18 OCTOBER 2014 HEALTH ADVISORY: MERS SARRS , POLIO; EBOLA; CHIKUNGUNYA. OPTIMIZE VITS C AND D3 DOSES. DIARY JOURNAL: DEATH BY VITAMINS/MINERALS DEFICIENCY?: THE EASILY AVOIDABLE FLARE? AND EASY CURE? 2012-2014- MIDDLE-EAST CORONAVIRUS OUTBREAK: its not primarily the virus, but a deficiency syndrome?.

neil.burman@gmail.com Cape Town, South Africa

CONSPIRACY OF SILENCE, DENIALISM?  THE FLARE AND CURE OF MERS?- MIDDLE-EAST SEVERE ACUTE RESPIRATORY- RENAL SYNDROME SARRS  CORONAVIRUS  OUTBREAK; AND EBOLA?  : An Inconvenient truth?  human (sunshine-) vitamins C+D DEFICIENCY  syndrome facilitating  a benign virus spread from eg  camels  (or mosquitos) to middlemen eg camelmen  to human vit C/D deficient  contacts- in whom the infection becomes lethal ?.   Copyright reserved.  A narrative  diary journal since August 2013

ALWAYS READ IN CONCERT WITH avoiding-the-semmelweis-reflex-vitamins-c-d3-avoiding-vitamin-denialism

and  diet-nutritional– vitamin risks-and-benefitS 

and THE CRUCIAL ROLE OF PROHORMONES (SOLTRIOL-VITAMIN D3 -NOT  VIT D2  – AND VITAMIN C ) AS HRT IN REDUCING ALL MAJOR DISEASE. Salute Dr Walter Stumpf.

19  Oct  2014:       HEALTH ADVISORY FOR VISITORS TO OR FROM MIDDLE & FAR EAST,  EUROPE,  AFRICA, the AMERICAS:  The MERS infection – > a case a day past week; 15 cases (one of whom returned home to Qatar) – and deathrate (8 deaths) this month in KSA  has doubled past month,  awesome for such a rich and sophisticated country,\

though well below that of the ebola epidemic – some 8000 cases with up to 70% deathrate  so far-  that is ravishing central  west Africans impoverished by genocidal warlords; not to mention flu, cholera, HIV, TB, polio-and dengue-like illnesses.  Liberian workers  who flew to USA  and Germany  with Ebola died; but now two  Dallas  nurses who treated him have ebola. .  The nurse who treated an ebola visitor to Spain  is again critical. But West Africans are reportedly trying to flee to South Africa to escape the epidemic. and 9 out of 16 Medicine sans Frontiers staff who contracted ebola have died. .

SO  OPTIMIZE YOUR DIET, VITAMINS D3   &  C DOSES, SUNSHINE, AND  AVOID  SELFSABOTAGE- SMOKING, SUGARS, ALCOHOLISM, AND RASH HYGIENE.

18 Oct 2014:  now the KSA declares   12 Cases Under Treatment   430 Cases Recovered   766 Cases,   325 dead; ie 7 more cases in KSA past week . So thats 11 cases in 18days ie the case rate up to 0.65/day this month. But 7 in the past 7 days ie 1/day.. all details of the 2 cases, on 16 Oct, have been omitted from the KSA website.

14  Oct 2014  The first MERS case outside KSA was reported yesterday in Qatar, in a returnee from KSA, ie thats 5 cases this week contracted in KSA, reportedly bringing world total to 892 cases and 356 deaths.  Crof says Over the past 30 days Saudi Arabia has reported 17 MERS infections, 9 of which were from the Taif region; which concurs with the HSA stats excluding the backlog of old cases reported last month…  Four  Saudi males this week  with MERS in Jubail, Taif and now Riyadh , and  deaths each in Riyadh and Taif..  so Saudi MERS  cases there  now 10 Cases Under Treatment, 429 Cases Recovered, 763 Total; and 324 deaths ie 43% death rate . In 14 days this month that’s 9 new cases in KSA, 5 deaths, 3 cases recovered; compared to September’s  net   ?12  new cases. The stats for September (incl  19  deaths)  are blurred by the adjustments announced on 19 Sept (with previously unreported cases up to 3 June, with net 16 new cases after other corrections); so the new cases and deaths reported in August may be correct-4 new pts,  4 deaths; and July 9 new  cases, 6 deaths; and June 28  new cases? .. .

So the MERS  case rate in KSA so far this  month has mushroomed from the  0.3/day  in July, the  nadir of 0.13/d in August, ? 0.4  in Sept,  to 0.64/d this month; and the deathrate from 0.2/d  in July to the nadir of 0.13/d in Aug to >0.6/d this month.

BUT 6/9 OF THE NEW CASES THIS MONTH HAVE BEEN IN THE GARDEN RESORT CITY OF TAIF 100 KM SOUTH OF MAKKAH- mostly in Saudi men with camel contact.  perhaps this may be because of a resevoire of MERS in camels there. The climate may be favourable for humans BUT ALSO FOR MERS- October temps of 15 to 30c, humidity of 40%, 11 mm rainfall.’

 

     MORE ON OPTIMAL VITAMIN D3  DOSE, AND THE DIFFICULTY OF ACHIEVING CLINICAL  OVERDOSE:      Four  new reports highlight  how  difficult, and important  it is to achieve adequate optimal bloodlevels of vitamin D with vigorous vitamin D3 supplements, let alone overdose with any significant adversity: note three   used the  recommended vitamin D3,   not the long-condemned mislabeled Lennons/Aspen vitamin D2 (which is misleadingly labelled  “caciferol” without disclosing that it is D2 not D3). Even a single  2 million iu overdose of vit D3 in nonagenarians had no adverse effect-since the bloodlevel was back to zero by 3 weeks, thats above 100 000iu/day on average….

 with serum 25-hydroxy vitamin D (25(OH)D) < 30 ng/mL  on  placebo or vitD3 (n = 35)   60,000 units/week for 6 weeks.   mean baseline level of 25(OH)D was 9.6+-9.6 ng/mL, and after 6 weeks doubled to 19.5 ± 4.3 ng/mL,  (P < 0.0001). After discontinuing supplement at 6 weeks, serum 25(OH)D level dropped moderately  by  12 weeks (16.1 ± 8.3 ng/mL) as compared with the baseline.  The change in serum 25(OH)D level from baseline to 6 weeks in the intervention group was inversely related to baseline 25(OH)D levels and patient’s weight. In the control group, change in 25(OH)D was not significant.  Thus  vit D3 about
10 0000iu/day in these small and often malnourished people raises bloodlevel by only about 10ng/mL.
        Kearns ,Tangpricha ea, Emory University Georgia USA   in Eur J Clin Nutr. 2014 Oct 1 describe    The effect of  single  250 000iu bolus of vitamin D3  in healthy adults over the winter and following year: a randomized, double-blind, placebo-controlled trial.   At baseline, young healthy participants had a mean plasma 25(OH)D concentration of 17.5±6.1 ng/ml. Only two subjects exhibited plasma 25(OH)D concentrations >30 ng/ml. At 5 days, subjects on  vitamin D3 had  only doubled mean plasma 25(OH)D (39 vs 19 ng/ml, P<0.001). Plasma 25(OH)D concentrations returned to baseline by  90 and 365 days in the vitamin D3 group,  remained unchanged in the placebo group. PTH and calcium concentrations were unrelated to changes in 25(OH)D levels and similar between groups over time.

   van den Ouweland ,  Vollaard ea  Nijmegen, The Netherlands in    BMC Pharmacol Toxicol. 2014 Sep 30   describe  Pharmacokinetics and safety issues of an accidental overdose of 2,000,000 IU of vitamin D3 in two nursing home patients: a case report.      intermittent high doses  vitamin D3 is increasingly used as  strategy for rapid normalization of low 25-hydroxyvitamin D (25(OH)D) blood concentrations in patients with vitamin D deficiency. Oral overdose of 2,000,000 IU of vitamin D3 in two nonnagenarian  nursing home patients was monitored from 1 hr up to 3 months . Peak blood 25(OH)D3 concentrations were observed 8 days after intake (210  and 162ng/mL, respectively (ref: 20-80 ng/mL),   followed by a rapid decrease to undetectable levels after day 14.  Remarkably, plasma calcium levels increased only slightly up to 2.68 and 2.73 mmol/L, respectively (ref: 2.20-2.65 mmol/L) between 1 and 14 days after intake,; phosphate and creatinine levels remained within reference range. No adverse clinical symptoms were noted.   CONCLUSION:A single massive oral dose of 2,000,000 IU of vitamin D3 does not cause clinical toxicity requiring hospitalization. Toxicity in the long term cannot be excluded as annual doses of 500,000 IU of vitamin D3 for several years have shown an increase in the risk of fractures. This means that plasma calcium levels may not be a sensitive measure of vitamin D toxicity in the long term in the case of a single high overdose. 

 

            As previously reported, to avoid dehydration stones and vascular calcification – especially in hot dry climates – , the precautions with vigorous vit D3   are to add some vit K2 and magnesium to the supplement, and maintain good water intake .
           The fourth current paper, from Morocco, reports inexplicable use of dangerous massive dose of vit D2 in neonates- amounting to about 120 000iu/kg ie about 12 times the maximum adult dose reported :   Hmami , Bouharrou  ea Morocco University,  Arch Pediatr. 2014 Oct;21:1115-9.        [Overdose or hypersensitivity to vitamin D   Vitamin D intoxication with severe hypercalcemia is rare in the neonatal and infancy period. nine cases of babies were admitted between the ages of 25 and 105 days for treatment of severe dehydration  8 to 15% with  hypercalcemia, with preserved diuresis and loss weight between 100 and 1100 gm secondary to taking 600,000 units of vitamin D (Sterogyl(®). The pregnancies & deliveries  were normal. Clinical signs were dominated by weight loss, vomiting, and fever. The vitamin D values in nine patients were toxic (139 – 300 ng/mL, ; normal >20ng/mL; toxicity if >100ng/mL). Nephrocalcinosis was shown  in seven patients. DNA study  in eight patients, did not reveal a mutation of the vitamin D 24-hydroxylase gene (CYP24A1). Treatment consisted of intravenous rehydration with diuretics and corticosteroids. Serum calcium returned to  normal range within 4-50 days, with weight gain progressively over the following weeks. The follow-up (2 years for the oldest case) showed persistence of nephrocalcinosis. Genetic susceptibility and metabolic differences appear to modulate the threshold of vitamin D toxicity. However, respect for recommended doses, recognized as safe in a large study population, reduces the risk of toxicity.
and as in adults,    Yao ,  Huang  ea  Prediction of Allergies in Taiwanese Children (PATCH) Study Group in  J Pediatr. 2014 Oct 1 demonstrate a significant relationship between insufficient serum vitamin D levels and worse lung function in children in the community with a suggested dose-response effect.

            8 Oct 2014  1st Ebola case diagnosed in Dallas USA in  a Liberian visitor, who died today (one of > 4000 deaths  in W Africa estimated so far); and a new case in Spain, the first infection outside Africa. Ebola anxiety spreads..                                                                                                                                                  It is alarming that the MERS deathrate is not falling but rising  there-5  new MERS  cases already this month,  vs 12 in Sept,  5 cases  in August; and  now 8 deaths  in past 38 days..

VITAMIN D3 DOSE: We get excellent results in outpatient adults with loading oral dose of  vit D3 of about 200 000 to 400 000iu depending on illness severity and body mass; then pro rata about 50 000iu  per week till better, tapering to fortnightly when well; pro rata in kids. We monitor calcium and 25OH vitamin D3 levels occasionally  if affordable – but with the tapering regime, and published data, do not see or expect hypercalcemic problems from a mean conservative weekly maintenance dose of about 3500iu/d longterm, with predicted bloodlevel of 25OHvitD of about 35-40ng/ml.  As a senior with average chronic dis-ease load, I take 50 000iu vit D3 weekly, but double it occasionally if I do get a bad cold; so I never miss a day’s work;   recent stress-related shingles (2nd attack in 30 years)  was just a nuisance, settled in 3 weeks with this regime plus multigrams of buffered vit C a day; oral lysine and alphalipoic acid each about 1/2 gm/day; and for a few days some weak steroid and humic acid cream topically for the neuritis and blistering, which has already healed to almost invisible.  This week at a family practice clinic I saw two successive women with shingles – now a frequent occurrence, even  without HIV…

Khan in Toronto in OHDM  this September  describes a ~60yr old man with tongue cancer who was treated inter alia with Vit D3 10 000iu a day; after a year his 25oH vitD level was ~106ng/ml; when his dose was halved; his dose response  bore out the general experience that at average adult mass, vit D level rises by about 10ng/ml for every 1000iu vit D3 per day or pro rata dose weekly etc  eg 50 000iu/wk or 100 000iu fortnightly may give average vit D level of ~70ng/ml.  .

Singh & Bonham 2014 at Kansas University describe  A Predictive Equation to Guide Vitamin D Replacement Dose in Patients. The recommended daily allowance for vitamin D is grossly inadequate for correcting low serum concentrations of 25-hydroxyvitamin D in many adult patients.  In their population (average BMI 31.5) ,about 5000 IU vitamin D3/day is usually needed to correct deficiency, and the maintenance dose should be ≥2000 IU/day. The required dose may be calculated from the predictive equations specific for ambulatory and nursing home patients”   A BMI of 31.5kg at a mean height of about 1.7m gives a mean weight of 91kg, which at the consensus daily  vit D3 dose of 80iu/kg/d totals ~7100iu/d or 50 000iu/wk- perhaps a reasonable maintenance dose for winter, half  that in summer if reasonable weekly sun exposure. .

​​​​​​30 Sept 2014 another new Mers case in KSA, a 70yr old Saudi man in AlMadinah. 

AND   From: David Ponsonby  September 29, 2014   http://healthimpactnews.com/2014/flu-vaccine-is-the-most-dangerous-vaccine-in-the-united-states-based-on-settled-cases-for-injuries/ 

       “The last report issued  December 2013 for the previous 3 months  by the USA Department of Justice (Vaccine Court), for compensation made by the USA Services for people injured or killed by vaccines – available as a Power Point presentation –   139 claims settled , with 70 of them being compensated. So, just over 50% of the claims filed for vaccine damages were compensated during this period.     Once again, the greatest percentage of damages compensated were for the influenza vaccine, and most of those were for Guillain-Barré Syndrome (GBS).           Yet these facts, in a Department of Health website, are never reported in the mainstream media. Read the report yourself in the Power Point file here.   Of the 70 cases compensated, 42 ie 60% were for the flu vaccine. The combined total of the other 40% of cases settled included the following vaccines: Hep B, Tetanus, HPV, DTaP, MMR, IPV, PCV, Hib, Meningococcal, Varicella, TD.”

