Sayer Ji: Willfully misunderstanding overdiagnosis and misdiagnosis since...forever
By oracknows on May 1, 2016.
If there's one lesson that I like to emphasize while laying down my near-daily dose of Insolence, both Respectful and not-so-Respectful, it's that practicing medicine and surgery is complicated. Part of the reason that it's complicated is that for many diseases our understanding is incomplete, meaning that physicians have to apply existing science to their treatment as well as they can in the context of incomplete information and understanding. The biology of cancer, in particular, can be vexing. Some cancers appear to progress relentlessly, meaning that it's obvious that all of them must be treated. Others, particularly when detected in their very early stages through screening tests, have a variable and therefore difficult-to-predict clinical course if left untreated. Unfortunately, some people, such as a man whom I consider to be a promoter of dangerous quackery, Sayer Ji, either can't or won't understand that. They like their medicine black and white, and if physicians ever change guidelines in order to align them more closely with newer scientific understanding, they write blisteringly ignorant articles like "'Oops... It Wasn't Cancer After All,' Admits The National Cancer Institute/JAMA."
Not exactly. What really happened is that an expert panel recommended reclassifying a specific thyroid lesion as not cancerous based on recent science. It's called medicine correcting itself. Admittedly, this reclassification was probably long overdue, but what would Mr. Ji rather have? Medicine not correcting itself in this situation? In any case, when last I met Mr. Ji, he was gleefully abusing the science of genetics to argue that Angelina Jolie and other carriers of deleterious cancer-causing mutations don't need prophylactic surgery because lifestyle interventions will save them through epigenetics, which to "natural health" enthusiasts like Mr. Ji seems to mean the magical ability to prevent any disease. Most recently, he has appeared on the deeply dishonest "documentary" about alternative medicine cancer cures, The Truth About Cancer , to expound on how chemotherapy is evil. His rant about the reclassification of a non-encapsulated follicular variant of papillary thyroid cancer as not cancer is more of the same, as you will see.
Overdiagnosis and the question of what is and isn't "cancer"?
The sort of issue mangled by Mr. Ji in his article is one that those of us who treat breast cancer have been dealing with for a long time now. For example, as a breast cancer surgeon, I deal all the time with a disease entity known as ductal carcinoma in situ (DCIS). Basically, it's a condition in which cancerous-appearing cells are found in the milk ducts of the breast but have not crossed the basement membrane, which surrounds the milk ducts. Generally, we consider DCIS to be stage 0 breast cancer, specifically cancer that hasn't invaded through the basement membrane into the breast yet. Of course, as I've written before many times, it's not as simple as that. Many—probably most—DCIS lesions never progress to cancer in the patient's lifetime, particularly the so-called low grade lesions, which are called low grade because their cells resemble normal milk duct cells. On the other hand, higher grade lesions, which look more like frank cancer, likely progress to cancer at a much higher rate. However, because we have no reliable means of predicting which DCIS lesions will progress to invasive cancer and which will not, we end up treating them all in basically the same way: surgical excision plus or minus (usually plus) radiation plus or minus an estrogen-blocking drug.
Confusing the question of treatment of very early stage breast cancer is the apparent massive increase in incidence of DCIS over the last 40 years. Basically, as I've described multiple times before, the incidence of DCIS has increased 16-fold since 1975. Given that it's highly implausible and unlikely that the "true" incidence of DCIS has increased so markedly in such a short time (and three or four decades is a short time for a change this massive), the likely explanation is the institution of widespread mammographic screening programs beginning in the early 1980s, leading to overdiagnosis.
Overdiagnosis is a phenomenon that's been discussed here many times. Basically, it is the detection of disease that would never go on to harm or kill the person harboring it. If there's one thing that the mass screening of large asymptomatic populations for diseases has taught us, it's that there's a lot more preclinical disease out there in healthy people than we had previously suspected, or, as I put it, if you look very hard for a condition you will find more of it. Always. Indeed, thanks to a mass thyroid screening program after the Fukushima nuclear disaster, we recently learned that even children have way more preclinical thyroid cancer than we had previously thought. As I've discussed before, in autopsy studies half of men over 65 and three-quarters of men over 80 have tiny foci of cancer in their prostates; thyroid cancer can be found in 36% of adults, and the study's investigators estimated that if the slices had been made thinly enough for microscopic examination they could have "found" thyroid cancer in close to 100% of adults between 50-70, even though clinically apparent thyroid cancer requiring treatment only has a prevalence in the population studied of around 0.1%. In breast cancer, it has been estimated that as many as one in three mammographically detected cancers in otherwise asymptomatic women might be overdiagnosed, although other estimates are around 10%. The reason the estimates vary so much is that we can't do a study in which mammographically detected small invasive breast cancers are not treated is because, even if these estimates are correct, most of them do appear to progress. We're thus forced to rely on inferences from epidemiological studies. Whatever the true number is, given that there are 240,000 new cases of breast cancer diagnosed every year, overdiagnosis is a huge problem, no matter how much some physicians would try to claim otherwise.
Once we acknowledge the existence of overdiagnosis, the questions then become:
Does the disease found at such an early, asymptomatic stage need to be treated?
Will treating the disease earlier, before it becomes symptomatic, lead to improved outcomes in terms of survival and/or morbidity?
Are these early lesions actually cancer?
The answers to these questions are not straightforward in the least, particularly given how difficult it is to show a survival benefit due to early intervention, thanks to lead time bias and length bias. It is this accumulation of evidence of overdiagnosis that has led to a rethinking of cancer screening and changes in recommended screening guidelines. They're also leading scientists and physicians to reexamine the classification of cancerous-appearing lesions formerly classified as cancer:
In fact, said Dr. Otis Brawley, chief medical officer at the American Cancer Society, the name changes that occurred went in the opposite direction, scientific evidence to the contrary. Premalignant tiny lumps in the breast became known as stage zero cancer. Small and early-stage prostate lesions were called cancerous tumors. Meanwhile, imaging with ultrasound, M.R.I.'s and C.T. scans find more and more of these tiny "cancers," especially thyroid nodules.
"If it's not a cancer, let's not call it a cancer," said Dr. John C. Morris, president-elect of the American Thyroid Association and a professor of medicine at the Mayo Clinic. Dr. Morris was not a member of the renaming panel.
