Another Use of PSA Tests

In a just released paper the authors note that the PSA levels of a man in his 40s are a strong determinant of whether he will come down with PCa.

The paper states:

Measurement of PSA concentration in early midlife can identify a small group of men at increased risk of prostate cancer metastasis several decades later. Careful surveillance is warranted in these men. Given existing data on the risk of death by PSA concentration at age 60, these results suggest that three lifetime PSA tests (mid to late 40s, early 50s, and 60) are probably sufficient for at least  half of men.

Specifically they note:

In an earlier paper, we showed that PSA concentration at age 60 had a strong association with the risk of death from prostate cancer by age 85 (AUC 0.90), with extremely low risk (≤0.2%) in men with PSA concentration below the median (≤1.0 μg/L). Taken together with our current data, this suggests a simple algorithm for prostate screening. All men with a reasonable life expectancy could be invited for PSA screening in their mid to late 40s. Men with a PSA concentration <1 .0="">µg/L would be advised to return for screening in their early 50s and then again at age 60, whereas men with PSA ≥1.0 µg/L would return for more frequent screening, with literature suggesting repeat tests every two or four years.

The choice of 1.0 μg/L as a tentative threshold might vary according to preference.  At age 60, men with PSA at median or lower—that is, ≤1.0 μg/L (or possibly below the highest quarter, ≤2.0 μg/L, depending on preference)—would then be exempted from further screening; men with a higher concentration would continue to undergo screening until around 70.1

The ROC for this type of test was lacking but survival data was present. The lowering of the age to 40 and the PSA level less than 1 till 60 is interesting and worth following.

Academic Costs

As by now we all know the costs of College education has exploded beyond any reasonable level. In the NY Times today a left wing academic presents a self justifying demand that the Government should spend more on College support, not less.

This economist states:

Some wonder how the American ideal of equality of opportunity has eroded so much. The way we finance higher education provides part of the answer. Student debt has become an integral part of the story of American inequality. Robust higher education, with healthy public support, was once the linchpin in a system that promised opportunity for dedicated students of any means. We now have a pay-to-play, winner-take-all game where the wealthiest are assured a spot, and the rest are compelled to take a gamble on huge debts, with no guarantee of a payoff.

Even if compassion isn’t a factor — even if we focus just on recovery now and growth and innovation tomorrow — we must do something about student debt. Those concerned about the damage America’s growing divide is doing to our ideals and our moral character should put student debt at the top of any reform agenda.

Now one must remember that he is at Columbia, and that Columbia has always been a bastion of socialist and communist sympathizers who also have in my experience harbored abject hatred for Catholics and the like, as demonstrated in my rejection for being a Catholic in 1960. Not that I still remember it, just like yesterday! Still have the letter and all. Again MIT had no problem.

The real problem is two fold:

1. Costs: Consider what it costs to educate a class. Let us do a simple example. Sort of back of the envelope. Assume a class has say 30 students. Let us assume the average Prof teaches two of these a semester, I know some big whigs like the author of the piece may be exempt, but let us look at the typical schlub. Now assume the typical student take 5 of these courses and thus a faculty member supports 2 of them and this means 2.5 faculty members are the cost of the classes. Let us assume we pay them $150,000. so the costs per 30 students is $375,000 per year! Now divide by 30, and that is a cost for the teacher of $12,000 per year. Use 100% overhead, not unrealistic in a service business, especially economics, and you get the total cost per student in say economics of $24,000 per year. However the charge is $48,000! Whoops, where did it double? Administration and excess building overhead. Why, the Government supports and in some cases demands it. So here we have another economist who seems to be ignorant of the old adage, profit equals revenue less costs.

Now there are other economists who also fail to examine the numbers. For example Becker states:

The growth in tuition is not explained by any conspiracy theory, but mainly by increases in the cost of producing college education. Professors and other teachers are the principal input in colleges, so that the cost of these teachers is an important determinant of the cost of producing education. College teachers are well educated since they almost always have Masters degrees, and at the better colleges and universities they are very likely to have PhDs or similar advanced degrees. 

