The Counterintuitive Nature of Cancer Screening

 The first rule of cancer recovery is the extreme need for early discovery and treatment.  Researchers are continually seeking more accurate methods to deliver those early discoveries.  Yet, when physicians discuss cancer screening, they seem hesitant in recommending it, as if screening too often or too early might be bad for a patient.  Siddhartha Mukherjee provides a enlightening summary of the relevant issues in a The New Yorker article: The Catch in Catching Cancer Early.

Mukherjee tells the reader that several things must be recognized to understand the issues.  The first is that not all cancers are equal.  In fact, not all cancers are even dangerous.  Detecting them is one thing, responding to them is another.

“We have become adept at locating cancer’s physical presence—its corporeal form—but remain largely blind to its character, its behavior, its future. We employ genomic assays and histopathological grading, but many early-stage tumors remain biologically ambiguous. They might be the kind of early cancers that surgery can cure. They might be slow-growing and unlikely to cause harm. Or, most concerning, they might already have metastasized, rendering local intervention moot. Three possibilities—yet we often cannot tell which we’re confronting.”

The second concern that must be recognized is that there can be numerous false positives leading to unnecessary medical interventions that might risk the health of the patient.  Mukherjee uses the example of a group of 1000 smokers being screened with one case of cancer being present.  The screening procedure seems quite good with an accuracy of 99%.

“So what does it signify if someone in the group tests positive—what are the chances the person actually has cancer? Bayesian arithmetic gives a surprising answer: the test can be expected to identify the one person who actually has cancer, but it will also wrongly flag about ten people who don’t. That means there will be roughly eleven positive results, but only one of them is accurate. The chance that someone who tests positive has cancer, then, is just over nine per cent. In other words, eleven people would be sent for follow-up procedures, such as biopsies. And ten of them would go through a risky and invasive process—which can involve a punctured lung, bleeding, or other complications—with no benefit.”

It is critical that the statistical reality from this example be understood.  Apparently, it is either not understood, or it is being ignored.

“The consequences of ignoring these principles are staggering. In 2021, according to one estimate, the United States spent more than forty billion dollars on cancer screening. On average, a year’s worth of screenings yields nine million positive results—of which 8.8 million are false. Millions endure follow-up scans, biopsies, and anxiety so that just over two hundred thousand true positives can be found, of which an even smaller fraction can be cured by local treatment, like excision. The rest is noise mistaken for signal, harm mistaken for help.”

There are other statistical approaches that have been used to suggest that screening is always beneficial, but Mukherjee debunks them and concludes that the only way to show that screening works is to demonstrate that people who were screened actually live longer than those who were not.  This is a long and expensive process, but it has been done.

Colonoscopies have been proved to be beneficial as a screening process.  A colonoscopy is a rather risk-free process that allows a suspicious structure to be extracted as part of the procedure for detailed study after the fact.  The nature of the cancer can be identified if it is cancerous.

“The point isn’t that screening can’t pay off. The success stories are real. In 2022, The New England Journal of Medicine published the results of a landmark colonoscopy trial involving 84,585 participants in Poland, Norway, and Sweden. After more than a decade, the data showed an estimated fifty-per-cent reduction in deaths associated with colorectal cancer among those who received colonoscopies. Every four to five hundred colonoscopies prevented a case of colorectal cancer. The benefit was real—but demonstrating it required years of painstaking research.”

Not all endeavors have been so successful.

“The effectiveness of screening varies dramatically by cancer type. Consider ovarian cancer, a disease that often remains hidden until it has scattered itself across the abdomen. In 1993, researchers launched a major trial to test whether annual ultrasounds and blood tests could lower mortality. The scale was extraordinary: more than seventy-eight thousand women enrolled, half randomly assigned to screening. For four years, they endured transvaginal ultrasounds; for six years, routine blood draws. Then came more than a decade of monitoring.”

“And what did we learn? Among the screened, 3,285 received false positives. More than a thousand underwent unnecessary surgeries. A hundred and sixty-three suffered serious complications—bleeding, infection, bowel injury. But after eighteen years there was no difference in mortality. Even with three to six additional years of follow-up, the results held.”