Dr. Barnett S. Kramer, director of the division of cancer prevention at the National Cancer Institute, said, "There's a growing concern that many of the terms we use don't match our understanding of the biology of cancer." Calling lesions cancer when they are not leads to unnecessary and harmful treatment, he said.
Exactly. It is entirely rational and scientific to adjust medical nomenclature to reflect more recent science and understanding of disease. Again, doing so is anything but simple, as there will always be disagreements, and, yes, turf wars and fears among some physicians who treat these early lesions of losing business, but just because the renaming process is messy and contentious doesn't mean there is nefarious intent to it or that there was nefarious intent in the nomenclature being replaced.
Reclassifying thyroid cancer
Mr. Ji, of course, is not interested in any of the complexities briefly touched on above. Rather, he is interested in vilifying "conventional" medicine:
Back in 2012, The National Cancer Institute convened an expert panel to evaluate the problem of cancer's misclassification and subsequent overdiagnosis and overtreatment, determining that millions may have been wrongly diagnosed with "cancer" of the breast, prostate, thyroid, and lung, when in fact their conditions were likely harmless, and should have been termed "indolent or benign growths of epithelial origin." No apology was issued. No major media coverage occurred. And more importantly, no radical change occurred in the conventional practice of cancer diagnosis, prevention, or treatment.
No major media coverage? Seriously? Besides Medscape, The Wall Street Journal covered it. So did The New York Times . I remember several stories about it in the national media, including television, at the time. Since then, there's been a lot of coverage of the scientific controversy about overdiagnosis, particularly due to mammographic screening, in the national and international press. Perhaps Mr. Ji's memory is faulty, which is why I am glad I was able to help jog it.
In any case, the summary to which Mr. Ji refers in his introductory rant is this article published in JAMA in 2013 by Laura Esserman (a breast surgeon whose work I admire) and colleagues. It summarized the NCI panel's recommendations thusly:
Physicians, patients, and the general public must recognize that overdiagnosis is common and occurs more frequently with cancer screening.
Change cancer terminology based on companion diagnostics.
Create observational registries for low malignant potential lesions.
Mitigate overdiagnosis.
Expand the concept of how to approach cancer progression.
Esserman et al concluded:
The original intent of screening was to detect cancer at the earliest stages to improve outcomes; however, detection of cancers with better biology contributes to better outcomes. Screening always results in identifying more indolent disease. Although no physician has the intention to overtreat or overdiagnose cancer, screening and patient awareness have increased the chance of identifying a spectrum of cancers, some of which are not life threatening. Policies that prevent or reduce the chance of overdiagnosis and avoid overtreatment are needed, while maintaining those gains by which early detection is a major contributor to decreasing mortality and locally advanced disease. The recommendations of the task force are intended as initial approaches. Physicians and patients should engage in open discussion about these complex issues. The media should better understand and communicate the message so that as a community the approach to screening can be improved.
In this light, it is easy to see how utterly silly Mr. Ji's rant is. The task forces' recommendations were meant as a starting point for discussion, not a pronouncement. Moreover, one could very much view the reclassification of a variant of thyroid cancer as not being malignant as addressing recommendations #2, 4, and 5. Indeed, this is the first time a lesion that had been classified as a cancer has been reclassified as not cancer.
Let's take a look at the actual study.
When is thyroid cancer not cancer?
The relevant study, whose first author is Yuri E. Nikiforov, vice chairman of the pathology department at the University of Pittsburgh, basically tells you what you need to know: "Nomenclature Revision for Encapsulated Follicular Variant of Papillary Thyroid Carcinoma: A Paradigm Shift to Reduce Overtreatment of Indolent Tumors." There it is right there in the title: This study is addressing recommendations #2 and 4 (at minimum) from the NCI workshop. In fact, it says right in the introduction that that was the purpose of this study! In essence, this paper lays out the case for changing the nomenclature of "encapsulated follicular variant of papillary thyroid carcinoma" (EFVPTC), which is generally treated like thyroid cancer now, to call these lesions "noninvasive follicular thyroid neoplasm with papillary-like nuclear features" (NIFTP). As I've discussed before, with the widespread use of thyroid ultrasound, overdiagnosis of indolent thyroid cancers has become a major problem, with large increases in the incidence of these lesions being reported, including noninvasive EFVPTC.
What the authors did was an international, multidisciplinary, retrospective study of patients with thyroid nodules diagnosed as EFVPTC, including 109 patients with noninvasive EFVPTC observed for 10 to 26 years and 101 patients with invasive EFVPTC observed for 1 to 18 years. Noninvasive EFVPTC included EFVPTC that had not invaded through its capsule. Twenty-four pathologists making up the Endocrine Pathology Society working group developed consensus criteria for the diagnosis of EFVPTC, and these were applied to the pathology slides. Molecular analysis of the tumors was also carried out using using ThyroSeq v2, which looks at a panel of 14 oncogenes for mutations.
The authors observed that none of the patients with noninvasive EFVPTC died of their disease in the follow-up period, while five of the patients with EFVPTC developed metastatic disease and two died. Genetic analysis of the lesions showed that noninvasive EFVPTC was predominately driven by mutations in the RAS oncogene, which are associated with follicular thyroid cancer, as opposed to the mutations in invasive EFVPTC, which were driven by BRAF and RET rearrangements, which have classically been associated with papillary thyroid cancer. On the basis of these observations and a review of the literature the authors recommended their proposed name change and listed rigorous, reproducible diagnostic criteria they propose for differentiating EFVPTC from NIFTP. Because approximately 20% of thyroid cancer is EFVPTC, this name change could affect up to 45,000 patients worldwide per year.
