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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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Near Death Experiences and the Medical Literature

MIRACLE MAX: See, there’s a big difference between mostly dead, and all dead. Now, mostly dead: he’s slightly alive. All dead, well, with all dead, there’s usually only one thing that you can do.

INIGO: What’s that?

MIRACLE MAX: Go through his clothes and look for loose change.

The Princess Bride

Can you trust anyone when they purport to tell you what the medical literature says? No. As an example we will use the issue of near death experiences, or NDE’s.

We will avoid the obvious paradox in this entry, sort of the ‘everything I say is a lie paradox’ that will cause computers in the Federation to shut down.

Why am I going to comment on this issue? Well, this months Skeptic has a back and forth between Michael Shermer and Deepak Chopra about life after death.

No. I am not going to comment on whether there is life after death. I am more interested in life during life, thank you very much. I’ll let the afterlife take care of itself.

But in their point counterpoint, they both refer to a Lancet article about NDE’s and it then begs the question:

Does anyone actually read or understand the literature they quote ?

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Posted in: Clinical Trials, Neuroscience/Mental Health, Science and the Media

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Science and Health News Reporting – The Case of the Regenerating Finger

Last week it was widely reported that an Ohio man, Lee Spievak, had regrown the end of his finger that had been chopped off in an accident. Reporters informed us, for example:

A man who sliced off the end of his finger in an accident has re-grown the digit thanks to pioneering regenerative medicine.

But this was not the real story. The true and amazing tale, rather, is of how the mainstream news media utterly failed to properly report this story. This is not an isolated incident, but a commonplace example of a broken system, and one that is getting worse. But first, let’s see how this reporting went wrong.

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Posted in: Science and the Media

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Mercury emissions from coal-burning power plants and autism: Is there a correlation?

ResearchBlogging.orgOn April 30, outside the courthouse in Dallas, a press conference/rally was held. This particular rally was in response to a new study published by a group led by Dr. Raymond F. Palmer in the Department of Family and Community Medicine at the University of Texas Health Science Center in San Antonio, whose conclusion was that autism prevalence correlates strongly with proximity to mercury-emitting coal-burning power plants and other industrial sources of airborne mercury, the implication being that such sources of mercury may be causal or contributory to the development of autism. Unfortunately, the rally was reported by the media as though this study were slam dunk evidence that mercury environmental mercury is a definite contributor to the development of autism. For example, there is some video (also here) from local news sources of the rally, in the first of which it is stated as fact that mercury caused autism in the child featured in the story and in the second of which a mother who thinks that mercury causes autism is quoted credulously. This study has had much less play in the national news, but antivaccination activists, such as the ones at the Age of Autism website, a site whose main theme is that either mercury in the thimerosal preservative that used to be in childhood vaccines before 2002 or vaccines themselves cause autism, both promoted the rally and posted a glowing and credulous take on the study, as did “alternative medicine” and antivaccinationist website NaturalNews.com.

My first thought upon reading of this is that it is yet more vindication of the science showing that the claim that mercury in thimerosal-containing vaccines is a failed hypothesis. After all, as I have predicted time and time again, as the scientific and epidemiological evidence continued to mount that thimerosal is just plain not associated with autism or autism spectrum disorders, even the most diehard adherents to this belief are starting to realize that they were backing a losing horse, especially since thimerosal was removed from all childhood vaccines other than the flu vaccine in 2001, leaving only trace amounts from the manufacturing process and there is no sign that autism prevalence is falling. That’s why lately, their effort has shifted from primarily demonizing mercury to blaming other “toxins” in vaccines, even to the point that their efforts to demonize some ingredient–any ingredient–in vaccines often reaches ridiculous levels of blatant silliness, such as touting sucrose as one of those “toxins.” Indeed, I was puzzled. If environmental mercury is the new cause of autism, then the rationale antivaccinationists use to demonize vaccines and portray their children as “vaccine-damaged” is much less potent. Why on earth would they tout this study, which, even if a good study (and it’s not), would weaken their arguments against vaccines immeasurably and take power away from their whole new propaganda slogan “Green Our Vaccines”? The only reason I could think of is that perhaps they somehow think that if mercury in the environment can be linked to autism that maybe–just maybe–they can convince people that they were right about mercury in vaccines all along. Indeed, this seems to be the sort of tack that David Kirby took a year ago when he started arguing that mercury emissions from coal-burning power plants in China (which do reach California), coupled with mercury emission from crematoria in which cadavers with mercury fillings were burned, were contributing to the continued increase in the autism caseload in California despite the elimination of thimerosal in 2001.

