Recent reports from the Alzheimer's Association International Conference (AAIC) remind us of the complexity of mind and body integration. The AAIC may be well intentioned but it is quite possible that they are waiting for a hero that may not exist. A recent blog AAIC Holding Out for a Hero highlights the potential risk of blunting evolving paradigms and strategies in hope for a scientific discovery or monotherapeutic solution to a devastating chronic disease. Humans express genetic profiles mediated by environmental triggers and exposures. This partially explains why your grandfather lived until 101 smoking a pack of unfiltered Camels every day of his life but your non-smoking colleague succumbed to lung cancer at 47. An infiinte variety of genetic variablity and environmental exposures describe the field of epigenetics.
I review data reporting effectiveness of screening and diagnostic testing on a regular basis. The cost of health vs. the cost of healthcare is a topic of intense media coverage as we struggle with escalating costs and unsustainable economics not to mention unremarkable patient outcomes. Yesterday I had my "annual" physical. Admittedly my routine participation in screening and rituals of pursuing high-value health balanced by high-value outcomes has been less than stellar. Being of a certain age the topic of colonoscopy was uttered and screening recommendations became a topic of conversation. I presented a few of the statistics regarding cost-effectiveness and the advancing utility of less-invasive strategies but I only managed to delay the invasive colonoscopy until next year. A physician's perspective that guideline directed care is directed to the numbers (averages and hazard ratios)-- individualized care is an n of 1. Stating that if she can save one patient from colon cancer, easily identified in its pre-cancer stages, it is worth the cost both physically and financially.
Colonoscopy or less invasive screening?
Figure Approaches to select those individuals who may benefit the most from colonoscopy (i.e. patients with colorectal cancer or advanced adenomas) in a population-based screening scenario.
Primary prevention of colon cancer includes dietary and lifestyle management to decrease risk. As diets and lifestyle go I should be low risk--triathlete, grass-fed beef, organic vegetables, lots of high-quality seafood moderate grains, low sugar...but we have leap=frogged directly to secondary strategies, screening. I certainly can appreciate that cancers detected by screening are usually diagnosed at early stages and, therefore, curable by endoscopic or surgical intervention but perhaps there is a place for indivualized care with less-invasive strategies where appropriate and moving to secondary or tertiary strategies when indicated versus including them as first reflexive option (pun intended).
Understanding the risks and prevention strategies is important but the literature lacks the human element that triggers emotional response to our intellectual understanding.
Colorectal cancer is heterogeneous and lends itself to the evolving understanding of epigenetics, interaction of environmental factors and genetic transformation. Steven Pinker also discusses the role of environment and social determinants of health although not specifically in that context. We need more discussions of worthwhile investment of research dollars into our societal infrastructure throughout the lifespan and not a myopic preoccupation of disease as we begin to age...
Thoughtful discussions about content development and outcomes analytics that apply the principles and frameworks of health policy and economics to persistent and perplexing health and health care problems
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In a world of "evidence-based" medicine I am a bigger fan of practice-based evidence.
Remember the quote by Upton Sinclair...
“It is difficult to get a man to understand something, when his salary depends upon his not understanding it!”
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