An Apple A Day

If you have been reading my thoughts for some time, you know that I am not a big advocate of mammograms. I really wish they would do the job they are supposed to do, but they just don’t.

Another study appeared recently, documenting the unpleasant consequences of well-intentioned mammographic screening. It is not the first study highlighting a dilemma that would be much more comfortable to deny. Years ago two large studies, including nearly one half million women, found that mammograms often found breast cancers that spontaneously disappeared, and that breast self exam did not reduce deaths from breast cancer. Much of the medical community and society at large have tried, pretty successfully, to ignore those powerful findings.

The principle author (H. Gilbert Welch) is someone I respect highly, partly because he thinks so clearly and critically about the application of research in clinical practice. Like me, he is trained in Family Medicine in addition to his research bona fides, so he always considers the “bottom line” outcomes. In the past I have recommend one or another of his books because they contain such clear discussions of the vitally important but infinitely confusing matter of using research to make health care decisions. The concepts he explains so well confused just about every medical student, resident and practicing physician I have worked with through my career. It is no surprise then, that his review of mammography data created a white-hot firestorm of controversy. You can read a simple discussion of the study and its implications in an editorial he wrote- http://www.nytimes.com/2012/11/22/opinion/cancer-survivor-or-victim-of-overdiagnosis.html

The essential findings of the study, reviewing the impact of three decades of mammographic screening in America, were:

• Mammograms did not lower the rate of widespread, life-threatening breast cancer
• Improved breast cancer survivor rates are the result of more effective treatment, not screening
• 1/3 of the diagnoses of cancer by mammogram were needless, consequently -
• 1.3 million women have undergone treatment for breast cancers that would never have caused harm

Unneeded treatment causes significant harm. The Hippocratic Oath begins with the admonition, “First, do no harm”. The obvious conclusion is that we need to find better ways to determine which cancers need to be treated and which do not.

The reaction of much of the medical community has been highly emotional. It has not been reasoned and scientific, like we pretend to be. I admit that I have enjoyed the controversy for a few reasons. Welch’s points are valid, but carry frightening implications about our ignorance. Maybe it is because I was already aware of our ignorance in this way (as well as in some many others), that I see mostly good in the controversy. It is another blow against erroneous assumptions. Sometimes it is necessary stir things up. Personally, having had decades of experience as a lightning-rod for narrow-minded criticism, it is nice to see someone else saying the right thing, accepting that it will be unpopular. I dedicated my medical textbook on homeopathy “to those with the courage to ask questions”, both because it is a rare quality in medicine and because it is essential to fundamental progress.

The universal assumption has been that cancers must be treated, or they will kill you. We have so much data, on so many cancers, refuting this facile falsity, that there is no excuse for sticking our heads in the sand. We urgently need to recognize our previous ignorance and move forward to answer the vital question of when treatment for cancer is needed and for whom.

It is nice to report good news. In this case, the good news is that a recent study of prostate cancer found that drinking coffee reduced risk.

It is always essential to view dietary studies skeptically. There are so many reasons they can be misunderstood, or just plain wrong. The world is too complicated to neatly study it. It is very difficult and ethically dubious to conduct ideally controlled dietary research. A little story about such presumptions might help.

One day a student in the homeopathy class I used to teach in the UCSF medical school inadvertently dramatized the assumptions one can make about research overlooking the requirements of studies in the real world. Seeking to discredit my research credentials, he belligerently demanded to know where my lab was. I pointed out that, despite the advantages to science, people just do not like being locked up in cages for the convenience of scientists.

Wild humans, living in their natural environment, have an annoying habit of eating a variety of mixed up food items with such unpredictability that their eating patterns seem almost whimsical. It is as if they actually select what they eat based upon some internal preference or external appearance. They/we are then extremely poor experimental subjects. I hope he went into basic sciences research or had some humanistically transformative experience. He did apologize, so there is hope for his wizened soul.

Although still far from certain, the most reliable research data comes from intervention studies. One group of people, exactly the same as another group, is treated differently and watched to see what happens. Yes, this is potentially every bit as creepy as the medical student’s thoughtless question. Studies of the long-term effects of dietary differences are essentially impossible. Would you volunteer for a study where someone else would tell you what you could and could not eat for a decade or two?

