Mike the Mad Biologist

When Woo-ism Meets Cancer Prevention

Friday, the NY Times described the relatively paltry efforts in cancer prevention, compared to those for heart disease. Not that researchers haven’t been busy figuring out how to prevent various cancers:

Then, in 1999, he had a chance to do another breast cancer prevention trial, this time of an osteoporosis drug, raloxifene, or Evista, which did not have the cancer drug taint. It was to be compared with tamoxifen.

The $110 million study, involving 19,000 women, ended in 2006. The two drugs were found to be equally effective in preventing breast cancer, but with raloxifene there was no excess uterine cancer and the clotting risk was 30 percent less.

“It was a spectacular clinical trial,” Dr. Vogel said. But, he added, “Once again, the world met the result with a shrug and a harrumph.”

Mind you, we’re talking about lowering breast cancer probabilities from twenty percent to ten percent: this isn’t some ridiculously low probability event that becomes a ridiculously low probability event divided by two. So what gives? I think it’s patient fear:

He cannot understand why no one cares, but some doctors say they see a number of problems. It is usually not the cost; tamoxifen is about 30 cents a day and raloxifene $3.30 a day. It is doctors’ practices and women’s concerns.

Most doctors, said Dr. Therese B. Bevers, medical director of the Cancer Prevention Center at M. D. Anderson, do not take the first step — calculating a woman’s lifetime risk of getting breast cancer — in part because that can lead to the next step, spending an hour or so discussing cancer risk and drug risks and benefits.

Dr. Bevers suggests the drugs for women whose lifetime odds exceeds 20 percent. That could include, for example, a 55-year-old woman who began menstruating early (increasing the risk), had her first child late (again increasing the risk), and whose mother and sister got breast cancer. About half the time, though, women with that kind of risk turn down the drugs, Dr. Bevers said. “The No. 1 reason I hear is, ‘Oh, I just don’t like to take medications,’ ” she added.

I’m guessing, but a lot of people just don’t like thinking about the possibility of being sick (understandable), and decide to ignore the problem (fucking stupid). But some people go farther, and engage in ‘woo-istic thought’ (based on ScienceBlogling Orac‘s derogatory phrase, woo, for altie medicine):

Others, like Cecilia Anderson, who is 57 and lives in Houston, worry about side effects. “I felt like my quality of life was in question,” she said. “I am busy, I am out there. I totally love my life and don’t want it to be compromised.” Her lifetime risk of breast cancer is 20.5 percent, compared with an average risk of 9.8 percent for a woman her age. Ms. Anderson declined the drugs. “I live a different lifestyle,” she said. “I eat organic foods, I exercise. Through all of that comes a spiritual element as well. Mind, body, and spirit are all connected.”

I could understand if you tried the medication, and you felt lousy. Somehow, I don’t think “a spiritual element” is going to halve the probability of breast cancer. (Before anyone thinks I’m picking on women, men seem just as idiotic regarding prostate cancer prevention–which has a much lower survival rate). But people who are frightened will engage in activities that lend the illusion of control (there is little conclusive evidence that diet can significantly lower breast cancer rates in older women*). The terror of knowing that there’s is a one-in-five chance of getting cancer, combined with the knowledge that, even with medication, there is still a one-in-ten chance of getting cancer has to be terrifying.

Woo-meisters prey on this fear: false certitude is far more comforting than statistical probabilities.

In a larger context, this irrationality–and it is irrational–affects all of us: when we, as a society, do not engage in prevention, we all end up paying more in healthcare costs. I’m not sure how to do it, but somehow we have to figure out a way to reach frightened patients.

*A healthy diet and exercise are good for you for other reasons.

Comments

  1. #1 Sam c
    November 18, 2009

    I’m guessing, but a lot of people just don’t like thinking about the possibility of being sick (understandable), and decide to ignore the problem (fucking stupid).

    Ah, the cultural arrogance of the science-meisters!

    If we don’t do as you think we should, we’re fucking stupid are we? Well, you’re both fucking ignorant and fucking arrogant then! And arrogance and ignorance are an unpleasant combination. Sorry, a fucking unpleasant combination. Quite why you think inserting “fucking” into your burble improves it, I don’t know. It just points up its patheticness.

    People make choices. Regardless of risk, many of us healthy folk simply don’t want to take “preventive” drugs, not proper scientific medicines, not vaguely sane (but unnecessary) supplements (such as vitamins), and certainly not wooey concoctions of Nepalese Sloth Vomit Essence. I think an attitude of “I’m basically healthy, I’m just going to get on with life and see how it turns out” is quite sane. Equally I think an attitude of “I care about my health and I will investigate all relevant risk factors and consider mitigating action” is also sane.

    Choosing to take a relaxed approach is not wilfully negligent (like crossing a busy road with your eyes closed would be). It’s a personal choice.

    So these drugs halve a risk? Big deal. That’s not actually that much when one looks at the odds. Odds are still massively in favor of being one of the lucky ones. You think differently? That’s your right.

    You think it’s irrational. That’s typical of the bloggers here, who can’t understand why anybody wouldn’t bow their knee to their ex cathedra pronouncements. Medical trials are great, evidence-based medicine is a wonderful thing, but how do you expect non-medics to react when one year they are being told that taking aspirin is a generally good thing for anybody with possible heart issues, but now they are being told that the risks might outweight the benefits for many of the target group?