         As detailed elsewhere n this column, there is at least 70 years of strong experience worldwide that  all microorganism infections are greatly diminished by natural  prevention (not synthetic vaccines loaded with toxic heavy metals and allergenics eg egg) , and  easily treated ie  thrown off, with vigorous immune-boosting supplements:  (mega)grams a day of vitamin C or as kgs/day of fresh produce;        vitamin D3 80+ iu/kg/d to  >10 000iu/d ie 300 000  to 600 000iu loading dose; then    +-50 000iu/wk,  plus  plenty of skin exposure to sunshine; iodine; zinc; selenium; silver; the other vitamins; Ecchinacea etc.  This applies both to acute and chronic infections and degenerative conditions.

to be used in highrisk cases eg MERS, AIDS, ebola etc: The  landmark trial  Effect of High-Dose Vitamin D3 on Hospital Length of Stay in Critically Ill Patients With Vitamin D Deficiency- The VITdAL-ICU Randomized Clinical Trial  by Amrein, Dobnig ea ,   published   today in JAMA  from Austrian hospitals  is most encouraging about the immense value of vigorous dose and bloodlevels of vitamin D3 against all types of severe disease.  The dose used in this trial (loading dose 540 000iu  =~18000iu/d 1st month, but averaging only ~8000iu/d in the first 3mo) did not achieve vigorous vit D bloodlevel, presumably because the loading dose of vit D3 in oil (540 000iu) was given by tube into the stomachs of critically ill patients; it would have better been given by transdermal injection, or else a much higher loading gastric dose given so as to speedily achieve a bloodlevel of around 70 (60 to 80) instead of half of this that was achieved in the crucial first few weeks .                                      from May 2010 through September 2012 at 5 ICUs the trial recruited  492 medical (60%) and surgical (40%)  critically ill adult white patients , 35% women, BMI mean 27, mean age  64.6 years (SD, 14.7) with vitamin D deficiency (≤20 ng/mL) assigned to receive either vitamin D3 540 000 IU, or  placebo    given orally or via nasogastric tube; ;  followed by monthly maintenance doses of 90 000 IU for 5 months- ie= about 18000iu/day for the first mo, then 90 000iu   mthly ie only 3000iu/d.           .     RESULT: on placebo the 25hydroxyvit D3 level doubled  from 13 at baseline to 17 at a month to 26ng/ml at 6mo.. By contrast, on vit D3 supplement it doubled to 34 at days 3 and 7 and day 28, but up to 46 at 6 months ie only 80% higher than the control group – thus 1/3 to 1/2 of the optimal target; with this, where 100% of patients were below 25OHvitD at baseline ie on admission to ICU, by 7 days, 87% were still in this bracket and none above 60ng/ml on placebo vs 25%  below 20  and 13% above 60 on vit D3; and by 6mo 35% were still that low on placebo, vs 5%  at that low, but 22% above 60 on vit D3. So it is not surprising that Median hospital stay 20 days was not significantly different between groups  Hospital mortality and 6-month mortality were also not significantly different (hospital mortality: 28% for vitamin D3 vs 35% for placebo; hazard ratio [HR], 0.81  P = .18; 6-month mortality: 35.0%  for vitamin D3 vs 42.9%  for placebo; HR 0.78  P  = .09). For the severe vitamin D deficiency subgroup analysis (n = 200), length of hospital stay was not significantly different between the 2 study groups: 19.5 days. Hospital mortality was significantly 40% lower with 28 deaths among 98 patients (28.6% ) for vitamin D3 compared with 47 deaths among 102 patients (46.1% ) for placebo (HR, 0.56 P for interaction = .04), but not 6-month mortality (34.7%] for vitamin D3 vs 50.0%  for placebo- ie 31% lower; HR, 0.60, P for interaction = .12). No serious adverse events were observed. The highest 25-hydroxyvitamin D levels measured were 107 ng/mL on day 7 and 106 ng/mL at month 6- well below the theoretical minimum toxic threshold of 150 or 250ng/ml..”

BUT  compared to the Austrian trial in overweight 27+kg BMI elderly whites given 540 000iu to start  by tube,              in   Salahudfin ea’s  randomized controlled trial in young emaciated   Pakistani men BMI 17.2kg, Vitamin D3 600 000iu  injection (which achieved twice the blood 25OH vit D3 level of the Austrian patients), had  accelerated clinical recovery from tuberculosis with  “impressive clinical (weight gain, chest xray and sputum clearing)  improvement  over 3 months on outpatient TB therapy (Directly Observed Therapy (DOTS) with 2 months of  4 antituberculous drugs followed by 6 months Isoniazid and Ethambutol)  with two doses 600 000iu vit D3 imi (vs placebo inj)  a month apart-  ie = ~20 000iu/d for the first 2 months, but equivalent to about 7 000iu/day over the 3 months treatment period . This dose  of vitamin D is as recommended for vitamin D supplement by the Pakistan Endocrine Society.  Trough  25OH vit D levels increased from about 20 to 90ng/ml.    After 12 weeks, the vitamin D supplemented pts (mean 28 yrs, BMI 17.2kg, 85% moderate to far advanced lung disease)  had  significantly greater mean weight gain (kg) + 3.75,  versus + 2.61, p 0.009; lesser residual disease by chest xray-  30% fewer zones involved 1.35 v/s 1.82 p 0.004,   and 50% or greater reduction in cavity size 106 (89.8%) v/s 111 (94.8%), p 0.035. Vitamin D supplementation led to significant increase in MTBs-induced IFN-g secretion in patients with baseline ‘Deficient’ vitamin D serum levels (p 0.021). Patients in the vitamin D arm and serum < 30 ng/mL (‘Insufficient’ and ‘Deficient’ groups) at enrollment had significantly greater improvements in TB severity scores compared to patients with normal baseline vitamin D levels; p 0.014.”

         “This corresponds with the earliest reports of the benefits of vitamin D in TB patients published in 1848 [21] that describes disease arrest, weight gain and reduction in mortality in patients with TB treated with cod liver oil compared to standard therapy alone. More recently, Martineau et al  [7]  demonstrated that a single oral dose of 2.5 mg (100,000 IU) of vit D2 significantly reduced growth of mycobacteria . A randomized, placebo controlled study on 67 Indonesian patients, by Nursyam et al , Jakarta  [22] reported that pulmonary TB patients given 420,000 IU of vitamin D over 6 weeks  ie 10 000iu/day had significantly higher sputum conversion rates as compared to placebo (p 0.002). Martineau et al. [8] showed that 100,000 IUs of 25-hydroxyvitamin D3 supplementation significantly improved sputum conversion rates in patients with the Taq1 25-hydroxyvitamin D receptor polymorphism of the tt genotype. ”                                                                    .

As Salahuddin ea note, the good results in Pakistan in only 3 months with vigorous  INITIAL dose vit D3  contrasts with Two recently published large randomised, controlled trials of conservative vitamin D3 over months  that achieved far lower blood vitamin D levels found no difference in clinical outcomes or mortality after 400,000 IU of 25-hydroxyvitamin D3 or placebo were given by   Martineau ea  in London, UK to 146 pulmonary TB patients – where mean (trough  or midpoint)  vit D level  (after 100 000iu vitamin D(3) or placebo at baseline and 14, 28, and 42 days after starting standard tuberculosis treatment) – was surprisingly only  40ng/ml at 56days – ie after a mean of 7000iu/d by  56 days,  vs 10ng/ml  on placebo)- less than half of the bloodlevel  achieved on vit D3  in the Pakistan trial.

So the Austrian ICU patients would undoubtedly have done much better if given more effective  (ie in critically ill pts intramuscularly imi or subcutaneously) loading dose like the Salhuddin trial did.

 

29 Sept 2014  MAJOR  SAUDI  UPDATE:   FRESH MERS FLAREUP WORSENS:  There have lately been 3 new cases, (2 Saudis and an expat), near Mecca; 2 in Riyadh- and now   death of  a  38yr old previously well  Saudi woman in Riyadh.

Thats  3 MERS deaths; and 4 new cases – Saudis- in central KSA  the past  10days, 11 this month; contradicting  the puzzlingly optimistic comment this week from KSA  health ministry’s Fakeih that  “MERS is not an issue in Saudi anymore. We are  doing all we can to have a safe Hajj for all our guests.”  If MERS is not an issue, why is the new caserate  there picking up, and the deathrate not falling?

the KSA Ministry‘s recent audit found  some 19 previously unlisted MERS cases in the 10 week April -May 2014 surge – all but three of the cases were in Jeddah- plus some false positives , and  changes of status..

The totals there now are 8 Cases Under Treatment, 426 Cases Recovered,753 Total; and 319 deaths ie 42% death rate .

But outside KSA there have been no further MERS cases or deaths reported for months, so thats apparently worldwide 885 cases , deaths 353 = 40%. But the deathrate outside KSA remains only 26%. and outside Arabia the deathrate remains 10/30 ie 33%.
     Despite the surge in KSA in the ~10 weeks mid-March till early June, before  the peak summer season in the Northern Hemisphere,   the ongoing outbreak in KSA (14 cases there since the month’s lull till mid-August)  contrasts with the last MERS cases reported outside KSA  in early-mid-July   about 10 weeks ago - 2 cases in Abu Dhabi ie the UAE,  & 5  in Iran. .

So thats a total in KSA of 20 more new cases  and 13 more deaths  than was reported before the audit on 12 Sept.  Of the  KSA 749 total,   27% were  healthcare workers; 65% were Saudis-  the vast majority this season in Jeddah and Riyadh;  ​​​​61% male; 4% under 16yrs, 45% between 16-45, 27% 45-60. and 24% 60+ years. ie approx  15% of all cases in  every 15year age bracket from 16yrs up, but only 4% in the first 15 years. Deathrate was “only” ~18% in  EACH OF the three  15year agebrackets up to 45 years, but 45% in the 46-60yr olds; and quadrupled to 80% over age 60years.Thus unlike eg flu, only in the KSA elderly is  MERS par excellence a highly risky infection    .

MERS IN KIDS:   the likely number in KSA extrapolated from 4% of 749 cases is about 30  kids under 16yrs;  but the new KSA  bargraphs show ~18% deaths in kids ie about 5-6 died. so the child deathrate has doubled from  9% 1/11.    In Dr Memish’s April paper there were only    11 pediatric cases  positive by screening and confirmatory PCR for MERS-CoV reported from Saudi Arabia. Two patients were symptomatic and the other 9 cases were asymptomatic. The median age of patients was 13 (range 2-16) years. There were eight females and three males (2.7:1 ratio). One symptomatic patient died  (1/11 = 9%) and the other symptomatic patient recovered. The diagnosis of patients was based on positive nasopharyngeal swabs on the majority of the patients.  Most cases of childhood MERS-CoV infection was asymptomatic and tested positive during contact investigation of older patients. Severe disease can occur in children with underlying conditions.

So in KSA  with a mean population age close to 20 years, the age distribution of MERS is roughly spread across adult lifespan, sparing  (with both low incidence and low mortality) children who make up almost half the population. This is the opposite of the claimed swine flu severity in kids in the “pandemic” of 2009.  Perhaps in KSA this is as expected since generally schoolchildren take more dairy products, get more exercise, sunlight, fresh produce  and supplements, and wear less sun-exclusive clothing- supporting  vit D+C deficiency evidence as the proximate  cause of MERS-CoV susceptibility in KSA adults..

So despite repeated published warning from the top KSA scientists that their conservative (ie covered) dress and diet  code puts Saudis at very high risk of known vitamins C & D & Zinc deficiency, the blackout on acknowledging this and promoting vigorous vits C and D3 & Zinc supplements continues, with 80% death risk for the elderly and 20% for every  child who contracts MERS in KSA. Until proved otherwise by simple trial of vigorous supplements, this  denial, omission    in fact may be culpable homicide on the part of KSA authorities- especially as the KSA, with a mean annual income per head similar to UK and western Europe and with similar Caucasian origin population, notoriously has life expectancy 5 years lower than that of UK and much of the North Atlantic  lands. .

16 Sept 2014  one new case today 31yr old expat male, prev chronic, in ICU Riyadh; yesterday  76yr Saudi male  in the far south, prev chronic, in ICU. total thus 730, 29 active,…  already 5 in 2wks this month.. as the Hajj picks up…

12 Sept 2014 Bad news strikes KSA with the Hajj in full swing- after 3 clear days, 2 new MERS cases but not in the eastern provinces like the last cluster, this time one each in Riyadh and the Mekkah region, both Saudis, both in ICU;  but not the usual seniors- a 38yr old male with previous health issues;  and 28yr old female, neither of them healthcare workers.                                                                    So now the KSA numbers are 28 under care;  399 recovered; 729 total; 302 died.

8 SEPT 2014 after 9 case-free days, the 727th  new case, 60y old male expat, in Jubail, in ICU…

31 August 2014 THE KSA MERS CASE RATE PICKS UP: 42% death- rate: another new case 29 Aug, a 34 yr old expat health worker in Jubail, ie 3 cases in past 7 days. another MERS-related death- a 69yr old Saudi man in Dammam- as usual, with preexisting disease. .  So KSA has  now  25 Cases Under Treatment;    399 Cases Recovered ; 302 cases died;  total  726 Cases ie 42% died.  45% dead or impaired.    5 new cases past month.  and apparently 4 deaths. KSA reporting does not allow analysis of duration of illness to assess the current mortality rate.

Yet  Drosten, Memish ea from the international  Corona Virus Study Group write in the NEJM this week:  “Transmission of MERS-coronavirus in household contacts is only 5% in 26 MERS index patients and their 280 household contacts. Strategies to contain the MERS-CoV depend on knowledge of the rate of human-to-human transmission, including subclinical infections.   The median time from the onset of symptoms in index patients to the latest blood sampling in contacts was 17.5 days (range, 5 to 216; mean 34.4d“.

This again confirms  the obvious, that the virus, like the common cold, is low virulence and transmissibility EXCEPT in the frail  and elderly – who (perhaps like many overworked hospital workers)  in KSA who as reported there  apparently get little sunshine, little vitamin D3, and likely little vitamin C. The rate of MERS in students, kids, farm workers, labourers  remains very low, presumably because they get plenty of sunshine. And no article/report on MERS from KSA – where all adults are forced to cover up their skin outdoors- says that anyone is encouraged to vigorously top up their vits C and D3 levels.
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OUTCOMES: triangulating cases  scantily reported on the KSA MERS website   with 30 new cases since mid-June,  5F (28-55yrs, 4 Saudis)  and 25 men; there have been 8 deaths all in men between 38 and 80yrs old. The high deathrate in the men may be because their average age was about 59yr vs 41yr in the women.

August:   5 new cases  (1 Saudi  female; 1 male  an expat HCW; 2 of the men- 69 and 72yrs, Saudis, chronics,   died within 3 and 6 days respectively ),

July:  10  cases;  2 Saudi female; of the 8 men, 2 are HCW , 2  expats- one of whom died the same day aet 73yrs.

June: 24 cases.  Reporting was upgraded 1 June, so stats before July- with the ~100 case undated backlog reported- are problematic. from mid June there were 15 cases reported, 3 females; 5 deaths (2 expats aet 38 & 42)  in the 12 men; the Saudi deaths were aet 45-80yrs.

