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The cancer screening kerfuffle erupts again: “Rethinking” screening for breast and prostate cancer

I see that the kerfuffle over screening for cancer has erupted again to the point where it’s found its way out of the rarified air of specialty journals to general medical journals and hence into the mainstream press.

Over the last couple of weeks, articles have appeared in newspapers such as the New York Times and Chicago Tribune, radio networks like NPR, and magazines such as TIME Magazine pointing out that a “rethinking” of routine screening for breast and prostate cancer is under way. The articles bear titles such as A Rethink On Prostate and Breast Cancer Screening, Cancer Society, in Shift, Has Concerns on Screenings, Cancers Can Vanish Without Treatment, but How?, Seniors face conflicting advice on cancer tests: Benefit-risk questions lead some to call for age cutoffs, and Rethinking the benefits of breast and prostate cancer screening. These articles were inspired by an editorial published in JAMA last month by Laura Esserman, Yiwey Shieh, and Ian Thompson entitled, appropriately enough, Rethinking Screening for Breast Cancer and Prostate Cancer. The article was a review and analysis of recent studies about the benefits of screening for breast and prostate cancer in asymptomatic populations and concluded that the benefits of large scale screening programs for breast cancer and prostate cancer tend to be oversold and that they come at a higher price than is usually acknowledged.

For regular readers of SBM, none of this should come as a major surprise, as I have been writing about just such issues for quite some time. Indeed, nearly a year and a half ago, I first wrote The early detection of cancer and improved survival: More complicated than most people think. and then followed it up with Early detection of cancer, part 2: Breast cancer and MRI. In these posts, I pointed out concepts such as lead time bias, length bias, and stage migration (a.k.a. the Will Rogers effect) that confound estimates of benefit due to screening. (Indeed, before you continue reading, I strongly suggest that you go back and read at least the first of the aforementioned two posts to review the concepts of lead time bias and length bias.) Several months later, I wrote an analysis of a fascinating study, entitling my post Do over one in five breast cancers detected by mammography alone really spontaneously regress? At the time, I was somewhat skeptical that the number of breast cancers detected by mammography that spontaneously regress was as high as 20%, but of late I’m becoming less skeptical that the number may be somewhere in that range. Even so, at the time I did not doubt that there likely is a proportion of breast cancers that do spontaneously regress and that that number is likely larger than I would have guessed before the study. Of course, the problem is that we do not currently have any way of figuring out which tumors detected by mammography will fall into the minority that do ultimately regress; so we are morally obligated to treat them all. My most recent foray into this topic was in July, when I analyzed another study that concluded that one in three breast cancers detected by screening are overdiagnosed and overtreated. That last post caused me the most angst, because women commented and wrote me asking me what to do, and I had to answer what I always answer: Follow the standard of care, which is yearly mammography over age 40. This data and these concerns have not yet altered that standard of care, and I am not going to change my practice or my general recommendations to women until a new consensus develops.
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Posted in: Cancer, Public Health, Science and the Media

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Mainstreaming Science-Based Medicine: A Novel Approach

I have often mused about the difference between being right and being influential – especially in light of the relative success of the anti-vaccine movement. Despite the fact that there is no evidence for a link between vaccines and autism, celebrities like Jenny McCarthy have manufactured public mistrust in one of the safest, most cost effective means of combating disease known to humankind.

So if scientists are not persuading the public with appeals to carefully designed trials and factual data, how should they make their point? I’m not sure I have the full answer, but I think I might have struck a nerve with the public lately. I decided to try a novel approach to communicating my concerns about pseudoscience on the Internet – and presented 20 slides at 20 second intervals to a conference of ePatients in Philadelphia. I did it with powerful and humorous images, tied together with a long Limerick. Sound kooky? Maybe so… but it resonated, and was received with cheers and applause. Now that’s how we like science to be recognized! (more…)

Posted in: Cancer, General, Science and the Media

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Suzanne Somers’ Knockout: Dangerous misinformation about cancer (part 1)