But what does the study say itself? Is it good evidence that airborne mercury from coal-fueled power plants is an important contributor to the development of autism? I will argue no, because the study’s flaws are so innumerable that it is well nigh uninterpretable. For simplicity’s sake, to summarize its findings, I’ll quote a Science Daily press release about it:
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Posted in: Neuroscience/Mental Health, Public Health, Science and the Media, Vaccines

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Charlie Woo TV

Some of us received the announcement a week ago of the Bravewell Collaborative’s planned conference on “Integrative Medicine” co-sponsored with the National Academies’ Institute of Medicine, to take place in February, 2009.  (Note: I like to cap slogans and commercial trademarks and such and enclose them in quotation marks. Especially when the terms have no consensus meaning or are intended to obscure and confuse. ) 

Several of us may blog on the announcement. I want to emphasize a few points that struck me as revealing.  

The announcement also listed Friday’s Charlie Rose Pub TV interview program with Harvey Fineberg, MD, President of the “IOM,” Christy Mack, wife of the CEO of Morgan Stanley and the ideologue behind Bravewell and the project, and Ralph Snyderman, ubiquitous former dean of Duke University Medical School now vagabond “CAM” promoter and fund raiser. 

First off was a significant disclosure. Charlie Rose had been married at one time to Christy Mack’s sister, and Christy and he were still dear friends. As if disclosure is enough to help a viewer distinguish between facts and views obscured by a haze of politeness, appreciation, and gooey mutual stroking.

So much for  investigative, penetrating, and revealing journalism.

Snyderman, whose school was recipient also of large Templeton Foundation grants to ivestigate significance of spirituality and religion in “healing” revealed that he at one time was one of those straight arrow physicians who treated disease (instead of a person.) Until he experienced some of “the techniques” – unspecified – himself. In typical testimonial phrasing, he found it wondrous that something as intangible as hope could help heal. (Some of us also find that wondrous – even dubiousl.)  And then the tried and trite criticisms of docs being too involved in details (like what works and how to use it) and losing sight of the “whole person.”  ”Health is a value and one can have impact…” Eyes roll at such platitudinous and vacuous language.

If that were not enough, Fineberg demonstrated his deep knowledge of “Integrative Medicine” by telling the difference between “healing” and “curing,” and his democratic outlook by wanting to test any methods that works – regardless of the origin. David G’s blog the other day and Kim Atwood’s previous words discussed that issue, which still befuddles the NCCAM, which seems to test anything whether it contains molecules or not, and whether the idea generated in a crucible of observation and experimentation, or descended in a 2 AM drug-induced revelation.  He then used artemisinin (for resistant malaria) to illustrate the potential mining of miraculous natural drugs from traditional Chinese Medicine. I assume he assumed that TCM practitioners had  had been using it for malaria for centuries…despite the fact that there was no description of infectious diseases in TCM. Finding artemisinin for malaria was a product of extraction and purification from plants, known as modern pharmacology.

Christy Mack tried to introduce new concepts, explaining that one of her new aims is to empower the patient to heal oneself…That is not only decades old, but a word-linkage that, as with all esoteric ideation , means a lot to her and her co-believers, but little to the uninitiated.  Another concept was for each person to make a personal health plan for one’s life.  Can’t I do that now if I want? Seems I already did, then chance and nature intervened…

When Snyderman let slip the term, “CAM”, Mack jumped in saying, “Integrative Medicine” is not “CAM”.  Here was a clue to the joining of these otherwise poorly fitting edges of “IM” and the “IOM.”   We just won’t talk about those inconvenient absurdities that “IOM” might shrink from. My take is that Mack and ”CAM” advocacates want the blessings of as many System organizations as possible to fill their “CAM” CV as prelude to legitimization, licensing, and insurance reimbursement.  “CAM” practitioners are using the Bravewell as internediary to using “IOM.” Morgan Stanley money being an efficient lubricant. Simple.