Colleges have to compete for highly educated persons against employers in both the private and public sectors. Since after 1980 earnings of highly educated persons has risen rapidly in these other sectors, colleges have had to pay a lot more for their faculties and administrative staffs. The greatly increased pay of faculty has substantially raised college costs, which in part have been passed on to students through higher tuition and other fees.

This analysis also explains why tuition has grown most rapidly at 4-year private colleges and other elite schools. These schools tend to have faculties that are considered the most skilled and productive, and they invariably have PhDs or other advanced degrees. Since the rise in earnings in recent decades has been greatest for the most educated individuals, the costs of more elite colleges and universities have risen faster than that of other schools. They too have passed through to students some of these much greater costs via much higher tuition.

In my opinion what he says is total nonsense. It was necessary to get great engineering Profs even in the 50s. It is not the salaries. It is the overhead. If one were to make a statement like this then one must be able to have a basis. I have seen the numbers and the costs. It is the cost of all these new Deans, the new buildings with their staff and maintenance. The massive growth in infrastructure, human and inert, is what is the driver. College Presidents are recruited for their ability to raise money while not really bothering the faculty. The problem with raising new funds for buildings is that these monsters need care and upkeep. They need "management" and they consume resources that are just added to the tuition burden. For the most part no College President has a clue about this until one of the "cost centers" economically explodes.

It is a shame that the economists who are justifying these increases have not a clue from whence they come. Perhaps that is why I have never seen an economist run a real company. Just our Government.

2. Majors: Let us face it, one really goes to college to get a job. Employed, the fact that you now have a skill that someone can use to make money. If you are a philosophy major, a fine arts major, a French Literature major, perhaps you cannot find a job. That is your problem. Should you be educated in that fact? Not really, it becomes one of those things you learn as part of life. Should you be allowed to gamble with other people's money when the odds are stacked against you? I would not think so. Then why give aid to those majors which are unemployable. Give tuition support to Engineering students, not art students. Give it to Computer Science and Bio students, not French Literature. Want to major in philosophy, get a wealth set of parents and live off of them. Not us.

Thus this economist has missed all of the key issues. The problem is that we allow these things to happen.

Caveat Politics

Science details the intent of Congress to institute a Science Laureate for the United States. Beware what one asks for. It would undeniably be a "politically correct" person whose contributions may all too often be questioned.

The magazine states:

"The U.S. Science Laureate will be a national role model who can encourage students to learn more about the sciences," Hirono said in the statement. "By elevating great American scientific communicators, we can empower students - especially girls and minorities - to get excited about science." 

 What gets people excited by science is all too often a visceral reaction to things not readily reproduced. It is that stumble across a set of books in a library, some presentation they get hauled into, or emptying out trash cans.

The last places to award anything is the Government. Just look at the Peace Prizes, non-peer related awards. Even Nobel Prizes have political content, yet generally driven by some explainable notion. But a Science Laureate awarded by the Government? People would wonder what favor was called in for that award. In a sense we are becoming more like pre-revolution France by awarding titles and pensions to anyone by the Government.

For example they want the person to:

introduced legislation that would empower the president to select a "nationally renowned expert" who would "travel around the country to inspire future scientists,"

 Now any scientist worth their salt will not be taking two years off at the peak of their career to talk to High School students in the backwaters of the country. It makes no sense. With all the problems we have one wonders why this is even considered.

The Patient and the Facts

There is an interesting piece today in the NY Times by a Resident at one of the Harvard Teaching Hospitals. I guess it has become fashionable for residents to now discuss the insight they have obtained halfway through their training process. The responses are more telling than the piece, and they are worth a read. Namely the consensus is the person is quite naive. Why, because they felt that as an Intern they managed to convince Resident s and Attending to change a protocol for some terminal patient. Was that good or bad? Well it all depends.

Statistics are often used, by physicians and patients, to justify actions. Take some of the recent melanoma therapeutics. Fifty percent of the patients last an additional six months. Yet some 20% keep going on. Thus if you are one who has the choice for the drug, what do you bet on? Frankly the bet only applies to a large cohort, and never to a single patient. You just do not know, what will happen will happen. There is always a bit of fatalism.

However people like Kaplan managed to change the survival for Hodgkin's disease, It went from 0% to almost 90% with radiation and multi drug cocktails. Yet along the way there were many failures and distressed families. Yet as a species we learned and made progress.