 There is an intriguing opportunity to replace the current screening procedures with a simple blood test—simple for the patient at least.  As part of the normal cellular life cycle, cells die and spread their DNA in bits and pieces into the blood stream.  Researchers have determined that cancer cells go through the same process and DNA from cancerous tumors can be detected in a blood sample.  In principle one could detect the existence of cancer this way and also determine properties of the cancer that would provide an informed treatment plan.  Also, in principle, one could detect not just one form of cancer but screen for many options.  There are research teams out there trying to accomplish that and demonstrating potential for the approach.  It seems an incredibly difficult task, but one absolutely necessary.  Mukherjee details the state of progress and ends with guarded optimism.

“Perhaps, in time, we’ll build tools that can not only detect cancer’s presence but predict its course—tests that listen not just for signals but for intent. Early work with cell-free DNA hints at this possibility: blood tests that may one day tell us not only where a cancer began but whether it’s likely to pose a threat to health. For now, we dwell in a liminal space between promise and proof. It’s a space where hope still outpaces certainty and the holy grail of perfect screening remains just out of reach.”

 

Boys Seem to be Losing in the Parenting Game: Gender Preference

 Evolution has tried its hardest to produce equal numbers of male and female babies.  However, humans are cultural animals, and they develop preferences that effectively alter the ratio by abortion, infanticide or other means of disposal of an unwanted gender.  For most of recorded human history male cultural dominance has produced a tendency to view a male offspring as more important than a female one.  A fascinating article in The Economist, More and more parents around the world prefer girls to boys, tells us that this attitude is changing.

In some developing cultures, male preference has created an overabundance of males, or a cohort of disappeared females.  This was a common situation in countries such as China and India, but recent data from developing nations indicates that fewer girls are disappearing and gender ratios are approaching the natural value.  That is definitely a significant and pleasing discovery.   However, recent data from wealthier countries seems to indicate that it may be part of a trend favoring girl children over boys.

 When women wanted to revolt against male domination they took to the streets to protest their plight and worked and studied hard to compete with men for jobs and other positions.  As girls/women became more prominent in society’s activities, many boys/men seem to be unwilling or unable to compete. 

“The growing desire for daughters may also reflect the social ills that afflict men in much of the rich world. Men still dominate business and politics and earn more for the same work almost everywhere—but they are also more likely to go off the rails. In many rich countries, teenage boys are more likely to be both perpetrators and victims of violent crimes. They also are more likely to commit suicide. Boys trail girls at all stages of education and are expelled from school at far higher rates. They are less likely than women to attend university.”

This has led to many activities aimed at helping boys become more functional members of society. 

“A telling sign of the general alarm about boys in the rich world is the interest politicians have begun taking in the subject. Last year Britain’s Parliament opened an investigation into male underachievement in schools. Norway has gone a step further, launching a Men’s Equality Commission in 2022. Its final report in 2024 concluded that tackling challenges for boys and men would be the ‘next step’ in gender equality.”

“Legislators across America’s political spectrum are making similar noises. Utah’s governor, Spencer Cox, a Republican, has created a task-force on male well-being; Maryland’s governor, Wes Moore, a Democrat, has committed to 'targeted solutions to uplift our men and boys'; Michigan’s governor, Gretchen Whitmer, a woman (and a Democrat), wants to get more young men into Michigan’s colleges and vocational courses.”

Prospective parents are aware of these issues, and they seem to take them into account when considering having a child.  The article provides plenty of evidence that preferences are strongly tilting towards girl babies

“In the rich world…evidence is growing of an emerging preference for girls. Between 1985 and 2003, the share of South Korean women who felt it ‘necessary’ to have a son plunged from 48% to 6%, according to South Korea’s statistics agency. Nearly half now want daughters. Similarly in Japan, polls suggest a clear preference for girls. The Japanese National Fertility Survey, a poll conducted every five years, shows that in 1982, 48.5% of married couples wanting only one child said they would prefer a daughter. By 2002, 75% did.”

“In America parents with only daughters were once more likely than parents with only sons to keep having children, presumably to try for a boy. That was the thesis set out in a study published in 2008 by Gordon Dahl of the University of California, San Diego, and Enrico Moretti at the University of California, Berkeley. The report, which analysed census data from 1960 to 2000, concluded that parents in America favoured sons.”

“That preference has since reversed, however. A study in 2017 led by Francine Blau, an economist at Cornell University, found that having a girl first is now associated with lower fertility rates in America. The research, which uses data from 2008 to 2013, suggested a preference for girls among married couples.”

