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Recent Developments and Recurring Dilemmas in Cancer Screening: Colon, Lung, Thyroid

Cancer screening - lead time bias small

Screen detection and tumor growth rates. Cancers have different growth rates, which determine their potential to be detected by screening. Tumor A remains microscopic and undetectable by current technology (although more sensitive tests in the future might render it detectable). Tumor B eventually becomes detectable by screening (*), but its growth rate is so slow that it will not cause symptoms during the life of the individual; its detection will result in overdiagnosis. Tumor C is capable of metastasizing, but it grows slowly enough that it can be detected by screening (*); for some, this early detection will result in survival. Tumor D grows very quickly and therefore is usually not detected by screening. This will present as an interval cancer (i.e. detected clinically in the interval between screening examinations) and has a particularly poor prognosis. Note that of the four tumor types, only Tumor C has the potential to benefit from screening. Red dashed lines represent the natural history of a tumor in the absence of detection by screening. (Figure 1 from Gates, 2014).

A new stool DNA test was recently approved by the FDA for colon cancer screening. My first reaction was “Yay! I hope it’s good enough to replace all those unpleasant, expensive screening colonoscopies.” But of course, things are never that simple. I wanted to explain the new test for our readers; but before I could start writing, some other issues in cancer screening barged in and demanded to be included. They exemplify the dilemmas we face with every screening test. We have covered these issues before, but mainly in reference to mammography and prostate (PSA) screening. My article morphed into a CLT sandwich: colon, lung, and thyroid cancer screening.

The current issue of American Family Physician has a great article on cancer screening. It uses lucid graphics to illustrate lead time bias, length time bias, and overdiagnosis bias, as well the effect of varying tumor growth rates on screening success rates, all concepts that have been covered by Dr. Gorski here. Briefly, screening may do more harm than good if:

  1. It detects cancerous cells that never would have developed into invasive cancers or harmed the patient in any way;
  2. Early diagnosis and treatment decrease quality of life without reducing death rates; or
  3. The test falsely indicates cancer in patients who don’t have it or fails to indicate cancer in some who do. (more…)

Posted in: Cancer, Diagnostic tests & procedures

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Ontario fails to protect the life of a First Nations girl with cancer

First Nations

A few weeks ago, Steve Novella invited me on his podcast, The Skeptics’ Guide to the Universe, to discuss a cancer case that has been in the news for several months now. The case was about an 11-year-old girl with leukemia who is a member of Canada’s largest aboriginal community. Steve wrote about this case nearly a month ago. Basically, the girl’s parents are fighting for the right to use “natural healing” on their daughter after they had stopped her chemotherapy in August because of side effects. It is a profoundly disturbing case, just as all the other cases I’ve discussed in which children’s lives are sacrificed at the altar of belief in alternative medicine, but this one has a twist that I don’t recall having dealt with before: The girl’s status as part of the First Nations. Sadly, on Friday, Ontario Court Justice Gethin Edward has ruled that the parents can let their daughter die.

The First Nations consist of various Aboriginal peoples in Canada who are neither Inuit nor Métis. There are currently more than 630 recognized First Nations governments or bands in Canada, half of which are located in Ontario and British Columbia. This girl lives in Ontario, which is basically just next door to Detroit, just across the Detroit River. Unlike previous cases of minors who refuse chemotherapy or whose parents refuse chemotherapy for them that I’ve discussed, such as Sarah Hershberger, an Amish girl whose parents were taken to court by authorities in Medina County, Ohio at the behest of Akron General Hospital, where she had been treated because they stopped her chemotherapy for lymphoblastic lymphoma in favor of “natural healing,” or Daniel Hauser, a 13-year-old boy from Minnesota with Hodgkin’s lymphoma whose parents, in particular his mother, refused chemotherapy after starting his chemotherapy and suffering side effects, there’s very little information about this girl because of Canadian privacy laws. I do not know her name. I do not know anything about her case except that she has acute lymphoblastic leukemia, that she started treatment but her parents withdrew her because of side effects.
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Posted in: Cancer, Faith Healing & Spirituality, Politics and Regulation, Religion

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Eminent Harvard psychologist, mother of positive psychology, New Age quack?

Eminent Harvard psychologist, mother of positive psychology, New Age quack?