The authors conclude:
The results of this study, together with previously reported observations, suggest that when the diagnosis of NIFTP is made on the basis of careful histopathological examination, the tumor will have a low recurrence rate, likely less than 1% within the first 15 years. Of note, most differentiated thyroid carcinomas relapse within the first decade after initial therapy, although late recurrences and distant spread are documented. Importantly, a large proportion of patients with tumors diagnosed as NIFTP in the present study underwent lobectomy only and none received RAI [radioiodine] ablation. This suggests that clinical management of patients with NIFTP can be deescalated because they are unlikely to benefit from immediate completion thyroidectomy and RAI therapy. Staging would be unnecessary. In addition to eliminating the psychological impact of the diagnosis of cancer, this would reduce complications of total thyroidectomy, risk of secondary tumors following RAI therapy, and the overall cost of health care. Avoidance of RAI treatment alone would save between $5000 and $8500 per patient (based on US cost). Decreased long-term surveillance would account for another substantial proportion of cost reduction.
In other words, for this lesion, taking the involved thyroid lobe (or even perhaps just excising the lesion) is probably enough treatment. No completion total thyroidectomy would be necessary, nor would radioactive iodine or follow-up tests to screen for recurrence. The need for lifelong thyroid hormone supplementation would be eliminated in most patients because they would not require a total thyroidectomy.
As hard as it is to come to a science-based agreement on a set of diagnostic guidelines and a reclassification of a disease entity, where the rubber hits the road will be how these recommendations will be viewed by practicing physicians. It's reassuring to learn that eight leading professional societies have signed on to the new classification and the new name. That will definitely help with the adoption of the new classification and nomenclature, but it won't be enough. As I've pointed out before, change in medicine is slower than we would like in some areas. We've learned that lesson from the Choosing Wisely program, and as the co-director of a statewide quality consortium I've learned that implementing change is complex and difficult, and that the wrong kind of change is often too easy to implement.
Practice is also changing to reflect these new realities. For example, men with low grade prostate cancers now often undergo "watchful waiting," with no intervention unless the tumors progress. (Indeed, I know someone whose treatment involved just that. Unfortunately, he ultimately required radiation therapy, but that was because his tumor progressed.) In breast cancer treatment, recommendations are now less aggressive. For instance, in women over 70 with well-differentiated hormone receptor-positive cancers, radiation is now no longer routinely recommended. Our treatments have become more targeted, as well. For another example, there is the OncoType assay that measures the expression of 21 genes to predict whether women with hormone receptor-positive breast cancers with negative lymph nodes require chemotherapy, resulting in less chemotherapy being given; and this is only one of several such assays.
Indeed, it's funny how Mr. Ji fails to note that, in this case, Dr. Nikiforov is basically going back to do what Mr. Ji thinks he should do: Let the patients previously treated as though they had cancer know that they didn't. From a New York Times story on the change:
Dr. Nikiforov says he owes it to patients with reclassified tumors to tell them they never had cancer after all. At the University of Pittsburgh Medical Center, he and others are going to start reviewing medical records and pathology reports to identify previous patients and contact them. He estimates there have been about 50 to 100 each year at the medical center. They no longer have to go back for checkups. They lose the shadow of cancer that the diagnosis hung over their lives.
Informing these patients, Dr. Nikiforov said, "is a moral obligation of doctors."
Indeed it is. In fact, this reclassification of EFVPTC as NIFTP is arguably the first fruit of the NCI recommendations that Mr. Ji keeps pointing to that actually involved renaming a disease entity. It's not the first fruit of those recommendations, however. The ACS recommendations for mammographic screening are another. However, renaming disease entities is more difficult in other cancers because the delineation is not so clear-cut. There is no doubt that DCIS can progress to cancer at a substantial rate; the same is true for a lot of other early lesions classified as cancer that might be candidates for a name change, such as prostate cancer. Indeed, when doctors proposed doing just what the NCI proposed for early prostate cancers, there was a great deal of push-back—and not just from physicians. Great care and weighing a huge body of evidence, some of it contradictory, will be required, and it is taking years, as anyone who knew anything about the issues involved in 2012, when the NCI conference occurred, knew it would.
Of course, Mr. Ji isn't about the careful weighing of evidence. He is about attacking "conventional" medicine and using the "science was wrong before" trope to try to claim that he was right all along and, by implication, he must be right about the "natural" treatments for cancer that he promotes on his website. Even then, he doesn't understand:
Another topic I have been trying to spread awareness about is thyroid cancer overdiagnosis and overtreatment. When I first reported on this two years ago in my article, Thyroid Cancer Epidemic Caused by Misinformation, Not Cancer, a series of compelling studies from around the world revealed that the rapid increase in diagnoses in thyroid cancer reflected their misclassification and misdiagnosis. As was the case with screening detected breast and prostate "cancers," and even many ovarian "cancers," the standard of care often required the removal of the organ, as well as irradiation and chemotherapy -- two known cancer promoting interventions.
Actually, overdiagnosis does not involve misdiagnosis. The two are not the same thing. A breast cancer picked up on screening mammography is a breast cancer. Its cells look just as malignant as cells from cancers picked up when a lump forms. The same is true for prostate cancer and, yes, most thyroid cancers. Remember, it's not just the cancers being reclassified here that are being overdiagnosed by the widespread use of thyroid ultrasound. The real issue is that over the last decade we are learning that many of these cancers are indolent and would never harm the patient if left alone; the problem, of course, is figuring out which are dangerous and which can be either be safely watched or be adequately treated by excision alone. Dr. Nikiforov's team's work addresses exactly that question: Which cancers don't need aggressive treatment? A side benefit of his work is that he identified a variant of thyroid cancer that is so indolent that it basically never metastasizes and therefore shouldn't be called cancer.
It is useful in these situations to compare alternative medicine to science-based medicine. Those of us advocating for SBM realize its shortcomings better than most, and at least as well as Mr. Ji. We also actively work to change areas where conventional medical care is not adequately science-based. Indeed, this proposed reclassification of a type of thyroid cancer came about because a physician looked at medical practice and saw something not science-based:
The reclassification drive began two years ago when Dr. Yuri E. Nikiforov, vice chairman of the pathology department at the University of Pittsburgh, was asked his opinion about a small thyroid tumor in a 19-year-old woman. It was completely encased in a capsule and the lobe of her thyroid containing it had been removed to establish a diagnosis.
Over the last decade, Dr. Nikiforov had watched as pathologists began classifying noninvasive tumors as cancers and attributed the change to rare cases in which patients had a tumor that had broken out of its capsule, did not receive aggressive treatment and died of thyroid cancer. Worried doctors began treating all tumors composed of cells with nuclei that looked like cancer nuclei as if they were cancers. But this young woman's story drove Dr. Nikiforov over the edge.