If there’s one thing I’ve become utterly disgusted with in the time since I first became interested in science-based medicine as a concept, its promotion, and the refutation of quackery and medical pseudoscience, it’s empty-brained celebrities with an agenda. Be it from imbibing the atmosphere within the bubble of woo-friendly southern California or taking a crash course at the University of Google and, through the arrogance of ignorance, concluding that they know more than scientists who have devoted their lives to studying a problem, celebrities believing in and credulously promoting pseudoscience present a special problem because of the oversized soapboxes they command. Examples abound. There’s Bill Maher promoting anti-vaccine pseudoscience, germ theory denialism, and cancer quackery on his show Real Time with Bill Maher and getting the Richard Dawkins Award from the Atheist Alliance International in spite of his antiscience stances on vaccines and what he sneeringly calls “Western medicine.” Then there are, of course, the current public faces of the anti-vaccine movement, Jenny McCarthy and her boyfriend Jim Carrey, the former of whom thinks it’s just hunky dory (or at least doesn’t appear to be the least bit troubled) that her efforts are contributing to the return of vaccine-preventable infectious diseases because she apparently thinks that’s what it will take to make the pharmaceutical companies change their “shit” product (her words), and the latter of whom spreads conspiracy theories about vaccines and contempt on people suffering from restless leg syndrome. Finally, there’s the grand macher of celebrity woo promotion, Oprah Winfrey, who routinely promotes all manner of medical pseudoscience, be it “bioidentical” hormones, the myth that vaccines cause autism (even hiring Jenny McCarthy to do a blog and develop a talk show for her company Harpo Productions), or other nonsense, such as Christiane Northrup urging Oprah viewers to focus their qi to their vaginas for better sex.

Unfortunately, last week the latest celebrity know-nothing to promote health misinformation released a brand new book and has been all over the airwaves, including The Today Show, Larry King Live, and elsewhere promoting it. Yes, I’m talking about Suzanne Somers, formerly known for her testimonial of having “rejected chemotherapy and tamoxifen” for her breast cancer, as well as her promotion of “bioidentical hormones,” various exercise devices such as the Thighmaster and all manner of supplements. Her book is entitled Knockout: Interviews with Doctors Who Are Curing Cancer–And How to Prevent Getting It in the First Place. It is described on the Random House website thusly:
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Posted in: Book & movie reviews, Cancer, Science and the Media

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The “Iron Rule of Cancer”: The dangerous cancer quackery that is the “German New Medicine”

Given that I trained as a cancer surgeon, do laboratory and translational cancer research, and spend my clinical time taking care of breast cancer patients, not surprisingly one topic that gets me the most irritated and provokes a lot of my verbiage for SBM is cancer quackery. As I was perusing my list of posts the other day, it occurred to me that there’s one huge topic that in the more than a year and a half I’ve been blogging for SBM I’ve never covered. It’s a particularly pernicious and dangerous quackery. Indeed, it’s a quackery I mentioned during part of my talk at the Science-Based Medicine Conference, which Steve organized and where several SBM bloggers spoke the day before TAM7 started.

I’m referring to the dangerous and vile quackery known as the German New Medicine (Die Germanische Neue Medizin). Pioneered by Ryke Geerd Hamer, it is a quackery that claims lives. So what is this German New Medicine? Well, it appears to be a Theory of Everything Medical, and in particular everything having to do with cancer:

THE GERMAN NEW MEDICINE provides us with illuminating explanations about the origin, development and healing of both physical and mental disorders. In 1981, Dr. Hamer discovered that every DISEASE is caused by a shock experience that catches us completely off guard. He found that this shock not only occurs in the psyche but simultaneously in the brain and on the organ level. At the moment the unexpected trauma takes place the shock impacts a specific area in the brain causing a lesion that is clearly visible on a brain scan as a set of sharp concentric rings. With the impact the affected brain cells communicate the disturbance to the corresponding organ. Whether the organ responds with a tumor growth (cancer), with tissue degeneration, or with functional loss, is determined by the exact type of conflict shock. Based on the analysis of over 40,000 case studies Dr. Hamer is the first to provide scientific proof that cancer is not caused by a malfunctioning organism producing deadly cancer cells but is rather the result of an innate meaningful survival program that has been successfully practiced for millions of years. Since HEALING can only occur after the conflict has been resolved, the GNM-therapy focuses on identifying and resolving the original conflict. By understanding healing symptoms such as painful swelling, infections, fever, or inflammation in their psychological, biological and evolutionary context, we are able to liberate ourselves from the fear and panic that often come with the onset of an illness. Dr. Hamer’s findings offer a completely new understanding of so-called diseases. His scientific discoveries revolutionize entirely our view of medical conditions and their causes.

