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But only a handful of cancers—of the breast, lung, colon and cervix—have screening tests recommended by the U.S. Preventive Services Task Force

Many companies are developing blood tests that can detect cancer signals before symptoms occur, and Grail’s is the most advanced. A study found it can identify more than 50 types of cancer 52% of the time and the 12 deadliest cancers in Stages I through III 68% of the time.

There’s a hitch. The test costs $949 and isn’t covered by Medicare or most private insurance.

The trouble is that this cancer is almost never caught early. There’s no routine screening for it, and symptoms don’t develop until it is advanced. Mr. Royse, 64, had no idea he was sick until he took a blood test called Galleri, produced by the Menlo Park, Calif., startup Grail. He had surgery and chemotherapy and is now cancer-free.

Mr. Royse visited Grail’s website, which referred him to a telemedicine provider who ordered a test. Another telemedicine doctor walked him through his results, which showed a cancer signal likely emanating from the pancreas, gallbladder, stomach or esophagus.

An MRI revealed a suspicious mass on his pancreas, which a biopsy confirmed was cancerous. Mr. Royse had three months of chemotherapy, surgery and another three months of chemotherapy, which ended last February. Because pancreatic cancer often recurs, he gets CT and MRI scans every three months. In addition, he has signed up for startup Natera’s Signatera customized blood test, which checks DNA specific to the patient’s cancer and can signal its return before signs are visible on the scans

Grail’s test likewise looks for DNA shed by cancer cells, which is tagged by molecules called methyl groups that are specific to a cancer’s origin. Grail uses genetic sequencing and machine learning to recognize links between DNA methyl groups and particular cancers

The test “is based on how much DNA is being shed by tumor,” Grail’s president, Josh Ofman, says. “Some tumors shed a lot of DNA. Some shed almost none.

ut slow-growing tumors typically aren’t shedding a lot of DNA.” That reduces the probability that Grail’s test will identify indolent cancers that pose no immediate danger.

Grail’s test has a roughly 0.5% false-positive rate, meaning 1 in 200 patients who don’t have cancer will get a positive signal

Its positive predictive value is 43%, so that of every 100 patients with a positive signal, 43 actually have cancer

the legislation’s price tag could reduce political support. According to one private company’s estimate, the test could cost the government $39 billion to $145 billion over a decade. Mr. Goldman counters that analysts usually overestimate the costs and underestimate the benefits of medical interventions.

Because Grail uses machine learning to detect DNA-methylation cancer linkages, the Grail test’s accuracy should improve as more tests and patient data are collected

regulators may balk at approving the test, and insurers at covering it, until it becomes cheaper and more reliable.

How would the FDA weigh the risk that a false positive on a test like Grail’s could require invasive follow-up testing against the dire but hard-to-quantify risk that a deadly cancer wouldn’t be caught until it’s much harder to treat? It’s unclear.

some experts urge the FDA to require large randomized controlled trials before approving blood cancer tests. “Multicancer screening would entail tremendous costs and potentially substantial harms,” H. Gilbert Welch and Tanujit Dey of Brigham and Women’s Hospital wrote

Dr. Welch and Mr. Dey also suggested that companies should be required to prove their tests reduce overall mortality, even though the FDA doesn’t require drugmakers to prove their products reduce deaths or extend life. Clinical trials for the mRNA Covid vaccines didn’t show they reduced deaths.

One alternative is to rely on real-world studies, which Grail is already doing. One study of patients 50 and older without signs of cancer showed that the test doubled the number of cancers detected.

One recurring problem he has seen: “Epidemiologists are always getting cancer wrong,” he says. “Epidemiologists a decade ago said U.S. overtreats cancers. Well, no, the EU undertreats cancer.”

A 2012 study that he co-authored found that the higher U.S. spending on cancer care relative to Europe between 1983 and 1999 resulted in significantly higher survival rates for American patients than for those in Europe

By his study’s calculation, U.S. spending on cancer treatments during that period resulted in $556 billion in net benefits owing to reduced mortality.

He expects Galleri and other multicancer early-detection tests to reduce deaths and produce public-health and economic benefits that exceed their monetary costs

Expanding access to multicancer early-detection tests could also help solve the chicken-and-egg problem of drug development. Because few patients are diagnosed at early stages of some cancers, it’s hard to develop treatments for them

the positive predictive value for some recommended cancer screenings is far lower. Fewer than 1 in 10 women with an abnormal finding on a mammogram are diagnosed with breast cancer.

Mr. Royse makes the same point with personal force. “I would be dead right now if not for multicancer early-detection testing,” Mr. Royse told an FDA advisory committee last fall. “The longer the FDA waits, the more people are going to die. It’s that simple.”

Even as India has expanded defense ties with the United States and doubled bilateral trade over the past decade, to about $130 billion in goods alone, it has resisted American pressure to reconsider its strong relations with Russia. India has deepened connections with Europe and the Middle East, too; trade with the United Arab Emirates alone has reached $85 billion.

While India remains wary of becoming a pawn in the West’s fight with Beijing, and has not forgotten its frosty history with the United States, China has become an unavoidable focus after being a secondary threat for much of modern Indian history.

India’s socialist founding prime minister was accommodating of Communist China, but the bonhomie was shattered by a monthlong war in 1962 that left thousands dead. The relationship began to normalize in the 1980s even as incursions continued, and open channels of communication kept tensions down and elevated trade.