Be less curious about people and more curious about ideas.
– Marie Curie’s advice to journalists

langer cbs this

Harvard psychologist Ellen Langer was on CBS This Morning News explaining plans for a psychosocial intervention study with women with Stage IV metastatic breast cancer. The project would attempt to shrink women’s tumors by shifting their mental perspective back to before they were diagnosed.
Seeing her on TV unsettled me because I had just supplied a journalist with quotes for his article in the New York Times about Langer. I hadn’t been following her recently. Instead I focused on her now-famous study from the 70s. Langer had claimed that giving nursing home residents a plant for which they were responsible cut their mortality by half (the nursing home residents, not the plant), compared to residents whose plants were attended by staff. The paper continues to get uncritical coverage in the media and in introductory psychology texts.

I looked up the Timesarticle after seeing CBS This Morning News, and it accurately quoted me:
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Posted in: Cancer, Clinical Trials, Medical Ethics

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Blaming breast cancer on autism

From the Wikimedia Commons, originally posted by Flickr user Alex E. Proimos (link)

From the Wikimedia Commons, originally posted by Flickr user Alex E. Proimos (link)

Gayle DeLong has been diagnosed with what she refers to as “autism-induced breast cancer”. She’s even given it an abbreviation, AIBC. Unfortunately, as you might be able to tell by the name she’s given her breast cancer, she is also showing signs of falling into the same errors in thinking with respect to her breast cancer as she clearly has with respect to autism. As a breast cancer surgeon, regardless of my personal opinion of DeLong’s anti-vaccine beliefs, I can only hope that she comes to her senses and undergoes science-based treatment, but I fear she will not, as you will see. Her brief post announcing her diagnosis and blaming it on autism, however, does provide what I like to call a “teachable moment” about cancer.

We’ve met DeLong before on this blog. For instance, she published an execrably bad study that—of course!—tried to link vaccine to autism and failed miserably, despite doing some amazing contortions of analysis, combining diagnoses willy-nilly, all in the service of the discredited vaccine-autism hypothesis. As I said at the time, it just goes to show that someone who is an associate professor of economics and finance shouldn’t be doing epidemiological research. As I also described at the time, if the sorts of analytical techniques she used in her study are acceptable in the world of economics and finance, no wonder our economy has been so screwed up for so long. Another time, DeLong wrote a broadside against the regulatory machinery that oversees vaccine development and safety that was full of the usual antivaccine misinformation, tropes, and pseudoscience and hugely exaggerated perceived “conflicts of interest” among the various parties.
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Posted in: Cancer, Neuroscience/Mental Health, Vaccines

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Using the fear of Ebola to promote the placebo legislation that is “right to try”

rick-snyder

Perhaps the most pervasive medical conspiracy theory of all involves stories that there exist out there all sorts of fantastic cures for cancer and other deadly diseases but you can’t have them because (1) “they” don’t want you to know about them (as I like to call it, the Kevin Trudeau approach) and/or (2) the evil jackbooted thugs of the FDA are so close-minded and blinded by science that they crush any attempt to market such drugs and, under the most charitable assessment under this myth, dramatically slow down the approval of such cures. The first version usually involves “natural” cures or various other alternative medicine cures that are being “suppressed” by the FDA, FTC, state medical boards, and various other entities, usually at the behest of their pharma overlords. The second version is less extreme but no less fantasy-based. It tends to be tightly associated with libertarian and small government fantasists and a loose movement in medicine with similar beliefs known as the “health freedom” movement, whose members posit that, if only the heavy hand of government were removed and the jack-booted thugs of the FDA reined in, free market innovation would flourish, and the cures so long suppressed by an overweening and oppressive regulatory apparatus would burst the floodgates and these cures, long held back by the dam of the FDA, would flow to the people. (Funny how it didn’t work out that way before the Pure Food and Drug Act of 1906.) Of course, I can’t help but note that in general, in this latter idea, these fantastical benefits seem to be reserved only for those who have the cash, because, well, the free market fixes everything. At least, that seems to be the belief system at the heart of many of these conspiracy theories.

