The Peter Attia Drive - #289 - AMA #56： Cancer screening： pros and cons, screening options, interpreting results, and more

00:00:00.000 Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.

00:00:16.480 I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can

00:00:20.440 access the AMA episodes in full, along with a ton of other membership benefits we've created,

00:00:25.420 or you can learn more now by going to peteratiyahmd.com forward slash subscribe.

00:00:31.120 So without further delay, here's today's sneak peek of the ask me anything episode.

00:00:39.500 Welcome to ask me anything episode 56. I'm once again joined by my cohost Nick Stenson.

00:00:45.780 In today's episode, we focus the entire episode on cancer screening. Cancer is what I refer to as

00:00:51.600 one of the four horsemen of death, and it's certainly a killer that we've all been affected

00:00:56.440 by in some way or another. It's a topic that has a lot of confusion around it, that is the screening

00:01:03.600 part of it, and it's one that we see a lot of questions come up. In today's AMA, we gathered

00:01:09.260 those questions, and we cover the following. The arguments for and against cancer screening,

00:01:15.260 and why some trials may show no benefit to cancer screening. The various modalities that are

00:01:21.000 available to people to screen for different cancers, and the pros and cons of each of these.

00:01:26.520 And then we discuss what people should know, and how they should think about undergoing cancer

00:01:31.260 screening individually. In other words, all of these data focus on the population, but the question is,

00:01:36.880 how do you take those population data and bring them to your own life as you make decisions?

00:01:42.560 We talk about how you should interpret results, and we talk about how people should think about this

00:01:48.880 if they plan to go outside of the relatively narrow and confined screening guidelines and pay out of

00:01:55.840 pocket for various types of screening tests. I think this is an especially important topic

00:02:01.240 because unlike the other horsemen, cardiovascular disease, neurodegenerative disease, and metabolic

00:02:08.400 disease, cancer is the one for which we have the least insight into how to prevent the disease.

00:02:15.400 We know the obvious environmental triggers such as smoking and poor metabolic health. But the reality

00:02:21.460 of it is, many cases of cancer arise for purely bad luck. In other words, there are many people who

00:02:27.820 are doing everything right, and they still get cancer. And as such, early identification of cancer is an

00:02:35.680 essential part of cancer strategy. The reason for that is simple. The lower the burden of tumor,

00:02:42.480 the greater the outcomes in cancer therapy. If you're a subscriber and you want to watch the full

00:02:49.040 video of this podcast, you can find it on the show notes page. If you're not a subscriber,

00:02:53.600 you can watch a sneak peek of this video on our YouTube page. So without further delay,

00:02:58.420 I hope you enjoy AMA number 56. Peter, welcome to another AMA. How are you doing?

00:03:08.700 Very well. How are you? I'm doing good. Any stories you'd like to share before this AMA starts? I asked

00:03:15.400 this question with nothing in particular in mind. I'm just curious if anything jumps out to you.

00:03:19.760 Yeah. Okay. That's funny you say that because I was worried that there was something that I didn't

00:03:23.380 know that I was supposed to be aware of, but no, there are no stories to share.

00:03:26.620 Okay. All right. With that, we'll get rolling. So today's AMA is going to focus all around one

00:03:34.180 topic and it's a topic we see questions come through weekly. And it seems like there's a lot

00:03:39.820 of confusion around this topic. And that topic is cancer screening. And ultimately we see questions

00:03:47.320 around how should I think about cancer screening? Is it important? Is it beneficial? There'll be

00:03:52.680 sometimes articles in the news talking about how cancer screening is beneficial.

