prostate cancer

No, the PSA test probably didn't save Ben Stiller's life

oracknows — Fri, 07 Oct 2016 01:54:06 +0000

No, the PSA test probably didn't save Ben Stiller's life

A frequent topic of discussion on this blog is the concept of overdiagnosis. It’s a topic I’ve been writing about regularly since around 2007 or so and is defined as the detection in an asymptomatic person of disease that, if left alone, would never progress to endanger that person’s life or well-being within his or her lifetime. The problem with overdiagnosis is that it pretty much always leads to overtreatment, the treatment of overdiagnosed disease that is not health- or life-threatening. The key shortcoming in our knowledge that leads to overtreatment is that, once we detect disease with many screening tests, we usually do not have any tests that can identify which lesions are potentially dangerous and which ones can be safely watched because they are unlikely to progress (or to progress fast enough) to be a problem within the patient’s lifetime.

Most commonly, I’ve discussed overdiagnosis in the context of mammographic screening programs, but I’ve also looked at the overdiagnosis of thyroid cancer, prostate cancer, and other diseases. The bottom line, from my perspective, is that screening asymptomatic populations for breast and prostate cancer does have some benefit, but over the years that benefit was likely exaggerated as the downside of screening (overtreatment) underestimated. On the other hand, there are those out there whom I view as nihilists, who have gone too far in the other direction, declaring certain forms of screening (particularly mammography) to be worthless or even harmful.

The purpose of that preamble is to let new readers know where I’m coming from, as what I’ve just written will have been no surprise to regular readers. The longer you’ve been a reader, basically, the less of a surprise it will be. So you can probably predict how I reacted to an article that’s been going around social media since it was first published four days ago. In fact, I was going to write about it yesterday, but my Dug The Dog complex hit, and I was distracted by two articles in the latest New England Journal of Medicine. Still, many of you can guess which article I’m talking about, as the title is akin to my retort to an article by a fellow physician that, no, the New York Times did not kill your patient, only in the other direction. This time around, it’s not a physician, but rather an actor and comedian, Ben Stiller, who wrote about The Prostate Cancer Test That Saved My Life. My response is not quite as definitive as my response about the NYT. In response to Mr. Stiller, I can only respond: No, the prostate cancer test probably didn’t save your life, but we can’t know for sure.”

Stiller is clearly very intelligent. His essay is well written and well-argued and even includes a poignant description of his reaction to his diagnosis of prostate cancer:

I got diagnosed with prostate cancer Friday, June 13th, 2014. On September 17th of that year I got a test back telling me I was cancer free. The three months in between were a crazy roller coaster ride with which about 180,000 men a year in America can identify.

Right after I got the news, still trying to process the key words echoing dimly in my head (probability of survival–vival-vival-val…” “incontinence-nence-nence-ence…), I promptly got on my computer and Googled “Men who had prostate cancer.” I had no idea what to do and needed to see some proof this was not the end of the world.

John Kerry… Joe Torre… excellent, both still going strong. Mandy Patinkin… Robert DeNiro. They’re vital. OK great. Feeling relatively optimistic, I then of course had to do one more search, going dark and quickly tapping in “died of” in place of “had” in the search window.

If you’ve just been diagnosed with cancer, never do that search, people.

Pretty much any cancer patient can relate to Stiller’s story, particularly if the cancer is a common one, like prostate, for which there will likely be lots of news stories about celebrities bravely battling the disease. Here’s where Stiller goes wrong, but understandably so given the issues involved:

Taking the PSA test saved my life. Literally. That’s why I am writing this now. There has been a lot of controversy over the test in the last few years. Articles and op-eds on whether it is safe, studies that seem to be interpreted in many different ways, and debates about whether men should take it all. I am not offering a scientific point of view here, just a personal one, based on my experience. The bottom line for me: I was lucky enough to have a doctor who gave me what they call a “baseline” PSA test when I was about 46. I have no history of prostate cancer in my family and I am not in the high-risk group, being neither — to the best of my knowledge — of African or Scandinavian ancestry. I had no symptoms.

What I had — and I’m healthy today because of it — was a thoughtful internist who felt like I was around the age to start checking my PSA level, and discussed it with me.

If he had waited, as the American Cancer Society recommends, until I was 50, I would not have known I had a growing tumor until two years after I got treated. If he had followed the US Preventive Services Task Force guidelines, I would have never gotten tested at all, and not have known I had cancer until it was way too late to treat successfully.

It’s understandable why Stiller feels this way and believes this. Also, in fairness, one aspect of Stiller’s case that tends to be in his favor is how young he is. Prostate cancer before the age of 50 is very uncommon. Be that as it may, it is a maddeningly intuitive notion that early detection always saves lives. Yet, as I’ve pointed out time and time again, beginning back in 2007, the relationship between the early detection of cancer and the likelihood of cure and long term survival is not nearly as straightforward as it seems on the surface. There are a number of factors that confound this seemingly obvious and intuitive relationship, but the two most important are lead time bias and length bias.

I’ll illustrate the concept of lead time bias with a graph that I’ve used many times before to explain:

And a slightly more complex one:

I have explained the concept of lead time bias in more depth here and here, but I do these graphs for illustrating the concept that lead time bias can make it look as though survival from a cancer screened for is longer even in the absence of any therapeutic effect whatsoever from treatment. Since it’s been a while since I’ve shown this particular graph, I’ll add it to the mix, as it shows the effect of lead time bias on cancer survival curves:

Before I move on, I’ll even cite Aaron Carroll again, as he gives one of the simplest and most straightforward explanations of lead time bias that I’ve yet to see. Of course, the phenomena of lead time bias and overdiagnosis are intertwined. Think of overdiagnosis as the detection of a tumor with a lead time, as illustrated above, that is longer than the remaining expected lifespan of the patient, and you’ll see what I mean (I hope). In such a case, patient survival will seem to be, in essence, infinity, at least with respect to the cancer in that the patient dies of something else before the tumor progresses significantly. Now, Stiller does make one good point when he says there might be high risk groups for whom PSA screening is appropriate, and there is certainly research looking at that very question. However, now, based on what we know now, for the vast majority of men at average risk for prostate cancer, PSA screening is more likely to cause harm through invasive testing and over treatment than to save their lives.

The other problem with screening tests that confounds the relationship between early detection and improved cancer survival is a phenomenon known as length bias. Basically, length bias is the term used to describe how regular screening tests tend to detect slower-growing, more indolent disease preferentially. How many of you know someone who had a mammogram on schedule as recommended but came back the next year with a big, advanced breast cancer. Did mammography fail? Probably not. Rather, the tumor was just too fast growing. It went from undetectable by the test (mammography) to advanced during the interval between screenings. More often, what is detected by screening tests like mammography is disease the grows relatively slowly. This concept is illustrated here, by another chart that I also like to use a lot:

The other problem with length bias is that the more sensitive the test, the more likely it is to detect tiny indolent tumors that are so slow-growing that they wouldn't progress to the point where they would endanger the patient's life within the lifetime of the patient. Some, particularly screen-detected cancers, even spontaneously regress. Length bias and overdiagnosis are also related concepts in that length bias contributes to the tendency of screening tests to overdiagnose the disease they are looking for.

So, unfortunately, Ben Stiller is wrong in that there’s no way of knowing that the PSA test “saved” his life or that if he hadn’t been screened at all his tumor would not have been found until it was “too late.” Those are common assumptions on the part of patients and even many physicians. In brief, there is no surefire way of knowing whether or not he was overdiagnosed. However, as we’ve come to appreciate over the last decade, prostate cancer is very commonly overdiagnosed. In fairness, Stiller is definitely more savvy and informed than the average celebrity writing about medical issues. He clearly at least recognizes the controversies involved in screening:

The criticism of the test is that depending on how they interpret the data, doctors can send patients for further tests like the MRI and the more invasive biopsy, when not needed. Physicians can find low-risk cancers that are not life threatening, especially to older patients. In some cases, men with this type of cancer get “over-treatment” like radiation or surgery, resulting in side effects such as impotence or incontinence. Obviously this is not good; however it’s all in the purview of the doctor treating the patient.

This is exactly what happened to Stiller. His PSA rose for a year and a half before he was referred to a urologist, who did an examination and ordered an MRI. This led to a biopsy, which diagnosed a tumor with a Gleason score of 7 (3+4), which is categorized “mid-range aggressive cancer.” The Gleason score, however, is not the be-all and end-all as a criterion for starting treatment. Stiller doesn’t tell us how many cores of his biopsy contained cancer, whether cancer was found in both sides of the prostate, or how much of each core contained cancer, or how fast his PSA was rising. Be that as it may, he is far more likely than not to be mistaken when he declared so bluntly that the PSA test definitely saved his life. This infographic from the National Cancer Institute tells why there’s at least a 95% chance he was mistaken. In fact, for every 1,000 men who undergo PSA screening, only one life is saved, but 100-120 get false positive diagnoses and 110 will get a prostate cancer diagnosis. Again, it’s understandable why he would believe as he does, but that doesn’t make it any less misguided.

Let’s just put it this way. If even Dr. Mehmet Oz throws cold water on your claims, you should rethink:

Of course, Oz then went on to oversell dietary and exercise interventions for preventing death from prostate cancers, but you can’t expect Oz to do a whole segment without getting into some woo, now, can you?

The main problem with Stiller’s article, besides its mistaken argument that PSA screening almost certainly saved his life. He also cited a study by Edward Schaeffer, his surgeon and the chair of urology at Northwestern University, to support his point, stating, “There is growing evidence that these guidelines have led to increased cases of prostate cancers that get detected too late for the patient to survive the disease.”

You might remember this study, as it was in the news back in July. Basically, it purported to find that the incidence of metastatic prostate cancer has been climbing since PSA screening began to fall, the implication being that decreased screening is leading to more men being diagnosed with metastatic (and therefore incurable) prostate cancer. I first saw the study, but it was at a time when I had a lot of other things going on; so I didn’t look at it carefully. Concerned, I whipped off a quick e-mail to a relevant expert whom I trusted and had published with before asking him what he thought of the study and whether maybe I should consider starting PSA screening again. His response was blistering.

I’m not going to quote his e-mail directly because I do not publicly reveal e-mail contents without permission of the person who sent it to me. I can say that he did dismiss it, pointing out that, although the authors used the word “incidence,” what they were really counting were gross numbers of cases reported to the National Cancer Data Base (NCDB) from 1,000 health care facilities and changes in gross numbers from 2004 to 2013. He pointed out that true incidence is the number of cases divided by the number of people in the population (usually expressed per 100,000). So here’s the problem. Schaeffer’s group reported the numerator, but had no idea what the denominator was (the number of people in the population from whom the cases came from), as they even basically admitted:

Limitations to the current study include the lack of national annual incidence rates in the NCDB. Thus, our outcome variable was annual incidence of prostate cancer at over 1000 health-care facilities in the United States relative to that of 2004, the initial year of our study period.

In fact, the incidence of metastatic prostate cancer has been stable from 2004 to 2012 (the time period of the study cited by Stiller) and in fact the incidence was lower in 2012 than it was in 2000. Clearly, the incidence of metastatic prostate cancer is not increasing using more standard methods of measurement.

Suffice to say, I was horribly embarrassed for having asked about this study when in retrospect I knew enough to have figured out how useless it was myself.

Others have been critical of Stiller as well, for example, Kevin Lomangino, the managing editor of HealthNewsReview.org, who wrote Ben Stiller’s misguided prostate cancer recommendations aren’t based on evidence. He hit many of the same points I did, although he didn’t go into lead time bias and length bias, as I did and some I didn’t, noting, as I did, that Stiller is “smart, persuasive, and famous,” but that “his skewed piece may do a great deal of harm to men who may be led astray by his faulty reasoning.” He also cites oncologist Vinay Prasad, MD, MPH, who made a similar point to that which I’ve made many times regarding mammography:

Ben Stiller says everyone over 40 should get a PSA, but why does he discriminate against 39 year olds? If you accept Ben Stiller’s logic, that we should do anything to find cancer early (with near total disregard for net effects, harms or overdiagnosis), why is 40 Ben Stiller’s cutoff? He criticizes the American Cancer Society for 50, and yet equally arbitrarily chooses 40. If Ben Stiller thinks a 40 year old should be offered a PSA, why not a 39 year old? Why not every man? Since Ben Stiller does not employ careful scientific reasoning to reach his position, I would argue that Ben Stiller is logically inconsistent.

I’ve basically said the same thing about mammography to those criticizing newer recommendations that increased the age at which mammographic screening should begin for the average risk woman and argue for retaining the existing guidelines that recommend beginning at age 40. Why not begin at age 35? Or 30? Or even 20? In other words, even the most enthusiastic advocates of screening realize that there is an age below which incidence of breast cancer is so low that the harms from screening far outweigh the potential benefits. It’s always a judgment call to set those cutoffs, and there is always harm from overtreatment whenever there is screening with a significant incidence of overdiagnosis. Balancing the risks and benefits is what is so difficult about constructing screening programs for common cancers like breast and prostate. I only wish that Ben Stiller had done more than acknowledge those risks in passing and avoided concrete declaratory statements like, “Taking the PSA test saved my life. Literally.” And: “I believe the best way to determine a course of action for the most treatable, yet deadly cancer, is to detect it early.”

Unfortunately, we’ve been learning that this is not always true. It’s complicated. I am gratified, though, that the reaction to Stiller’s article has been, unlike what would likely have been the case in the past, to take him to task for making assertions not supported by evidence. Unfortunately, Stiller’s celebrity will likely trump evidence.

oracknows Thu, 10/06/2016 - 21:54

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biology

cancer

medicine

Science

Skepticism/Critical Thinking

We recently discussed exactly this issue on the Great Orange Satan, in the context of Rudy Giuliani using confusion of mean survival times to sneer at the communist National Health in Britain, and the concensus is that many Kossacks are Really Fucking Stupid about the interpretation of medical statistics - but that doesn't stop them from having belligerent and contemptuous opinions.

Here's my take on that common right wing talking point:

http://scienceblogs.com/insolence/2012/04/24/more-cancer-care-isnt-alwa…

Orac, didn't you co-author a paper saying that PSA screening implementation led to a dramatic drop in prostate cancer metastasis?

FWIW, this article is a nice counter-point to the USPSTF recommendations against screening for prostate cancer: http://annals.org/mobile/article.aspx?articleid=1166178

Rather than relying on anecdotal evidence like Stiller's story, it does a nice job of explaining the flaws in their reasoning, and it's not behind a pay-wall, which is always nice!

There isn't really any way of determining if a prostate tumor will turn out to be dangerous (I dont think even Gleason scores do this adequately) and no way of telling if the tumor has already metastasized. Both of these are big areas of research.
2 years after treatment is a little too soon to be sure that there won't be recurrence.

Though I actually don't know the stats of how often we see metastasis if the primary tumor is removed before any are detected. It's not the area of research I am familiar with.

Having Gleason 3+4 prostate cancer at age 48 seems pretty high risk to me. Simply an elevated PSA at that age is associated with an 8 fold higher risk of death from prostate cancer (http://jco.ascopubs.org/content/early/2016/06/09/JCO.2016.66.7527 and a couple of other studies)
Leaving such a cancer until it produces symptoms gives a high risk of it already having metastasised, which is incurable although slow.
Two problems with the NCI infographic:
- it only considers death within 10 years of PSA testing . Deaths go up after then
- we have treatments that will control metastatic prostate cancer for 3 or so years, but they are quite unpleasant - chemical castration to start with. That's not death but worth avoiding.

Small low risk prostate cancers are common (about 50% of diagnoses) and should not be treated, but larger and higher risk once can kill. Low-Intermediate risk ones like Ben Stiller's take 10-15 years to kill but they are still dangerous. Mine was the same Gleason score but by age 52 it had already grown into a 20cc tumor. Leaving it for another decade would not have been wise.

I think the best PSA testing recommendation is to test once in the mid 40's to see if you're in the high PSA = high risk group. If not, leave it until 50+. Statement 4 in this: http://www.bjuinternational.com/bjui-blog/the-melbourne-consensus-state…

I'm 6-years post surgery, and my most recent PSA was below detectable limits - two more years of remission before "cured."

I started screening at age 50 - and for ten years it was in the normal range. 3.5 or so. Then it rose to about 4.5 in one year. Hmmmmm.

Next year it was 5.5, and the year after, 7.8. That's when my primary physician referred me to a urologist.. Not once did my PCP note any nodules during my annual digital exam, but the urologist found several right away.

Biopsy found 12/12 positive, Gleason score 7 (4+3).

Upon resection, the diagnosis was Stage II (b): clear margins, no infiltration to the capsule, no lymph nodes involved. At that rate of increase, I was probably two years away from metastatic disease, Lupron, and (mostly ineffective) chemotherapy.

The problem is not with screening per se, but with the response to the data. I agree with Mr. Stiller that screening might well have saved his life - it seems to have saved mine.

fusilier
James 2:24

I think it is difficult to second guess Stiller's decision to be treated without seeing the pathology report. In the absence of a family history, it is likely that he had a minimal prostate cancer, but that is not a given. If he had a large tumor, then the decision to be treated at age 48 is probably the correct one. There is still no guarantee that the PSA saved his life.

The timeline that he gives suggests that he had radiation, not surgery, because the urologists like to wait 8-10 weeks after the biopsies before operating so that the area is completely healed, and you have to wait almost as long after the surgery to do that first PSA in order to get an accurate result. That is perhaps not the best choice for a 48 year old. The consequence of failing radiation is a salvage prostatectomy which carries with it a very high incidence of complete impotence and complete incontinence. In my mind, it would be better to have the surgery first and save the radiation for a potential relapse. That's what I did at age 49. I have to wonder whether he was getting the best advice.

He pointed out that true incidence is the number of cases divided by the number of people in the population (usually expressed per 100,000).

I don't know if something got lost in translation but incidence is the number of new cases/population at risk.

I'm aware of that. Missed the new cases. It's usually per year, too.

If he had a large tumor, then the decision to be treated at age 48 is probably the correct one.

I can't argue with that, but Stiller didn't give us that information, unfortunately, which is why I mentioned that we need more information than just his Gleason score, which is basically all he gave besides his diagnosis.

There is still no guarantee that the PSA saved his life.

Yep. Lead time bias means that it probably didn't, but there's a small chance that it might have.

@ Michael Finfer, MD:

I truly hope that you're doing well now.

I am always leery of population based statistics applied to individual cases. If there is consensus that PSA screening may have saved his life - saying it did or it did not are just political interpretations of that reality.

The population based arguments always assume a certain cost that individual patients and their physicians may not want to assume. I see this as the cost of biological complexity rather than who has the best argument.

Worth repeating:

"The United States Preventive Services Task Force has analyzed the data from the PLCO, ERSPC, and other trials and estimated that, for every 1,000 men ages 55 to 69 years who are screened every 1 to 4 years for a decade (5):

0 to 1 death from prostate cancer would be avoided.
100 to 120 men would have a false-positive test result that leads to a biopsy, and about one-third of the men who get a biopsy would experience at least moderately bothersome symptoms from the biopsy.
110 men would be diagnosed with prostate cancer. About 50 of these men would have a complication from treatment, including erectile dysfunction in 29 men, urinary incontinence in 18 men, serious cardiovascular events in 2 men, deep vein thrombosis or pulmonary embolism in 1 man, and death due to the treatment in less than 1 man."

https://www.cancer.gov/types/prostate/psa-fact-sheet

So yes, we should listen to Ben Stiller talk about how PSA testing saved his life - if we also listen to 50 men talk about the devastating effects on their lives of prostate cancer treatment. Their "roller coaster ride" did not turn out so well.

Here's hoping we get good molecular testing going ASAP so we don't have to depend on crude measures like PSA levels, Gleason scoring and so on. In the short term, adopting age-specific PSA reference ranges (to avoid over-biopsy/treatment in older men) would help.

I am always leery of population based statistics applied to individual cases. If there is consensus that PSA screening may have saved his life – saying it did or it did not are just political interpretations of that reality.

That is how the best evidence base is formed though. Of course there will always be outliers. If you have a better way, I would be interested in hearing that. There can't be a "consensus" without all of the information. And no one here is saying with absolute certainty that it did or didn't.

Only because you mentioned Dug the Dog, here is a little bit of coincidental fun. Talking Dug Dog

Not once did my PCP note any nodules during my annual digital exam

I'm reminded that I've never had one. Is the standard of care to start at age 50?

Now here's an interesting take on going the opposite direction: Active surveillance.

http://www.medpagetoday.com/hematologyoncology/prostatecancer/58880

Narad beat me to it. If a 48 yr old had a 2X swolen prostate, would it be prudent to start getting the test at 50? I've gotten confused on if a swollen prostate leads to/is associated with cancer or not.

Is there anything to this https://www.superbeta.com/ or is it just another case of 'one weird trick to invert your dick'..

"If you have a better way, I would be interested in hearing that"

A better way was just posted by Orac above. I have followed a number of patient with cancer diagnoses who have lived a long life with this approach. I am not an oncologist, but I am treating them for other problems and need to know their associated conditions.

I am also undoubtedly biased by knowing men 50 years of age or less who died of aggressive prostate cancer. I would like to know how these outliers get reflected in the screening statistics of the US Preventive Services Task Force. Stiller is currently 50 years old suggesting the Task Force data may not apply to him.

A better way was just posted by Orac above. I have followed a number of patient with cancer diagnoses who have lived a long life with this approach.

I would have to disagree. This doesn't work on a population basis (see comment #15 Dangerous Bacon). Again, applicable to outliers but the number needed to treat would far outweigh any benefits and increase the risk of side effects from biopsies etc.

RE: Lead time bias.

Consider that the earlier you first get tested for xyz (assuming you eventually do get tested at some point), the longer your survival time will be after your first test, regardless of whether you even look at the results of the test or not. It's magic!

First tested at birth for xxy, die on your 80th B-Day, survival time =80 years.
First tested for xyz the day before you turn 80 & die the next day, survival time= 1 day.

QED.
Please get your first test as early as possible. :)

Isn't a biopsy a greater chance to spread cancer, should it exist?

Davidp@7: I was just listening to a presentation on the current state of treatment (approved and clinical trial) for metastatic castration-resistant prostate cancer and the oncologist made an interesting comment that many patients who are described as MCR have never actually had their testosterone tested, so we don't actually know that the disease is castration resistant, or if more vigorous application of androgen deprivation (sounds better than 'chemical castration') would still be effective.

It might be an area for urologists/oncologists to consider.

@#15
Bacon, one of the subtle problems with the USPSTF recommendations is that urologists and oncologists are now doing a better job of uncoupling the side effects of treatment from screening and biopsy. Active surveillance is now a rapidly growing part of the management strategy for lower risks forms of prostate cancer. Using information from MRI and molecular testing, many patients can go for years without requiring treatment. Add that to the fact that PSA screening does save lives, according to the best studies done on the subject (i.e. NOT the PLCO trial), and a recommendation against screening seems foolish.

Read the best ever PSA screening medical journal article by a former Stanford Prof of Medical Ethics written in 1996!

http://ijme.in/index.php/ijme/article/view/1765/3803

These authors and other articles I've read would take issue with Orac's statement " Prostate cancer before the age of 50 is very uncommon." The articles cites autopsy studies of men who've died of unrelated causes showing 30% of men in their 40's with pathological evidence of cancer. Other autopsy studies I've read have shown pc in 8% of 20 year olds and increasing incidence all the way up to 100% of 100 year olds. The inventor of the PSA test has been quoted as saying that all you need is an excuse to biopsy and you'll find cancer. That is somewhat supported in this old article about a poor guy who's doctor inadvertently tested his blood for PSA as part of a routine physical when he was 29 years old: http://online.wsj.com/public/resources/documents/SB110350121947304355.h…

Methinks you're bordering on pedantry here. I thought it was clear from the context that I meant clinically evident prostate cancer requiring treatment. After all, over 75% of men over 80 have foci of prostate cancer in their prostates, but the vast majority of them die without clinically evident prostate cancer.

I've written about this very issue myself on more than one occasion, but you appear to be new; so it would be unreasonable for me to expect you to know that.

Well then I'll go on and take issue with your interpretation of "clinically evident requiring treatment." Just where are the studies and data to support the notion that Stiller's Gleason 7 (3+4) requires treatment? We do have a great study that shows that Gleason grade progression is uncommon. http://www.medscape.com/viewarticle/809443 “These findings suggest that grade may be established early in tumor pathogenesis,” conclude the authors
How do we know anyone truly has clinically evident pc requiring treatment? Have we ever randomized localized Gleason 7 patients into treatment and non-treatment groups?

Ok I'll check out your past posts. I wonder if you had ever seen the medical ethics journal article I referenced and what do you think of it?

As a non-professional who does understand statistics and costs, I have to say that the patient clearly should be given the information that can be gleaned from the PSA. The entire concept of not performing the test because it could lead to unnecessary, even harmful treatment, is not what we pay you for.

I want the information and the medical bureaucracy has no right at all to withhold it. The same bureaucracy has been wrong time and again about these topics. I'll make my own decisions, thanks. Just give me the information I need.

Stiller is clearly very intelligent.

Looks like somebody hasn't watched Tropic Thunder.
Ben Stiller:

But this head movie makes my eyes rain!

...is not doubt exactly what he said when he got the test results.

@ Denice Walter: I am seven years out, and I am fine. By the way, that prostate cancer saved my life. It lead to the discovery of an incidental renal cell carcinoma.

@ Sullenbode: I know of no evidence that prostate cancer can be upstaged by a core biopsy, and certainly urologists are doing so many core biopsies that I think such a phenomenon would have been noticed by now. Under certain circumstances, that may be true for other tumor types, particularly sarcomas, but you do what needs to be done in any given circumstance. If you need a diagnosis, and that's the only reasonably safe way to obtain one, you do it and deal with the consequences, if any, later.

OK ... well some of you might be interested to read what read what a Stanford Prof of medical ethics said about PSA screening in 1996 soon after it was widely introduced in the USA! 1996!

“The implication of screening males to detect slow, benign, non-progressive prostatic carcinoma is clear. A test which was epidemiologically perfect (100% specificity, 100% sensitivity) would not, on these grounds alone, be acceptable for screening apparently normal males. The test would also be required to separate males with progressive disease (candidates for treatment) from those with indolent disease (not candidates for treatment).”

He goes on to say: ” In prostatic cancer, only about l/400 patients will show progressive disease. The use of PSA screening could only increase the percent of patients being treated needlessly. ” Should doctors be required to provide that basic statistical fact to patients before they are screened? Or how about afterwards to their potential “active surveillance” patients? Do they even know it themselves? Do they want to know? I doubt it. Their patients then might logically decide to go home and never come back and just skip all those repeat biopsies and blood tests and doctor visits. And even more men might decide to just skip PSA screening in the first place!

And as for unnecessarily telling someone they have “CANCER” and the for-profit medical industrial complex unnecessarily creating millions of new pseudo cancer patients for the rest of their lives via the newly invented term “active surveillance” he had this to say: “Asymptomatic men are urged to undergo a screening test for the early detection of a disease that may well be treated with ‘watchful waiting. ‘ Watchful waiting will result in a large population of men (up to 15,000,000 in the U S alone) (8) held captive by urologists.” … and I imagine the urologists and the oncologists along with the entire for-profit medical industrial complex just loved that idea -- they picked up the PSA screening ball and ran with it as fast as they could ... and dissenting voices like Dr. Robin had to go all the way to India to get his prescient viewpoints published ... and meanwhile millions of lives were needlessly ruined.