"I told the surgeon, who was a good friend, 'This is a very low grade tumor. You do not have to do anything else.' " But the surgeon replied that according to practice guidelines, she had to remove the woman's entire thyroid gland and treat her with radioactive iodine. And the woman had to have regular checkups for the rest of her life.
"I said, 'That's enough. Someone has to take responsibility and stop this madness,' " Dr. Nikiforov said.
It's doctors like Dr. Nikiforov who see a medical practice that is not adequately science-based and fix it, not quacks like Mr. Ji, whose main interests in cancer seem to be to convince you that chemotherapy kills and causes far more harm than untreated cancer (wrong), that patients with cancer-causing gene mutations don't need surgery (wrong), and that natural lifestyle changes and whatever supplements he likes can prevent cancer through the magic of epigenetics (wrong again). He latches on to examples like the reclassification of thyroid cancer of SBM correcting itself as evidence that conventional medicine is hopelessly flawed not because he wants to improve medical practice, but because he wants to substitute pseudoscience for science and non-evidence-based "alternative" treatments for validated science-based treatments. Doctors, like Dr. Nikiforov, who promote evidence-based practice are not a validation of Mr. Ji's profoundly misguided beliefs.
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I applaud steps to better stratify cancer patients and possible patients, both to prevent overdiagnosis and to yield more specific treatments, even beyond std of care.
As usual, I am a little concerned about indiscriminate negative supplement statements, when I see so many science and medical papers on their numerous effects on molecular biology and cellular activities. Cancer patients may need more tx components than one type of source offers. Many pseudomedical purveyors I can reject, but to me it is more important which unconventional ones have actual answers that are being neglected or attacked as is usual.
By prn (not verified) on 01 May 2016 #permalink
I had a mammogram not all that long ago (as in a month ago). I, a mid-50's man, had nipple pain and enlargement of one breast, with an unidentified mass under the areola.
The mammogram and confirming ultrasound confirmed simple gynecomastia, secondary to hyperthyroidism.
A few women I know, counting my own wife, had asked, "Let me know how *you* liked it" or similar words. I happily reported back, it was mildly uncomfortable, but not painful at all and my breast was quite tender.
At least it wasn't something harmful going on, just another symptom of hyperthyroidism, among the constellation of other symptoms of the disease.
I'm still confounded how it's unilateral, the other side remains unchanged, but we're into the mysterious land of endocrinology. Things get weird when one departs the land of plumbing!
As for refining various diagnoses, that's a good thing. Redefining an improperly defined condition, even better. After all, we're talking about evidence based medicine here, not static dogma. If it helps the patient live a life with a high quality of life conditions, doesn't shorten life expectancy and is more accurate, all to the better!
I only ponder how many more changes will occur in the next 20 years! The majority of which will be for the better, others, refinements upon previously coarser diagnosed conditions.
Indeed, I'm quite certain that our intrepid host would agree, it'd be a wonderful thing of medical science could put him out of work by preventing entirely or effectively and universally treating all forms of breast cancer. Who knows? That might be one of the changes yet to come in the next two decades.
For, I've learned one thing during my decades of life: When a physician deals day in and day out with our more dire medical conditions, that physician would be the happiest human in the universe to have to find a new line of work due to his or her current line becoming obsolete by a cure or set of cures.
By Wzrd1 (not verified) on 01 May 2016 #permalink
"Basically, as I've described multiple times before, the incidence of DCIS has increased 16-fold since 1975."
This makes sense, because DCIS are usually diagnosed by mammography. This does not tell us that DCIS does not occur frequently as a stage of the cancer process.
The conclusion that "most DCIS lesions never progress to cancer in the patient's lifetime" rests on analyses of primary BC incidence, which may partially reclect mammography-induced breast cancer, and analyses of metastatic BC incidence that are hampered by the benefits of early surgery.
I am wondering which "misunderstanding of overdiagnosis" is more worrying.
By Daniel Corcos (not verified) on 02 May 2016 #permalink
but what would Mr. Ji rather have? Medicine not correcting itself in this situation?
I would say yes. His goal of "vilifying 'conventional' medicine" is easier to accomplish when he can deal with a non-self-correcting straw man. His mind is made up, so facts would only confuse him.
By Eric Lund (not verified) on 02 May 2016 #permalink
Yeah, that's Sayer's schtick. He actually uses sciency words and ideas to obfuscate. Seen it on vaccines, GMOs, all the stuff he hates.
He uses the "The Asymmetric Advantage of Bullsh-t" as his oeuvre. \http://scienceblogs.com/mikethemadbiologist/2009/04/20/the-asymmetry-of…
The rebuttal, by contrast, may require explaining a whole series of preliminary concepts before it's really possible to explain why the talking point is wrong. So the setup is "snappy, intuitively appealing argument without obvious problems" vs. "rebuttal I probably don't have time to read, let alone analyze closely."
Loathsome misinformation peddling. I'm sure it sells his books and courses, though.
By Mary M (mem_so… (not verified) on 02 May 2016 #permalink
Where has my comment gone? And why?
To add my 2 cents:
Ji's position is not a scientific position, but a dogmatic one - a position of ideology, or should I say, a religious position.
It doesn't matter that medicine or science get it right in the second pass, or ever in the first one. For him, medicine is the wrong approach, the wrong ideology, period.
By Helianthus (not verified) on 02 May 2016 #permalink
To Orac, since my previous comment has disappeared:
"It is unlikely that the "true" incidence of DCIS has increased so markedly"
What do yo mean by "true? Are cancers diagnosed at a later stage (after DCIS) not true?
Daniel Corcos,
Our blinking-box host has written about DCIS many times before. In the passage you mention, he mentions a 16-fold increase in documented cases of DCIS over a few decades. So which is the more likely explanation--that this condition happens sixteen times more often in patients today than it did for their parents at the same age, or that detection tools have become much more powerful since then, leading to increased diagnosis of a condition that was always more common than we knew? Nothing to do with which cancers are "true" or not.