00:03:56.260 Others talking about how studies came out in cancer screening is not beneficial. And so I think

00:04:00.780 it just creates a lot of confusion for people around this topic. And so what we decided to do

00:04:06.600 is just gather all these questions for today's AMA and just kind of go through cancer screening in

00:04:13.060 general. This will be the cases for and against cancer screening, why some trials may show benefit

00:04:19.340 while others don't. What modalities do people have? And what are the different options for cancer

00:04:24.620 screening, including the pros and cons of each of them? And then also what should people think about

00:04:29.940 when they get cancer screen, whether it's within traditional guidelines or what we're seeing more

00:04:34.920 so now is if people are paying out of pocket outside of traditional guidelines. And so I think it will be

00:04:41.220 really good. I think at times it can get a teeny bit technical, but I also think that's the price you have

00:04:47.300 to pay to really understand how to think about this. So all that said, anything you want to add

00:04:53.960 before we get started with the first question? No. I think it'll be really helpful to set the stage

00:05:00.840 for people understanding how common is a cancer diagnosis. And then from there, how common is it

00:05:07.960 for someone who gets diagnosis to die from cancer? I think that would be helpful for people to

00:05:13.640 understand why it's worth putting the time and effort into understanding this topic at a deeper

00:05:18.860 level. I remember when I was training, you always wanted to keep things sort of simple. So the really

00:05:25.080 simple heuristic that we used to keep in mind, which you'll see in a moment when I provide more detail

00:05:29.960 is actually not perfectly correct, but is reasonable is that a person in the U S has a lifetime incidence of

00:05:37.140 cancer, about one in three and about half the time it's going to be fatal. So one in three chance of

00:05:43.760 getting cancer in your lifetime, one in six chance of dying. Now it turns out that that's an under

00:05:49.220 estimate. So what are the most recent numbers? Most recent numbers are that men have a lifetime

00:05:54.200 incidence of just under 41%. And indeed about half of those are fatal. So 20.2% lifetime risk of dying

00:06:04.220 from cancer for women. The numbers are slightly better. 39.1% lifetime risk of cancer diagnosis

00:06:13.840 with just under half of those being fatal 17.7%. So again, the adage that it was one third,

00:06:21.060 one sixth, you could see is an underestimate there. I think a more relevant way to look at this though,

00:06:26.260 is not just to look at it through that lens, which by the way, people have probably heard me say many

00:06:30.280 times and I certainly talk about it in the book. Cancer is the second leading cause of death in the

00:06:35.100 United States and globally second, of course, only to ASCVD. But I think it's probably more

00:06:41.200 maybe insightful to compare this through decades of life. And rather than just have me rattle these

00:06:48.620 off, let's pull up the first table, Nick. I will of course, rattle these numbers off because I know

00:06:53.720 that there are people who are only listening to us, but this certainly sets the stage. The way this

00:06:58.160 table is organized, of course, is by decade. So we're looking at people aged 25 to 34, 35 to 44,

00:07:04.460 et cetera, all the way up to 85 and plus. And we're looking at kind of three things. So the first is

00:07:10.780 what percentage of deaths in that decade are attributed to cancer? Then we're looking at the

00:07:17.820 actual rate of cancer death. And this is always done in deaths per hundred thousand. So what is the

00:07:23.740 number of deaths per hundred thousand? And what is the rank of cancer relative to other types of

00:07:30.540 death within that decade? And for the cases where cancer is not number one, what is number one?

00:07:37.500 With that said, let's start at the lowest end of the spectrum. This is lowest in terms of lowest

00:07:42.220 mortality, because the number you really want to anchor to is what's the absolute death rate. And

00:07:47.140 that's going to be in how many cases per hundred thousand. So in that first decade, we compare

00:07:50.900 in the ages of 25 to 34, cancer accounts for eight deaths per hundred thousand individuals. Not many

00:07:58.020 people fortunately are dying that young. It represents 6% of total deaths ranking third. So

00:08:05.100 there are two things that rank significantly higher. And not surprisingly, the number one cause of death

00:08:12.300 in that demographic is accidental death. And of course, we've talked about this before, accidental death.

