0:15

All right, recording in progress.

0:22

What's the time?

0:31

Yeah.

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Let's see.

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It's over there.

0:52

Oh.

0:54

Welcome to the first 2024 burn health lectures.

1:00

Spring started yesterday not today but almost spot on starting some season soon. I'm really really pleased to have met the color guard and make hybrid tower here from Norway, also the University of Oslo.

1:17

I'm not sure how much you might have Googled them, what they published on. So cancer screening is a topic you have regularly published. We have mentioned it on the flyer here.

1:31

Perhaps this comes up at some point. I was puzzled that both of you work at the Department of Transplantation Medicine. I didn't expect that. Perhaps you have an explanation later on.

1:41

We will have sort of 40 minutes of lectures and you decided to split it up. Somehow you figured out how you do it.

1:50

And of course, you too were involved in running large screening trials which is impressive. Also the one I was keenly waiting for the results, the first sigmoidos, not the full colonoscopy screening trial for colon cancer.

2:08

I also noticed that small, the world is sometimes small, but if you look at the list of authors who are on it, there is also Miguel on that paper, who since 2014 comes to teach causal inference in observation and epidemiology regularly.

2:25

And so, and I think when I read the paper I knew why he is on it. You have to have correct protocol analysis which is not trivial.

2:34

There even are some other historical connections. So it's 2013, for those who might know it or remember that the Swiss Medical Board came out with a statement on mammography breast cancer screening where basically they said it's not working, stop it.

2:54

And I think Peter Uni at that time was around that time also director of that institute, was responsible for that report. I remember him telling me that he talked with you, Mete, on what type of good trials should we nowadays do on breast cancer screening, not sure whether anything happened there.

3:13

And Peter Uni has left later on for Toronto and now is in the UK, professor for clinical trials, and now I stop with the anecdotes. So there are some little connections around the corners, but actually we haven't properly met before, but I'm very glad you made the journey from Norway to come here.

3:31

And I think I forced the title on you a little bit. I saw a science paper actually where you both wrote about improving cancer screening programs. Didn't sound like future of, but I thought it sounds more catchy, but you do whatever you want to do with the title.

3:51

Now I stop here. I know you want to do it and we'll see somehow in a also interactive way. And who is starting now? I'll start. Do you want to sit here, Mete? No, I'll sit here. Good. I hand over. Thank you. 40 minutes, 45, and depending how interactive you do it, it might get longer. That's not a problem. Okay. Over to you. Thank you.

4:19

Well, I'm Michael. And I'm Meta. Yeah. And we will do this together. This is actually, we talked about this. This is a first. We have not done a lecture like this before where we try to interact and try. We have decided which slide will be mine and yours, but I'm not sure if we will remember.

4:41

I was just going to say, if we start to fight, it's because we are married.

4:48

Well, the Department of Transplantation Medicine is.

4:55

I'm a gastroenterologist, the gastroenterology department in my hospital where we work is serving the transplantation people a lot with transplantation related GI problems. And at some point in time, 15 years ago, the departments merged and it became transplantation medicine.

5:15

So, it's a little bit of local history and stuff, and we are very happy there. I have to say. So, it works for us. Although none of us is doing organ transplantations.

5:28

Meta is a surgeon by training. So, it's kind of close and they treat us very well. I don't have patients anymore, but I will go back actually to primary care. I think a little bit because I miss people. I miss understanding where people are at.

5:45

Okay, disclosures important. There is a couple of things that we have been doing and obviously we have a strong academic interest in this topic. That's probably why we are here.

5:54

So, before we start, I would like to know, we would like to know who you guys are to understand your background, your knowledge, your expertise.

6:04

So, I will just start with a few questions, and then you can just raise your hand. So, who of you is a medical doctor? Many of you. Okay. Are there the other people? Are you public health people? Nurses? Something else. Okay.

6:23

Epidemiologists? Is that a profession? Can you can you earn money with that? Okay, cool. Great. And also, we would like to know, before we do the talk, what your perception is about cancer screening. So, we have put together a list of people who have done cancer screening.

6:44

So, we would like to know if you are, in general, positive towards cancer screening. You think if you hear the word cancer screening, yeah, that's a good thing. Or if you are negative, or if you are indifferent. So, who is positive? Okay. Who is negative? It depends.

7:05

Okay. I agree. And who is indifferent? Okay, cool. Good. So, we start with a teaser, and Marcel, you mentioned it a couple of, well, one and a half years ago, we published this paper in the New England Journal of Medicine. This is, and I don't want to talk about the results, because it doesn't matter for the talk, but this is the paper.

7:28

This was a large, randomized trial on colonoscopy screening for colorectal cancer. It was the first randomized trial that has been done and published results in October 2022. We had been working with that trial for more than 15 years.

7:42

And the trial received a lot of positive attention, but also received criticism. Criticism, we were expecting that, of course, but criticism was very emotional.

7:57

Very vocal, and came from especially one specific country in the world. And this is, and it came from my fellow friends, the gastroenterologists in the United States. And as background information, we found that colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for colonoscopy screening for

8:28

I mean, I'm a gastroenterologist in Norway, I earn okay money. The people who are my my people in the US they earn about 20 times what I do. And the reason they're doing that, it's rather new. The reason they're doing that is that they're doing screening colonoscopies, before they already bought same as I do. So, not surprisingly, they had a lot of complaints.

8:52

Emotions wrapped in into two arguments about why the trial was not good or at least not

9:01

interesting for the United States.

9:04

And I think the most funny thing is what's here from actually a colleague in Seattle

9:09

who wrote the editorial who said, well, the trial is blah, blah, blah, blah, but however,

9:14

we know that this works.

9:17

This is kind of funny.

9:18

You know, we have evidence-based medicine and then we say, ah, we know this works.

9:23

This is the landscape we're operating in and screening.

9:26

This is the landscape.

9:27

So I did a lot of podcasts and explaining and all that, but, but that's, and this is not

9:32

the first time we see that in screening.

9:34

Screening cancer screening is a field that creates a lot of emotions.

9:42

Okay.

9:43

That was the teaser.

9:45

Now a test.

9:46

Is this still my slide matter?

9:49

Yeah.

9:51

This is a test.

9:54

So here we have a disease, two diseases, X and Y, and, and we have a screening test

10:02

for those diseases, which is a very nice screening test.

10:05

It's noninvasive.

10:06

It doesn't cost anything for the people who take it and it is available for disease X

10:11

and Y.

10:12

Now we have the following scenarios and this is what people are usually presented for.

10:18

So here you have a five-year survival of the disease and then you have numbers without

10:25

screening and with screening and with screening, the survival is 99% and without screening

10:30

68%.

10:31

And also the early stage detection is without screening lower than with the screening.

10:39

Who of you would recommend this test to your patients?

10:47

About half of you.

