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How should we treat DCIS?

How should we treat DCIS?

I’ve written more times than I can remember about the phenomenon of overdiagnosis and the phenomenon that is linked at the hip with it, overtreatment. Overdiagnosis is a problem that arises when large populations of asymptomatic, apparently healthy people are screened for a disease or a condition, the idea being that catching the disease at an earlier stage in its progression will allow for more successful treatment. Two prominent examples include—of course—screening for breast cancer with mammography and screening for prostate cancer with prostate-specific antigen (PSA) testing, and I’ve written about the problem of overdiagnosis with each of them on many occasions. Basically, overdiagnosis occurs when the screening test picks up what we call “preclinical” disease (i.e., disease that hasn’t become symptomatic) that, if left untreated, would never become symptomatic or endanger the health or life of the patient). Although intuitively, it seems to the lay public (and, truth be told, most doctors) that detecting cancer earlier must be inherently better, it turns out that it’s way more complicated than you think. There is a price to be paid for early diagnosis in the form of overtreatment of disease that doesn’t need treatment and for disease that is destined to threaten the life of the patient earlier treatment doesn’t always result in better outcomes. Also, whenever you screen for a condition in asymptomatic people, you will always—always—find much more of it, and the significance of those added diagnoses is not always clear, as a new study in JAMA Oncology shows.

DCIS and mammography: Some background

Before I get to the meat of the study, from my perspective, nowhere is the problem of overdiagnosis and overtreatment in cancer screening as pronounced than in the condition known as ductal carcinoma in situ (DCIS). DCIS is commonly referred to as “stage 0″ breast cancer and is characterized by milk duct cells that appear malignant but remain confined to the milk ducts. In other words, they haven’t invaded the tissue surrounding the ducts. In general, DCIS is treated similarly to breast cancer, with surgical excision, either by mastectomy or breast-conserving surgery, followed by radiation therapy if breast conserving surgery is used. Then, depending on its hormone receptor status, adjuvant treatment consists of blocking estrogen for five years. The rationale for this treatment is the view of DCIS as being a precursor to fully invasive breast cancer and that treating the DCIS will prevent the development of breast cancer. Over the last couple of decades, however, it has become clear that not all DCIS is created equal. Much of it will never progress to breast cancer in the lifetime of the woman (particularly if the woman is older, which means less time for fully malignant transformation to occur). Evidence suggesting this includes studies showing an increase in DCIS incidence by 16-fold since the 1970s, when mammography started to be introduced on a large scale, with little change in the incidence of invasive cancer. Today, 20-25% of mammography-detected breast cancer diagnoses are DCIS; forty years ago, DCIS was an uncommon diagnosis, except associated with an invasive cancer.
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Posted in: Basic Science, Cancer, Clinical Trials, Science and the Media

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Medical Theater

Me and my wife, in a very small number of years from now.  YOU KIDS GET OFF MY LAWN!

Me and my wife, in a very small number of years from now. YOU KIDS GET OFF MY LAWN!

And all the men and women merely players;

They have their exits and their entrances,

And one man in his time plays many parts,

His acts being seven ages. At first, the infant,

Mewling and puking in the nurse’s arms.

Then the whining schoolboy, with his satchel

And shining morning face, creeping like snail

Unwillingly to school. And then the lover,

Sighing like furnace, with a woeful ballad

Made to his mistress’ eyebrow. Then a soldier,

Full of strange oaths and bearded like the pard,

Jealous in honor, sudden and quick in quarrel,

Seeking the bubble reputation

Even in the cannon’s mouth. And then the justice,

In fair round belly with good capon lined,

With eyes severe and beard of formal cut,

Full of wise saws and modern instances;

And so he plays his part. The sixth age shifts

Into the lean and slippered pantaloon,

With spectacles on nose and pouch on side;

His youthful hose, well saved, a world too wide

For his shrunk shank, and his big manly voice,

Turning again toward childish treble, pipes

And whistles in his sound. Last scene of all,

That ends this strange eventful history,

Is second childishness and mere oblivion,

Sans teeth, sans eyes, sans taste, sans everything.