So “IOM,” in exchange for more $?millions as it did for the NCCAM committee, sells itself and its merit badge for ”CAM”‘s  CV sash.  Fair exchange in this capitalist system, yes?  Seems that the only factor nissing in this exchange that keeps it from illegality is a sexual act. The Quiet Revolution moves on. 

Personal note: In 1993 when I awoke from 3 weeks of post-op unconsciousness in the ICU, the first things I recalled were on the overhead TV: the NCAA basketball finals, the Waco cult building complex on fire, and Charlie Rose interviewing another talking head with that ominous blacked-out background. The Quiet Revolution moves on as the Nightmare recurs. �

Posted in: Faith Healing & Spirituality, Health Fraud, Medical Academia, Science and Medicine, Science and the Media

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How Can Smart People Be So Stupid?

This is a quick posting that begins to respond to the question posted today by Joe:

What I don’t understand is why the majority of doctors at Columbia did not say “This is obvious abuse of patients, and it will not be tolerated here.” Given his richly-deserved malpractice record, why was [Gonzalez] even associated with Columbia?

David Gorski answered it in part: “Grant money.” There are also other factors: widespread naivete about the nature of quackery, ignorance of the methods themselves, widespread lack of scientific sophistication among physicians (!), unwillingness to appear contrary to whatever the current trendy thing may be and more. I’ll mention some of the particulars regarding Columbia and Gonzalez over the next couple of weeks.

But today this advertisement arrived:

FOR IMMEDIATE RELEASE

A discussion about Integrative Health with Christy Mack, President of The Bravewell Collaborative, Ralph Snyderman, Chancellor Emeritus for Health Affairs at Duke University, as well as President and CEO of Duke University Health System and Dr. Harvey Fineberg, President of the Institute of Medicine will air on the Charlie Rose show tonight. Please check your local listings for times and future air dates.

For more information or to view the segment on-line, please click on the following link: http://www.charlierose.com/shows/2008/03/28/2/a-discussion-about-integrative-health

Those of you who’ve been following SBM will recognize the imprints of all 3 of Charlie Rose’s guests in recent posts: Harvey Fineberg, who presided over the IOM’s entry in the most recent W^5/2; Christy Mack of the Bravewell Collaborative, which bankrolls the Consortium of Academic Health Centers for Integrative Medicine; and Ralph Snyderman of Duke. Snyderman and the “Consortium” were the authors of two of the misleading passages quoted in Misleading Language: the Common Currency of “CAM” Characterizations Part II.

I suspect that this show will reveal a lot—to those who are aware of the language distortions—about the insidious creep of pseudomedicine into places where it has no business going. If you can’t watch it tonight, go to the website and see it another time.

Posted in: Health Fraud, Medical Academia, Science and the Media

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The Business of Being Born

One of our readers asked for a critique of the movie “The Business of Being Born.” I guess my sex and specialty make me the best qualified to comment. I delivered over 200 babies as a family physician. I had two babies of my own (at age 37 and 39), one with intervention (forceps) and one 9-pounder who almost “fell” out before the obstetrician was ready.

“The Business of Being Born” is a movie about midwives, home births, and hospital births in America. It’s a sort of kinder, gentler “Sicko” with onscreen births, gooey, bloody newborns and fat naked women. The message of the movie is that for an uncomplicated pregnancy, natural home births with midwives are better and safer than medicalized hospital births with obstetricians. It’s strong on sound bites, emotional appeals, and superficial arguments, but weak on substance, depth, and scientific evidence for its claims.
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Posted in: Science and Medicine, Science and the Media

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The Hannah Poling case and the rebranding of autism by antivaccinationists as a mitochondrial disorder