The German New Medicine presents a comprehensive system that allows us to understand what type of conflict causes the onset of a particular disease, how the disease manifests itself in the conflict active phase, what can be expected in the healing phase, and how all the developments are connected to the brain, verifiable with a brain scan.

The German New Medicine is a natural science, based on FIVE empirically disovered BIOLOGICAL LAWS that apply, in a strong scientific sense, to each and every case of disease of man and mammal.

The repository of quackery known as Mercola.com describes the “Five Biological Laws” of German New Medicine thusly:
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Posted in: Cancer, Health Fraud, Science and Medicine

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Bill Maher endorses cancer quackery

Over the last five years or so, I’ve often asked, “Is Bill Maher really that ignorant?” I’ve come to the conclusion that he is, and a couple of weeks ago laid out the evidence why right here on this very blog. (Lately Maher has been issuing Tweets that call people who get flu shots “idiots.”) Indeed, I even included in the post perhaps the most hilariously spot-on riposte to Maher’s crankery. This occurred when Maher proclaimed that he never gets the flu and wouldn’t get the flu on an airplane, which his guest Bob Costas to exclaim in exasperation, “Oh, come on, Superman!”

Bob Costas won my respect that day. My favorite part was when Maher looked at his guests, who were shifting in their seats, all embarrassed and unsure of what to say, and observed, “You all look at me as though I’m crazy.”

Why, yes, Bill, we do. Let’s put it this way. When Age of Autism likes you, you have a serious problem when it comes to being credible about medical science.

In that same post, I complained about Maher’s being awarded the Richard Dawkins Award by the Atheist Alliance International (AAI). I liken giving Bill Maher an award that lists “advocates increased scientific knowledge” anywhere in its criteria, not to mention being named after Richard Dawkins, to giving Jenny McCarthy an award for public health, given that, at least when it comes to medicine, Maher is anti-science to the core. Along the way, I’ve ruffled the feathers of some of both Dawkins’ and Maher’s fans.

I regret nothing.

Not only do I regret nothing, but on September 18, a mere two weeks before the AAI Convention, Maher provided me with more ammunition. In fact, this is probably the most blatant bit of crankery I’ve seen from Maher in a long time. Watch and learn. The “alternative medicine” nuttery begins at around the 0:50 mark:

Laetrile? Really? Laetrile?? How 1970s cancer quackery!
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Posted in: Cancer, Faith Healing & Spirituality, Health Fraud, Science and the Media, Vaccines

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Tom Harkin, NCCAM, health care reform, and a cancer treatment that is worse than useless

ResearchBlogging.orgPRELUDE: SOME BAD NEWS FOR ADVOCATES OF SCIENCE-BASED MEDICINE

It was a bad week for science-based medicine. It was a good week (sort of) for science-based medcine.

First the bad.