Despite the inevitable weaknesses, this study is relatively compelling. That is because the effect was proportional to the amount of coffee consumed. In other words, a bit of coffee reduced the risk, while a lot of coffee reduced risk a lot. Six cups a day (not unusual in Scandinavia where the study took place) reduced the risk of developing of prostate cancer by 20% and the death rate from prostate cancer by 60%. Coffee would seem then to prevent the worst forms of prostate cancer.

As the risk reduction persisted when the coffee was decaf, the most likely anti-cancer effect is the antioxidants in the coffee. Now, if that theory holds water (sorry), a cup or two of Mediterranean coffee, which typically has 50x higher levels of antioxidants then the coffee most of us drink, should have really powerful effects. It would also be a more tolerable means to achieve the results. Six cups of coffee a day would have me bouncing off the ceiling, not just the walls. Other studies, including studies of high blood pressure and Alzheimer’s, suggest that coffee has benefits beyond the buzz and flavor desired by so many. The blood pressure study specifically considered Mediterranean-style coffee (finely ground coffee heated in water short of boiling temperatures), which is very different from the coffee most of us drink. Due to the uncertainties of such research, the complexity of compounds in “coffee” and the fact that many people react badly to some types of coffee, further study is warranted. Unlike most medical research, I am sure that recruiting subjects will not be a problem!

As of July 1, children in California are subject to a new law which requires an additional dose of the whooping cough (pertusis) vaccine. Unlike the “required” doses for younger children, which can be waived after a discussion between the child’s physician and parents, this draconian legislation only allows a waiver if the parents sit down with a school representative. The hope being that this additional pressure will reduce the number of families refusing the vaccine. Beyond the bizarre message that it is better to discuss a medical issue with a school secretary than a physician, I have some other thoughts to share.

The impetus for this new law is an epidemic described as the worst in decades. If you are at all open to vaccinations, reports of an epidemic of a disease which often makes small children very ill, will certainly grab your attention.

My own experiences are far less compelling, in fact I am really dubious about this situation. Given the nature of my practice, I have far more experience with whooping cough than the average MD.

During my training, many of my patients were Hmong refugees from Southeast Asia. I saw much more extreme illness among these patients as they had had limited access to western health care but more because they were extremely independent and did not do what we told them to do unless they agreed it was a good idea. We would present nightmarish, worst-case scenarios to them hoping to convince/coerce them and earn their compliance with our instructions. These situations were not minor by any means, a young man with a brain abscess and a laboring woman with a prolapsed umbilical cord immediately come to mind. Although we were sincere and well-intentioned, it was disturbing and quite enlightening to see how often we were wrong.

I have learned to honor, respect and prefer patients who care enough about their health to make their own decisions. Often patients have their own personal wisdom, extending beyond the inevitably limited and generic scientific data. I like as much information as possible. When a course of treatment is not 100% clear, it seems to me that, even more than usual, the patient has an important decision-making role and should provide input. I am not the boss, I work for my patients.

Consequently, for decades the majority of my patients have not toed the party line as far as immunizations. Actually, that is not unusual. At an AMerican Academy of Pediatrics meeting I attending many years ago, the speaker asked the audience to raise our hands if we gave a specific vaccination to our patients. The minority of the medical doctors at this meeting gave their patients vaccinations “by the book”. I think the physician “compliance” rate would be higher now, but in any event, my patients are far less likely to be fully immunized.

As could be expected then, I have treated many patients for whooping cough. 20 years ago I personally learned what it was like after my two oldest children (who were then quite young) and I caught whooping cough from a friend’s child after having dinner at their home in the Bay Area.

Here is where it gets weird. Every year I have had patients with whooping cough, UNTIL this “epidemic” began. Yep, I have not had a single patient with whooping cough during this “epidemic” despite the fact that I had them every year before the “epidemic”. Expecting to see it, I even referred a couple of possible cases to public health for testing. Neither of them had whooping cough. Adding to the mystery - Off the record, a public health official told me that every case of whooping cough she had seen had been properly immunized.

