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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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Touch – a Trojan Horse

Touch – Ouch. here they are again.

I had planned to post contents of a letter written a decade ago to a Washington Post reporter on why med schools would entertain associating with quacky methods and their advocates. But an article in the SF Chronicle intruded on May 25 on a research project at Stanford on “Healing Touch” (HT). The project is to test if HT affects symptoms of cancer and chemo- and radiotherapy. HT at Stanford?

I had sat down to write a letter to the editor when a call came through Center for Inquiry, where the reporter had called asking for someone to give her information on HT at Stanford. She called within a minute, apologetic for not having included critical comments from others. She had received emails already from irate scientists who told her about 11 year old Emily Rosa’s experiment published in the AMA Journal showing non-existence of human energy fields, which the HT practitioners claimed to be manipulating. And wasn’t HT different from Therapeutic Touch – (TT?) From the reporter’s description, I saw little difference except these HT people seemed to make more of fixing subjects’ chakras.

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Posted in: Energy Medicine, Medical Academia

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The Media and Vaccines

As the name of this blog makes clear, the authors believe that the public is best served when the institutions of medicine and health care are science-based. The basis of medicine has many levels and institutions in our society. They include not only the practitioners of medicine, but hospitals, medical schools and other academic institutions, government and regulatory agencies, industry, insurance companies, the legal system, media, and (last but not least) the public. Defending science-based medicine requires advocacy at every level.

Arguably, the acceptance of science-based medicine at all levels is influenced greatly by public opinion (too much, in my opinion, as a profession, almost by definition, should rise above the lowest common denominator of public opinion), and public opinion is influenced greatly by the mainstream media. There is one issue, however, for which public opinion has a direct and measurable effect on the efficacy of a medical intervention and that is the vaccination program. Therefore we pay particular interest to how the media deals with the issue of vaccines, especially the recent false controversy over an alleged link between vaccines and autism.

It is my observation (and also supported by a recent study) that the quality of mainstream science reporting has been generally low, attributed to the scaling back of dedicated science journalists. On this issue I have found the reporting to be mixed, with both good and bad examples, but with the highest quality outlets generally getting the story right. This week Time magazine’s cover story is The Truth About Vaccines by Alice Park. The article is excellent – it covers the controversy without pandering and without pretending that there is more of a scientific controversy than there is. She states quite succinctly that the evidence has been evaluated by scientific organizations and there simply is no credible evidence for a link between autism and vaccines.

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Posted in: Public Health, Science and the Media, Vaccines

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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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The Weekly Waluation of the Weasel Words of Woo #6

An Apology

OK, I plead guilty to being a week late in this crucial series—one that has the vast readership of SBM sitting on the edge of its collective seat! Proof of that assertion, of course, is found in the overwhelming number of Waluations submitted for the passage offered in the W^5/2 #5: Six. Another apology, if only a minor one: when I wrote, “the ‘plot’ of that paragraph has a little something that’s different from the usual fare,” I was probably wrong. I thought, somehow, that the passage had promoted the idea that “the integrative medicine movement” might offer physicians an antidote to “the limitations managed care has placed on their earning capacity.” Upon rereading the passage, I realized that it had not explicitly made that assertion.

A Wawiety of Cweative Waluations

Your faithful judge was faced with a difficult task this time: there were several clever and thoughtful Waluations, but they were so different from one another, stylistically, that choosing among them became an Apple ’n’ Orange typa thing. Let’s get to it: (more…)

Posted in: Humor

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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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The Real ID

Stein: When we just saw that man, I think it was Mr. [PZ] Myers, talking about how great scientists were, I was thinking to myself the last time any of my relatives saw scientists telling them what to do they were telling them to go to the showers to get gassed.Stein (speaking about the Holocaust): …that was horrifying beyond words, and that’s where science — in my opinion, this is just an opinion — that’s where science leads you.Crouch: That’s right.

Stein: … Love of God and compassion and empathy leads you to a very glorious place, and science leads you to killing people.

I am a full time Infectious Disease physician. In the short hand of the medical field, I am an ID doc. Recently, saying I do ID is kind of like having last name like Himmler. No relation, but a vague discomfiture that I might be misrecognized as something else.

My ID, the real ID, along with medicine, is a branch of science (I always hear Mangus Pyke in the Thomas Dolby song when I type the word) with a long history, of, well, saving lives. Lots of lives. Millions and millions of lives. And relieving suffering. The simplest of things have been responsible for the long and reasonably healthy lives we get to have here in the industrialized world.

The Science-Based Medicine Blog deals with what Merlin Mann refers to as first world problems. The fine points of botanicals and prostatism or whether the placebo effect is the cause of the response to acupuncture. Interesting though these topics can be to some, when it comes to the overall health of most of us in the first world the main triumphs of science (Or is Ducks Breath I hear? “I have a masters degree in Science”) occurred over a century or two ago. The science of 200 years ago, by the standards of today, was simple, with simple results, but lead to remarkable advances in longevity and health.

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Posted in: Science and the Media

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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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