10:49

Okay.

10:50

In comparison, disease Y, we have the five-year mortality from that disease without screening

10:57

two per thousand with screening 1.6 per thousand.

11:02

And the incidence is 27 per thousand versus 46 with screening as compared to without.

11:07

Who would recommend this test to your patients?

11:12

Pure.

11:14

Perhaps.

11:15

A lot fewer.

11:16

Okay.

11:17

We're going to come back to these points.

11:23

Hey, you're spot on.

11:27

So now you've heard a little bit about all the emotions in screening and I am unlucky.

11:34

I draw the luckiest straw or unluckiest straw because I'm going to just be talking like

11:39

a teacher.

11:40

I'm not going to be interactive and cool and show you a lot of fancy stuff.

11:46

So what I'm or we're going to talk about now is the difference between preventive screening

11:53

and early detection screening and the effects of screening over diagnosis.

12:00

Are you familiar with over diagnosis?

12:03

All of you?

12:04

Great.

12:05

We're going to talk about absolute numbers and we're going to end with the learning screening

12:09

programs and the paper that you quoted in science.

12:15

So we have to remember that screening differs from clinical practice.

12:21

It is for most parts, healthy individuals with no complaints, but they are under risk

12:28

of cancer.

12:32

And there are two types of screening.

12:34

It says two types of cancer.

12:35

It should be two types of screening.

12:38

One is preventive screening, the other one is early detection screening.

12:43

Preventive screening is when you have a precursor that for cancer that you can remove.

12:52

And the goal with preventive screening is to reduce incidence and mortality from cancer

13:01

with a screening tool.

13:04

The early detection screening, on the other hand, is to the goal is to detect cancer at

13:11

an early curable stage and thereby reduce cancer mortality.

13:18

But if we do not have cure, there will be no cure if we do not have treatment.

13:27

And if cure is not dependent on tumor stage at detection, there is no need for early detection

13:34

because then people are cured anyway.

13:36

Do you agree?

13:38

Sorry?

13:39

Not at all.

13:41

Do you agree?

13:42

Good.

13:44

So which tests are what?

13:47

So on the slide, we have mentioned different screening, different cancers that we screened

13:53

for, breast cancer, cervical cancer, colorectal cancer, prostate cancer, and lung cancer.

14:01

Of these, which ones are preventive screening tests?

14:07

It's cervical cancer because you remove precursors of cancer.

14:12

And there's some colonoscopy or flexible sigmoidoscopy examining only the distal part

14:19

of colon.

14:20

These two or these three are preventive screening tools.

14:25

And what is the difference in this preventive screening and early detection screening when

14:31

it comes to incidence of cancer?

14:34

Do you know?

14:44

Yeah.

14:47

Yeah, absolutely.

14:59

This is a crucial point.

15:02

Preventive screening, removing precursor, we don't get the cancer.

15:07

Early detection on the other hand, we cannot expect that.

15:11

And what we actually see is that the incidence is increasing.

15:17

So this is a big difference.

15:18

And this is why we, when we talk about screening, talk about preventive screening and early

15:24

detection screening.

15:26

And we are aware that there could be mixtures.

15:28

So you know, this is a simplification.

15:31

But it's an important simplification.

15:34

So in terms of incidence, reducing incidence and mortality can be reduced with both screening

15:40

tools or screening practices.

15:45

So when you look at this slide, here you see harms, which is increasing incidence.

15:52

And the benefit would be reducing mortality from the cancer we screen for.

15:58

And when you look at the red circle, that's the preventive screening tools.

16:04

That is cervical cancer and it's colorectal cancer screening with colonoscopy and flexible

16:09

sigmoidoscopy.

16:10

And this is an older slide.

16:11

That's why we don't have colonoscopy in there, because there were no randomized trials when

16:16

we published this in 2013.

16:18

And you see here that for all screening tests, we may reduce the mortality of the cancer,

16:27

but not the incidence.

16:28

And it is indeed increasing when it comes to lung cancer, prostate cancer, and breast

16:33

cancer.

16:36

And I'm happy you said that you do know what overdiagnosis is.

16:41

The definition that we use is finding a lesion, malignant, or precursor at screening that

16:47

would not progress to symptoms or death.

16:50

But why is overdiagnosis a problem?

16:54

And this is for you.

16:56

Why do you think it's a problem?

16:58

Is it just a theoretical problem for you?

17:05

It's a treatment.

17:06

It's just a cycle.

17:07

You need to live with it, and you might suddenly become somebody's cancer potentially.

17:14

Yeah, so you are suddenly a cancer patient.

17:16

Yeah.

17:17

And why is that a problem?

17:18

I think lots of people would suffer psychologically.

17:23

Psychologically.

17:24

And you said?

17:25

By the treatment.

17:26

You said treatment, yeah.

17:29

Not only are you a cancer patient, but you receive cancer treatment.

17:35

And what is cancer treatment?

17:37

Is it like you take a pill and then, you know, you feel fine?

17:41

How do we treat cancers?

17:44

Chemotherapy and radiotherapy.

17:45

Yeah.

17:46

Chemotherapy, radiotherapy, surgery, removing stuff.

17:52

So it's massive.

17:53

It's a big problem.

17:55

Because we cannot distinguish overdiagnosed lesions from lesions not overdiagnosed.

18:01

All lesions, all cancers are treated.

18:05

And then, when we talk about the benefits and harms, this needs to be put in the harm

18:10

side for cancer screening.

18:13

And up till today, that's not usually the case.

18:16

We do not really care about overdiagnosis.

18:19

We care about it in a theoretical way, but not really in a sense of what are we really

18:24

doing here to people.

18:25

On the precursor side, I think we are a bit more relaxed.

18:31

I think so, too.

18:32

And there might be good reasons for it.

18:34

And I will show you a little bit about that.

18:36

Yeah, no, that's perfect.

18:38

I like that.

18:39

So this is PSA screening.

18:41

It's for prostate cancer screening.

18:43

And it's a screening test that is recommended some places in the world.

18:47

And even if it's not recommended, it's a test that we will give to our male patients.

18:53

And this is a scenario without screening where the risk of prostate cancer is 9%.

18:59

And then you ask people to undergo screening.

19:03

And with PSA screening, you detect four more cancers per 100 people.

19:08

So the incidence increases to 13%.

19:11

You see there are more red people.

19:14

The people with cancers are the red people in this set.

19:17

It's substantial.

19:19

Four people per 100 people screened.

19:24

And they have no benefit of the screening.

19:26

They're over-treated.

19:27

Overdiagnosis with mammography, you have the same background incidence without screening

19:33

is about 9%.

19:34

And this is lifetime.

19:36

And the same three more cancers per 100 people screened.

19:39

And these are data from the randomized trials.

19:42

So you know where the data is coming from.

19:45

Increases the risk of breast cancer to 11% with screening.