The old whooping cough vaccine (DPT vs today’s DTaP) was ineffective and toxic. A study by the Minnesota Department of Public Health found that children who received the original HIB vaccine were MORE likely to get the disease than those who did not. (The HIB vaccine used for the last 15 years seems to work much better). There is precedence for vaccine-failure. Maybe I am just a statistical aberration this time? Something odd is going on.

Shingles Vaccine
There has also be a media blast promoting the shingles vaccine. Shingles is a reappearance of the virus that causes chicken pox. That class of viruses (including genital herpes) lives in the nerves even when otherwise invisible and inactive. It lies dormant for decades. Shingles is the reemergence of the virus. It appears that weakening of our immune system with age and stresses allows the virus to break loose. Shingles can be very disabling mostly because of the chronic nerve pain it can create (postherpetic neuralgia). No treatments - conventional or alternative are as reliable as we’d like.

Data suggest that the vaccine is highly effective, with minimal adverse effects and that shingles is quite common. Looking at it that way, the recommendations for most people age 60+ to get the vaccine seems reasonable. I am just a bit uncomfortable with this. Over and over and over we find that treatments turn out to be both less effective and more harmful than we thought after large number of people start using them. The data cited in these studies indicate that a much larger percentage of people get shingles than I see in my practice. Does that mean that the habits of my patients make them less likely to develop shingles or that these data are suspect? I do not know and that uncertainty will continue for a while inevitably and annoyingly.

Swine Flu
BTW - Remember all the terror about the swine flu? Currently the swine flu is under discussion in many medical journals although not because of the health impact. The most highly regarded medical journals are pointing out that it was not significantly worse than an average annual flu and then asking why there was such hysteria. I suggest that the editors reread their own publications and accept responsibility for their own lack of skepticism.

Those of you who have been reading my newsletter for the last few years will probably remember the article I wrote (posted also on my website) regarding the huge investment drug companies have made in their efforts to influence physician prescribing, the success of those efforts and the facts about how this compromises your health care. Unfortunately, the situation is not improving. Worse yet, I have to say that the integrity of medicine is also compromised. There is considerable evidence that physicians, despite our belief in our own impartiality, are in fact unquestionably influenced by relationships with companies who sell health care products of all sorts. It is becoming clear that too many doctors have become shills for industry, especially drug companies and the manufacturers of medical devices.

This unfortunate state of affairs has developed chiefly as an innocent consequence of our own naivete and the natural human inclination to trust those close to us. Ethical standards can appear contrived and overly restrictive, but they are necessary, as abundant evidence proves that our judgment is easily impaired and manipulated.

My best friend in medical school first became known to most of our class because of an open letter he wrote to us, urging that we refuse the free stethoscopes donated by a drug company. He pointed out that “free” is not free. These “gifts” cost somebody something. Companies charge more for the drugs they make to cover such costs. Eventually this comes out of the pocket of patients. The goodwill generated by the company becomes a blood debt. Docs inevitably feel indebted to the company. My truly wonderful medical school advisor dismayed and disheartened me when he told me that he always brought an empty suitcase to the annual meetings of the American Academy of Family Practice to carry home the “gifts” from the exhibitors (i.e. usually drug companies). He was an excellent and thoughtful physician and human being whom I still admire in many ways. But I think he was less concerned about this influence than I think he should have been.

The latest unpleasant reminder of this dubious relationship is focused on treatment guidelines in cardiology. These guidelines establish the standards of clinical care. Major medical organizations advise practicing physicians and patients as to what sort of treatment should be provided to patients who have specific diagnoses, test results or symptoms. These guidelines almost invariably recommend prescription medication far more than I think is reasonable, based upon my consideration of those same research facts. An investigation of these guidelines found that the majority of the physicians on the advisory committees who consider the data and create the guidelines, are also paid-consultants for drug and device manufacturers who stand to gain from the treatment recommendations.

This is clearly unethical. Most disturbing is that the organizations who establish these guidelines are supposedly the most highly regarded, reputable groups in conventional medicine. I am saddened and angry, as you should also be. You dutifully try to take care of yourself, trusting that the recommendations for healthy cholesterol, blood pressure, blood sugar, etc, are scientifically based and promoted in YOUR interest. That is not as true as it should be.