All too often it is the family who demands all life extending actions, often at massive costs and incurring great distress for the patient. This is a difficult issue, it involves the ultimate demise of all of us and all too often our own demise is denied, for good reason.

As the author states:

And yet studies have shown that patients almost universally prefer to be told the truth. If physicians cannot deliver the hard facts, not only do they deprive their patients of crucial information, but they also delay the conversation about introducing palliative care. 

Many times the physician just does not know. Certain malignancies, such as prostate cancer, may be indolent or aggressive.  The physician really does not know, at least at this time. The "truth" is that one just does not know. On the other hand a Stage IV melanoma with brain mets may in almost all cases be terminal. Should the patient be told, yes, and should the family, yes. Is there much to do about it, possibly, but frankly what may be done will be to add to a data base of understanding ant note necessarily be curative.

The author concludes:

The patient’s condition got worse. The tumor grew to the point that we had to put in a tube to deflate her intestines. She developed clots in her lungs, but we couldn’t treat them with blood thinners because she was already bleeding internally. She had to get all of her medications and nutrition through an I.V. It was clear to the team that the more humane thing to do would be to focus on her symptoms and keep her comfortable rather than trying to extend her life. But there was nothing we could do to uproot the horror of irrational optimism that had spread through her body like a cancer uncontrollable. 

 In the case of colon cancer mets to the liver one sees the ascites expanding the abdomen, the severe discomfort, and the care is at best palliative. This was know for centuries, and the author seems to be grasping this for the very first time. There is the perception that the physician must treat each new symptom of the terminal illness rather than just making the patient as comfortable as possible. That is why the most insight to this issue resides in the commentaries when discussing the lack of experience of the author.

Organic Chemistry and the 21st Century

On PLOS Blogs there is an interesting piece on Organic Chemistry and Medicine. The author remarks:

I looked up Friedel-Crafts alkylation, a phrase hovering in my distant memory, and soon discovered that this is the addition of a carbon-containing group to a benzene ring. According to the textbook, “In Friedel-Crafts alkylation, the electrophile is typically a carbonium ion. It, too, is formed in an acid-base equilibrium, this time in the Lewis sense,” followed by several reactions.

“What has this to do with setting a bone, removing a spleen, delivering a baby, or treating cancer?” I bellowed to my husband.

“The human body is a giant chemistry set that’s making and breaking covalent bonds,” he answered, obviously brainwashed. So I asked the same of the good Dr. Fowler.

“If anything, a molecular knowledge is more important for physicians and people going into health care now than it ever was. My dermatologist said, ‘I never use organic!’ But skin cancer is a perfect example of photochemistry of the skin,” Fowler said.

 Having taken this back in 1962, a decade or so before the author, and retaking it a year ago, fifty years later, I saw the difference up to the point where the mass of memorized reactions started again, halfway through the second semester. Molecular knowledge is important, just look at the hydrogen bond and DNA. But it is not organic that one needs for melanoma but pathways and reaction rates, stuff we never had fifty years ago.

The problem with Organic is that it the revenge by all those 19th century German Chemists, memorizing reactions which any good physician or cancer researcher may look up but not have memorized.

The Sales Tax Issue

The current issue about placing sales tax requirements on Internet sales will have significant unintended consequences. The loss of such a tax is a true loss to the state involved but the costs are much more than just the tax.

Back a couple of decades ago I saw the complexity up close when we started operating cellular systems here in the States. I had to have complex tax schedules for each state and city and then apply them in a complex manner. The costs associated with that process are quite significant.

Namely":

1. You must maintain adequate detailed and current tax tables for thousands of various municipalities, not just 50 states.

2. You have to collect and distribute the taxes.

3. You have to account for and audit the process.

4. You have to file local and state forms ad infinitum.

5. You have to deal with complex annual state and local audits in locations which are often near impossible to get to.

By the time you add the staff, the software, the system integration, the accountants, the lawyers, and so forth it may easily increase costs by 5-8% on top of taxes from 4-14%. That is a possible 22% increase to the consumer.

Now I heard some lobbyist from the Retail Industry say that you just get the software and there are no costs. Frankly the woman was clueless, truly clueless. Now that Internet sales are a significant part of our economy just watch what this does!