27 August 2014  2 new cases past 3 days, Saudi man and woman in Dammam.(one subsequently proven false +ve)   25 Cases Under Treatment, 399 Cases Recovered ;   725 Cases   Total;   301 cases passed away .
​​​​​​​​​

 24 August 2014: 12 days free of new MERS cases in KSA.      but on 22 Aug the death of another male, a 66yr old expat, was reported in Riyadh,  this  totals  23 Cases Under Treatment, 399 Cases Recovered; 301 cases passed away, (May Allah have mercy upon them). * Total  723 Cases.  44.8% dead or impaired.

​​​​But Alghamdi ea from the KSA Govt &  Universities, and Lincoln University UK have this week  published  The pattern of Middle East respiratory syndrome coronavirus in Saudi Arabia: from June 2013-May 2014  ie some 425 cases (before the recent June “discovery” of another 100+ cases there). This study deduces that the outbreak thrived especially in Riyadh and Jeddah  with high temperature and low humidity ie summer desert conditions;   older men being at much higher risk than their kinswomen. . But once again, the paper  studiously avoids the obvious reasons why KSA is at the hub of the MERS storm. The authors   like the KSA authorities totally ignore the repeatedly published studies by their own academics the past decade, and even by USA authorities like Prof Mike Holick, that Saudis have markedly low vitamin C and D and even zinc levels. And their increasingly orthodox overdress as they age and have more leisure time drastically increases their vitamin D deficiency.

This comes back to usual Media and Governmental  Semmelweis denialism , persisting  with the myth that good diet  and prescription medicines are  enough.  In fact balanced nutrition with fresh natural produce is becoming a rarity even in stable progressive urban cities, and  the resultant epidemics of infections let alone degenerative diseases are in most cases due, (apart from deliberate pollution especially with plastics, estrogenics , pesticides, endocrine disruptors eg phthalates,  heavy metals including fluorides, bromates;   dioxin etc,  radioactivity,  and high refined carbs,  and inadequate fish oil and medium chain triglycerides  and water intake),  to micronutrient deficiencies especially of vitamins C, D3, K2,  and crucial minerals like magnesium, zinc, iodine, selenium, chromium  etc.

Modern infectious outbreaks like the resurgence of influenza, polio, TB, HIV  and MERS, and hemorrhagic fevers like Ebola and Marburg, are arguably as others have proposed deficency diseases – eg scurvy, since all the severe infections listed, never mind acute bacterial infections, have been shown for almost a century to respond dramatically to highdose vit C, vit D3 and some zinc, and multivite (A,B), without antibiotics or much benefit from eg ARVs or tuberculostatics. .

     As of 12 pm  August 20, 2014:  “now only 25 Cases Under Treatment; 398 Cases Recovered Total  723 Cases;  300 cases passed away”

​​​​    19 August 2014 : KSA  updated figures  no new MERS cases past  7 days.  BUT  another death- a 72yr old Saudi man  with previous chronic disease,  in Riyadh on 17 Aug. so  “As of 12 pm  Aug 19, 2014:  723 Cases,  26 Cases Under Treatment; 397 Cases Recovered; 300 cases passed away   (May Allah have mercy upon them).”. ie the death + impaired rate  326/723 has risen to 46.4%, deathrate 41.6%. ?? 855 cases, 334 deaths  worldwide?

So thats 326 patients in KSA who died or are still impaired by MERS, who might have been spared by simple highdose vits (D3 +  C) supplement-at trivial cost,  no major adverse effects, but massive evidence of protection and cure against all serious diseases; in a population at long-known high vits C+D3 deficiency risks. .

The Zeitgeist occupation analysis of MERS cases to 4 June shows unchanged pattern: 164 Health workers,    150 retired persons,  23 children,  11 pilgrims, 3 tourists,  2 construction labourers, 1 butcher, 1 camelbreeder, 1 shepherd… (out of 838 cases reported till then- ie occupation was disclosed in only 44% ie 380 pts) . The reason for the majority nondisclosure is not given.

The question remains: why are (inter)national authorities ignoring all the published evidence linked below, that vigorous dose vitamin D3 supplement eg 5000iu/kg  loading dose then 1500iu/kg/fortnight eg 100 000iu every two weeks , plus a few grams of buffered vitamin C a day, drastically reduces all diseases including virus infections?

12 August 2012 KSA  reports (after a month free of new cases)  despite peak summer there, two new  previously chronically ill   Saudi cases  in two days:  a 72year Riyadh man; a 59 year old  man far south of Riyadh; and death of a previously reported apparently formerly  well 74 year Riyadh Saudi man. But they dont say when these recent elderly Saudis took ill or died.  Total in KSA now 723 cases, 41% deaths. 28 cases under treatment  ie 45.2% dead or impaired. ..

To put MERS in perspective, Ebola in Central Africa this year has  infected  over 2000 cases, 50% deaths, probably worsening the >100 000 malaria deathrate per year in the region, globally >200 million cases a year with a million ie 0.5% deaths.. ..  Mosquito-spread Chikungunya virus spreads from Africa/Asia   to over 570 000 people  across  the central Americas .. …   .

9 Aug 2014  still not over:  NOT THE END OF THE ARABIAN MERS CoV OUT- BREAK-  STILL MORE QUESTIONS THAN ANSWERS, :  its now  30 days since the last reported MERS case –  BUT  the  fact  is that the KSA Bulletin chillingly reports  “As of 12 pm  9  Aug, 2014:    1.” still 27 Cases Under Treatment     2. 396 Cases Recovered.  3. 298 cases passed away (May Allah have mercy upon them).  total 721 case.   so 30 days after the last recorded new case,   27 patients there are still suffering from MERS sequelae – for at least four weeks duration now, likely now permanent?. .

27 cases out of 721 total reported in KSA is only about 4%. But since these 27 cases remain under care a month  after the last reported new case, they must now  be at best approaching chronically impaired, if not on renal  or respiratory assistance.  ie the total of dead and impaired rises to 325/721 = about 45%. More important, KSA has apparently not yet released an analysis of the demography and primary and secondary causes of death of these cases- presumably by MERS definition, respiratory and renal . This analysis is urgently needed. All we know for certain is that there was a MERS outbreak apparently in one of their Dialysis units; and that the outbreak was especially bad in health workers especially hospital staff.

COMBINED SEVERE ACUTE RENAL AND RESPIRATORY FAILURE: Forty years ago we (Burman ND, Austin M, Thatcher GN ea) delivered a review of Groote Schuur Hospital experience at a local South  African renal congress on the high mortality of combined  acute renal and respiratory failure in the age of hemodialysis and ventilators, respiratory intensive care, antibiotics and immunosuppression. . Apart from the common major sepsis,  trauma and allergic eg antibiotic  causes, the obvious “primary” cause – which any virus eg MERS-CoV  may mimic- , is the “autoimmune” hypersensitivity Goodpastures Syndrome GPS – which untreated has a mortality of ~80% but with modern treatment perhaps 20%. This is half the deathrate reported in KSA from MERS. There is no shortage of respiratory and renal ICU and dialysis, advanced medical specialists  in KSA centres. So from GPS perspective, much better salvage might be expected.

GPS is rare affecting about 1ppm (0.5-1.8 per million people) per year in Europe and Asia.[5] The peak age ranges for the onset of the disease are 20-30 and 60-70 years.[5]  It is also unusual among autoimmune diseases in that it is more common in males , less common in blacks than whites. This may partly explain why the inhabitants of the dromedary-exporting Horn of Africa have been spared MERS outbreaks.

A recent review from Germany gives the mean time from onset of MERS to acute renal failure of only 11 +-2 days (c0mpared to 20 days in SARS). It is well reported that those contracting acute MERS are already sufferers from major chronic illnesses eg diabetic- cardiorenal-respiratory ie heavily predisposed to  immune failure if not already in renal failure.

Humans have some four  primary excretory/detox  systems: hepato-gastrointestinal; skin; renal; and  lung. In Arabia, water is scarce, the desert climate is hot and dry, and the obligatory dress for the observant almost total body cover by robes. So MERS SARRS is high risk especially as it knocks out the two main excretory systems- renal, respiratory, and in  very high ambient temperatures  also the skin;  except for the affluent minority  who have aircooled spacious private homes and offices;  with  often a reported  element of viral gastroenteritis, akin to influenza. .

The mystery remains: why is the  UAE reporting 73 cases/9.2million ie 8 per million,  but only 12% mortality, compared to the adjoining KSA 721 cases/30 million ie 24 per million?  with 93% of world MERS cases recorded from KSA and UAE, and all cases anywhere traceable back to the Arabian Peninsula. The KSA and UAE urgently need to publish an analysis of the demography and pathophysiology of their MERS cases. Is it mostly indigenous Arabs who are contracting and especially dying from MERS in these countries, or also many foreign workers, mainly malnourished labourers?

A major factor is likely demographic: Wiki says In KSAThere are 20 million Saudi citizens and 5 million foreigners living in Saudi Arabia.[14] Most Saudis are Sunni Muslims, approximately 23 percent are Wahhabis, With the world’s second largest oil reserves , the Kingdom is categorized as a high income economy with the 19th highest GDP in the world.   Saudi Arabia is an absolute monarchy.[70] However, according to the Basic Law of Saudi Arabia adopted by royal decree in 1992, the king must comply with Sharia (Islamic law) and the Quran, while the Quran and the Sunnah (the traditions of Muhammad) are declared to be the country’s constitution.[71] According to The Economist‘s 2010 Democracy Index, the Saudi government is the seventh most authoritarian from among the 167 countries rated.[72]. The ethnic composition of Saudi citizens is 90% Arab and 10% Afro-Asian.[212] Saudi Arabian dress strictly follows the principles of hijab (the Islamic principle of modesty, especially in dress).

In the UAE ie Emirates, Wiki says in 2013  UAE’s total population was 9.2 million; 1.4 million Emirati citizens and 7.8 million expatriate ie  16.6% Emirati (citizenry), 23% other Arabs,  54.4% Asians,  and 6.0% other expatriates. Thus the relatively democratic  & liberal  UAE has only 40% Arab ie (majority also Wahhabi) Muslim  population, compared to  some 90% in the KSA. .    in 2005, 76% of the total UAE population was Muslim, 9% Christian, and 15% other (mainly Hindu). Census figures do not take into account the many “temporary” visitors and workers while also counting Baha’is and Druze as Muslim.[65] Among Emirati citizens, 85% are Sunni Muslim, while Shi’a Muslims are 15%.

The comparable life expectancy in the  bigger but relatively poor mostly caucasian countries of Europe is 80 yrs (Portugal), 81 (UK) to 83yrs , and 84.6 in Japan. Why the richer   KSA has so much lower life expectancy can only be due to combination of culture (overdress?) and perhaps genetics-  but Israel, also a predominantly eastern mediterranean semitic people, like Europe  has life expectancy of  82.1 years. on that tabulation, UAE expectancy is 79.2yrs, USA 79.8, but KSA  only 74.3.

Comparison of Gross domestic product and per capita income for 2014 fail to explain the differences in life expectancy ie survival between the highest earning countries, with KSA, UAE, Israel and much of the middle east countries falling in the $30 to $40 000 per capita income bracket.

NO NEW CASES WORLDWIDE: 4 suspected  MERS cases  investigated in Hong Kong after arriving there  via Dubai have proved negative for MERS.

while Ebola, AIDS, cholera, polio  and bubonic plague spread despite major efforts at containment… with at least USA and UK preparing for ebola outbreak, and China for the  bubonic plague.

8 August 2014  Ebola virus disease EVD update – West Africa  Disease outbreak news     Between 5 and 6 August 2014, a total of 68 new cases of Ebola virus disease (laboratory-confirmed, probable, and suspect cases) as well as 29 deaths were reported from Guinea, Liberia, Nigeria, and Sierra Leone.     On Wednesday, 6 August and Thursday, 7 August, an Emergency Committee  determined  that   the current outbreak constitutes a Public Health Emergency of International Concern. and advised that:                 it constitutes an ‘extraordinary event’ and a public health risk to other States; the possible consequences of further international spread are particularly serious in view of the virulence of the virus, the intensive community and health facility transmission patterns, and the weak health systems in the currently affected and most at-risk countries.

It was the unanimous view of the Committee that the conditions for a Public Health Emergency of International Concern (PHEIC) have been met.   New cases and deaths attributable to EVD continue to be reported by the Ministries of Health in Guinea, Liberia, Nigeria, and Sierra Leone. Between 5 and 6 August 2014, 68 new cases (laboratory-confirmed, probable, and suspect cases) of EVD and 29 deaths were reported from the four countries as follows: Guinea, 0 new cases and 4 deaths; Liberia, 38 new cases and 12 deaths; Nigeria, 4 new cases and 1 death; and Sierra Leone, 26 new cases and 12 deaths.

As of 6 August 2014, the cumulative number of cases attributed to EVD in the four countries stands at 1 779, including 961 deaths. The distribution and classification of the cases are as follows: Guinea, 495 cases (355 confirmed, 133 probable, and 7 suspected), including 367 deaths; Liberia, 554 cases (148 confirmed, 274 probable, and 132 suspected), including 294 deaths; Nigeria, 13 cases (0 confirmed, 7 probable, and 6 suspected), including 2 deaths; and Sierra Leone, 717 cases (631 confirmed, 38 probable, and 48 suspected), including 298 deaths.- mortality rate so far 55%.

For a viral hemorrhagic illness, as for acute MERS and flu,  Ebola treatment and prevention  remains supportive, including plenty of fluids and salts, multivites incl K1,   highdose vitamin C eg a few grams hourly to tolerance,  vitamin D3 perhaps 300 000iu orally to start then 100 000iu weekly, iodine, zinc, selenium, garlic, ginger, ecchinacea and colloidal silver till out of the woods.. . 

29 July 2014  the first Wiki update in weeks  indeed shows no reported increase in KSA cases with 41% fatalities; but total Arabian Peninsula cases up to 825 with 321deaths  ie 39% fatalities, and  96.3% of global – 855 cases and 331 deaths ie 39%.

 28 July 2014 THE END OF THE ARABIAN MERS CoV OUTBREAK? its now apparently 18 days without new MERS cases reported from KSA , compared to 6 cases in the previous week… .              so the Wiki figure of WHO-reported cases  in the Arabian Peninsula (plus the 2 recent cases in UAE)  totals 814/(835 globally  ie 97.5%  of reported world cases),  with 315 Peninsula  deaths ie 38.7% fatality rate- but only 13% in the  far less coverup- restrictive UAE with its huge foreign worker population. . . supporting the studies of KSA scientists  of more severe vit D deficiency in the most covered-up observant people, citizens of Saudi Arabia and its fellow ultra-observant Wahhabi bordering neighbour states (except the UAE)  to the south and east. .

and now Ebola epidemic outbreaks kill hundreds in central Africa.  The nocturnal fruit bat (that locals eat)  is apparently the vector. There is strong reasoning that these could be prevented, successfully treated (humans if not bats) with safe highdose vits C and D3.  Like humans, all tested families of bats, including major insect- and fruit-eating bat families, cannot synthesize vitamin C,.    and have very low vit D levels,  make vitamin D only if they roost in sunlight.

and Central Africans are very darkskinned, and the masses malnourished from rampant  genocidal wars, so they will have the lowest levels of vitamins C and  D3. 

