Smarter to be Lucky

Which is healthier, a Big Mac or a Whopper? On the face of things it's tempting to guess the Whopper. After all, it has recognizable bits of vegetable matter on it -- a couple of slices of tomato, some lettuce, and onions if you want them -- while the Big Mac only has pickles and a tiny bit of shredded lettuce and chopped onion bogged down in cheese and that orange "special" sauce that looks like it might be radioactive.

If you actually look at the nutrition specs the Big Mac looks better. It has "only" 576 calories (vs 670 for the Whopper) -- 32.5g of fat (vs 39), 38.7g carbohydrates (vs 51). One can easily make the case that the Big Mac is the healthier sandwich. I imagine somewhere in the Micky D PR department there is a guy who cares.

But the PR guys at Burger King might counter that at 290g (vs 215g) the Whopper is simply a bigger sandwich and that's why it has more calories and more fat. It has more of everything. If you look at the typical meals that people order you will see that people order more sides with a Big Mac and any nutritional advantage of eating at McDonald's goes away.

If the argument goes on long enough -- back and forth, with people joining in on this side of the argument or that side -- what can get lost is that the question isn't that important. Neither sandwich is health food and both make a nice lunch.

We recently had a discussion here that asked whether one treatment option was better than another for certain classes of prostate cancers. This sort of thread often degenerates into a shouting match but I thought it went well this time. Everybody was on their best behavior and, while the discussion was spirited at times, it seemed mostly respectful. I was proud to be a member of this forum.

But since that discussion I have noticed postings from a number of men who are in the process of making their decision with regard to primary treatment. They have read the discussion and feel more pressure to make the right choice -- more anxiety that they may choose wrong and spend the rest of their lives in regret. This is unfortunate, since the information presented on both sides, properly understood, should have depressurized the choice.

There are two reasons why the discussion should have been reassuring. The first is obvious: in terms of treating the disease both treatments are pretty good. The cure rates for the risk categories under discussion were generally in the 90 to 95 percent range (which is which depending on whose research was being quoted.) Even for side effects (the area where one side vigorously claimed an advantage) both treatments offered better than even money chances of avoiding the side effects that men worry about.

The second reason not to worry obsessively about ones choice of treatment is that, even if there are significant statistical differences between the treatments, those differences are fairly small in real terms and the reality is that each individual's outcome depends mostly on luck.

Consider two treatments A and B where treatment A causes erectile dysfunction at a rate of 50 percent and treatment B causes it at 35 percent. Given 20 men deciding between the two treatments seven will get ED no matter which choice they make and another ten will avoid ED, again no matter what they choose. There are only three men (15 percent) for whom the choice makes any difference.

It would be nice if we had more control over the results -- if there were a list of things we could do to guarantee the outcome but that's not how it works. There are things we can do to tinker with the odds -- choose the right treatment, the right venue, the right doctor, lose weight, eat right -- but in the end you have to pull the lever and watch the cylinders spin. After everything you can do it's still mostly luck.

When you see testimonials from men who have done a lot of research, selected a particular treatment, had good results and become enthusiasts, remember that even if they are right about the advantages of their treatment, they are still only 15% smart and 85% percent lucky. Maybe the treatment sounds promising -- a Diet Coke prostate infusion with disruption of tumors by inserting tiny Mentos -- but remember that even if its all true it just buys the patient is a tiny edge in the odds.

With a game of chance you want to do what you can to have the best odds for each play but the secret to winning is to have a plan to stay in the game long enough for your luck to turn around.

Or, as the song "War is a Science" said in the musical Pippin...


In conclusion gentlemen....

Now listen to me closely I'll endeavor to explain
What separates a charlatan from a Charlemagne
A rule confessed by generals illustrious and various
Though pompous as a Pompey or daring as a Darius
A simple rule that every good man knows by heart
It's smarter to be lucky than it's lucky to be smart

And if the fates feel frivolous
And all our plans they smother
Well suppose this war does shrivel us
There'll always be another!

I think there is a difference between luck and probabilities, although many use them interchangably without really thinking about the implications. The probability of flipping a coin and getting a head is .50. Is getting 3 heads in a row luck or just a probabilistic outcome that will in fact happen a given amount of time? One can greatly improve his probability of outcome by making the right choices, like staying on 16 when the dealer is showing a 5 or a 6.
A good book to read is "The Signal and the Noise" which puts probabilities and statistics in terms that anyone can understand. The author correctly predicted the outcome of the electoral college in 49 of 50 states in the last election. Far better than any of the policital pundants. Understanding probabilities will give one a significant edge in life over one who just guesses or goes with his gut feelings.

