Quotes from H. Gilbert Welch

any one of us can draw the bad card of an aggressive cancer. Good people—doing all the right things—still get sick. It's tempting to want to find something—or someone—to blame.

It's important to acknowledge the role of chance in health.

I am often asked about three assumed benefits of mammography: less metastatic disease, less need for aggressive treatments, and important reassurance. Unfortunately, reviewing the actual evidence suggests that these "benefits" are limited or nonexistent.

But multiple studies have shown what is labeled overweight (BMI between 25 and 30) is actually associated with lower death rate than what is labeled normal weight (BMI between 18.5 and 25).

No matter how many determinants of health we throw in the mix, we will never be able to perfectly predict who will experience good health.

To the extent that I have control over my cause of death, avoiding a heart-disease death, an aneurysm death, or a cancer death isn't my top priority. I'm more concerned about suffering a lingering cognitive decline in a long-term-care facility. And

Given the number of small cancers they did find and the number that they reasoned they had missed...the researchers concluded that virtually everybody would have some evidence of thyroid cancer if examined carefully enough.

The only way to know if the screening is saving lives is by doing a randomized trial. It's easy to forget this and assume that if technology can find more cancer, it will save more lives. Marketers exploit this assumption. Don't fall for it.

The United States is one of only two countries in the world that allow direct-to-consumer advertising of prescription drugs

The right half of the table shows you data from 2001 on spiral CT screening on more than five thousand volunteers, some of whom smoked, some of whom did not.13 This study measured the rate of lung cancer diagnosis in smokers and nonsmokers. What it shows you is that with the advent of spiral CT, nonsmokers have about the same risk of lung cancer as smokers. It sure looks like the use of spiral CT has made cigarette smoking much better for you.

What is most certain about screening mammography in the United States is that it leads to a lot of false alarms: worrisome mammograms, and yet subsequent testing—another mammogram, an ultrasound, an MRI, and/or a biopsy—ultimately finds no cancer. For example, among 1,000 American women age fifty screened annually for a decade, how many will have at least one false alarm? Somewhere between 490 and 670. And 70 to 100 will be biopsied to prove they don't have cancer.

Of course, I'm guilty of oversimplification here. First, there are real-world legal concerns: doctors aren't punished for overdiagnosis, but they are punished for failing to diagnose. So it's hard for doctors to ignore incidentalomas. Second,

Patients could help by being a little less enthusiastic about scanning in general. In particular, they should avoid whole-body scans, which can open a Pandora's box of incidentalomas. They could also be a little more hesitant about other scans and, when given the choice, choose the most anatomically focused exam to avoid stumbling onto things outside of the area of interest. A

Patients with very high blood pressure, for example, stand to benefit a lot more from treatment than do patients with blood pressures slightly above average.

Some of it is simply luck.