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Steve Jobs’ medical reality distortion field

As I pointed out in my previous post about Steve Jobs, I’m a bit of an Apple fan boy. A housemate of mine got the very first Mac way back in 1984, and ever since I bought my first computer that was mine and mine alone back in 1991 (a Mac LC), I’ve used nothing but Macintosh computers, except when compelled to use Windows machines by work—and even then under protest. Indeed, as I searched for jobs at various times in my life, I asked myself whether I could accept a job at an institution that didn’t permit me to have a Mac in my office, such as the V.A. Fortunately, I never had to make that choice. All of this explains why I paid a lot of attention to Steve Jobs and also why his death saddened me and, relevant to this blog, the clinical history of the cancer that killed him fascinates me.

It’s often been said that there was a sort of “reality distortion field” around Steve Jobs. It was a part joking, part derogatory, part admiring term applied to Jobs’ talent for persuasion in which, through a combination of personal charisma, bravado, hyperbole, marketing, and persistence, Jobs was able to persuade almost anyone, even developers and engineers, of almost anything. In particular, it referred to his ability to convince so many people that each new Apple product was the greatest thing ever, even when that product had obvious flaws. Unfortunately, as more news comes out about how Steve Jobs initially dealt with his diagnosis of a neuroendocrine tumor of the pancreas (specifically, an insulinoma) back in 2003 and 2004, it’s become apparent that Jobs had his own medical reality distortion field, at least in the beginning right after his diagnosis of a rare form of pancreatic cancer, that allowed him to come to think that he might be able to reverse his cancer with diet plus various “alternative” modalities.

In the immediate aftermath of Steve Jobs’ death, I summarized the facts about Jobs’ case that were known at the time. In particular, I took issue with the claims of a skeptic that “alternative medicine killed Steve Jobs.” At the time, I pointed out that, although it was very clear that Steve Jobs did himself no favors by delaying his initial surgery for nine months after his initial diagnosis, we do not have sufficient information to know what his clinical situation was and therefore how much, if at all, he decreased his odds of survival by not undergoing surgery expeditiously. To recap: Did Steve Jobs harm himself by trying diet and alternative medicine first? Quite possibly. Did alternative medicine kill him? As I’ve argued before, that’s impossible to say, and any skeptic who dogmatically makes such an argument has taken what we known beyond what can be supported. Regular readers know that when I see a story that looks as though “alternative medicine” directly contributed to the death of someone, I usually pull no punches, but in this case I had a hard time being so definitive because the unknowns are too many, with all due respect to Ramzi Amri, a Research Associate at Harvard Medical School who in my opinion also went too far. I did, however, point out that I’m always open to changing my opinion if new evidence comes in. Jobs was always incredibly secretive about his medical condition, so much so that it didn’t even come out in the press until after it had happened that he had undergone a liver transplant in 2008 for metastatic insulinoma in his liver, just as his cancer diagnosis in 2003 remained secret for 9 months, not being revealed until he sent an e-mail to Apple employees announcing that he had undergone surgery.

It turns out that, with the imminent release of a major biography of Steve Jobs, more information is finally trickling out about his medical history. For instance, Jobs’ biographer Walter Isaacson is going to appear on 60 Minutes this Sunday, and apparently he is going to say this:
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Posted in: Cancer, Nutrition, Science and the Media

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Steve Jobs’ cancer and pushing the limits of science-based medicine

Editor’s note: There is an update to this post.

An Apple fanboy contemplates computers and mortality

I’m a bit of an Apple fanboy and admit it freely. My history with Apple products goes way back to the early 1980s, when one of my housemates at college had an Apple IIe, which I would sometimes use for writing, gaming, and various other applications. Indeed, I remember one of the first “bloody” battle games for the IIe. It was called The Bilestoad and involved either taking on the computer or another opponent with battle axes in combat that basically involved hacking each other’s limbs off, complete with chunky, low-resolution blood and gore. (You youngsters out there will be highly amused at the gameplay here.) Of course, it’s amazing that nothing’s changed when it comes to computer games except the quality of graphics. Be that as it may, this same roommate was one of the first students to get a hold of the new Macintosh when it was released in early 1984. I really liked it right from the start but only got to play with it occasionally for a few months. After using a Macintosh SE to do a research project during my last year of medical school, I have used the Macintosh platform more or less exclusively, and the first computer I purchased with my own money was a Mac LC back in 1990 or 1991. Today, I have multiple Apple products, including my MacBook Air, my iPhone, and my old school iPod Classic, among others. Oddly enough, I do not have an iPad, but that’s probably only a matter of time, awaiting software that lets me do actual work on it.