The great American pseudo-epidemic of cancer of the prostate

http://ijme.in/index.php/ijme/article/view/1765/3803

OK … well some of you might be interested to read what read what a Stanford Prof of medical ethics said about PSA screening in 1996 soon after it was widely introduced in the USA! 1996!

Posting the same thing repeatedly is not going to endear you to anyone around here.

Thanks. Wasn't trying to endear myself with anyone. I guess I've noticed that most of you here are entrenched in the "system." Orac seems to have positioned himself as the champion of overdiagnosis and overtreatment more than a little late and AFTER the fact and after the direction of the wind began to change with the USPTS recommendations. Where was he 10 and 20 years ago while all the real damage was being done. Then I see we have here some of his endeared followers with m.d.s after their names still attempting to perpetuate this disgusting (and what should be embarrassing to every m.d. ever involved) bogus prostate cancer epidemic. (I could repeat much of the same about his particular specialty and the mammogram debate that never happened either.

I'll move on and you can be sure that you won't be hearing from me again.

Thx, #33. So different techniques for different tumors; was thinking it would be like this

But a biopsy is rarely done for a testicular tumor because it might risk spreading the cancer. The doctor can often get a good idea of whether it is testicular cancer based on the ultrasound and blood tumor marker tests, so instead of a biopsy the doctor will very likely recommend surgery to remove the tumor as soon as possible.

http://www.cancer.org/cancer/testicularcancer/detailedguide/testicular-…

Ed - promises, promises.

Meantime, there appears to be dead silence about Ben Stiller's endorsement of PSA testing emanating from the bastion of health wackdoodlery, Natural News* (remember, their intrepid reporter(s) have labeled the test a "complete medical hoax"). Can't imaging their continuing to be silent when a celebrity has something good to say about organized medicine.

I apparently missed this gem the first time, but NN got caught selling a "health" product that exposes the public to Evil Formaldehyde.

https://badscidebunked.wordpress.com/2016/07/15/unnatural-news-the-heal…

*I realize this item follows the format of Monty Python's "News For Parrots", i.e. "No parrots died today on the M15 highway".

@Narad #18

I’m reminded that I’ve never had one. Is the standard of care to start at age 50?

It seems to be. Doctors take all kinds of interest in one's colon region after age 50.
Colonoscopy, prostate check.
Which reminds me, I really do need to reschedule mine. They're (as am I) quite interested in viewing my esophagus. I'm willing to place a bet on Barretts esophagus, due to the extreme longevity of GERD and increased frequency/ease of vomiting.

@ Wzrd1:

I would have someone er... look into that if I were you.

I know a great deal about BE because my late father had this condition
( relax, he succumbed to an unrelated condition- VT- at a rather extravagant age)
You can do things ( SBM-wise) to reduce the chance of it progressing to a more serious condition. He did very well despite being over 85 when he learned he had it.

Thanks, Denice. I intend to.
Coughing a few times, such as due to seasonal allergies, results in projectile vomiting. Yeah, I *really* need to get that taken care of. :/
It's on my list...

I began yearly PSA testing in the early 90's because my dad had prostate cancer. All tests were in the low 2s until 2013 when it jumped to 8.8.

My urologist stated that I had probably had prostate cancer for 14 to 15 years and it had only became aggressive recently (it was dx as high stage 2 or low stage 3 depending on the oncologist). I had radiation and chemo in 2014 and two years of quarterly PSA's have been below detection level since. I will now do semi-annual testing for several years.

The good part about having prostate cancer is that it indirectly saved my life two months ago today. Because I had to loose a bunch of weight (200 lbs so far) and that I have been rebuilding my conditioning; I survived my heart attack (less than 7% survival rate). It also helped that I had great medical care along the way.

For me personally, yearly PSA screening didn't save my life until the very end but there were other signs that I had a problem.

I've been told that repeatedly posting things that have been posted already won't endear you with anyone here.

But here we have a poor doctor lamenting the fact that the "public" are demanding their PSA tests!

Be afraid ... be very afraid. "If you are a man you have a 1 in 6 chance of being diagnosed with prostate cancer in your lifetime!. The medical industrial complex cancer fear mongering campaigns all say. Step right up and get your free PSA screening test before its too late. "We care about you." "What about free treatment?" "No ... we don't care that much." "Hopefully you have insurance to cover all the medical expenses you'll likely have after we unnecessarily tell you that you have cancer."

The key word here being "DIAGNOSED." But here's the follow up information that they never ever tell you:

"There are about 380 men with cancer of the prostate for every patient who dies of the disease."

How many "doctors"? People with with "do no harm" m.d.'s after their names? Who should know better? Do you think might have flat out refused to be a part of this scam? How many honest doctors have walked away from any association with it? How many have flat out refused to perform needless "cut it out" surgeries of minor Gleason 6 "cancers" on frightened patients who through no fault of their own were drawn into this fiasco. My experience says its its likely to be a big fat ZERO. Where were the AMA and the AUA on the the unproven benefits of PSA screening right from the start? Promoting it ... thats where they were. (BTW its the same place the AMA is on direct to consumer advertising -- a national embarrassment -- with the same results -- poor hapless m.d.'s being "forced" to prescribe drugs their patients demand as "being right for them."

The 'system" of which they are an integral part of -- sends them these poor uninformed patients -- and they willingly "accommodate" them. Let's see ... should I take the time to do the right thing or should we just get this guy to the OR because that's what "he" wants? (As another poor m.d. commenting on the above referenced blog posts says while shamelessly referring to the insurance reimbursements of his dilemma: "So get the next patient in so we can keep the lights on.")

I hope there is a special place in hell along side the likes of Dr. Mengele for each and every one of them.

Ed @44:
One, step away from the Nazi analogies, please.

Two, you seem to be under the impression that no one dies of prostate cancer. While yes, it is true that most men with prostate cancer will die of something else, there are still plenty of people who *do* die of prostate cancer. So why shouldn't it be treated?

Three, this post was about the risks of overscreening and overdiagnosis, so why are you telling at everyone that too many people are being screened and treated? I'm pretty sure that was the point. What do you want us (or Orac) to say?

So much for Ed's sticking the firmly worded flounce.

Justa Tech @45
One -- the analogy is perfectly appropriate.

Two - I don't know where you got the idea that I thought that no one dies of prostate cancer. But I do know here you got the idea that "plenty" of men die of pc and we ought to be doing something about it! (see #3)

Three -- People do die everyday for all sorts of reasons. Car accidents deaths in the USA every year +32,000, with 2,000,000 injured. Deaths from influenza: 36,000 annually. Estimated deaths from prostate cancer: about 30,000 give or take a few thousand.

The medical industrial complex scare tactics and free PSA screening tout sheets invariably state figures like 30,000 men will be killed by prostate cancer in any given year. Killed I tell you! (Not die of ... its never "die of"). As if each and every one of them could be heroically saved by early detection and treatment ... only if.

But here are some interesting stats from direct from the NCI website: "Between 2003-2007, the median age at death for cancer of the prostate was 80 years of age. Approximately 0.0% died under age 20 0.0% between 20 and 34 0.1% between 35 and 44 1.4% between 45 and 54 7.5% between 55 and 64 19.9% between 65 and 74 40.3% between 75 and 84 and 30.8% 85+ years of age."

So right off the bat we see that most men who die of PC are elderly -- who by any past or current guidelines should never be ethically tested or treated and who unfortunately have to die of something. (But lets also ask the good doctors why a recent study found that 25% of men over 85 were still getting PSA screening?)

According to these stats if you are between 55 and 64 like most people who are caught up in this fiasco -- 7.5% of 30,000 is about 2250 men. 2250 out of a population of about 15,000,000. Just 2250! In reality, prostate cancer is just not a risk worth a second thought. Dying from pc is not even on a par close to that of pedestrians killed crossing the street every year! Don't expect the medical industrial complex to add that complete disclosure to your PSA informed consent form. Neither will it say that there is no possible way to identify these 2250 men in advance -- or that most are simply unlucky and have aggressive PC that likely would never be helped regardless of any amount testing or early detection or treatment.

But cancer scares people. Death from PC can be horrible. The for-profit medical industrial complex has shamelessly pandered to those fears and continues to blow the risks way out of proportion to other more serious risks we face -- harming many men and ruining many lives in the process. And paradoxically it is those very men ...the "survivors"... the 47 out of 48 men who were treated for nothing, many we all know, who also serve to wrongly elevate the perception of PC risk in our minds. The medical industrial complex has created a million man army of "PSA saved my life" dupes who are unaware of the statistical basis of modern medicine and who, along with their doctors tacit consent are only serving to perpetuate this fiasco with their "misery loves company" pronouncements to "get yourself tested." And they all go on to kiss the hands and sing the praises of the doctors who "saved" them. And the doctors eat it up -- all the way to the bank -- and besides, its a good feeling to be appreciated with someone's undying gratitude, however undeserving.

(As another poor m.d. commenting on the above referenced blog posts says while shamelessly referring to the insurance reimbursements of his dilemma: “So get the next patient in so we can keep the lights on.”)

What the fυck are you babbling about?

Ed @47
What on earth are you talking about? I've read your post 3 times and all I can get is that you are very, very upset that anyone is ever tested for PSA.

So, PSA is not the only way to screen for prostate cancer.

More to the point, there is general agreement here that over screening, overdiagnosis and overtreatment are problems! So why are you shouting about it?

And how does pedestrian deaths have anything to do with cancer treatment? It's not like not running a PSA test will somehow prevent someone from walking into the street and getting hit by a bus.

Finally, for you to equate every oncologist and urologist to a evil mass murder is cruel, stupid, nasty and pointless. Would you say that to your doctor's face?

You need to seriously refocus and explain succinctly what you want to change.

Poor Eddie is upset that no one understands him, and we really don't care about his feelings.

The medical industrial complex scare tactics and free PSA screening tout sheets invariably state figures like 30,000 men will be killed by prostate cancer in any given year. Killed I tell you! (Not die of … its never “die of”).

A simple G—le search reduces the Bayesian prior rather drastically, but I suppose this is pointless, given that Ed hasn't produced any "tout sheets" in the first place.

Dangerous Bacon @#38

You see ... the way "science" is supposed to work is -- first you do the research and then you do the vetting and then you PROVE the efficacy and value of the screening test and then you introduce it into the population. This very basic scientific method was not followed for either PSA or mammography. And when you initially do stupid things like that and responsible voices looking at the mess its created finally begin to be heard and attempts are made to reverse the damage -- you naturally open yourself to understandable, if misinformed criticism, not only from the likes of Natural News but the Obamacare health rationing conspiracy wing nuts.

Narad @#48
See the comment of the m.d. here:
endearing reposting:

http://scienceblogs.com/insolence/2016/10/10/evidence-based-medicine-gu…

“So get the next patient in so we can keep the lights on.”

Justa Tech @#49

I'll keep it simple stupid.

Prostate cancer is really a non-issue not worth a second thought.

It was made an issue by the marketing departments of the medical industrial complex.

PSA screening continues to do enormous harm with the active participation of doctors.

Eddie: "Prostate cancer is really a non-issue not worth a second thought."

Then why are you here?

“So get the next patient in so we can keep the lights on.”

The only incidence of that quote is from you, which was not referenced to anything. Why should we care about your issues with reading comprehension?

Seriously, this article was about the over testing and over evaluation leading to over treatment. Which exactly what you are complaining about. Did you not even understand that title says "No, the PSA test probably didn’t save Ben Stiller’s life."

Okay, find a dictionary and look up these two words: "No" and "didn’t" (a contraction of "did not"). Then when you are done with that, go somewhere else to clutch your pearls.

Justa Tech @ #49

"Finally, for you to equate every oncologist and urologist to a evil mass murder is cruel, stupid, nasty and pointless."

OK ... maybe the real evil is in that mindless all consuming profit machine called the medical-industrial complex. People can and do rationalize all kinds of things to be able to sleep at night … as I’m sure the guards at Treblinka somehow did — and as I’m am sure many urologists did and still do. They’ve somehow convinced themselves that they are doing the right thing. Before PSA testing urologists didn’t have all that much to do — but since the introduction of PSA, incomes of urology as a specialty have skyrocketed. Somebody got paid for those +1 & 1/2 million unnecessary surgeries these last few years. If a study is ambiguous, as most are, they will interpret it to their benefit. Convinced they are saving lives, the fact that they are making lots of money doing it is just a little side benefit — they see the Wall Street wiz kids making billions shuffling money around — its taken them 12 years of hard work to get where they are — if anybody deserves the big money, its someone heroically saving lives — like they are (even if its only 1 life in 50) ... (and the fact that those other 49 men are patients for life is just another nice side benefit). In my experience talking to many urologists — they are often perplexed when I ask them about one major new PC study or another. Many if not most don’t have the time or interest to keep up with the state of the art and do their own research. They leave all that to their special interest group and cover organization, the AUA (American Urological Association) — Just two weeks after two huge studies in March of 2009 were published showing no benefit to PSA screening, the AUA went charging ahead and changed its guidelines, they completely disregarded all of the science and LOWERED their recommended age for screening from 50 to 40! It was unbelievable! But probably smart … they were well aware that sometimes the best defense is a good offense. They saw the train coming and they wanted to slow it down … or more likely it could just be that over the past 20 years they had completely depleted the 50 and 60 year old patient pool and there were still lots of swimming pool and McMansion payments their members had to make. (They embarrassingly were eventually dragged along kicking and screaming into going along with the USPTS recommendations) Still -- while a lot of harm of PSA screening was being done -- the AUA issued “guidelines” played a big part -- many urologists blindly followed them. It served two purposes — first,they didn't have to do any independent thinking — and second, it provided excellent cover in case they got sued for malpractice.

But eerily “I was just following the guidelines of my profession” does sound a lot like “I was just following the orders of my superiors.”

That excuse didn't work at Nuremberg ... and it won't work on judgement day.

Chris @#55

Oops! I went back and read the title as you advised ... and then the whole article.

Stupid me! Wrong blog! Leaving with my pearls now.

Eddie: "Stupid me! Wrong blog! Leaving with my pearls now."

Good. Buh bye!

Wow, just wow.
Comes here, doesn't read the blog, doesn't even read the title, comments and goes Godwin. Then proceeds to complain about best business practices that keep medical practices open.
Then, goes the rest of the way off of the wire with conspiracy theories and things I have no idea what he was going on about.

Oh well, at least he corrected the initial error of not even reading the title.

Have we been joined by Emily Litella?

Good grief. What a maroon Ed was/is. And, to top things off, he went all Godwin on us. If he honestly *didn't* read the title AND the post before commenting, he's just ignorant.

By the way, Eddie...our host, Orac, gets no money out of prostate screening/surgery. He happens to be a breast cancer surgeon. So all your snipes about him doing unnecessary surgeries on men were just as silly as the rest of your comments.

Also - before you say it - he has posted MANY times, here and his other blog, about overutilization of mammograms to diagnose breast cancer. He's not out trolling the streets and dragging women off to have mammograms, then tossing them on an OR table.

@ Ed Dwulet
Here is the place where you should have put your comments:
http://www.nejm.org/doi/full/10.1056/NEJMp1510443#t=article
Unfortunately, the comments are closed now.
Don't believe everything published in NEJM.

Just Tech @#49

"Finally, for you to equate every oncologist and urologist to a evil mass murder is cruel, stupid, nasty and pointless. Would you say that to your doctor’s face? "

Oh .. I'd go a lot further than that -- if I could find the SOB that gave my dad a PSA test back in 1996 at age 85 as he was happily going about enjoying the last years of his life -- then told him he had incurable cancer and began treating him with Lupron injections -- I'd introduce the back of his head to a baseball bat!

Google: Lupron Medicare fraud

So, I finally got round to reading a bit more on this
According to http://urology.jhu.edu/highlights/2.php (JAMA, 1999), about 35% of men with prostate removal see a rise in PSA after 10 years
http://www.aacr.org/Newsroom/Pages/News-Release-Detail.aspx?ItemID=613#…
Is more recent and seems to make a similar point, that a substantial percentage of men see rising PSA and possible metastic prostate cancer 5-10 years after a prostatectomy
Gleason score and PSA level are associated with recurrence, but it isn't a slam dunk
I think I can stand by my initial comment, that not only does he not know that the cancer would have been fatal if not treated now, he can't know if it will come back.
Maybe "there's a good chance this helped me" would have been better?

Holy..! I think I'm glad it took me so long to see Ed's comment.

Hey Ed - You do not know anything about the rest of the people in the world with prostate cancer. I'm sorry someone screened your dad. Most docs I know wouldn't screen someone that old for anything.

But that has *nothing* to do with all of the much younger men who have been diagnosed, treated and lived. Some of them are diagnosed by feel, you know that? They or someone noticed a lump.

My friend's dad has had 20 more years with his family because he was diagnosed and treated for prostate cancer. My godfather is still with me because he got treated. I know literally dozens of me who are alive now because they actually got treated for prostate cancer. Metastatic prostate cancer.

So you take your "non-issue" and bury it in the backyard.

""I know literally dozens of me who are alive now because they actually got treated for prostate cancer.

That sux. Clones do exibit a high degree of genetic aberrations from the process -- That, and no belly button.

Justa Tech @#66

Future Headline C. 2028 "Ben Stiller says his unnecessary prostate cancer surgery gave him lung cancer"

Let's ask Orac M.D. AMA why there isn't a registry that tracks stuff like this so that men can made "aware" of how badly they are being screwed by the "system" that only pretends "do no harm."

Prostate Cancer Awareness Month my Ass!

You want to trade anecdotes Justa Tech? I know a guy who just had PSA begin to show up in his blood 15 years post his unnecessary prostate surgery at age 58!

https://www.utoledo.edu/med/grad/pa/pdf/Brendan_Boyer_-_JAAPA.pdf

"An elusive tumor in a man who has evidence of prostate cancer metastasis"

G. Shelly @65
See link in #69 Great comment except for your last line. He should have said nothing and kept his mouth shut about his unnecessary surgery and his heroic publicity seeking doctors (who themselves should have set him straight before he published anything). I guessing maybe he was caught drunk driving and his PSA (Public Service Announcement) is part of a court ordered community service sentence. I'm also guessing that his unethical doctors now have a long waiting list of pc surgical patients who want to brag that they had the same m.d. as Stiller.

If I ever finish my PhD thesis on writing styles of the woo-prone and medicine-bashers, there will be a section on inability to bring a sentence to a close.

"Let’s ask Orac M.D. AMA"

Against Medical Advice? Anti-Mitochondrial Antibody? American Motorcyclist Association?* Academy of Model Aeronautics?

*if I had to guess, it's this one. Orac is notorious for his loud pipes.

@DB, way too much information there. ;)

@Ed, oh, how horrible! A patient, operated upon when a specific test was thought to be highly reliable for a very specific cancer, now has, some decade later, a metastatic tumor in the lung, after said original tumor was never located!
Since you suffer from the nirvana fallacy, if you suffer a severe injury, don't go to the hospital - they might screw up. Treat yourself.

his PSA (Public Service Announcement) is part of a court ordered community service sentence

Nonsense! "Psa" is Pseudomonas syringae pv actinidiae, a bacterial disease of kiwifruit that is ravaging NZ orchards.

@Ed Dwulet 65

I will maintain that in my view, overall PSA screening does save some live. There were a couple of papers a few years ago, one in Europe and one in America that generated a lot of discussion at the time, but they did show a benefit. It was difficult, because there wasn't always a standard practice, and certainly, the US and European versions differed (and for the US one, the differences between the PSA arm and non PSA arm may have been so small that we wouldn't expect to see anything even if PSA tests worked)
I found a re-analysis of some of the data (https://www.ncbi.nlm.nih.gov/pubmed/21189374) that for the European one states "they estimated a number needed to screen (NNS) of 1,410 and a number needed to treat (NNT) of 48 to prevent one prostate cancer death at 9 years."
which found very similar numbers,
According to our model, the NNS and NNT at 9 years were 1,254 and 43, respectively. Subsequently, NNS decreased from 837 at year 10 to 503 at year 12, and NNT decreased from 29 to 18.
So, yeah. Unless there is something about his case we don't know, or the numbers for people his age/ symptoms (or whatever) are well established to be different to the general population, it might have saved his life. But there isn't really any good reason to think he would be the one in 20 to 1 in 50 that benefited from the treatment

G.Shelly @ #74

Their is no cure for pc - period -- end of sentence. No one single person diagnosed with pc is ever "cured" by his treatment. Remove a lot of otherwise healthy prostates and you are going to prevent some deaths.

The concept of NNT, is a fun-with-numbers statistical game better suited to promoting the efficacy of drugs not surgery -- has apparently never ever been explained to the legions of "PSA testing saved my life" proponents BEFORE or AFTER their surgeries -- thats because all these unethical doctor's (including Stiller's) stand to benefit financially from the charade -- and besides their inflated "life saving" surgeon's ego's feed on the undying adulation of their conned patients.

Wrzd1@#72
"...after said original tumor was never located!"
You're an idiot who is apparently incapable of reading simple English.

The original tumor was in his prostate which had been removed 11 years earlier after he had a PSA test (his level was only 3) and had been diagnosed with "organ confined" prostate cancer.

How does someone with a PSA of only 3 who has a radical prostatectomy and is told he is "cured" end up with pc metastasis in his lung 11 years later?

@Ed, you're the same idiot that claims that "it's in the living room" is considered precise coordinates.
"In the prostate" isn't precise, within a centimeter or less is precise and hence, a location.
Otherwise, the *entire* prostate is removed and being able to control urine or any other genitourinary function is utterly impossible.

Meanwhile, if it's undergone metastasis, it isn't precisely located, it's "somewhere" in the body and by definition, not located at all, save in the general idea of my car keys are lost somewhere on this damned continent!
I can have a tag that gives a hint that they're on the same continent, but that's it. Nowhere good enough to actually put one's hands on them.

So, who is the idiot? The one that thinks that a found tumor that has metastasised to Christ knows where and he ain't talking, still is precise knowledge of location?
Or someone who recognized that a metastasised tumor isn't local any longer and hence, its location is unknown, even if blood work shows that it's potentially present?

Let me help you a bit.
Tomorrow morning, either take half a usual serving of your usual breakfast of a double helping of stupid flakes and your double heaping slosh of moron milk.
As a tumor not within the prostate could be *anywhere* and still give a positive PSA test. Be it in the big toe or the brain or anywhere in between.
Now knowing that discloses to one and all your usual breakfast, I've given a gentle education, after others have tried to far more gently educate you.

Now, do try to cut down on either the stupid flakes or the moron milk, you might get all three brain cells to actually fire in a more synchronized fashion.

@Wizd1
You're either can't read or didn't bother to read to report. Wzrd1 says:
"... if it’s undergone metastasis, it isn’t precisely located"
" ...that has metastasised to Christ knows where"
"... As a tumor not within the prostate could be *anywhere* "

The report reads:

"However, focal radiotracer reactivity appeared in the upper lobe of the left lung (Figure 1). Chest CT revealed a spiculated lesion measuring 2.8 cm in diameter. The nodular density resembled a primary lung carcinoma; however, the lesion’s location correlated with the area of reactivity seen on the scintigram (Figure 2). Biopsy confirmed that the tumor was a prostate cancer metastasis."

Actually, at the time, I didn't read it, as the network was blocking traffic to that site. Interestingly, I'm at work now (when I'm usually online here as well) and the site isn't blocked any longer.

"Furthermore, clinical evidence of distant metas-
tases develops within 10 years after radical prostatectomy in
15% of patients."

15% isn't especially rare, but it also means that 85% won't have metastatic disease.

"However, lung metastasis with no known bone
or lymph node involvement is extremely rare and has been
described in only a handful of case reports. Therefore, imag-
ing studies of the lungs are usually not warranted when the findings on pelvic/abdominal CT and bone scan are negative
and the patient has no respiratory symptoms."

Also discussed was autopsy results with patients with metastatic disease showing 46% had metastasis to the lung, pelvic lymphatic system and bones, with it being rare to not be present in the lymphatic system and bone, when present in the lung. Unfortunately, there is no mention of the percentage that are so, but it's acknowledged to be a rarity.

So, this is a very, very rare type of case, atypical in several ways.

You’re either can’t read or didn’t bother to read to report.

Well played.

Ben Carson's alternative cancer cure testimonial for Mannatech

oracknows — Fri, 09 Oct 2015 07:00:15 +0000

Ben Carson's alternative cancer cure testimonial for Mannatech

Over the years, I've frequently made the points that the vast majority of physicians are not scientists and, in fact, that many of them suffer from a severe case of Dunning-Kruger when it comes to science. Even going back to the very early history of this blog, you can find examples, the most common of which seemed to be physicians denying evolution and embracing creationism. Of these, the doctor I wrote about most frequently back in the day was the creationist neurosurgeon Michael Egnor, but with the onset of the 2016 Presidential race there's been a new creationist neurosurgeon in town with arguably even more ignorant attacks on evolution. I'm referring, of course, to noted neurosurgeon Ben Carson, whose creationist stylings and other idiocies have been so bad that I had to use him as a reason to update my posts regarding how physicians are not scientists and often have an inordinate and unjustified confidence in medicine as a "check on BS."

Over the last couple of weeks since that post, unfortunately, Ben Carson has continued to spew statements that are nothing but downright embarrassing, be they his statement in the wake of the Oregon mass shooting that it would be advisable to attack an armed gunman during a mass shooting "because he can't get us all" or his many other statements that make me wonder how someone with so little critical thinking skills could get through medical school and a neurosurgery residency to become such a respected surgeon.

While I knew Dr. Carson shows an uncanny lack of critical thinking when it comes to most issues outside of medicine, I had never in general doubted his medical abilities. Oh, sure, I was disturbed and disappointed when during the second Republican debate, instead of repeating his full-throated defense of vaccines, he waffled and pandered to the G.O.P. base regarding Trump's antivaccine views, but I didn't think that was because he truly thought vaccines cause autism but because he was too cowardly to speak out as clearly as he had in the past. I expect behavior like this from Rand Paul, the other physician running for office, but not from Ben Carson, at least not based on his history.

Then, over the weekend, while I was away at the American College of Surgeons meeting, there was an article in the Wall Street Journal entitled Ben Carson Has Had Ties to Dietary Supplement Firm That Faced Legal Challenge. Unfortunately, I'm not a WSJ subscriber; so I can't read the whole article. Fortunately, there's enough of it excerpted out there in various blogs and other news outlets that I can get the gist of the story and what he said. Actually, I could experience everything he said in this 2004 YouTube clip of Ben Carson shilling for Mannatech, and now you can too:

The video is 1:19 long; so I admit that I haven't had time to watch the whole thing. What I have seen in it is quite disturbing. A bit of background was in order. Over ten years ago, Ben Carson faced prostate cancer at a relatively young age, his early 50s, and he went to an unexpected source for help:

Faced with a prostate-cancer diagnosis more than a decade ago, Ben Carson, the Republican presidential hopeful and retired surgeon, consulted an unusual source: the medical director of a Texas company that sells nutritional supplements made of substances such as larch-tree bark and aloe vera extract.

The company doctor “prescribed a regimen” of supplements, Mr. Carson told its sales associates in a 2004 speech.