20 July 2014  MAYBE..  JUST LACK OF REPORTING?          ‘s A Time’s Memory   to 17 July shows  17  more reported MERS cases (all outside the KSA -still 721  cases, 297 deaths): globally 852 with 329 deaths;   Arabia 829 with 319 deaths; ie rest of world 23 cases and 10 deaths-  similar mortality 41% in Arabia compared to 43% in the 23 infected cases who returned to  their own countries  (middle east, north Africa, Europe, USA, Malaysia, Philippines) not on  the Arabian peninsula- from  their visit/working  there or,  rarely, contact with returnees. .  So has the outbreak  stopped in the past 10 day

ps the USAEBN radio website reports startlingly different case numbers in far fewer  nations, especially tenfold more cases  in Qatar and half the number in UAE.  Time will tell. . this high occurrence in Qatar is not reported anywhere else? on 24 July it reports for KSA alone  834 Cases (897 in the Arabian Peninsula); 288 Fatalities. globally 873 cases with death rate only 35%.      still the massive discrepancies with startlingly far more cases in Qatar and Philippines and far less in the UAE. This website claims, perhaps not implausibly,  that “Government Organizations Do not want to publish total numbers of cases for fear of panic, USAEBN will be trying to track it.”

Virologist Dr Ian MacKay IN MID JULY  puts the world total of cases at 846 in his informative analysis of age and gender demography.

But with neighbouring Iraq in civil war breakdown and even polio flareup, who knows how many there are suffering and dying from unmonitored  MERS CoV.

14 July 2014  The UAE reports 2 new cases of MERS CoV – the first in a long time-, bringing their total to about 73 cases, 9 deaths ie 12% fatality. . KSA reported one new case 10 July ie  4  past week, and 5 in each of the  the  previous few weeks; with no deaths, tally now 721 cases, 295 deaths ie 41%.                       The UK Gov travel warning is about terrorism in the region, not MERS.

The vexed question of the method of spread of MERS CoV between animals- dromedary camels- and humans  continues to be hotly debated between expert virologists and camelmen. The KSA has still not issued [ any restriction on camel imports from the suspected source of the MERSCoV- the Horn of Africa.

But the argument is irrelevant for practical purposes.  Tradition, belief  dies hard, like the strictly enforced hijab overdress, and camelkeeping: Riyadh’s camel market stretches several miles along a highway out of the city. It’s not true. Camels occupy a special place in Saudi society,  We live,  sleep,  eat and spend our whole lives with camels, we drink their milk, its a medicine.. There’s no disease,” said a trader at the market”.       Its the story of 160 years ago, the cholera-spreading London’s  Broad St water pump until Dr John Snow recognized and stopped the source of the cholera diarrhoea epidemic.   This  far more lethal KSA  lung-kidney epidemic is simpler- encourage people worldwide to get plenty of free natural sunshine , or if living at far north darker  latitude or  practicing hijab and unable to sunbathe- especially over Ramadan- take at negligible cost  vigorous supplement of vitamin  D3 to a high safe  bloodlevel .

8 July 2014  Spread of MERS CoV- Down but not out: from 15 cases a day in early May,  now KSA has reported  8 new cases past 7 days;   ie 720 total, 294 deaths- 4 new cases past 3 days, with 1 new death. 18 new cases in 24 days since 13 June. So the rate of new cases is not dropping there the past month – or simply more cases being tested and reported. Only sick cases who see doctors, and their contacts, and city  health workers,  are likely being screened.

The death rate in KSA  since the outbreak 2 years ago remains 40%.      why should this be? other than that Saudis do not benefit from the midsummer as do other populations-  they remain shrouded in overdress and thus severely vitamine D deficient? and the virus seems to spread not airborne  but by direct contact – human to human, or camel-(milk?)-human?  and the KSA has not yet been reported to have stopped mass camel importation from the Horn of Africa for butchers to supply meat.

MERS CASES BY OCCUPATION:     Shane Granger has tabulated more recent reported MERS  cases by occupation where data is available  –  >375 cases:Health Care Workers (HCW) the  largest group – 161:  includes all types of unidentified Health workers (i.e. Nurses,  Doctors, hospital and clinic staff).                             Retired: also  161 (incl Pilgrims 11).                                             Schoolkids 18 -third. Farmers 12 – fourth.  .  tourist 3; construction 2;  Camelbreeder, butcher , shepherd one each.

The retirees are the elderly, generally frailer, probably more at leisure, more orthodox ie more ritually overdressed?  and circulating /concentrated more through/in  the cities especially Mekkah, Riyadh,  Jeddah, and visiting the more frail and sick worldwide; thus more susceptible.

Healthworkers are obviously the most stressed and hardworking,  exposed to concentration of symptomatic MERS cases and thus ingestion and surface (if not droplet) contamination .

The major surprise is the low occurrence in schoolkids, pilgrims, and non-health industry workers, teachers, clergy, armed forces,  shop  and office staff, non-healthcare  govt workers,    etc.

This also favours nutritional ( sunlight/vit D/C/zinc) deficiency as a significant factor in susceptibility of retirees and healthworkers to MERS. The general population (unless seriously ill with other disease)  is largely immune to MERS, like flu and common colds, in them  the MERS CoVirus seemingly causes nothing more.

4 July 2014  frail pilgrims  should postpone the Hajj this year.  the  European Centre reports     KSA 716 cases, 293 deaths;    worldwide 843 cases (817 in Arabia incl now 4 in Iran), 322 deaths. in 21 countries, ie 21 cases outside the Middle East (ie outside the camel contagion area  south-east across the Arab states that have had 791 cases so far)  .  So thats about 10 new cases over the mid summer  in KSA the past 15 days so far. Only 1 new  death.  Case reporting from the rest of the world lags behind.

So the Philippines has advised its citizens to postpone Hajj to Mecca this year.

Certainly  frail pilgrims – especially with diabetic and cardiorenal/respiratory diseases -all over the world will be wise to  postpone. And the KSA is at last considering stopping import of camels (4.7 million a year mostly for human consumption,  – mostly from Somalia, which has never reported a MERS case) –  from the Horn of Africa- their main meat supply. This appears to be the source of the outbreak- simply camel colds that kill only sickly humans who unlike camels avoid sunshine by edict… .    Up to April 2014, it was predominantly a disease of older men; (it appears that camels are men’s work);  but by midMay the male dominance in human MERS cases was fading.

But is the core problem the well-camel MERS-Covirus carriers? It is in fact more likely that the prime cause is that the entire KSA population is at extreme risk – both because those who can afford it overdress by religious edict, especially upperclass Muslim women in total coverup and thus badly vitamin D deficient;  and  because the KSA imports vast numbers of mostly poor unskilled foreigners to do mostly manual work. Such poor labourers are usually undernourished, living in poor conditions, and with poor access to medicines and medical care until they collapse; and unless outdoor labourers, living and working long hours indoors, and hence also badly vitamin-D and C deficient. .   The Wiki review  Saudi Arabia  “Foreign workers estimated them to number 1/3 of KSA residents recently.  Saudi Arabia has become increasingly dependent on foreign labour, and although foreign workers remain present in technical positions, most are now employed in the agriculture, cleaning and domestic service industries. The hierarchy of foreign workers is often dependent on their country of origin; workers from Arab and Western countries generally hold the highest positions not held by Saudis, and the lower positions are occupied by persons from Africa, the Indian subcontinent, and Southeast Asia.  the situation has persisted because of a reluctance by Saudis to take on menial work and a shortage of Saudi candidates for skilled jobs.[.. The Saudi economy has, therefore, remained dependent on importees for expertise in specialized industries, and on the Asian workforce for the construction industry, menial and unskilled tasks.[8]  Saudization is generally considered to have been a failure.[10]

THE MERS-CoV CAMELTRAIN FROM AFRICA:   This again begs the huge question:  if camels carrying asymptomatic airways MERS CoV are indeed the virus vector from Africa –  almost 5000 a year from Somalia alone- imported into KSA  through Jeddah port,  WHY ARE THE  EXPORTING  CAMEL- TRADERS and camel- breeders IN NORTH AFRICA NOT  SUFFERING vastly from MERS  respiratory-renal syndrome?  They are likely Muslim if not black Africans;  oil-rich Arabia employs vast numbers of overseas expats as labourers, and outside the KSA, Arabia especially the UAE  hosts hundreds of thousands of non-Muslim professionals. But unlike say Indians and other Asians, Pinoys and Malaysians are mostly Muslim, so are more likely to observe cover-up dress code,  and thus be more vulnerable to MERS. . This again supports the evidence that   the current symptomatic serious MERS-CoV   SARRS – Severe Acute Respiratory Renal Syndrome –  that occurs in and kills almost exclusively vit D deficient frail observant Muslims  – is due to conditioned  sunlight deficiency.          The north African camel breeders and traders, and  the camel herders and camel men in Arabia  ( like cowboys on the prairies and herders worldwide in hot  climates), are unlikely  devout well -berobed  Bedouin  of Arabia.  Camelmen like cowboys get  plenty of sunshine vit D, if only via bare faces and arms; and thus can with probable impunity,  immunity against MERS, drink raw camel milk and travel with vast camel herds.

27 June 2014 update: (compared to  13 June 2014 KSA  702 cases, 292 death, worldwide 826 cases, 326 deaths): there are now reported in KSA 710 or 718 cases ie 8 -16 in 2  weeks, no more deaths; and globally  833 cases & 322 deaths. . Australian virologist Dr Ian Mckay postulates why vast camel imports (from Africa, via Jeddah  port)  for eating  is likely the source of MERS in Saudi Arabia.                 He omits the obvious link in the chain, that the deathrate from MERS CoV is far  lower outside Saudi Arabia because  this sunny  country is the strictest in the world for enforcing Wahhabi hijab total overdress code   and thus profound acquired vitamin D deficiency even in men,  and worse in  females who  in public  – unlike men- must have even their  heads and faces veiled by a niqab- and in pilgrims from other lands who as part of  their holy pilgrimage undertake to follow permanently  the strict hijab dresscode. Their simple option is  to take effective permanent  vitamin D3 orally  eg 50 000 iu weekly.

IT IS COMMON CAUSE THAT ONE DOESNT, CANNOT   PREVENT OR TREAT INFECTION BY POOR NUTRITION OR LOWDOSE ANTI- MICROBIALS- such policy is futile if not dangerous for breeding resistance as well as disease extension.   The studies below confirm the obvious, (as Klenner, Pauling,  Cameron ea showed the past 50 years with highdose vit C injection), that  vitamin D3 orally also works as a multiantimicrobial agent if given as early as possible in safe very high dose and bloodlevel eg 600 000iu monthly (in the first month, – in Salhuddin’s  Pakistan PTB patients (presumably also Sunni muslim) initially mean wt 45kg, thats vit D3 ~440iu/kg/d) for two doses ie a mean of 300iu/kg/day over 90days;   not the current preventative recommendation of 80iu/kg /day to a safe blood level of around 50-60ng/ml. As Holick has said, with adequate water intake  even 50 000iu vit D3 a day ie 1.5million iu/month for months causes no toxicity. Given the 40% mortality rate in the frail Saudi MERS patients, and in acute severe influenza and other serious viral infections, it can be expected that such  highdose immediate vitamin D3 therapy orally with eg 600 000iu, combined with highdose vitamin C, zinc and some multivite,  (never mind appropriate antibiotics in acute bacterial infection) will similarly virtually eliminate mortality.

But no KSA Govt website mentions this- except the Saudi Gazette a year ago which strongly urged vitamin D supplement in the KSA as even daily sun exposure does not bring most Saudi women above the vitamin D deficiency threshold. It says Since Muslim women can only reveal the hands and face, they may need to be out in the sun for longer than 30 minutes. But the review conspicuously  fails to mention that in public outdoors in KSA, women must have even the head and face covered. It also  propagates surprising  dangerous  nonsense that “severe deficiency needs monthly vitamin D injectionMom, have you taken your vitamin D injection this month?, when all it requires is an oral daily, weekly  or fortnightly  dose vitamin D3  at trivial cost.” It does stress  “One of the main reasons why vitamin D deficiency is so common in the Kingdom is because there are very few food sources of vitamin D. Foods which have fairly good amounts of vitamin D are fish liver oil, sweet potatoes, egg yolks, vegetable oils, butter, and fatty fish such as salmon, sardines, and tuna,” said Dr. Rasha Jameel, a consultant in family medicine at a local hospitalIn the United States, all milk and dairy products are fortified with vitamins A and D, but no such measures are in place in the Kingdom“.

This correlates with a new metaanalysis (in the  BMJ this month) of observational studies from Europe and USA, that all-mortality hazard ratio over a mean of 10 years  increases by 57% as vit D level falls from the highest to the lowest level. The KSA apparently chooses to ignore that, as this column reported recently from WHO data, despite  apparently being the wealthiest country per capita  of bigger populations  in the world,  KSA’s population life expectation is about 5 years lower than eg far less sunny Britain’s; ie KSA  all-cause mortality rate is avoidably materially higher. Despite KSA medical professors  having reported in studies  that most of the KSA population is deficient in vits D and C, the  KSA Govt website  chooses to ignore this on official websites;  unlike other even Middle-Eastern governments promoting vit D fortification or meaningful safe supplements costing trivial amounts.

Even a new study last year from KSA universities confirmed that ” Most commonly consumed food products by Saudi population which are supposed to be fortified by vitamin D are either not fortified or contain an amount less than  (apparently  from their table 2 ~ half of)  recommended by guidelines set for US marketplace”. Even a UAE authority recently stressed “Can fortified milk fight Vitamin D deficiency? Shockingly low levels of D3 among UAE population cannot be rectified by milk alone.” As Holick ea, including  a Turkish University 2010  trial report,  oral vitamin D3 is far more  effective , and safer than,   either vitamin D2, or vitamin D injection -never mind much cheaper. This current ostrich-head-in-the-sand denialism by the KSA government is like that of the RSA govt under Presidents Mbeki and Zuma 10-15 years ago about preventing and treating HIV-AIDS  – considering that the safe and beneficial daily intake of vitamin D3 is now universally recognized as 4000 if not 10 000iu/day (ie about 80iu/kg/day or pro rata up to perhaps fortnightly) , to a mean blood vit D  level of about 60 to 80ng/ml. .