Adoption and IVF provide opportunities for prospective parents to express their gender preferences.

“Adoptive parents, too, tend to want girls. Those in America were willing to pay as much as $16,000 to secure a daughter, according to a study published in 2010. In 2009 Abbie Goldberg of Clark University asked more than 200 American couples hoping to adopt whether they wanted a boy or a girl. Although many of them said they did not mind, heterosexual men and women and lesbians all leaned on average towards girls; only gay men preferred boys.”

“IVF and other fertility treatments are also becoming cheaper, more effective and so more common. In America, where sex-selective IVF is legal, around a quarter of all IVF attempts now lead to live births, compared with 14% during the 1990s. Some 90% of couples who use a technique called sperm-sorting to select the sex of their child said they wanted a balance of sons and daughters. Even so, in practice 80% of them opted for girls. If that imbalance endures even as such methods spread, America’s sex ratios will soon start to skew.”

The article also provided this interesting perspective on the factors that enter into child gender preference.

“Competitive parents may see girls as more likely to reflect well on them than boys. After all, boys develop fine motor skills later than girls. They are also worse at sitting still. Those are drawbacks in a world of toddlers’ music lessons and art classes. ‘We no longer have trophy wives,’ says Richard Reeves, president of the American Institute for Boys and Men, which seeks to remedy male social problems. ‘We have trophy kids’.”

If you are someone who sees your child as an indicator of your status as a human being and as a parent, you are more likely to look good if you choose a girl baby.

 

Police, Protestors, Violence, and Tear Gas (Tear Gas Is Illegal in Warfare, but Legal on Protestors)

 As this note is being written, organized protests have broken out in Los Angeles against Trump’s immigrant deportation activities.  These protests are far from being the biggest and the most contentious that that the LAPD has ever had to deal with.  No request for assistance was made, yet Trump decided to inflate the affair by sending in federal National Guard troops.  In addition, several hundred marines were ordered to go to LA and assist the National Guard troops.  Whatever one might think about the legality or intention of what Trump is doing, one should be questioning the wisdom of sending in people trained to use lethal force against enemies of the state to do duty controlling fellow citizens staging a protest.  The LAPD knows it will face these situations and has plans for how to deal with them.  Marines and National Guard soldiers do not. 

Kevin M. Kruse and Julian E. Zelizer have produced an interesting collection of essays by noted historians in the book Myth America: Historians Take On the Biggest Legends and Lies About Our Past.  One is titled Police Violence, by Elizabeth Hinton, a Yale professor of history.  According to her, the myth that police are merely doing their duty when using force against protestors produces a dangerous misunderstanding of our history.

“…officials and much of the American public have widely assumed that police violence primarily occurs as a reaction to community provocation.  The myth holds that the fires and the looting of the immediate post-civil rights period, and in our own time, began with disaffected groups themselves; the police were ‘merely doing their jobs’ in reacting to a dangerous situation with force.”

“Contrary to the fearmongering rhetoric of politicians, history reveals that police violence very often inflamed community violence, not the other way around.  Although protestors are often blamed for creating violent situations where the police are forced to respond in kind, from Miami in 1967 to the George Floyd uprisings in 2020, law enforcement officials were the instigators.  Indeed, protests have grown more peaceful since the fiery post-civil rights era, but the police response to them has escalated in its violence.  Dominant narratives have confused where the responsibility lies, in part because of the police’s increased reliance on tear gas and other chemical weapons that tend to be regarded as relatively benign riot-control tactics.”

Tear gas is not the only “benign” crowd control weapon available to the police, rubber bullets, bean bag rounds, and stun grenades are also available.

That premature violence was counterproductive in crowd control, was well known back in the 1960s.

“The widely distributed 1967 FBI manual called Prevention and Control of Mobs and Riots recognized that the application of force was a delicate matter, for its premature use ‘would only contribute to the danger, aggravate the mob, and instill in the individual a deep-rooted hatred of the police.’  Likewise, in it 1969 report the National commission on the Causes and Prevention of Violence concluded that ‘excessive force is an unwise tactic for handling disorder’ that ‘often has the effect of magnifying turmoil not diminishing it’.”

Tear gas was invented during World War I for use in rendering an enemy incapable of fighting back and requiring him to retreat, but to not kill him.  In 1925, the international community banned its use in warfare, but for reasons of convenience nations decided it was okay to use it against their own misbehaving citizens.