The video above is basically an infomercial for Mannatech. The video was taken down from the company website, apparently after the WSJ made inquiries about it, but the Internet never forgets, and so the video is still around. Fortunately the part about his prostate cancer diagnosis is near the beginning of the video; so you don't have to watch the whole hour and 19 minutes of it.

According to Carson, a couple of years before his talk, he was diagnosed with prostate cancer. He described himself as an individual who underwent routine medical screenings and annual physicals and had his PSA checked. However, he noticed that when he was in the operating room for long periods of time he became very interested in the clock because, unlike in the past, he couldn't go many hours without having to go to the bathroom. So he went to see the chief of urology at Johns Hopkins, who thought at first that he had some prostatitis and gave him antibiotics. The symptoms, however, didn't go away. So the urologist suggested that maybe he had some prostatic hypertrophy and gave him some Flomax, but the symptoms still didn't resolve. His PSA was checked again, and it was somewhat elevated; so a biopsy was recommended. Now, I have to admit, Carson is a very folksy and engaging speaker, particularly the part where he described undergoing his prostate biopsy. I can see why Mannatech would want him to shill for it: A famous neurosurgeon who is a very likable speaker (or at least was, as I don't find much of Carson's schtick that likable any more).

In any case, he related getting the news in the operating room that he had high grade cancer. Now, personally, if I were in the operating room and received news like that, I'm not entirely sure that I could "put it out of my mind" the way Dr. Carson relates, and continue with the operation. On the other hand, that's what surgeons do; patients must not be abandoned just because of our own personal traumas. Be that as it may, next Carson described getting an MRI and having a copy given to him without a radiologist reading. Looking at it, he saw "lesions up and down my spine."

So how did his association with Mannatech begin? Basically, somehow the news got out that Carson had some sort of cancer, and as a result people started sending him products from all over the world. The father of one of Carson's patients also apparently heard the news and asked him if he had ever heard of glyconutrients. This recommendation from his patient's father led Carson to contact Mannatech and a "Dr. Reg," who I can only assume must have been Dr. "Reg" McDaniel, who was at that time medical director of Mannatech and is now Director of Research at Wellness Quest, LLC, who doesn't appear to be particularly science-based. Let's just say that "Dr. Reg" is proud of having been awarded the "Discovery of the Year Award" by the American Naturopathic Medical Association n 1996 for his glyconutrient work and claims and that he's still selling dubious dietary supplements. In any case, Carson described how Dr. Reg sent him some product and prescribed a regimen. He began to take it, and "within about three weeks my symptoms went away, and I was really quite amazed." Carson even stated that "I actually toyed with the idea of not having surgery done, because it was recommended that I undergo surgery."

Let's stop right there for a second. According to his story, Dr. Carson was diagnosed with high grade prostate cancer. He apparently thought it had metastasized to his spine based on reading his own MRI scan. That's a terminal diagnosis, although prostate cancer can be fairly indolent and even at stage IV take a long time to kill. Yet, surgery was still being recommended to remove the prostate? Something doesn't quite add up here, because usually the treatment for metastatic prostate cancer is not surgery, but castration, because most prostate cancers are androgen-dependent. In the old days (back when I was a resident), that would have been surgical castration, but these days chemical castration is used. Castration can often give a long period of palliation before the prostate cancer becomes androgen-independent and starts growing again. As I listened, all I could think is that Carson's surgeon must have thought that the cancer was still localized and therefore potentially curable. Otherwise, it's doubtful he would have offered radical prostatectomy, which is an operation not without risk and significant morbidity.

In any case, Carson continued on about how he read up on the "theory behind" Mannatech, the "bolstering of the immune system," saying "this makes an awful lot of sense," and thought about whether the cancer could just be controlled. Now here's why he decided not to rely solely on Mannatech:

Then I began to realize that, having a high profile, if I did that, a lot of other people might follow that example too, but they might not be quite as diligent as I was about taking the product, and there might be a lot of needless deaths, and I didn't feel as though I could have that on my conscience. So I went ahead and had the surgery done.

So let me get this straight. He thought that Mannatech's product would work but that others would die if they followed his example because they wouldn't be as awesomely diligent as Dr. Carson. Yes, Dr. Carson's rationale for undergoing the surgery was, apparently, that he might be able to cure himself with Mannatech's supplements but others would die because they wouldn't follow the protocol closely enough. How many times have I discussed this victim-blaming explanation for the failure of alternative cancer cures? More times than I can remember. It's a common thread in alternative cancer cure advocacy, that if you don't follow the protocol to the letter it will fail and it will be your fault. So, awesomely selfless guy that Carson was, he underwent major surgery in order to save people from that fate. Or perhaps he didn't believe quite as strongly as he made it sound in his speech. Probably the latter.

Whatever the case, Carson underwent a nerve-sparing prostatectomy, which is designed to spare the nerves responsible for sexual and bladder function whose damage was a common complication of radical prostatectomy, later to discover that the MRI findings were a congenital abnormality of the bone marrow and not metastatic cancer at all. The cancer was within 1 mm of the capsule of the prostate, but still confined to the prostate, meaning that the surgery was potentially curative. Given that it's something like 12 years later and Carson is still alive and kicking, the surgery was just curative. In his talke, Carson attributed his good fortune to prayers more than Mannatech, but he was still basically shilling for Mannatech. In fairness, Carson also pointed out that, although people have told him that it was the glyconutrients that cured him—an odd thing to say, given that he still had cancer in his prostate that was almost to the capsule—he does advocate what might be called "integrative" medicine, at least with respect to Mannatech:

Now some people have concluded that I was cured without without surgery and that I was just cured by the glyconutrients. Maybe it would have happened, maybe it would not have. I do not advocate abandoning traditional medical cures that have been shown to work. What I would, however, advocate is using natural products to supplement what's done by traditional medicine. The two things do not have to be adversarial. In fact, they can be extremely complementary.

Oddly enough, he then said that he was not a Mannatech associate, because he didn't think that would be appropriate, nor was he a Mannatech spokesman, because he didn't think that would be appropriate either. Really? He just gave what amounts to a Mannatech cancer cure testimonial to an auditorium full of Mannatech associates! He might not have been an associate, but he was definitely an unpaid spokesman. He even pointed out how he set up a system in his office to people asking him about Mannatech to the "right people" and described how he and his wife were still taking Mannatech glyconutrient supplements every day and later said in a promotional video:

The wonderful thing about a company like Mannatech is that they recognize that when God made us, He gave us the right fuel. And that fuel was the right kind of healthy food. You know we live in a society that is very sophisticated, and sometimes we’re not able to achieve the original diet. And we have to alter our diet to fit our lifestyle. Many of the natural things are not included in our diet. Basically what the company is doing is trying to find a way to restore natural diet as a medicine or as a mechanism for maintaining health.

Fast forwarding in time, it turns out that this wasn't the only time Carson promoted Mannatech. He spoke at Mannatech conferences in 2011 and 2013 and spoke about glyconutrients for a PBS special just last year. His relationship with Mannatech thus went on for at least a decade, apparently only to be severed when he decided he wanted to run for President.

It must be emphasized just how dubious Mannatech is. As this National Review article points out:

Mannatech has a long, checkered past, stretching back to its founding more than a decade before Carson began touting the company’s supplements. It was started by businessman Samuel L. Caster in late 1993, mere “months,” the Wall Street Journal later noted, before Congress passed the Dietary Supplement Health and Education Act of 1994, which greatly loosened restrictions on how supplement makers could market their products. Within a few years of its inception, the company was marketing a wide variety of “glyconutrient” products using many of the same tactics previously described in lawsuits against Eagle Shield, Caster’s first company.

In November 2004, the mother of a child with Tay-Sachs disease who died after being treated with Mannatech products filed suit against the company in Los Angeles Superior Court, seeking damages for intentional infliction of emotional distress, negligent misrepresentation, and conspiracy to commit fraud. The suit alleged that the Mannatech sales associate who “treated” the three-year-old had shared naked photos of the boy — provided by his mother as evidence of weight gain, with an understanding that they’d be kept confidential — with hundreds of people at a Mannatech demonstration seminar. The sales associate was further accused of authoring an article, in the Journal of the American Nutraceutical Association in August 1997, explicitly claiming that Mannatech’s supplements had improved the boy’s condition, even though the boy had, by that time, died. The suit also presented evidence that Mannatech was still using photographs of the boy in promotional materials on its website in March 2004, “with the clear inference that [the boy] was alive and doing well some seven years after his actual death.”

I also note that Mannatech's associates hawk one of its products, Ambrotose, as a near cure-all for everything from cancer to multiple sclerosis to AIDS. It's even been described as a sham in a journal article. I might have to do a post on Mannatech, but in the meantime if you doubt the dubious nature of the company and its products, Quackwatch has a resource.

As disturbing as Dr. Carson's advocacy of pseudoscience like creationism is, I find this revelation about his longstanding relationship with Mannatech to be far more disturbing, striking as it does at the heart of his strength, his reputation as a physician and neurosurgeon. It turns out that Carson's lack of critical thinking skills goes beyond just evolution, the Big Bang Theory, geology, and physics. As great a neurosurgeon as he was, he was so easily persuaded by pseudoscience that he was willing to promote nonsense like Mannatech as a treatment for prostate cancer.

oracknows Fri, 10/09/2015 - 03:00

Tags

cancer

complementary and alternative medicine

Skepticism/Critical Thinking

complementary and alternative medicine

medicine

Science

If we didn't have people as stupid, and patently dishonest, as the current crop of Republican candidates, we'd have to invent them just for the laughs. (The political climate would, however, be much better without their ilk.)

"It turns out that Carson’s lack of critical thinking skills goes beyond just evolution, the Big Bang Theory, geology, and physics."

Sounds like Carson has successfully made the transition from surgeon into a GOP politician.

All of that fabulous woo PLUS Murdock thinks he's really black!

I especially like the part where he says that G-d made us and gave us the "right fuel" which, of course, we've totally ruined until Mannatech came along and did G-d's will!

I wonder how many supplements are sold to evangelicals based upon copy like that.

I don't know his ancestry, but there is a set of pathogenic BRCA mutations that are common in people of west African descent. I would suggest genetic counseling, not dietary supplements, for Dr. Carson.

I especially like the part where he says that G-d made us and gave us the “right fuel” which, of course, we’ve totally ruined until Mannatech came along and did G-d’s will!

I assume you caught the reference in the company name. Of course this company's products are heaven-sent.

@ Eric Lund:

I missed that- I suppose it was embedded far too much for my secularism ( I'm usually very good at that sort of thing) but I'm sure that someone tuned into Holy Writ would spot it immediately.

Interestingly, Mikey has aimed his spiel at conservatives through various rants against the liberal media ( compleat with a cartoon token lesbian broadcaster) which targets Christians, white, straight people and rural dwellers LIKE HIM! But he doesn't quite call his products manna from heaven yet- only Superfood. The other alt media honcho casts his nets for fundamentalists in a less obvious fashion because he also courts Jewish folk in NYC- so it's more about his downhome fundamentalist background complete with sermonising and gospel songs ( some black listeners might be impressed with that)..

"Persuaded by pseudoscience" or per$uaded by p$eudo$ien$e?

“I don’t know that he’s ever had a compensated relationship with Mannatech,” says Armstrong Williams, Carson’s
business manager.

Such a lovely non-denial, denial. We do know Carson makes $40,000 'above the table' for each speaking appearance...

You have to give it up for the 'I only got the surgery because had I cured myself with the Mannatech supplements, lesser humans would have imitated me and done it wrong' routine. What would be obvious BS from anyone else becomes credible from Carson because it's consistent with his massive ego. Sorry Ben, everything else you've ever said shows you don't give a flying f-bomb about anybody else. You got the surgery because you didn't want to die, and knew the supplements wouldn't do the job. Then you had to come up with an excuse in order to cash in as a Mannatech shill. Bingo! The great Carson is just looking out for the weak! As if!

He may believe some of the moon-loonie things he says, but this guy shows too many signs of a classic con-artist to think true-woo is all that's going on here.

Forget the "autism epidemic". It seems the real epidemic is Narcissistic Personality Disorder — how else could support for Trump, Carson and Fiorina combine to over 50% in GOP polls if voters weren't being drawn to kindred spirits? ...It must be the vaccines! ;-)

I think they used the wrong biblical term in their name. A more appropriate name would be Mammontech...

More Loony-Tunes from Carson.

http://www.huffingtonpost.com/entry/ben-carson-holocaust-gun-control_56…

@ sadmar:

I don't know if there are REALLY more people with NPD or are they just more visible/ audible because of the internet and because talking about yourself adoringly has become more acceptable that it had been in former times?
That's just a guess, I have no data to support it.

Orac, I'm glad you're driving home the point about the lack of critical thinking skills. Speaking as a urologist, Dr. Carson's comments are jaw-dropping in their lack of consistency. As you pointed out, if the glycoproteins cured the prostate cancer, why was it present on his final pathology? If it were already cured, he would have had pT0 disease (no evidence of cancer on final pathology). While the proximity to the margin of the cancer on the final specimen is less of an indicator of virulence (that finding is usually related to the aggressiveness of the nerve-sparing dissection by the surgeon), if it were gone...it would be gone! How does someone reconcile these two facts without being intellectually dishonest? Sadly, as I'm sure the other docs who read and comment on this blog will attest, graduating from medical school does not imbue anyone with critical thinking skills. I believe these need to be taught from an early age to "hard-wire" them from the start. Otherwise, it's very easy to become susceptible to the siren-song of woo (which sounds like "woo woo woo, woo woo," in case you were wondering).

@JeffM:

Yes, the whole "What if the Jews had been armed?" nonsense. Well, we know what happened when the Jews armed themselves and resisted, as they did in the Warsaw Ghetto Uprising and other uprisings, such as the Białystok Ghetto Uprising and the Częstochowa Ghetto Uprising and uprisings in the Sobibor, Treblinka, and Auschwitz. The Nazi war machine crushed them and sent the survivors to the death camps.

Dr, Carson should have known better.It seems he was only one of who knows how many cancer patiens,who fell for Mannatech's scam artists.In 2007,there was an ABC 20/20 Full Investigative Report on MannatechIt revealed sophisticated multilevel marketing and DVDs preying on desperate cancer patients,in particular.At 8:57,we see a young woman with a serious brain tumor saying she believes "God has put this product in front of her".

Apparently Mannatech also made claims glyconutrients could cure AIDS,Multiple Sclerosis,Down Syndrome,Cystic Fibrosis,and yes autism as well.The researchers who were doing serious work in glyconutrients were appalled at how Mannatech was twisting their research,and admits the claims Mannatech makes are false.

Note what the 20/20 story says about the shady background of Carson's buddy Sam Caster.Who was also mentioned in this National Review story earlier this year.Caster admits,on camera,that glyconutrients do not cure cancer,or anything else.Class action suits for fraud,investigation by state attorney generals were all initiated against Mannatech.Mannatech was also funding its own research to cite in its conferences and promotional material.

And Carson has the gall to go after vaccines.

SMH!!

Re Carson's own-a-gun-avoid-the-Holocaust comments:

There was a character in the novel Fail-Safe who argued that if Jews had owned and used guns on the first Nazis who came to arrest them, the rest would have backed off. I always thought this was stupid on multiple levels, including the assumption that Jews in Germany knew they were going to be not just imprisoned but slaughtered, and thus would've been willing to sacrifice their lives and those of their families in order to take some Nazis with them.

Like a lot of other things, Ben hasn't thought this through.

I'm a humble community "flea", but I know enough to google "ProductName scam" when I hear about a product with claims that are too good to be true. Maybe fancy, academic surgeons are too pressed for time?

Dr, Carson should have known better.It seems he was only one of who knows how many cancer patiens,who fell for Mannatech’s scam artists

It's an all-too-common phenomenon that victims of scammers don't want to admit that they've been scammed. See also Burzynski, Stan. Some of his biggest boosters have been next-of-kin of people who tried his treatments and died anyway. Including, in at least one case, a policeman who ought to have known a thing or two about scams.

Oh pleas please PLEASE do a post on Mannatech products! My inlawas have been selling it for decades (in Canada) and have tried to convince me that their products will "cure" my Type 1 diabetes. Well, they said, not "exactly" cure but reduce the amount of insulin I take! It's amazing! Ugh. I can't stand the way they are hooked on this as some kind of magically health supplement - no they insist on calling them "foods" not medicines, even though they are all pills and powders and lotions - even though there is no real science to support it. I would love to see a proper scientific evaluation of the supposed merits of Mannatech!

Isn't Ben Carson a Seventh Day Adventist? They're big into all kinds of health food and supplement nonsense. In fact, some of them even opened up a health food store in the town I went to school in as a kid - it's since moved to the town across the river in Oregon. I mainly remember that they used to sell vegan "pizza" from a "deli."

Incidentally, the Adventists are basically "cousins" of the Jehovah's Witnesses - you can trace both groups back to Billy Miller in the 19th century - so I grok a lot of their weirdness.

Ernie Gordon@2:

Sounds like Carson has successfully made the transition from surgeon into a GOP politician.

Like an enchillada through the intestine of Dr Oz.

many of the same tactics previously described in lawsuits against Eagle Shield, Caster’s first company.

Definitely worth noting that Caster has a previous history of frauds, which went bankrupt until he realised that the path to success was to tie it in with religion and tap into the affinity fraud. The guy has even been convicted in Texas!

“I don’t know that he’s ever had a compensated relationship with Mannatech,” says Armstrong Williams, Carson’s business manager.

Williams is of course noted for corruption and dishonesty. IIRC, he has elsewhere conceded that Carson was well-remunerated for pimping Mannatach, but on a purely professional basis where he didn't know who was paying him.

I know enough to google “ProductName scam” when I hear about a product with claims that are too good to be true.

Everyone in the Mannatech ziggurat scheme thinks that other people are the suckers, and apart from Caster at the top, everyone in Mannatech thinks that God wants it that way.
There's nothing like the conviction that God wants you to be rich, to help rationalise being part of the con-job. For Carson and all the lower echelons, sincerity and cynicism go together...

2018 State of the Union speech

Let me now take 30 seconds to tell you about the wonders of Mannatech.

"How does someone reconcile these two facts without being intellectually dishonest?"

They don't.

He knows they're inconsistent. But God has given him, the most exceptional Ben Carson, the privilege of not having to trouble with such minutiae, such is his higher calling.

It's not a lack of critical thinking skills. It's putting other motives first. It's not caring whether your sh!t makes sense, not even TRYING, because you believe. The guy's a 7th Day Adventist, a denomination that adheres to biblical literalism and infallability: Among the Adventists listed by Wikpedia under "Science, health and engineering" after Carson:
Robert Gentry - A nuclear physicist and young Earth creationist, known for his claims that radiohalos provide evidence for a young age of the Earth
Frank Lewis Marsh – Creationist and the first Adventist to earn a doctoral degree in biology.
Walter Veith - South African Zoologist, creationist and end times lecturer.

... and speaking of things Ben hasn't thought through.

His argument isn't 'What if the Jews had been armed?' He told Wolf Blitzer "I think the likelihood of Hitler being able to accomplish his goals would have been greatly diminished if the people had been armed,." That's "the people" as in everybody. See, Ben loves invoking Hitler, and did so again on The View in an analogy to his opposition to all things Obama.

So what I said is most of the people in Nazi Germany did not believe in what Hitler was doing, but did they speak up? No. They kept their mouths shut. And when you do that, you’re compromising your freedom and the freedom of people that come behind you. You have to be willing to stand up for what you believe in.

Apparently flabbergasted, Joy Behar replied, "“But… Hitler won the election in Germany... He won the election.” And Carson, apparently non-plussed, simply explained, It doesn’t matter what he did. We know he’s an evil man.”

If Carson was thinking, he'd realize people are going to interpret his remarks as 'What if the Jews had been armed?', since the proposition that the Aryan population of Germany was so opposed to "what Hitler was doing" they would have taken up armed rebellion against the Reich if only they'd had the guns is just too batsh!t crazy to hear.

And if he was thinking, he'd realize that people could take certain implications from statements about armed resistance to bigotry/ghettization/legalized-murder-of-minority-populations, coming from an African-American man. Yo, Ben! Brothers Huey Newton and Bobby Seale were way ahead of you, my man! Not to mention brothers Nat Turner (hanged), Field Marshal Cinque (burned alive in police shootout) and Fred Hampton (assassinated by the Chicago PD).

Speaking of Chicago, that's one place where African-American folks have definitely not been disarmed. Lots of guns in West Garfield Park, West Englewood, Chatham... If Ben was thinking, he might conclude that if folks in those hoods actually listened to him, his right-wing backers might not like it too much...

Or Ben's more of a sly fox than we realize, since if any bloods took his advice, there's the excuse to round 'em all up and make Ferguson look like a cakewalk...

Nah! Just a delusional jebus-ranting tool...

@ JP:

Yup on the Aventists as veggie/vegan health foodies. I'm not sure that necessarily extends to supplements, or just leaves some of them more open to that.

The Adventists with the biggest effect on American culture were likely the Kellogg Brothers: John invented Corn Flakes and Will started the breakfast food company. Together they had run the Battle Creek Sanitarium, "a pioneering effort " (Wikipedia) based on Adventist principles described by Will as "a composite physiologic method comprising hydrotherapy, phototherapy, thermotherapy, electrotherapy, mechanotherapy, dietetics, physical culture, cold-air cure, and health training." Corn Flakes, of course, were created in the belief eating would prevent masturbation. C.W. Post allegedly stole the recipe for Corn Flakes from John Kellogg's safe when he was a patient at Battle Creek. It was Post's market success that led Will to leave the sanitarium biz and start his breakfast food company, though John stayed on to help poor mad devils by reducing their wanking through diet.

Does this sound familiar?

Kellogg made sure that the bowel of each and every patient was plied with water, from above and below. His favorite device was an enema machine that could rapidly instill several gallons of water in a series of enemas. Every water enema was followed by a pint of yogurt — half was eaten, the other half was administered by enema, “thus planting the protective germs where they are most needed and may render most effective service." The yogurt served to replace the intestinal flora of the bowel, creating what Kellogg claimed was a squeaky-clean intestine.

Kellogg believed that most disease is alleviated by a change in intestinal flora; that bacteria in the intestines can either help or hinder the body; that pathogenic bacteria produce toxins during the digestion of protein that poison the blood; that a poor diet favors harmful bacteria that can then infect other tissues in the body; that the intestinal flora is changed by diet and is generally changed for the better by a well-balanced vegetarian diet favoring low-protein, laxative, and high-fiber foods; and that this natural change in flora could be sped by enemas seeded with favorable bacteria, or by various regimens of specific foods designed to heal specific ailments.

Toxins! Gut bacteria! Colon cleansing! Now why would a guy who preached, and presumably practiced, sexual abstinence be so obsessed with enemas?

Anyway, it seems it all traces back to Michigan! Who knew! Thankfully Orac and JP seem unscathed for all their time there...

The weird thing about Carson and the gun nonsense: I was always under the impression that SDAists, like JWs, were supposed to be pacifists. JWs aren't supposed to take any job that involves packing heat, for instance, and they reject military service. Personal hunting rifles or something might be okay, though I'm not even entirely sure about that; thinking back, the JW guys I knew were pretty much all bow hunters if they hunted.

I’m not sure that necessarily extends to supplements, or just leaves some of them more open to that.

This place, which I made reference to, has a big supplement shelf at least.

^I think Ezekiel Bread is an SDA enterprise, too. (I actually like the stuff, although I think Dave's Killer Bread is superior. I've never seen either out here, though.)

Lots of SDA conscientious objectors. Perhaps it's OK to enlist in an army as long as it's only for six days and you can revert to civilian status while keeping the 7th Day Holy.

The church seem to oppose a militarised society:
http://www.adventist.org/information/official-statements/statements/art…

Carson manages to combine his feigned religious sincerity with a betrayal of most of the tenets of his purported religion. From the perspective of his Religious Right supporters, that is only further reassurance that he really is one of them (as opposed to belonging to some weird cult).

@ sadmar:

And now we have hymns of praise to the microbiome.. ( Conrick @ AoA)

I'm sure that either you or JP ( and others) can think of a verse or two.

HDB @21
Armstrong Williams.Now there's a name I hadn't heard in years.I remember catching a little of his nutty radio show,back when he was shilling NCLB,and even earlier when he was going after the Clintons in the late 90s.He was heavily syndicated on virtually every Christian talk station in the country.A typical conspiratorial whackaloon.I had no idea Williams was "Ben Crazy's" campaign manager.

The GOP field in 2016 really is a bottom of the barrel clown car.Most of us have seen the Enquirer story about Carson leaving a surgical sponge inside a girl's skull,causing her to have brain damage,but Carson's response is getting a smaller amount of coverage,

“My reaction is that I did 15,000 operations,” Carson said. “And the people who oppose me have been crawling through every ditch, every place I’ve ever been my whole life looking for stuff. They found five or six disgruntled people, that’s a very small number, and many of those cases never went anywhere, because the legal system said, ‘Are you kidding me?’ and threw it out.”... “I would probably find myself in some difficulty if I do begin to discuss that stuff publicly,” Carson continued, adding that “generally speaking there is no one who does the number of operations that I did who aren’t going to find some people who are going to be disgruntled.”

Colmes pressed Carson on the question of the sponge. The candidate responded, saying that “it is true that we put a certain type of sponge in to pad things away and sometimes there is a reaction to that sponge and that’s what happened.”

Of course this wasn't the only screwed up operation our brilliant brain surgeon and Presidential wannabe had performed.As the family of one Mary Perna could tell you.Carson did four unsuccessful brain operations on MS patient Perna,without reviewing the literature.Perna had lesions on her brainstem,and after Carson's botched operations,was left with seizures,muscle spasms,and more.There was an out of court settlement.

All this,and Mary Perna still supports Dr. Carson

Came here to make a comment about manna and saw that I was beat. However, I do feel safe declaring to be the only one here who as an alter boy, muttered "hosanna on rye" for the really early masses to get back at the priest making the schedule.

So, Carson thinks that 1 in 15,000 can be written off as acceptable casualties, and ~80% of the remaining allegations are those of the "disgruntled" and couldn't sustain their burden in court?

I wonder how that scales.

The GOP field in 2016 really is a bottom of the barrel clown car.Most of us have seen the Enquirer story about Carson leaving a surgical sponge inside a girl’s skull,causing her to have brain damage,but Carson’s response is getting a smaller amount of coverage,

This is what I said on Facebook about this particular story yesterday:

As much as I detest Ben Carson's views and his advocacy of creationist pseudoscience, as a surgeon I find this story agonizingly and infuriatingly dumb. First, there are few neurosurgeons who have practiced as long as Carson did who don't have at least a few malpractice suits against them, particularly if they practice in high risk areas and even more so if they practice in highly urban areas, where juries tend to be more sympathetic to patients and generous in judgments. It's the way things are in our system. Indeed, few are the doctors, period, who've practiced as long as Carson who don't have at least one malpractice suit against them. Second, there is only one side of the suits presented in the story and then it's presented in the most inflammatory way possible.

Finally, even leaving a sponge in a patient is usually not the surgeon's fault. It's usually due to a failure of the system. The OR team does sponge, instrument, and needle counts before and after the case. At the end of the case, the surgeon asks if the counts are correct. It's only if the counts don't match that the surgeon has to start looking. If the surgeon's told the counts are correct, there is no reason to go looking for a missing sponge, instrument, or needle. The surgeon, however, takes the blame for the failure of the system, unless he ignores the OR team telling him a count is incorrect. I've known a couple of what I would consider excellent surgeons over the past couple of decades who have had this happen.

