they are rare. These syndromes have been closely studied and in many cases early colectomy, such as by age 30 or 35, is recommended to prevent onset of colon cancer. Now, screening recommendations can always be changed as I have outlined above; they are not set in stone. But there is always a balance between risks and benefits of screening. Colonoscopy involves anesthesia as well as the risks of perforation of the colon and bleeding. (These complications are rare, but they can happen.) The less invasive forms of screening, FIT and Cologuard, can give false negative and false positive results. This means that someone could wind up getting an unnecessary colonoscopy due to a false positive result, or that a cancer can be missed. Going on a snipe hunt to check a questionable result leads to increased risk and expense. In a very low risk population (such as below age 45), the risks and expense will outweigh the benefits. For every cancer found in this age group there are a lot of useless procedures. It's all about statistics, and this is why doctors as well as insurance companies - and the US preventive services task force, come to that - are generally reluctant to recommend screening at a very early age. 

    Symptoms of colon cancer at an early stage are very nonspecific. Constipation, bloating and abdominal pain can all be symptoms; unfortunately the majority of the time, they are not. Functional bowel symptoms are incredibly common, meaning that the patient has symptoms but no disease can be found even with radiologic testing or colonoscopy. It is simply not possible to work up everyone who presents with these symptoms. Of course, trying to point this out to someone who has lost a relative or close friend to cancer is a loser's game. What I try to do is listen, do a good exam, run a blood count to check for anemia and encourage the patient to follow up or email me if the symptoms continue or change. Screening has done a lot to extend lifespan by catching problems early, but it is not perfect. 

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    Sunday, June 05, 2022

     You Can Sell Your Soul and Still Lose

    One of my longtime goals has been to write mysteries (I do write fan fiction but would like to write something I can sell to the public). In pursuit of this goal, I have started to follow several blogs about writing including According to Hoyt, Mad Genius Club, Robert KroeseMonster Hunter Nation and Celia Hayes

    These blogs and their authors have some things in common. They tend to work in the scifi/fantasy genres, though not all of them do; they publish independently, usually via Amazon (some of them also have conventional publishers but do at least some independent publishing); and they trend to the conservative/libertarian side of the aisle, or at the very least they keep politics out of their writing. As a result they have met more setbacks in the course of their careers than one might expect (and Lord knows, most writers face enough of those). They don't whine about it but they do discuss it. Most publishers strongly prefer "diversity" in the works they publish these days, as defined by issues related to race, sexuality or gender. If the author's work checks more than one of those boxes it's even better. That is not to say that the writers I follow limit themselves to tales about strong, silent white men who conquer new worlds and exploit their resources when they are not killing dragons and marrying princesses. Their works are far more interesting than that, often irreverent and tweak quite a few sacred cows. This, of course, is why they keep running into roadblocks. Publishers expect novels to meet certain criteria (see my recent post on Charles Stross and his Laundry Files series, which has turned into a labored metaphor for global warming). The rule for books, I feel, is that the work should be fun and interesting rather than grim and judgemental.

    But... denizens of the scifi universe now appear to be turning on even the most rigorously diverse writers. The most recent example is an author named Stephanie Burke. She was a guest presenter at the scifi convention Balticon last month and her bio reads, in part, as follows: 

    Stephanie Burke is a USA Today best selling multi-published, multi-award-winning author, master costumer, handicapped, wife and mother of two. From sex-shifting, shape-shifting dragons to undersea worlds, up to sexually confused elemental fey and homoerotic mysteries, all the way to pastel challenged urban sprites, Stephanie has done it all and hopes to do more.

    So far, so diverse. I wish to point out here that I have not read any of her works and do not intend to analyze or criticize her writing, as I am unable to do so. My point is that today I learned from Twitter that midway through Balticon she was accused of making "offensive statements" (details unspecified) and was asked to leave. Her presentations were canceled even though the accusation was apparently unsubstantiated. Link is here. Ms. Burke was extremely upset by this incident, and rightfully so.

    Example Number Two: right around that same time, author Mercedes Lackey was speaking on a panel for the Science Fiction and Fantasy Writers of America (SFWA) and used the term "colored" when speaking about an author and critic named Samuel Delany. He is well known, well-respected and, yes, African-American. Mr. Delany specifically said that he was not offended by the term or by Ms. Lackey, who was praising his work at the time. Not only was she kicked out of the convention after this incident, but so was her husband. 

    Per Wikipedia, [Ms. Lackey] has... published several novels re-working well-known fairy tales set in a mid-19th to early 20th century setting in which magic is real, although hidden from the mundane world. These novels explore issues of ecology, social class, and gender roles.

    I'm beginning to discern a pattern here. Are you? It doesn't matter how much diversity street cred you have, if you don't toe the political line your readers and publishers can turn on you in a heartbeat. If you need another example, look at the one everybody knows: J.K. Rowling. Her adoration ratings, already quite high, jumped after she stated that Dumbledore was gay and had been in love with his nemesis Grindelwald - until she stepped up to the plate to support the rights of cis women. Since that time she has been pilloried on social media. (Incidentally, I think this explanation of Dumbledore's motivations is consistent with everything we learn about him in the series. But it was not touched upon because it was a children's book series, and because as a product of the nineteenth century, Dumbledore would have had very good reasons to conceal his sexuality for his entire life.)

    So my takeaway from these developments is as follows. Write what you want to write, but don't join the diversity conga line in a misguided hope for success. All it takes is one wrong turn of phrase, or even (as we have seen above) one wrong word. Your career will be instantly trashed. 

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    Saturday, June 04, 2022

     Mission Accomplished

    My move is over, thank goodness. Furniture was moved in an all-day marathon (twelve hours!) on May 31; since then I have made a couple trips back to the house to pick up a few forgotten items and to take my tenant to the airport. She is currently staying in Hawaii with family. She is finally out, which has justified this entire ordeal. I volunteered to take her to the airport to make sure she would leave. A nice enough woman, but she wasn't paying rent for several years and it was like pulling teeth even to get her to pay utilities. I had discussed this with her and we had come to an agreement that she would move in February of 2020... you know what happened then. 

    Now the work begins of cleaning, arranging and organizing and that will indeed be a long process. Fortunately my siblings have more or less given me carte blanche to sell, give away or trash nearly everything (the funds will be divided among us). So of course I sat down to blog instead. There are a lot of stairs in this house!