By Pickwick (not verified) on 02 May 2016 #permalink
I perfectly agree that a 16-fold increase of DCIS at the time diagnosis is the consequence of early detection. However, nothing can be said concerning the incidence of DCIS which could be evidence for overdiagnosis. The 16-fold increase in incidence is not incompatible with the possibility that all of them evolve as invasive cancers.
Daniel: This post is not about DCIS. It is about thyroid cancer and the reclassification of one form of thyroid cancer. Please don't think you can resurrect your obsessive discussion over a small point in this post. At my not-so-super-secret other blog when an earlier version of this post was published, eventually I told you to knock it off because you became so annoying. Your obsession with this, to the point that you latch on to a small part of the post and perseverate about it, has officially become annoying enough here for to me to warn you.
Stop it. I will not permit you to hijack this comment thread the way you did for a time at my other blog. If you have something to say about thyroid cancer, fine. No more discussion of DCIS or beast cancer overdiagnosis on this thread from you because you inevitably segue from that to your other obsession, mammography in women with BRCA1/2 mutations. I'm heading that off before you get there.
Other readers/commenters: Sorry about this message. However, Daniel can't seem to resist to hijack threads that mention breast cancer overdiagnosis due to mammography, even if it's only mentioned in passing, and I was in no mood to put up with it again this morning.
By Orac (not verified) on 02 May 2016 #permalink
To my non-medical understanding of this reclassification, it strikes me as akin to changing the definition of cancer from a noun to a verb. That is, cancer is not so much a description of what a cell is but what it does.
By rs (not verified) on 02 May 2016 #permalink
Hopefully this won't be taken as thread hijacking, but this is my personal anecdote. My mother-in-law has been diagnosed with breast cancer, cone biopsy confirmed neoplastic cells in the tumour. She underwent lumpectomy, it turned out to be DCIS after all - and following a consultation with another specialist, her oncologist decided against adjuvant radiation, mostly because of her age. A few years ago she would probably get adjuvant radiation anyway but guidelines have changed.
Diagnosis, biopsy, lumpectomy - all within a month and we all hope that's the end of the story.
And then a few days ago she called me about high dose Vitamin C that a friend of hers recommended her. Fortunately, I managed to convince her it would be waste of money - thanks to everything I've read here and on the other blog.
By Alia (not verified) on 02 May 2016 #permalink
@prn #1:
Many pseudomedical purveyors I can reject, but to me it is more important which unconventional ones have actual answers that are being neglected or attacked as is usual.
Where's the evidence that unconventional medical purveyors do have actual answers? I don't tend to think that we're swimming in it.
By Rich Woods (not verified) on 02 May 2016 #permalink
David, it is you, not me, who are conflating the utterly unproblematic situation of thyroid cancer overdiagnosis with the highly contentious postulate of breast cancer overdiagnosis of breast cancer, carrying ethical, legal and financial implications.
OT ( and I hope that this isn't threadjacking either because I certainly wouldn't want to do that- it being not Kosher and all
AND it's late - practically nightfall- and there are already more than a dozen responses)
BUT are antics by woo-fraught Minions of Mikey (tm) ever TRULY OT @ RI? ( I would think decidedly NOT)
Today Julie Wilson ( Natural News) tells us how her altie allies plan on revealing sceptics' evil at Wikip----, TAM and other hideouts. Someone we know is mentioned. Other woo-meisters and their enablers have told us the same tale many times before. It's only a matter of time until the tsunami of PARADIGM SHIFT washes over us all!
I only today listened to a 2012 tape of Gerald Celente & friend predicting an economic catastrophe within 24 months. Amazingly, they leave these videos up.
By Denice Walter (not verified) on 02 May 2016 #permalink
Could Denatured News really be a front for the Pharma-Big Govt-Bill Gates plan to depopulate the earth?
After warning us repeatedly about the horrific hazards posed by vaccine adjuvants and other sources of aluminum (Alzheimer's, chronic disease, greasy hair etc.), DN posted a link to a prepper article advocating use of alum to purify water (when the Big One comes, you better have access to drinkable water). But what is alum, but ALUMINUM SULFATE!!!!!! DN wants us to aluminize our bodies!!!!!!
Truly, the ways of the Lizardati are dark and scaly.
By Dangerous Bacon (not verified) on 02 May 2016 #permalink
@ DB:
HOWEVER the other day Mikey noted that if you look into Gates's eyes you see......."demons"
( in that 30+ minute video I watched)
I wouldn't say that the problem of thyroid cancer overdiagnosis is "utterly unproblematic". Didn't Orac just recently have a post about thyroid cancer screening in children in Japan as related to the nuclear accident?
It's very much problematic for children who end up having their thyroids removed!
By JustaTech (not verified) on 02 May 2016 #permalink
Point of terminology: if you have a huge increase in the incidence of a condition once you screen for it, is it overdiagnosed now or was it underdiagnosed before?
By Mephistopheles… (not verified) on 02 May 2016 #permalink
Denice @16 -- is this "paradigm shift" like mine, where you take 20 cents in two equal parts and move them smartly from one point to another?
By palindrom (not verified) on 02 May 2016 #permalink
I don't mean to be flip (well, yes I do), but it depends. If earlier intervention makes a difference in outcomes, then you can argue it was underdiagnosed. If not, then it's probably mostly overdiagnosis.
I don't mean to be flip (well, yes I do), but it depends. If earlier intervention makes a difference in outcomes, then you can argue it was underdiagnosed. If not, then it's probably mostly overdiagnosis.
1. I am shocked - Shocked! - to find there is flippancy going on here.
2. Does the appropriateness of diagnosis* depend on potential outcome? I ask that seriously as not any kind of medical person whatsoever.
* As opposed to correctness. If something is diagnosed incorrectly, say the common cold as leukemia, that would be a misdiagnosis and therefore incorrect. Is it an overdiagnosis to diagnose something correctly even though it's irrelevant?
palindrom@21: It's more like the legendary treatise a monk named Canou wrote on the social implications of panhandling. To this day people talk about Brother Canou's Paradigm.
#illbehereallweek
it appears that Tim Bolen has entirely re-vamped his aggressively ugly website, the Bolen Report, which is now only partially so ( 75% rather than 100) and includes diverse writers ( Rapaport, Faloon, Estave and other loons ).