As Prof Mike Holick pointed out a few years ago, “Even in Saudi Arabia, Qatar and South Africa, more than 50% of the population is deficient in vitamin D, all because of their avoidance of sun. Based on some of the literature, it seems that we could probably decrease health care costs across the board by 25% if everybody had optimal vitamin D status.” As Al Faraj ea reported in Riyadh in 2003,   Prof Zahid Naeem from a KSA university wrote in 2010,Vitamin D deficiency is an ignored epidemic in KSA  and globally“; confirmed by a KSA study by Ali ea in 2012:Even in a sunny country like Saudi Arabia the prevalence of vitamin D deficiency in young female is high“..  One does not need to  speculate why the KSA and all governments globally choose to ignore this inconvenient truth,  downplay effective vigorous  vitamin C and D3 (sunshine) supplements-  such widespread vitamin D and C deficiencies, like cigarette smoking and alcohol abuse,   suit governments and Big Pharma-  the Disease Industry- in reducing populations growths and creating jobs for the highly profitable Disease Industry and it’s shareholders-   for whom Only Disease Pays. Cheap safe natural  Prevention Does not Pay since it at least halves sickness never mind disease industry jobs, taxes  and profiteering in the global $multitrillion Disease and Diet and Vaccine and Invasive Screening Industry scams.

And Karen Hansen ea at Univ Wisconsin 2014 have  just shown  that  giving vitamin D2  (not D3)  50 000iu fortnightly for a year is actually adverse – as Holick and others have  show – IT DEPRESSES – perhaps halves – THE BIOLOGICALLY ACTIVE blood 25OHVIT D3 while boosting perhaps 5 fold the far less active blood 25OHvit D2 levels , and actually worsens  rheumatoid arthritis clinically and serologically . One can speculate whether vit D2 actually blocks optimal function of VDRs vitamin D receptors. Trials published 2012 from Japan and Netherlands showed that vitamin D3 – blood 1,25(OH)2D3 (but not TNFalpha blockers) blocked  inflammation (ie TNF tumour necrosis factor alpha activation of vascular calcification).                                                 

Salahudfin ea’s new randomized controlled trial  from Pakistan Vitamin D3 injection accelerates clinical recovery from tuberculosis  shows “impressive clinical (weight gain, chest xray and sputum clearing)  improvement  over 3 months on outpatient TB therapy (Directly Observed Therapy (DOTS) with 2 months of 4 antituberculous drugs [Isoniazid, Rifampicin, Ethambutol and Pyrazinamide] followed by 6 months Isoniazid and Ethambutol)  with two doses 600 000iu vit D3 imi  (vs placebo inj)  a month apart-  ie equivalent to about 7 000iu/day over the 3 months treatment period . This dose  of vitamin D is as recommended for vitamin D supplement by the Pakistan Endocrine Society.  Trough  25OH vit D levels increased from about 20 to 90ng/ml.    After 12 weeks, the vitamin D supplemented pts (mean 28 yrs, BMI 17.2kg, 85% moderate to far advanced lung disease)  had  significantly greater mean weight gain (kg) + 3.75, (3.16 – 4.34) versus + 2.61, p 0.009; lesser residual disease by chest xxray-  30% fewer zones involved 1.35 v/s 1.82 p 0.004,   and 50% or greater reduction in cavity size 106 (89.8%) v/s 111 (94.8%), p 0.035. Vitamin D supplementation led to significant increase in MTBs-induced IFN-g secretion in patients with baseline ‘Deficient’ vitamin D serum levels (p 0.021). Patients in the vitamin D arm and serum < 30 ng/mL (‘Insufficient’ and ‘Deficient’ groups) at enrollment had significantly greater improvements in TB severity scores compared to patients with normal baseline vitamin D levels; p 0.014. This corresponds with the earliest reports of the benefits of vitamin D in TB patients published in 1848 [21] that describes disease arrest, weight gain and reduction in mortality in patients with TB treated with cod liver oil compared to standard therapy alone. More recently, Martineau et al  [7]  demonstrated that a single oral dose of 2.5 mg (100,000 IU) of vit D2 significantly reduced growth of mycobacteria . A randomized, placebo controlled study on 67 Indonesian patients, by Nursyam et al , Jakarta  [22] reported that pulmonary TB patients given 420,000 IU of vitamin D over 6 weeks  ie 10 000iu/day had significantly higher sputum conversion rates as compared to placebo (p 0.002). Martineau et al. [8] showed that 100,000 IUs of 25-hydroxyvitamin D3 supplementation significantly improved sputum conversion rates in patients with the Taq1 25-hydroxyvitamin D receptor polymorphism of the tt genotype.                                                                     .        

            As Salahuddin ea note, the good results in Pakistan in only 3 months with vigorous  INITIAL dose vit D3  contrasts with Two recently published large randomised, controlled trials of conservative vitamin D3 over months  that achieved far lower blood vitamin D levels found no difference in clinical outcomes or mortality:           after 400,000iu of 25-hydroxyvitamin D3 or placebo were given by   Martineau ea  in London, UK to 146 pulmonary TB patients – where mean (trough  or midpoint)  vit D level  (after 100 000iu vitamin D(3) or placebo at baseline and 14, 28, and 42 days after starting standard tuberculosis treatment) – was surprisingly only  40ng/ml at 56days – ie after a mean of 7000iu/d by  56 days,  vs 10ng/ml  on placebo)- less than half of the bloodlevel  achieved on vit D3  in the Pakistan trial ;      

        and  by Wejse et al  2009  in  Guinea-Bissau to 365 TB patients  – who received  300,000 IUs of vit D3   ie only 100,000 IU or placebo at inclusion and again 5 and 8 months after the start of treatment,  ie below 1000iu vit D3 per day over the 12 month trial period “. The Guinea-Bisseau pts thus might have achieved a mean blood vit D level boost of only  10ng/ml.. and now Havers ea (Baltimore)   show Low 25(OH)D is common in diverse HIV-infected populations and is an independent risk factor for clinical and virologic failure; Low 25(OH)D was associated with high body mass index (BMI), winter/spring season, country-race group, and lower viral load. Baseline low 25(OH)D was associated with increased risk of human immunodeficiency virus (HIV) progression and death (adjusted hazard ratio (aHR) 2.13; 95% confidence interval [CI], 1.09–4.18) and virologic failure (aHR 2.42; 95% CI, 1.33–4.41). and Shepherd ea (Eurocoord) Low Vitamin D predicts short term mortality in HIV-positive persons Odds of death decreased by 46.0%( P = .04) for a 2-fold increase in latest 25(OH)D level.. In patients with current 25(OH)D <10 ng/mL, hsIL-6 concentration increased by 4.7%(95% CI, .2,9.4, P = .04) annually after adjustment for immunological/inflammatory markers, and no change in hsCRP rate was observed (P = .76)

19 June 2014 update  no new cases reported from anywhere the past few days, may be because the KSA is not reporting regularly.   so the great news is that more than 2 years after the onset of the MERS CoV outbreak in Arabia, no ongoing transmission has been reported from any of the 22 countries so far affected.

THE POLIO  SPREADING GLOBAL EPIDEMIC This decline of the MERS outbreak with the heat of summer contrasts sadly with the now-declared  global epidemic of wild natural  poliomyelitis- which was hoped to be extinct by now, with Hindu- run India being declared polio-free; but now  spreading out with mass refugees from wherever war and chaos are successfully ignited by profiteers and fanatics  to neighbouring countries. Eg   an expanding militant  Islamic Wahhabi  arc – ie ultraorthodox overdress code – predisposing to vitamin D deficiency?  from Asia- Pakistan, Afghanistan, to middle east – Syria, Palestine, Iraq, Israel;        to East/West Central Africa eg Somalia, Cameroon, Ethiopia,  Kenya, Nigeria, Guinea-Bissau, –  with 365 cases reported in 2013. Perhaps more important is zero natural virus cases in Niger and Chad but cases caused by the circulating vaccine derived virus.  The wartorn  DRCongo  and Sudan are likely next polio outbreaks, while Angola has banned Islam because of its perceived militancy. …

And in February,   never mind an outbreak of polio-like paralysis in northern California, a new case was  reported  in a  South African neighbour-  in Botswana – for the first time there  in 20 years -; “Polio virus is endemic in five countries besides Nigeria: Afghanistan, Egypt, India, Niger and PakistanScientists confirmed that the virus isolated from the boy in Botswana came from Nigeria by laboratory tests that showed it was genetically similar to the strain that has been infecting children in Nigeria . In the past 18 months, polio viruses genetically linked to northern Nigeria have caused new cases of polio in nine previously polio-free countries. Besides Botswana, they are Benin, Burkina Faso, Cameroon, the Central African Republic, Chad, Ghana, Ivory Coast and Togo.” So polio is likely to break out in RSA  not because of Islamic overdress but because of the masses of war refugees absorbed by democratic dispensation  from the polio-afflicted African states to the north, and poor water supplies, sanitation and nutrition,   in so many areas in the northern provinces, despite mass polio vaccination. . In Cape Town’s poorer  areas’  clinics, we see almost as many foreign pan-African refugees as we do local black Africans.

VITAMIN C & D AGAINST POLIO: but as with flu, HIV, TB and likely all infections, the rescue remedy that the Disease Industry  firmly ignores  is freely available also against polio (and all other infections –  as shown so successfully by Dr Fred Klenner after WW2 with highdose vitamin C);  and at least two  published studies  in modern times ie on Pubmed (FDA- Ivanov 2006 USA)  shows the predictable enhancement by vitamin D3 as an adjuvant  of immune response to vaccine against  poliovirus- presaged by a 1949 paper from Foster ea Univ Pennsylvania . .

15 June 2014 new case reported in the 23nd country – Bangladesh, arrived from USA via Abu Dhabi airport. But now disproven. CRUCIAL EFFECTIVE VITAMIN D3 DOSING: TRIALS USING SUBOPTIMAL VIT D DOSES AND LEVELS ARE MISLEADING:            A major new  metaanalysis of the benefit of Vitamin D and Respiratory Tract Infections VIDARIS in PLOS 2013  by Sweden’s Karolinska  Institute Bergman ea showed that in the 11 relevant trials (published between 2007 and 2012 ie done through the first decade of this century) using vit D3, “Overall, vitamin D showed a protective effect against RTI (OR, 0.64; 95% CI, 0.49 to 0.84). And the average vit D level at baseline was only 24ng/ml, but with the mediocre  vit D3 doses used then  of average 2000iu/d (300 – 4000iu/day) given for between 7wks and 3 yrs, the average bloodlevel achieved on replacement was only 50% higher at 36ng/ml”.      This confirms more direct experience  with higher doses that blood level increment, and benefit,  is proportionate to vit D3 dose, at least up to the proven speculative  safe upper dose of at least 10 000iu/day (whereas the proven safe longterm daily dose is> 50 000iu/day). “More important, the protective effect was larger in studies using once-daily dosing compared to eg monthly  bolus doses (OR = 0.51 vs OR=0.86, p = 0.01)”. This concurs with our experience of major benefit  against respiratory infection that is  based on published studies giving a loading month’s dose of about 80-100 iu/kg/day  ie ~3000iu/kg; then that monthly dose split conservatively eg 50 000iu every week or two depending on mass, and severity of ill-health; to a more successful blood-level of 60 to 100ng/ml. Similarly, the  2014 VIDA trial   across USA-    Effect of Vitamin D3 on Asthma Treatment Failures in Adults With Symptomatic Asthma and Lower Vitamin D Level, Castro ea,  showed “Vitamin D3 for 28 weeks did not reduce the rate of first treatment failure or exacerbation in adults with persistent asthma and vitamin D insufficiency. These findings do not support a strategy of therapeutic vitamin D3 supplementation in patients with symptomatic asthmaBut this trial had the same severe limitation as the Swedish metanalysis of vit D3 benefit- it also used only 4000iu/d. “While all were vitamin D insufficient ie below 30 ng/ ml  before the trial and half were deficient with levels below 20 ng/mL, supplementation brought levels above the 30 ng/mL threshold for 82% in that group – mean levels were 41.8 ng/mL at week 28 in the supplement group, while the mean stayed in the deficient range for those who got placebo. ”  So 4000iu/day merely doubled the bloodlevel to only about 40ng/ml – only about half of the putative optimal dose.  These recent studies force us to conclude that bad weather, and  bad prevalent respiratory viruses,  and especially with major acute, or chronic illness as in those with or at risk of serious infections eg major trauma or sepsis,   MERS-CoV, Ebola, malaria, cholera, cancer, diabetics, smokers, asthmatics, bronchitics,   AIDS-TB., pneumonia and old age  sufferers, and especially hospital, laboratory  and clinic- health workers-  we should for an average 70kg adult give a loading dose of about 4000iu/kg, ie 300 000iu, then 10 000 iu/d,  or 50 000iu every 5 days, or more simply 75 000iu (about 1.5ml of 100cws vit D3 powder) weekly; or at a stretch, 300000 if not 400 000iu monthly. . As  the common  imported vit D3 powder concentrate  is 100 oooiu / Gm ie per 2 ml, it is simple to take the slightly sweetish powder up to  2 or more 4 ml teaspoons ie 200 000  -400 000 iu on the tongue.    The majority of residents of developed countries now live urbanised with mechanized transport, and – especially in Muslim or cold countries-  dont  live and work / walk  all day stripped in the sun. The poor malnourished  peasants  live crowded in ghettoes , and  the poorest are generally the darker skinned and therefore make the least vitamin D3. So with rare exceptions, everyone needs the vigorous vitamin D 3 doses discussed above. But at the prevalent bulk vit D3  powder price of  at most about  US$0,o2 per 100 ooo iu, at a mean population age of around 20 to 25 yrs -outside  Europe- it would cost a country of eg 50 million people perhaps $o.5 per head per  year ie conservatively $25 million a year to prevent > 90% of common illnesses including drugging and violence consequences.  Of course no government can tolerate  such massive loss of jobs and taxes  in a decimated disease industry that now turns over $ trillions annually – up to 18 % of national budgets.     So it’s up to individual adults, especially householders, educators and employees ,  to see that the cheapest cure-all  after clean water – vitamin D3 – at $2/citizen per year-  is recommended and freely available.