The idea that the FDA is keeping cures from desperate terminally ill people, either intentionally or unintentionally, through its insistence on a rigorous, science-based approval process in which drugs are taken through preclinical work, phase 1, phase 2, and phase 3 testing before approval is one of the major driving beliefs commonly used to justify so-called “right-to-try” laws. These bills have been infiltrating state houses like so much kudzu, and the Ebola outbreak has only added fuel to the fire based on the accelerated use of ZMapp, a humanized monoclonal antibody against the Ebola virus, in some patients even though it hadn’t been tested in humans yet (more on that later). Already four of these laws have been passed (in Colorado, Missouri, Louisiana, and now Michigan) with a referendum in Arizona almost certain to pass next week to bring the total to five states with such laws. Basically, these laws, as I’ve described, claim to allow access to experimental drugs to terminally ill patients with a couple of major conditions: First, that the drug has passed phase I clinical trials and second that the patient has exhausted all approved therapies. As I’ve explained before more than once, first when the law hit the news big time in Arizona and then when a right-to-try bill was introduced into the legislature here in Michigan, they do nothing of the sort and are being promoted based on a huge amount of misinformation detailed in the links earlier. First, having passed phase 1 does not mean a drug is safe, but right-to-try advocates, particularly the main group spearheading these laws, the Goldwater Institute, make that claim incessantly. Second, they vastly overstate the likelihood that a given experimental drug will help a given patient. The list goes on.
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Posted in: Cancer, Clinical Trials, Pharmaceuticals, Politics and Regulation

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“Quackery: A $10 Billion Scandal”

Rubber ducky
Who would you guess authored a 250-page report which begins with this Preface?

This report marks the culmination of an intensive four-year review of quackery and its impact on the elderly. . . As this report details, quackery has traveled far from the day of the pitchman and covered wagon to emerge as big business. Those who orchestrate and profit from the sale and promotion of these useless and often harmful “health” products are no longer quaint and comical figures. They are well organized, sophisticated and persistent. [We estimate] the cost of quackery – the promotion and sale of useless remedies promising relief from chronic and critical health conditions – exceeds $10 billion a year. The costs of quackery in human terms, measured in disillusion, pain, relief forsaken or postponed because of reliance on unproven methods, is more difficult to measure, but nonetheless real. All too frequently, the purchaser has paid with his life. While the impact of quackery on our lives has been increasing and growing in sophistication, public and private efforts designed to address and control this problem have diminished, been redirected or disbanded.

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Posted in: Acupuncture, Cancer, Diagnostic tests & procedures, Health Fraud, Herbs & Supplements, Politics and Regulation

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Breast cancer myths: No, antiperspirants do not cause breast cancer

antiperspirantbreastcancer

Four weeks ago, I wrote a post in which I explained why wearing a bra does not cause breast cancer. After I had finished the post, it occurred to me that I should have saved that post for now, given that October is Breast Cancer Awareness Month. The reason is that, like clockwork, pretty much every year around this time articles touting various myths about breast cancer will go viral, circulating on social media like Facebook, Twitter, Pinterest, and Tumblr like so many giant spider-microbes on the moon on Saturday. Sometimes, they’re new articles. Sometimes they’re old articles that, like the killer at the end of a slasher film, seem to have died but always come back for another attack, if not immediately, then when the next movie comes out.

So I thought that this October I should take at least a couple of them on, although I can’t guarantee that I’ll stick to the topic of breast cancer myths for the whole month. After all, our “atavistic oncology” crank (you remember him, don’t you?) is agitating in the comments and e-mailing his latest “challenge” to my dean, other universities, and me. It was almost enough for me to put this post on hold for a week and respond to our insistent little friend’s latest “evidence,” but for now I’ll just tell Dr. Frank Arguello, “Be very careful what you ask for. You might just get it.” Maybe next week. Or maybe on my not-so-super-secret other blog. Or maybe never. Because Dr. Arguello has officially begun to bore me.

In the meantime, I’m going to stick with the original plan, at least for now.

So, first up this week is a myth that I can’t believe that I haven’t covered in depth sometime during the nearly seven years of this blog’s existence, other than in passing a couple of times, even though it’s a topic that deserves its own post. I’m referring to the claim that antiperspirants cause breast cancer. I bet you’ve seen articles like this oldie but not so goodie from über-quack Joe Mercola entitled “Are Aluminum-Containing Antiperspirants Contributing To Breast Cancer In Women?” or this older and even moldier article from seven years ago entitled “Why women should avoid using anti-perspirants that could cause breast cancer” or this one from last year entitled “Attention Deodorant Users: New Studies Link Aluminum To Breast Cancer“. Surprisingly, I haven’t found that many from this year yet. (Maybe the Ebola scare is distracting the usual suspects and diverting their efforts.) The same ones, however, keep reappearing every year, and they’re all based on the same sorts of claims and the same studies. So let’s dig in, shall we? (more…)

Posted in: Cancer, Epidemiology, Public Health, Science and the Media

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Yahoo News spews NaturalNews anti-vaccine (and other) propaganda

Yahoo News appears to have confused NaturalNews with actual news. It’s not. NaturalNews is the in-house propaganda organ for Mike Adams, whom I’ll introduce in a minute (although he needs no introduction for most readers here). A couple of recent examples:

 

 

A recycled story, over a year old, from NaturalNews, appearing on Yahoo News last week. It starts out as a fairly straightforward report of the Japanese’s governments suspending its recommendation if favor of the HPV vaccine pending further research, although government health officials were still standing by the vaccine’s safety. Actually, Medscape reported that the actual rate was 12.8 serious adverse side effects reported per 1 million doses, a fact not revealed in the NaturalNews story. These effects were correlated with the vaccine; there is no evidence of causation.