00:08:17.600 The number one cause of that is hands down overdose death. Okay. So you go up to the next category,

00:08:24.380 35 to 44, the percent of deaths attributed to cancer goes up from six to 13%. And the rate of death

00:08:32.640 goes up threefold, goes to 26 deaths per hundred thousand. It is still the third leading cause of

00:08:39.760 death, trailing accidental death. Again, the leading cause of death. And again, tragically, that turns out to

00:08:46.480 be overdoses as well. So we go into the next decade. This is where I sit plumply 45 to 54 here. Cancer

00:08:53.700 now accounts for 23% of all deaths in someone my age. The rate of cancer deaths again, jumps sharply

00:09:02.960 from 26 to now 88 per hundred thousand. And it technically ranks second. Although I put a little

00:09:09.740 asterisk here because here is where cancer and ASCVD are constantly switching with each other. So I would

00:09:17.320 say it kind of ranks first or second here, and it's either ASCVD or cancer that are in the number one

00:09:23.340 spot. And then accidents tends to fall to number three here. So you go one decade up 55 to 64. The

00:09:30.540 percentage of deaths attributed to cancer is now almost a third. It's 30% of deaths. And by the way,

00:09:36.500 this is almost the maximum share of cancer deaths you'll see. It now rises to the number one cause of

00:09:43.440 death in that age group. And it now accounts for 267 deaths per hundred thousand. This is a very big

00:09:50.600 number. Go up another decade. And it basically is the same story. It's 31% of deaths attributed. It is

00:09:58.720 the leading cause of death. And it now has doubled to 553 deaths per hundred thousand. Now you've made

00:10:07.240 it to the age of 75. What happens? Well, it turns out that other diseases are kind of exploding. And so

00:10:13.500 cancer now falls to second. Again, ASCVD takes over, but cancer still accounts for a quarter of deaths,

00:10:20.620 but the absolute rate continues to rise. It doubles again to 1036 deaths per hundred thousand people.

00:10:30.200 Again, ASCVD is number one. And when you go out past 85, ASCVD holds onto its number one spot and

00:10:37.420 cancer takes the number three spot. It tends to fall, although it's absolute numbers go up. 1649 deaths

00:10:46.440 per hundred thousand falls to 12% share. So here a neurodegenerative disease tends to come up and

00:10:52.900 take that place of cancer. So again, why do I go through all of those stats? Well, I think the

00:10:57.020 point I'm trying to make here is there's really no decade of life in which cancer is not at least

00:11:02.700 top three causes of death. And by extension, then I guess anybody listening to this is probably

00:11:09.360 thinking of cancer. The other thing I would say is it would be impossible to listen to this and not

00:11:14.540 know someone who has either battled cancer or who has outright died of cancer.

00:11:19.900 Yeah, Peter, I think that's really good for people to kind of see decade by decade,

00:11:23.440 just how prevalent it is and start to see how once you hit that 45 plus range, it starts to become much

00:11:30.500 more relevant, which is the vast majority of people listening to this. And so I think the next question

00:11:35.960 then is how does cancer screening fit into this? So why is cancer screening something important for

00:11:42.200 people to think about if hearing that their goal is to not die early from cancer?

00:11:48.980 I think we want to sort of take a step back and compare again, cancer to ASCVD. It shouldn't be

00:11:54.700 lost on anybody that ASCVD is the leading cause of death at this point, but we understand what drives

00:12:00.720 ASCVD so well. We really understand the relationship between lipoproteins, hypertension, smoking, and metabolic

00:12:08.820 health. And those are basically the big four drivers of ASCVD. There are certainly genetic

00:12:15.440 things in there that one has to pay attention to, such as LP little a familial hypercholesterolemia and

00:12:19.900 things like that. But again, those tend to be relegated down into issues that can be managed

00:12:25.760 pharmacologically. And so in other words, we have a clear understanding of how that disease progresses

00:12:31.900 and we can monitor a person's progress towards that disease. We have the biomarkers that predict

00:12:38.360 risk. Furthermore, we have tools like CT angiograms that allow us to at least somewhat grossly look at

00:12:44.900 the anatomy of the coronary arteries and get a sense of how advanced disease might be.

00:12:49.900 When it comes to cancer, none of that's really true. Outside of smoking, and as we'll talk about

00:12:55.000 certain genetic conditions, poor metabolic health, it's still a little bit of a black box as to why people

00:13:00.260 get cancer. And more importantly, what one can do to reduce risk. So we've talked at length about the

00:13:06.680 things that one can do to reduce risk, and we won't rehash that here. What we have to acknowledge

00:13:11.800 is that we have two things working against us in the cancer equation that we have working for us in

00:13:17.780 the heart disease equation. So one is just that, right? We have a far less command over the biology

00:13:23.480 of the disease. Secondly, we have far fewer effective treatments for the disease once it is advanced.