All of this is my typical long-winded way of explaining why I was immensely saddened when I learned of Steve Jobs’ death last week. Ever since speculation started to swirl about his health back 2004 and then again in 2008, capped off by the revelation that he had undergone a liver transplant for a rare form of pancreatic cancer in 2009, I feared the worst. Last week, the end finally came. However, there is much to learn relevant to the themes of this blog in examining the strange and unusual case of Steve Jobs. Now, after his death five days ago, which coincidentally came a mere day after the launch of iCloud and the iPhone 4S, it occurs to me that it would be worthwhile to try to synthesize what we know about Jobs’ battle with cancer and then to discuss the use (and misuse) of his story. Of course, this is a difficult thing to do because Jobs was notoriously secretive and I can only rely on what has been published in the media, some of which is conflicting and all of which lacks sufficient detail to come to any definite conclusions, but I will try, hoping that the upcoming release of his biography by Walter Isaacson in couple of weeks might answer some of the questions I still have remaining, given that Isaacson followed Jobs through his battle with cancer and was given unprecedented access to Jobs and those close to him.

In the meantime, I speculate. I hope my speculations are sufficiently educated as not to be shown to be completely wrong, but they are speculations nonetheless.
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Posted in: Cancer, Medical Ethics, Nutrition, Science and the Media, Surgical Procedures

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Chemotherapy doesn’t work? Not so fast…

“CHEMOTHERAPY DOESN’T WORK!!!!!”

“CHEMOTHERAPY IS POISON!!!!”

“CHEMOTHERAPY WILL KILL YOU!!!!”

I’ve lost count of how many times I’ve come across statements like the ones above, often in all caps, quite frequently with more than one exclamation point, on the websites of “natural healers,” purveyors of “alternative medicine.” In fact, if you Google “chemotherapy doesn’t work,” “chemotherapy is poison,” or “chemotherapy kills,” you’ll get thousands upon thousands of hits. In the case of “chemotherapy kills,” Google will even start autofilling it to read “chemotherapy kills more than it saves.” The vast majority of the hits from these searches usually come from websites hostile to science-based medicine. Examples include Mercola.com, the website of “alternative medicine entrepreneur” Dr. Joe Mercola and NaturalNews.com, the website of Mike Adams, where you will find cartoons like this one, which likens the administration of chemotherapy to a Nazi death camp:

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Posted in: Cancer, Science and Medicine

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Seven Deadly Medical Hypotheses revisited

Back in February, Mark Crislip and I both deconstructed an article written by Dr. Reynold Spector that appeared in the March/April issue of Skeptical Inquirer (SI), the flagship publication for the Committee for Skeptical Inquiry (CSI). The article was entitled Seven Deadly Medical Hypotheses, and, contrary to the usual standard of articles published in SI, it used a panoply of spin, bad arguments, and, yes, misinformation to paint a picture of seven horrifically deadly “medical hypotheses,” most of which, even if the reader accepted Dr. Spector’s arguments at face value in a worst case scenario, weren’t actually all that deadly at all, with the alleged deadliness of the others being in dispute. In addition, Dr. Spector painted a picture of medical science that is not nearly rigorous enough. While we at SBM would probably agree that much of medical science is insufficiently rigorous, given how so-called “complementary and alternative medicine” (CAM) or “integrative medicine” (IM) has found a prominent place in medical practice in all too many academic and private medical centers, Dr. Spector got it so wrong that he wasn’t even wrong when he conflated preliminary, hypothesis-generating studies with the big, randomized, phase III clinical trials necessary to achieve FDA approval for a new drug or device. This latest article by Dr. Spector seemed to be of a piece with his previous article in the January/February 2010 issue of SI entitled The War on Cancer A Progress Report for Skeptics, which was so negative in its assessment of scientific progress against cancer that for a moment I was wondering if I were reading NaturalNews.com or Mercola.com.