After this rather tame start, NaturalNews cranks it up to 11 and beyond, as David Gorski would say. Governments which still recommend HPV vaccinations “remain under the thumb of Merck’s vaccinations spell” even though Merck is “an organization of murderers and thieves.” A scary list of adverse events are described as “side effects of Guardasil” even though causation has not been shown.

 

 

Two days ago there was an “ongoing debate”? There is no ongoing debate about “whether or not vaccines cause autism” because there never was any credible evidence that vaccines cause autism and there still isn’t.

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Posted in: Cancer, Critical Thinking, Health Fraud, Herbs & Supplements, Homeopathy, Nutrition, Pharmaceuticals, Science and the Media, Vaccines

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Announcement: “Integrative oncology” – Really the best of both worlds?

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One of our goals here at SBM is to do more than just blog about the issues of science and pseudoscience in medicine that are our raison d’être. We also want to publish our science-based critiques in the peer-reviewed medical literature. Our first crack at this was an article by Steve Novella and myself published last month in Trends In Molecular Medicine entitled “Clinical trials of integrative medicine: testing whether magic works?” Even better, thanks to a press release and how the editors made the article free to all, it garnered more social media attention than any article previously published in TMM, and the editor has informed me that it “shot straight to the top of TMM’s ‘Most read’ article list and I anticipate it staying there for quite some time.” For this, Steve and I thank you, our readers, and those of you who spread the news. We’re hoping that this success garners more offers to write review and commentary articles for the peer-reviewed literature about topics near and dear to us.

Now, I’m happy to announce another commentary in the peer-reviewed literature. It’s an article I wrote for Nature Reviews Cancer that just appeared online yesterday entitled “Integrative oncology: Really the best of both worlds?” I must say, I’m quite proud of this one, and it is a big deal, hopefully to more people than just me. If you look up the impact factor for NRC, you’ll see it’s around 35, which is between The Lancet and JAMA.
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Posted in: Announcements, Cancer

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Medicine past, present, and future: Star Trek versus Dr. Kildare and The Knick

mccoyvs20thcen

I’ve been a big Star Trek fan ever since I first discovered reruns of the original Star Trek episodes in the 1970s, having been too young (but not by much!) to have caught the show during its original 1966-1969 run. True, my interest waxed and waned through the years—for instance, I loved Star Trek: The Next Generation, while Star Trek: Enterprise and Star Trek: Voyager pretty much left me cold—but even now I still find myself liking the rebooted movie series. In the original series, my favorite characters tended to alternate between Spock, the Vulcan first officer and science officer on the Enterprise, and Dr. Leonard “Bones” McCoy, the ship’s chief medical officer. I sometimes wonder if my love of these two characters had anything to do with my becoming a doctor and researcher myself. It probably did.

One aspect of all the Trek shows that always interested me was its portrayal of medicine in the 23rd and 24th centuries. After all, what doctor wouldn’t like to have a device like the tricorder that he could wave over the patient and come up with an instant diagnosis and course of treatment? Who knew, of course, that nearly 50 years after the first Trek episode first aired, we would have technology that makes the communicators on the original series (TOS, for those Trek non-fans) look primitive and large by comparison and that we’d be well on the way to developing devices that can do some of what tricorders did on the show. Throughout all the shows and movies, the medical technology of a few hundred years in the future is portrayed as vastly superior to what we have now, with 20th century medicine at times denigrated by “Bones” McCoy and other Star Fleet medical personnel as barbaric quackery.

A confluence of events and media led me to want to explore a couple of questions. First, which procedures that we consider state-of-the-art science-based medicine will be considered “barbaric” 50 or 100 years from now? Second, is the contempt expressed for the medicine of the past (e.g., by “Bones” McCoy) justified? These are questions that I’ll explore a bit with the help of the Star Trek universe, a recent new cable television drama series, and a couple of articles that appeared on medical sites as a result of the premier of that series.
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Posted in: Cancer, History, Science and the Media, Surgical Procedures

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