And, as I also noted on Facebook:

One other note: In fact, neurosurgery is at the top of the list of specialties for malpractice suits, according to a 2011 NEJM study. According to the study each year 19% of neurosurgeons face a malpractice suit, and, by age 65, 99% of neurosurgeons have faced at least one malpractice suit.

http://www.nejm.org/doi/full/10.1056/NEJMsa1012370

So, personally, as much as I detest Dr. Carson's creationism and other nonsensical statements revealing a profound lack of critical thinking skills, I consider that National Enquirer to be a despicable and unwarranted smear job that has no relevance whatsoever to Dr. Carson's competence as a neurosurgeon. He is, in fact, correct, and probably has at most an average number of lawsuits for a neurosurgeon with the number of years of practice he has. I was going to blog about it or include it in this blog, but didn't. I was, however, waiting for someone to bring it up so that I could tell him he's full of shit for believing it. You just won that honor.

I might have to do a blog post on this. It irritates me just that much.

The "Ezekiel bread" sounds a lot less appealing if you read a little more of the bit of the bible the recipe is based on. (The FDA may be prepared to tolerate a small amount of animal droppings in grain, but adding them on purpose would be another matter.)

So, Carson thinks that 1 in 15,000 can be written off as acceptable casualties, and ~80% of the remaining allegations are those of the “disgruntled” and couldn’t sustain their burden in court?

Actually, in a specialty as risky as neurosurgery, 1 in 15,000 is pretty damned good. Seriously.

Yep. More and more I'm thinking a blog post might be in order. We'll see if I'm still as irritated on Sunday, when it's time to write Monday's post.

Roger Kulp@31
To be fair, I think this is quite accurate:

...Carson continued, adding that “generally speaking there is no one who does the number of operations that I did who aren’t going to find some people who are going to be disgruntled.”

I had a teacher who used to say, "there's a reason we call in practicing medicine."

I wouldn't be surprised if even our esteemed host has made a mistake or two in his career and I don't mean that as knock on him but rather that people make mistakes as a matter of course. There's a reason why there are checklists and the like in place now and it's not because leaving surgical tools behind was a vanishingly rare mistake only committed by incompetent bozos.

By all accounts it seems Carson was indeed a skilled surgeon. Lambast him all you want for the stupid sh!t he says and the shady things he does (i.e. the subject of this article) but I think denigrating his surgical competency is unwaranted mud-slinging.

...and Orac beat me to it.

Ben Carson

this makes an awful lot of sense

I think it is safe to assume anything that makes a lot of sense to Ben Carson is Fractally Wrong

He will however have the last laugh as he will outlive us all. As Georges Clemenceau said about Henri Petain - He is an immortal - he has no heart, no brain and no guts. How can a man like that die?

Actually, in a specialty as risky as neurosurgery, 1 in 15,000 is pretty damned good. Seriously.

I know that. I thought the analogy to the antivaccine Nirvana Fallacy and NVICP would have been clear, but perhaps I've been reading too much of the political babbling of the AoA commentariat.

I agree with 95% of what you say here. I come here to learn the reality behind some of the crazy views people have on medicine. I absolutely bow to your knowledge on medicine. But my expertise is training people to deal with terrorism. Carson is pretty close to correct on that one thing. If you are unarmed, and unable to get away from a shooter, you go after them with whatever you can grab. If the day comes when this is everyone's instinctive reaction, the shooters will have to come up with another plan. Of course, many will be unable to do anything but just stand there, and it is hard to predict who will react in a particular way. But it does not really take that many people. It is kind of like aircraft hijacking. Hijacking is over. You try to hijack a plane, and you are going to get ripped apart by the other passengers. Because we no longer tolerate hijackers. Just my two cents.

Finally, even leaving a sponge in a patient is usually not the surgeon’s fault. It’s usually due to a failure of the system.

What is more concerning is Carson's insistence that any error in his operating theatre is inconceivable, and therefore he must have meant to leave a sponge in the patient's brain -- like foam packing -- so any subsequent brain damage was the patient's fault for reacting badly.

“it is true that we put a certain type of sponge in to pad things away and sometimes there is a reaction to that sponge and that’s what happened.”

I would have thought that Americans have had enough of complete reality denial in their Presidents.

it would be advisable to attack an armed gunman during a mass shooting “because he can’t get us all”

Well...one would think that taking evasive action is the best option when someone is shooting at you and I'm guessing the average individual will instinctively do so.

We were taught (this would be 1979) that troops in the kill zone must turn in the direction of the ambush and immediately, everybody, assault through it. This of course required troops in the kill zone be armed and shooting back at the ambusher.

(I remember thinking at the time "yeah, right. You first.")

I have been told (I wasn't in the infantry and have never been ambushed except in training) that this is what you call an oh shit moment, but by reacting instantly you can increase a "no chance" to "some chance."

The “Ezekiel bread” sounds a lot less appealing if you read a little more of the bit of the bible the recipe is based on.

Fortunately this is a parody.

@41

Well, you thought wrong didn't you.

/young frankenstein

I consider that National Enquirer to be a despicable and unwarranted smear job

Geraghty's Mannatech-themed hit-piece in NRO did not halt the rise in Carson's popularity, so the Republican establishment turned to Jen Rubin as their mouthpiece; now it sounds like they're stovepiping stories through National Enquirer. Perhaps there is more hope that way of reaching the target audience.

Of course this wasn’t the only screwed up operation our brilliant brain surgeon and Presidential wannabe had performed.

That Guardian story from May (at Roger Kulp's link) notes that the number of malpractice claims leveled at Carson is in line with the statistical background.
The author does not do any favours for his research skills or his concern for accuracy by opening with the claim that

Carson was known as a master of his craft, and renowned as the first surgeon to successfully separate siamese twins.

herr doktor bimler@41:

What is more concerning is Carson’s insistence that any error in his operating theatre is inconceivable, and therefore he must have meant to leave a sponge in the patient’s brain — like foam packing — so any subsequent brain damage was the patient’s fault for reacting badly.

Exactly this. Carson seems to have an excellent record as a neurosurgeon, but the pathological inability to accept or acknowedge an honest error or analyze why it happened damns his suitability as a leader.

Not that this will slow him down, mind. While the reluctance to admit one's own mistakes has always been a universal failing in humans, US right-wingers now enthusiastically embrace absolute denial as massive personal strength - and are utterly unafraid to bomb the other party down to bedrock just so they never have to say "sorry'".

Hell, most of today's GOP base would vote Greg Stillson if they could; that's how out of control their masturbatory power fantasties and craving obsequiousness has become.

Dirk@41: Do you seriously expect untrained, unarmed civilians to spontaneously rush a shooter as soon as an incident starts? As shay notes below you, it's hard enough to get trained and armed soldiers to react that way.

The situation on UA93 was exceptional and, for the reasons you describe, unlikely to be repeated. Hijackings were treated as hostage situations until sometime between 9 and 10 AM EDT on 11 September 2001, because that was how they had always played out prior to that day. The passengers on UA93 knew what had happened to three other planes that morning and knew that they were unlikely to survive no matter what happened. More importantly, they had at least several minutes to plan their attack--time which people in shooter situations don't have.

In a shooter situation, instinct will tell most people that they have a chance of survival if they either (1) duck and cover or (2) run in a direction other than the line of fire. Most of the time, they are right, and they won't have time to figure out whether this particular incident is an exception. Running straight at a shooter is likely to get them killed, even if the shooter had specific targets in mind and is willing to ignore anybody who doesn't interfere with their objective (which is the case in a significant fraction of shooting incidents--not all shooting incidents are mass kills like Roseburg or Sandy Hook).

I absolutely agree that shelter in place and flee the scene are the best tactics when faced with a shooter or similar danger. But in a situation where you cannot flee or hide, you should attack with what you have. In a classroom, throw a book or chair, or grab a desk and charge. I absolutely understand that many people are unable to do this. I have a lot of experience with studying people under such stress, and predicting the ones who will act is very counter intuitive. And you will not have time for a strategy meeting when you are being herded into the corner and shot. Just like on aircraft, we should change the agreed-on default response to a shooting situation. One of the reasons that we have repeat instances of these shootings is that the perpetrators have a twisted sort of romantic vision of what they are doing. They see themselves as tragic figures, getting revenge and going out in a blaze of glory. They do not have fantasies of being shown on the news in a hospital, on a ventilator, covered with lacerations and bruises.
Each situation is different, and I understand that it is easy to advise someone to charge a gunman, when you are not yourself in peril. I will offer no criticism of those who cannot or will not act.

I just saw a presentation on television that illustrated exactly what Dirk W describes: people in an enclosed classroom throwing books at the shooter as distraction, interfering with his plan.

Also, about that 'romantic vision', which is another place where we can- hopefully- proactively interfere IF news coverage focuses less on the shooter ( I believe that his name was mentioned much less in the Oregon situation by design) and portrays victims and survivors more prominently.
It's difficult to understand motives but I venture that tampering with the screen play-like scenarios of the Tragic Loner Finally Bursting Free is a place to start.

OT but since we are speaking of deluded Tragic Visions...

Dan at AoA, visits Japan, drinks coffeee and notes that the lighter vaccination schedule may be linked to lower infant mortality there, is taken to task by - surprise!- a commenter who snarkily calls the "investigative reporter" out, explaining why mortality rates are not relevant here.

Hijacking is over. You try to hijack a plane, and you are going to get ripped apart by the other passengers. Because we no longer tolerate hijackers. Just my two cents.

There have been six hijackings this decade so far. There were seven at this point in the 2000's***, and eight in the first five years of the '90s.

I wouldn't call that "over."

Passengers have fought back during three of the thirteen hijackings that have occurred since UA 93.

I wouldn't call that a guarantee that if you try to hijack a plane, you're going to get ripped apart by the other passengers.

Furthermore, were that to become the standard, it would be perfectly possible for hijackers to plan for and work around it, considering that they have the advantage of advance preparation for the conflict.

One of the reasons that we have repeat instances of these shootings is that the perpetrators have a twisted sort of romantic vision of what they are doing. They see themselves as tragic figures, getting revenge and going out in a blaze of glory. They do not have fantasies of being shown on the news in a hospital, on a ventilator, covered with lacerations and bruises.

No. Nor will they ever, even if showing them on the news like that became routine. You're not talking about rational people. And you're also not talking about reality, but rather fantasy.

Each situation is different, and I understand that it is easy to advise someone to charge a gunman, when you are not yourself in peril. I will offer no criticism of those who cannot or will not act.

You just did, implicitly. IMO. And I don't say that because I take it personally. I personally would be exponentially more likely to charge a gunman who was threatening someone else's life than I would be if I were the one being aimed at.

But I don't know why that is.

***Counting September 11th as one incident.

The "active shooter" scenario training that we get here (so far the most heavily-armed client we've had to deal with was a gentleman who walked in with a golf club looking for his ex-wife) teaches "bug out, hide out, strike out."

Run if you can -- if you can't, hide. And if you can't run or hide, then you fight back.

The problem with fighting back is that to overwhelm the shooter you have to rely on everyone else in the room with you to do the same thing.

AND needless to say, it's much harder to get weapons onto planes than it was in 2001.

Hell, most of today’s GOP base would vote Greg Stillson if they could; that’s how out of control their masturbatory power fantasties and craving obsequiousness has become.

For me, pictures of Ted Cruz often bring Greg Stillson to mind.

Device Walter@55

AND needless to say, it’s much harder to get weapons onto planes than it was in 2001.

But is it? My understanding is that the TSA is largely ineffective and the policies put in to place since 9/11 are mostly "feel good" policies that don't really do anything. The acupuncture of security if you will.

Acting TSA director reassigned after screeners failed tests to detect explosives, weapons
7 Reasons the TSA Sucks (A Security Expert's Perspective)

Heh, Device Walter again. Sigh. Please accept my apologies Denice Walter.

Dr Carson and Mal-practice cases. In one of the above posts Dr Carson was quoted as saying that he had done 15,000 surgeries. This is obviously an exaggeration. The average neurosurgeon does between 200 and 350 cases a year. Academic neurosurgeons do less since the Residents and Fellows are doing the bulk of the surgery. If Dr Carson did 15,000 surgeries over 35 years that would be 500 per year. This is not true.

Um, I've known academic neurosurgeons who averaged 400-500 cases a year; so I don't find Dr. Carson's estimate that far beyond the pale.

^^Irresoective of all of which, Ben Carson literally does not know what the debt limit is.

So even if his critical thinking skills were first-rate, he still would be too ignorant of the basics involved in running a country for his opinion about how best to do it to mean much of anything..

Has anyone considered that Ben Carson's idiotic statements are actually due to brain damage caused by vaccines?

NaturalNews has astutely noted that Hillary Clinton displays all the signs of vaccine-induced brain injury (among other things, she was noted to have said "uh-uh" 88 times during a recent appearance caught on video).

Repetitiveness - tics - thimerosal. The correlation is inescapable.

"Yes, the whole “What if the Jews had been armed?” nonsense. Well, we know what happened when the Jews armed themselves and resisted, as they did in the Warsaw Ghetto Uprising and other uprisings, such as the Białystok Ghetto Uprising and the Częstochowa Ghetto Uprising and uprisings in the Sobibor, Treblinka, and Auschwitz. The Nazi war machine crushed them and sent the survivors to the death camps."

Dunning Kruger Affect? You are a scientist, so now you know about everything? Plus, how does science determine when is the correct choice to stand up and fight? Maybe this specific comment of yours has NOTHING to do with science? Just a thought. But you are correct on his pseudo science BS.

I'm also rather well versed in WWII and Holocaust history because I've studied it extensively. I'm not a historian-level expert, but I'm quite knowledgeable.

JP @ #19: "Isn’t Ben Carson a Seventh Day Adventist? They’re big into all kinds of health food and supplement nonsense."

According to National Geographic Magazine, "Residents of Okinawa, Sardinia, and Loma Linda, California, live longer, healthier lives than just about anyone else on Earth." Loma Linda is the location of Loma Linda University, the Adventist medical school. The magazine wrote, "Loma Linda is home to a concentration of Seventh-day Adventists with a remarkable distinction: Study results have shown that, as a group, they currently lead the U.S. in longest life expectancy." I've got distant relatives who are Adventist and that side of the family definitely has 80 and 90-year-old members who are still going strong after this side has long since expired. There is something to be said for healthy living.

http://ngm.nationalgeographic.com/2005/11/longevity-secrets/buettner-te…

Jay@63

Dunning Kruger Affect? You are a scientist, so now you know about everything?

Orac cut his teeth debunking Holocaust denial. Like he said, he's not a historian but he's smarter than the average bear.

Plus, how does science determine when is the correct choice to stand up and fight?

I'm not a sociologist but I imagine one method would be looking at historical precedent, which as Orac noted, mostly (entirely?) involved armed Jewish uprisings being crushed. Brutally and mercilessly (without so much as denting the Nazi war machine).

More importantly than whether or not it is true, many Jewish people frown upon using the Holocaust to advance political agendas.

...the Anti-Defamation League (ADL) today called on critics of gun control legislation to stop using references to Hitler and the Nazis, saying they are “historically inaccurate and offensive,” especially to Holocaust survivors and their families.

The ADL doesn't represent the entirety of the Jewish people, but for what it's worth as a Jew who often finds the ADL way oversensitive I fully agree here. Coopting the Holocaust to advance your own agenda is just low.

Orac's position is better supported by historical evidence while Carson's is both inaccurate and insensitive. Regardless of how apt you think the reference when you ignore the pleas of "get your grubby hands off our Holocaust" your position is weakened significantly simply by way you being an exploitative sh!tbag.

@Ernie Gordon:

Healthy living is one thing. It wouldn't surprise me if SDAists lived longer than average, what with the vegetarianism and all. (I'm one myself. Well, okay a pescatarian, and I make hospitality-related exceptions.)

But most supplements have been proven to be worthless, and I doubt that so-called health foods like spirulina and bulghar wheat and whatnot do anything special. They certainly don't cure cancer.

Jay @63:
Dunning Kruger Affect? You are a scientist, so now you know about everything?

It is not a pretty sight when an academic goes Emeritus so if Orac is spiralling down into D-K syndrome then you're only doing him a favour by pointing it out. Of course the best way to make the point is to call his attention to an error he has made in his depiction of the Holocaust, and see how he reacts.
Spelling "Effect" properly also helps.

It also occurs to me that the question, "Are the opinions of a surgeon on late-30s / early-40s European history worth the pixels they're printed on?" would be better addressed to Ben Carson than to Orac, if only to reflect the former's academic priority.

Jay@63: So would you like a baggie to carry your ass home in?

Also worth noting: owning guns didn't do squat either for Poles, Dutch, French, or other European nations when the Nazis came from them. And it's not like they weren't already tooled up, trained, and fully expecting trouble to kick off at some point, nor was it even their first time in such a crisis situation, with the Great War still fresh in mind and myriad European conflicts spanning the centuries before.

This constant braggagio about the Good Guy with the Gun being the Hero of the Hour is nothing but witless wank fantasies for Travis Bickle/Willy Lomax/Walter Mitty sad-sack wannabes with bloated voracious "American Dream"-fed egos and not a single actual life achievement to feed it. Its unending, uncritical indulgence is an appallingly unhealthy habit for both individual practitioners and democratic society as a whole - the sort of behavior one expects from tantrum-throwing teens or toddlers, not supposedly responsible decision-making adults in one of the most powerful and influential nations of the world.

So please, grow the f*ck up already. Or, if you can't do that, then at least have the good grace to shut-up while the grown-ups are talking, because as it stands you and your kind have not a single thought of worth to offer.

Denice,

And now we have hymns of praise to the microbiome.. ( Conrick @ AoA)
I’m sure that either you or JP ( and others) can think of a verse or two.

I couldn't get this idea out of my head so, but here is my attempt, FWIW. Think of a Church of England dirge (them's my roots).

Mighty biome up my bum,
Oh how I worship thee.
You help me to digest my food
Boost my immunity.

My probiotic microbes thrive
on prebiotic pills.
They make me very flatulent
but overcome all ills.

A billion years we coevolved,
Now which is me, which thee?
Our metabolisms entwine,
In symbiotic biochemistry.

So sing this to a dreary tune,
Grammar be sure to torture.
Rejoice! All those bugs up your ass,
are of a Holy Ordure.

Sorry about the odd "so, but here" edit above.

Jay@63: Now let me correct you on a few things, OK? Aristotle was not Belgian. The central principle of Buddhism is not "Every man for himself." And the London Underground is not a political movement. These are mistakes, Jay. I looked them up.

In the real world, stopping the Nazis took all of the combined resources of the USSR and the UK, plus substantial resource commitments from the USA and Canada. And even then it was a close thing. A bit of better strategy on the Axis side (such as not opening a second front by betraying the USSR while still fighting a pitched battle against the UK) might have been enough for them to prevail. The uprisings Orac mentioned are historically documented. That's how we know for sure they were ineffective--they barely distracted the German war effort. If the US Army were ever needed to put down a rebellion of American gun nuts, the latter would be no more effective than the ghetto uprisings were against the Wehrmacht.

“Yes, the whole “What if the Jews had been armed?” nonsense. Well, we know what happened when the Jews armed themselves and resisted, as they did in the Warsaw Ghetto Uprising and other uprisings, such as the Białystok Ghetto Uprising and the Częstochowa Ghetto Uprising and uprisings in the Sobibor, Treblinka, and Auschwitz. The Nazi war machine crushed them and sent the survivors to the death camps.”

Dunning Kruger Affect? You are a scientist, so now you know about everything?

It doesn't really take more than a modicum of common sense and a moment's thought to grasp that it takes more than gun ownership and the willingness to fight to defeat an opponent that not only has guns but also tanks, planes, bombs and -- in short -- a fully trained and equipped army and police force.

That's just as true in the here and now as it was in the '30s and '40s. It's a pure childish fantasy to suppose that preserving the Second Amendment will protect you from unwelcome armed incursions by the state. I mean, what are you going to do? Beat their drones to death with an open-carry permit?

Focus on preserving the First and Fourth Amendments if you really want to be in a position to go up against the government. That way you'll be organized and prepared enough that if it gets to the point of armed conflict, you can find a way to buy whatever arms you need on the black market. Just being a bunch of liberty-loving but politically powerless individuals with guns will get you nowhere.

Kreb:

Excellent! One brilliant line after another. A great fart joke, followed by the more profound and perfectly worded, "which is thee, which me?" A+.

ann: "It’s a pure childish fantasy to suppose that preserving the Second Amendment will protect you from unwelcome armed incursions by the state."

So much this. Tanks, planes, bombs, and always vastly superior numbers. Of course, where the two strands of this thread cross — SDA and armed resistance to the Feds — didn't turn out so well for the Branch Davidians.

Jay @63 tries a little sophistry by straw-manning Orac, who never claimed his remarks about Jewish resistance had anything to do with science. If he'd taken away the science deflection and the ad hominem, Jay might have had a point: 'It's not always a simple matter to determine if the coreect choice is to run away or stand and fight.' The fact that Carson is a major newsmaker has us paying within his loopy premises – so we're talking about the Warsaw ghetto, and rushing gunmen like they're similar things, which they're not at all. The Jews in Warsaw were trapped, didn't have much of a 'run' option, were facing death camps anyway, and weren't reacting on the spur of the moment. We could say they gained nothing for themselves, but lost little (already targeted for) and their actions had profound historical importance.

By the same token, I was taking liberties including Nat Turner in my comment above. The thing is – you and has are spot on about the gun nuts as spoiled children. We're talking about mostly white-male wage-earners with enough capital to buy fairly expensive weapons legally, and keep a big 4 x4 in their two car garage – who imagine themselves as some kind of repressed minority comparable to Jews under the 3rd Reich, plantation slaves, and so on. It's a tautology: we have to have guns because we're afraid the guvment will come to take our guns. (Talk about burning stupid...)

And, of course, the serious undertone of my satire @24. Carson especially might be expected to understand how the whole focus on "postal" mass-shootings is a deflection from the real gun problem: everyday violence in street crime in impoverished neighborhoods, and domestic disputes that turn fatal because guns are in the house when people are angry and intoxicated.

Krebiozen, that's hilarious.

-btw- Readers who have never "enjoyed" the creative talents of Teresa Conrick ( who is Gamondes' closest rival at AoA) should peruse her collected works. Anyone can pull stuff like this out of their microbiome-enhanced orifices but it doesn't mean that it has any relationship to reality.

Conrick has an adult daughter with autism which she wants to explain away through any trope she can find and vaccines-disrupt- the-microbiome-leading-to-autism appears to be her choice.

But she's not the only one! TMR often features variants on the theme and recipes for kim chi and sauerkraut. Then there are diverse schemes involving yougurt. as well as interpersonally transplanted poo.
Ideas about microbiomial omnipotence are rife in alt media-
it's an integral part of their culture- vegans use soy yoghurt.
But yeast in bread or wine is totally evil.

ann@74

Focus on preserving the First and Fourth Amendments if you really want to be in a position to go up against the government.

Oddly enough, there seems to be significant overlap between 2nd Amendment nuts and supporters of invasive data gathering policies. The NSA's warrantless data collection and the constant push by the 3 letter agencies to legislate against crypto are the real threats to freedom.

sadmar@76

Carson especially might be expected to understand how the whole focus on “postal” mass-shootings is a deflection from the real gun problem: everyday violence in street crime in impoverished neighborhoods, and domestic disputes that turn fatal because guns are in the house when people are angry and intoxicated.

Dwarfing even those is suicide by firearms. Greg Laden recently wrote on gun control. It's worth reading all the through but the takeaway is the success rate of suicide by firearm is 85% vs for example 20% by jumping. Since only 10% of people who attempt suicide and live make a second attempt removing that method (or at least making it significantly harder) would save many lives.

I'd be curious in a comparison with Australia or the UK to look at if that actually pans out and I didn't really care enough to double check his references so make of that what you will. Regardless about two thirds of gun deaths are suicides and about half of suicides are by firearm (per the CDC's 2013 mortality data [pdf, p22-23]).

Denice Walter@77

[...] as well as interpersonally transplanted poo.

Ugh. There's growing evidence that this is effective for C. diff but done by quacks to cure autism is just squicky.

And now we have hymns of praise to the microbiome

"Hymn to In-Anna" is crying out to be a microbiome-themed sonnet by a Metaphysical poet.

[…] as well as interpersonally transplanted poo.

I'm waiting for the arrival of fecal transplants from celebrity sources. If not in the real world, then as a plot device in a Cronenberg movie.

Speaking of fecal transplants, guess what's shown up over at SBM?

guess what’s shown up over at SBM?

Goodness me! Phillip Hills has become stupider! But he seems to be confining himself to random insults rather than copy-pasting his own fabrications.

But he seems to be confining himself to random insults rather than copy-pasting his own fabrications.

Except when he's making them even less coherent:

"Was that the one by the Cochrane collaboration that looked at the top claims for flu vaccine over 96 seasons of data?"

Thank you very much: I truly relish my role as straight man.
It's an art form,

I’d be curious in a comparison with Australia or the UK to look at if that actually pans out

The suicide rate in the United States is double that in the UK, per the World Health Organization.

I don't know how much of the difference is attributable to guns, though. It appears to be true in all demographics, and I don't think there are enough female suicides by gun in the US to account for that.

Incidentally, the two countries that have high suicide rates for no very apparent reason (that I can think of) are France and Belgium. Were it not for them, the US would have the highest suicide rate of any country on earth that wasn't impoverished, war-torn, unfree and/or regularly plunged into darkness for long periods of time.

I’d be curious in a comparison with Australia or the UK to look at if that actually pans out and I didn’t really care enough to double check his references so make of that what you will. Regardless about two thirds of gun deaths are suicides and about half of suicides are by firearm (per the CDC’s 2013 mortality data [pdf, p22-23]).

IIRC, putting one's head in the oven was once the most popular (and a very effective) suicide method in the UK; when coal gas was switched out for less lethal natural gas, the suicide rate dropped by a third, and it was a permanent reduction. Having (or not having) a ubiquitous, quick and lethal method to hand does make a large difference.

Incidentally, the two countries that have high suicide rates for no very apparent reason (that I can think of) are France and Belgium.

Ennui?

I'm sure that some religious apologists would attribute the suicide rate in France to their relatively large number of atheists. Or fast living or alcohol.

@JP --

Ha.

Thanks for that.

But, you know. The Flemish.

JP@86

IIRC, putting one’s head in the oven was once the most popular (and a very effective) suicide method in the UK; when coal gas was switched out for less lethal natural gas, the suicide rate dropped by a third, and it was a permanent reduction. Having (or not having) a ubiquitous, quick and lethal method to hand does make a large difference.

Very interesting, I had never heard that before. A quick Google suggests you did remember correctly and that it is generalizable[1]. I don't follow the gun control debate very closely but am I right in assuming that when not ignoring the issue gun nuts claim people who want to kill themselves will find a way so gun control wouldn't have an effect? If so there's yet another anti-science position from the conservatives.

[1] Restriction of access to methods of suicide as a means of suicide prevention (PDF)

#35 Viki

I had never even heard of Ezekiel Bread. This really is not a Poe?

Ezekiel 4:9 products are crafted in the likeness of the Holy Scripture verse Ezekiel 4:9 to ensure unrivaled honest nutrition and pure, delicious flavors.