00:13:30.260 So I think the easiest way to understand that is to look at both five and 10-year survival curves.

00:13:36.840 So we pulled these up for just a couple of the most common cancers out there. In fact, these are

00:13:41.720 the five leading causes of cancer death, only in alphabetical order. The rank, of course, goes

00:13:48.080 lung first, and pancreatic would be the lowest in the top five. But the point I want to make here is

00:13:53.560 when you look at five-year survival, you look at this in two stages. You look at what we consider

00:13:58.200 early stage one, stage two. So this is regional cancer, local cancer actually, hasn't even spread

00:14:04.080 to a lymph node. You look at stage three, which is the cancer has spread to a lymph node, but no

00:14:08.660 further. And you look at stage four, which is to say this cancer has now left the lymph node and gone

00:14:13.960 to a distant site. And so you can see that in breast cancer, by the way, we always think about this in

00:14:20.080 two forms. We think about HER2 new positive and negative, estrogen receptor positive and negative,

00:14:26.200 and triple negative. And if anybody needs a refresher on that, we have a great podcast we did

00:14:30.300 on breast cancer that explains why these are three basically very different diseases. But you can see

00:14:35.160 the difference in survival between all of these cancers at an early stage, where it ranges from 92%

00:14:42.540 to 100%, stage one, two survival, to stage four, where you have metastatic disease, it's 13% to 40%.

00:14:52.100 So significant difference. And by the way, those are much better numbers than they used to be.

00:14:57.480 Breast cancer is probably one of the bigger success stories of the past 20 years in terms of stretching

00:15:03.160 out median survival. When you look at colorectal cancer, if it's a colorectal cancer that is caught

00:15:09.400 before it's gone to the lymph nodes, we're talking about 88% for five years survival. But if it's

00:15:14.400 gone to lymph nodes, that goes down to 70%. And if it's spread to the liver, it's down to 16%.

00:15:20.060 Lung cancer ranges from 59% early to 6% late. Prostate is 100% early, 33% if it spreads.

00:15:30.740 And of course, the worst of all of these is pancreatic. If you can at least catch it in stage

00:15:34.740 one, stage two, it's 38% five-year survival versus 3% if it's distant. I won't go through

00:15:41.700 the same analysis for 10-year survival for the sake of time, but we'll include the table

00:15:46.640 so that people can see. The only thing I'd point out is, of course, the trends are even more dramatic

00:15:52.800 when you start to go to 10-year survival. In other words, the difference between stage one and stage

00:15:58.520 two survival versus stage four survival at 10 years is even a bigger chasm. So why do I bring

00:16:07.200 this all up? Well, I bring this up to say that despite all of the advances we've had in the past

00:16:12.840 20 years, and clearly hormone therapy for breast cancer and immunotherapy for a number of other

00:16:20.220 cancers, particularly checkpoint inhibitors, still leave us with a lot to be desired, especially when

00:16:26.840 it comes to late-stage cancer. I think that just leaves anyone who thinks about this realizing

00:16:32.400 if you're going to get cancer, you certainly do not want to be in the position where that diagnosis

00:16:38.500 is being made once the cancer is advanced, once the cancer has had a chance to spread.

00:16:43.800 You really want to be able to diagnose cancer and manage it when it's in the stage one, stage two

00:16:49.480 phase. Peter, I think that leads to one of the questions that we get asked about by far the most,

00:16:55.120 which is people reading stories, reading studies, and really wondering, do clinical trials on cancer

00:17:02.020 screening show any benefits in reducing cancer deaths? This is really the crux of what we're here

00:17:07.920 to talk about today because this has become a controversial topic. Thank you for listening

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00:20:32.860 We'll see you next week.

00:20:41.300 We'll see if you next week.

The Peter Attia Drive - February 12, 2024

#289 - AMA #56： Cancer screening： pros and cons, screening options, interpreting results, and more

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