19:49

And then we have precursors, adenomas.

19:52

And these people are not red.

19:54

They're blue.

19:56

So they don't have cancer.

19:57

But they have an adenoma.

19:59

And in a 50-year-old person, average person, the risk of detecting an adenoma or having

20:06

an adenoma is 40%.

20:07

40 out of 100 will have an adenomas.

20:12

And when we do screening, colorectal cancer screening, we do remove adenomas.

20:19

But not every cancer, every colorectal cancer will come from adenomas.

20:25

It might be another pathway.

20:30

Okay.

20:32

So what we see with colorectal cancer screening is that the risk, and this is without screening,

20:39

the risk of cancer is 5%.

20:43

Now we can talk about overdiagnosis and the problems.

20:46

The problems of overdiagnosis with colorectal cancer might not be chemotherapy, but the

20:52

amount of people who will have a colonoscopy, who will have an adenoma removed, and who

20:59

will enter surveillance programs, because these are risk factors for future risk of

21:04

colorectal cancer.

21:05

So 40 out of 100 may have additional recommendations to undergo even more colonoscopies.

21:16

I think, Michael, that...

21:17

In Switzerland, once you have that, they say come back in five years.

21:21

Exactly.

21:22

So this is a loop.

21:23

Now healthy people are being looped into the healthcare system.

21:28

And it's a matter of the individual, but also costs, that are we going to spend our health

21:36

resources on healthy people, or are we going to spend it on people with actual disease?

21:42

It's something to at least discuss.

21:47

You want to take this as well?

21:48

No, go ahead.

21:49

It's just a wrap-up.

21:50

Yeah.

21:51

Go ahead.

21:52

And it's exactly as you say, Marcel.

21:53

I mean, once you have that adenoma removed, and it's about 40% of us who are about 50

21:58

who have those small foliage, our friends, they never let you go.

22:05

That's where the money comes from.

22:08

And there may be a small benefit.

22:09

We're not talking about benefits yet, but it comes with the screening.

22:17

So now we're going back to the test.

22:21

So Mette has talked about some of the benefits.

22:23

We will show you that a little bit more later, then about over-diagnosis, both as concept

22:28

and then some numbers.

22:29

We will have more numbers in a couple of minutes.

22:32

But now we're going back to the test where I showed you disease X and disease Y, and

22:38

then the screening.

22:39

And I asked you if you would recommend that.

22:42

And more people of you recommended the one where there was the survival.

22:48

And I understand why you do that.

22:49

So now we're going to talk about survival and cancer screenings.

22:54

And I will start.

22:55

A colleague from Zurich sent me this two years ago when I was visiting Zurich, and I had

23:01

a talk at a gastroenterology conference in Zurich.

23:04

And I wasn't negative towards screening, but I had some concerns, as this talk today.

23:13

And he said, Michael, look, in Switzerland, this works.

23:18

Homography screening is great in Switzerland.

23:20

And this is in, those of you who know German, this is from Eastern Switzerland.

23:24

I don't know.

23:25

This is not Eastern.

23:26

We are central.

23:27

Okay.

23:28

So these are totally different people.

23:29

Okay.

23:30

Okay.

23:31

So this is from their webpage, the mammography screening program webpage, and they say, look,

23:44

it works in this site, so survival.

23:47

They say people who have been diagnosed here with us in the screening program, they survive

23:52

for a longer time than the people who have been diagnosed elsewhere.

23:57

Happens all the time.

23:58

It's on your public webpage.

23:59

It's not on your webpage.

24:00

It's not on your site here, but on the Swiss public webpage.

24:08

And I must distance ourselves from that.

24:12

And it's just scientifically bullshit.

24:17

And I will show you why.

24:18

I need two volunteers, two people.

24:22

It doesn't going to hurt.

24:23

We don't going to do any colonoscopy.

24:24

We are just.

24:25

Okay.

24:26

We have one there.

24:27

Okay.

24:28

Just going to explain to you why.

24:29

We have to stand.

24:30

You have to stand here next to each other.

24:31

Okay.

24:32

Okay.

24:33

So now we're pretending that you are.

24:34

Let's take colorectal cancers.

24:35

It doesn't really matter what cancers.

24:36

Let's say the two of you are in, have been in our randomized trial colonoscopy screening.

24:56

So 15 years ago, you both received a letter signed by me saying, we would like to invite

25:02

you to a colonoscopy screening and blah, blah, blah, blah.

25:08

And let's say you say, Oh, I like that offer.

25:13

And you say, yes, I'm coming to the colonoscopy while you say, Oh, you know, I'm healthy.

25:22

I don't smoke.

25:23

I don't, you know, I'm not going.

25:25

So you decline.

25:26

Yes.

25:27

Fine.

25:29

So you come to the colonoscopy and this is just an example, come to the colonoscopy.

25:35

I do the colonoscopy.

25:36

I find the cancer.

25:38

So you are diagnosed with the cancer, you get the treatment, you get removed part of

25:45

your large bowel, then you need to chemo probably.

25:48

You go all through that.

25:50

And then the surgeon says, now it looks fine.

25:53

Everything is out.

25:55

Okay.

25:57

And after three years, you go to a checkup.

26:03

So you can go three steps, one, two, three, three years, three years, you've lived through

26:10

that cancer for three years, right?

26:13

After three years, you come to a checkup and then there's metastasis found.

26:20

You live.

26:21

You didn't do the job.

26:22

I agree.

26:23

It's my fault.

26:24

You live for another, let's say three years, three more steps, six years, and then you

26:35

die.

26:36

It's bad enough.

26:37

You said, no, I don't want to do that.

26:45

Two and a half years later, you get symptoms of bowel cancer.

26:50

Let's say three years.

26:51

Three steps.

26:52

Okay.

26:53

No cancer.

26:54

No cancer.

26:55

You get your diagnosis, you get treated, everything, but you have, let's say stage three disease

27:06

and you live for another three years and then you die.

27:12

We die at the same time.

27:13

You die at the same time.

27:16

So Marcel, what is Marcel's survival?

27:21

You're all, or most of you are happy people.

27:24

How do you calculate survival?

27:26

What is it?

27:27

What is it?

27:28

What time span is it?

27:30

From the diagnosis until death, right?

27:35

So what is Marcel's survival?

27:37

Three years.

27:38

So what was your name?

27:40

What is Barbara's survival?

27:42

Barbara's survival is six years.

27:45

Did Barbara have any gain from the increasing survival?

27:50

No.

27:51

You die at the same time.

27:53

Do you know what this bias is called in epidemiology?

27:57

It's lead time bias.

27:59

Okay.

28:00

Thank you.

28:01

It's lead time bias.

28:04

So when some people in Switzerland count survival for patients who are diagnosed at screening

28:12

and compare them with patients who are diagnosed without screening, it's bullshit because it's

28:18

hopelessly biased by lead time bias.