    What about the folk who were on blood pressure reduction pills a couple of years ago and now find that they are being taken off these because the pills reduced blood pressure but not the complications (stroke etc.) that high blood pressure is supposed to be a risk factor for? One could say that this shows the self-correcting nature of good scientific and medical research. That would be true, but it also shows that the state of knowledge at any time was less certain that its proponents believed at the time.

    Quite simply, many punters don’t trust the certainty of scientists. And the bloggers here just can’t get their heads around why that might be, can they?

    If there’s one characteristic of the scientist bloggers here, it’s that they massively under-estimate their ignorance. Oh yes, there’s lip service to not knowing everything… but as Donald Rumsfeld pointed out, there are unknowable unknowns, and the scientists generally hugely under-estimate those.

  2. #2 NJ
    November 18, 2009

    My, Sam, quite an outburst!

    Frankly, Mike nailed it with the quote that pushed your button. You want certainty. You want THE answer. And when science (or scientists or ScienceBloggers) can’t give you THE answer, you look for someone to blame.

    Well, here is your someone: Reality.

    Science is by definition the current understanding, subject to change if enough data is gathered. But you (and others of your kind) don’t like that. We’re truly sorry that the real Universe cannot be made to conform to your simple desires, and that you find it comforting to rage at the messengers.

    Although you claim that:

    If there’s one characteristic of the scientist bloggers here, it’s that they massively under-estimate their ignorance.

    in fact, you have it bass-ackward. I’ve yet to meet a scientist that wasn’t keenly aware of their own ignorance. The real problem is that we over-estimate your ability to process information.

  3. #3 Ian Musgrave
    November 18, 2009

    Sam wrote:

    What about the folk who were on blood pressure reduction pills a couple of years ago and now find that they are being taken off these because the pills reduced blood pressure but not the complications (stroke etc.) that high blood pressure is supposed to be a risk factor for

    [citation needed] Hmm, lets look at the literature then.
    Curr Top Med Chem. 2009 Oct 22.
    “Clinical trials of antihypertensive treatment, both in studies that have compared active drugs against placebo or in those comparing different types of drugs have clearly demonstrated a protective effect of blood pressure reduction in the prevention of stroke.”
    Curr Opin Nephrol Hypertens. 2004 Sep;13(5):507-12.
    “Data from controlled trials of blood-pressure-lowering treatment have demonstrated that treatment considerably lowers the risk of stroke within a few years of starting treatment.”
    Ther Adv Cardiovasc Dis. 2009 Jun;3(3):197-204. Epub 2009 May 14. “Blood pressure reduction by antihypertensive treatment is clearly efficacious in the prevention of stroke (both primary and secondary).”
    Cochrane Database Syst Rev. 2009 Jul 8;(3):CD001841.
    Antihypertensive drugs reduce all over mortality, stroke, cardiovascular events etc. etc. (some better than others)

    I think this illustrates another point, that peoples irrationality is fuelled by “factoids” not real information.

  4. #4 10000li
    November 18, 2009

    Both of the replies to Sam C were completely off the mark, of course, and both proved exactly what Sam was talking about.

    NJ just kept dissing on all the non-scientists as being too slow on the uptake (you poor slobs who don’t have PhDs and are unable to process information like us special people can).

    Ian Musgrave followed up with a literature search.

    Hmm. How many Americans who have not taken a 3rd-year college science class know how to do a literature search?

    Not very many that I have met. Most non-science people (which means at least 80% of the population) get their medical and science information from mass media.

    Who provides the majority of that information to mass media? Scientists or drug company PR firms?

    Who is more likely to spin the information they provide? In turn, since Chang and Eng on the street also believe that drug companies provide most of the information to the mass media, then Chang and Eng are likely to be sceptical of the claims they read and hear.

    If you can show Chang and Eng how to carve out of their schedule time for literature searches, around jobs, communting, day care, struggling with the kids, school projects, birthday parties, house- and yardwork, taxes, politics, and the five minutes on Saturday night they have with eachother, then teach them how to find the pertinent literature, read it and understand its implications, at that point I think you would have the right to wag your finger if people base their actions on “factoids” rather than what has been published this week in teh journals.

  5. #5 sailor
    November 22, 2009

    I think Sam has a point. Consider:
    ‘Dr. Bevers suggests the drugs for women whose lifetime odds exceeds 20 percent.”
    Ok that is lifetime odds, does not even mean it is going to kill you.
    In the initial study you did not mention what the statistical benefit of taking the drug was. I’ll make a guess and suppose it is a good drug and saved 20% of people getting cancer. Looked at that way that is going to be quite a few people taking the drug for a lifetime to stop one getting cancer. And if they did get cancer, it might be treatable and not necessarily kill them.
    This is just breast cancer. Say we start doing the same for a dozen other Cancers? Like Finasteride for prostate cancer. We could all be RX junkies very fast. This of course would vastly entrich the drug companies.
    We will all die sometime. Few want to rush it, but one can make a perfectly sane choice to take ones chances, not spend a lot of time and money dealing with medical possibilities, and yet be willing to deal with the consequences if it turns out one is unlucky. That does not have to be your choice, but it is a sane choice. I think Sam is right taking a relaxed attitude is perfectly reasonable.
    It is up to everyone to make their own medical decisions. The best science can do is give the the right information to make those decisions.