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Screening for disease in people without symptoms: The reality

One of the most contentious questions that come up in science-based medicine that we discuss on this blog is the issue of screening asymptomatic individuals for disease. The most common conditions screened for that we, at least, have discussed on this blog are cancers (e.g., mammography for breast cancer, prostate-specific antigen screening for prostate cancer, ultrasound screening for thyroid cancer), but screening goes beyond just cancer. In cancer, screening is a particularly-contentious issue. For example, by simply questioning whether mammography saves as many lives lost to breast cancer as advocates claim, one can find oneself coming under fire from some very powerful advocates of screening who view any questioning of mammography as an attempt to deny “life-saving” screening to women. That’s why I was very interested when I saw a blog post on The Gupta Guide that pointed me to a new systematic review by John Ioannidis and colleagues examining the value of screening as a general phenomenon, entitled “Does screening for disease save lives in asymptomatic adults? Systematic review of meta-analyses and randomized trials.”

Before I get into the study, let’s first review some of the key concepts behind screening asymptomatic individuals for disease. (If you’re familiar with these concepts, you can skip to the next section.) The act of screening for disease is based on a concept that makes intuitive sense to most people, including physicians, but might not be correct for many diseases. That concept is that early intervention is more likely to successfully prevent complications and death than later intervention. This concept is particularly strong in cancer, for obvious reasons. Compare, for example, a stage I breast cancer (less than 2 cm in diameter, no involvement of the lymph nodes under the arm, known as axillary lymph nodes) with a stage III cancer (e.g., a tumor measuring greater than 5 cm and/or having lots of axillary lymph nodes involved). Five year survival is much higher for treated stage I than for treated stage III, and, depending on the molecular characteristics, the stage I cancer might not even require chemotherapy and can be treated with breast conserving surgery (“lumpectomy” or partial mastectomy) far more frequently than the stage III cancer. So it seems intuitively true that it would be better to catch a breast cancer when it’s stage I rather than when it’s stage III.
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Posted in: Cancer, Clinical Trials, Epidemiology, Public Health

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An aboriginal girl dies of leukemia: Parental “rights” versus the right of a child to medical care

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One topic that keeps recurring and obligating me to write about it consists of critically analyzing stories of children with cancer whose parents, either on their own or at the behest of their child, stop or refuse chemotherapy or other treatment. It is, sadly, a topic that I’ve been discussing for nearly a decade now, starting first on my not-so-super-secret other blog and continuing both there and here. Indeed, the first post I wrote about this problem was in November 2005, a fact that depressed me when I went back through the archives to find it because so little has changed since that time.

I was painfully reminded of this last week when stories started circulating in the media about the death of Makayla Sault, an Ojibwe girl and member of the New Credit First Nation in Ontario:

The entire community of New Credit is in mourning today, following the news of the passing of 11 year old Makayla Sault.

The child suffered a stroke on Sunday morning and was unable to recover. Friends and family from across the province travelled to New Credit First Nation today to offer condolences, share tears and pay their respects.

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Posted in: Cancer, Public Health, Religion, Science and the Media

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The Disneyland measles outbreak: “Dr. Bob” Sears says measles isn’t that bad, and an antivaccine activist invokes the Brady Bunch fallacy

Editor’s note: There is an extra special bonus guest post today in addition to my regular post. It’s by Paul Knoepfler, a stem cell biologist, and it’s about unregulated stem cell clinics. Be sure to check it out!


BradyBunch

Last week, I wrote about a rather impressive measles outbreak at the “happiest place on earth,” a.k.a. Disneyland. At the time I wrote that post, the outbreak, which had reached several states, had spread to 17 people. As I sat down to write this, I wasn’t actually sure that this topic needed another post, but then I saw this:

As the number of measles cases continues to rise in Southern California following an outbreak at Disneyland last month, about two dozen unvaccinated students at one Orange County high school have been forced to stay home after a classmate contracted the disease.

In a message to students and parents at Huntington Beach High School on Thursday, Pamela Kahn, health and wellness coordinator at the Orange County Department of Education, said that students “who do not have any documented [measles, mumps and rubella] immunizations will be excluded from attending school until January 29.”

