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Diagnostic Dilemmas

Sometimes diagnosis is straightforward. If a woman has missed several periods and has a big belly with a fetal heartbeat, it’s pretty easy to diagnose pregnancy. But most of the time diagnosis is much more difficult. Alzheimer’s can’t be diagnosed for sure until the patient dies and you do an autopsy. If only we had one of those Star Trek gadgets to point at our patients and give us a quick and accurate answer! Alas! We are far from perfect. All too often, we really have no idea what’s causing a patient’s symptoms. We do a complete workup and still don’t know. What then?

We all know people who have symptoms that a series of doctors have failed to diagnose, who continue to doctor-shop, hoping to find that one doctor somewhere who will find something the others have missed. Occasionally they do; but far more often these people spend a great deal of time and money chasing a will-o’-the-wisp. Sometimes as they are searching, the illness gradually runs its course and goes away. When this happens, whatever they tried last gets the undeserved credit for the “cure.” Sometimes the symptoms persist and these searches consume their life, encourage unhealthy self-absorption, and permanently ensconce them in the “sick” role.

One of the attractions of alternative medicine is that it offers far more certainty than scientific medicine. If your scientific doctor can’t see anything on x-rays, your chiropractor can. He’ll tell you he knows exactly what’s wrong: a subluxation that he can fix. Sherry Rogers will tell you all illness is due to toxins accumulating in your cells and you must “detoxify or die.” Hulda Clark will tell you it’s all parasites that she can eliminate with her magic zapper. Robert Young says the cause of all disease is acidosis. They all have confident, precise answers. Wrong ones.

The One Cause of All Disease?

It’s really easy to figure out what’s causing a patient’s symptoms if you believe there is one simple cause for all disease. While I was writing this I got sidetracked and searched the Internet for “the one cause of all disease.” I found a lot of them, including: (more…)

Posted in: Diagnostic tests & procedures, Science and Medicine

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Early detection of cancer, part 2: Breast cancer and MRI

Note: If you haven’t already, you should read PART 1 of this two-part series. It defines several terms that I will be using in this post, and I don’t plan on explaining them again, given that they were explained in detail in Part 1. Of course, if you’re a medical professional and already know what lead time bias, length bias, and stage migration are, then it goes without saying that you should still read Part 1 for its scintillating prose.

ResearchBlogging.orgWhen last I left this topic three weeks ago, I had discussed why detecting cancer at ever-earlier stages and ever-smaller sizes is not necessarily an unalloyed good. At that time, I discussed in detail a landmark commentary in the New England Journal of Medicine entitled, Advances in Diagnostic Imaging and Overestimations of Disease Prevalence and the Benefits of Therapy. The article, although nearly 15 years old, rings just as true today in its cautioning doctors about whether ever-increasing diagnostic sensitivity that imaging technology and new blood tests were (and are) providing was actually helping patients as much as we thought it was. Before we dive into this problem as applied to breast cancer, let’s review what Drs. Black and Welch had to say about screening tests for breast cancer 15 years ago, as way of background and linking my last post and this one:

Before the widespread use of mammography, most breast cancers were discovered on physical examination, as palpable lumps. In one of the few studies to assess directly the accuracy of physical examination in screening for breast cancer, only 27 percent of tumors more than 1.0 cm in diameter and 10 percent of those less than 1.0 cm in diameter were detected by physical examination. However, the mean size of breast cancers detected by state-of-the-art screening mammography is about 1.0 cm, and many of the cancers detected as microcalcifications are only a few millimeters in size.