13 June 2014 KSA now has apparently reported 702 cases, 292 deaths ie 14 more cases, 12 more deaths in past 11 days.. worldwide 826 cases, 326 deaths. And a new multinational vitamin D study  confirms why vitamin D3 not D2 must be given. TIME TO SWOP FROM MISNAMED  “STRONG CALCIFEROL” VIT D2 TO THE REAL VIT  D3. 6 June 2014   on the 10th anniversary of the SARS epidemic , a new 2013 review (by Japanese epidemiologists) Remembering SARS-CoV: A Deadly Puzzle and the Efforts to Solve It brings home the lessons, the similarities between the two recent killer coronavirus outbreaks, in both outbreaks affecting only residents of closed communities (Arabia and China respectively), with carriage of the virus by travelers into their closed kin communities elsewhere. .  Especially the problems of hospital confinement, and superspreaders.          Sun-blocking culture among the Chinese whereever they live in their ethnic communities is also stressed in modern literature. Lu et al 2012 show very high levels of vitamin D deficiency in Shanghai. The  obvious lesson of the past decades was not noted then or now- prevention is better than cure, as in AIDS and pneumonia and all other infections, simply by superboosting the immune boosters within sensible limits –  sunshine/vitamin D3 and C, zinc, iodine, selenium; and for the likely deficient, appropriate iron .. 4 June 2014. Saudi Arabia reports confirm they have indeed  uncovered many more cases, as tabulated by the Wiki report yesterday- 689 cases, 283 deaths. Shane Granger in his Random Analytics concurs. The graph by the KSA authorities shows that most of the unreported cases reputedly occurred from March through to the first week of May, and that that outbreak is almost over, down from a peak of over 100 cases a week ie at the end of their winter- when vitamin D levels are at their lowest-  to about 25 cases a week. .They do not say when the excess MERS-related deaths occurred. Who knows how many more cases and deaths are underreported from the KSA, when the annual Hajj is imminent, and religious tourism is a vast industry for the KSA. This  MERS outbreak is in contrast to  the 8200 recorded case SARS (coronavirus) outbreak of 2002/3 in China, S.E.Asia, (Canada and USA)  and sparsely across Europe – but only 1/4 of the MERS’ ie  9.6% mortality . Just one case was recorded in the middle east and Africa- in Kuwait. Although the SARS and MERS  viruses were traced through mammals to bats, the affected populations were genetically  different-  Chinese  versus Arabic ie Caucasian. But a decade after the SARS outbreak, Chinese in Shanghai also had 85% below the vit D insufficiency threshold (30ng/ml) at the end of winter.  An International Osteoporosis Foundation study of 2009 showed very high prevalence of vit D insufficiency throughout Asia including China- but worse in Malays. Thus the susceptibility to and mortality from SARS and MERS  in the respective races- like Swine flu susceptibility in the frail in USA and Mexico in 2009 and anywhere since-   is likely due like any disease to the combination of both socioeconomic  burden, genes and sunshine vitamin deficiency. But whereas socioeconomics;  genes; and ethnic taboo on sun exposure as in strict Muslims,  are not easily correctable,  traditional micronutrient deficiency is- especially vigorous vitamin and mineral  supplements, without offending cultural taboos.                                                                  

3 June 2014 update :   In the past 5 days, Google websites  reported 2 new  cases/d in KSA.  BUT Wikipedia this evening reports the latest collation: in KSA, 688 cases with 282 deaths ie 41% mortality; this is far higher than in its close 7 Arab neighbours  including Iran, with a total of only  89 cases but only 26% mortality. If these figures are accurate, there have apparently been 125 cases in KSA since 29 May ie 25 new cases/day there; but 96 deaths ie 19 per day. But this gross epidemic has not been reported on Google, so hopefully the Wiki MERS tabulation will be corrected- unless it because the KSA was not announcing cases. .  Apart from the 8 Middle East nations counted above, the Wiki  figures for the outside 16 countries in the rest of the world  – 25 cases,  7 deaths ie 28% mortality, are more consistent with reports to date outside KSA, and moderately lower than  the fatality rate reported in KSA . All MERS- confirmed cases were contracted in the Arabian peninsula (or from travelers from there). All adults  in the KSA including visitors  would by edict be  almost totally robed  when  outdoors, the women also with hijab. On the other hand,   observant pilgrims from non Arab countries are more likely both older-  having chronic degenerative diseases ie more vulnerable- , but  likely  get more sunshine skin exposure at home,   and taking protective supplements before and after; thus possibly explaining  the lower mortality and low  prevalence of carriage of MERS outside Arabia.  The average  Saudi Arabian is aged around 20years, but  the young there presumably  face the same policy   against skin sun exposure,  and apparently against protective micronutrient supplements. 31 May 2014  Mers update   the past 2 days just one new case in Saudi Arabia, but 2 cases in Algeria back from KSA  - the 21st country ; and now a total of 6 cases in Iran with 1 death.

29 May 2014: The 26 May Cape Town suspect’s  deep nasopharyngeal swab screens  have proved negative for Influenza A eg swine flu, and MERSCoV, and she is recovering. . The NICD says they have perhaps  5 requests for screening in returnees from KSA, all negative for MERS CoV. KSA reports 3 new cases past 48hrs ,  while of recent screened cases there, 4 more  have recovered and gone negative. ie  565 cases , but 6 more deaths ie 186 died -  33%;                Worldwide  thus at least 680 cases / 215 died. But apart from KSA and Jordan (5/10 died= 55%) the fatality rate in the other 19 countries reported is thus  also 22.6%, as low as 13% mortality in UAE if their figures are to be believed.  The problem is we dont know how many subjects were screened in each country to get the perspective.. Perhaps UAE simply screened many more ‘well’ people with “flu’. of recent cases reported from countries outside Arabia, virtually all presented clinically with serious URTI.  Only 2 MERS-COV cases have been finally confirmed in USA, both travelers back from KSA. Thus it is apparent from all the screening patchily reported  the past 2 years that:                                                                                                                                                          1. air/physical contact  crossinfection between humans (as between camels and humans)  is common; 2. but resultant  actual colonization (ie the asymptomatic MERS CoV carrier- akin to say the common staph nasal carrier)  is reassuringly low- likely in mildly immunocompetent people with suboptimal   vigorous eg vit D3 levels and intake of vits C, zinc etc; and  cleared naturally within days; 3. BUT of those colonized with  invasive MERS CoV  who actually present sick enough-ie with MERS-  (generally those with  comorbidities) to consult doctors, mortality may be > 50% (as eg in KSA,  Jordan, Qatar, UK) – likely because they have poorly controlled diabetes, HIV, heart/lung/kidney disease;  or very low vit D3 levels and very low intake of vit C, zinc etc. 4. So far survivors of MERS  apparently do not stay carriers of the virus. These observations will be simple to affirm/ refute by storing, or immediately testing, all carriers’ and cases’ blood  for 25OH vit D3 (albeit expensive)  as well as the other obvious markers  . But it is harmless and virtually cost-free to treat all such people anyway with vigorous vits D3, C and zinc against all latent/patent  diseases. Parallel experience with seasonal flu/ common colds  is that while the URTI  may have been protracted till the patients consult, virtually all cases quickly resolve with vigorous supplements (vits C, D3, iodine, multivite,  appropriate iron, and appropriate decongestants/ “vix” steaming. And of course it is simple and appropriate to deep-sniff pure vit C + D3 powder- as easy as using a nasal sprayer. .                                                                                                                         27 May 2014  Jordan reports  a  fresh (10th) case;      KSA  now 562 cases -no new cases, but one  more death;   national  school exams start there irrespective.. so global total now may be 650..now   2 in Iran. – – the 21st country?. Its not to say that >650 people have caught the illness,  since apart from 30% who died of MERS , at least 20% were well, found only on viral swabs of contacts, ie by definition did not have the MERSyndrome that has killed 30%.. The  global  authorities have not revealed how many of the balance of 50% of those who screened positive actually developed any flu-like symptoms, as opposed to those who survived pneumonia & renal failure. Vigilance is necessary everywhere since both seasonal (H1N1) flu is spreading in the southern hemisphere, and MERS from Arabia with the recent peak there, and business, social and umrah travelers pouring through the Middle East  hubs- especially to and from the worldwide Muslim diaspora , and trade hubs, . . “If you get sick within 14 days of being in the Arabian Peninsula, call a doctor and tell the doctor where you traveled.” said an NBC report earlier this month. 26 May 2041 Our  first ‘ground zero’ MERS suspect returnee from Riyadh  today screened in Cape Town?:  after a weekend with  my own flu attending a 3day medical congress here, and bad family news last night, I was caught flatfooted this morning at a  walk-in local family practice clinic full of people with sudden flu/gastro gripes: the first lady  in (robust, no chronic illness)   with usual sudden  overnight flu   had after two weeks visiting her family in KSA, jetted back from there   just two weeks ago, having sat  behind a man coughing and spluttering.               Before starting highdose  supplements etc, she was  deep nasopharyngeal swabbed for flu and MERS  exam  by our South African National Institute for Communicable  Disease.  Then we will,  if she/her family prove positive,  contact the airline to start tracing all passengers and contacts here. She is hardly in the  risk category that has rocked the KSA. We dont know yet about her flight fellows..

25 May 2014:  HOPEFULLY THE MERS SURGE IN KSA IS OVER?      latest  cumulative Saudi reports are of  ~558 MERS cases in KSA,   179 deaths ie ~7 new cases detected a day (none elsewhere) . Thus in the 3 weeks since 3 May, unverified reports mainly from middle east websites  are of about 101 new cases ie about 5 new cases a day, and 42 deaths in KSA   ie 2/day- ~40% mortality. The rate of new cases presenting and being detected is down, but with the incubation time-lag (5 to 14 days till illness if any),  assuming that all sick citizens are  promptly tested, the mortality rate will fall next week from its peak a week ago.  Tightening protective measures in the KSA  and no doubt  in all global air-hubs outside KSA are hopefully working- there has apparently not been another reported cases outside KSA the past week. 96% of all cases detected have been in KSA & UAE, with 90% of deaths from MERS being  in detected cases there. The lack of new cases reported elsewhere suggests that the global figures are now about 641 cases and 208 deaths ie about 32% mortality. .

22 May 2014 update:    in KSA   544 cases, 176 deaths  ie  so far 18 cases/million, 32% mortality;    UAE 7/million;    worldwide 661 cases,  207 deaths  ie 32% globally. But excluding KSA and UAE, the occurrence of MERS  in the rest of the world – including most of the >billion Muslims-  has been 50 cases ie <1 / 100million; and all of these cases have apparently  been direct human returnees from the middle  east, or their immediate contacts.  Has one non-Muslim died or been seriously ill from the virus? This information is not available on the internet. But there is No pandemic in sight.  At least, as Australian observer  Ian Mackay points out, the trend in new cases in KSA is downwards the past month. The common denominator in KSA appears to be  that especially city Muslim women there must be virtually totally  covered when outdoors in public view.. But as noted earlier in this column, repeated university studies there by their own specialists have shown that their people are especially vulnerable to vitamins D and C deficiency, so easily correctable , a testable hypothesis at trivial cost? This perhaps easily controllable plague  is surely an unintended consequence for  one of the most highly learned and religiously devout peoples in the world? Is the  epidemic growing solely  in the KSA because by strict custom, Saudi Arabian residents (and their pilgrim   visitors-who also are likely  ultraobservant)   have  to  cover up maximally, Dress to Kill? In the rest of the Arabian peninsula the MERS incidence rate is only a fraction? although the deathrate is similar.

19 May 2014 update:  KSA toll now  537 cases / 173 deaths  ie 31% mortality. The total there was inflated by 19 patients in the Jeddah  dialysis unit contracting MERS some time recently. It remains to be disclosed  how many of these cases were diabetic, were on vigorous vits C/D supplements, and died? The global figures are now 620 cases tested positive and 202 deaths.

17 May  2014 including a 3rd case (by direct contagion from a newly arrived traveler) in USA, there are  now  about 650 MERS cases reported  worldwide, 200 deaths ie 32%  fatalities;   14 new cases daily globally  the past 3 days;   KSA  529  cases   168 deaths (ie 11 new cases  a day; and 16  deaths the past 3 days). But 96% of all cases worldwide  to date  presented in the Arabian peninsula’s  80 million Arab population, and apparently   all 27 outside cases were exports from KSA or their immediate contacts. .. The Wiki entry  Tourism in KSA  states plainly :  “In December 2013, Saudi Arabia announced its intention to begin issuing tourist visas for the first time in its history.  Restrictions and security : Visas are only issued for business, relatives of Saudis, transit to a third country, and Muslim pilgrims; general tourism is not allowed.”   So effectively  in KSA cities  there are in public  only heavily-garbed  Muslims.  Apparently nownon-muslim tourists can visit the KSA in a group organized by an accredited agency”, obviously provided they conform to local religious norms. But “A limited tourist visa programme was cancelled in March 2014.[5]       Saudi Arabia does not currently issue a visa for tourist travel. Hence apparently the KSA population especially in the cities is  overwhelmingly  Muslims conforming to orthodox Wahhabi  Sunni outdoor   attire- although there are apparently  some 1 million christians (ie 1:30 of the population -presumably mostly professional/technician experts- in the big cities) in the KSA. Apparently there are over a million camels in the KSA,  (apparently nearly 25million worldwide) with a lifespan akin to humans. “Camels  come from neighboring Middle Eastern countries, in part, but also from countries in eastern Africa, including such already beleaguered places as Sudan and Somalia, Nigeria, Tunisia, Ethiopia.     Just now online, not scheduled for formal publishing until this summer, is a brand-new CDC report  finding widespread evidence of MERS-CoV in African dromedary camels too.” With the dromedary  numbers (at least 1 per 30 Saudi  citizens), camels’ huge stamina ie resistance to disease, including apparently the MERS virus they carry,  their cherished role including as pets, meat, transport, racingstock,  and supply of fresh warm milk  in KSA society; and  the reported low human vitamin D (and perhaps C) levels in the heavily-garbed city  citizens,  no wonder camels  are an ongoing source  of the hitherto unknown MERS coronavirus illness for immunodepleted citizens in KSA? whereas the camels themselves apparently suffer no more than a mild cold. A  respiratory virus infection in a temperate climate is usually easily thrown off with symptomatic Rx, supplements and plenty of fluids; but on the other hand, in  middle east desert  temperatures and in all-over robes, hyperthermia and dehydration from MERS  may more obvious cause of pneumonia and  (pre)renal failure- especially in a population with high rate of sickle cell, diabetic, overweight, cardiovascular and hypertensive disease. Average temperature  are about 29-330C ie mean peaks of 40C; with humidity  17% in Riyadh & Medina, but much higher in Jeddah;  intermediate in Mecca..

And “Middle Eastern countries import tens of thousands of camels from eastern Africa annually. Many Saudi camels are imported. Scientists don’t yet know where the MERS virus originated or how camels got it, but it has been found in African countries and as far away as Spain’s Canary Islands, where a tiny population of camels lives for the past 400 years .        ” Camels in the kingdom are like dairy cows, beef cows, racehorses, pulling horses, beloved Labradors, and living daily reminders of holy scripture, all in one. (Camels appear, honorably, in the Quran.)” As the latest report from Pulitzer Centre Prof Cynthia Gorney’s Nat Geographic account of MERS ends, “Fresh warm camels milk straight from the udder is “Very heavy, very sweet, very therapeutic” Ameer said, after I stopped shouting at him over the phone.  If I were still in Saudi Arabia at this moment, I told him, I would be smacking him upside the head.”  What likely gave Ameer his claimed  immunity? that he had been years in USA?, and like Arabian desert camel-keepers probably  lightly clothed and much in the sun- thus with good vitamin D levels?