Also, the number of confirmed measles cases has climbed to 52, 46 of them in southern California. In Orange County itself, there were 16 cases as of Friday, ten of them linked to Disneyland, the rest not, a finding that’s led health officials to conclude that “measles has become more widespread throughout the county.” Not surprisingly, health officials in Californian are warning that the number is likely to go higher still. In fact, it’s already happening as “satellite” outbreaks are being reported as children infected at Disneyland come home and infect others.
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Posted in: Science and the Media, Vaccines

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Say it ain’t so, Mickey! A holiday measles outbreak makes the happiest place in the world sad

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Last week, the self-proclaimed “happiest place on earth” wasn’t so happy.

One of the disadvantages of posting once a week is that, unless I muscle in on someone else’s day I can’t respond rapidly to stories that appear early. Of course the flip side of that is that if a story appears over the weekend it’s all mine, and, besides, I have my not-so-super-secret other blog to respond to issues that occur earlier in the week. Another advantage is that, if I do decide to write about something from earlier in the week, I have the advantage of time to think.

You’ve probably figured out that what I’m referring to is the latest measles outbreak. Not surprisingly, it happened in the Los Angeles area. Surprisingly (or perhaps not so much), it happened at Disneyland. I say “not surprisingly” because it’s been well-publicized over the last few years that there are pockets of low vaccine uptake and high personal belief exemptions in California, complete with measles and pertussis outbreaks. This is thanks to pockets of affluent, entitled parents full of the Dunning-Kruger effect who think that they can learn as much about vaccines and autism via Google University as pediatricians and researchers who have devoted their entire professional careers to studying them. Of course, these parents are also facilitated by pediatricians who cater to their fears, the most famous of whom is Dr. Bob Sears, whose The Vaccine Book is a very popular, reasonable-sounding (to parents not aware of the antivaccine tropes within) bit of antivax lite, but there is also our old buddy Dr. Jay Gordon and a host of others.

So what happened at Disneyland? On January 7, the California Department of Public Health confirmed seven measles cases:
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Posted in: Public Health, Vaccines

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Is cancer due mostly to “bad luck”?

One of the more difficult conversations to have with a patient as a cancer doctor occurs when a patient, recently informed of her diagnosis of, for example, breast cancer, asks me, “Why did I get this? What caused it?” What almost inevitably follows is an uncomfortable conversation in which explanations of the multiple known causes of breast cancer do not satisfy the patient. The reason, of course, is because when a patient asks, “What caused it?” she doesn’t mean what causes breast cancer in general or in statistical terms. Rather, she means, what caused my breast cancer? It’s a question that can only occasionally be answered. For instance, if it’s lung cancer and the patient is a smoker, then it was almost certainly smoking that caused the cancer, because lung cancer is a relatively rare cancer in the absence of smoking. In the case of breast cancer, contrary to the prevailing belief that leads women with breast cancer to be puzzled about how they could get it when there’s “no cancer” in their families, only around 5-10% of cases have a familial or genetic component. That means that around 90% of breast cancers are what we call “sporadic,” which means that we can’t identify a specific cause. Or, as I like to say, “We just don’t know.” Worse, in the case of breast cancer, the environmental factors we know about appear to contribute modestly at best to the risk of cancer. (More on this later.)

Understandably, patients hate hearing “We just don’t know,” some vague handwaving about genes, and that there is nothing that we know of that they did that caused their cancer. People—including oncologists—really don’t like the concept of “sporadic” cancer, mainly because humans crave explanation. The default assumption is that everything must happen for a reason and there must be a cause for every disease or cancer. Perhaps the most ridiculously emphatic statement of this that I’ve encountered thus far comes from (who else?) über-quack Mike Adams when he heaped contempt on the idea of sporadic disease as “spontaneous disease.” He did this in the context of a story describing how, after Dr. Mehmet Oz had followed recommended care and undergone screening colonoscopy to look for polyps, he was shocked that he actually had some. This led Adams, in his usual inimitable fashion, to construct a straw man so massive that it could be seen from space when he set it on fire, declaring that “colon polyps, in other words, appear without any cause!” and that “mainstream medicine…believes in the theory of ‘spontaneous disease’ that ‘strikes’ people at random.”