Again, prevalence depends on the degree of scrutiny. According to the Connecticut Tumor Registry, clinically apparent breast cancer afflicts about 1 percent of all women between the ages of 40 and 50 years. In a recent medicolegal autopsy study, however, small foci of breast cancer were found in 39 percent of women in this age group. Most cancers were in the form of ductal carcinoma in situ. Furthermore, over 45 percent of the women with cancer had two or more lesions, and over 40 percent had bilateral lesions. Although it has been argued that such small in situ lesions are not detected by and are therefore irrelevant to screening mammography, about half the lesions in that study were detected, usually as microcalcifications, on postmortem plain-film radiography of the resected breasts. Because of continual technical improvements and increasingly broad criteria for the interpretation of mammograms, the detection threshold for breast cancer has fallen considerably since the time of the Breast Cancer Screening Project of the Health Insurance Plan of Greater New York (1963 to 1975). This can explain the increased prevalence of cancer on mammographic screening, from 2.717 to 7.614 per 1000 examinations (with the incidence increasing from 1.517 to 3.214 per 1000 examinations). The lower detection threshold can also explain the increase in the percentage of carcinomas in situ (stage 0) among all mammographically detected cancers — from 12.7 percent to over 30 percent. The principal indication for biopsy has changed from suspicious mass to suspicious microcalcifications. This can explain why the reported incidence of breast cancer has increased and why most of the increase is in smaller lesions, particularly ductal carcinoma in situ.

About a year ago, three major articles hit the medical press that made me start thinking about this more than I had in the past. It’s my job, after all, because breast cancer surgery is a large part of my practice, and I do breast cancer lab-based research. What also tweaked me not to put off doing part 2 of this series is that, just two days ago, there was an abstract presented at the American Society of Clinical Oncology Meeting (where I still am today) that also serves to highlight just how difficult this question of integrating a test as sensitive as MRI into a screening regimen for and preoperative evaluation of breast cancer is and how MRI should fit into in this regimen can be.
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Posted in: Clinical Trials, Public Health, Science and Medicine, Science and the Media, Surgical Procedures

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The TACT is at least as Bad as We Predicted

I had wanted to follow Dr. Sampson’s discussion of “Healing Touch” with one of my own, because I had an interesting experience with one of its proponents years ago, and I’ll do that soon. I had also wanted to begin a series of posts about acupuncture, which I’ll also do eventually. Just yesterday, however, Liz Woeckner, co-author of our recently published critique of the NIH Trial to Assess Chelation Therapy (TACT), made a startling discovery: the TACT “Portal” website, intended for investigators and others associated with the trial and previously password protected, is now available to anyone: http://www.chelationwatch.org/s/tact/index.html It is a goldmine of information and I’ve barely begun to look at it, but so far it verifies much of what we’ve written and more. For example, the latest version of the Consent Form is dated 2006 and includes this statement under “risks”:

EDTA, or ethylenediamine tetraacetate is in the chelation solution. It is approved for use by the FDA as a treatment for lead poisoning but not for coronary artery disease.

Yet three Investigator Brochures, dating back to 2003, contain this language:

Edetate disodium USP should not be confused with its calcium salt (calcium edetate), which is used to treat lead toxicity.

We had called attention, in our article, to TACT literature repeatedly conflating Na2EDTA and the safer CaNaEDTA. Now we have reason to believe that this has been done cynically, with eyes wide open.

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Posted in: Clinical Trials, Medical Ethics, Politics and Regulation, Science and Medicine

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Christiane Northrup, MD: Science Tainted with Strange Beliefs

After her daughter left for college, Christiane Northrup, MD, went for a morning walk one day. About halfway through her walk she developed an ache in her throat radiating up into her jaw. It felt like a fist was squeezing her esophagus. It persisted even after she returned home. What would you have done?

I think even the average layperson knows that this sounds like a possible heart attack and would call 911 or head for the nearest ER. Instead, Northrup called a medical intuitive who came over and “took out the Motherpeace tarot cards to try to get some clarity.” Together, they interpreted her “heartache” as resulting from her recent disappointment and grief over her family situation. She had unmet needs and it was “no wonder my heart was forced to speak up.”

This behavior from a scientifically trained MD boggles the mind. Christiane Northrup, MD, is a board certified OB/Gyn who has become something of a guru for American women’s health through a series of books, a newsletter, a website, appearances on Oprah, etc. Her third book, The Wisdom of Menopause, has been updated and revised; a friend told me all her menopausal friends are talking about this book. I read it and was appalled. (more…)

Posted in: Book & movie reviews, Science and Medicine

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A real “Era III Emergency Room”

Due to the holiday, I have not had time to compose the usual lengthy and analytic post that readers have come to know and (hopefully) love. However, Dr. Atwood’s Weekly Waluation of the Weasel Words of Woo #6 so perfectly brought a famous (or infamous) parody back from the depths of my memory that I had to go straight to YouTube and find it. I think our readers will appreciate if they haven’t seen it before. The quote that inspired me to resurrect this gem is:

This new era is composed of a blend of the best of what we know of physical, material-based medicine (”Era I”), mind-body medicine (”Era II”), and the caring, compassion, and consciousness that characterize “Era III.” A compelling example is given in the use of all three levels of caring in the “Era III Emergency Room.”He vividly shows us a new kind of emergency department in which an auto crash patient is not only stabilized and sutured but has the suggestion of relaxation imagery along with the lidocaine and nylon. Meanwhile, caring healers take a moment to pray and visualize a positive outcome based on the scientific evidence of the effects of nonlocal mind, employing a network of nonlocal healers as they work.

No, this is the real “Era III Emergency Room”:

The sad thing is, I fear that the above video is not too great an exaggeration of the way medicine is going.I will return next Monday (possibly even sooner) with new material.

Posted in: Humor, Science and Medicine

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We Have to Draw the Line Somewhere

Passive acceptance of Alternative Medicine has eroded the quality of medical care in this country. With the DSHEA of 1994 and political correctness, we have lost the reverence afforded to us in times past. Our professional knowledge is called into question as our standards deteriorate. There no longer exists a line separating proven fact from speculation. There is no border separating reality from mythology. Our colleagues treat with antibiotics and homeopathy. With beta-blockers and energy fields. Qi and narcotics.

For many years, it has seemed that I was nearly alone in my skepticism. Anytime I would bring up an alternative medicine topic, (in reality: criticize it) others in my field would have a ho-hum reaction to it. It was politically incorrect to rant about the growth of alternative medicine, the growing use of herbs, and how something should be done about it. We family and internal medicine doctors are a generally easy lot to live with. We accept patients and their faults, and it is hard to suddenly become judgmental when it comes to our colleagues. I had no idea as a resident that there was so much woo in Colorado. Specifically, I had no idea how much there was at my academic institution. This was in the late 80s, early 90s! Oh my, how things have changed, and not for the better.

I was a naïve resident in 1990, when a nurse practitioner at my residency called me about one of my patients. She wanted to help a 20 year old woman stop smoking by… wait for it….Therapeutic Touch. I was post call, and had trusted this NP as she had been with the residency for many years. I said “yes, go ahead,” not knowing what exactly it entailed. When I did have time to look into it, I was appalled. I was guilty by association. The patient never returned to me, and I don’t blame her. She must have thought I believed in magic. It turns out that the School of Nursing at the University of Colorado had to be called out by the Rocky Mountain Skeptics on their aggressive promotion and advocacy of Therapeutic Touch.

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Posted in: Politics and Regulation, Science and Medicine

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Changing the Rules of Evidence

My daughter, Julia, loves to play games and has a bit of a competitive streak. She can make any activity into a game and is adept at making up rules on the spot. When she was younger, like most children, she had a tendency to add to or change the rules on the fly – usually to ensure a favorable outcome for herself. “Oh, Daddy, I forgot to mention that the ball can bounce once and that still counts.”

It was an opportunity for me to gently teach her that in order for rules to work everyone has to know what they are ahead of time and you can’t change them after the fact. Her smile told me that even at five she intuitively knew this already – that changing or making up new rules was not fair. What I was really teaching her was that she wasn’t going to get away with it with me, and by extension that it is socially unacceptable to mess with the rules to suit oneself.

Adults are really no different than children in our basic emotional makeup. We all want to change the rules to suit our own needs. The true difference is that as we mature we become more socially sophisticated; we become more subtle in our manipulations, and we develop the capacity to rationalize our wants and desires. We also learn that we are playing a bigger game – the social game. So we adhere to the rules of fairness, even if it means losing a competition, because we want to succeed at the more important game of socialization. (I’m not making any moral or ethical judgments here, just observing human behavior.)

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Posted in: Clinical Trials, Science and Medicine

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Reading Medical Literature with a Critical Eye

A long time ago I read a study about what makes a good doctor. Some things you might think were important, like grades in medical school, were irrelevant. What correlated the best was the number of medical journals a doctor read. I don’t know whether that means good doctors read more journals or reading more journals makes a better doctor.