28:22

There are other measures where you can calculate if screening works.

28:26

But this, which is commonly used on public webpages and scientific journals, it's complete

28:30

bullshit.

28:34

But you can use it if you don't see a difference there, then it probably doesn't work.

28:39

Well, there's always a difference because you always have to be online.

28:45

Or can you?

28:46

This is survival.

28:47

This is mortality.

28:48

You can use mortality because it's a different calculation.

28:53

People do this mistake all the time.

28:56

Even people who work in the screening programs.

29:00

Very strange.

29:01

We don't say it, but it happens.

29:03

Okay.

29:04

Is that yours again?

29:06

No.

29:07

So what would you like to know when you consider screening?

29:11

What would you like to know?

29:15

I would like to know at least three things.

29:17

What would you like to know?

29:19

Decrease in all-cause mortality.

29:21

There's a decrease in all-cause?

29:23

That's cool.

29:24

We're going to come back to that in a minute.

29:26

You want to know is there a decrease in all-cause?

29:29

So does everybody live longer here at the end?

29:32

Yeah.

29:33

Okay.

29:34

Where would I start?

29:36

What would you like to know?

29:38

Well, I would like to know, first of all, what is my risk of cancer?

29:42

Yeah.

29:43

I agree.

29:45

First, I would like to know what is my risk?

29:49

The effect of screening.

29:51

I like the all-cause mortality, but I don't like colon cancer.

29:56

I don't like cervical cancer.

29:59

But I would also like to know, then, what is my risk of, let's say,

30:05

over-diagnosis and the harms of the screening?

30:08

Yeah.

30:09

So you would like to know the harms?

30:11

Are there any harms?

30:12

Are there any burdens?

30:13

Is it painful?

30:14

Is it expensive?

30:15

Does it take a long time?

30:16

Yeah.

30:17

Yeah.

30:18

You would like to know what is my risk?

30:20

The risk is 50% or 0.5% if they make a difference.

30:24

What is the effect from that risk?

30:26

And what are the downsides?

30:28

What's my payment?

30:29

And I want that in absolute numbers.

30:32

That's also important.

30:33

And, again, some of you epidemiologists, we talk about relative numbers.

30:37

We, as medical doctors, at least, we are superb in talking to patients

30:42

about relative numbers.

30:44

We suck with absolute numbers.

30:46

So let's talk about numbers.

30:48

Here's another example.

30:54

Meta and I, we are very lucky.

30:56

We have three daughters.

30:58

They're good girls, really good girls.

31:02

They love to do shopping.

31:04

And sometimes, and usually you don't answer your telephone when we are at

31:09

work.

31:10

I do.

31:11

So they call me and said, Dad, we are downtown in Oslo.

31:16

We see this beautiful jacket.

31:19

Can you send some money?

31:22

We have another app here.

31:26

It's so easy.

31:28

Just do this.

31:30

It's so easy.

31:32

And I say, okay.

31:34

I may consider it.

31:36

So I say, okay, how much is the jacket?

31:38

Oh, it's on 50% sale.

31:40

Smart.

31:42

Relative numbers, right?

31:44

It's on 50% sale.

31:46

So just send it over.

31:48

And I said, okay, that sounds like a good deal.

31:51

But what is the price of the jacket?

31:53

I'm like, I don't understand.

31:55

It's on 50% sale.

31:57

It's a good deal.

31:59

And then I say, look, yes, I understand.

32:01

But I need to make a conscious decision.

32:03

I need, and you can decide.

32:05

I either need the number before sale or after.

32:09

And then I can make the calculation myself.

32:11

But you have to give me at least one of those two numbers.

32:14

Otherwise, I don't want to send you the money.

32:18

This is what I mean with absolute numbers.

32:20

You have to have absolute numbers to make a conscious decision about

32:23

saying yes or no to something.

32:25

In healthcare and in life.

32:27

And with the jacket.

32:29

I mean, it will come out at the end.

32:31

Because they need to tell me how much money I need to send them.

32:34

But they want to tease me into it by just giving me the relative

32:37

risk reduction.

32:39

The sale price.

32:41

So we do this all the time.

32:45

Are these really your daughters?

32:47

Yes.

32:49

It's not from the web.

32:51

This is Lupinella.

32:53

She's 22 in law school.

32:55

This is Freda.

32:57

She's in gymnasium.

32:59

What is it?

33:01

High school.

33:03

And this is his oldest.

33:05

She's 20.

33:07

He's studying to be a nurse.

33:09

Yes.

33:11

This is obviously.

33:14

Let's start with the risk.

33:16

Here's the risk of the cancers we usually talk about when it comes to

33:19

screening.

33:21

Colorectal, breast, cervical, and prostate.

33:23

And lung is a little bit different.

33:25

Because they're only the heavy smokers that are interesting.

33:27

So we left that one out.

33:29

First impression is it's all very low.

33:31

So we blew it up a little for you.

33:33

So you can see it.

33:36

So the research has shown that people are grossly overestimating their

33:40

risk of these cancers.

33:42

So colorectal cancer is 5% of getting it.

33:44

2% of dying from it.

33:46

Breast cancer.

33:48

This is all without screening.

33:50

About 9%.

33:52

3% dying of it.

33:54

Cervical cancer is a much smaller disease.

33:56

Less than 2% of women get it.

34:00

About 0.4, 0.5 die from it.

34:03

It's still, it's tough diseases.

34:05

I don't want any of those.

34:07

But you have to have those numbers.

34:09

Prostate is as common for men as breast is for women.

34:13

This is without screening.

34:15

Now, with screening.

34:17

Colorectal goes a little down with screening.

34:19

Breast, we talked about.

34:21

This is over diagnosis.

34:23

You increase the risk.

34:28

Same with prostate.

34:30

You increase the risk if you start going there.

34:32

From 9 to 13.

34:34

Little things on the top, they're all over diagnosis.

34:36

It's far.

34:38

It's far.

34:40

But it goes a little down on mortality here.

34:42

This is what we're dealing with.

34:44

And here's another way of showing it.

34:46

With different screening tests.

34:48

So we're going to go a little down.

34:51

This is what we're dealing with.

34:53

And here's another way of showing it.

34:55

With different screening tests.

34:57

The preventive ones that Matta talks about are on the far side.

34:59

On the left side.

35:01

Colonoscopy.

35:03

You could do sigmoidoscopy there as well.

35:05

But the effect is very similar.

35:07

And cervical cancer screening.

35:09

Or now HPV testing.

35:11

They reduce incidence.

35:13

You can see it.

35:15

From 5 to 3 for colonoscopy.

35:17

From 2 to 1 for cervical cancer.

35:20

And you can see it.

35:22

It's very similar.

35:24

But you can only decrease death of the disease.