Unfortunately, Seven Deadly Medical Hypotheses itself is not yet online on the CSI website; so readers without a subscription to SI cannot at the present time judge for themselves whether Mark and I were too harsh on Dr. Spector, but our criticisms, along with that of SBM partner-in-crime Harriet Hall, did have an impact. Seemingly genuinely stunned at the level of criticism leveled at an article published in SI, SI’s editor Kendrick Frazier, to his credit, invited several responses to Dr. Spector’s article, which Harriet Hall, Mark Crislip, Carol Tavris, Avrum Bluming, and I eagerly provided. These letters were originally scheduled to be published a couple of issues ago, along with Dr. Spector’s response. Unfortunately, publishing in dead tree media being what it is, Harriet Hall and I were disappointed to find that the latest issue of SI still didn’t contain our rebuttals. Fortunately, Mr. Frazier has posted this material online for your edification, although, again, I wish he had also published the original article as well.
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Posted in: Cancer, Clinical Trials, Science and Medicine

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Dummy Medicines, Dummy Doctors, and a Dummy Degree, Part 1: a Curious Editorial Choice for the New England Journal of Medicine

Background

This post concerns the recent article in the New England Journal of Medicine (NEJM) titled “Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma.” It was ably reviewed by Dr. Gorski on Monday, so I will merely summarize its findings: of the three interventions used—inhaled albuterol (a bronchodilator), a placebo inhaler designed to mimic albuterol, or ‘sham acupuncture’—only albuterol resulted in a clinically important improvement of bronchial airflow; for that outcome the two sham treatments were equivalent to “no intervention.” For all three interventions, however, self-reported improvements were substantial and were much greater than self-reported improvements after “no intervention.” In other words, dummy treatments made the subjects (report that they) feel better, whereas real medicine not only made them feel better but actually made them better.

Before proceeding, let me offer a couple of caveats. First, the word ”doctors” in the flippant title of this post refers mainly to two individuals: Daniel Moerman, PhD, the anthropologist who wrote the accompanying editorial, and Ted Kaptchuk, the Senior Author of the trial report. It does not refer to any of the other authors of the report. Second, I have no quarrel with the trial itself, which was quite good, or with the NEJM having published it, or even with most of the language in the article, save for the “spin” that Dr. Gorski has already discussed.

My quarrels are the same as those expressed by Drs. Gorski and Novella, and by all of us on the Placebo Panel at TAM. This post and the next will develop some of those points by considering the roles and opinions of Moerman and Kaptchuk, respectively.

A True Story

Late one night during the 1960s a friend and I, already in a cannabis-induced fog, wandered into a house that had been rented by one of his friends. There were about 8-10 ‘freaks’ there (the term was laudatory at the time); I didn’t know any of them. The air was thick with smoke of at least two varieties. After an uncertain interval I became aware of a guy who was having trouble breathing. He was sitting bolt upright in a chair, his hands on his knees, his mouth open, making wheezing sounds. He took short noisy breaths in, followed by what seemed to be very long breaths out, as though he was breathing through a straw. You could hear the wheezing in both directions. Others had also noticed that he was in distress; they tried to be helpful (“hey, man, ya want some water or somethin’?”), but he just shook his head. He couldn’t talk. My friend, who had asthma himself, announced that this guy was having an asthma attack and asked if he or anyone else had any asthma medicine. No one did.