One thing I do know is that most of us could learn better journal-reading skills. When I was a busy clinician, I did what I suspect many busy clinicians do: I let the journals pile up for a while, then tackled a stack when I got motivated. I would skim the table of contents to pick out articles that I wanted to read, then I would read the abstracts of those articles. If the abstract interested me, I would read the discussion section of the article. If I was still interested, I might go back and read the entire article. But until after I retired, I never really developed the skills to evaluate the quality of the study.

I knew enough not to jump on the bandwagon the first time something was reported, because I had seen promising treatments bite the dust with further testing. But I really wasn’t aware of all the things that can go wrong in a study, and I didn’t know what to look for to decide if the results were really credible. I’m not an academic; I thought the authors knew a lot more than I did, and I trusted them to a degree that was not warranted. (more…)

Posted in: Pharmaceuticals, Science and Medicine

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The “Art” of Clinical Decision-Making

Much nonsense has been written about the “art” of medicine. All too often, it amounts to a rationalization for doctors doing what they want to do instead of following the evidence. Medicine is not an art like painting. Neither is it a science like physics. It’s an applied science. Since patients are not all identical, it can be very tricky to decide how to apply the science to the individual.

The New England Journal of Medicine periodically runs a feature called “Clinical Decisions.” They present a case history, then they present 2 or 3 expert opinions on how to manage the case. They stress that none of the options can be considered either correct or incorrect. They allow readers to “vote” as well as to submit comments about why they voted that way. It is understood that the voting is only for interest and to stimulate discussion: it does not result in a consensus.

In April 2008 the topic was the management of carotid artery stenosis. The patient is a 67 year old man who has no symptoms but who is found to have a narrowing of 70-80% in one carotid artery and 20% in the other, putting him at increased risk for stroke. He has other risk factors for cardiovascular disease: hyperlipidemia, hypertension, and overweight. The 3 options are medical management, stent placement, and carotid endarterectomy. (more…)

Posted in: Science and Medicine

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The early detection of cancer and improved survival: More complicated than most people think

“Early detection of cancer saves lives.”

How many times have you heard this statement or something resembling it? It’s a common assumption (indeed, a seemingly common sense assumption) that detecting cancer early is always a good thing. Why wouldn’t it always be a good thing, after all? For many cancers, such as breast cancer and colon cancer, there’s little doubt tha early detection at the very least makes the job of treating the cancer easier. Also, the cancer is detected at an earlier stage almost by definition. But does earlier detection save lives? This question, as you might expect, depends upon the tumor, its biology, and the quality and cost of the screening modality used to detect the cancer. Indeed, it turns out that the question of whether early detection saves lives is a much more complicated question to answer than you probably think, a question that even many doctors have trouble with. It’s also a question that can be argued too far in the other direction. In other words, in the same way that boosters of early detection of various cancers may sometimes oversell the benefits of early detection, there is a contingent that takes a somewhat nihilistic view of the value of screening and argues that it doesn’t save lives.

A corrollary of the latter point is that some boosters of so-called “alternative” medicine take the complexity of evaluating the effect of early screening on cancer mortality and the known trend towards diagnosing earlier and earlier stage tumors as saying that our treatments for cancer are mostly worthless and that the only reason we are apparently doing better against cancer is because of early diagnosis of lesions that would never progress. Here is a typical such comment from a frequent commenter whose hyperbolic style will likely be immediately recognizable to regular readers here:

Most cancer goes away, or never progresses, even with NO medical treatment. Most people who get cancer never know it. At least in the past, before early diagnosis they never knew it.

Now many people are diagnosed and treated, and they never get sick or die from cancer. But this would have also been the case if they were never diagnosed or treated.

Maybe early diagnosis and treatment do save the lives of a small percentage of all who are treated. Maybe not. We don’t know.

As is so often the case with such simplistic black and white statements, there is a grain of truth buried under the absolutist statement but it’s buried so deep that it’s well-nigh unrecognizable. Because we see this sort of statement frequently, I thought it would be worthwhile to discuss some of the issues that make the reduction of mortality from cancer so difficult to achieve through screening. I will do this in two parts, although the next part may not necessarily appear next week
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Posted in: Cancer, Public Health, Science and Medicine, Science and the Media

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