The situation changed in the years before Mr. Modi took office, she said. As its economy soared, China began flexing its muscles — investing heavily in its Belt and Road infrastructure initiative, which India saw as threatening its security and spheres of influence, and moving more aggressively on its borders and in the Indian Ocean.

As prime minister, he did not allow the embarrassment of the Chinese incursion in 2014 to dampen his red-carpet welcome to Mr. Xi. His subtle message — a warning that “a little toothache can paralyze the entire body” — carried the hope that Mr. Xi would come around.

That hope ended with the deadly 2020 clash in Eastern Ladakh. Now, it is clear that New Delhi is resigned to a long-term threat from China, a shift evident in Mr. Modi’s push for road and tunnel construction in border areas to support a large troop presence.

The big question, then, is how do you bring about widespread, deep-seated cultural change within the organs of government and institutions connected to it?

Can you legislate to change a culture?

Sir Brian Langstaff, the report author, thinks you might be able to – or at least make a start.

He suggests there should be a so-called duty of candour demanded in law for civil servants and others.It would then become a legal obligation to speak up, rather than a cultural expectation to shut up.Whistleblowing would be mandatory.But will it happen, and will it make any difference?

Still others believe that the advent of civil rights laws created, in essence, a second Constitution entirely, one that privileges group identity over individual liberty.

Protestant Christian nationalists tend to have a higher regard for the American founding, but they believe it’s been corrupted. They claim that the 1787 Constitution is essentially dead, replaced by progressive power politics that have destroyed constitutional government.

Catholic post-liberals believe that liberal democracy itself is problematic. According to their critique, the Constitution’s emphasis on individual liberty “atomizes” American life and degrades the traditional institutions of church and family that sustain human flourishing.

The original Constitution and Bill of Rights, while a tremendous advance from the Articles of Confederation, suffered from a singular, near-fatal flaw. They protected Americans from federal tyranny, but they also left states free to oppress American citizens in the most horrific ways

if your ultimate aim is the destruction of your political enemies, then the Constitution does indeed stand in your way.

Right-wing constitutional critics do get one thing right: The 1787 Constitution is mostly gone, and America’s constitutional structure is substantially different from the way it was at the founding. But that’s a good thing

its guardrails against tyranny remain vital and relevant today.

Individual states ratified their own constitutions that often purported to protect individual liberty, at least for some citizens, but states were also often violently repressive and fundamentally authoritarian.

The criminal justice system could be its own special form of hell. Indigent criminal defendants lacked lawyers, prison conditions were often brutal at a level that would shock the modern conscience, and local law enforcement officers had no real constitutional constraints on their ability to search American citizens and seize their property.

Through much of American history, various American states protected slavery, enforced Jim Crow, suppressed voting rights, blocked free speech, and established state churches.

As a result, if you were traditionally part of the local ruling class — a white Protestant in the South, like me — you experienced much of American history as a kind of golden era of power and control.

The Civil War Amendments changed everything. The combination of the 13th, 14th, and 15th Amendments ended slavery once and for all, extended the reach of the Bill of Rights to protect against government actions at every level, and expanded voting rights.

But all of this took time. The end of Reconstruction and the South’s “massive resistance” to desegregation delayed the quest for justice.

decades of litigation, activism and political reform have yielded a reality in which contemporary Americans enjoy greater protection for the most fundamental civil liberties than any generation that came before.

And those who believe that the civil rights movement impaired individual liberty have to reckon with the truth that Americans enjoy greater freedom from both discrimination and censorship than they did before the movement began.

So why are parts of the right so discontent? The answer lies in the difference between power and liberty

One of the most important stories of the last century — from the moment the Supreme Court applied the First Amendment to state power in 1925, until the present day — is the way in which white Protestants lost power but gained liberty. Many millions are unhappy with the exchange.

Consider the state of the law a century ago. Until the expansion of the Bill of Rights (called “incorporation”) to apply to the states, if you controlled your state and wanted to destroy your enemies, you could oppress them to a remarkable degree. You could deprive them of free speech, you could deprive them of due process, you could force them to pray and read state-approved versions of the Bible.

The argument that the Constitution is failing is just as mistaken as the argument that the economy is failing, but it’s politically and culturally more dangerous

Powerful people often experience their power as a kind of freedom. A king can feel perfectly free to do what he wants, for example, but that’s not the same thing as liberty.

Looked at properly, liberty is the doctrine that defies power. It’s liberty that enables us to exercise our rights.

Think of the difference between power and liberty like this — power gives the powerful freedom of action. Liberty, by contrast, protects your freedom of action from the powerful.

At their core, right-wing attacks on the modern Constitution are an attack on liberty for the sake of power.

An entire class of Americans looks back at decades past and has no memory (or pretends to have no memory) of marginalization and oppression. They could do what they wanted, when they wanted and to whom they wanted.

Now they don’t have that same control

Muslims, Sikhs, Jews, Buddhists and atheists all approach the public square with the same liberties. Drag queens have the same free speech rights as pastors, and many Americans are livid as a result.

when a movement starts to believe that America is in a state of economic crisis, criminal chaos and constitutional collapse, then you can start to see the seeds for revolutionary violence and profound political instability. They believe we live in desperate times, and they turn to desperate measures.

“You shall know the truth, and the truth shall set you free.” So much American angst and anger right now is rooted in falsehoods. But the truth can indeed set us free from the rage that tempts American hearts toward tyranny.