“Tear gas had been intended for the battlefield, to harm enemy forces for a brief period of time without leaving a trail of blood.  The chemical weapon produced immediate effects, attacking the senses of its intended targets, leaving them incapacitated anywhere from ten seconds to ten minutes and causing, as the army manual Military Chemistry and Chemical Agents described it…’extreme burning of the eyes accompanied by copious flow of tears, coughing, difficulty in breathing, and chest tightness, involuntary closing of the eyes, stinging sensations of moist skin, running nose, and dizziness or swimming of the head’.”

“The 1993 Chemical Weapons Convention upheld the international prohibition of tear gas and other chemical weapons in warfare, but they are still regarded as humane alternatives to violently arresting or shooting into crowds of people, and law enforcement officials around the world are still permitted to apply the devices at their discretion.”

The summer of 2020 with its numerous protests following George Floyd’s murder gave Donald Trump opportunities to demonstrate his feelings for his fellow citizens.

“One of the most egregious incidents of that summer involved US Park Police and Secret Service agents who used tear gas, riot batons, and other weapons against nonviolent protestors in Lafayette Square near the White House to make way for a photo opportunity for Trump in front of the nearby St. John’s Church.”

Let us hope that the people in charge of dealing with the current protests, and the many future protests, against the current immigrant deportation activities realize that tormenting people who attended peacefully with chemical weapons because a few troublemakers angered you is not a good strategy.  The anger, as well as the number of troublemakers, will only increase.

Trump may or may not understand this dynamic.  He probably doesn’t care.  He is acting as though he sees a benefit from inducing violence.  Yes, things can get much worse.

Ukraine, Russia, and Fighting the Next War: Fighter Jets

 Technological developments have made it difficult and expensive to prepare for the next military conflict.  The mindsets of the military leaders and defense contractors call for weapons of greater lethality and greater survivability.  These goals, of course, lead to greater expense that results in the ability to pay for ever smaller numbers of weapons, which in turn leads to even greater emphasis on lethality and survivability, and even greater costs.  This military, technological, political dance came face to face with an example of how the next war might be fought.  When Russia invaded Ukraine some three years ago, it was interesting to note that a vast superiority in manpower, tanks, and other mechanized vehicles was of little value to the Russians.  They were prepared for an easy victory, while the Ukrainians viewed the invasion as a more severe version of the war they had been fighting since 2014.  Russia was forced to surrender many of its initial gains but were able to retreat to lines they could hold, and the battle became essentially a stalemate.

Then things got really interesting.  Ukraine, at a material disadvantage in almost all areas, began to look into strategies that could be effective, but at little cost.  Thus begins the battlefield use of surveillance and attack drones.  It was discovered that a few small weaponized attack drones could be used to destroy tanks and other armored vehicles, and that those expensive beasts had little opportunity to go unobserved while in motion.  Russia was forced to duplicate such tactics.  Both sides compete for the slightest advantage with new systems being introduced in weeks or months.  The battle line now comes with a kill zone where no one can be safe that extends for about ten miles.  If the Russians wish to attack, they must span that space as quickly as possible without any vulnerable troop concentrations.  Traditional military vehicles are too dangerous.  Russia seems to have decided that individual motorcycles are the best bet for an attacking force.

Ukraine has also used relatively cheap marine drones to drive Russian warships away from its shores, another example of inexpensive technology putting at risk tremendously expensive assets.

One has to wonder what NATO forces think about these developments.  Are the weapons in their warehouses rapidly becoming obsolete?  Will NATO generals have to be taught how to wage war by the Ukrainians?  Are defense contractors trying to figure out how to make billions of dollars manufacturing motorcycles?

Another area in which tactics have moved in an unexpected direction is air warfare.  There are no tales of dogfights between jet pilots because neither side can afford to let its expensive jets cross into enemy territory because air defenses have become so effective.  Fighter pilots launch missiles at the enemy from afar or they help provide defense against missiles and drones.  Thus far there does not appear to be any cheap technology that could change this picture.  The enemy’s planes are most at risk when they are on the ground.  Both sides try to use missiles and drones, whatever is available, to take out planes they can reach.  The Russians have had to move their planes further back into Russia or keep them in armored bunkers to protect them.  As this article was being written, Ukraine demonstrated an audacious way to use inexpensive drones to destroy Russia’s advanced planes. More on that below.