As You Like It, Act II, Scene VII

This summer my wife and I have been transitioning somewhere between stage 5 and 6. My eldest left Tuesday for law school in Boston and my youngest leaves for college next week in LA. So we will soon be empty nesters. As part of the change we have been making a point of going out, to dinners, bars, concerts and theater. (more…)

Posted in: Science and Medicine, Science and the Media, Vaccines

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Learning quackery for Continuing Medical Education credit

accme-screenshot

 

The Integrative Addiction Conference 2015 (“A New Era in Natural Treatment”) starts tomorrow in Myrtle Beach, SC. Medical doctors, doctors of osteopathy, naturopaths and other health care providers will hear lectures on such subjects as “IV Therapies and Addiction Solutions,” given by Kenneth Proefrock, a naturopath whose Arizona Stem Cell Center specializes in autologous stem cell transplants derived from adipose tissue. Proefrock, who was disciplined for using prolotherapy in the cervical spine without proper credentialing in 2008, claims that stem cells treatments are an “incredibly versatile therapy” and uses them for variety of conditions, such as MS and viral diseases. At the same time, he admits that they are not FDA approved and he is not claiming they are effective for anything (and he’s right), which leads one to wonder why he employs them.

Proefrock also offers a typical naturopathic mish-mash of services, from oncology to urology to “naturopathic endocrinology,” and claims he specializes in treating influenza, high blood pressure and kidney stones, as well as addiction. In other words, he doesn’t seem to be the sort of expert you’d find speaking at a science-based conference on addiction medicine.

You’ll find similarly troubling bios of some of the other speakers, as well as dubious treatments for addiction, on the conference website. Here, for example, are speaker Giordano’s and Eidelman’s websites.

Dalal Akoury, MD, is the “Title Sponsor” of the conference and appears to be running the show. Although she is listed by the S.C. Board of Medicine as board certified in pediatrics, she is the founder of the “Integrative Addiction Institute” and runs the “AwareMed Health and Wellness Resource Center” in Myrtle Beach. Like the Arizona Stem Cell Center, it offers a range of treatments that defy categorization as any particular specialty: addiction recovery, “adrenal fatigue” treatment, stem cells, “anti-aging,” weight loss, “functional medicine” and “integrative cancer care“. Yet, only Akoury and one licensed practical nurse are on the staff of the Center. Again, it is questionable whether she is has sufficient qualifications in addiction medicine to run a conference on the subject. (more…)

Posted in: Acupuncture, Cancer, Chiropractic, Dentistry, Diagnostic tests & procedures, Energy Medicine, Homeopathy, Medical Academia, Medical Ethics, Naturopathy

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Coca-Cola Science

COKE-1-tmagArticle

Science functions best when it is free from any bias or conflict of interest. All those engaged in the process should value what is actually true more than anything else. Unfortunately, there are many sources of bias in science.

Researchers may want their pet theory to be supported. Journal editors want to publish research that will have a high impact. And of course, corporations would prefer that the results of scientific research favor their products and services. A recent round of editorials accuses the Coca-Cola company of trying to put its thumb on the scale of science in order to deflect attention away from sugary drinks as a source of obesity and overweight. What are they doing and what does the science actually say?

Promoting uncertainty

According to The New York Times:

The beverage giant has teamed up with influential scientists who are advancing this message in medical journals, at conferences and through social media. To help the scientists get the word out, Coke has provided financial and logistical support to a new nonprofit organization called the Global Energy Balance Network, which promotes the argument that weight-conscious Americans are overly fixated on how much they eat and drink while not paying enough attention to exercise.

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Posted in: Public Health

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An Alternative to Appendectomy: Antibiotics

An appendix, mid-appendectomy.

An appendix, mid-appendectomy.

My title doesn’t refer to alternative medicine, it refers to an alternative within medicine: treating appendicitis with antibiotics instead of surgery. You may be surprised to learn that patients with appendicitis don’t always automatically need an appendectomy. A recent randomized controlled trial in Finland compared surgery to medical treatment.

History of appendicitis treatment

There is an excellent, detailed history of appendicitis available online, complete with anecdotes illustrating its importance. The appendix was not mentioned in early anatomical studies, probably because they were done on animals that didn’t have an appendix. The organ was first described in 1521. The existence of appendicitis (called “typhlitis” until 1886) was gradually recognized during the 19th century, and by the end of that century surgical removal of the appendix had become the standard treatment. Walter Reed, the yellow fever researcher for whom the Army hospital was named, died of a ruptured appendix. King Edward VII’s coronation was delayed while he underwent a life-saving appendectomy.

Appendectomy predated antibiotics, and it was believed that appendicitis would invariably progress to perforation. Once antibiotics were available, doctors experimented with treating appendicitis with them instead of with surgery, starting as early as 1956. The published trials had limitations, so the new study was done to try to get a more definitive answer to the question of whether the antibiotic approach was as effective as the surgical approach.

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Posted in: Clinical Trials, Pharmaceuticals, Surgical Procedures

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“Aborted fetal tissue” and vaccines: Combining pseudoscience and religion to demonize vaccines

Yes, there are antivaccinationists who actually believe this.