On the blog, second entry, he praises Mike Adams's recent expose of sceptics involving a few people we know.
Somebody is becoming a big name in woo-topia:
Dr DG enters the rarified atmosphere with Gates, Deer, Offit and other sane smart people.. Woo Hoo.
I'm glad that palindrom and Eric Lund's jokes rely on correct pronunciation whereas if we saw attempts at some of the places I survey the results would most likely be a play on the expression 'dig'em'.
Bob Black (the "post-anarchist" writer and all-round curmudgeon) has IP rights for the "youse paradigm" joke.
http://www.inspiracy.com/black/abolition/prey.html
By herr doktor bimler (not verified) on 02 May 2016 #permalink
Well, Rapaport and Adams both hate me. So do Ty Bollinger and Sayer Ji. Add to them the old contingent of antivaccine loons at Age of Autism. If I'm going to be hated, it's good do be hated by quacks.
Rich Woods@14
@prn #1: Many pseudomedical purveyors I can reject, but to me it is more important which unconventional ones have actual answers that are being neglected or attacked as is usual.
Where's the evidence that unconventional medical purveyors do have actual answers? I don't tend to think that we're swimming in it.
The evidence mostly resides in the global medical literature base, as disconnected papers of varied types and levels of evidence. Often leads and advances, diamonds in the rough, misunderstood and/or misrepresented by their detractors, marketers, the ignorant and the obtuse, pro or con.
Thought you'd like to know that It's Always Sunny in Philadelphia has its own take on the "science was wrong before" gambit, called "Science is a Liar Sometimes." Warning for crude language.
https://www.youtube.com/watch?v=Zgk8UdV7GQ0&t=1m
By Cavoyo (not verified) on 02 May 2016 #permalink
@ Mephisto
You have raised a good point. Talking about overdiagnosis means that you can guess what would be the differential outcome after early intervention or without. In another cancer I will not talk about, you can't.
@ Denice
the other day Mikey noted that if you look into Gates's eyes you see……."demons"
Um. The eye is reflecting light. So is the surface of a computer screen. Methink Mike was seeing his own demons.
@ M O'B #23
Does the appropriateness of diagnosis* depend on potential outcome? I ask that seriously as not any kind of medical person whatsoever.
Disclaimer: I am not much of a medical person either.
Well, for correctness, as you point out, I guess the outcome would validate the correctness of the diagnosis. But as for appropriateness....
Now I am stumped.
Wouldn't overdiagnosis and diagnosis appropriateness be interchangeable, within limits?
On second thoughts, I would also nitpick on the "potential outcome" of your definition. I would almost prefer to use "actual outcome" - the diagnosis is validated by the patient developing more symptoms and/or responding to the treatment as expected.
Or maybe I'm just joyfully mixing up diagnosis and prognosis terms. So I will stop playing doctor.
@ Helianthus
Overdiagnosis would mean that the investigation leading to diagnosis and the subsequent treatment does not benefit to the patient. So, it means much more than diagnosis and requires the appreciation of the potential outcomes.
@ JustaTech
What I mean is that there cannot be a debate on whether this is overdiagnosis or not, because these cancers are diagnosed by ultrasound, which is not known to be carcinogenic, and because the rise in cancer diagnosis incidence is such that it is consistent with overdiagnosis. Obviously there is a problem concerning what to do know for these patients, but in the other cancer, which I am not allowed to talk about, answers may be easier when the questions relating to the overdiagnosis issue have been
addressed satisfactorily.
"what to do now", sorry
Alia - "fortunately, I convinced her that it would be a waste of money" (high dose vitamin C for breast cancer). There are many natural substances that have great value in fighting cancer, like curcumin, ginger, mushrooms, hemp oil, yet the herd mentality of doctors prefers the highly debilitating treatments, chemotherapy and radiation, and fixates on these, to substitute their "good offices" for the clean wholesome light of God's natural world. Waste of money? Wow! Those you read, will not admit the many resolutions achieved, by a more natural approach. Because, they will say, they are not scientific, and by that they mean, because they do not agree with what traditionally has not made the kind of money for them, they are accustomed to. Science should be about openness to truth, and certainly not about money. Linus Pauling, double Nobel winner, favoured vitamin C megadoses for cancer, and they have worked miracles for people. And he also said, almost all cancer research, is a fraud. Check out Ty Bollinger's The Truth About Cancer.com, before you wreak havoc with your family. Some people speak to serve truth, others to hide it. There is a difference, in their manner of speaking, that often will give a clue, about their objectives.
By Henri (not verified) on 23 May 2016 #permalink
I have checked out some of the videos on The Truth About Cancer. As a cancer surgeon and researcher, I was appalled at the misinformation, distortions, and outright incorrect information I saw just watching parts of the videos. I might have to go through them and blog each video over the course of the next month or two.
In reply to by Henri (not verified)
the clean wholesome light of G[]d's natural world
Then again, some say that the, ah, difficulty incurred by Lot's wife was in fact seeing G-d's "clean wholesome light."
By Narad (not verified) on 23 May 2016 #permalink
There is a difference, in their manner of speaking, that often will give a clue, about their objectives.
You're a shill for Big Comma?
Yep. The ones trying to sell you something will speak softly, make plenty of promises and talk about how their approach is easy, risk-free and always successful. And cost about nothing at all.