Not exactly.

On the other hand, there is a lot of randomness in disease, not just cancer, as hard as it is for Mike Adams, or anyone to accept. Just because there is a varying amount of randomness in who gets a disease does not mean that mainstream medicine claims there is no cause to these diseases. Rather, for diseases like cancer, it’s a stochastic process, meaning that chance can play a role—sometimes a big role—in determining who gets sick. Indeed, just last week there was more evidence supporting this idea published in Science. Unfortunately, much of the mainstream press coverage presented the message of the paper a bit too simplistically. Even more unfortunately, it was the authors who encouraged this, as did the Johns Hopkins University press release about the study, which was entitled “Bad Luck of Random Mutations Plays Predominant Role in Cancer, Study Shows“. Yes, I groaned when I read this title.
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Posted in: Basic Science, Cancer, Epidemiology, Science and the Media

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Stem cells versus Gordie Howe’s stroke, part 2

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Another Christmas has come and gone, surprisingly fast, as always. I had thought that it might make a good “last of 2014″ post—well, last of 2014 for me, anyway; Harriet and Steve, at least, will be posting before 2014 ends—to do an end of year list of the best and worst of the year. Unfortunately, there remains a pressing issue that doesn’t permit that, some unfinished business, if you will. I’m referring to a story I commented on last week, specifically the credulously-reported story of how 86-year-old hockey legend Gordie Howe is doing a lot better after having undergone an experimental stem cell therapy for his recent stroke. As you might recall at the time, I saw a lot of holes in the story. It turns out that over the last week there have been developments that allow me to fill in some of those holes. Unfortunately, other holes still remain.

First, a brief recap is in order (You can click here for a more detailed timeline). Gordie Howe suffered a massive stroke on October 26, leaving him hemiplegic and with serious speech impairment. Since then, judging from various media reports, he has been slowly improving, although not without significant setbacks. We also know that Howe suffers from significant dementia. Out of the blue, a press release issued on December 19 by the Howe family announced that on December 8 and 9, Gordie Howe “underwent a two-day, non-surgical treatment at Novastem’s medical facility. The treatment included neural stem cells injected into the spinal canal on Day 1 and mesenchymal stem cells by intravenous infusion on Day 2.” His response was described as “truly miraculous,” although, as I pointed out in my post, it’s not clear exactly what “miraculous” meant, given conflicting contemporaneous news accounts before the Howe family press release, particularly his hospitalization from December 1 to 3 for a suspected stroke that turned out to be dehydration.

I noted a number of problems with the story, the first of which is that Howe was clearly not eligible for the clinical trial offered by Stemedica, a company in San Diego that manufactured the stem cells used. Another glaring issue was my inability to locate any description of an actual clinical trial for stroke offered by Novastem. I could find no such trial listed in ClinicalTrials.gov, and you, our intrepid readers, searched the registry maintained by the Mexican Federal Commission for the Protection Against Sanitary Risk (COFEPRIS) and were not able to find any registered clinical trials for stroke being carried out by Clínica Santa Clarita, the clinic Novastem operates. What you, our intrepid readers, did find were trials of stem cells for:

I did the search again over the weekend, and there were no further trials that I could find.
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Posted in: Clinical Trials, Medical Ethics, Science and the Media

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Stem cells versus Gordie Howe’s stroke

GordieHowe1

Note: There is now a major update to this story published here, which explains a lot of the questions remaining in this blog post.