Good lord (oops) there are all kinds of google hits for it.

Denice/Shannon have you seen it up here?

#78 capnkrunch

Your wish is my command. Actually fell over the ref today while looking for something es and have only read the abstract but the strict gun laws in Oz seems to had a humungous effect on suicides.

Leigh, A., & Neill, C. (2010). Do Gun Buybacks Save Lives? Evidence from Panel Data. American Law and Economics Review, 12(2), 509–557. http://doi.org/10.1093/aler/ahq013

http://aler.oxfordjournals.org/cgi/doi/10.1093/aler/ahq013

@jrkrideau:

Ezekiel Bread is totally for real and it TASTES GOOD, I do not care if it is silly. I just found some at Trader Joe's, and I am pretty happy about it.

Ezekiel 4:9 products are crafted in the likeness of the Holy Scripture verse Ezekiel 4:9 to ensure unrivaled honest nutrition and pure, delicious flavors.

Oh yes. An Old-Testament description of famine bread, eking out palatable grains with disgusting stuff that people will only eat when the alternative is starvation, so the nimrods convince themselves that the description must be an instruction -- and therefore the resulting Dwarf Bread must taste good.

I wonder if they can be sold on my 2 Kings 6:25 recipe

But Nimrod was a mighty hunter among men; shirley he would've been able to eat just about any part of any animal he wanted.

In any case, plenty of people voluntarily eat head cheese. And blood pudding.

jrkrideau@92
Thanks! Here's the full text if anyone is interested:
http://www.econstor.eu/bitstream/10419/36943/1/629737827.pdf

I also haven't read it but the takeaway from the abstract seems to be:

We find that the buyback led to a drop in the firearm suicide rates of almost 80%, with no significant effect on non-firearm death rates. [emphasis mine]

Suicide by firearms decrease significantly and isn't accompanied by an increase in other methods. This is in line with what JP said as well as what Greg Laden wrote and what the reference I posted in #90 said.

Before I read that Greg Laden article I had never even put together gun control and suicide prevention. Like I said, I don't follow the debate closely but it seems like this should be focused on way more than it is. Mass shootings are flashy but suicide prevention seems like where the most lives would be saved. I wonder if lack of public sympathy for suicide victims makes it an ineffective argument.

JP@95

And blood pudding.

As a child I was tricked into eating blood pudding by my Irish relatives. I think that may have been the exact moment I stopped being able to trust people.

Ezekiel 4:9 products are crafted in the likeness of the Holy Scripture verse Ezekiel 4:9 to ensure unrivaled honest nutrition and pure, delicious flavors.

Oh yes. An Old-Testament description of famine bread....

There's a line of breads carried by "America's Most European Supermarket" that I don't think is Mestemacher (more varieties, at least), but I've seen the Ezekiel stuff in the freezer section of the local hippie mart, and I'm putting strong odds in favor of the latter's being more appetizing than even the normal varieties.

I'm guessing that the Ezekiel's pretty crumbly (read: "best toasted"), though. I was a great fan of "Natural Ovens" over here before the Stitts sold the operation.

^ Let's see...

"that I don't think is Mestemacher ... but is pretty similar in appearance"

and

"even the normal varieties of those bricks."

My father, I have heard, was fond of head cheese growing up; then one day he was over at the neighbor lady's house and nosing around the kitchen. He noticed a pot boiling on the stove, and lifted the lid to see what was cooking; back at him stared a partially desiccated pig's head in boiling water. He never ate head cheese again.

Very interesting, I had never heard that before.

Sylvia Plath springs to mind.

I'm pretty sure I meant something more like "disintegrated" rather than "desiccated."

He never ate head cheese again.

I haven't been able to face liverwurst since encountering a package of Oscar Mayer as a boy that seemed to be full of ~1 mm (if that), inedible, glistening spheres.

plenty of people voluntarily eat [...] blood pudding.
My fondness for the Hanseatic Diet -- coffee, beer and black pudding -- is on record.

Sylvia Plath springs to mind.
Alvarez in "The Savage God" records gas ovens as being the UK suicide of choice. The shift to natural gas (non-carbon-monoxide) hadn't occurred at the time he was writing.

Spike Milligan:

When Daddy saw what he'd done, he put his head in the gas oven.
That must have been terrible.
No, it was delicious!

He noticed a pot boiling on the stove, and lifted the lid to see what was cooking

Does this recipe work for the ass's head that I just bought for fourscore pieces of silver?

You might want to clean the fur off first.

As a child I was tricked into eating blood pudding by my Irish relatives. I think that may have been the exact moment I stopped being able to trust people.

As a kid I loved blood pudding, but I seem to've lost the taste for it.

(Other things I've lost the taste for are fish balls and soda. There doesn't seem to be much of a pattern here.)

@ shay #54

Run if you can — if you can’t, hide. And if you can’t run or hide, then you fight back.

Or as Sun Tzu put it in his still-taught-in-officer's-school Art of War:
"If surrounded, plot. If cornered, fight."

(well, it's actually a quote from the video game "Shogun: Total War", but it was lifted more-or-less straight from the book)

The problem with fighting back is that to overwhelm the shooter you have to rely on everyone else in the room with you to do the same thing.

And hoping no-one will be shooting in your direction, mistaking you for the miscreant or just not watching their line of fire.

@ Jay #63

how does science determine when is the correct choice to stand up and fight?

If the question was about the moral decision to take arms, your remark would be accurate.
But the question's context here is about being somewhat successful in the process; specifically, about German Jews repelling the whole Nazi war machine all by their lone selves.
And WW2 historical examples of local uprisings show how doomed the notion of personal resistance is.

Organised resistance movements in west Europe and in Serbia (by example) did manage to force the Germans to commit military forces which could have been very useful somewhere else, like in Africa or in Russia. But in these cases, they were backed-up by government funding and provided with military-grade weapons (or stole them from the German). And, at least in West Europe, they still paid a very high price for this.

Worse, the Nazi propaganda would have - and had - seized on any example of gun-totting Jews and pointed them as criminals, foreigners, terrorists. Feeding back "reasons" to keep rounding-up and interning Jews and other undesirables.

The French-famous "Affiche Rouge" is an example of such propaganda. We like to think it didn't work much, but my compatriots had 4 years of Occupation to figure out who the invaders really were. Pre-war, such propaganda would have been much more effective, if the political atmosphere at the time is to be believed.

Alvarez in “The Savage God” records gas ovens as being the UK suicide of choice. The shift to natural gas (non-carbon-monoxide) hadn’t occurred at the time he was writing.

For certain values of "non." My last place had a nice, roomy oven. And two nice, yellow-burning back stovetop burners. Then again, I only hit 97 ppm one Thanksgiving. With the doors and window open thanks to the heat.

There must be a Brandy/Looking Glass/"Mercaptain" gag in here, but I'm too tired to find it.

@Narad: I still love liverwurst - but I get it from the deli, not OM. I can't eat it as often as I used to, or in as large quantities. On the other hand, I never got into head cheese or blood pudding (rare to find in the US). My former FIL loves head cheese, but the look and smell makes me sick.

"I know what would be tasty, congealed boiled pig's head," said absolutely no-one ever.

And WW2 historical examples of local uprisings show how doomed the notion of personal resistance is.

Probably true against a larger force. What if it's a single armed person in a train who's shoting?

I have seen Ezekiel bread in a hippie-ish store. No thanks..

And right, blood/ black pudding, liverwurst, sausages in general, no, thank you very much. Unfortunately, the Eastern Europeans nearby have stores which sell diverse products which will never be bought by me but are sometimes prominently displayed ((shudder)) so I see them.
Chinese hung ducks are alright though.

Interestingly, around hipsterville and hippietown- i.e. places I frequent- I seem to notice two trends in dining amongst the youngsters:
- ultra- ( supposedly) healthy, GMO-free, sometimes vegan choices, non-antibiotic fed meat ,raw, free range poultry, etc
- over-indulgent meats - double burgers- bacon-laden, comfort foods, ridiculous desserts, deep-fried, BBQ-
the other day near the galleries, I saw 20 people ( young men, mostly) waiting outside a newly opened place that served over-laden sandwiches and bizarre combinations like peanut/ plantain/ bacon.
But no congealed pig's heads YET. I'm sure it's on its way.

But the question’s context here is about being somewhat successful in the process; specifically, about German Jews repelling the whole Nazi war machine all by their lone selves.

Then there's the question's subtext:

Carson supporter pens Fox News op-ed blaming Jewish timidity for the Holocaust

It's a true dog-whistle, in that most non-haters probably really can't hear it. But that Ben Carson might not be as innocent as he looks. SDAs were decidedly not rooting for the Jews to oust the Nazis, back in the day.

@#112 --

Probably true against a larger force. What if it’s a single armed person in a train who’s shoting?

Per Ben Carson, the correct response to that kind of situation is to assist him or her by identifying the target:

On Wednesday, Carson told SiriusXM radio host Karen Hunter that he had been held at gunpoint before. But in his telling, he did not react as he said he would, and he definitely did not attack the gunman:

I have had a gun held on me when I was in a Popeyes [in Baltimore]. … A guy comes in, puts the gun in my ribs, and I just said, "I believe that you want the guy behind the counter." … He said, "Oh, okay."

But if you're asking me, I think that if you find yourself in a position where you can do something to prevent potentially lethal violence, you should do it.

@ M O'Brien

Probably true against a larger force. What if it’s a single armed person in a train who’s shoting?

Oh, good point. I was talking in the context of resisting a large organised force. A few people may survive the first encounters, but unless they receive some help or manage to go into hiding, it won't matter in the long run.
Well, again, the topic is about armed resistance of a few citizens stopping a larger force. A lot of people escaped Nazi Germany, with or without using guns, but their escape didn't stop the Nazi from going after the people left behind.

On the other hand, in the context of a single encounter, in an enclosed space to top it, rushing the shooter is making more sense. If cornered, fight.
(easy to say on my part, I know)

If you are evoking the recent wannabe "highwayman" in a French train ('twas his line of defense, he is no terrorist, just a common armed robber), at least half the courageous people who tackled him were trained soldiers. Their training must have helped them going for the right decision and the appropriate approach (including watching for the guy pulling spare weapons out of various pockets).

Expecting ordinary citizens to decide to intervene is doable; wish I was as courageous as the above heroes; but for an ordinary guy or lady to have these types of combat reflexes is maybe putting the bar a bit high. If I go against an armed guy, I have a higher than average chance of getting offed, given how untrained and slow I am.

Well, I suppose I can go into some sort of autodefense school. Won't help me much against a squad of armed paramilitary nasty guys, to go back to the original question. Especially with relatives (children, etc.) right behind me in the line of fire.

Re #73

I am in agreement that launching an attack against the former Soviet Union before forcing Great Britain out of the war was a colossal blunder on Frankenberger's part. However, the big strategic mistake was made long before the war started, which consisted of building the battleships Bismarck and Tirpitz instead of Uboats. Had the manpower and materials expended in building those ships had been instead utilized to construct Uboats, Germany would have had available in 1940 40 or 50 oceangoing vessels which would have been sufficient to starve Britain out of the war in 1940. By the time that a such numbers were available in 1943, Britain had greatly strengthened its anti-submarine Bismarck and Tirpitz contributed forces, which in addition to the intelligence provided by ULTRA, turned the tide. Bismarck and Tirpitz contributed little to the German war effort.

@ ann

Then there’s the question’s subtext:

Ah, of course. I missed it the 1st round. But now that you mention it...
Sounds familiar, we had a Quebecois holocaust denier on a RI thread a few years back. It was my first encounter of the type.

Funny how some opinions are like a corroded copper coin: the head side is not much to look at, and the accompanying flip side is even worse.

at least half the courageous people who tackled him were trained soldiers.

And one of them was the size of Hoover Dam.

# 113 Denice Walter
Thank's Denice,
We don't have many hippie-ish stores here but I'll have a look around.

Scratched the blood pudding---I had it in Rivière de Loup once due to my bad French and the server's bad English accent but I am envious of the sausages and the duck. Perils of living in a small city.

Team,

Here's a thought experiment:

So far, there are three people with a real or, in the case of the last one, potentially real desire to see me dead. The threat is very very real.

First one is an excellent social parasites and was my first case of PCL-R certifiable psychopath with an excellent self-control most of the time.

The others two are certifiable total bonkers loose cannon whose self-control ability is non-existent (ask any questions leading to introspective thinking of the subject and see the subject goes into full blown psychosis).

One of the last two is sitting in the provincial forensic hospital after a not-guilty verdict by insanity.

In both last cases, I can assert with very reasonable confidence that in both of the last two, there isn't a day they don't think about me.

If I meet them on the street, what can I do?

Discuss ;)

Alain

Ah, of course. I missed it the 1st round. But now that you mention it…

It's not obvious. And (to be scrupulously fair) it isn't always -- and might not be for Carson -- an antisemitic or denialist argument.

Hannah Arendt made a very similar case in Eichmann in Jerusalem, for example. And while I personally think it would be fair to say that making it was functionally a form of denial for her, she wasn't denying the Holocaust as much as she was the regular old things people have an emotional motivation to deny -- ie, their own vulnerability and their fears about it, etc.

To some extent, that's very likely true for many present-day guns-rights types as well, imo. The difference is that they have much less basis in reason for the fear.

You know, one thing this comment thread is teaching me as a blogger is never, ever—ever!— to mention anything having to do with guns, even in passing, if the main topic of the post is not about guns because invariably even the most passing mention of guns will lead to a hijacking of a major part of the comments to be about guns, much to my annoyance.

As it did here.

Orac,

Sorry, I was more interested in the tangential point of self-defence but I am truly sorry to add oil to the fire.

Alain

There is a vast difference between an uprising and resistance fighting.

Back to main topic of this blog. Mr. Carson (I refuse to use his MD when he is acting as a politician and not a Dr.) is basically saying do as I say not as I do. If he really believed in manna from haven (Mannatech) he would not have had the surgery and probable chemo for his prostate cancer.

Mr. Carson seems to be courting a strange segment of the population for his nomination run.

JP @ 100

Why do you think they call it"Head Cheese" anyway?Have you ever looked up a recipe for this culinary delight? Take a look at these two web pages with graphic pictures and details galore.

From the second article

"A pig's head is an embarrassment of riches."

" The snout is pure skin and fat; since the entire head is covered with skin,you have, literally, square footage of skin with which to fashion your dishes. The ears, in addition, offer the unique textural crunch of cartilage."

"If you've gone through the trouble of stewing a whole pig's head, making headcheese is simply a matter of taking everything that you've cooked and plopping it into a pan with salt and pepper."

".Head flesh wants to bind. If you add the gelatinous meat with collagen and tissue into your loafpan, then the entire mixture will easily come together into one solidified mass."

"Head flesh wants to bind."This woman has a wonderful way with words.If you peruse Ms Wang's other recipes,she will tell you how to prepare such delights as Octopus,Jellyfish or,Lamb's Face Salads,Deep Fried Brains,Beef Lungs and Omasum,Pig Ear Pizza,the proper way to cook penis and testicles (Hopefully not your husband's.),and lots more.

Denice Walker@ 77

"Ideas about microbiomial omnipotence are rife in alt media-
it’s an integral part of their culture- vegans use soy yoghurt.
But yeast in bread or wine is totally evil."

Not sure what you mean here.Care to elaborate?

I went (mostly) vegan a couple of years ago,after developing very bad protein malabsorption.I do most of my own baking.I use yeast in bread.Using eggs to bake with does not cause the acute pain,and odd looking poo that eating a nice omelette would.It may be similar to alcohol? Wine is a definite no-no for me.I have mitochondrial disease.I can't drink the slightest bit of alcohol.I causes either seizures or acute mito crashes.But baking or cooking with alcohol is no problem.I know it has something to do with cooking evaporating the alcohol.

the proper way to cook penis and testicles

Ah, yes, I have heard of this: Rocky Mountain Oysters, as sheep testicles were called back where I grew up. Thankfully we were never quite that backwoods.

Bull penis, or "pizzle" (seriously) is often dried and sold as a chew toy for dogs, incidentally.

@Orac --

I apologize for causing you annoyance.

But I'm not sure I understand why you're annoyed. And I don't mean that in an argumentative spirit. On the contrary, actually. I don't dispute that it's your call to make. I'm just seeking guidance.

Ann:

I didn't read Orac's comment about threadjacking as directed against you. It takes more than one commenter to go off on a tangent. But I must also say I'm perplexed Orac is chiding himself for opening McGee's closet of guns. Orac may see the OP topic as specifically about Mannatech, and prefer the comments stay to Carson's positions contrasted to medical science.

However, this is not just a medical science blog, but a skeptic blog. 'Science' here is typically associated with 'critical thinking skills' that ought to be more broadly applicable in dealing with a variety of issues. That is, we often find encouragement in the forums (meaning the skeptic community generally) to treat social issues the ways scientific experts treat questions in their fields of expertise.

Orac expressed his intent to focus on the more specific this way:

[Carson's] statements i[e.g., re: the Oregon shooting] make me wonder how someone with so little critical thinking skills could get through medical school and a neurosurgery residency to become such a respected surgeon.

While I knew Dr. Carson shows an uncanny lack of critical thinking when it comes to most issues outside of medicine, I had never in general doubted his medical abilities...

Which kind of begs the question, 'why the hell not?' Orac may have reason to detach Carson's Dunning-Kruger on medicine outside of neurosurgery to his Dunning-Kruger crankery on science, or to detach his Dunning-Kruger crankery on science to his Dunning-Kruger crankery on social/historical issues. But if readers make that connection, I don't think that's necessarily a deflection.

The discussion of 'guns' here strikes me as based in Carson's views, and framed as evidence of bizarre thought patterns. If it veers away from Carson a bit to consider the general prevalence of "if they'd only been armed!" mythologies, that's evidence of what sort of political masters and agendas Carson is serving instead of the scientific rationality some expect of him.

Some RI regulars may see an apparent irony in my response to Orac's #122: He frequently evokes the concept of "crank magnetism," which suggests that folks inclined to one loopy view typically have many, or that a fall for one loopy view leads to another. And I often note that I don't buy that at all as any kind of valid general principle at all. People compartmentalize, have different approaches to different subject, might even be said to adopt different personas in different contexts...

But I certainly don't contest the observation that some people seem attracted to a host of different 'irrationalities'. I just don't think that's all that common, or that 'one leads to another'. Rather, I'd posit some underlying X-factor accounts for such wide-ranging 'wrongness' in certain individuals, something quite different from what might lead other to embrace one woo while rejecting others.

In fact, I came back to this thread today to note a tidbit on Carson from today's news feed that supports a "crank magnetism" thesis in his case. The latest headline-grabbing quote from Dr. Ben is that he's opined we're getting "closer" to "the end of days." I just happened to note this view came out in an interview he did with Sheryl Attkisson – known here for anti-vaxer friendly 'journalism'.

The question of an armed citizenry may not be a medical science issue per se, but beyond being a logic and rationality issue in general, gun violence is a massive public health problem that would seem to call for something like a scientific approach, not anecdotes of imaginary tough-guy responses. But just as I'm still not buying "crank magnetism" as a widely applicable mechanism, I doubt Orac would claim the "hijacking" is irrelevant. I have the feeling he's just personally had his fill of this particular line of argument...
______

While I agree that Carson's "if only the Germans had guns!" ideas are not necessarily denialist or anti-semitic*, I have to take exception to your suggestion that Arendt "made a very similar case" to his proposition. From the get-go, reading the stuff about Carson's anti-Nazi fantasies brought the whole Arendt/Goldenhagen 'debate' to my mind. Now, I'm not confident I know exactly what Arendt was thinking with Eichmann in Jerusalem, e.g. I'm not sure she settles into a definitive position, or was just working through some different, perhaps contradictory, lines of thought. But the legacy of that work (perhaps inaccurately?) is the concept of "the banality of evil", or more properly 'the evil of banality'. From this POV, Eichmann and the everyday Germans who were complicit in the Holocaust by simply playing 'hear/see/speak no evil' are not getting any kind of pass for not having the enthusiastic genocidal bloodlust Goldenhagen attributes to them. On the contrary they are seen as MORE monstrous because their evil is so cold, amoral, so devoid of human passion, and framed by instrumentalist 'rationality'.

It's the critique of "I wasn't invested. I was just following orders, doing my job the best I could." In this interpretation, Eichmann's personal feelings about Jews were utterly secondary to his desire to rise through the ranks by doing whatever job he was given skillfully, and delivering quantifiable improvements in efficiency – the man who Taylorized mass murder. The German public then, may have been generally anti-semitic to some degree, but that wasn't the driving motive behind their non-action. They were just being 'good Germans', staying in line, not making waves, max-ing their 'go along to get along.'

I have no desire or intent to re-stage the debate over this take here. I just wanted to note that afaik NO serious scholar of the Holocaust thinks the German public was so opposed to Hitler's ideologies they would have engaged in wide pro-active resistance to them not matter how well they had been armed. He's just MAKING SH!T UP, totally off-the-wall, based on his religious views.

[*] His BS isn't anti-semitic, because it's not about the Jews. As I noted upthread, he's NOT saying "the Jews should have armed themselves and fought back." Both his reply to Joy Behar, and his statements about issues, clarify the context. He's claiming German Christians would have overtly, actively and aggressively opposed Hitler (a stand in for 'Satan' in this mythos) had they not been disarmed. He's reading Germany in the 1930s through lenses borrowed from Phil Robinson, and other wing-nuts who fantasize a mass armed revolt against the Satanic socialism represented by Barrack Obama. It's truly daft...
___

@Orac: apologies if this late entry adds to your annoyance. But honestly, I don't think the comments are "about guns", but rather about just how far bat-quano wacky can go with someone extraordinarily qualified in an elite medical specialty. I'd say we're more following the "doctors aren't necessarily scientists" lead and suggesting it goes much deeper than that...

I do wonder, between his anti-vaccination and his Natural Healthy Eating, how much overlap now exists between Bill Maher and the current GOP frontrunners.

"It’s difficult to understand motives but I venture that tampering with the screen play-like scenarios of the Tragic Loner Finally Bursting Free is a place to start."

I am re-reading Assassination Vacation, and your comment reminds me of how John Wilkes Booth was motivated by the general Northern veneration of John Brown. (JWB disagreed with his politics, but loved his style.)

"Bull penis, or “pizzle” (seriously) is often dried and sold as a chew toy for dogs, incidentally."

I have handled more cast-off bits of farm animals in the service of my dogs than a vegetarian ever expected to.

@ Roadstergal:

I notice that dear old Bill is now in sympathy with those who link shooters with anti-depressant usage. He is going off towards the deep end but that's not new. He's gotta go woo any way he can.

I do think that news coverage can over-simplify shooters and their illnesses, motives and life histories. Does this affect youth with problems? Who knows? But murder is never simple and actions like these should not be fodder for tv explanationeers.

"He is going off towards the deep end but that’s not new"

What pisses me off more than anything is that the scientists who come on his show never challenge him on his various inanities. NdGT didn't, Bill Nye didn't - Dawkins didn't, but he's thrown off rationalism for a membership in the Aggrieved Affluent White Male club, and Maher is a member. I am endlessly disappointed in his guest scientists.

@ Roaderstergal:

I know. So far, I've only seen Chris Matthews and Andrew Sullivan really argue against him to much effect ( about vaccines and meds, respectively).

@Denice:

Interestingly, around hipsterville and hippietown- i.e. places I frequent- I seem to notice two trends in dining amongst the youngsters:
– ultra- ( supposedly) healthy, GMO-free, sometimes vegan choices, non-antibiotic fed meat ,raw, free range poultry, etc
– over-indulgent meats – double burgers- bacon-laden, comfort foods, ridiculous desserts, deep-fried, BBQ-

Yeah, I've been noticing this for a while. The whole hipster-bacon thing is pretty much old hat at this point, for instance.

It seems to be mostly divided along gender and age lines. It's mostly the guys who go for the decadent, meat-and-gravy-and-biscuits-and-bacon and whatever type stuff, although some young women indulge along with them. It's mostly women (and some young men, but mostly older men going along with their wives/partners) who go for the super-"clean," "healthy" stuff.

I don't know if I've ever mentioned it before, but in some ways it seems to me that food has become our culture's center of both weird asceticism as well as hedonism; it's almost a new religion, with sinners and saints to go along with it. I mean, don't get me wrong, I like food a lot, and/but I also (especially lately) try to eat fairly sensibly. (Even when it comes to the few "health" foods that I eat, like, say, Ezekiel bread, I eat them because I like them for whatever weird reason.)

I mean, I sort of think nostalgically back on the days when people indulged in sex and drugs and whatnot - it's like that has all gotten transposed onto food now. (Well, okay, not all. But you catch my drift.) And the converse is the super-duper "healthy lifestyle," the juice cleanses and asparagus water and whatever it is those people do. I find it kind of odd.

Anyway, I have been up to things. (Yes it hurt; and the photo quality is sadly poor. I only have my kindle right now, and it's a difficult angle.)

^ Oh: and not just saints and sinners: aesthetes, too. Food is the new art and, generally culture these days, it seems. I mean, certainly there's an art to it, but...

JP,

Have a look at mine: http://www.securivm.ca/2013/12/a-work-of-art.html

@Alain:

Wow, that's gorgeous, and also huge! It looks like you got at least the wings in a separate sitting, though. BTW, is that a nod toward the Hermetic* tradition I see? I think Asclepius's rod traditionally has just the one snake. ;)

The biggest single tattoo I have is these two phoenix feathers (constantly taken for peacock feathers, but whatever, and it's probably apropos anyway) that go all up my arm, including through the "ditch" of the elbow; getting it was a real b!tch, but I am kind of weird and actually enjoy that kind of thing.

*I have this story...

It seems to be mostly divided along gender and age lines. It’s mostly the guys who go for the decadent, meat-and-gravy-and-biscuits-and-bacon and whatever type stuff

I can assure you that these represent different subpopulations. And you left out the tail of the pork-belly distribution.

On-Cor "salisbury steaks," however, are often out of stock. If the hipsters weren't aging off, I'd call those as a decent long play.

JP and Narad:

There are definitely sub-cultures in foodie world- I left out the Posh and the Exotics- who will go to any lengths to acquire either extremely over-priced esoterica or that which originates in farflung locales- e.g. a tall tower of artfully arranged Adriatic seafood or Nepalese cuisine, respectively- this is especially true of the City where money flows like Italian mineral water.

But on the vegan vs carnivore dimension- which is especially apparent in a place which has arisen like a Phoenix from an old drug-infested, post-manufacturing area attracting artists and the fashionable from more expensive rentals. Quite a few areas like that actually. But this particular one is a veritable barometer of restaurant chic, changing as frequently as the fashion scene does. I am often invited to the Scene because I know a few gallery owners/ artists.

Perhaps food IS the New Sex, JP, because it although it can be discussed and photographed endlessly on the net- unlike sex- you actually have to BE there to eat- that part can't be virtual. ( I DO wonder how much virtual obsession is based upon lack of funds though)

So there's the Healthy vs Indulgent and artistic vs deliberately messy dimensions which may correlate. Oddly, I saw a food truck with insanely expensive sandwiches ( lobster, steak, cheese) parked across the street from the aforementioned sandwich place so I suppose they aren't direct competitors.