Regular readers of this blog may have noticed that I seem to have taken on the role of the primary vaccine blogger of this little group of bloggers trying desperately to hold the forces of pseudoscience and magical thinking at bay in the face of powerful forces trying to “integrate” prescientific belief systems with science- and evidence-based medicine, a process that would be unthinkable in just about any other field of applied science, such as aeronautics or the physics used in engineering, just as creationists try to “integrate” religion with biology. Although I do have a strong interest in the antivaccination movement in general and the claim that vaccines, or the mercury in the thimerosal preservatives that was in many childhood vaccines in the U.S. until late 2001 or early 2002 (when they were taken out) are a major cause or contributor to autism, such had not been my intention. When I started here on SBM, I had intended to be a lot more diverse. Indeed, I had even had another topic entirely in mind for this week’s post, but, as happens far too often, news events have overtaken me in the form of a story that was widely reported at the end of last week. It was all over the media on Thursday evening and Friday, showing up on CNN, Larry King Live, the New York Times, and NPR. It happens to be the story of a girl from Georgia named Hannah Poling whose case before the Vaccine Injury Compensation Program (VICP), which had originally part of a much larger proceeding known as the Autism Omnibus in which nearly 5,000 parents are petitioning the VICP for compensation based on the claim that their children’s autism were caused by vaccines, was settled by the government. This settlement was based on the observation that Poling had a rare genetic mitochondrial disease that may have been exacerbated by a series of vaccines that she had, after which, among many other problems, Hannah regressed and developed some autism-like symptoms and then months later a seizure disorder. Instantly, it was being trumpeted all over the Internet, blogosphere, and media that the government had “admitted” that vaccines cause autism. One particularly excitable antivaccinationist named Kent Heckenlively (whom we’ve met before), even went so far as to foreshadow the propaganda blitz that was to come as he wrote on the antivaccine blog Age of Autism a full week before this news blitz began:

It’s official.  The sky has fallen.  The fat lady has sung.  Pigs are flying.

[...]

In a settlement, the settling party tries to admit as little as possible.  It’s like what I imagine the settlement claim against Bill Clinton in the Paula Jones case must look like.  Nowhere in the document does he admit to dropping his pants in a hotel room and asking her to kiss it.  It likely says something along the lines of he concedes they were in a hotel room together, they were alone, and something happened which formed the basis of her law suit.

But we all know what happened there.  And we know what this settlement means.

The government just dropped its pants.

One thing this shows us is just how the blogosphere can be bubbling with information that lets one predict a public relations blitz like this. The mainstream press seemed to have been totally blindsided by this story, but if reporters had only been checking the right blogs, they would have known about it a full week before, if not longer. In any case, since Thursday, there has been a very well orchestrated public relations campaign to frame this settlement as the government “admitting” that vaccines cause autism. It’s not, as I will try to explain, but framing it that ways has thus far been a very effective PR strategy for antivaccinationists. In my nearly three years of following this topic, I thought that I had never seen anything like it before.

But I had.

This case is nothing more than a demonstration that everything old is new again and that, no matter what the science says, it’s always all about the vaccines, the claims of antivaccinationists otherwise notwithstanding, as I will now show. What we are seeing now, as we did a few years ago, is the rebranding of autism as a condition in order to serve the purposes of the antivaccination movement.
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Posted in: Public Health, Science and Medicine, Science and the Media, Vaccines

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Toxic myths about vaccines

Ever since there have been vaccines, there has been an antivaccination movement. It began shortly after Edward Jenner discovered how to use the weaker cowpox virus to induce long-lasting immunity to smallpox, there has been resistance to the concept of vaccination, a resistance that continues to this very day. Reasons for this resistance have ranged from religious, to fear of injecting foreign substances, to simple resistance to the government telling people what to do. Some fear even the infitessimally small risk that vaccines pose for the benefit of resistance to disease far more than they fear the diseases themselves, a result of the very success of modern vaccines. Of course, vaccines, like any other medical intervention, are not without risks, making it easy for them to jump on any hint of harm done by vaccines, whether real or imagined, even though vaccines are among the very safest of treatments.

