Oh my goodness

If you want to hear a guru of evidence based medicine pwn the influenza vaccine industry,

http://www.cochrane.org/podcasts/issues-1-3-january-march-2010/two-updated-reviews-influenza-vaccines

here it is :)

In the news

http://www.msnbc.msn.com/id/35834880/ns/health-health_care/

http://health.yahoo.com/news/ap/us_med_unnecessary_tests.html

http://abcnews.go.com/WN/WorldNews/doctors-recommending-tests/story?id=10078164

http://topnews.us/content/213115-obama-being-over-treated-reports

(multiple links because these main stream media websites keep changing the address of their articles)

Oh my goodness, there's A LOT to talk about in this article.

wow

I'll have to come back to it later, but check it out:

Experts dispute how much routine cancer screening saves lives. It also sometimes detects cancers that are too slow-growing to cause harm, or has false-positive results leading to invasive but needless procedures — and some risks. Treatment for prostate cancer that may be too slow-growing to be life-threatening can mean incontinence and impotence. Angiograms carry a slight risk for stroke or heart attack.


There is it again, mentioned in passing but at least it's mentioned. The HARMS from tests. Not just false positives but the harms from an unnecessary diagnosis and the harms from complications of testing. The "slight risk" for a stroke or heart attack by the way is larger than the benefit from screening mammography (1 in 2000 40 yo women over 10 years will have her life saved by screening mammography and around 1 in 100 people who undergo a heart cath have a stroke or heart attack)

The news frames this like it's a debate of opinions among experts but the reason the keeps coming up is because we have learned through experience and studying the data, that we are harming more people than we're saving!

And the news also leaves out the all important fact that the individual patients making these decisions are in charge of what lives and what dies in medicine.

Tyranny always requires the consent of the victim.

Withdraw your consent my friends and you end this madness.

The Lottery

I was told by a friend that the statistics of screening mammography are too confusing for people to possibly understand so clinicians need to continue to make recommendations.  I mean it's ok to talk about the greater likelihood of antibiotics making someone sicker with a viral infection than speeding up their recovery.  10 years ago that was a discussion that would have taken a great deal of time.  Nowadays a child has a cold and parents generally would have to be convinced to give the kid antibiotics.  They accept the fact that the odds of harm outweigh the chance of benefit.  They know there's a problem with antibiotic resistance and some know the harms from allergic reactions and colon infections that antibiotics cause not infrequently.  

And then we were talking about the lottery last evening at sunset on the bikes and it hit me,  screening mammograms are like slot machines.  

We have 30 years of experience and now we can tell you the odds of winning or breaking even or losing at the screening mammogram machine.  

So picture the big expensive slot machine that is screening mammography in your head right now.  40 year old women pay some money and go pull the lever and there's 2 possible results displayed on the screen positive or negative.  If it's negative,  she leaves and returns next year to pay and play again.   Most women get a negative result.

Now if it's positive,  there's another machine next to the 1st and it has a lever that's pulled and the screen can say negative or positive.  (this is the follow up mammogram or ultrasound because of a concerning screening finding).  And most of the time this is negative. 

This is as far as most women get playing the screening mammogram game.  They break even.  The second group has a good degree of anxiety and fear between pull one and two but no harm done (except for the radiation exposure but that's another story)

Now some women get a positive result on the 2nd pull and have to go on to a biopsy which can be negative or positive;  if it's positive that means they found cancer.  It's treated and hopefully it's cured.  

Well those women who get this far,  have cancer found and are ultimately cured because it was caught by the mammogram early,  they won.  Screening mammography saved their lives.  The chance this will happen is 1 in 2000 over 10 years for women age 40.  This represents 15% of all the women destined to die of breast cancer over those 10 years.  Screening mammograms won't save the other 85%  (better treatments for cancer and not handing out hormone replacement therapy after menopause saves another 15%)  

The big problem is that the slot machine also tells some women after going through the 3 rounds of tests,  getting diagnosed and treated for cancer that it saved them also.  But there are 10 women for every 1 really saved by the test who were diagnosed and treated for a cancer destined never to cause symptoms in their life.  These women are the ones who lost at the slot machine.  It harmed them with the unnecessary label of "breast cancer survivor".   It's impossible to know on an individual basis who really won the game and who was harmed.  Which is pretty damn infuriating to me.  What we do know is the ratio of 10 to 1.  10 harmed with an unnecessary diagnosis for every one saved.  