Seven years ago I returned to Michigan, where I was born and spent the first quarter century of my life, after an absence of more than 20 years. In the interim, I had done my surgical residency and earned my PhD in Cleveland, a surgical oncology fellowship in Chicago, and worked in New Jersey at my first academic job for eight and a half years. Then I was lured back with a job in Detroit. One of the odd things about this return after such a long absence was the culture shock, how much I had forgotten about the Detroit area. One of those things that I had forgotten is just how crazy about hockey Michigan, in particular Detroit (meaning the Detroit metropolitan area), is. Detroiters love their Red Wings—love them. Hockey is ingrained in the suburban culture from a very young age, so much so that many Canadians would feel right at home here. Memories of trying and failing to be halfway decent at street hockey and of not being anywhere good enough a skater even to try real hockey as a teen came flooding back to me. (It didn’t help that back then I was approaching six feet tall and weighed only 135 lbs.; “beanpole” didn’t even begin to describe me back then.) In fact, the “cultural center” of the town where I live consists of—I kid you not—a hockey rink and some classrooms that are used for various community functions. No, really, it’s named the city’s Cultural Center.

So it should be no surprise, given how much Detroiters love hockey in general and their Red Wings in particular that it was big news here in late October when Red Wing legend Gordie Howe at age 86 suffered a debilitating stroke that paralyzed the right side of his body, a condition known as hemiplegia. Understandably, there was an outpouring of good wishes for recovery, coupled with retrospectives of Howe’s stellar hockey career. Indeed, I remember that Howe’s condition sounded bad enough from the tenor of the news reports at the time that it seemed likely that he would not survive. But survive he did, and is apparently recovering slowly, with occasional setbacks, such as a recent hospitalization in early December for a suspected “mini-stroke” that turned out to be dehydration and several much smaller strokes before that. The most recent press report I saw before the announcements I’m going to discuss described Howe as on the upswing again.

Then, on Friday, I saw headlines all over the place that were basically similar to this Detroit Free Press headline, “Gordie Howe underwent stem cell clinical trial in Mexico.” The story consisted largely of a press release from Howe’s family that read:
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Posted in: Clinical Trials, Medical Ethics, Pharmaceuticals, Science and the Media

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Hostility towards scientific consensus: A red flag identifying a crank or quack

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I have yet another grant deadline to deal with, this time for the Department of Defense Congressionally Directed Medical Research Programs, this time around its Breast Cancer Research Program. Unfortunately, that put a high degree of time pressure on me. Fortunately, there’s still stuff in the archives of my not-so-secret other blog that I deem quite appropriate for this blog and that can be updated with minimal effort. If you don’t know what I’m talking about when I refer to my not-so-secret other blog, then it’ll definitely be new to you. If you haven’t been reading that blog for at least four and a half years, it’ll be new to you as well. And even if you have seen it before, I think it’s worth revisiting.

Why? It came up because of an encounter I had on Twitter with Jane Orient, MD, who, as you might recall, is the executive director of the American Association of Physicians and Surgeons (AAPS). I’ve written about the AAPS before. You can get the details in the link, but if you don’t have time suffice to say that it is an entire organization of libertarian-leaning “brave maverick doctors” who think Medicare is unconstitutional, don’t believe that the government should have much, if anything, to do with regulating the practice of medicine, and reject evidence-based guidelines as an unholy affront to the independence of the physician. Along the way, the AAPS, through its journal, The Journal of American Association of Physicians and Surgeons (often abbreviated JPANDS), promoted antivaccine views, including the discredited concept that vaccines cause sudden infant death syndrome, HIV/AIDS denialism, and the scientifically unsupported idea that abortion causes breast cancer (a topic I might have to revisit, given the activity promoting it recently).

In any case, two or three weeks ago, I was having a bit of an exchange with Dr. Orient over anthropogenic global climate change (often abbreviated as AGW, for anthropogenic global warming, for short), the well-accepted science that concludes that CO2 generated by human activity is having a serious warming effect on the earth’s climate. As you might expect, she’s not big on this particular scientific consensus. I forgot about it, but then the other day saw this Tweet exchange between Dr. Orient and Ed Wiebe:
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Posted in: Critical Thinking, Science and Medicine

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Vani Hari, a.k.a. “The Food Babe,” finally responds to critics

WhatifItold

It’s no secret that we here at Science-Based Medicine (and many scientists and skeptics with a knowledge of basic chemistry and biology) have been very critical of Vani Hari, better known to her fans as The Food Babe. The reasons for our criticisms of her are legion. Basically, she is a seemingly-never-ending font of misinformation and fear mongering about food ingredients, particularly any ingredient with a scary, “chemically”-sounding name.