On the clean food movement/ vegans/ ascetics - I truly wonder how much those loons I survey have had on general culture ( or is it the other -opportunistic- way around?). Although the organics/ vegans/ health compulsion has always been around, I think that the internet makes it more commonplace as they spread their fears about electronically like Vani Hari - but I admit that a small part of what they say is true- there is some unhealthy food and some people eat terribly.
Some but not all.

The paragon of precious clean veganism is of course Gary Null who has opened a spa/ resort/ health counselling villa which features design=conscious vegan meals- all photographed with the overly conscientious care which one usually devoted to babies and small pets ( seen on his various websites ).

It's sad to discuss food without lilady though,

-btw- artful tattoos kids, but not my cup of tea,

JP,

One sitting, 4 hours. The wings were more painful than the spine.

Good decision on behave of Dr. Carson to search out for natural solutions!! He's still alive with surgery, but favors natural solution, too!!
Keep an open mind to the possibility that NATURAL CURES for cancer do exist and will continue to surface worldwide...until big pharma can NOT block the human spirit for natural solutions any more. Natural solutions will never pass FDA approval, why? Bc the FDA doesn't approve natural solutions.
The name of the game at big pharma (which contrls the FDA) is to discover some drug that will keep the patients depended on a drug for life. So they can PROFIT. Natural solutions don't make money, they are too inexpensive.

Look ahead: "Keep an open mind to the possibility that NATURAL CURES for cancer do exist and will continue to surface worldwide…"

Okay, post the PubMed indexed study from any country to support that assertion.

"Bc the FDA doesn’t approve natural solutions."

The FDA is only in the United States of America. There are other countries, so just post the verified proof from another country.

Natural solutions will never pass FDA approval, why? Bc the FDA doesn’t approve natural solutions.

Natural solutions don't receive FDA approval because natural solutions don't receive FDA approval.
I can't argue with logic as flawless as that.

Chris,
Did you know big pharma is the second largest economic power in the world? Big oil is #1. Wars are fought over oil. Big pharma will silence anyone anywhere in the world - who has the potential to reduce their profits.
Side note: Doctors only have an optional 8 hour class in nutrition as part of their professional training. They are trained (brainwashed) to prescribe drugs only!
The whole system has to changed to favor natural solution - even if there are less profits. That's the challenge and the best choice, imo.
Stay healthy and informed.

@look ahead

I see you haven't provided any citations to support your assertions, so I have to assume that you are a blatant liar or just deluded.

Either way, you are just a sad troll until proven otherwise.

Doctors only have an optional 8 hour class in nutrition as part of their professional training.
All doctors, everywhere in the world, go through a single standardised curriculum of professional training. Everyone knows that.

Did you know big pharma is the second largest economic power in the world?

Biblioteca Pléyades is not your friend when the lights are on.

Look Ahead inhabits a happier world than ours, in which no-one ever needs to eat, so there is no agriculture / food-production economic sector.

Actually, most physicians don't have a class in nutrition, because it's integrated into the whole education, rather than pulled out as a specific class. Most medical classes (nursing and medical, that I'm aware of) focus on the person and the illness - i.e., when learning about diabetes, you learn about the appropriate diet (s) and if necessary, medication (insulin, metformin). When learning about children, you learn about appropriate nutrition at each stage of life (newborn: breastmilk/formula. Infant: breastmilk/formula/start solids), and so on.

So, in effect, Look Ahead is *kinda* correct...but mostly wrong.

"the FDA doesn’t approve natural solutions...Natural solutions don’t make money, they are too inexpensive."

Somebody at the FDA must therefore have been asleep at the switch when all these "natural solutions" (plant-based drugs) were approved:

http://www.rain-tree.com/plantdrugs.htm#.VjDJHFPiU5g

Note that the above article was written by a naturopath (make of that what you will).

Formal nutrition classes as part of the curriculum at many medical schools. Example:

http://nutrition.med.harvard.edu/education/edu_undergrad.html

As noted, principles of nutrition, nutritional and metabolic disorders are incorporated into med student required learning as part of multiple courses, and studies continue through residency and practice as continuing education. But do keep repeating "doctors don't know anything about nutrition" if it makes you feel better.

Orac, you need to listen to the rest of the video. Let me know what you learn about Carson's position regarding Mannatech product efficacy.

A male BRCA mutation carrier "emulates" Angelina Jolie by having preventative surgery to remove his prostate? Not so fast there, pardner...

oracknows — Tue, 21 May 2013 01:00:20 +0000

A male BRCA mutation carrier "emulates" Angelina Jolie by having preventative surgery to remove his prostate? Not so fast there, pardner...

Just when I thought I was out, they pull me back in.

OK, I know I use that line entirely too much, but I also don't really care. When something fits, wear it. And if it doesn't fit, you must acquit. Sorry, I'll stop. I'm in a weird mood as I write this. But it's really hard not to get into a weird mood after reading the lastest bit by that crank to rule all cranks, that quack who tries to rule all quacks, Mike Adams, founder of NaturalNews.com. Last week, he laid down the vile stupid fast and furious to attack Angelina Jolie's decision to undergo bilateral prophylactic mastectomy. It was hard not to note his fixation with referring to the surgery as "mutilation" and to rant about how surgeons don't remove other organs to prevent cancer in patients with gene mutations that predispose them to very high risk of specific cancers. It turns out, as I pointed out, that we do. It was also hard not to note his fixation with testicles and prostate and why men supposedly don't undergo surgery to remove their reproductive parts in order to prevent cancer. He might have had a tiny spore of a point, buried in a black hole of pure pseudoscientific crazy, if there were in fact a gene mutation that conferred an 87% chance of testicular cancer or prostate cancer.

Then I woke up yesterday morning, and you, my readers, were bombarding me with yet one more article by Mike Adams, entitled Angelina Jolie copied by men! Surgeons now cutting out healthy prostate glands of men who carry BRCA gene. In it he references a story about a 53-year-old British man who underwent a prostatectomy after testing positive for a BRCA mutation. The news titles were almost as bad as Adams' title: UK Man has Prostate Removed after Tests Reveal 'Jolie' Gene Flaw (International Business Times) and British father, 53, becomes first man in the world to have his prostate removed to beat cancer flaw which struck Angelina Jolie (Daily Mail). Indeed, the Daily Mail even began its article by writing, "A British father has made medical history by having his healthy prostate removed after discovering that he carries a defective gene that boosts his risk of cancer, it was reported last night." As you will see, this sentence is every bit as much a misrepresentatino as Adams' rant and the statement in the IBT article that proclaimed, "After receiving the news the man asked doctors to remove his prostate, which tests had shown to be healthy."

Characterizing the decision as "Medical self-mutilation... a new fashion statement for the chronically stupid" and speculating that surgeons (yeah, that's me) are pushing people into having surgery (we're usually not), Adams couldn't help but let his imagination run away with him:

Hey, I want to see Brad Pitt's prostate gland stuffed into a glass tube and hanging around Angelina Jolie's neck like she used to reportedly do with Billy Bob Thorton's blood. That wouldn't be weird, would it?

I think we should start a "Skin Removal Foundation" to have all the skin surgically removed from people who might someday have skin cancer... which includes everyone.

Or better yet, the "Young Women Breast Cancer Prevention Society" which chops off their breasts at age nine, before puberty really kicks in. Just tell your little girls how much you love them before the anesthesia kicks in. That's what good mommies do, isn't it?

And for the young boys, why stop at slicing off their foreskin at birth? Penis mutilation is just a warm-up for today's insane medical monsters. Why not remove their colons at birth so that they never run the risk of dying from colon cancer? Why not cut off their testicles and make sure they never face the future possible risk of testicular cancer, too?

I know, it's insane. Disgusting. Outrageous. And yet it's happening right now thanks to women like Angelina Jolie who are publicizing and pushing this idea that women should have healthy breasts cut out of their bodies even though there is no rational medical justification for doing so.

He finishes up with "satire" (which is about as unsubtle and heavy-handed as you would expect from Adams) in which he advertises "1-800-CHOP-OFF," drive-through double mastectomies, and the Organ Whacker Saw for "do-it-yourself medical mutilation." Yeah, that's just Mikey being Mikey. He's terminally vile.

But what about the story itself? I didn't even bother with the Daily Fail or the other article. I happened to see a description of this case on Medscape. it was obvious I should go with that over other accounts. The first thing that I noticed about the man who underwent preventative prostatectomy is that he was part of a research study:

The man who underwent surgery was participating in a clinical trial, conducted by the Institute of Cancer Research (ICR), that involved more than 20,000 men. Previous results from this trial have shown that a man with a BRCA2 mutation has an 8.6-fold increased risk of developing prostate cancer, and with a BRCA1 mutation has a 3.4-fold increased risk. Just weeks ago, the ICR researchers reported that prostate cancer in men with the BRCA2 mutation is more aggressive and more likely to be fatal (J Clin Oncol. 2013;31:1748-1757).

"Knowing you are a carrier is like having the sword of Damocles hanging over you," Dr. Kirby said in an interview with the Sunday Times. "You are living in a state of constant fear. I am sure more male BRCA carriers will follow suit."

The man who underwent the surgery is described as a 53-years-old businessman from London who is married with children and has several family members who have had breast or prostate cancer. When he found out he was carrying the BRCA2 mutation, he asked to have his prostate removed.

Initially, the ICR researchers were reluctant, the newspaper reports, because there was no indication of a problem, either from prostate-specific antigen tests or from a magnetic resonance imaging scan. However, a biopsy showed microscopic malignant changes.

Here's the thing that's not being emphasized, however. This was not preventative surgery. It's being represented that way in the press or, if it's mentioned, the fact that there was already cancer there is mentioned but not put in proper context So I will say it again: This is being represented as a case of a man "emulating" Angelina Jolie, but that's not what it is. This man did not, as the Daily Mail and IBT reported, have a "perfectly healthy prostate." He had early stage prostate cancer. We don't know the details, but his surgeon said that he normally wouldn't have operated, which implies that the cancer cells seen on the biopsy were considered to be of the kind and level that urologists would consider it safe to watch and only intervene if the cancer showed signs of progressing. But this man's case was different. He had a BRCA2 mutation, and the clinical trial that he was on had shown that BRCA2 mutations are associated with much nastier, more lethal prostate cancers than your run-of-the-mill sporadic prostate cancers. That put his surgeon in a bind over what to do.

Indeed, let's take a look at the study cited above, which was published just last month. It's entitled Germline BRCA Mutations Are Associated With Higher Risk of Nodal Involvement, Distant Metastasis, and Poor Survival Outcomes in Prostate Cancer, and the title pretty much says it all. BRCA-associated prostate cancers are nastier cancers. But how much nastier?

The study examined tumor features and outcomes of 2,019 patients with prostate cancer, 18 of whom had BRCA1 mutations and 61 of whom had BRCA2 mutations. Investigators looked at prognostic factors correlating with overall survival (OS), cause-specific OS (CSS), CSS in localized PCa (CSS_M0), metastasis-free survival (MFS), and CSS from metastasis (CSS_M1). What they found is that BRCA1/2 mutation carriers were more likely than noncarriers to have poorly differentiated cancer when diagnosed (35% versus 15%), locally advanced ancer (37% versus 28%) or cancer that had already metastasized (18% versus 9%). In patients whose cancers had spread past the capsule of the prostate at diagnosis, more carriers had metastatic disease within five years (23% versus 7%). While it is true that this study was a retrospective study, with all the shortcomings of retrospective studies, its results were sufficiently clear that it's hard not to take them as a strong indication that BRCA2 associated prostate cancer tends to be a lot more aggressive and lethal, with the five year OS being 86% for noncarriers and 58% for BRCA2 mutation carriers. That's a big difference.

Of course, given my discussions of lead time bias and length bias, in which it is not always clear that earlier treatment actually results in better treatment outcomes, you might reasonably ask if more aggressive surgery earlier in men with BRCA2 mutations who have prostate cancer will really improve their odds of surviving the disease (or, more specifically, significantly decrease their odds of dying from it). After all, this man had no indication of prostate cancer by standard measures, including serum PSA levels and a magnetic resonance imaging scan. It was only an prostate biopsy (a procedure for which he had no standard clinical indication to undergo and apparently only underwent because he was on the study and was a BRCA2 carrier). If you look at it another way, he underwent far more intensive screening than the average 53 year old, and it early stage cancer, leading to the question: What to do?

It's an open question. However, it's also a question that can't be answered until a prospective clinical trial is done, a clinical trial that might never be done because of the difficulty between randomizing men with BRCA2 mutations with early stage prostate cancer that normally would be observed, with intervention reserved for men who show evidence of progression on followup ultrasound and biopsy to either immediate surgery or standard "watchful waiting." At least, such a trial will be very difficult to do because BRCA2 mutations are relatively uncommon causes of prostate cancer, making it difficult to accrue enough subjects, particularly when the two groups are immediate surgery versus delayed surgery. Most men with BRCA2 mutations would very likely want early surgery and would be unlikely to be comfortable being observed knowing that BRCA2 mutations are associated with significantly worse outcomes in prostate cancer. According to Ros Eeles, MBBS, PhD, professor of oncogenetics at the ICR and honorary consultant in clinical oncology at The Royal Marsden NHS Foundation Trust in Surrey:

"It must make sense to start offering affected men immediate surgery or radiotherapy, even for early-stage cases that would otherwise be classified as low risk. We won't be able to tell for certain that earlier treatment can benefit men with inherited cancer genes until we've tested it in a clinical trial, but the hope is that our study will ultimately save lives by directing treatment at those who most need it," she said in an ICR statement.

Exactly. This man and his surgeon made a difficult decision based on data with a great deal of uncertainty over what the right thing to do was. In the context of a BRCA2 mutation that is associated with a nastier and potentially more lethal variety of breast cancer, it is not unreasonable for a man with early stage prostate cancer to opt for immediate surgery. For all we know, if this were the US, surgeons might very well have recommended immediate surgery anyway even if the man didn't have a BRCA2 mutation. In the US we tend to treat prostate cancer more aggressively, and only relatively recently have urologists and radiation oncologists become more comfortable with "watchful waiting" for low risk early stage prostate cancer. This man's decision had nothing to do with Angelina Jolie. It had nothing to do with prevention. It was a therapeutic surgery. One might argue if it was necessary or not. It's hard to know without knowing the full pathology found on prostate biopsy. But it was not "preventative" surgery. Given that BRCA2 mutations do increase the risk of prostate cancer by around 8-fold, it might actually make sense to consider prophylactic prostatectomy in men with BRCA2 mutations, but that's a question for future research, and this case is not a case of doing that.

I expect idiotic nonsense from people like Mike Adams. It's just a shame that this man's story is being misrepresented by mainstream news organizations as somehow being an indication that men are rushing to emulate Angelina Jolie.

oracknows Mon, 05/20/2013 - 21:00

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No, the New York Times did not "kill your patient."

oracknows — Mon, 08 Apr 2013 08:30:03 +0000

No, the New York Times did not "kill your patient."

One of the more depressing things about getting much more interested in the debate over how we should screen for common cancers, particularly breast and prostate cancer, is my increasing realization of just how little physicians themselves understand about the complexities involved in weighing the value of such tests. It's become increasingly apparent to me that most physicians believe that early detection is always good and that it always saves lives, having little or no conception of lead time or length bias. A couple of weeks ago, I saw another example of just this phenomenon in the form of an article written by Dr. George Lombardi entitled My Patient, Killed By The New York Times. The depth of Dr. Lombardi's misunderstanding of screening tests permeates the entire article, which begins with his recounting a story about a patient of his, whose death he blames on The New York Times. After describing the funeral of this 73-year-old man who died of prostate cancer, Dr. Lombardi then makes an accusation:

This one filled me with a special discomfort as I knew a secret: He didn't have to die. I knew it and he had known it. Had he told?

About 5 years ago he had just retired and had a lot more time on his hands. He was a careful man, lived alone, considered himself well informed. He got into the habit of clipping articles on medical issues and either mailing them to me or bringing them in. They came from a variety of sources and were on a variety of topics. He wasn't trying to show me up. He was genuinely curious. I kidded him that maybe he'd like to go to medical school in his retirement. 'No' he laughed, 'I just like to be in the know.'

When he came in for his physical in 2008 he told me he'd agree to the DRE but not the PSA (his medical sophistication extended to the use of acronyms: DRE stands for digital rectal exam where I feel the prostate with my gloved finger for any abnormality and PSA for prostatic [sic] specific antigen which is a blood protein unique to the prostate and often elevated in prostate cancer). He had read that the use of PSA as a screening test was controversial. This was the year that the United States Preventive Services Task Force, a government panel that issues screening guidelines, recommended against routine PSA screens for older men. It was often a false positive (the PSA was elevated but there was no cancer), led to unnecessary biopsies, and besides most prostate cancers at his age were indolent and didn't need to be treated. I countered that prostate cancer was the second leading cause of cancer deaths in men and that it was better to know than not to know. This way it would be our decision. The patient with his doctor deciding what was best. But no, he wanted to stick to his guns and since the DRE was normal no PSA blood test was sent.

After describing a conversation with the man's daughter, who said, "My father was killed by The New York Times," Dr. Lombardi then goes on to anecdotal evidence and a cherry-picked publication to support his view, quoting an oncologist who says he's "seeing more men presenting with advanced prostate cancer" and then referring to a single paper in the current Annals of Internal Medicine about PSA screening. Before I look at the article and a recently published paper on screening mammography that made the news, I can't help but point out that I (mostly) agree with Dr. Lombardi when he says:

Public health doctors, policy experts and journalists tend to look at the population as a whole. It is a better story if it is one story. It makes a better headline. Their statistics are people I sit across from everyday trying to figure out what the future holds. We each have our job to do.

The problem is, of course, that Dr. Lombardi takes that observation and draws the wrong conclusion, namely that his patient died because of lack of screening. He attacks a straw man, sidestepping the true argument, namely that evidence shows that PSA screening probably causes more harm than good for men at average risk of prostate cancer. Unfortunately, Dr. Lombardi obviously does not understand some very basic concepts behind cancer screening, nor does he apparently recognize that doctors who deal with the population-level data that we have regarding screening tests and try to apply them to individual patients are actually looking in a very systematic way about what the benefits of screening are to the individual patient. More on that later. In the meantime, although I wouldn't go quite as far as Dr. John Schumann did in criticizing Dr. Lombardi, I do view his lament as a jumping off point to look at some recent data on screening for the two most common cancers, breast and prostate.

The problem with screening (yet again for the umpteenth time)

Before I get to my updates on cancer screening, to set the stage I think it's critical to revisit these two key concepts that you must understand to understand a bit about the difficulties involved in using a screening test to decrease cancer mortality. I've explained them both in depth before, so I don't feel the need to resurrect a detailed explanation again other than to boil them down to two points, with relevant links and illustrative graphs that illustrate the concept. Those who want the more characteristically (for me) verbose versions can follow the links.

First, let's briefly recap lead time bias, which tells us that earlier detection does not necessarily result in improvements in survival and more successful treatment. In fact, even if earlier treatment has no effect whatsoever on the natural history of a cancer, earlier detection will still give the appearance of an increase in median survival. That increase is simply the "lead time" that comes from detecting the tumor earlier (hence the term "lead time bias"), before it becomes clinically apparent on its own. This concept is illustrated below in these two graphs, first a simpler one:

And a slightly more complex one:

I have explained the concept of lead time bias in more depth here and here, but I do like that graph for illustrating the concept, as well as this one, which demonstrates the effect of lead time bias on a survival curve:

Perhaps my favorite simple and clever explanation of how lead time bias can result in apparently increased survival rates even if treatment has no effect whatsoever on a cancer's progression comes from Aaron Carroll. It's well worth reading.

Now let's briefly move on to length bias. It turns out that most cancer screening tests have an inherent bias towards detecting more indolent, less deadly cancers because of length time bias. Aggressive, fast-growing tumors tend to go from undetectable to clinically apparent due to symptoms, often already having progressed to an advanced stage, in a shorter time than the time interval between screening tests. These tumors thus do not count as having been detected by the screening test because they go from undetectable to symptomatic between, for example, mammography scans. The slower-growing a tumor is, the longer the length of time between its reaching the minimal detectable size of the screening test and becoming symptomatic, the longer the time there is for a screening test to detect it, as illustrated by these two graphs, beginning with this one:

The length of the arrows above represents the length of the detectable preclinical phase, from the time of detectability by the test to clinical detectability. Of six cases of rapidly progressive disease, testing at any single point in time in this hypothetical example would only detect 2/6 tumors, whereas in the case of the slowly progressive tumors 4/6 would be detected. Worse, the effect of length bias increases as the detection threshold of the test is lowered and disease spectrum is broadened to include the cases that are progressing the most slowly, as shown below:

The other problem with length bias is that the more sensitive the test, the more likely it is to detect indolent tumors that are so slow-growing that within the lifetime of the patient they wouldn't progress to the point where they would endanger the patient's life. Some, particularly screen-detected cancers, even spontaneously regress. Such indolent or self-limited cancers do not require treatment, but are frequently diagnosed by screening, a phenomenon known as overdiagnosis. The problem, of course, is that our ability to detect such cancers far surpasses our knowledge of how to predict which ones will regress or remain indolent. So we err on the side of aggressive treatment because we quite reasonably view the consequences of guessing wrong as being so much worse for individual patients than overtreating other patients who don't require treatment. However, for the average patient, the odds of being helped by a screening test are rather small. For instance, to avert one death from breast cancer with mammographic screening for women between the ages of 50-70, 838 women need to be screened over 6 years for a total of 5,866 screening visits, to detect 18 invasive cancers and 6 instances of DCIS. The additional price of this was estimated to be 90 biopsies and 535 recalls for additional imaging, as well as many cancers treated as if they were life threatening when they are not. For prostate, to prevent one death from cancer, 1,410 men need to be screened over 9 years, for a total of 2,397 screening visits and 48 cancers detected. In other words, screening takes a lot of effort for, on an absolute basis, not as many lives saved as we had hoped. Moreover, in the case of breast cancer, on an absolute scale, the reduction in the risk of dying from cancer is small, as I've discussed, and the risks of overtreatment are high.

PSA Screening: Smarter, not harder?

Given that Dr. Lombardi cited it, I thought I'd look at the recent Annals article first. The article comes from a group at the Fred Hutchinson Cancer Center at the University of Washington and is entitled Comparative Effectiveness of Alternative Prostate-Specific Antigen-Based Prostate Cancer Screening Strategies: Model Estimates of Potential Benefits and Harms.

I can't help but notice, first off, that this is a modeling paper. In other words, the investigators did what the hated U.S. Preventative Services Task Force (USPSTF) did in changing its recommendations for mammographic screening for breast cancer and PSA screening for prostate cancer. They took existing data and ran a bunch of computer simulations in order to model the effects of different screening regimens, noting that they were looking for ways to "screen smarter." Of course, Dr. Lombardi's argument is basically a straw man in that no one is saying that PSA screening is necessarily completely useless. What is being said is that there is a significant risk of overdiagnosis, overtreatment, and harm that must be balanced against the relatively small benefit of most of the recommended screening regimens. Back when radical prostatectomy was the preferred treatment for early stage prostate cancer, the risk of harm from overtreatment was significant, up to and including death, but more frequently including complications from surgery, such as incontinence, erectile dysfunction, and other less specific risks of major pelvic surgery, such as injury to the colon, bladder, and other bowel. Later, as radiation therapy supplanted surgery as the preferred treatment for very early stage prostate cancer, the potential complications, such as radiation proctitis. Dr. Schumann described these complications dramatically in his rebuttal to Dr. Lombardi's article.

In other words, a "one size fits all" approach will not do; we need a more "personalized" approach, if you'll excuse the term in the wake of its corruption by people like Stanislaw Burzynski. That's exactly what the investigators on this paper (Gulati et al) tried to do.

What Gulati et al did was to model an large number of screening strategies, thirty-five in all, and then estimate the benefits and harms of each compared to the reference screening strategy of annual screening for patients aged 50 to 74 years with a PSA threshold of 4.0 g/L for biopsy referral. They also tried to validate the models when possible by seeing if it predicts incidence beyond the years of calibration (1975-2000) and to perform sensitivity analyses. Gulati et al summarize their results thusly:

Our results yield several important conclusions. First, we find that aggressive screening strategies, particularly those that lower the PSA threshold for biopsy, do reduce prostate cancer mortality relative to the reference strategy. However, the harms of unnecessary biopsies, diagnoses, and treatments may be unacceptable. Quantifying the magnitude of these harms relative to potential gains in lives saved is critical for determining whether the projected harms are acceptable.

Second, we find substantial improvements in the harm/benefit tradeoff of PSA screening with less frequent testing and more conservative criteria for biopsy referral in older men. These approaches preserve the survival effect and markedly reduce screening harms compared with the reference strategy. In particular, using age-specific PSA thresholds for biopsy referral (strategy 20) reduces false-positive results by a relative 25% and overdiagnoses by 30% while preserving 87% of lives saved under the reference strategy. Alternatively, using longer screening intervals for men with low PSA levels (strategy 22) reduces false-positive results by a relative 50% and overdiagnoses by 27% while preserving 83% of lives saved under the reference strategy. These adaptive, personalized strategies represent prototypes for a smarter approach to screening.

It should also be noted that the decrease in risk of dying of prostate cancer, even under the most optimistic scenarios in the models, was on the orders of a fraction of a percent in absolute terms. Under the models studied by Gulati et al, the risk of death due to prostate cancer without screening was 2.86% but could be reduced to between 2.02% and 2.43%, depending on the model. That's at most a 0.84% absolute risk reduction, although on a relative scale, a decrease in risk of dying from 2.86% to 2.20% is 29%. The overall conclusion from the modeling study was that it is possible to "screen smarter" if the PSA threshold to refer for biopsy is higher, screening for men with low PSA values is decreased in frequency, and older men, who tend to have elevated PSA anyway, are screened less aggressively. All of these are not unreasonable ideas, and they illustrate the tradeoffs involved in any sort of screening program. They are also far removed from Dr. Lombardi's straw man characterization of arguments that PSA screening can result in more harm than good as "ignorance is bliss when it comes to PSA screening."

But what about mammography?

We also screen for breast cancer in women. The preferred test, of course, is mammography, and there is no doubt that regular mammography in women between the ages of 50 and 74 definitely reduces mortality from breast cancer. Of that much, we can be certain, although the risks of overtreatment are not insignificant. Over the last decade or so, the recommendations that screening should begin at age 40, that it should be done annually, and that it should continue for the rest of a woman's life became the basis of public health policy with respect to breast cancer, as well as breast cancer awareness campaigns by advocacy groups. Then, in 2009, the USPSTF dropped its bombshell, in which it suggested that this screening campaign was too aggressive, resulted in too much overdiagnosis and overtreatment, and should be scaled back. Its recommendation was to begin screening for asymptomatic women at average risk (and this must be emphasized: we're not referring to women at high risk or women who notice a lump in their breast or other symptoms) at age 50 and to perform it every two years instead of every year. I discussed this when the recommendations caused a stir three years ago, and I stand by what I wrote then.