So when you chose to participate you have a 1 in 2000 chance of being saved and a 10 in 2000 chance of being harmed.  

There's another group that goes through all this mess and gets diagnosed earlier with cancer but it doesn't affect their survival either way.  They are going to survive the cancer or not regardless of whether it's caught a year or 3 earlier.  You could argue that they are harmed by the machine stealing a sizable chunk of what feels like cancer free living.  We know the odds of being one of those folks,  it's also 10 in 2000 over 10 years.  

I don't know,  maybe it is confusing.  

I need to make a video with animation and pie charts and such.  

Anything to make the decision to participate completely understood.  It's important since the same analysis of benefits/harms can guide most medical decisions.  Which keeps the individual in charge and empowered;  Perhaps even immune to the tricks of marketing.  

How much less expensive and less harmful do you think health care would be with people thus immunized?  

Kindred Spirit

http://healthjournalclub.blogspot.com/2010/02/david-graham-and-tragedy-of-vioxx.html#more

MD and former FDA employee started his blog the same month I started mine.  

http://healthjournalclub.blogspot.com/2010/02/avandia-and-earwax.html

Many interesting articles in his blog.  

The Cochrane Collaboration

http://www.newsweek.com/id/205616

When people talk about "evidenced based medicine".   They mean Cochrane.

Wiki Wiki

From the Wikipedia article on screening mammography.

Critique of screening mammography

The use of mammography as a screening tool for the detection of early breast cancer continues to be debated. Critics point out that a large number of women need to be screened to find cancer. Keen and Keen indicated that repeated mammography starting at age 50 saves about 1.8 lives over 15 years for every 1,000 women screened.^[17] This result has to be seen against the negatives of errors in diagnosis, overtreatment, and radiation exposure. Countercritics argue that the benefit is greater. The Cochrane analysis of screening indicates that it is "not clear whether screening does more good than harm". According to their analysis one in 2,000 women will have her life prolonged by 10 years of screening, however, another 10 healthy women will undergo unnecessary breast cancer treatment.^[18] Newman points out that screening mammography does not reduce death overall, but causes significant harm by inflicting cancer scare and unnecessary surgical interventions.^[19] Finally, a significant recent article points out that a successful screening program should result in an increase in the number of early breast cancers, followed by a decrease in the number of late-stage cancers. However this is not happening with current mammography screening. ^[20]

http://en.wikipedia.org/wiki/Mammography

The Declaration of Helsinki

http://en.wikipedia.org/wiki/Declaration_of_Helsinki

Prior to the 1947 Nuremberg Code there was no generally accepted code of conduct governing the ethical aspects of human research, although some countries, notably Germany and Russia, had national policies [3a]. The Declaration developed the ten principles first stated in the Nuremberg Code, and tied them to the Declaration of Geneva (1948), a statement of physician's ethical duties. The Declaration more specifically addressed clinical research, reflecting changes in medical practice from the term 'Human Experimentation' used in the Nuremberg Code. A notable change from the Nuremberg Code was a relaxation of the conditions of consent, which was 'absolutely essential' under Nuremberg. Now doctors were asked to obtain consent 'if at all possible' and research was allowed without consent where a proxy consent, such as a legal guardian, was available (Article II.1).

Basic principles

The fundamental principle is respect for the individual (Article 8), their right to self determination and the right to make informed decisions (Articles 20, 21 and 22) regarding participation in research, both initially and during the course of the research. The investigator's duty is solely to the patient (Articles 2, 3 and 10) or volunteer (Articles 16, 18), and while there is always a need for research (Article 6), the subject's welfare must always take precedence over the interests of science and society (Article 5), and ethical considerations must always take precedence over laws and regulations (Article 9).

The right to informed decisions, AKA informed consent, is the ethical cornerstone of every bit of counseling clinicians provide. Tell me, do you think it was proper informed consent to leave out the prospect of the unnecessary diagnosis of breast cancer in the 30 years of screening mammogram counseling?