Not surprisingly, as the Food Babe has gained prominence her antics have attracted more and more criticism for her toxic combination of ignorance of chemistry coupled with fear mongering. The criticism started with science and medical bloggers and leaked into the mainstream press, most recently in the form of a recent NPR blog entry entitled “Is The Food Babe A Fearmonger? Scientists Are Speaking Out” that liberally quotes from yours truly and our fearless founder Steve Novella, as well the professor and chair of the Horticultural Sciences Department at the University of Florida, Kevin Folta, who in October complained about the Hari being invited to speak at his university, where she didn’t take questions after spewing her usual disinformation. Indeed, her most recent foray into fear mongering, an attempt to attack Starbucks for its pumpkin spice latte because it not only contains “no real pumpkin” but also contains a “toxic dose of sugar,” and—brace yourself—uses dairy from “Monsanto milk cows fed GMO,” failed.

With a book and media tour scheduled for early 2015, apparently the Food Babe is feeling the heat and has finally responded to criticism on Saturday in a rather long post entitled “Food Babe Scam: My Response To The Attacks On Me and Our Movement“. Utterly predictably, she started with a quote commonly attributed to Mahatma Gandhi, “First they ignore you, then they laugh at you, then they fight you, then you win.” Never mind that Gandhi almost certainly never actually said it. Rather, Nicholas Klein of the Amalgamated Clothing Workers of America did. It’s also a misquote of what Klein did say. What Klein actually said was, “First they ignore you. Then they ridicule you. And then they attack you and want to burn you. And then they build monuments to you.”

Yes, they did build monuments to Gandhi, but I highly doubt anyone will be building monuments to The Food Babe, either now or many years from now. Her response to criticism is worth examining, however, because her defense itself reveals the many flaws in science and reasoning that led to the criticisms in the first place. (more…)

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

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No, the CDC did not just “admit” that this year’s flu vaccine doesn’t work

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Since the press release was originally issued on Thursday by now surely most of you have seen the news stories that popped up beginning yesterday morning with headlines like “CDC Warning: Flu Viruses Mutate and Evade Current Vaccine“, or “Flu vaccine protects against wrong strain, US health officials warn“, or “Flu shots may not be good match for 2014-15 virus, CDC says“, or “Health Officials Warn This Year’s Flu Vaccine Won’t Prevent New H3N2 Strain Of Influenza“. You get the idea. This year, apparently, the flu vaccine isn’t as effective as health officials and physicians would like. How could this have happened?

Those of you who are knowledgeable about the flu vaccine know that, as useful as it is, it’s not one of the greatest vaccines as far as effectiveness. Actually, that’s not true. Its effectiveness can and does vary considerably from year to year. The reason is simple. There are many strains of influenza, and the vaccine as currently formulated generally only covers a handful of strains. Basically, every year the World Health Organization, in collaboration with the CDC and other health organizations throughout the world, has to make an educated guess which strains of influenza will be circulating the following winter. Many months’ lead time is required because vaccine manufacturers require it to develop and test the new formulations and then to ramp up their manufacturing capabilities and distribute the vaccine. Generally, the WHO chooses the three strains it deems most likely to cause significant human suffering and death in the coming flu season. Specifically, the chosen strains are the H1N1, H3N2, and Type-B, although, starting with the 2012–2013 Northern Hemisphere influenza season, the WHO has also recommended a second B-strain for use in quadrivalent (four strain) vaccines. Basically, the WHO coordinates the contents of the vaccine each year to contain the most likely strains of the virus to attack the next year. Wikipedia has a helpful article that lists the formulations of all the flu vaccines recommended for the Northern and Southern Hemispheres dating back to 1998, to give you an idea what’s been recommended in the past. Also, there are exceptions. In the 2009-2010 season, for example, the H1N1 pandemic was occurring, and it was recommended that everyone be vaccinated against H1N1 in addition to the normal flu vaccine.
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Posted in: Vaccines

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