There has been a development that anyone who supports science in medicine and opposes quackery will likely find disturbing. Do you remember Senator Tom Harkin (D-IA)? We’ve written about him extensively over the last several months on this blog. First of all, he is the man most responsible for the creation of that government-sanctioned, government-funded bastion of pseudoscience, the National Center for Complementary and Alternative Medicine. He’s also one of the men most responsible for the Dietary Supplement Health and Education Act (DSHEA) of 1994, which has done more to protect the supplement industry from making dubious health claims than any other piece of federal legislation. More recently, Harkin has made a name for himself in the health care reform debate currently ongoing by inviting advocates of “integrative” medicine (IM), which in essence integrates quackery and the pseudoscientific with scientific medicine, to Capitol Hill as a means of trying to persuade his fellow legislators to include a CAM/IM version of “wellness” care as part of any bill that might pass this fall. In essence, he is trying to hijack any health care reform bill to include government sanction of unscientific medicine. Meanwhile, he has been chastising NCCAM because it hasn’t “validated” enough “alternative medicine” for his taste. (Actually, it’s validated none, because virtually none of it is likely to be valid.)

This is the man who, according to reports, will almost certainly be taking over the chair of the Senate Committee on Health, Education, Labor, and Pensions (HELP) after the death of its former chair, Senator Edward Kennedy. This committee is among the most important for government health policy and will be in the thick of the final negotiations and battles over any health care reform that may arise from Congress this fall.

The existence of powerful supporters of pseudoscience in the highest eschelons of government has real consequences. As I’ve described before, NCCAM, being based entirely on studying highly–even ridiculously implausible–notions about disease and how to treat it, has resulted in the infiltration of quackery into academia, where ideas once rightly dismissed as quackery are respectfully given deference and studied as though they were anything other than Tooth Fairy science, a process that Dr. R. W. Donnell has amusingly termed “quackademic medicine.” One result was the expenditure of $30 million on an unethical, poorly designed, and corrupt trial of chelation therapy for cardiovascular disease. Another result was an even more unethical trial of an even more scientifically implausible remedy for a deadly cancer. Although the fact that the trial was even done is a horror, at least last week we finally found out the results, which had been suppressed for nearly four years, namely that this protocol is not just useless, but worse than useless. It’s a Pyrrhic victory for science-based medicine and cold comfort to patients with pancreatic cancer who may have continued to use this protocol during those four years, but at least we finally know.

Let’s take a look at the study. But first, a little background.
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Posted in: Cancer, Clinical Trials, Politics and Regulation

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“Gonzalez Regimen” for Cancer of the Pancreas: Even Worse than We Thought (Part I: Results)

ResearchBlogging.org

Review

One of the more bizarre and unpleasant “CAM” claims, but one taken very seriously at the NIH, at Columbia University, and on Capitol Hill, is the cancer “detoxification” regimen advocated by Dr. Nicholas Gonzalez:

Patients receive pancreatic enzymes orally every 4 hours and at meals daily on days 1-16, followed by 5 days of rest. Patients receive magnesium citrate and Papaya Plus with the pancreatic enzymes. Additionally, patients receive nutritional supplementation with vitamins, minerals, trace elements, and animal glandular products 4 times per day on days 1-16, followed by 5 days of rest. Courses repeat every 21 days until death despite relapse. Patients consume a moderate vegetarian metabolizer diet during the course of therapy, which excludes red meat, poultry, and white sugar. Coffee enemas are performed twice a day, along with skin brushing daily, skin cleansing once a week with castor oil during the first 6 months of therapy, and a salt and soda bath each week. Patients also undergo a complete liver flush and a clean sweep and purge on a rotating basis each month during the 5 days of rest.

Veteran SBM readers will recall that in the spring of 2008 I posted a series of essays* about this regimen and about the trial that compared it to standard treatment for subjects with cancer of the pancreas. The NIH had funded the trial, to be conducted under the auspices of Columbia, after arm-twisting by Rep. Dan Burton [R-IN], a powerful champion of quackery, and much to the delight of the “Harkinites.”

In the fall of 2008 I posted an addendum based on a little-known determination letter that the Office for Human Research Protections (OHRP) had sent to Columbia during the previous June. The letter revealed that the trial had been terminated in October, 2005, due to “pre-determined stopping criteria.” This demonstrated that Gonzalez’s regimen must have been found to be substantially worse than the current standard of care for cancer of the pancreas, as ineffective as that standard may be. I urge readers who require a review or an introduction to the topic to read that posting, which also considered why no formal report of the trial had yet been made available.