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Posted in: Acupuncture, Cancer, Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Health Fraud, Homeopathy, Medical Academia, Medical Ethics, Naturopathy, Pharmaceuticals, Public Health, Science and Medicine, Science and the Media

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Virtual Colonoscopy Can Be Hazardous to Your Health

The US Preventive Services Task Force (USPSTF) recommends that everyone aged 50-75 be screened for colon cancer with any one of three options: colonoscopy every 10 years, flexible sigmoidoscopy every 5 years, or fecal occult blood testing (FOBT) every year. Conventional colonoscopy is considered the “gold standard” since it allows for direct detection and biopsy of early cancers and removal of precancerous polyps. It involves passing a long colonoscope via the rectum through the full length of the colon and is also known as optical or visual colonoscopy. A newer and less invasive alternative, virtual colonoscopy or CT colonography, is being promoted by some as the test of choice. Others disagree. One area of controversy is that CTs frequently find “incidentalomas” that require further investigation. An article in the journal Radiology highlights this problem, describing “the clinical drama that follows screening or diagnostic tests.” (more…)

Posted in: Cancer, General

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Failed Flaxseed and Bad News Brownies

Well, it’s been a tough month for herbs since my last monthly soiree here at SBM.

Just last week at the American Society for Clinical Oncology (ASCO) meeting, a group out of the Mayo Clinic presented data from a study showing that a well-characterized flaxseed extract was ineffective against hot flashes in postmenopausal women. But as Steve Novella noted here earlier this week, negative clinical trials data on supplements rarely influence the behavior of those who continue to advocate for their herbal use.

Flaxseed, known to contain phytoestrogen compounds such as secoisolariciresinol diglucoside (SDG) and enterolactone, has been purported to relieve hot flashes.

But I think the hypothesis was flawed in the first place: while these compounds bind the estrogen receptor, they have largely been shown to be estrogen receptor modulators that act in a negative manner. Work from the group of Dr. Lillian Thompson at the University of Toronto has repeatedly shown in an estrogen-dependent animal model of human breast cancer that flaxseed components act in a predominantly anti-estrogenic manner. One might suspect that hot flashes would be made worse by flaxseed, although this was not the case in the study presented as ASCO.

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Posted in: Cancer, Clinical Trials, Herbs & Supplements

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Hash Oil for Gliomas? What Would You Do?

A friend asked me to look at the evidence for hash oil as a treatment for glioma. His teenage daughter was recently diagnosed with brain cancer: a grade 3 anaplastic ependymoma. It recurred very rapidly after surgery and radiotherapy and the latest tissue diagnosis shows an aggressive grade IV glioma. Her prognosis is not good. No further attempts at curative therapy are indicated; the oncologist prescribed only palliative therapy with temozolomide. Her father, who had recently lost his wife to cancer (breast cancer metastatic to lungs and brain), was understandably devastated. As he puts it, he remains “focused on the belief that just maybe a cure can be found.” He stumbled on what he calls “earth-shattering news” regarding hash oil. He and his friends established a private wiki website which they are constantly updating with information about THC (tetrahydrocannabinol, the active ingredient in marijuana and hash) and other possible cancer cures: everything from curcumin to diet. He asked me to look at the information he has accumulated. He said

I hope to convince you in the same way I have done with my daughter’s GPs and her neuro-oncologist at BC Children’s Hospital.

The oncologist was not exactly convinced. He didn’t say he thought hash oil was likely to work; he only said it would be reasonable to try it as a complementary therapy. He said

the data published so far appears very preliminary, most of its potential effectiveness in vivo so far appears in colonic disease, having said that there doesn’t appear to be any obvious down side as a complementary therapy and may have synergistic effect, so may be reasonable as add on to temodal if she tolerates it

I wasn’t convinced either.

I will discuss two issues here:

  1. What does the evidence say about gliomas and hash oil?
  2. When is it reasonable to try an unproven treatment as a last resort?

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Posted in: Cancer, Herbs & Supplements

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Hope and hype in genomics and “personalized medicine”

“Personalized medicine.” You’ve probably heard the term. It’s a bit of a buzzword these days and refers to a vision of future medicine in which therapies are much more tightly tailored to individual patients than they currently are. That’s not to say that as physicians we haven’t practiced personalized medicine before; certainly we have. However it has only been in the last decade or so that our understanding of genomics, systems biology, and cell signaling have evolved to the point where the vision of personalized medicine based on each patient’s genome and biology might be achievable within my lifetime.