A new report today from WHO chillingly details a party of at least 9  Umrah pilgrims since April 2014 who  from Jeddah visited Mecca and Medina  and then back via Jeddah to Amsterdam, Greece and USA with developing MERS – from the Jeddah sub-clade which has been identified in at least 30 cases there.. These linkages do not explain why the MERS outbreak has mushroomed solely in KSA residents – not in Muslim communities outside Arabia into which travelers flying home via Jeddah  have imported the virus. The co-factor may be that, having inhaled/ingested  the virus from human carriers in the KSA, these foreign travelers, often with co-morbidities, were also more vulnerable to the MERS virus because of their adherence to the same  all-over dress orthodoxy, and dietary vitamins D & C and perhaps zinc depletion  (with or without sickle cell trait) as has been reported prevalent in the KSA; and detailed with references below. A study is awaited of comparative skin shade,  diet and skin sunshine exposure (ie degree of conformance to strict Sharia covering) between Saudi Arabians of longterm Arab descent, and their relatives and  similarly conforming co-religionists in the distant diaspora Muslim overseas communities  that send Umrah and Hajj  pilgrims through Jeddah to Mecca and the other shrines. A current  wiki-islam website stresses the serious health hazards (both skeletal- rickets and osteoporosis – and across all system diseases including immune-infection- protection) of full-cover Islamic ie hijab dress through sunlight vitamin D deficiency, unless vigorous vitamin D supplement is taken.  It is no surprise that this is as much of a danger for hijab Muslims  in high-sunshine desert latitudes as in bleak low-sunshine cities far north.. This might explain why the latest WHO population statistics (perhaps 2011 ie before the MERS outbreak) show that – despite being perhaps  the richest  per-capita nation (from oil reserves)  in the world,- the KSA has expected survival age 5 years below that of UK, especially from combined (hypertension-diabetes-coronary heart- kidney ) disease rate of 375 in KSA vs eg 80 in UK. But even then, a different WHO website showed flu and pneumonia deathrate (before the MERS outbreak)  37 in hot, dry KSA ie 50% higher vs 23.7 in UK. and in about 2011, KSA had a mean population age of 20 years, with annual (agri-and seafood)  imports  ie dependence of US$17billion, due to its desert-limited agripotential; with predicted rapidly increasing urbanization .  It will cost pennies, and a few weeks’ followup of supplement dispensing to KSA citydwellers, (and incoming pilgrims before they leave their diaspora homes for the KSA),  of vigorous dose vitamins D3 +  C and a multisupplement including the other vitamins , magnesium, zinc,  iodine; and  fish oil and virgin coconut oil (ie a blanket antioxidant, antiinfection, antihypertensive  insulin-sensitizing umbrella supplement)  to confirm if the emerging epidemic of  MERS (let alone hypertension-heart-diabetes-kidney  disease)  in KSA  is significantly slowed, as  common infective and degenerative diseases  are here  in Cape Town, by such supplements. This simple prospective clinical monitoring of those receiving or not receiving  the swine flu vaccine in 2009 was universally recommended, but Authorities refused to enforce such simple monitoring, so there is  no clinical  evidence that the swine flu vaccine significantly reduced morbidity from the outbreak, which was globally statistically trivial except in the Mexican source outbreak. Similarly, there is no evidence that the spread of MERS-CoV  in KSA is epidemic considering that even in the four most densely populated cities – in the three abutting  midwest  provinces  – containing almost half the national population,  – the detected spread of MERS illness is still so low (except in the incubator hospitals). Even though camels are so widespread. it is intuitive that rural/desert citizens may take  both more fresh  (desert)  crops (ie vit C) and more  vit D- from both camel milk  and more sun exposure from  outdoor work with more skin exposure in such labourers. Some  pictures of camel attendants apparently in the KSA  on the internet  show bareheaded men in vests.  16 May 2014   the latest  KSA  stats reported are 515 cases, 160 deaths ie 30% mortality. Globally 621, deaths 189 14 May 2014  now ~592 cases reported in 20 countries – the latest in the Netherlands, and a 3rd case in USA;  with ~31% mortality (KSA 495 cases, 152 deaths ie 31%; with 20% asymptomatic). 12 May 2014:  USA reports a 2nd case arrives there. a 5th death with MERS has been reported in Jordan.  Saudi Arabia reports 8 new cases since yesterday, and 2 more deaths.   But  as expected, in the KSA eye of the storm , it appears that only contacts of  patients are being screened- at least 20% of patients who screen positive for the virus have remained well. So the morbidity and mortality% are in fact very skewed, they are apparently not screening the local population for carriers. The ~28% death rate refers only to deaths in the cohort that were afflicted  with MERS and their contacts.

11 May 2014  A new Reuters report today highlights the widespread intimate contact with camels in KSA. “Does the KSA want to control the uncontrollable?                                So far, the reported cases have all originated in Saudi Arabia or in the southeastern part of the Empty Quarter, in the UAE. There are no reports of those outside Saudi Arabia having transmitted the disease to others. the past week has seen another ~116cases  ~15 cases a day- reported in the Middle East, and another 34 deaths  there ie the total has reached ~578 cases (483 in KSA- Kingdom of Saudi Arabia) and ~163 deaths (142 in KSA). So  the death rate has fallen  to  <28% overall.  Lebanon and USA  become the 18th/19th countries to report a case of  a returning traveler.  But virtually all  identified cases originated in the KSA neighbourhood. The latest figures show that MERS originated and breeds exclusively in the Middle East- (cases per million ppm the past 2 years) in 16 ppm in KSA(483 cases total), 6ppm in UAE (53 total),    3.5 ppm in Qatar(7  total)  and  1ppm or less  in Jordan (9 total- the first reported cases, in April 2012)) or elsewhere. Apart from the frequency of camels, and the high prevalence of deficiency of vitamin D and possibly vitamin C reported below, ethnic culture may play a major role:  In KSA, Qatar and UAE the great majority of citizens are Wahhabi Sunni muslims. By contrast, Yemen is only 65% Sunni, but  Oman is distinctly different Sharia culture. Iraq and Iran are predominantly Shia culture.

Jordan on the other hand is a unique  Hashemite culture although also  70% Sunni;  so contrary to the Wahhabi countries,  “ Jordan is one of the most liberal countries in the Middle East, with a secular government“. So the increasing prevalence of MERS in the Wahhabi Arabian peninsula peoples relates perhaps  to the likely cluster of predisposing factors:   well-covered male and especially female orthodox attire, if not also higher prevalence of sickle cell trait, and diet,  which is associated with deficiency of vits D, C, A and E as referenced below. Feminist Muslim websites may correctly argue that Hijab does not cause vitamin D deficiency;  but it likely contributes significantly to it’s spread via lowered vitamin D production in skin – with orthodox Muslim women arguing that such women can arrange private sunlight skin exposure. This trend to vitamin D deficiency from low oral   and sunlight-mediated  vitamin D is incidentally mirrored in  new studies:. :                                                            from  USA – The Vitamin D status of Prison Inmates- which confirmed that, on a ‘sufficient’  diet including vitamin D intake,  the higher the security isolation of inmates (and therefore least sun-exposed), the lower the vitamin D status- especially in the darkest-skinned inmates; from Israel   Effect of different dress style on vitamin D level in healthy young Orthodox and ultra-Orthodox students in Israel; and in southern Italian nuns.

So vit D deficiency in MERS  may be like  in AIDS:  Vitamin D Deficiency in HIV: A Shadow on Long-Term Management)? (2014, London UK).  But vigorous vitamin D charge – by sunshine and especially vit D3 supplement- as an immune and anabolic booster is one of the safest and cheapest preventions of all disease that there is. With the Ramadan Hajj to the KSA this year only 6 weeks  away, intended pilgrims need to top up their vitamin D3 levels and multivites vigorously now, to boost both their infection resistance and improve control of all major diseases they have;  and take plenty of vitamin C with them.  So should  their communities, contacts  here as pilgrims return from the Hajj. SUNSHINE AND ORANGES: ANTIBIOTICs VITAMINS C AND  D like vitamin CVitamin D is hardly a new anti-infective agent as an Israeli study (Borella ea 2014) now confirms, since sunshine sanatoria were  the only effective treatment of tuberculosis in the pre-antibiotic era even after WW2; and ” An association has been established between low levels of vitamin D and upper respiratory and enteric infections, pneumonia, otitis media, Clostridium infections, vaginosis, urinary tract infections, sepsis, influenza, dengue, hepatitis B, hepatitis C, and HIV infections“. Especially in this post-antibiotic age of rampant antibiotic resistance. Sunshine and Oranges - Empty Cradles-  is  ironically,  the account of Britain’s infamous ruthless  export- banishment to the Colonies -from the early to post WW2  20th C   of thousands of surplus children of poor or orphaned families. Shades of the forced transport of ‘felons’ to Devil’s Island and the British outposts of previous centuries.  Usually clad in scanty rags, in Australia  they certainly   had plenty of sunshine ie vitamin D , and  the abundant local oranges (vitamin C);  but like their surviving mothers, much grief and poverty – while from lack of these same nutrients, their kith and kin back in UK  were ailing with infections and rickets . .

3  May 2014  four months later:  MERS RESURGENCE: NOT A PANDEMIC BUT A DEFICIENCY SYNDROME? more precautions needed:  With the recent flareup of MERS Middle Eastern Respiratory Syndrome in the Gulf States, the number of reported cases since New year has more than doubled to 457 ie to >24 cases a week there, but still only in residents/ travelers from/through the Middle East hub, and their contacts;   in 17 countries including Europe, Egypt, Malaysia,  Philippines and now a traveler from Riyadh to USA.  The death toll has reached 133/457    ie the death rate  has  fallen steeply   from 42% last December to 29% overall, understandably as more cases are detected by screening in the source, the Kingdom of Saudi Arabia KSA.   Wiki   and Reuters seem to give  the most update  (if not WHO-confirmed) stats. So the evidence so far is that, while camels are endemic carriers there,  most  recent sick cases have apparently been been traceable  human to human transmission – apparently all among Muslims, and in the malnourished or chronically ill older, and  health workers as in the case just reported in USA.      So there is no apparent spread by other vectors eg bird and farmyard swine as in the case of influenza. Since the reports available indicate that the MERS virus is dangerous only in those already malnourished or with serious other systemic disease, it is like flu-  pretty harmless in the well adequately nourished and housed. While frequent flyers are generally well off and well nourished, the same cannot be said for those in virtual ghetto  slavery all over the world, eg migrant labourers  working on contract  in the Gulf States, who have apparently been among the latest victims . So as with the overblown Swine Flu non-pandemic of 2009, there is no good evidence to label MERS  a deadly epidemic, it in fact seems to have low cross-infectivity compared to say influenza which spreads like wildfire- but with no more morbidity (except in Muslims?) than the common cold corona viruses.

WHY IS MERS  LIMITED OVERWHELMINGLY TO AND SPREADING ONLY IN THE KSA and UAE?  is it a unique genetic trait of Saudis?  or is it micromalnutrition unique to this  ultra-orthodox Muslim nation with unique almost total skin coverup outdoors? why was there no outbreak of MERS in the millions of pilgrims who did the Hadj to the KSA last year?   the KSA is 100% muslim, whereas the UAE only 76%, with far more foreigners working and living there. It is common cause that peoples who keep well covered during daylight hours – as ultraobservant Muslim (and ultra-orthodox Jewish)  women and  men do, have much lower vitamin D levels. Those on restricted diets are also more prone to malnutrition including vit D deficiency, especially if low in dairy products. Common sense perhaps explains  why Saudis – in the heart of Islam (Mecca, Riyadh, Jeddah, Tobuk) have low vitamin D and likely also low vitamin C and zinc levels, and thus more infections. Moderate to severe vitamin D deficiency was reported prevalent  last year in Saudis by Al-Daghri,  Sabico  ea  from King Saud University Riyadh- where Hasanato in 2006 reported low vitamins A, C and E and zinc levels in severe sickle cell disease. El-Hazmi ea  from the Saudi College of Medicine also in 2011 reported that Saudi Arabia and Bahrain have the highest prevalence of sickle cell genes in the Middle East,  at up to 18%. Bahrain has just opened a sickle cell hospital, but Bahrain has the tiniest population (1.3million) of the Gulf States although the highest population density, compared to the 38million of the KSA plus the UAE which have had over 90% of MERS cases. Most if not all the camels in Bahrain are in a zoo; whereas in the KSA camels are a favourite if not sacred possession and listed first as the  domestic animal. So the absence of MERS in Bahrain is unsurprising.

The UAE on the other hand also has many camels as entertainment if not also for travel – with 5000 camels entered in a beauty contest there alone.. So, despite long days ie much sunshine exposure in Arabia, low  fresh water availability likely reduces hygiene  (washing and oral hydration) capacity for the masses let alone camels.  And the well-covered dress code, and low availability of private sun-exposed balconies and courtyards  (unlike apparently more liberal Muslim countries) mean that the Saudi masses do not have the opportunity to get much-needed sun exposure to even the face, neck and limbs let alone the torso.

        Hence Saudis have as obvious  major risk factors for MERS  -not just the teeming MERS reservoir in their valued  camels (also a staple   milk supply), but more importantly endemic deficiency of vitamins C, D (and perhaps E, zinc) and water compared to relatively less clothed populations in other  hot but also better water-supplied  countries that also do not carry much sickle cell disease.

Camel meat is apparently no longer a staple in the KSA where staples now include Bread, hummus, rice, and  Tabbouleh- a “salad” generally made of parsley, bulgur, tomatoes, garlic, and lemon; Kapsa: the national dish is chicken and rice with vegetables; and Kebab:  a base of roasted lamb or chicken and vegetables in pita bread. There seems  little vitamin D in that varied diet, especially not pita bread or rice.

      The only good unfortified and unprocessed food sources of vitamin D are apparently oily fish,  liver, mushrooms, and (if fortified),  egg yolk and dairy products ; or else vitamin D3 supplements. ..

Finally, it is common cause from published studies and our local experience that infections eg HI, TB,  influenza,  herpes  and the common (Corona virus) cold are easily treated and prevented by vigorous safe intake of vits C & D combined with the other multivites, zinc, iodine, iron and selenium. In advanced infection cases of eg HIV and TB (in trials  from Central Africa and Canada), combining even modest doses of just 2 or 3 of these supplements with appropriate antivirals and antibiotics reduced dreadful morbidity and mortality by two-thirds. NATURAL PREVENTION/TREATMENT: with the theoretical double peril of influenza and MERS-   (ie as with the looming  Influenza A gastro-/respiratory season in the southern hemisphere),  with no proven  vaccines or antivirals reported or likely, those in contact with Middle East travelers- or any infection eg flu  outbreak- are again reminded to boost their immunity  and global health with safe effective lowcost NUTRITIONAL ANTIINFECTIVE supplements: 1.VITAMIN D3 CHOLECALCIFEROL 2500-4000iu/kg/month  (not the weak  vit D2 ergocalciferol  falsely labelled  “Strong” Calciferol tabs) most simply taken as a few scoops ie 50 000 to 250 000iu of vit D3 powder/MONTH at all ages (AND IDEALLY target BLOOD- LEVEL 80-100ng/ml depending on overall illhealth state. IT IS VIT D3 THAT IS STRONG CALCIFEROL, NOT VIT D2, since experts report that vit D3 is apparently four times more potent than D2. 2. MULTIVITES with zinc selenium and iodine (and iron for likely deficient eg kids, young women), but  especially 3.  buffered VITAMIN C ASCORBATE  at least 3gm/d orally ( if not with bad infection symptoms – 10 or >30gms / day if not ivi)  at trivial cost as powder;  to tolerance; 4. with eg  ecchinacea, melatonin, garlic, colloidal silver, sutherlandia and whatever other antiviral available locally. Since flu and colds disrupt both sleep and outdoor activity, nothing makes as much sense as co-supplementing both of the day and night hormones melatonin and vitamin D; as well as the other sunshine vitamin- ascorbic acid (solar-produced in abundance in  eg fruit) – to improve both sleep, rest and immunity. For small kids/infants the vitamins and minerals can simply be taken as powder in liquid ie in feeding bottle or a  glass. It is increasingly notorious how depleted modern breastfeeding mothers (on the industrial polluted fructose-sucrose-  aspartame PUFA-antibiotic-hormone-glyophos- GMO laden  food chain now prevalent)  and baby formulae  (unlike colostrum from pasture-fed eg New Zealand dairies) are in such lifesaving  immune and anabolic anticancer  boosters.