35:26

Logic.

35:28

You can only die of a cancer that you first have gotten.

35:30

Nobody dies of a cancer that they have not gotten.

35:32

But on the other hand here.

35:34

There's blood.

35:36

We haven't talked about that a lot.

35:38

Hormography and prostate.

35:40

Incidence stays the same or goes up.

35:48

And there's a little bit of reduction on that.

35:50

Over to you.

35:52

So, someone.

35:54

You wanted to have absolute.

35:56

Looking at the total death.

35:58

Or what you die from.

36:00

Does it matter what you die from?

36:02

It matters when you die.

36:04

Some would at least claim that.

36:06

So, saving lives.

36:08

Means for most of us.

36:10

Living longer.

36:12

So, does screening save lives?

36:14

Or does screening make us live longer?

36:16

What do you think?

36:18

You want that.

36:20

No.

36:25

It's very discouraging in a sense.

36:27

And of course.

36:29

These are group numbers.

36:31

And people tell me that it might be worth it for me.

36:33

Because I'm not part of a group.

36:35

And that's true.

36:37

We might save a life.

36:39

But we're talking about a lot of people.

36:41

And we're talking about a lot of people.

36:43

And we're talking about a lot of people.

36:45

And we're talking about a lot of people.

36:47

And we're talking about a lot of people.

36:49

And we're talking about a lot of people.

36:51

And we're talking about a lot of people.

36:53

And we're talking about a lot of people.

36:55

And we're talking about a lot of people.

36:57

So, here you have a meta analysis.

36:59

Looking at overall mortality.

37:01

Total mortality.

37:03

And we see different kinds of screening tests.

37:05

For different kinds of cancer.

37:07

And you have on the pink.

37:09

Is the lifetime lost.

37:11

And on the green side.

37:13

Is the lifetime gained.

37:15

And it's not really convincing.

37:17

really convincing. And this is not about power. Some people say oh it's because we didn't include

37:24

in many enough people. I don't believe that. That's not the case. These are the numbers

37:30

because people, very few people after all die of cancer. Most people die of other causes.

37:38

So Michael, why is that so? Yeah and it's yeah why is that so? We were wondering about that for

37:46

years before we finally published that paper in 1993. And what were the reactions to that then?

37:53

Make friends I guess. No whatever. You mean this paper? Yeah. You're the only one left.

38:04

No people are very interested and we see you know and it's both sides and you know we started that

38:09

talk with it's a lot of emotions on both sides. Some people are very violently against it. Some

38:15

people are very violently for it. So it's everything. So what we think and it's really

38:22

the only logical explanation that and you said this is on a group level. Yeah. And that's the

38:28

only analysis we can do we as science people. We believe that some people actually do live longer.

38:38

There are people who go to mammography screening who have a small tumor detected who get it

38:44

removed. There are some of those who live longer. There are people like in our example who get

38:50

removed small colon cancer and we believe these people actually live longer. However the fact is

38:56

from these large randomized trials in some as a group it's zero or very close to zero. That means

39:03

it's also logical that some people by going to screening live shorter. How is that possible?

39:09

Well it's quite logical because some people die off the treatment they receive from skin

39:15

infected cancers. We just talked about it. It's surgery. It's chemotherapy. It's radiations. And

39:22

we know some people die of those treatments. And there is a lot of studies that say you know for

39:27

example for a hemicolectomy which is things I've I work with removing the part of the colon the

39:35

30 day mortality is about 1 to 2 percent post-surgery. You know you get an infection

39:43

or you get an osmosis leakage. So most people do fine. Some people die. And when the number of

39:49

people who live longer and the number of people who live shorter are the same then the effect

39:55

gets zero. And I think that's what's happening. But you have a few. It looks promising.

40:06

Even PSA looks almost on the good side of it. I was surprised. The sigmoidoscopy.

40:14

Sigmoidoscopy is the only one where actually there is a significant gain.

40:20

The UK study basically.

40:22

It's far. It's 600000 people. So it's large. It's two and a half months.

40:30

If you consider that a lot. So Michael what can we do about this.

40:39

Yeah this is this is this is towards the end. But what what's the solution here.

40:44

What's the future.

40:45

What's the future.

40:49

Before we come there and you have your slide on what the future what we propose the future could

40:54

be is. We talked about all these tests that we have been knowing for many many years mammography

41:00

PSA all that stuff just to illustrate you that this is continuing. We have a continuous problem

41:08

as is this like last week the New England Journal of Medicine published two papers

41:13

or two new screening tests. New two new screening tests for colorectal both. The

41:19

first one is what everybody is talking about. It's a blood test for cancer blood test for cancer.

41:26

It's the new holy grail of preventive medicine. This is the first one which has been published.

41:34

It's currently in in under consideration for the FDA. I think the FDA in America will approve it

41:40

soon. The sensitivity for cancer is actually OK. About 80 percent the sensitivity for

41:50

polyps for enomas is not good at all. But they're buried down there in the paper.

41:57

The other paper is what has been on the market in the United States for about eight years.

42:02

It's a stool test a DNA marker stool test. It's a company in Wisconsin that makes it.

42:07

They're making a ton of money. It's got six hundred dollars. One test. It's not approved

42:12

in Europe. Is that the one that the original report is mostly Imperial. Yes this is Tom Imperial

42:20

and Tom is also the first author on this one now. But that's the new. That's the second

42:26

generation. If you ask me why do they need a second generation. I tell you the patent runs

42:31

out for the first generation. So then more money and they put a second generation out.

42:37

It doesn't perform. It performs well but it's not really better than.

42:43

Then the fit test the fickle the cold blood test. It's not Tom's Tom is the academic author.

42:53

The company's test sells for six hundred dollars in the United States. The fit test sells for four

42:58

dollars. OK. People buy this in the US. So this is going on. What what the effect is on

43:08

instance of mortality as compared to the a lot. Nobody knows. That's where you come in. Yeah.

43:13

And when we hear that a lot that for example our cholera or colorectal cancer screening trial

43:20

colonoscopy screening trial. It's obsolete. It's so long time ago. You know everything is

43:26

evolving. Everything is going to be better. So we can disregard this this old trial.

43:32

But if you're going to do trials and cancer screenings it needs to be old because it

43:37

takes so long from when you remove a cursor to you see a reduction in incidence. It takes more

43:45

than seven to eight years maybe even 10 15 20 years before you can see the effects.

43:52

So that's why it's so much better to introduce these things and you can say

43:57

we know it's worse. So then this must work. And you said something about the sensitivity

44:05

being very high and the specificity being very low. And what do you want when you are

44:12

looking for screening test. You want to have a high specificity as well. I mean sensitivity

44:20

is great. We like that too. But you need to push the specificity. So what we have been talking

44:27

about for years and we fight about who whose idea was this mainly. Between you two. Yeah.