Now, finally, the formal report has been published online by the Journal of Clinical Oncology (JCO):

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Posted in: Cancer, Clinical Trials, Health Fraud, Herbs & Supplements, Medical Academia, Medical Ethics, Politics and Regulation, Science and Medicine

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The price of cancer quackery

I don’t have much to add to this one, as it’s a tragic tale. Shadowfax, a blogging ER doc, relates to us what happens when cancer patients rely on quackery like the Gerson protocol instead of scientific medicine:

This was a young woman, barely out of her teens, who presented with a tumor in her distal femur, by the knee. This was not a new diagnosis — it had first been noted in January or so, and diagnosed as a Primary B-Cell Lymphoma. By now, the tumor was absolutely huge, and she came to the ER in agonizing pain. Her physical exam was just amazing. The poor thing’s knee (or more precisely, the area just above the knee) was entirely consumed by this massive, hard, immobile mass about the size of a soccer ball. She could not move the knee; it was frozen in a mid-flexed position. She hadn’t been able to walk for months. The lower leg was swollen and red due to blood clots, and the worst of the pain she was having seemed due to compression of the nerves passing behind the knee. It was like something you see out of the third world, or historic medical textbooks. I have never seen its like before.

So we got her pain managed, of course, and I sat down to talk to her and her family.

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Posted in: Cancer, Health Fraud, Medical Ethics

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If you’re sick, even the ridiculous can seem sublime

Let’s say you have cancer. And let’s say you’re really, really sick of having cancer. And let’s say that you’re also pretty tired of scans, chemo, radiation, hair loss, nausea. And let’s say you’re not really sick and tired of living, but actually pretty happy to be alive.

Finally, let’s say someone says that they can get rid of your cancer, without all of those pesky side-effects. It’s a win-win, no?

No.

It’s easy to believe in promises that are congruent with our wishes. That’s what makes human beings so easy to deceive. A case in point is the VIBE Machine, a discredited quackery device. This thing was marketed until about a year ago. Not surprisingly, Orac has written about this thing in his Friday Dose of Woo. Stephen Barrett, the King of Quack-Busters, has also tracked the sordid history of this rip-off. The device was recalled back in 2008, so this shouldn’t even be a story anymore, except that word of the device still circulates among cancer patients and their friends. The company’s website is down, which is good, but this thing is still out there.

At least one website is still promoting it in detail. The website is, needless to say, a whole lot of words that make no sense: (more…)

Posted in: Cancer, Health Fraud, Science and Medicine

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Are one in three breast cancers really overdiagnosed and overtreated?

ResearchBlogging.orgScreening for disease is a real pain. I was reminded of this by the publication of a study in BMJ the very day of the Science-Based Medicine Conference a week and a half ago. Unfortunately, between The Amaz!ng Meeting and other activities, I was too busy to give this study the attention it deserved last Monday. Given the media coverage of the study, which in essence tried to paint mammography screening for breast cancer as being either useless or doing more harm than good, I thought it was imperative for me still to write about it. Better late than never, and I was further prodded by an article that was published late last week in the New York Times about screening for cancer.

If there’s one aspect of medicine that causes more confusion among the public and even among physicians, I’d be hard-pressed to come up with one more contentious than screening for disease, be it cancer, heart disease, or whatever. The reason is that any screening test is by definition looking for disease in an asymptomatic population, which is very different from looking for a cause of a patient’s symptoms. In the latter case, the patient is already being troubled by something that is bothering him. There may or may not be a cause in the form of a disease or syndrome that is responsible for the symptoms, but the very existence of the symptoms clues the physician in that there may be something going on that requires treatment. The doctor can then narrow down range of possibilities for what may be the cause of the patient’s symptoms by taking a careful history and physical examination (which will by themselves most often lead to the diagnosis). Diagnostic tests, be they blood tests, X-rays, or other tests, then tend to be more confirmatory of the suspected diagnosis than the main evidence supporting a diagnosis.
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Posted in: Cancer, Clinical Trials, Public Health, Science and Medicine, Science and the Media

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