Interestingly, a recent study from the Breast Cancer Surveillance Consortium published in JAMA Internal Medicine a week ago (Outcomes of Screening Mammography by Frequency, Breast Density, and Postmenopausal Hormone Therapy) seems to support the findings of the USPSTF in 2009. It's a prospective cohort study examining outcomes of women screened at mammography facilities in community practice that participate in the Breast Cancer Surveillance Consortium (BCSC) mammography registries, and the question to be answered was whether there was a difference in outcomes between women screened on a yearly basis with mammography and women who underwent screening on a biennial basis. Data were collected prospectively on 11,474 women with breast cancer and 922,624 without breast cancer who underwent mammography at BCSC facilities, so this is a large study. The study's findings are summarized thusly:

Mammography biennially vs annually for women aged 50 to 74 years does not increase risk of tumors with advanced stage or large size regardless of women's breast density or HT use. Among women aged 40 to 49 years with extremely dense breasts, biennial mammography vs annual is associated with increased risk of advanced-stage cancer (odds ratio [OR], 1.89; 95% CI, 1.06-3.39) and large tumors (OR, 2.39; 95% CI, 1.37-4.18). Cumulative probability of a false-positive mammography result was high among women undergoing annual mammography with extremely dense breasts who were either aged 40 to 49 years (65.5%) or used estrogen plus progestogen (65.8%) and was lower among women aged 50 to 74 years who underwent biennial or triennial mammography with scattered fibroglandular densities (30.7% and 21.9%, respectively) or fatty breasts (17.4% and 12.1%, respectively).

Leading the authors to conclude:

Women aged 50 to 74 years, even those with high breast density or HT use, who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of false-positive results than those who undergo annual mammography. When deciding whether to undergo mammography, women aged 40 to 49 years who have extremely dense breasts should be informed that annual mammography may minimize their risk of advanced-stage disease but the cumulative risk of false-positive results is high.

In other words, in terms of reducing their risk of being diagnosed with an advanced stage tumor or a large sized tumor, it appears not to matter whether women between 50 and 74 undergo mammography every year or every other year. This is not the case when it comes to women between 40 and 49, where less frequent screening is associated with a statistically significant increased risk of being diagnosed with advanced disease. However, one has to balance that with the increased risk of false positive mammography and the absolute risk of dying of breast cancer in this age range, which is only in the range of 0.3%. This is a number that increases with age, but it is still small. For instance, Esserman et al characterized it thusly for a 60 year old woman:

Essentially, mammography reduces the odds of a 60-year-old woman dying of breast cancer in the next decade by 30%. Sounds impressive, until you look at her absolute risk: by getting her annual mammogram, her chances of dying from breast cancer are whittled from 0.9% to 0.6%. Overall, for every 1,000 women in their 60s screened for breast cancer in the next 10 years, mammograms will save the lives of 3 people but 6 others will still die. (The numbers edge up or down in lockstep with a woman's age.)

As is often the case, this study illustrates the difficulty in balancing the risks and benefits of screening for breast cancer. Remember, the idea behind screening for a cancer — any cancer — is that detecting it early will allow early treatment, better prognosis, and a decrease in the number of people who are diagnosed with later stage cancer, which is more likely to be fatal. As a study that I discussed a few months ago showed, mammography has not reduced the number of breast cancer cases diagnosed at an advanced stage as much as one would expect, meaning that there is significant overdiagnosis. Welch's study estimated overdiagnosis to range from 22% to 31%. From my reading of the literature, this is only a little bit higher than the rate of overdiagnosis of screen-detected breast cancers that has been estimated, namely around 20%.

The bottom line

Does this mean that we should throw up our hands and stop screening for breast and prostate cancer? Of course not! However, we have to balance the risks versus the benefits in a way that doctors like Dr. Lombardi are seemingly unable to do. Dr. Lombardi clearly views screening as an unalloyed good and believes that his unfortunate patient could have been saved if only he hadn't listened to the NYT, which described the controversy over PSA screening for prostate cancer, and decided that it wasn't for him. Never mind those pointy-headed docs in the USPSTF who say that PSA screening for men over 75 can't be recommended and that balance between the benefits and the drawbacks of prostate cancer screening in men younger than age 75 years cannot be assessed, because the available evidence is insufficient. The American Cancer Society emphasizes that the decision to be screened should involve the man being screened. In any case, the danger of relying on anecdotal information, as Dr. Lombardi apparently does, is that there is no good evidence that PSA screening would have saved his patient's life. Earlier detection could just as easily have ended up with an apparent increase in survival time that was entirely due to lead time bias. Similarly, those of us who take care of breast cancer patients have to be careful not to be seduced by the idea that mammography is some sort of panacea that will give us power over this dread disease.

The idea that finding cancer earlier almost always saves lives is a seductive one. It gives us, the physicians, the idea that we have power over cancer in contrast to how we frequently feel as though we lack such power. While there is no doubt that screening can decrease mortality from cancer, the devil is in the details. Effect sizes and absolute risk reductions are usually very small, even though they might be fairly impressive as relative values. Screening programs are resource intensive. Most importantly, nothing is free. The benefits of screening do not come without a significant cost in terms of money, overdiagnosis and overtreatment, and psychic anguish. It is entirely appropriate to openly discuss these issues, as it is not possible to have true informed consent on the part of the patient if he or she doesn't understand the potential risks of screening, so that these risks can be balanced against the not-inconsequential benefits that screening could bring.

I'd like to conclude by putting on my scientist cap. I was once a bit like Dr. Lombardi in that I didn't think much about screening for cancer and assumed that finding disease early is almost always a good thing. I've since come to appreciate that, like many things in medicine, it's not that simple. Medicine is hard and complicated. Real hard and complicated. It's very rare that any test or treatment is an unalloyed good or ill. Every test or treatment demands a balance between benefits and risks. Screening is no different. If admitting that to our patients and honestly discussing it with them causes us problems as a physician, then it will just have to cause us problems.

To me, the best solution will come from basic research. The shortcomings of screening, including overdiagnosis, overtreatment, lead time bias, and length bias, are not reasons to give up on screening. They are reasons to learn how to screen smarter. They are also reasons that we desperately need to understand the pathophysiology of the diseases for which we screen. After all, after finding a cancer or ductal carcinoma in situ by mammography, it would be so much better to be able to analyze, for example, its gene expression profile, and to predict whether it's a cancer that will remain indolent or whether it's one that's going to progress rapidly. Prediction based on biology, be it biology as determined by genomic profiling, proteomic profiling, metabolomic profiling, or whatever combination of tests it takes, will allow us to usher in the era of true personalized medicine, in which patients receive treatment as aggressive as their disease's biology requires or no treatment at all, if their disease's biology tells us that it's highly unlikely to end their lives or cause serious disability. I only hope I live to see that day.

In the meantime, we muddle through, balancing benefits and risks as best we can and, hopefully, explaining adequately to patients why we do what we do.

oracknows Mon, 04/08/2013 - 04:30

Tags

Do you take Vitamin E to avoid prostate cancer? Stop. Now.

gregladen — Wed, 02 Nov 2011 15:06:18 +0000

Do you take Vitamin E to avoid prostate cancer? Stop. Now.

In a recent study, 35,533 prostate cancer-free men in a higher risk age group for prostate cancer in the US, Canada and Puerto Rico were given various treatments of Vitamin E, selenium, and placebo in order to see if claims that Vitamin E and/or Vitamin E with selenium were effective in reducing prostate cancer risk.

8752 received selenium alone - 575 developed prostate cancer.
8737 received Vitamin E alone - 620 developed prostate cancer.
8702 received both - 555 developed prostate cancer.
8696 placebo - 529 developed prostate cancer.

It turns out that Vitamin E may increase the risk of prostate cancer. Using Vitamin E and/or Selenium to reduce risk of prostate cancer in men old enough to have a higher risk of this disease is ineffective.

Klein, E., Thompson, I., Tangen, C., Crowley, J., Lucia, M., Goodman, P., Minasian, L., Ford, L., Parnes, H., Gaziano, J., Karp, D., Lieber, M., Walther, P., Klotz, L., Parsons, J., Chin, J., Darke, A., Lippman, S., Goodman, G., Meyskens, F., & Baker, L. (2011). Vitamin E and the Risk of Prostate Cancer: The Selenium and Vitamin E Cancer Prevention Trial (SELECT) JAMA: The Journal of the American Medical Association, 306 (14), 1549-1556 DOI: 10.1001/jama.2011.1437

gregladen Wed, 11/02/2011 - 11:06

Tags

Stop taking the vitamin E...but get yourself some placebo :)

Prostate = an organ in the human body
Prostrate = lying flat on the ground

Hahaha. Damn you autocorrect!!! Thanks for the catch.

The overriding concern with studies of vitamin E efficacy (or lack thereof) is the failure to consider, or incorporate, the various isomers of tocopherol (to say nothing of tocotrienol) available in the human diet. Use of high dose alpha-tocopherol supplements, for instance, selectively depletes humans of gamma-tocopherol, a tocopherol with activity distinct from that of the alpha isomer. An equally likely scenario to "Vitamin E increases the risk for prostate cancer" would be "preferential supplementation with alpha tocopherol, sans regard for balanced intake with respect to the other isomers of tocopherol, may result in a physiological environment more conducive to the development of prostate tumors". The role of vitamin E in human health is far more complicated than the "if...then" scenario spun by the popular press, or even by those clinical researchers who cannot, or will not, control for such factors in the course of their investigations.

"Stop taking the vitamin E...but get yourself some placebo :)"

Do homeopathic placebos work better than the organically grown herbal placebo teas? If I'm going to use a placebo I want only the best.

I want a large double-blind, study of the relative effectiveness of various placebos.

Do homeopathic placebos work better than the organically grown herbal placebo teas?

Well, they should be cheaper, just buy some distilled water and label it ...

I want a large double-blind, study of the relative effectiveness of various placebos.

Some work has been done. The result depends on what you're trying to treat and the cultural expectations of the patient, but yes, there can be a significant difference in effectiveness between different kinds of placebos. For example, intravenous placebos are usually more effective than oral placebos, red pills make better stimulant placebos and green pills make better sedative placebos. (In European tests, at least. Cultures with different colour associations would probably fare differently.)

How many in around 8700 men who don't take VE, Sel. or placebo normally get prostate cancer? I understand that the placebo group is the control, but it would be good to have the numbers for normal occurrences along with the rest.

@Jon Tomas: Your argument was well stated. Another factor was the kind of vitamin E used in this study - synthetic DL-Alpha Tocopherol, which has much less biological activity than natural vitamin E.

Fortunately there have been vitamin E studies like this one which stress the importance of combining all the various forms of vitamin E. Unfortunately these studies are ignored by most media outlets.

Those are some very wide variation in the results.

Of course +17% cancers in the Vitamin E case is very worrying but when you see that Vitamin E together with selenium is only +5%, whilst selenium alone is +8,7%, you conclude that either selenium somehow quite significantly reduces the bad effect of Vitamin E, despite having no positive effect alone, or that "something" in this study caused a abnormally large dispersions of results which makes it very hard to get any statistically significant result out of it.

Virus linked to both chronic fatigue syndrome and prostate cancer

edyong — Thu, 08 Oct 2009 12:00:28 +0000

Virus linked to both chronic fatigue syndrome and prostate cancer

Chronic fatigue syndrome (CFS) is a disease that afflicts people with extreme and debilitating tiredness that lasts for many years and isn't relieved by rest. Some estimates suggest that it affects up to 1% of the world's population. We don't know what causes it. Prostate cancer is one of the most common cancers in the world and kills around 221,000 people every year. Its causes too are largely unknown. What do these two diseases have in common? They have both been recently linked to a virus called XMRV (or xenotropic MulV-related virus in full).

This doesn't mean that you can 'catch' either prostate cancer or CFS. We don't even know if XMRV actually causes either disease - it could just be that people with weakened immune systems (such as cancer patients or those with CFS) are more easily infected by the virus. For the moment, it's a fascinating link but one that raises more questions than it answers.

XMRV was first discovered in prostate cancer patients in 2006, and a recent study found XMRV genes in 6% of prostate cancers compared to just 2% of healthy prostates. The virus's proteins were more starkly linked to cancerous prostates and overall, these tissues were 5 times more likely to carry the virus than their healthy counterparts. Now Vincent Lombardi and Francis Ruscetti have discovered that the XMRV is also over 50 times more common in CFS patients than in the general healthy population.

The idea of a virus as the culprit behind chronic fatigue syndrome isn't far-fetched. People who have the condition have abnormal immune systems that seem to be permanently activated, but that lack the normal complement of defensive "natural killer cells". They're also more likely to have faulty version of an antiviral protein called RNaseL. just as infected prostate cancer patients are.

Spurred on by these results, Lombardi and Ruscetti showed that the virus is a common hitchhiker in the blood of CFS patients. Around two-thirds of these samples contain XMRV's gag gene and carry traces of the virus's proteins. In healthy people, the virus is a much rarer visitor - its genes only showed up in 4% of such samples, and its proteins never did. These stark differences mean that people with chronic fatigue syndrome are 54 times more likely to be infected with XMRV than your average person on the street.

The detection of the same virus in two such different diseases - prostate cancer and CFS - seems very strange, but for the moment, it's clear that we're dealing with the same virus. The genetic material taken from the CFS sufferers were 99% identical to strains found in prostate cancer patients, and distinct from MLV, a related virus that infects mice. That certainly rules out the possibility that the tests are just picking up MLV, a common contaminant of cancer cells in labs.

The virus can even pass from one tissue from another - infected blood cells from CFS patients can transmit the virus to uninfected prostate cancer cells if the two are mixed together. Lombardi and Ruscetti even managed to photograph the viruses under an electron microscope, as they travelled from one cell to another.

This research is just the beginning. Above all else, we need to establish if XMRV cause disease or if it simply exploits sick cells? Is XMRV in the driving seat or is it just along for the ride? Perhaps these two conditions simply make it easier to pick up the virus? The answer to these questions are worth finding out, especially since 3.7% of the healthy people in this study tested positive for XMRV. If that's reflective of the general population, it means that millions of people could be infected with a virus with undetermined links to major diseases.

Reference: Science 10.1126/science.1179052

More on viruses:

edyong Thu, 10/08/2009 - 08:00

Tags

cancer

Medicine & Health

viruses

chronic fatigue syndrome

wow! This is really interesting. It's pretty hard to fulfill Koch's postulates when the disease in question is species - specific (deliberately re-infecting a human with a purified organism, just to see if they get sick, isn't considered good practice); I wonder if there are mice (or if we can make GE mice) that would be vulnerable to this virus.

I wish everyone would quit using this statement in relation to CFS/CFIDS: "Its very existence is questioned by many..."

Who are the many? If you are not willing to quote from their published scientific articles, why would you give them this credit in your article? The somatic theory is old news still propagated by a few die-hards. Citing this archaic bias without scientific support weakens your otherwise good interpretation of this very big news for sufferers.

You clearly state "People who have the condition have abnormal immune systems that seem to be permanently activated, but that lack the normal complement of defensive "natural killer cells". They're also more likely to have faulty version of an antiviral protein called RNaseL. just as infected prostate cancer patients are."

Hmm, sound like childhood trauma to you? Come on, this is a science blog. Why introduce an unsupported controversy?

I don't hear you saying that many still believe prostate cancer is caused by not having enough sex (a widely believed myth). We know what causes prostate cancer now, and soon, very soon hopefully, we will know what causes CFS.
- 20 year sufferer

Diana I've chopped out the offending bits of the intro.

From an "end-user" point of view:
I was diagnosed w/ Epstein - Barr Virus in college ('88), then, the term became CFS. Without a doubt I have a weird immune system, as I had confirmed Chicken Pox 3 times as a kid and still have very high levels of CMV and Epstein Barr and CRP. Whenever something is going around, I am the last to catch it, although I can feel my body "fighting" it off. Then, sadly, I succumb, and it takes me such a long time to get better. Other people get sick right away, but then get better right away. Without a doubt, I suffer from extreme fatigue. I had pretty good luck deciding that I refused to have CFS when in college, since the prognosis was so poor. Denial & ephedra then anti-depressants & adderall, etc. helped me make it through each day. However, as I turn 40, I have decided to try to pursue a definitive diagnosis. The whole autoimmune diagnostic process is a NIGHTMARE -- do I need a rheumatologist, a neurologist, etc.

Research like this is great, but we also really need a better diagnostic process. While the somatic theory may be "old news", I think most people w/ autoimmune issues are made to feel like complete hypochondriacs during the long path to an accurate diagnosis. I know how daunted I have felt, and I have great health insurance. Strangely, diagnosing my DOG w/ Myasthenia Gravis was a fast & relatively easy process for the Veterinary Neurologist, yet it took over a year for a friend's father to be correctly diagnosed w/ MG vs. the stroke they originally suspected. It's very, very frustrating, so I am very glad to hear that researchers are working on it.

If this turns out to be true, what would the treatment be, and does it exist now?

Could you please explain how this type of retroviruses are transmitted?
We know how HIV is transmitted (!), but what about this xenotropic MulV-related virus?
In other words, since our daughter was diagnosed with CFS 2 years ago, should we take precautions to ensure that her siblings do not fall prey to the same horrible disease? And I do mean horrible. This has been a nightmare and I cannot even imagine having 2 children with the same disease.
Any advice?

Thanks for writing about this and acting on Diana's comment. It's interesting how almost every news article on the subject of CFS has to lead in with mentioning that many doctors don't believe it's real. It gives those people an affirmation that it's still okay to not believe it.
Unfortunately, it's really not just a few die-hards but still the vast majority of doctors who have probably not read anything substantial or recent on the subject.

There have also been studies about people recalling false information as true, especially with repetition:

Helping patients separate true health information from false
http://www.boston.com/jobs/healthcare/oncall/articles/2008/02/28/in_oth…

So perhaps writers can make a difference.

Anne V - there is some information about how this XMRV virus is transmitted on the Whittemore Peterson Institute website here, http://www.wpinstitute.org/xmrv/xmrv_qa.html
hth

OMG! I totally alerted my oncolgist to expect a flood of calls in the next few weeks.

Later, I may be able to say something more coherent.

I sit here numb. Not only do I have fibromyalgia and chronic fatigue, but my dear husband had radiation for prostate cancer and his PSA is rising again. I have suffered over 20 years and this is real HOPE for a cure.

This illness has taken my whole life since 15 years old. The suicide rate in cfs is 9 times the average due to the lack of care and downright cruelty cfs patients encounter from others on a daily basis.

There has been very little research into the physical side of cfs for a long time. This discovery comes from a group funded by sick people and their families.
There have been lots of small studies funded by cfs sufferers and their families but almost no major research funding except to psychiatrists. We are told that those small studies don't count because they are not big enough etc but we cant afford big studies and they know it.
One Study showing high levels of choline in the brains of cfs patients years ago. Highly significant but unrecognized becuse you need a bigger study which costs money and that money is been given to psychiatrists not mediacal researchers.
So they keep telling us we don't have proof unless we have a larger study to prove the smaller studies. But they wont give us money for the larger studies.
The bulk of reseach funding has been lining the pockets of physiatrists and the reasons for this may well lie with the health insurance industry in the United States. If cfs is not provable and therefore claims are hard to get, then their shareholders will get bigger returns and fat corporate cats will get fatter while destitute abused cfs patients will commit suicide and these guys don't care about anything but themselves and more money for themselves.

I am in pain every damned day and often its unbearable but I have no choice but to endure it. Then you have to put up with being treated like a bludger if you are lucky enough to receive a medical benefit which is not enough to live independently on. Somehow in an age where as a woman I could claim much higher benefits as a single parent than I can as an invalid people think I would go to the trouble of inventing an illness to claim the invalids benefit. I have no children because Iâm too sick to go out and meet anyone and certainly too ill to have a child. I donât have any life at all and people keep telling me to take up some sort of charity work etc. Well I would if I was physically able. They seem to think I just don't want to go out etc when the fact is its incredibly hard for me just to get to the supermarket and doing my housework often makes me so ill Iâm bedridden for days. I fought hard for years to get myself a home and lost it when I became so ill I couldnât eat anything at all. Its a long story b ut the cruelty others inflicted on me because of the propaganda surrounding this disease has left me broke and much sicker and most often miserable.
Yes I went through all my money trying to get well. So many of us do this. Why would patients spend 100's of thousands of dollars of their own money trying to recover from malingering. Why would they spend that money on supplements doctors etc etc if they wanted to malinger. Surely they would be better off spending their dough on a long holiday rather than trying various expensive solutions out of their own funds.

Right now all I can eat is meat and salad vegetables everything else makes me incredibly ill. If I eat anything with carbohydrates in it my pain levels go up exponentially and I start passing large clumps of white cells in my urine. My legs start to swell up also. The only remedies that are keeping me going are oil of oregano, small doses of zinc picolinate and iron supplements. The muscle aches and symptoms are often much worse than severe flu. It feels like I've been poisoned if I eat anything that disagrees with me. Its amazing Im still here but hereâs hoping after 33years there might be some relief or at least some kindness and care. I've had mostly derision so far. Tears used to be a private daily occurrence untill I got to the stage where crying would make me so much worse I had to block all my emotions to stop myslf being completely bedridden. Its often just so hard to get out of bed through the pain I can only liken it to the time I had to dress to go to hospital when I passed kidney stones. Thatâs how hard it is sometimes just to get to the shops and get food. But you have to cover it up because when people see how sick you are they are even nastier. This is how these assholes who have spread misinformation about this condition have affected my life for years. Their cruelty has killed probably thousands of CFS sufferers who have committed suicide.
They have inflicted misery on sooo may sick people they deserve to suffer a little.
Sorry Im bitter but the truth is just soo many people arenât very nice under their daily facade and you certainly see that a lot unless you are surrounded by the other type of person and these rare kind people do exist. I know if I ever do get better I will chose friends from the latter group and wont bother with the bulk of people many of whom can pretend to be nice people when it suits them. But you have to look hard at people and test them out a little. Some people have very good fakes at sincerity and but why would I want fake sincerity. I think though that sick women and maybe some sick men are mistreated even when there is a diagnosis. I spoke with a woman who had cancer and her (male) doctor told her that her husband would put up with it for a few months then leave which is apparently more common than not. And thatâs exactly what happened. Her husband dumped her because she was sick. Most women with multiple sclerosis are also abandoned by their husbands. Not all but the majority so what does that say about love. Is there such a thing. I guess the men or women who donât dump their sick partners do love them. The others I donât know?

Meanwhile there's a war on over getting mention of this into the Wikipedia article. People keep adding it, and WP regulars keep deleting it. One annotation they deleted noted that a more reliable detection method found XMRV in 95% of CFS sufferers, not just "two thirds", vs. less than 4% in others.

I second both eloquent posts from Diana (2) and M (7).

Having been decimated by CFS for almost a decade, brushed off by doctors for years with dismissive referrals to (useless) psychotherapy or (damaging) psychiatric meds, and basically left to rot, this news first left me in tears of relief - finally, finally, they are finding the cause of this wretched disease, thank God.

But after the tears, I'm angry. It is unconscionable that CFS patients have been abandoned as psychiatric cases for decades (and once you get branded as a psychiatric patient, God help you, an instant license for prejudice and scorn from doctors, nurses and medical staff), when not only is this a real physical disease, but now we are learning that it's a disease with an alarmingly high risk for cancer. This level of medical negligence is sickening.

I don't ever want to read another blustering science journalist carry on about putative controversy over the existence of CFS. Even the lead article in Science couldn't resist this ugly indulgence: "As if chronic fatigue syndrome (CFS) hasn't caused enough brawls..." (Sam Keen, 215). Enough!

When I explained to a new acquaintance that I had CFS, she had the solution. She also suffered from CFS, she said. But she solved it by taking a long, long hike in the park adjacent to her home every day when her husband came home form work. I should do the same. Well.....if I could take a daily long hike, I wouldn't have CFS, would I?

Unfortunately, I doubt if the identification of this virus means a cure. It doesn't even mean that a cause has been found. But gee, it does mean validation for those of us who have been told mostly that we should get over it, & if we can't to go into therapy.

I have had cfs for the past 3 years. The doctors all said there was nothing effective to treat it. However, I did end up trying a Chinese doctor. I've been going to him for 2 years, and I'm happy to say its working!! I am much better and now have hope of recovery. If you've lost hope, I would recommend trying out a Chinese doctor for acupuncture and herbs. It may take a few years of treatment to recover, but if you find the right doctor, it will heal you. Unfortunately there are some Chinese doctors out there unfamiliar with cfs and therefore unable to treat it effectively. You will want to find someone who specializes in it. There are a few such doctors in the Bay Area, California.

M wrote: It's interesting how almost every news article on the subject of CFS has to lead in with mentioning that many doctors don't believe it's real. It gives those people an affirmation that it's still okay to not believe it.

Similarly, the media clings to "Yuppie flu", although this last couple of years we are also seeing "...which used to be known as Yuppie flu". Perhaps journalists think this shift will be welcomed but it just serves to perpetuate its use. Why is it that so many journalists and sub editors are unwilling to let go of this trite and insulting phrase?

A plea to any journalists reading this site: if you wouldn't resort to groaners like "experts say..." or "leading scientists warn..." or using "toddler" for any child under five or "plucky grandma" for women over 47, then please resist the urge to drag out "Yuppie flu" and "Yuppie flu campaigners". The media created this damaging label in the 80s; we look to the media to bury it.

This XMRV info seems interesting but not groundbreaking, Many viruses are suspected to cause CFS, except in mild cases - Ask or demand from your MD treatment with antiviral meds and maybe IVIG. medical community just try the antivirals and throw in some immune support for good measure - end the suffering of million!!!

People with CFS keep educating yourself -Search on google "cause of CFS", "treatment for CFIDS","Viral Induced Fatigue" . See www.HHV-6foundation.org for one, look for studies at Stanford and other successful with strong anti-virals. Educated and advocate find a way to keep hope alive

I was reluctantly diagnosed with CFS by my doctor since, as he put it, he didn't believe in the disease. He felt I was actually suffering from depression. Well, I think both were true. I had been in a deteriorating condition for 6 months- dragging my sorry butt around as I ran a large (understaffed) branch for Citibank that was open 6 days a week, worked excessive hours, and I had a 1 year old, 2.5 year old and a 4.5 year old- the two youngest didn't sleep through the night. I got to the point that I couldn't think straight, truly felt I was babbling when I talked because I couldn't keep the thread of conversation in mind, at night couldn't find where I had parked my car that morning- every day. I had to nap the second I got home and on weekends. When driving, my eyes were rolling in my head. I would contract any illness that was around and get it worse and it would linger longer. The Epstein- Barr titer showed I had an acute infection, totally off the charts. My doctor didn't think it mattered- he said "Some call this the Yuppie Flu which means you can only afford to catch it if you are affluent- other people ignore it and go to work." This was in 1999. I kept up my demanding schedule until I finally collapsed and was out of work for 5 weeks. At that point, at 5'9" I weighed only 104 pounds. I thought I was dying. As to being depressed- of course I was- try pushing yourself that hard for that many months when you are seriously incapacitated. Every day at work I accomplished less and couldn't catch up, the laundry was undone, and each day I awoke with a nauseating migraine. For me to even take a long walk, I would collapse and sleep for hours. Years later I learned by reading Wikipedia that I probably had Mono. Even being told that much would have made me feel so much better. Also I would have known to go on bed rest instead of desperately trying to not give in. I believe I became that much sicker because I was not advised to rest when the problem first manifested itself. After 5 years of struggling to cover all my bases as the breadwinner, mother, I came down with yet another illness- labrynthitis of the inner ear, which causes vertigo and an "at sea" feeling. I only mention this minor illness because the doctor prescribed an anti-viral famocyclovir- after about 5 days, I was surprised to realize I felt generally much better, was not always waking up with a migraine. I felt like the permanent fog I had been living in began to lift. After 2 weeks I was substantially better than I had been in 5 years. It seemed to me that the anti-viral may have worked on clearing the CFS as well. I continued to improve gradually, and had to slowly work my way back to exercising. I consider myself recovered from CFS, however if I push myself too hard physically, I can go into a tail spin for a couple of days. I am also off the SSRIs and have gained back 35 pounds (OK, perhaps didn't need the last five lbs.) I feel pretty good now. But some anger lingers because I know I suffered unnecessarily: lacking a diagnosis that my doctor believed in, I was ignored medically. I was sent for psychological counseling instead. I did not only my best, but was over-performing, considering the horrible way I felt each day, but my husband, my mother, brothers all believed it was "all in my head" thanks to the doctor- even though I looked like hell, or as I was told "death warmed over." Being a CPA, graduate student, Executive VP when this struck- I was very ambitious- it made it all so much worse to suddenly be seen as someone who was not keeping up and treated like I "wanted to be a sick person" and was a little bit crazy. It was a bad bad 5 year nightmare for me. I fervently hope this virus discovery will ultimately provide an effective treatment regime for current CFS patients. And yes, I will feel vindicated.