44:40

I think it's my idea. And I mean it is. Yeah. So we keep fighting about this. But the way to

44:49

move forward might be. And this is we haven't really gotten a lot of feedback from let's say

44:57

public screening programs yet. They're doing it a little bit in their way but not really a lot.

45:02

Meaning that you take a test you test it like one of these two tests that Michael showed you

45:08

and you run it into a continuous loop of testing. So you randomize people who volunteer to to attend

45:16

screening. And then you randomize them to different tools different screening tools.

45:21

And then you run that and then you evaluate that after let's say seven years. And that you do that

45:26

continuously with every test. And by this we might do more good than harm when we do screening and

45:35

screening programs. So this this way of thinking which is more or less what we do in quality

45:42

assurance. It's a running loop. It keeps on running because we want to make it better.

45:49

So to wrap it up just to remind you of this I think it's really simple but we really don't

45:57

do it often. This is for your patients. This is for you as a scientific community. Even for

46:02

yourself because you're going to get those letters in the mail. Do you want to participate in this or

46:07

that. These are the four questions that you need to ask yourself. What's my risk. I wanted an

46:14

absolute numbers not as my daughters. What's then the absolute benefit. Reducing that number.

46:21

What are the harms. What's the pay for it. So there's always some parts. And what's the burden.

46:28

Does it cost money. How long does it take is painful etc. Or very easy questions that everybody

46:35

should ask their doctor or their health care provider. They can't ask answer those questions.

46:40

Issue. I also think Michael that we need to be clear that the future it's not revolutionary

46:48

because just presenting absolute numbers is a big step forward. As you saw it was survival was used

46:56

as an argument for you to come in which is is not a number you can really use to decide what to do.

47:03

So just by doing that it's important. I agree. We have friends and colleagues who would have

47:09

told us several times that we cannot do that. We cannot tell people the actual risk

47:16

absolute risk because it's so small that nobody will come. And so we need to remember I was the

47:23

head of the Norwegian breast cancer screening program for some years some time ago. And what

47:30

we said and what I said was that this was in the beginning the first 10 years of the program. I

47:37

said that if we don't have high attendance we're never going to prove this work. And this is

47:44

thinking about it. That's not the way it should be. It should be if it's a good test. People

47:48

want to come. They shouldn't come. So I can prove it's a good test. And we said that. And still

47:53

a quality measure for screening and screening programs in the EU is attendance. The number

48:01

of people attending should the higher the better the higher the more better quality of the program.

48:07

Which is not a culture thing like that. It's not. It's a fuse when you burn a fuse. It's

48:16

doesn't connect. No. OK. So we personally we think the early detection screening tests.

48:25

There's there's too many problems we believe. So mammography PSA also lung cancer for smokers. But

48:32

there is there is some interesting things going on. So I'm not that negative. At least

48:38

PSA mammography you have over diagnosis you have a relatively small effect. So we think that is

48:45

that should be taken away. We are more optimistic about the prevention screening tests like the

48:50

colonoscopy the sigmoidoscopy the cervical because you have that incidence effect which we like.

48:55

I think it's great to help people to not getting the cancer. I don't think people can expect to

49:04

live forever really. If then it's a month or two. So I don't think if that's the desire

49:11

find something else. Go exercise or eat vegetables or whatever it is.

49:17

And then this is about participation. I think we need to stop nudging people into screening. We

49:23

need to give them information. If they think it's a good deal for them then they will come. There

49:29

should be an offer for the screening tests. But if people are well informed and that should be

49:36

our effort as public health people as screening programs as governments

49:41

good information that everybody can understand. And then the people who say yes great.

49:47

People who say no. Fine. It's fine. Participation is not a good measure for quality of a program.

49:54

It's not. Yes it's as good as a no for informed people. Then I think we

50:03

or the people who run screening programs should implement the new tests in a randomized fashion

50:08

all the time. It just rolls in. We care about these topics a lot. We think about it a lot and

50:20

we do that with other people. We have founded the research group that we are part of clinical

50:26

effectiveness and we are about 40 people. We discuss a lot. We research a lot. We have

50:35

many clinical trials and observational studies. But most of all we try to have a lot of fun

50:42

together. I think that helps. So thank you very much for your attention. Are there any Swiss in

50:57

that group? I think so. We have a good friend. You know you mentioned Miguel Hernan and we have

51:08

been good friends with Miguel and his wife for many years. We were young researchers together.

51:17

There you go. There is a Norwegian guy who's now been in Switzerland for a long time

51:23

and who is affiliated to the group. He lives in.

51:37

We talk to him regularly. He was with Miguel some years ago. We lived in Boston together.

51:45

Yeah. All right. So let's open the floor to questions, comments, disagreements.

51:53

Of course. How do you think your research had an impact on the landscape in Norway?

52:00

Have there been political changes to change screening programs?

52:03

Yeah. So we started back. I did some studies on the multiple screening back in 2010-ish

52:12

and then there was a lot of stopping screening and I talked to the Minister of Health in the

52:18

public radio and we were discussing and said I acknowledge everything. I see there are problems

52:24

but I'm a politician. Eighty percent of women wants this. It's a no-go. I mean I'm not going

52:30

to touch that. And he was also male so probably even worse to say that. So I think that is part

52:37

of it that this is at least breast cancer in Norway. It's really related to feminism and

52:45

women and women health. This is a very political issue probably here too. But so you know it's

52:54

no longer about medicine. And what we see also the people running the screening programs are

52:59

they used to be medical doctors. Not anymore. So medical doctors are sort of out the screening.

53:07

Although other people biologists other people running the screening program and

53:13

that might be OK. But then the patient perspective in some sense is getting lost.

53:20

And then it comes to our randomised trials. We've been involved in FLEXIC

53:24

FLEXIC screening trial and also the colonoscopy screening trial and also other trials and that

53:32

has of course an impact. So the screening program colonoscopy screening program in Norway right now

53:41

it's more or less or somewhat learning screening programs. That's what they aimed for.

53:53

People tell me people tell me we don't do that. It does not exist.

53:57

I actually support that because it's right. You know I've been the old Sigma trials. I worked there

54:04

back in the early 2000s. I did 3000 sigmoidoscopies over two years. I hated it. It's dirty.

54:12

Because you go up to where the thesis start and then you go back down and what happens the thesis

54:17

come and go. It's not so. Yes. So it's it's a little bit schizophrenic. So many people are

54:28

interested in what we do. Politicians are interested. Then when the programs come up the bureaucracy

54:34

takes over and they're not interested anymore because for them it's their career. And we are

54:40

sometimes challenged because we for example we say you know no is as good as yes. They think

54:46

that's crazy because the more people come the more money they get from the government.

54:53

That's when we start to pull out because we don't. That's fine. But did you at least have

54:58

sort of let's say information leaflets. Are they according to what you think the information.