The F-16s that took so long to migrate to Ukraine for use are considered fourth-generation planes.  The US has already developed a fifth-generation plane, the F-35.  That plane is a Lockheed Martin product whose development began in 1996.  The contract for the company to produce the F-35 was signed in 2001.  Full-rate production did not begin until 2021.  It took over twenty years to go from concept to mass production.  The world’s militaries seem poised to commit to producing sixth-generation fighters. 

The Economist summarizes what is known of plans in the article The race to build the fighter planes of the future.  The need for more advanced models is influenced by a number of factors, including fear of the performance of current air defense systems as experienced in the Ukraine-Russia conflict.

“One shift they all predict is more, and better, surface-to-air missile systems, a lesson reinforced by the strong performance of air defences in Ukraine. That requires more stealth to keep planes hidden from enemy radar. Stealth, in turn, requires smooth surfaces—bombs and missiles cannot hang off the wing, but must be tucked away inside a larger body.” 

There are a number of developments underway, all indicating much larger structures to hold interior weapons, more fuel for longer range, and more complex electronics.  The US entry is suspiciously named the F-47.  More troubling is the award of the development contract to Boeing, which, of late, seems to have problems doing anything.  Little is known of the F-47 except that it is expected to be much larger than either the F-35 or F-22.

“In December China showed off what was believed to be a prototype of the J-36, an imposing plane with stealthy features and a large flying-wing design. Britain, Italy and Japan are co-developing their own plane, in Britain provisionally called the Tempest, which is due to enter service in 2035. France, Germany and Spain hope that their Future Combat Air System (FCAS) will be ready by 2040. Together, these represent the future of aerial warfare.”

One reason why longer range is required is security for the planes when not in use. 

“Finally, planes are especially vulnerable to long-range missiles when they are on the ground. That means they need to fly from more distant airfields, requiring larger fuel tanks and less drag for more efficient flight. The huge wings seen on the Tempest and the J-36 allow for both those things…Range is a particular concern for America. Its airbases in Japan are within reach of vast numbers of Chinese ballistic missiles. It plans to disperse its planes more widely in wartime and to fly them from more distant runways, such as those in Australia and on Pacific islands.”

Any strategy for development of expensive future aircraft must consider Ukraine’s most recent use of cheap drones.  The Economist provides comments in the article An astonishing raid deep inside Russia rewrites the rules of war.  The following lede is provided.

“Ukraine’s high-risk strikes damage over 40 top-secret strategic bombers”

Ukraine managed to get numerous small weaponized drones stationed near multiple Russian air bases on trucks.  A mechanism could be activated to release the drones at the appropriate time and as first-person-view drones they could be controlled by operators in Ukraine.  They were too small and too close in to be defended against.  And it doesn’t take much to destroy an expensive plane.

“Today’s operation is likely to be ranked among the most important raiding actions in modern warfare. According to sources, the mission was 18 months in the making. Russia had been expecting attacks by larger fixed-wing drones at night and closer to the border with Ukraine. The Ukrainians reversed all three variables, launching small drones during the day, and doing so far from the front lines.”

“Commentators close to the Ukrainian security services suggest that as many as 150 drones and 300 bombs had been smuggled into Russia for the operations. The quadcopters were apparently built into wooden cabins, loaded onto lorries and then released after the roofs of the cabins were remotely retracted. The drones used Russian mobile-telephone networks to relay their footage back to Ukraine, much of which was released by the gleeful Ukrainians.”

So, Ukraine did figure out a way to take out troublesome enemy planes and it really did not cost much, and did not require any exotic technologies either.  There is a lesson in this event for all those who wish to build ever more expensive aircraft.

“Western armed forces are watching closely. For many years they have concentrated their own aircraft at an ever smaller number of air bases, to save money, and have failed to invest in hardened hangars or shelters that could protect against drones and missiles. America’s own strategic bombers are visible in public satellite imagery, sitting in the open. ‘Imagine, on game-day,’ writes Tom Shugart of CNAS, a think-tank in Washington, ‘containers at railyards, on Chinese-owned container ships in port or offshore, on trucks parked at random properties…spewing forth thousands of drones that sally forth and at least mission-kill the crown jewels of the [US Air Force].’ That, he warns, would be ‘entirely feasible’.”

Perhaps people should learn how to protect the assets they already have before spending a fortune and a decade or two on new assets.