In 1970, a middle-aged American man's first sign of heart disease was, all too often, his last. Today, the same man walks into my office feeling fine, and I can tell him, with real precision, how likely he is to have a heart attack in the next decade and what we can do about it. Deaths from cardiovascular disease have fallen by more than half in my lifetime. Not mainly because we got better at treating heart attacks, though we did, but because we stopped waiting for them.
That is the story of my specialty: medicine that learned to look before the crisis. It is also why I have come to think of my career as half a success.
The patients whose hearts I have protected for 20 years are increasingly dying of cancer. A man whose arteries I have imaged and re-imaged, whose statin I have adjusted at every visit, comes in with vague back pain, and it is pancreatic cancer, already in his liver. A woman whose stress tests were always reassuring turns yellow one spring, and it is her bile ducts. We did everything right for the organ I was assigned. The disease came through a door no one was watching.
Here is the arithmetic that should trouble every doctor. Routine screening exists for exactly five cancers: breast, cervical, colorectal, prostate and lung, the last only in heavy smokers. Those programs work. But roughly 70 percent of cancer deaths come from cancers we do not screen for. Pancreatic, ovarian, liver, stomach, esophageal, most lymphomas. Caught localized, pancreatic cancer has a five-year survival rate around 44 percent. After it has spread, about 3 percent. The tumor is the same. What changes is when we find it.
On Sept. 23, an advisory panel to the Food and Drug Administration will consider the first test designed to expand how we look for cancer. The Galleri test, made by GRAIL, uses a single blood sample to look for signals associated with dozens of cancer types and can help identify where a signal may be coming from. Congress has already acted, creating a pathway for Medicare to cover F.D.A.-approved tests of this kind beginning in 2029.
I am not a neutral observer. I prescribe this test in my practice, and I have watched it find cancers that would otherwise have declared themselves in an emergency room. I have also watched it miss.
The largest randomized trial, conducted inside Britain's National Health Service with about 140,000 people over three years, did not meet its primary endpoint: no statistically significant drop in combined Stage III and IV diagnoses. But read the rest. By the second and third annual screens, Stage IV diagnoses fell by more than 20 percent, fewer cancers were diagnosed following an emergency presentation, MCED identified roughly four times as many cancers as standard screening alone.
What does a physician do with an imperfect test? Exactly what we did in cardiology. Cholesterol is a crude proxy for what kills people. Stress tests miss disease and flag phantoms. We did not discard these tools because they were flawed. We learned whom to offer them to, what to do with the results and how to help patients make decisions with incomplete information. That is the discipline of preventive medicine: acting on what we know before disease becomes a crisis.
The question before the F.D.A. is whether Galleri is safe, whether it performs as claimed, and can be deployed responsibly. It must be an addition to existing screening, never a substitute.
That is why the Medicare pathway matters to me as a physician. If this technology is approved and meets the requirements for coverage, more patients could have access to it.
Fifty years ago, we decided that waiting for the heart attack was unacceptable, and we built a specialty around refusing to wait. Cancer deserves the same refusal. I do not want to be the doctor who kept a man's heart beating for two decades so that something else could kill him unseen. For the first time, we have a way to look through the door. On Sept. 23, we should decide to open it.
Dr. Emrani is a cardiologist and an assistant clinical professor of medicine at the David Geffen School of Medicine at U.C.L.A.
That is the story of my specialty: medicine that learned to look before the crisis. It is also why I have come to think of my career as half a success.
The patients whose hearts I have protected for 20 years are increasingly dying of cancer. A man whose arteries I have imaged and re-imaged, whose statin I have adjusted at every visit, comes in with vague back pain, and it is pancreatic cancer, already in his liver. A woman whose stress tests were always reassuring turns yellow one spring, and it is her bile ducts. We did everything right for the organ I was assigned. The disease came through a door no one was watching.
Here is the arithmetic that should trouble every doctor. Routine screening exists for exactly five cancers: breast, cervical, colorectal, prostate and lung, the last only in heavy smokers. Those programs work. But roughly 70 percent of cancer deaths come from cancers we do not screen for. Pancreatic, ovarian, liver, stomach, esophageal, most lymphomas. Caught localized, pancreatic cancer has a five-year survival rate around 44 percent. After it has spread, about 3 percent. The tumor is the same. What changes is when we find it.
On Sept. 23, an advisory panel to the Food and Drug Administration will consider the first test designed to expand how we look for cancer. The Galleri test, made by GRAIL, uses a single blood sample to look for signals associated with dozens of cancer types and can help identify where a signal may be coming from. Congress has already acted, creating a pathway for Medicare to cover F.D.A.-approved tests of this kind beginning in 2029.
I am not a neutral observer. I prescribe this test in my practice, and I have watched it find cancers that would otherwise have declared themselves in an emergency room. I have also watched it miss.
The largest randomized trial, conducted inside Britain's National Health Service with about 140,000 people over three years, did not meet its primary endpoint: no statistically significant drop in combined Stage III and IV diagnoses. But read the rest. By the second and third annual screens, Stage IV diagnoses fell by more than 20 percent, fewer cancers were diagnosed following an emergency presentation, MCED identified roughly four times as many cancers as standard screening alone.
What does a physician do with an imperfect test? Exactly what we did in cardiology. Cholesterol is a crude proxy for what kills people. Stress tests miss disease and flag phantoms. We did not discard these tools because they were flawed. We learned whom to offer them to, what to do with the results and how to help patients make decisions with incomplete information. That is the discipline of preventive medicine: acting on what we know before disease becomes a crisis.
The question before the F.D.A. is whether Galleri is safe, whether it performs as claimed, and can be deployed responsibly. It must be an addition to existing screening, never a substitute.
That is why the Medicare pathway matters to me as a physician. If this technology is approved and meets the requirements for coverage, more patients could have access to it.
Fifty years ago, we decided that waiting for the heart attack was unacceptable, and we built a specialty around refusing to wait. Cancer deserves the same refusal. I do not want to be the doctor who kept a man's heart beating for two decades so that something else could kill him unseen. For the first time, we have a way to look through the door. On Sept. 23, we should decide to open it.
Dr. Emrani is a cardiologist and an assistant clinical professor of medicine at the David Geffen School of Medicine at U.C.L.A.