55:05

So there is something. I would definitely say we are on their back all the time.

55:12

Yeah. No but it is improving. Absolutely. So absolute numbers are more

55:17

present. It's not not in the letter you get but you can get it. Yeah. And of course you can discuss

55:24

should we include data from observational studies case control studies. I mean how are we going to

55:31

what kind of data ratings. Of course that's a discussion academic discussion. But we have I

55:36

think we have moved forward. But I think we it's this push and we don't only see it for screening.

55:48

We see it for all of the things that it's publicly offered. People are pushed into it and more or

55:56

less taken out of the health care system. And we discussed this because as far as I understood you

56:01

have more of the GPs are more involved in these decisions for the patients. They're not in Norway

56:09

OK. Because if you have big systems parallel to the health care system that the MPs are really

56:18

taking up. And I don't know whether this is a benefit or a disadvantage. It could be several

56:25

benefits but it could also be a disadvantage that you don't really get to talk to people. And you

56:29

know we're talking about shared decision making. How are you going to do that if you get a letter

56:36

and it says you have to be at the mammography screen

56:40

placing an appointment. And if you don't like it please tell us. It's like OK that better result.

56:47

So you don't have that shared decision making which I think is should be encouraged.

56:54

Thank you. Really really inspiring. And I'm not a critical pre-screened person at all.

57:01

I just wonder if anyone is thinking of this in terms of equity and health inequalities

57:11

from the point of view that if you are from an underserved population

57:17

and you are going to get cancer that you are more likely to present late and maybe have worse

57:26

for treatment. If you get taken into the screening program are you more likely then to when it gets

57:35

diagnosed you actually get into the health care system. So could it be something that actually

57:41

reduces health inequalities. OK I'm going to ask. It's a super important question. I'm going to

57:46

answer it the back door. So now you're asking if people with a worse socioeconomic background

57:58

if their cancer are detected at a later stage. That's not the answer you should ask.

58:06

The answer is are people with a lower socioeconomic status and a high socioeconomic

58:18

status. What is the rate of late stage disease in these two groups. Because once you go to screening

58:25

you will have a lot of early stage disease. Sure. And most studies study survival or a stage

58:33

not looking at the rate but the amount. That's very problematic for the same reasons we talked

58:39

about screening lead time bias and overdiagnosis bias playing into it. So the question is is there

58:48

a difference in the rate of late stage disease between that. And if it is that's something we'd

58:54

need to investigate. And I don't. But who's doing that. Who's researching that. So for most people

59:02

it's would be. Those social. Sociologists. Other people the screening programs will do that. But

59:12

then again they use the wrong statistics. And then you don't really answer it. So the quick the answer

59:18

to your question is yes there is a difference between the eastern part of Oslo and the western

59:24

part of Oslo when it comes to screening attendance. And therefore it's the nature.

59:29

Right. So therefore there is more late stage disease or early stage disease in the western

59:37

part. But when it comes to the late stage disease nobody's studying that which is the thing you

59:43

should be studying. So equity is important and Norway has a lot of focus on equity. And this is

59:50

an argument. Now again this is an argument to continue because the more late state more early

59:55

stage disease among the western parts the rich part of town. That's because they're attending

1:00:01

screening. But that's not the relative. That's not the statistics you're interested in. So this

1:00:04

is. And when you say that it sometimes you feel like you are against equal rights because you're

1:00:12

pointing out that you know this is not the right statistics. I think you have a well prepared

1:00:19

offer for screening. It can go both ways. Who throw away the invitation might be those

1:00:27

objectively on the burden of disease might need more to attend. So that's very often the case.

1:00:32

There are these rumors. It's also not well documented that the sort of what I hear from

1:00:39

normalty is half of the women who are diagnosed with cervical cancer never have been screened.

1:00:46

Other day they come to age 40 50. They didn't know a steady screening offer. You see the same

1:00:52

thing with vaccines. At least we saw that during Covid in Norway. There's a difference.

1:00:58

High economic states people have their vaccines. The lower not so much. But I think I think it's

1:01:07

not just as a very recent. I think it's important once you have to make a

1:01:14

decision on the society level. This is a good screening test for our population.

1:01:19

Then you need to make an effort to every everybody be well informed. And obviously that effort is

1:01:25

much easier with the people who are educated and then with the people who are not educated. You

1:01:29

need to make that effort. So the opportunity to consider should be equal. It's difficult.

1:01:40

Very difficult. But that's that's that's that's the start. And then.

1:01:45

You have to make sure there's access. And then after that. And that's also America is the

1:01:50

cost because of that. It needs to be access to treatment for the people who then get

1:01:56

diagnosed. You know we have all this talk in America about you know black people more screening.

1:02:01

The big problem is they don't have the insurance. What happens after the screening.

1:02:05

But that needs to be true. At least I know that most of the information available

1:02:12

for screening programs in our eyes are translated to every language you can imagine just because

1:02:19

they want to have give people equal opportunity to at least get the knowledge. But whether they

1:02:24

read it and understand it that's another topic and an important topic of course.

1:02:29

Yes. Lukas. Thanks a lot for this great presentation. I like it a lot. And I must say

1:02:37

you know I also agree that screening programs are not the silver bullet. On the other hand what I'm

1:02:44

missing a little bit is you know of course feeling that the screening is actually having a benefit

1:02:52

that such a program has also you know all the things that make sense. One of them was for example

1:03:02

said it's about access to information. It's also about you know quality control. For example

1:03:10

with breast screening you get the quality control limiting of the mammography. You have also

1:03:18

know I you know I'm not so negative about this. I think it's it can be part of an informed

1:03:27

decision making. Absolutely. And all of this you know and of course we also get data out of it.

1:03:34

That's something you know what you usually don't get when it's something outside of the hospitals.

1:03:41

And so I think to be fair we should also you know clearly mention that these programs have

1:03:48

good effects. I would not say benefits but they have good effects. Yeah. I'm saying this you know

1:03:54

I was in charge of introducing a breast cancer screening one of the accountants and I know I

1:04:00

share this experience. You cannot you know you cannot talk about the screening programs

1:04:06

within these you know political scenes and it's but what I you know I stopped I stopped

1:04:14

arguing about you know science. But I started to argue that you know you can look at these

1:04:22

three programs every way you want but it has good effects and one of them. If you organize it well.

1:04:29

Exactly. Of course. But then you know it's also how do you how do you be informed. I think it's

1:04:36

an essential part. Even there you know all the problems start. I mean what what is good

1:04:42

information. But but still you know it's better than nothing. I mean everyone is at least informed

1:04:50

you know about breast cancer for example. Yeah. I'm not totally negative about about the screening

1:04:57

programs but I think we need to come to a big you know a more rational discussion if that is all

1:05:06

possible. We both want to say something. It's very important. Let me just start with one thing.

