Yesterday, on twitter Mark Cuban revealed that he has his blood checked quarterly to keep tabs on his own health and there was backlash from the medical cognoscenti. The exchange revealed an interesting disconnect between where health care is now–those tests are a waste of money, and where healthcare is heading– they won’t be. My own knee jerk response was that the tests were silly, but the more I reflected, the more I thought it would be a bad idea to bet against the owner of the Dallas Mavericks.
The kerfuffle actually highlights two schisms in the medical firmament: healthcare costs and the role of prevention. Why not check your blood every 3 months? Because it’s expensive (more so if we consider offering this to large numbers of people), and we don’t know if it will be helpful. But Cuban can easily afford the cost of these tests and the bald fact is that despite the long-held notion that Americans don’t want “two tiered” medicine, we should admit that we already have tiers in our current system. I believe that acknowledging different tiers might make our healthcare system more efficient. Every US citizen is entitled to basic healthcare and that it is ridiculous that many states, by not expanding Medicaid, are failing to provide basic care to it’s poorest citizens. But at the same time, there is a huge pile of medical tests and procedures that are not cost effective, not basic, but hell, if folks like Cuban wants to spend their money on “doing everything,” then why the hell not. This is where the cutting edge belongs. He didn’t say this, but given Cuban’s proximity to high performance athletes, I strongly suspect that his quarterly tests might involve hormone assays and therapeutic adjustments. Testosterone and other hormones can be adjusted in a personalized manner to optimize performance. Multiple medical societies have made clear there is no evidence for benefit of this practice, but it seems dishonest to dismiss it totally while the same establishment is going crazy over the idea of “personalized medicine.”
In the Forbes piece and elsewhere, there is discussion about the failures of preventive medicine which are real (e.g PSA screening for prostate cancer, as Otis Brawley has eloquently told) and the idea of over-medicalization of our lives. Obama’s Precision Medicine Initiative has been sold as the way forward for finding “the cure” for diseases. In cancer, I’m getting a bit tired of hearing the molecular studies that reveal horrifying complexity of cancer, as a key to individualized treatments. I certainly don’t want to interfere with the ability of my colleagues to raise money, but just between you and me, it’s marketing. But what this technology will allow us to do is to improve and individualize disease prevention. PSA is an early generation screening test. One day it is perfectly reasonable to assume, yearly blood tests will be able to scan for cancer-causing mutations allowing treatment at the earliest possible point in cancer development.
The idea that Cuban would evangelize for his type of screening horrified some healthcare professionals, and I understand why–there are no data that these tests will do anything but waste money and generate false positive worries. But you know what? Understanding and treating cancer when it is advanced is hard. And by hard, I mean it may be impossible. Cancer sequencing data show us that the genome of a cancer cell is shattered like Humpty Dumpty*. Right now, we are putting tremendous resources into trying to put Humpty Dumpty back together again, but some of the best cancer researchers feel that genome data will be much more effective in the setting of prevention.
“Don’t encourage people to do what we don’t understand,” seems hypocritical to me given the history of US healthcare. “Spend money on what you want to,” seems about as American as apple pie, and in healthcare, just may be the stimulus to get our technology in line, eventually, with health needs of more people. Many companies are pushing big data in healthcare, I see no reason why Cuban can’t push too in his own way. Maybe quarterly is too frequent. Maybe we don’t agree on what tests are needed. But if the richest among us are willing to provide data and enthusiasm for high tech precision medicine, that’s a good thing. If something really useful comes out of these experiments, those of us with more limited means will likely benefit in the long run.
So yeah, ha ha, that Mark Cuban is a silly rich dude who doesn’t understand healthcare. Personally, I think he has the right idea.
* Actually, whole genome sequencing of cancer biopsies show that most cancers are made up of multiple distinct sub-clones with unique mutation profiles–a dozen Humpty Dumptys shattered in different ways. So all the king’s horses and all the king’s men had it easy!!