I was thinking about personalized medicine recently because of the confluence of several events. First, I remembered a post I wrote late last year about integrating patient values and experience into the decision process regarding treatment plans. Second, a couple of months ago, Skeptical Inquirer published an execrably nihilistic article by Dr. Reynold Spector in Skeptical Inquirer in which he declared personalized medicine to be one of his “seven deadly medical hypotheses,” even though he never actually demonstrated why it is deadly or that it’s even really a hypothesis. Come to think of it, with maybe–and I’m being very generous here–one exception, that pretty much describes all of Dr. Spector’s “seven deadly medical hypotheses”: Each is either not a hypothesis, not deadly, or is neither of the two. Third, this time last week I was attending the American Association for Cancer Research (AACR) meeting in Orlando. I don’t really like Orlando much (if you’re not into Disney and tourist traps, it’s not the greatest town to hang out in for four days), but I do love me some good cancer science. One thing that was immediately apparent to me from the first sessions on Sunday and perusing the educational sessions on Saturday was that currently the primary wave in cancer research is all about harnessing the advances in genomics, proteomics, metabolomics, and systems and computational biology, as well as the technologies such as next generation sequencing (NGS) techniques to understand the biology of each cancer and thereby target therapies more closely to what biological abnormalities drive each cancer. You can get an idea of this from the promotional video the AACR played between its plenary sessions:

Which is actually a fairly good short, optimistic version of my post Why haven’t we cured cancer yet? As I mentioned before, with this year being the 40th anniversary of the National Cancer Act, as December approaches expect a lot of articles and press stories asking that very question, and I’m sure this won’t be the last time I write about this this year.
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Posted in: Basic Science, Cancer, Clinical Trials, Politics and Regulation

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Ann Coulter says: Radiation is good for you!

Here at Science-Based Medicine, we try to be relatively apolitical. We might not always succeed, but in general our main concern is not so much with right-wing or left-wing politics, but rather with how prevailing government policies and regulation impact the delivery of medical care, in particular whether they tend to prevent, do nothing about, or promote the proliferation of non-science-based medical care. Consequently, when Kimball or I call for the disbanding of the National Center for Complementary and Alternative Medicine (NCCAM), it does not matter one whit to us who is President or which party controls Congress. All that matters is that we see NCCAM as a government entity that, through credulously studying many “alternative medicine” modalities, ends up inadvertently promoting them and providing them with the imprimatur of government approval. The same concept applies to state medical licensing boards licensing pseudoscientific modalities, such as naturopathy, acupuncture, and homeopathy. By regulating these “disciplines,” states also provide them with an unmerited mantle of respectability through their imprimatur of regulating them as professions, just like medicine and nursing.

As far as political views, although all of us have them and they occasionally even come to the fore in disagreements (remember when Wally Sampson occasionally clashed with others with differing political viewpoints?), we generally subsume them for purposes of the SBM blog experience into our advocacy for basing medicine on the best science available. Sometimes, however, when a pundit or politician makes claims that are either contrary to or distort science for ideological or political advantage, I feel the need to discuss those claims, sometimes even sarcastically. Such was the case last week, when Ann Coulter wrote a blisteringly ignorant column, entitled A Glowing Report on Radiation. She wrote this article in the wake of the fears arising in Japan and around the world of nuclear catastrophe due to the damage to the Fukushima nuclear power plant caused by the earthquake and tsunami that hit northern Japan on March 11. Coulter was subsequently interviewed by Fox News pundit Bill O’Reilly on The O’Reilly Factor on Thursday evening:

Yes, according to Coulter, radiation is good for you, just like toxic sludge! Even more amazing, in this video Bill O’Reilly actually comes across as the voice of reason, at least in comparison to Ann Coulter. He’s very skeptical of Coulter’s claims and even challenges her by saying, “So by your account we should all be heading towards the nuclear reactor.”

So, fellow SBM aficionados, is Coulter right? Are all those scientists warning about the dangers of even low-level radiation all wrong? Should we start hanging out in radioactive mine shafts, as Coulter mentions in her column (seriously) in order to boost our health and decrease our risk of cancer?

Not so fast, there, Ann. Here’s a hint: If Bill O’Reilly can lecture you on science and look more reasonable than you, you’re off the rails.
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Posted in: Cancer, Science and the Media

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