1:05:13

About 10 I don't remember 10 years ago maybe I wrote an editorial in the biggest Norwegian

1:05:19

newspaper and the title was mammography screening is great. Just take away the mammograms.

1:05:28

And my point was exactly yours. I mean when we were when we were doing our internship together

1:05:34

20 or this 25 telling my story. So I wrote that editorial and it's just making that point. Yeah.

1:05:42

You also have to say the small groups they they are anyway you know because every guy

1:05:49

I know colleges would say you know let's do that. You know what he called opportunistic screening.

1:05:54

But there you don't have any quality control. So there are two things. One thing is that what

1:06:01

they saw in Norway after they started cervical cancer screening program was that the number of

1:06:09

pap smears that they used back in the days and some used up went down because it was organized.

1:06:14

So you didn't have that a lot of doctors just doing it. You know you were three months ago.

1:06:19

Let's have another pap smear. So that's you're totally correct on that. And when it comes to

1:06:24

the screening program at least the mammography screening programs in Norway and I one of my

1:06:29

first studies was evaluating the effect of mammography screening in Norway.

1:06:36

And the screening program had of course mammography but it also required

1:06:45

most disciplinary teams. And I was a young surgeon working at one of the hospitals who

1:06:52

started mammography screening. And almost from one day to the next we changed everything. So

1:06:59

then we had a dedicated surgeon taking care of breast cancers. Prior to this it was in the

1:07:05

morning morning meetings like oh we got three mastectomies. Who's going to do that. You know.

1:07:11

No really. That was the way it was. And it was like oh I you know I have outpatient care. I can't

1:07:16

do it. Okay I'll do it. That was the sort of attitude. And after the screening program started

1:07:22

because a requirement to be part of the screening program you had to have dedicated surgeons. You

1:07:27

had multidisciplinary teams with pathologists radiologists nurses oncologists surgeons.

1:07:35

And you looked you looked at every single you'd looked at the mammogram. You looked at the

1:07:40

the pathology specimen and you looked at everything and you asked a lot of questions. Are you sure the

1:07:47

needle went you know. That per se had the same effect on mortality as screening. So you are

1:07:55

completely right. But I wish we could do if we only did that we didn't have we wouldn't have

1:08:02

over diagnosis. So we need to understand where we are at and not be once we started something and we

1:08:10

see that oh we have problems with over diagnosis for breast cancer. This is a big problem. How are

1:08:15

we going to lessen that. Do not take the screening program away but maybe start. Maybe we can screen

1:08:22

every third year or maybe we can screen women with dense breast a little bit more frequent and then

1:08:28

with non-dense every five year. Then we get rid of the problems and we might still have the benefits.

1:08:34

And I think that's very very important. So your point is well taken. Okay. One last.

1:08:44

Great talk. And we do agree that a team for example we have mammograms screening and it's

1:08:49

not going to be possible to stop it because the politicians come around and the people will say

1:08:54

go down in the street and say you're crazy why are you stopping it. I have a colleague in Zurich

1:08:59

which is special and now she has pressure from her politics to implement the screening

1:09:04

in Zurich. And well she is a scientist so she looks at the data and she said I don't want to.

1:09:11

What would you tell her. Well it's very hard. It's hard. What I for mammogram screening I don't do

1:09:20

research there anymore because of all the notions. I mean it's fun to discuss. It's fun to agree and

1:09:26

find better solutions for people. I'm a medical doctor. That's what I like. I don't think it's fun

1:09:32

when you get each other saying that you are an idiot because you are you are killing people.

1:09:37

I got so many emails from colleagues saying that I'm killing people because I said you know

1:09:44

that balance between benefits and harms are not really pushing in favor of the benefits. So we

1:09:49

need to do something else. So if she wants to have a peaceful life she just step back and say

1:09:57

we'll do the best I can. But if she's more of a fighter and wants to do what is right for society

1:10:04

then she needs to fight it and argue to give arguments in Zurich. Yeah or start that.

1:10:10

But maybe if she could go back to the future.

1:10:13

Yeah. Sure.

1:10:16

No question.

1:10:20

Since your title was future of the screen. Yeah.

1:10:24

I was just wondering about the target audience. Is that something you are looking at in

1:10:34

all your research programs? There's a lot of discussions around that.

1:10:42

Personalized screening.

1:10:43

Yeah. That's a buzzword. AI and personalized. If you do both of those. Wow.

1:10:52

No. Yes. Of course. I mean of course we already do targeted screening because we invite for

1:10:56

example only age groups. Right. That's target. We don't invite people who are 25 to colonoscopy.

1:11:02

That's our target. Of course. But the problem then is we don't have that many targets really.

1:11:11

I mean there are hundreds of research groups. Thousands of research groups around the world.

1:11:16

Here in Bern also at Inns Hospital. We'll look for markers in blood and tissue and everywhere.

1:11:24

Look for markers. And it's great. I support that these people do it. I don't like it personally

1:11:28

to be in the lab but great. We give them blood and everything. But I haven't really seen any good

1:11:34

outputs from that research. And I start to wonder if there really are any good better markers than

1:11:40

like you know we have age. Obviously sex we don't you know. But we have age. We have smoking.

1:11:46

We have other stuff. Family history we use. They're good calculators for example both for

1:11:51

breast cancer risk for colorectal that take into consideration things like that. And we use that

1:11:57

actively. But apart from that you know all the other stuff it's still out there or maybe it's not

1:12:03

out there. But it's still we don't have the markers yet. Everybody wants them.

1:12:12

Even though it's very fun to give the direction that future is going to be about you. We're going

1:12:18

to find your risk factor. Like Michael said I don't believe that. I haven't seen anything to

1:12:25

prove it. And I can't then stay here and say well you know that's the future. I really I

1:12:30

agree. I don't see. And also we have to remember that screening and cancer screening is

1:12:36

it's really also what we're doing when it comes to surveillance for patients.

1:12:40

We recommend them to come back because we feel or we have some markers. Some guidelines.

1:12:48

We don't have really the critical point or marker that could say you you are really on this. So that

1:12:57

is a problem. So maybe we get better markers if we not start to look for markers for the population

1:13:04

but start to look for markers for the specific patients and then we could derive from there.

1:13:09

But so far I haven't seen any any very good markers. But we have a venomas for example.

1:13:14

That is a marker in a sense that if you don't have another no one on the first screen it's

1:13:19

probably not worth to have another screening colonoscopy screening for example. At least

1:13:24

then you narrow it down but you don't narrow it down because it's 40 percent of us who has it.

1:13:28

And next year with A.I. it's going to be 60 percent of us who has another number that we can detect.

1:13:34

So again it's just going the other way around. So I'm sorry for not being more.

1:13:39

You're just not going to get that funding. I know.

1:13:44

I agree.