Your reputation as a cancer surgeon and researcher will only get you so far. The gist of this is, you are a colleague at the same hospital of Dr. Farid Fatah, serving 45 years for wrongfully treating large numbers people for cancer that did not have it, and a nigh-compulsive blogger, whose real concentration is on the social phenomenon that is threatening to take the wind out of the sails of much traditional medicine, and trying to manipulate same: the growing public realization that all is not as it seems, as concerns the sincerity of the direction medicine largely has taken. Your exhaustive provision of detail, in your blogs, is enticing to those who want to be truly informed, but your feet of clay, are the overly repetitive sections, (I think you used "quack" at least 5 times in a single paragraph of your blog about the woman with shoulder cancer, who died, while trying Gershon) where you denigrate naturopathy. It is a losing battle, whatever way your persistence tries to denote or connote the opposite. Big Medicine, and its focus on medications and surgeries that would have been unnecessary had a natural foods, and etc., lifestyle been followed, is a fleeting phenomenon that was only possible for a century or so, because of its vast bankrolling, as a business proposition, by Big Steel (Carnegie), Big Oil (Rockefeller) and Banking (J.P. Morgan). Promoting trolling, by others, for example, on the net, against the resumption of nature-based health care, which is gaining ground with good reason, may have strategic value, but all the people cannot be fooled all the time. Even with the increasing stridency of lawmakers supporting vaccination, because of this fact, the shit is hitting the wall. Please serve humanity, as a surgeon, if that is what really is called for, and relax. The gig is up. You can try to pick apart some, or however many, tiny details, based on your pre-formed beliefs, but the nature-based approach, requires none of the supposedly billion dollar testing regime that supposedly goes to treating various drugs. It is not dangerous in itself, so humanity does not need to be protected from it, as from medical drugs, which are often supremely harmful. Yet the established order, is trying to destabilize the natural foods and supplements suppliers, by trying to impose this completely inappropriate kind of testing regimen, on them, to make their work of aiding us with nature's bounty impossible. Big Money and Big Criminality, are the commonest of bedfellows. These entities act like they have copyrighted the idea of science, as if they have sole discretion to determine what can be accepted, for human health. I believe Dr. Joel Fuhrman, Dr. Michael Greger, and Sajer Ji, who are all very well educated and dedicated followers of real science, who can see the big picture, which is totally opposite to yours. That is the picture you constantly try to undermine and repudiate, with name-calling and more opprobrium. People will get tired of hearing from you, when you denigrate those such as these, Mike Adams, Gershon, and others, even though almost the entire history of medicine, in the past century, has been of a war waged, by political means, and with money, against the sanctity of the human body, and its existence based in the realm of nature, which contains its proper resources in health and sickness. Pretending superiority is the usual strategy of those such as yourself. The whole strategy of your profession, as promoted by Big Money, was to turn it into an elitist group, with no women, non-Caucasians, or members who did not come from the upper or at least the upper middle class. These were the ones whose craving for money and power, made them the most susceptible to Big Money's design, to create an exploitative profession, all the better to administer vast amounts of unneeded medicines and treatments, and denigrate the real potential of more naturally-based resources. Like pasteurized milk, and refined flour and sugar, when you see white-the white coat, you can expect an approach, that has little basis in nature, but expects to profit from that fact, in human estimation. It is a losing battle. Many individuals have been severely oppressed, for following truth, but Truth itself, will never die.
One more time: No, I did not and do not work at the same hospital that Dr. Farid Fata did. Dr. Fata never worked for my cancer hospital, nor did he even ever have privileges here. Similarly, I never worked for the hospital that Fata worked for, nor did I ever have privileges there. (Actually, Fata had privileges at several local hospitals.) The real story is that a few years ago my cancer hospital entered into a joint venture with a large local hospital. It turns out that my Dr. Fata rented space in the same office building where the joint venture was housed. (It was a large medical office building.) The joint venture went didn't work out and was dissolved. That's it.
As for the rest of your rant, well, it's nothing I haven't heard before, only more ranty than usual.
So how do you know to trust someone such as Mike Adams? He tells you something will help you and then he sells it to you. The funny thing is when I read about nutrition the last place I'll buy any 'nutrional' product from is one of these promotors on the web.
By Not a Troll (not verified) on 25 May 2016 #permalink
Henri, what do you have against Big Paragraph? You must be a shill for Big Wall of Unreadable Text.
By Chris (not verified) on 25 May 2016 #permalink
Henri -
trying desperately to help you: you might have missed a cliché or two. Next time try to have no more than 3 per para.: it'll help check whether you've forgotten anything.
Oh, by the way: check out a life expectancy curve over the last two hundred years. If you see any progress there, do you think it's due to the likes of Mike Adams & Co.?
By Peter Dugdale (not verified) on 25 May 2016 #permalink
These off-the-wall responses show little depth, brief as they may pointed-headedly be. Points, are just what they lack. Life expectancy, might have been the exception. It is currently decreasing, in North America. Just like the introduction of vaccines, starting in the early 1930's, just after the incidence of many childhood diseases having just decreased sharply because of improvements in quality of life via numerous technological developments, including indoor plumbing, heating, transportation of food, refrigeration, child labor standards, many others, the supposition of increased lifespan is used to by medical apologists to garner credit for their machinations. They never mention that the quoted "increase" is misleading, due to the fifty per cent infant mortality rate, that was the norm in western society in past centuries. Most babies died in their first year of life, a few of these in their second. They did not know about hygiene, suffered from poverty and lacked efficient heating, refrigeration, clean water, sewage disposal, and other important factors. Cities like London were hugely polluted by brick kilns, and coal fired operations. There were frequent wars. So this supposed lifespan benefit is not the result of any administered treatments that would pertain to those over that age, which the data is being used to support. "People are now living twice as long" they say misleadingly. Truth is, if you made it to the age of two, in previous centuries, you didn't have much less life expectancy than people today, so that is no argument for undergoing so many medical treatments today. If you, O., have heard some points before, you cannot respond to them, because of your inclusion and assumption of your professional mantle, with its professional benefits. Knowing about health, is intellectually impossible, without living it. The mind cannot understand, if the body is not observing. So many patients of doctors, as well qualified as yourself, like Dr. Caldwell Esselstyn, Dr. Dean Ornish (accepted by Medicare), Dr. John MacDougall, Dr. Joel Fuhrman, Dr. Neal Barnard, Dr. Michael Klaper, and many others, can be seen online, with amazing recovery stories, that never could have been instigated, by conventional medical treatment, and often, these patients were at the end of their ropes, after having suffered that kind of attention, and even having been told they were not long for this world, by standard doctors. There is no refutation for this. So many promising cancer researchers who gave vast help, have been serially abused, even to the point of death, by the "medical authorities" and their government cohorts, the atrocity of this is inconceivable to those coddled into inane sheepishness by persons such as yourself and the media. Go ahead and try to "refute" every episode of The Truth About Cancer, the two series by Ty Bollinger. You will have your "work" cut out for you. Not that what you say works, like what the doctors I mentioned say.