Even though the differences on treatments may be small, combined with the differences in doctors skill, differences in diagostic results and changes in lifestyle added together can result in a significant difference in total outcome as they all have a small but significant effect on outcome. Each difference could be ony 5% but when combined could add 25% or more to outcome probability, which is very significant. I believe in stacking the odds in your favor; it does not garantee a result, but increases the probability that you will have a better result than just guessing.
The reason many patients tout their own treatment is "cognitive dissonance" or the psychological need to justify one's decisions, especially on important matters. Most car ads are not to get new buyers, but to reinforce the decisions of people that have already bought their car. We all want to believe we have made the right decision and look for information that will support it and disregard information that does not. ("The Believing Brain" by M. Shermer.) This is just how our brains work and we should recognize this. It is natural to tout your treatment, even if it didn't produce the results you expected.

Peter,
I'll throw another one at you.
I think that patients are predisposed to choosing certain treatments by a combination of genetics and life exposures.
A treatment choice is much like a belief system, like gay marriage or abortion. You have a predisposition to believe or not to believe and a presention of facts will not likely change your beliefs, especially in the short term.
Some patients are predisposed to surgery as they believe that cutting it out is the only answer and others are predisposed to using alternative treatments which have no medical evidence supporting them. I don't think that it is a coincidence that a large proportion of Proton patients are engineers; it fits with the way they think. A naturally fearful or anxious patient is not likely to ever choose AS regardless of his stats.
Basically a person has already made his choice about treatment before even being Dxed based on his genetics and lifestyle. That should be some food for thought.

Wow! Can I please have the two minutes of my life I just wasted back?

i recall your irritation at my two-paragraph rule !

ed

As long as we're talking hypotheticals, how about this one:

Treatment A: you really like it, it's the way you want to go, but it costs $20,000 and your insurance won't cover it.

Treatment B: not your first choice, you really prefer A, but your insurance will pick up the $ 20,000 tab on this one.

You would really prefer that the cost of this not come out of your own pocket. Would cost by a major consideration in your decision on the way to go?

John T said...

A good book to read is "The Signal and the Noise" which puts probabilities and statistics in terms that anyone can understand. The author correctly predicted the outcome of the electoral college in 49 of 50 states in the last election. Far better than any of the policital pundants.

I've been amused at the notoriety around this particular prediction. I would venture to guess, that no matter what the outcome of the election had been, someone would have turned up who had gotten it exactly right.

There is nothing amazing or lucky about that. It's just that there are a lot of pundits out there ... someone was bound to get it right (and have the evidence to prove how smart they were).

Peter ... keep the long posts coming. I always find them interesting and thought provoking.

Peter,
A lot of what you say is useful to keep in mind, but misses the point of what I was getting at in starting the referenced thread. To repeat it: In the year during which I've read almost every post here, I have noticed a disconnect between the "common wisdom" that the only choice to be made among the three most-used treatments for T1/T2 diagnoses is a personal one, i.e., which would you "prefer," and what I see as a distinct difference in posted outcomes as far as SEs are concerned. So if the effectiveness is equal, why would anyone choose the treatment with an average "worse" outcome than another, and also why are they treated equally by the uros?. (Actually, it's worse than that, with uros seeming to recommend most frequently a treatment that seems to produce worse outcomes generally in the two most important SEs.) Maybe what I've just said isn't really true, that there are other reasons for my impression of the experiences as related by the members of HW. and it is certainly open to debate. But if it IS true, I believe that a change is needed in the way the major options for treatment are presented to patients. Things change, techniques change, attitudes change. What was for a long time considered the "gold standard" in treatment might have slowly become actually the silver or copper standard, whereas perceptions haven't changed so quickly. Can there be any argument that we are right now experiencing a profound change in the way AS is considered as an option? Can there be any argument that the recent panel recommendations to stop screening has been a bomb dropped on the conventional wisdom in this field? If I had followed their recommendation, my life would have been vastly different in the last two years. I'm not convinced yet that it would have been the best thing for me, but it certainly would have made a huge difference in the past year. That's real, that's very real. These are not philosophical arguments we're throwing around here, they're real, and have real and serious consequences to men's lives.
Henry

Post Edited (Phenom) : 1/12/2013 2:41:04 PM (GMT-7)

John,
You're assuming all the choices have been presented as equal in all respects, right? Under those circumstances, what other criteria would you ever use for your prediction?

Rove's still working the numbers with his whiteboard, it may not be over yet.

PeterDA, your amusing post actually provides a powerful testimonial for Option B (Brachytherapy). After conceding that the cure rates are equal, the difference in ED rates is actually HUGE rather than tiny. Looked at positively, an improvement in odds of no ED from 50% to 65% is dramatic especially in light of the other advantages of being a less invasive procedure and virtually no chance of incontinence. Projected over the population of men who get treated each year, this would mean many thousands of men without ED...that is hardly inconsequential.

Finally, I totally agree with JT's assessment that treatment choice is highly influenced by a man's psychological makeup and is somewhat predictable. This would make for an interesting paper...