One of the biggest myths that antivaccinationists believe and like to use to stoke the fear of vaccines is the concept that they are full of “toxins.” The myth that mercury in the thimerosal preservative commonly used in vaccines in the U.S. until early 2002 was a major cause of autism is simply the most recent bogeyman used to try to argue that vaccines do more harm than good, as was the scare campaign engineered in response to Andrew Wakefield’s poor science claiming a link between the MMR vaccine and autism. Now that study after study have failed to find or corroborate a link between thimerosal in vaccines or vaccines in general and autism to the point where even the most zealous of zealots are having a hard time defending the claim that mercury in vaccines cause autism any more, predictably the campaign against vaccines has fallen back on the old “toxins” myth. If you peruse antivaccinationist websites, it won’t take long to find articles claiming that vaccines are full of the most terrifying and nasty toxins. Examples in the media abound as well. For example, Jenny McCarthy, comic actress and former Playboy Playmate who has been doing the talk show and publicity circuit lately to plug her book in which she claims that vaccines caused her son’s autism and that she was able to cure it with “biomedical” interventions and diet, recently gave an interview in which she said:

What I really am is “anti-toxins” in the vaccines. I do believe that there is a correlation between vaccinations and autism. I don’t think it’s the sole cause, but I think they’re triggering–it’s triggering–autism in these kids. A really great example is…is, sometimes obesity can trigger diabetes. I do believe that vaccines can trigger autism…It’s so much more than just mercury. That is one ingredient in the recipe of autism…I’m talking about all of them. I’m calling for cleaning out the toxins. People don’t realize that there is aluminum, ether, antifreeze, still mercury, in the shots…People are afraid of secondhand smoke, but they’re OK with injecting the second worst neurotoxin on the planet in newborns.

Another example of what I sometimes call the “toxin gambit” comes from Deirdre Imus, wife of shock jock Don Imus, with both husband and wife being well-known and reliable media boosters of the claim that vaccines somehow cause autism:

So, where are the evidenced based (conflict free) studies that prove the safety of these “trace” amounts and proof that there are “no biological effects” of any amount of mercury being injected into our children and pregnant moms? Also, where are the evidence based studies proving the safety of vaccines given to pregnant moms and our children that contain other toxins such as aluminum and formaldehyde?

The most recent example of this tactic comes from an organization called Generation Rescue, which just last week ran a full-page ad in USA Today, paid for in part by Jenny McCarthy and her present boyfriend Jim Carrey:

antivaxgradvertisement.jpg

Besides being one of the most egregious examples of a post hoc ergo propter hoc fallacy that I’ve ever seen from an antivaccination site, this Generation Rescue ad demonstrates clearly a new strategy (or, more properly, a resurrection of an old technique) now that science is coming down conclusively against mercury in vaccines as a cause of autism, a strategy of propagating fear by linking vaccines with “toxins.” So what’s the real story? Are there really deadly toxins in vaccines that parents should be worried about?
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Posted in: Public Health, Science and Medicine, Science and the Media, Vaccines

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Alternative Medicine, and the Internet

When I think back to my own ‘discovery’ of the skeptical movement, it grew out of my experience watching the James Randi Secrets of the Psychics NOVA special. After being enthralled with the special (and with several Randi books already in my library) I sought Mr. Randi out on the Internet. In chat rooms, blogs, forums and skeptical conferences such as TAM this is a tale I’ve heard repeated many times; folks heard about the JREF of CSICOP (now CSI) and then used the World Wide Web to learn more about these organizations.

Recently I began to wonder about my own personal pet peeve (unscientific medicine) and how it has benefited from the Web’s huge explosion and influence. Certainly there are plenty of great sites out there that help to show much of so-called Alternative Medicine for what it really is – blogs like this, Dr. Stephen Barrett’s Quackwatch.org site, the National Council Against Health Fraud, and many other important sites; still the number of sites extolling the virtues of science and critical thinking pale in comparison to those that forward notions embracing magical thinking and quack-related products and health claims. A quick examination of the web’s most popular search tool (Google) shows us the cold hard facts about who’s winning the war of medical woo:

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