Yes, there are antivaccinationists who actually believe this.

As hard as it is to believe after seven and a half years of existence and nearly 2,400 posts on SBM, every so often, something reminds me that we here at SBM haven’t discussed a topic that should be discussed. So it was a couple of weeks ago, when I saw a familiar name in a news story that wasn’t about vaccines. You might recall a news story last month when a shadowy group with ties to radical antiabortion groups, the Center for Medical Progress, led by a man named David Daleiden, ran a highly questionable “sting” operation (complete with fake IDs) to “prove” that Planned Parenthood was selling aborted fetuses for medical research.

While reading news stories about Daleiden and CMP, I came across a familiar name, a name that many of us who discuss antivaccine misinformation are familiar with. I’m referring to Theresa Deisher, founder of the Sound Choice Pharmaceutical Institute. It turns out that Deisher helped to prepare Daleiden for his role as a biomedical representative that he assumed in order to deceive representatives of Planned Parenthood. She taught him how to talk the talk and walk the walk, so to speak, so that he was convincing as a representative of a biomedical research firm.

I can hear you asking: So what? What do Daleiden and CMP have to do with vaccines? It’s not CMP per se, but Deisher who is relevant. The reason that Deisher is so relevant to Science-Based Medicine (SBM) is because she is one of the foremost promoters of a particularly pernicious form of antivaccine misinformation that tries desperately to create a religious basis to oppose vaccines with antivaccine activism. It is a form of misinformation designed to deceive those who believe abortion is a moral wrong into thinking that vaccines, too, are a moral wrong because some of the viruses used to make specific vaccines are grown during the manufacturing process in cell lines derived from human fetuses decades ago. But Deisher goes one huge step beyond just guilt by association for vaccines. She is, as the news story cited above notes, the foremost promoter of a related and equally pernicious form of antivaccine information that claims that DNA from the fetal cell lines used to grow vaccine strains of viruses is a cause of autism. The truly depressing thing about Deisher is that she is, in fact, a real scientist (or at least was).

In any event, it occurred to me that, although I’ve mentioned Deisher briefly before in the context of the Disneyland measles outbreak, I’ve never deconstructed her antivaccine misinformation in detail here. Yet, her work is often cited by antivaccine activists to persuade those whose religion tells them abortion is morally wrong that they shouldn’t vaccinate their children by adding to the false claim that somehow “fetal parts” are used in the making of vaccines the even more false claim that fetal DNA somehow gets into the brain, recombines with the DNA in neurons, and causes autism. She’s also just released what appears to be a new paper claiming to show how fetal DNA causes autism. The confluence of her name coming up in stories about CMP and Planned Parenthood and her release of this new “paper” makes this a perfect time to write about Deisher.
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Posted in: Basic Science, Critical Thinking, Religion, Vaccines

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The Woo Boat, or: How far Andrew Wakefield has fallen

Sadly, this is not the crew of the Woo Boat, which is not the Love Boat. It would be awesome if that were the case, but it's not. I wonder if they'll be letting the astrologist navigate. The trip might end up being longer than expected.

Sadly, this is not the crew of the Woo Boat, which is not the Love Boat. It would be awesome if that were the case, but it’s not. I wonder if they’ll be letting the astrologist navigate. The trip might end up being longer than expected. Oh, and I couldn’t resist crossposting this from another blog because this is so damned hilarious.

File this one under the category: You can’t make stuff like this up. (At least, I can’t.)

Let’s say you’re a diehard all-conspiracy conspiracy theorist and alternative medicine believer (a not uncommon combination). You love Alex Jones and Mike Adams and agree with their rants that there is a New World Order trying to suppress your rights. You strongly believe that vaccines not only cause autism, sudden infant death syndrome, a shaken baby-like syndrome, autoimmune diseases, premature ovarian failure, and even outright death, but are a depopulation plot hatched by Bill Gates and the Illuminati who support his agenda. Heck, you even believe that black helicopters are keeping an eye on those who have discovered this plot. To you, genetically modified organisms (GMOs) are part of the same plot, pure poison and pure evil. And, of course, you just know that there is a cure for cancer—nay, cures for all diseases—out there but those evil pharmaceutical companies are keeping them from the people, the better to bolster their profits, just as they are preventing Brave Maverick Doctors like Andrew Wakefield, Mark Geier, and Sherri Tenpenny from telling the world the truth about vaccines. Heck, you just know that these same nefarious forces are even going so far as to kill vaccine “skeptic” heroes like Jeff Bradstreet (and, of course, make it look like a suicide) and holistic “pioneers” like Nicholas Gonzalez (and make it look like a heart attack).