Jim

Ooooh! So many responses! It's like Christmas. Let's see -- which to open first. Guess I'll take them in order.

Andrew: Actually there is a lot interesting to say about the Mac vs Pc analogy.

John T: I get the difference between probability and luck. We should all do our due diligence to make sure we understand the probabilities involved and how they might be improved. But there comes a point of diminishing returns where the cost of seeking further improvements in those probabilities exceeds the expected gains. At that point one makes an "educated" guess and takes one's chances.

You are quite right about cognitive dissonance. It is an impulse to avoid a psychological pain that, although not altogether rational is quite real. That pain is compounded of embarrassment and regret and it can be quite keen. I am hoping to facilitate a more dispassionate debate by reminding people that the choice of treatment makes a fairly small change in the probabilities. That way people who had a treatment that is being criticized in the discussion have less skin in the game. Rather than being backed into a corner where they must think "Because I chose the wrong treatment I have 100 percent ED now" -- which is painful -- they can think "Because I chose a less than optimal treatment I slightly harmed my chances but my ED is still mostly bad luck."

Casey: You mean you read the whole thing? I am soo sorry! I was fairly sure I would lose you with the first paragraph.

Jonh T (again): As to people being predisposed to a particular treatment I agree again. And there are sooo many interesting corollaries. For one thing it calls into question the whole idea of one treatment being "better" than another. I've wondered about that. If our personalities determine whether we prefer surgery or brachytherapy or proton beams then maybe they affect our responses to those treatments too. Maybe surgery really is better for people who seek it. I've wondered particularly about ED statistics. There is a strong psychogenic component to ED. I wonder how much of the difference in ED stats is biological and how much is patient self-selection?

DataDavid: Yeah, writing that made me hungry, too. I'm on a low carb diet and I was getting into fantasizing about the buns. I'm also on ADT so I have to make do with the fantasy I can manage. *sigh*

F8: The existence of ambidextrous people doesn't disprove the general rule of handedness.

81GyGuy: It would depend on how much money you have and how strongly you feel about the treatment choices. Fortunately, I didn't face that situation. I'm sure it would have made me crazy. I would probably have tried desperately to convince myself that I liked the treatment that somebody else would pay for. This is sort of cognitive dissonance only the other way around.

David: People are mostly good when they know they are talking to pre-treatment guys. But when we get to arguing among ourselves we sometimes forget they may be lurking and lose control of our tone. It is interesting that in discussion the words "passionate" and "dispassionate" are both generally used approvingly even though they are opposites. I think we have too much of the former at times and too little of the latter.

Upstate: So you like my long posts? Unusual. I thank you for the encouragement but I doubt that Casey does.

Henry: I understood your question and I was taking some pains not to make any pretense at answering it one way or the other in my thread. I think the reason your thread ultimately failed to make that much progress was because of an unfortunate tone on the part of several posters (on both sides of the issue) which forced people into entrenched positions and made it difficult to explore areas of agreement.

Jim: A number of us seem to agree that a man's psychological profile will affect his preferences for treatment option. What everybody but me also seems to think is that if those men don't choose whatever option they themselves prefer then those men are choosing wrongly and those psychological aspects are unfortunate. But if you think about it most men who get PC are past the general age of reproductive sex and, even without problems caused by PC treatments are in sexual decline. That being the case, why assume that a concern for possible ED problems is more sensible than a desire to get the sense of closure that a favorable post-operative pathology report gives?

The title of this thread sounded interesting so i opened it. It started out great then oops ... same members still pusing their favorite treatment under yet another thread. You guys ever get tired of this?

Dear RCS:

Since your post popped up right after mine I assume that somehow I have offended you.  That certainly was not my intent so please give me an opportunity to explain.  Somehow you must think that I am some rabid pro-brachytherapy zealot with the intention of gaining converts at every turn.  That is not the case and, in fact, I have not started a pro-brachytherapy thread on this forum for months...or maybe years.  What I have done is to honestly respond to requests from new posters for accurate information on treatment options.  What I have also done is to comment on threads where options are discussed and to attempt to clarify misconceptions that appear from time to time about brachytherapy.

Our friend PeterDA has developed a nasty little habit of making erroneous statements about brachytherapy or making comments that would lead the reader to mistaken conclusions.  This is his thread and in it he attempts to trivialize the difference between ED in surgery patients vs. brachytherapy patients.  In fact that difference is not trivial at all and thousands of men who choose surgery will have ED compared to a choice of brachytherapy.  Does that mean they should choose brachy?  Of course not.  But, if we are to have honest discourse on this forum, those men should at least be informed of the facts.

If you find that information in any of my posts is incorrect then I invite you to point that out and I will attempt to correct it and apologize.  If, however, it is the general tone of my posts that offends you then I invite you to use the "ignore" button so that you won't be further offended.

Jim