Yep, Henri is a shill for Big Wall of Unreadable Text.
"Just like the introduction of vaccines, starting in the early 1930's, just after the incidence of many childhood diseases having just decreased sharply because of improvements in quality of life..."
Really? The following is US Census data of measles incidence during the 20th century. Please tell us why the rate of measles incidence in the USA dropped 90% between 1960 and 1970. Please do not mention deaths, do not mention any other disease, do not mention any other decade (unless it has at least a 80% drop and did not go up again), and do not mention any other country (England and Wales are not American states).
From http://www.census.gov/prod/99pubs/99statab/sec31.pdf
Year.... Rate per 100000 of measles
1912 . . . 310.0
1970 . . . . 23.2
1980 . . . . . 5.9
1990 . . . . .11.2
1991 . . . . . .3.8
Chris, you say "Please do not mention deaths", because deaths from measles are so minuscule, that putting mercury and many other poisons into the body via measles vaccines, is blatantly uneconomical, for health purposes. No informed person would take such a vaccine. This is only one disease, the general point has not been disproved, but this is the style of argumentativeness you espouse. Check Natural News: the CDC or other "authoritative" medical body has just reinforced the notion that "shedding" of measles occurs from those vaccinated, for several weeks after. So the vaccines are a way of drumming up business, by causing more disease, not just measles, in point of fact, but many others. Pro-measles vaccine propaganda is one of the biggest scams ever. Is the US Census a qualified collector of disease statistics? How do they eliminate prejudice, from the correspondents? Doctors, I suppose...not that it disproves my point, accurate or not.
In reply to by Chris (not verified)
the CDC or other "authoritative" medical body has just reinforced the notion that "shedding" of measles occurs from those vaccinated, for several weeks after.
If the vaccine does not cause disease in the people being vaccinated, why would the virus being shed cause it in others? Logically, if vaccine shedding were really an effective means of spreading the virus, this would increase the level of immunity and, therefore, reduce the potential profits from selling the vaccine. Indeed, we'd expect that after vaccines were introduced that there would be higher, not lower incidence of measles if it caused the disease.
By the way, which is it - the CDC or some other "authoritative" medical body.
FWIW, of course people who immunosupressed/immunocompromised should avoid those who have recently been immunized with a live virus vaccine.
Henri, how many cases of measles have you personally seen? When and where did you see them?
According to what I've read, prior to the development of the measles vaccine, America was regularly swept by measles epidemics and 95% of eighteen-year-olds had had measles. You simply could not have grown up in America without seeing lots of measles cases around you.
And yet ...
Now you don't see measles around you. Outbreaks of ten people make the national news. If that change is not due to vaccination, what is it due to?
By LW (not verified) on 29 May 2016 #permalink
Henri: "Chris, you say "Please do not mention deaths", because deaths from measles are so minuscule, that putting mercury and many other poisons into the body via measles vaccines, is blatantly uneconomical, for health purposes"
No, I say it because you said "incidence." So if you posted a graph on "deaths", that would be not be "incidence." It would actually be you lying, and I am trying to prevent you from lying.
Also, there has never ever been thimerosal in any measles containing vaccine. I am not going to claim you lied, but that you just did not know.
Okay, let us try again with the same US Census paper I cited. You said (with added emphasis): "Just like the introduction of vaccines, starting in the early 1930's, just after the incidence of many childhood diseases having just decreased sharply because of improvements in quality of life…"
Again from From http://www.census.gov/prod/99pubs/99statab/sec31.pdf we have the incidence of diphtheria in the USA. Please tell me where the incidence of that disease decreased sharply before 1930:
YearRate per 100000 of Diphtheria in the USA
1912. . . 139.
1925. . . 82.1
1950. . . 3.8
Remember, you said "incidence", do not try to lie by saying you really meant "deaths." Besides deaths only measure how well medical care has improved. Though even today about one in ten who get diphtheria die even with medical treatment. Last year a little boy in Spain died from diphtheria.
@Henri,
Since you trust the CDC, but not the US Census Bureau for whatever reason, check out page 10 of this report which has graphs showing the same result.
http://www.cdc.gov/measles/downloads/report-elimination-measles-rubella…
The reason Chris keeps including the morbidity not mortality is to make the point that vaccines reduce the incidence/morbidity of the disease they protect against. Mortality is a secondary effect as are deafness, blindness, SSPI. And it is influenced by secondary factors like better lifesaving interventions.
As for life expectancy, this reference (also from the CDC) makes the point that it increased in the last century from about 50 for whites and less for blacks to over 70 for most groups with a big decrease in the white-black discrepancy.
http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_01.pdf
Please check out the graph in Figure 1.
I also saw a reference that life expectancy in the US reached a record high in 2012. (Newer years aren't available yet.)
Would you please provide a confirmed case of measles due to shedding from a vaccination?
By squirrelelite (not verified) on 29 May 2016 #permalink
By the way, Henri, the first diphtheria vaccines were introduced in the 1920s.
putting mercury and many other poisons into the body via measles vaccines
A better class of antivaccine crank is clearly warranted here.
Go ahead and try to "refute" every episode of The Truth About Cancer, the two series by Ty Bollinger. You will have your "work" cut out for you. Not that what you say works, like what the doctors I mentioned say.
The only reason refuting every episode of The Truth About Cancer would be difficult is because there are just so many damned episodes and so many bogus claims to refute in it. I've perused parts of some of the episodes and found easily refuted nonsense just with that brief sampling. If I were to undertake looking at all the episodes, I have no doubt that I would produce ten posts of 5,000 words apiece and still not have refuted all the deceptive claims made in the "documentary."
Who is this "Gershon" that Henri refers to?
I do recall a Gershon in Alabama, who ran "Gershon Weinberg's Real Pork Barbecue".*
*mentioned in Tony Horwitz's book, "Confederates In The Attic".
**Henri, there are charities that give away paragraphs for free to those in need. And they are guaranteed to be mercury-free.
Check Natural News: the CDC or other "authoritative" medical body has just reinforced the notion that "shedding" of measles occurs from those vaccinated, for several weeks after.
I second Narad's motion.
By Science Mom (not verified) on 29 May 2016 #permalink
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