And you like cruises.

So where do you go when you want to go on a cruise? Normal cruises are filled with people who just want to have a good time and tend to roll their eyes when you regale them with your ideas about how there is a shadowy conspiracy out there that is promoting toxic pharmaceuticals and vaccines and preventing natural cures from being used by the people, while simultaneously promoting GMOs to make people sick so that they think they need more of those pharmaceuticals and vaccines and more pliable so that their New World Order agenda faces less opposition. By the time you get to how they’re also using chemtrails as another means of control, AIDS is not caused by HIV, and Ebola can be cured with homeopathy, in other words, by the time you’ve been on the cruise a couple of days, you’ll find yourself basically shunned, eating alone at dinner, and drinking alone at the bar. When you sit down at a table, everyone suddenly finds a reason to be elsewhere.

Fear not! There is now a cruise for you. See the Conspira-Sea Cruise next January, embarking in Los Angeles and taking you on a cruise through the Mexican Riviera:
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Posted in: Science and Medicine

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New Study on Homeopathic Cough Syrup for Children Reveals a Lack of Effectiveness and Ethics

coughkid

Just say no to homeopathic cough syrup! Actually, avoid all cough syrups.

On the pages of SBM we frequently discuss homeopathy, and rightfully so considering its position as one of the most pervasive yet dumbest forms of alternative medicine. Just yesterday our own Scott Gavura, who is neither pervasive nor dumb, wrote an excellent review of some recent improvements in the regulation of these ridiculous remedies in Canada, and I encourage readers to check that out. Sadly, despite numerous high profile setbacks for the practice, including a thorough trouncing by the Australian National Health and Medical Research Council in March, proponents of what is essentially the belief in sympathetic magic continue to clutter the pubmeds and interwebs with worthless studies. (more…)

Posted in: Ethics, Homeopathy, Science and Medicine

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A homeopathic win for consumers

Homeopathy – not medicine

Do you believe in magic? It might surprise you to learn that some people believe sugar pills have healing properties. This belief system, called homeopathy, is a multi-billion dollar industry worldwide, and it’s growing. While there is no convincing evidence to demonstrate that homeopathic treatments are more effective than a placebo, many consumers and even some health professionals accept homeopathy as a legitimate health treatment, and its providers as legitimate health professionals. Responding to the perceived consumer demand for these products, government regulators have had a difficult decision to make: They could ignore homeopathy as a health practice, treating it like we might think of astrology: firmly outside of medicine. Or they could choose some form of regulation, targeting the providers (homeopaths) or the product (homeopathy), possibly with the goal of managing its use, or perhaps limiting harms to consumers. The risk of regulating nonsense, as has been described before, is the perceived legitimacy that recognition and regulation implies. Regrettably, regulation in many countries has had that exact effect. What’s worse, regulation often seems to have prioritized the commercial interests of homeopaths over the public interest, leaving consumers with little understanding that homeopathy lacks scientific credibility as a health practice. Consequently, homeopathy has attracted regular criticism from SBM’s bloggers, science and health journalists, and other science advocates over the years. It appears this advocacy is finally having an effect. Regular readers will recall several posts over the past few weeks, describing the possibility of new regulation of homeopathy by the US Food and Drug Administration (FDA). And just recently, Health Canada announced two important changes to its homeopathy regulation, which may signal a new direction. Are we witnessing the beginning of more sensible regulation of this prescientific practice? (more…)

Posted in: Homeopathy, Politics and Regulation, Science and Medicine, Vaccines

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We Should Abandon the Concept of “Alternative Medicine”

FALSE-DICHOTOMY-copyIn a recent editorial for the New York Times, Aaron E. Carroll argues, “Labels Like ‘Alternative Medicine’ Don’t Matter. The Science Does.” I agree with this headline thesis, but the details of his argument ironically show the harm that the so-called CAM (complementary and alternative medicine) movement has done.

Carroll starts out well, essentially pointing out that the division between “conventional” and “alternative” medicine, and the division between “Western” and “Eastern” medicine are false dichotomies. Despite this strong start, he muddles his way through the rest of his editorial.

The primary error he commits is to swing from a false dichotomy to a false equivalency, essentially saying that there is no difference between conventional and alternative practice or practitioners. In order to support this contention, however, he has to distort the facts beyond recognition.

In other words, Carroll commits the less-well-known false continuum logical fallacy. Let me explain.

The real differences between SBM and CAM

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Posted in: Science and Medicine

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