Thank you Ed for the link to the Whittemore Peterson Institute! I was able to forward it to all our friends who were asking whether we had read the news about the XMRV virus.

One more note: our daughter was diagnosed with CFS at the end of a thourough elimination process that included dozens of tests and visits to several specialists.
The list included evaluations by *2* psychiatrists, one of them an expert on somatization. Both of them agreed that our daughter was mentally healthy. The somatization expert even commented on how positive and upbeat she was about a disease that was so clearly physically debilitating.
So it seems that it is possible to find (in the US at least) psychiatrists who accept the reality of CFS as a disease with no mental cause.
In our daughter's case, Chinese medicine did not help, but sacrocranial therapy is slowly bringing back most of her energy:-)
Thank you again for your article!!
Anne

Imus---synonym for "stupid"

palmd — Tue, 17 Mar 2009 12:53:19 +0000

Imus---synonym for "stupid"

I've written a number of times how blindingly stupid and irresponsible Deirdre Imus has been. Now, Don Imus has revealed he has prostate cancer, and he is apparently surprised. According to ABC News, "he was surprised by the diagnosis because he had been following a healthy diet for the last decade." He also stated that, "... it was all the stress that caused this."

I'm not nearly as surprised as Mr. Imus. Prostate cancer is the malignancy most closely correlated with age (and of course, gender) and estimates are that between 14-70 % of men his age may have prostate cancer (occult or apparent). As to his healthy lifestyle, studies have failed to show any strong correlations between prostate cancer and "lifestyle". One of the largest studies to date on dietary supplements and prostate cancer (SELECT) failed to show any reduction in prostate cancer with vitamin E and selenium supplementation.

Imus's surprise at his diagnosis is a common feeling. When someone is diagnosed with cancer, they often feel the world falling away around them. It doesn't really matter if it's a "good" or a "bad" cancer--the emotional effect is usually the same. So, Imus's surprise doesn't, er, surprise me.

Hopefully (and I'm not counting on this, mind you), he will do a little reading and communicate to the public the facts about prostate cancer. It is a disease of age, and it is often said that any man who lives long enough will have it. It is also often said that most men will die with it rather than from it. Still, it is an important cause of morbidity and mortality, and since we don't have a great way to screen for it (meaning we don't know what PSA results necessarily mean) more research is being done.

But the little devil on my shoulder can't help wondering if, like Mrs. Imus, he will bring the stupid. I wonder if he will opt for "alternative" therapy, and when his cancer doesn't kill him, give credit to the herbs rather than to the fact that most prostate cancers won't kill you.

By the way, you can start reading about prostate cancer here.

palmd Tue, 03/17/2009 - 08:53

Tags

Why read about it? As you point out, there's little we can do to prevent it, no good way to screen for it, it mostly won't kill you, except when it does, and if the doctors find it they will either scratch their heads and say they want to watch you for a few years, or will recommend a treatment that either has partial success or a treatment that sucks.

Feh.

if the doctors find it they will either scratch their heads and say they want to watch you for a few years, or will recommend a treatment that either has partial success or a treatment that sucks

A treatment that sucks? Dying sucks. Losing a (very) small part of my life as the price of being around to see my grandchildren grow up? In a heartbeat, Dude.

Nice Washington Post article today, quoting Steven Salzberg and Steven Novella:

"Critics Object to 'Pseudoscience' Center"
http://www.washingtonpost.com/wp-dyn/content/article/2009/03/16/AR20090…

"estimates are that between 14-70 % of men his age may have prostate cancer"

Is that what you meant to say? That seems like kind of a wide range. Might as well say, we don't have any idea, except we know it happens.

Maybe he'll just decide to refuse the diagnosis.

The number 14-70 is from a review of autopsy studies...

The cdc's prostate cancer page can tell you the actual prevalence and incidence in living people.

I've noticed people airing that sort of thinking ("how did this cancer occur, the patient has a healthy lifestyle") quite a bit lately. I don't think the population as a whole has a good grasp of the idea that not everything is preventable at all times.

I don't think the population as a whole has a good grasp of the idea that not everything is preventable at all times.

They don't want to believe that Shit Can Happen To Them. There's a whole book on the subject: Job.

Dr. Dean Ornish: Turn away from the Dark Side! It's not too late!

oracknows — Thu, 05 Mar 2009 08:30:22 +0000

Dr. Dean Ornish: Turn away from the Dark Side! It's not too late!

I realize I've said it before, but I still can't believe as many people read what I like to lay down on a daily basis right here on this blog. Believe me, it has nothing to do with an sort of false sense of modesty. After four years at this, I know I'm good at blogging. Real good. But good isn't always enough to make much of a difference or even to garner an audience. Whether I've done the first, I don't know. I like to think that I have. As for the second, I've done pretty well for myself. Indeed, after a year of stagnant traffic, January and February were the best months, traffic-wise, in the history of this blog. What that means, I guess, is that sometimes people whom I would never have expected to give a rodent's posterior about what a nobody like me writes actually sometimes take note. Sometimes famous people, certainly far more famous and renowned than your humble pseudonymous blogger, are moved to leave a comment. Not surprisingly, these responses, on the fairly uncommon occasions when they appear, are usually provoked by something I've written that has--shall we say?--displeased the target of my insolence, be it of the respectful or not-so-respectful variety.

Such was the case late Tuesday night, when one of the Four Horsemen of the Woo-pocalypse himself, upon whom I had laid a bit of a smackdown in the course of lambasting Senator Tom Harkin (D-IA) for his plan to piggyback the legitimization of quackery onto any health care reform legislation that President Obama might try to get through the Congress. Because Harkin is a very senior and very powerful Senator, one who nearly single-handedly birthed the legislation that produced the Office of Alternative Medicine in the NIH, which later begot the monstrosity that has become the National Center for Complementary and Alternative Medicine (NCCAM), his intentions are very important, as he very well might succeed if President Obama is insufficiently serious about the promise he made in his Inaugural Address to restore science to "its rightful place." A few of you know of whom I speak, as you took up the slack when I couldn't respond right away due to yesterday being a travel day to the SSO Meeting in Phoenix. I'm referring, of course, to Dr. Dean Ornish, the Founder and President of the Preventative Medicine Research Institute, who left a comment that, because it got held up for moderation (I know not why), I did not see until very late. Suffice it to say, he is not particularly happy with me.

Although I can totally understand why Dr. Ornish might not appreciate my criticism, he should actually know that, of the Four Horsemen of the Woo-pocalypse, I consider him (probably) the least objectionable. Certainly he would not be Death (that would be Andrew Weil). Smart-ass that I am, maybe I'll consider Dr. Ornish to be Famine, given that his claim to fame is the use of very low fat diets, along with major lifestyle alterations, to effect changes in health. The reason that I find Dr. Ornish perhaps the least objectionable is that at least he tries to do science. It's preliminary science, and usually the controls aren't the greatest, but it is for the most part science. My main beef with him is how he represents that science to the public. For his claims for dietary treatment of prostate cancer at least he tends to take preliminary studies of highly select patients and make way too much of them. Indeed, he often says one thing in his papers, where peer-reviewers force him to remain tentative and keep him from going too far off into the deep end with his claims, but quite another thing to virtually everyone else, including the aforementioned Senator Harkin and, even worse, to the recent Institute of Medicine/Bravewell Collaborative conference on alternative--excuse me "integrative" medicine--from which he hopped over to the Senate to do a two-fer of woo promotion in our nation's capital.

My post about him and his fellow horsemen led him to respond in the comment section thusly (comment reproduced in its entirety), after which I will provide my response:

For someone who prides himself on attention to detail, it's surprising that you haven't done your homework. My testimony that comprehensive lifestyle changes may affect the progression of early-stage prostate cancer was not based solely on the paper that my colleagues and I published in the Proceedings of the National Academy of Sciences last year (Proc Nat Acad Sci USA 2008; 105: 8369-8374. Ornish D, Magbanua MJM, Weidner G, et al. Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Proc Nat Acad Sci USA 2008; 105: 8369-8374).
It was based on a randomized controlled trial that I directed in collaboration with Peter Carroll, M.D. (Professor & Chair of Urology, School of Medicine, University of California, San Francisco) and the late William Fair, M.D. (Chief, Urologic Surgery and Chair, Urologic Oncology, Memorial Sloan-Kettering Cancer Center) which was published in one of the leading peer-reviewed urology journals (Ornish DM, Weidner G, Fair WR, et al. Intensive lifestyle changes may affect the progression of prostate cancer. Journal of Urology. 2005;174:1065-1070). Other subsequent studies have shown similar findings.

In September, we published a pilot study in The Lancet Oncology in collaboration with Dr. Elizabeth Blackburn, who was awarded a Lasker prize for discovering telomerase, showing that these comprehensive lifestyle changes increased telomerase by almost 30%. This is the first study showing that any intervention may increase telomerase.

Our earlier studies showing that comprehensive lifestyle changes may stop or reverse the progression of coronary heart disease were published in several peer-reviewed journals, including:

â¢ Ornish D, Scherwitz L, Doody R, et al. Effects of stress management training and dietary changes in treating ischemic heart disease. JAMA. 1983;249:54-59
â¢ Ornish D, Brown SE, Scherwitz L, et al. Can lifestyle changes reverse coronary atherosclerosis? The Lifestyle Heart Trial. The Lancet. 1990; 336:129-133.
â¢ Gould KL, Ornish D, Scherwitz L, et al. Changes in myocardial perfusion abnormalities by positron emission tomography after long-term, intense risk factor modification. JAMA. 1995;274:894-901.
â¢ Ornish D, Scherwitz L, Billings J, et al. Intensive lifestyle changes for reversal of coronary heart disease Five-year follow-up of the Lifestyle Heart Trial. JAMA. 1998;280:2001-2007.

You can do a medline for more references.

Although you dismiss this statement as "nonsense," we are, in fact, more than just genes and germs, microbes and molecules. You might begin by reading some of Leroy Hood's work (no slouch as a scientist) who described systems biology and the concept of synergy. I cited his work in my keynote talk at the recent Institute of Medicine's "Summit on Integrative Medicine" at the National Academy of Sciences that will be posted later this week (http://www.iom.edu/integrativemedicinere) in which I describe the studies of those such as Sheldon Cohen in JAMA showing that not everyone who is infected with rhinovirus develops the signs and symptoms of a cold, and found a direct relationship between the degree of social support and immune function.

The best scientists are open to new ideas, not glibly dismissing them just because they don't agree with their preconceptions.

Dean Ornish, M.D.
Founder and President, Preventive Medicine Research Institute
Clinical Professor of Medicine, University of California, San Francisco

Ow. That's gonna leave a mark.

Well, not really. In fact, I'm rather disappointed that Dr. Ornish played the "close-minded" gambit so vociferously. Whether consciously or not, Dr. Ornish appears to have missed the broader point I was making about how pseudoscience had coopted what should be the very science-based interventions of diet and exercise as a "wedge strategy" designed to open the way for the entry of all manner of quackery in order to focus like a laser on the much narrower point of my criticism of his work. When I first saw Dr. Ornish's response, I was half-tempted to ignore his complaints about my criticism of him, because even if each and every point he makes about his diet and lifestyle interventions were 100% perfect science with overwhelming support and I really were a close-minded, lousy scientist, it wouldn't change one whit my annoyance with him for allying himself with supporters of pseudoscience to support Senator Harkin (the broader point of my broadside against Weil, Hyman, Oz, and him), as I'll explain a little later. However, when someone throws down the gauntlet like Dr Ornish, I have a tendency to pick it up and slap him across the face with it, accepting the challenge. Even if I end up losing badly, better to go down honorably than to slink away. So let me deal with a handful of the specifics of Dr. Ornish's complaints before I move on to finish this post addressing the broader point of why Dr. Ornish drives me crazy.

First off, Dr. Ornish is mistaken to assume that I have not read or was not aware of his other papers testing his diet against prostate cancer. I've read them all, although I've done a detailed deconstruction of only the microarray paper that I mentioned. I've even obliqulely alluded to his telomerase paper before, and I've read several of his others. Consequently, it's probably my fault that he got the impression that the microarray paper was the sole basis of my criticism. However, my post was long and a detailed discussion of all of Dr. Ornish's work in prostate cancer was beyond the scope of the post; so I picked one example that I had already discussed, which you can read again right here if you so desire. In the meantime, let's look at a couple of the other papers Dr. Ornish cites as evidence that I am a close-minded, careless dolt, as well as a brief look at the microarray paper again.

The telomerase study, which did indeed appear in The Lancet Oncology in September, was entitled Increased telomerase activity and comprehensive lifestyle changes: a pilot study, is very interesting in that Dr. Ornish reported telomerase activity results on the same patients upon whom he did his microarray experiments. This is what Dr. Ornish said about this problem in the discussion section of the PNAS microarray paper:

...our analysis was limited to normal prostate tissue because tumor tissue was present on the biopsy specimens of only a minority of patients. Thus, the implications of this study are not limited to men with prostate cancer. Because of the microfocal nature of low-risk prostate tumors and the limitations of ultrasound biopsy guidance, we were unable to precisely match pre- and postintervention tumor samples for individuals in our cohort...Because only one-third of patient biopsies in our study included tumor tissue, we were limited to examining the response of the normal prostate tissue (stroma and epithelium) to the intervention. It will be very important for future work to examine tissue molecular responses to determine whether the normal stroma, tumor stroma, normal epithelium, tumor epithelium, or a combination of these tissues respond to diet and lifestyle changes.

I will admit that it is fair enough to point out that, if the results are validated, that the changes in gene expression occurred in normal prostate cells does imply that his diet might be useful for prevention. However, given that he missed cancer epithelium 2/3 of the time, it's really difficult for him to conclude anything whatsoever about his microarray experiment. In fact, what I'd be interested in is a comparison of the array results of tissue samples with no tumor tissue versus those with tumor tissue. All it would take is a couple of patients whose pre-diet biopsy had tumor tissue but whose post-diet biopsy did not to significantly affect the results. That was the main basis of my skepticism over whether the PNAS paper meant much of anything.

Moving on, I have to admit that the telomerase paper led me to scratch my head. In cancer, telomerase is generally a bad thing. To put it simply, telomeres are repetitive DNA sequences at the end of chromosomes. They serve to keep chromosomes from degradation. The reason chromosomes degrade during replication is that the enzymes that replicate the chromosome cannot replicate the DNA all the way to the end of the strand. Consequently, during each round of cell division and chromosome replication, some DNA sequence is lost. With telomeres at the end, what is lost is noncoding repetitive DNA, and no important DNA sequences that code genes or regulatory regions are lost. In most eukaryotic organisms, an enzyme known as telomerase adds these DNA sequences to the end of the chromosomes. However, in the adult telomerase is generally active only in cells that need to divide a lot, such as stem cells and immune cells but only expressed little, if at all, in most normal cells. In immune cells, which is where Dr. Ornish looked, decreased telomerase activity has been associated with an increased risk of atheroclerosis, although, as he himself points out in the paper, telomerase length is not.

In any case, I went back and looked at the telomerase paper again. To boil it down, what Dr. Ornish found was that his diet is associated with an increase of about 25% in telomerase activity in peripheral blood monocytes (PBMC). The standard deviations are quite large and overlapping, and the statistical significance is there, but not impressive. I looked at the table that showed all the telomerase activity values "before and after" (statistical significance tested, appropriately, with Student's paired t-test) and saw huge variability, with telomerase activities actually decreasing slightly in some patients. This leads me to concede that there is probably a difference in telomerase activity, but to wonder whether the difference is clinically relevant. Moreover, that increased telomerase activity appears to be associated with Dr. Ornish's diet in PBMCs makes me wonder something. If his diet does definitely increase telomerase activity in PBMCs (something that remains to be demonstrated), then could it be possible that it does the same thing in cancer cells? Remember, many cancers have high telomerase activity, and telomerase inhibitors are being developed for various cancers. Just a random thought. I went back to look at the microarray paper to see if telomerase gene expression levels increased or decreased in prostate tissue as a result of the Ornish diet, but couldn't find anything.

Finally, there are the two papers, one in Urology and one in the Journal of Urology, reporting that the Ornish diet is associated with slower progression of early stage prostate cancer in men who choose watchful waiting for their tumors, and a longer time to progression, all of which is very interesting, although pretty preliminary given the few numbers of men. In addition, I won't go into the cardiovascular papers (much), because (1) I'm a cancer surgeon and (2) no one is arguing, least of all me, that diet and exercise don't play a very important role in contributing to (and potentially preventing) cardiovascular disease. I'm not even that skeptical that diet and exercise might be preventative for prostate cancer and other cancers--or even mildly therapeutic. It's a straw man to say otherwise. My sole purpose in mentioning some of the papers that Dr. Ornish cited is to emphasize that they are all pilot studies and that their results are tentative at best. Moreover, what I have been arguing is that Dr. Ornish has willingly and enthusiastically allied himself with the "alternative" medicine movement, many of whose leaders are boosters of pseudoscience, when the use of diet and exercise, the very health interventions he champions, are not and should not be in any way considered "alternative." Worse, Dr. Ornish is overselling his results to Congress, the medical profession, and the public in order to champion them as "alternative."

Which brings me back to my main complaint about him, the complaint that he completely ignored, which is why I'm going to e-mail him and make sure he sees this response, given that he was kind enough to comment.

As an example, let's go back to his article in the Washington Post in January, in which in addition to Dr. Weil, Dr. Ornish teamed up with, of all people, Deepak Chopra and Rustum Roy. Let's get one thing straight. Deepak Chopra is a booster of pseudoscience. There's no other scientifically accurate way to describe him. Indeed, he is so full of pseudoscience that I can take credit for coining a term that has spread through the blogosphere for the nonsense that he regularly that he regularly lays down: Choprawoo. I and others have deconstructed the nonsense about medicine, evolution, and other "quantum" nonsense. His contortions of science are legion (and legendary). The same is true of Rustum Roy, who has become known above all else for his support for the quackery that is homeopathy.

This leads me to ask: Does Dr. Ornish think there is anything at all to homeopathy or the "memory" attributed to water by homeopaths? If so, he has left the path of science, as homeopathy is quackery. Period. If not, then why on earth did he associate himself so publically with a booster of such quackery? Rustum Roy is one of the most famous current supporters of homeopathy. Talk about shooting oneself in the foot, scientifically speaking! Let's put it this way: Palling around with Deepak Chopra and Rustum Roy--and even going so far as to write an article on alternative medicine with them to be published in the Washington Post--do not exactly constitute a sound strategy to enhance one's scientific credibility, if you know what I mean. An analogy would be hanging out with Bernie Madoff as a strategy to enhance one's cred as an honest investment guru.

Given Dr. Ornish's obvious distress at my criticism, though, I had considered apologizing for having gone a bit far and getting a bit too testy (although I take back absolutely nothing that I said about Senator Harkin and the rest). Truly, sometimes I do get a bit carried away when I'm on a roll, particularly after coming up with a pithy phrase like "the Four Horsemen of the Woo-pocalypse," which, if I do say so myself, is one of my better ones. Then I saw Dr. Ornish's slide set from his presentation to the Institute of Medicine/Bravewell Collaborative woo-fest last week, which, not-so-coincidentally, overlapped Senator Harkin's woo-fest.

Now I'm half-tempted to conclude that I may not have been hard enough on him.

The first thing that bugs me is that Dr. Ornish invoked Leroy Hood. Since he told me in his comment, in essence, to "go read some Leroy Hood," I can't resist pointing out that I have, in fact, "read some Leroy Hood" and that I have, in fact, attended talks by Leroy Hood. It can even be said that I rather admire Leroy Hood. In fact, I have even blogged about Leroy Hood and exactly why I like his systems biology approach. I am even currently striking up a collaboration with a systems biologist at my own institution who's very big on network analysis. Nonetheless, I still have a great many reservations about whether the hype over systems biology as epitomized by Leroy Hood is an accurate reflection of its ability to deliver truly "personalized medicine" (very much like the dubious "individualization" of medicine claimed by CAM advocates, which is, in most cases, a synonym for "making it up as I go along). I won't rehash my comments here, but rather refer readers to my post on the issue. I will, however, reply to Dr. Ornish by saying, "You, sir, are no Leroy Hood." Nor is Dr. Hyman, Dr. Oz, Dr. Chopra, Dr. Roy, or Dr. Weil, for that matter. The reason is that Leroy Hood, for whatever faults he may have in perhaps overselling his work a bit, does not represent his approach as "alternative," nor does his approach embrace pseudoscience along with his science, as apologists for "alternative" and "integrative" medicine all too frequently do. Invoking Leroy Hood as a supporter of the kind of arguments that Dr. Ornish made at the IOM is akin to Deepak Chopra's invoking Einstein, the only exception is that it is not clear that Hood will have anywhere near the effect on medicine that Einstein had on physics.

Next, Dr. Ornish invokes Dr. Hyman's functional medicine, which is, in fact, nothing more than a mish-mash of a lot of old woo about "balance" (just leaving out the yin/yang or qi) given a fresh "science-y" gloss, as longtime skeptic Wally Sampson has described. Dr. Ornish also cites approvingly a paper that claims that "mindfulness meditation" improves the antibody titer response to the influenza vaccine. I went and looked up that paper to read while I was on the plane to Phoenix. I have to say, I was underwhelmed; indeed, it reminded me of a similar study of Tai Chi that I blogged about in that there was no attempt at blinding, but, even worse, the measures used to control for confounding factors were truly inadequate.

But Dr. Ornish hit the jackpot in provoking my annoyance when cited an acupuncture study thusly:

In patients with low back pain, response rate was 47.6% in the acupuncture group, 44.2% in the sham acupuncture group, and 27.4% in the conventional therapy group.

The medical blogosphere extensively covered this study, as did I. Suffice it to say, the study fell far short of how it was represented. Morever, the most obvious conclusions about acupuncture from the study are that: (1) it's a placebo effect and (2) acupuncture meridians are bunk, given that there was no difference between the sham acupuncture and "real" acupuncture group. In all fairness, I don't know what Dr. Ornish said about the slide, because the video of the conference hasn't been posted yet, but his slide sure does lead me to suspect that, when it comes to science-based medicine, he just doesn't get it, as does his comment to me remonstrating with me for taking him to task for saying that we are "more than just genes and germs, microbes and molecules." Indeed, if he thinks that Leroy Hood's work indicates that to be true, he is more misguided than I thought. Nothing in Leroy Hood's work indicates that we are "more" than these things, only that how these things work in human physiology and disease is likely to be far more complicated than we had previously thought. It does not imply any sort of dualism, which is what Dr. Ornish seems to think that it does. He can correct me if I'm wrong.

Finally, Dr. Ornish truly buried himself when he finished up with a series of slides that concluded:

"Integrative Medicine"
=
transformation

With all due respect, I ask: Transformation into what? One does not have to embrace pseudoscience to "transform" healthcare. Indeed, the best transformation of health care would be to make it more science-based. If science shows that lifestyle alterations are the best treatment for some conditions, bring it on! I'll be all for 'em, as they say. If science bears out Dr. Ornish's results, I would happily recommend his diet to men with early stage prostate cancer. To me, there is no such thing as "alternative" or "integrative" medicine. There is medicine that has been validated by science as effective and safe, and there is medicine that has not. In fact, I would happily recommend even something that I now think as ridiculous as homeopathy if science could show that (1) it works significantly better than a placebo and (2) provide an reasonable scientific mechanism by which it could work. Indeed, I'd even scratch #2 if someone could show me that homeopathy could cure an incurable disease like pancreatic cancer.

In the end, the problem is that Dr. Ornish has yoked his science to advocates of pseudoscience, such as Deepak Chopra and Rustum Roy. Why he's done this, I don't know. The reason could be common philosophy. It could be expedience. It could be any number of things. By doing so, however, Dr. Ornish has made a Faustian deal with the devil that may give him short-term notoriety now but virtually guarantees serious problems with his ultimately being taken seriously scientifically, as he is tainted by this association. Let me yet again reemphasize that this relabeling of diet, exercise, and lifestyle as somehow being "alternative" is nothing more than a Trojan Horse. Inside the horse is a whole lot of woo, pseudoscience and quackery such as homepathy, reiki, Hoxsey therapy, acid-base pseudoscience, Hulda Clark's "zapper," and many others, all contradictory, virtually all pseudoscientific, but all intentionally hidden within the Trojan horse of diet and exercise. Once the horse is within the fortress of scientific medicine, the quackery will leap out and take over. Thus, as far as I'm concerned, the answer is not to blindly accept diet and exercise as "alternative," but rather to smoke out the quackery from within the Trojan horse constructed by CAM advocates and then return diet, exercise, and lifestyle interventions to where they were before they became "alternative" and to where they should be: In the realm of scientific medicine. Dr. Ornish could be a huge help in accomplishing this. Indeed, one of my commenters put it very well:

You're doing science-based preventive medicine. Prevention and health care maintenance have always been core concerns of medical science. Nothing "alternative" about it.

So what do you need CAM for?

Why sit with that army of anti-science quacks on their side of the table when you could be over here with us? (Srsly. Take a look at Weil. Dude knows his way 'round a bong and a sandwich LOL.)

We try not to lie to the people, even though it might be fun. We don't like to over-state our data, unless we're really drunk. We don't like getting called on our bullshit, but we accept that this might sometimes be necessary for the greater good.

We are tough. We are rockin'. Chicks dig us!

So get yer ass over here!

I echo the sentiment, and say to Dr. Ornish: "Get your ass over here, back on the side of science- and evidence-based medicine." Or, channeling Luke Skywalker trying to persuade Darth Vader, "I know you can still turn away from the Dark Side."

What do you need "alternative" medicine for, Dr. Ornish? Really? Think about it. What has it done for you other than lump you together with the crystal gazers, shamanic chanters, and purveyors of quackery? I do not say "unfairly lump you," because you yourself chose this association, and you yourself can choose to end it.

You have the potential to be a pioneer in showing scientifically just what dietary and lifestyle interventions can really do, but instead, you're letting a bunch of opportunistic apologists for quackery coopt you and your work for their own purposes. They're using you, and your diet is nothing more than a convenient tool, a "foot in the door," if you will, behind which quackery will follow.

Stop it. Please.

oracknows Thu, 03/05/2009 - 03:30

Tags

cancer

complementary and alternative medicine