Ironically,  recently  Prof Zahid Naeem ea from the KSA Qassim University publicised in their university International Jnl of Health Science   Vitamin D Deficiency- An Ignored Epidemic in 2010  and 2012  , with prevalence there of up to 80% in the KSA despite the abundant sunshine, thus urging vitamin D supplementation. . But such simple prevention – of all disease but especially wished-for megaprofit  pandemics like flu and HIV-  is anathema to the multinational Big Pharma and their lobbyists in the global Disease Industry, which employs millions worldwide and generates trillions in income for government and corporates. Prevention does not pay. Simple prevention suits no-one working in the disease  and drug and hospital industry since it makes most health workers especially doctors and administrators and hospital  largely redundant. It seems that public health officials choose to go on ignoring the deficiency epidemic even in the KSA- unlike Dubai, there is no website of the KSA Govt promoting vitamin D supplementation.  The solution is too cheap – and embarrassingly simple.  An anonymous blogger details the numerous reasons for endemic vitamin D deficiency in especially the Gulf States.. at least the Dubai Govt publicises the deficiency, and supplementation. Is it irony, or an indictment of the prevailing world-wide largely male-dominated -subservient female culture,   that already back in 2001, there were strong warnings about Niqabs and Burqas as Impediments to Health? already in 2012, dairies in the UAE were fortifying milk with vitamin D; and in 2001 academics published a study showing the many reasons for prevalent vitamin D deficiency in the KSA. and Prof Mike Holick  in 2010 published an authoritative review  The Vitamin D Deficiency Pandemic: a Forgotten Hormone Important for Health urging vigorous vitamin D supplementation universally. As detailed elsewhere in this column last year,  the prophet of vitamin D and melatonin  the late Prof Walter Stumpf must be shaking his head repeatedly along with  the late Prof Linus Pauling, about the neglect of authorities  to promote and distribute vigorous supplements of vitamin C and D3 to the afflicted Arabian peoples let alone worldwide. But then we need to be reminded of the infamous Vitamin Murders, how Prof Sir Jack Drummond was mysteriously murdered with his family on holiday in France in 1952, when he and Linus Pauling were  the  leading vitamin discoverers and promoters  of the 20th century (as Walter Stumpf was of melatonin and vitamin D). The Big Pharma Disease Industry combined with the might of the FBI  and the FD  could never shut Pauling up;  but by whom and why the Drummonds were murdered remains unsolved, thus fertile conspiracy theory. Reading Drummond’s papers on the internet, one can understand why the burgeoning patent drug industry then as now hated natural lowcost unpatentable remedies, unbeatable natural safe  antiinfective agents like vits C and D and iodine – each almost universal panaceas. . .

This universal truth about industry suppressing  natural remedies  is the Semmelweis Paradox, that had the leading obstetrician of his day murdered in his prime by his jealous rivals.

27 Dec 2013  the outbreak not over:  9 new cases;   ie overall deathrate 42%, but past 2 weeks  4.5 cases a week just from the KSA..  :  Since April 2012, the European Centre reports  175 laboratory-confirmed cases, including 73 deaths, of acute respiratory disease caused by Middle East respiratory syndrome coronavirus (MERS-CoV), have been reported by national health authorities.  27 December,  Saudi Arabia confirmed nine cases (five asymptomatic healthcare workers and four patients suffering from chronic disease, two of whom had died).  24 Dec 2013 the score now stands at 166  (163 at 16 Dec)  cases and 71 fatalities- 42% –   in 18  months since the first identified case in June 2012; ie per week – 2  new cases and 1 fatality .  No pandemic. No outbreak. Considering the duration of the awareness  of the new virus in humans- apparently from bats/camels/swine,  even after 18 months of millions of pilgrims visiting the Middle East, and far more foreign travelers flying through those hubs, and intensive surveillance on those routes east and west,   the morbidity and mortality have been negligible with only a handful of perhaps related deaths in frail patients. Whether as with seasonal avian  ie H1N1 flu from China to the West and south there will be a flareup of MERS-CoV cases  in the pending winter from now on  in the Middle East, remains to be seen..

12 November 2013   Considering that the Hajj has just ended with millions of pilgrims returning home,  and vast numbers of multinational passengers transit through the Middle East hubs, its reassuring  that (depending on which reports are duplicates and delayed) only 3 or 5  tested positive cases and 1 or 2  deaths have been reported the past week:    especially since only serious flu-like cases are likely to be tested- but more so in the affluent who can afford to fly.   So far no reports of MERS-CoV case are apparent in South Africa, although flu-like illness remains  common here. Perhaps more people are heeding warnings to take multivites plus zinc plus vigorous vits C and D. The ECDC    and  OSAP  and NowNews  and GlobalAlert report   As of  11 November 2013, there have been  at least 154 laboratory confirmed cases of MERS  CoV worldwide, including 65 deaths ie 42% in TESTED cases. All cases have either occurred in the Middle East or have had direct links to a primary case infected in the Middle East.        Saudi Arabia has reported  at least 125 symptomatic and asymptomatic cases including 53 deaths  Jordan two cases both of whom died   United Arab Emirates five cases, including one fatality Qatar five cases, including two deaths  and  Oman one case who has  just died.       Thirteen cases have been reported from outside the Middle East: inthe UK (4), France (2), Tunisia (3), Germany(2), Italy (1) and Spain (1). 31 Oct 2013 with the Hajj over, the latest score is 149 cases and 63 deaths ie 42%. http://www.who.int/csr/don/2013_10_31/en/index.html ie 5 new cases a week from the region, 30% deaths. http://gmggranger.wordpress.com/2013/10/29/quikstats-mers-cov-in-the-arabian-peninsula-nov-2013/ 17 Oct 2013 with the Hajj in full swing, the latest tally is apparently 139 cases and 60 deaths.  So thats only 1 case  reported a week the past 4 weeks, and no deaths in that time.  Promising news, although we continue to see bad viral-like  respiratory-gastro infections in adults locally with the volatile weather.

20 Sept 2013 with below a month to go to the Hajj, the latest Quickstats are 135 cases confirmed, and 60 deaths ie 44% mortality- all new cases and deaths apparently in  KSA and the Gulf States. Thus in the past 7 weeks,  41 new cases have been reported ie 6  a week, all in the Gulf  States; with unaltered  mortality  (44%) apparently restricted to the chronically frail. This as the drastically variable  Cape Town weather alternates sunshine joy and freezing wet  snow or hail, with high prevalence of both respiratory and gastroenteritis attacks, sometimes with protracted debilitating bronchitis; how much of this is local seasonal colds- coronavirus– or  flu, orMERS-CoV,  or  the explosive Norwalk virus, is speculative and academic. Basically So What since management is symptomatic, and vigilant prevention  crucially effective with hygiene, home rest and multivites but especially highdose vits D3 up to 10 000 (100iu/kg)  iu/day or weekly equivalent plus  buffered vit C up to tolerance >100mg/kg/day, zinc, selenium and for the malnourished, iron; perhaps safe plant  immune boosters like sutherlandia, garlic etc; and avoidance of smoking, sugar and the likes-  boozing and sweetened soft drinks (fructose, aspartame,sucralose).

11 August 2013  OUT OF AFRICA?  no new cases of MERS-CoV have been reported the past week; but while camels (in Oman) are now also suspect hosts/ transmitters in the M E,  there is some evidence that the MERS virus has the closest virus match yet found to bat CoV  in South Africa. As a precaution, with upgrading of shrines in Mecca, KSA is actively reducing  overcrowding by Hajj visitors by 20%, and warning the frail  and elderly not to go this year. With the prevalent bad winter respiratory and gastroenteritis  infections at least around densely populated and polluted Gauteng and  KZ-Natal,  and especially the floral mountain kingdom of greater Cape Town-   all are encouraged to take vigorous doses of vitamins D3 and Superenhanced vitamin C with a broad multimineral-multivite –  extra vits A, E, B &   coQ10;  the minerals zinc,  selenium, iodine, colloidal  silver, (and iron in the young commonly at risk of deficiency);  probiotics ;  rooibos or buchu or green honey and lemon tea,  sutherlandia;  licorice, St John’s wort, garlic,  echinacea, olive leaf  etc;   including sniffing vitamin C ; and  if snotty rhinitis/sinus/bronchitis symptoms,  steaming with eucalyptus etc.. And during acute attacks especially of respiratory and gastro attacks,  avoid sugar,  fat,  dairy and wheat intake.

2 August 2013  The Hajj to Mecca this year is  in the third week of October.  While over 15 million (of the world’s ~1.5billion) Muslims visit Mecca – Umrah- annually, some 3 million pilgrims worldwide make the seasonal Hajj visit trip, with pro rata from South Africa  only 2000 (of our ~2.5million) apparently the quota of pilgrims allowed this year   by Saudi Arabia . But increasing numbers of frequent flyers of all nationalities and races to and from South Africa – Europe fly via the Gulf States  Emirates airline, if not commuting to work and visit family there – including professional sports teams for tournaments… So this week’s flood of warning bulletins  on the Gulf State respiratory infection outbreak are cause for urgent caution and prevention, perhaps grim news for those who fly that ME route, and their families and close associates and neighbourhoods. The 49% deathrate reported in the now 94 cases- 3 more reported  1 August  from KSA- so far from the MERS-CoV Corona Virus MiddleEast Respiratory Syndrome outbreak is alarming, that has spread the past 10 months  from the Kingdom of Saudi Arabia KSA  and  the Gulf States  to Tunisia, Europe – France, Germany, Italy-  and UK . It is now being recognized as distinct not just from the common cold coronavirus but also from the Chinese Severe Acute SARS-CoV virus outbreak since 2003, of which over 8000 cases have been recognized , but the latter virus having a fatality rate of only <10%; and the current violent but selflimited Norwalk virus  gastroenteritis (explosive vomiting and diarrhoea for 1 -3days;  (fatality rate <0.1%) raging in UK,  it recently is the commonest cause of foodborne infection in USA  .

No clinically effective vaccine or synthetic drug treatment has yet been found for these coronaviruses . The same lack of specific antiviral therapy applies against gastroenteritis viruses and influenza, but the mythical 2009 swine flu ‘pandemic’ was even milder (than some seasonal flu outbreaks) with a proven mortality rate far below 1% considering how rapidly far and widely it spread. The reservoir if any of MERS-CoV may  be cave bats, (and, ominously, perhaps swine – c/f the 2009 swine flu ‘pandemic’ that wasnt; shades of the deadly Nipah virus outbreak of 1999 – from bats to pigs to man).. But the fact that MERS-Co is spread human to human, and mainly men ,  has been attributed perhaps to women in strict sharia society being well veiled and thus shielded from inhaling (and transmitting) the air-born virus, never mind womens’ generally stronger immune systems and hygiene, self-care. So beware   all those in close contact with recent air-travelers through the ME states and surrounding subcontinent airports – never mind the S-E-Asia airhubs of Hong Kong and Singapore: it maybe  only a matter of weeks before cases occur on the other continents especially in city dwellers, public transport commuters, factory and office workers; and who knows, perhaps where bats and swine cohabit close to cities, as around South Africa.. .. Its cold comfort that the latest report  yesterday and today,  note that this stage is perhaps like SARS in 2002 and swine flu in 2009, the ‘bottom of the iceberg’, with only severe cases being admitted, tested, reported, in already chronically ill frail patients; especially diabetics and renal failure – to which older Muslims are particularly prone; while the virus spreads silently, mildly if not harmlessly  in the well majority, as in two young well  women health workers in contact with a chronically ill elderly female case in Riyadh, KSA … ANTI-INFECTIVE PROTECTANTS and advice are available from the Natural Remedies Centre, 15 Grove Bldg, Grove Ave, Claremont, Cape Town ph 002721-6831465 or -6717415: Fortunately  all Health Shops  are well stocked with the many  almost 100% protectants against serious infections including fungi bacteria and viruses – colds (ie corona-) and flu’-virus (let alone against all others) afforded by the basket of locally available (although mostly imported)  natural lowcost evidence-based  nutritionals – supplements  the past decades: safe  hefty combinations of a number of immune-boosting  vitamins, minerals and foods, herbs. This septuagenarian author has, touch wood, on this combination- increased at occasional  times of suspected colds-fever- , despite great stress, and flu ‘pandemics’, and avoiding vaccinations,     not had a bad infection lasting a day in the past 5 years despite working in the highest risk  poor townships and acute hospital clinics with rampant HIV – multiresistant TB cases .

BREAST SCREENING and BAD DIET ARE OBSESSIVE-COMPULSIVE DISORDERS. ASSAULT UPDATE 2014: FLOOD OF PROGRESS AGAINST BREAST CANCER/ DISEASE.

neil.burman@gmail.com  Cape Town.                   read this  in concert with:                       combatting rising-occurrence-of-breast-cancer-in-younger-women;  and
 UPDATE 18 OCT 2014: more arguments against screening mammography from UK and Canada:Curr Oncol. Oct 2014; 21(5): 210–214.  Reflections on screening mammography and the early detection of breast cancer.  A Countercurrents Seriesa    S.A. Narod, MD  *Women’s College Research Institute, Women’s College Hospital, Toronto, ON.A little learning is a dangerous thing.— Alexander Pope, An Essay on Criticism

In the stormy aftermath of the recent publication of results from the 25-year Canadian National Breast Screening Study (nbss)1, various opinions questioning the validity of the study’s results have been expressed27. I was a latecomer to the study. In 2005, I was charged with oversight of the final record linkage and the statistical analysis and interpretation of the final data set. Dr. Anthony Miller has been my mentor since 1987. Our first joint paper, on screening for cervical cancer, was published in 19918. I chose not to respond to individual criticisms, but instead to collect my thoughts and to try to explain why the study authors saw no benefit from screening.

Most of the criticism from the radiology community focuses on issues of study design (which they claim was inadequate) and on the quality of the mammography (which they also claim was inadequate). Cancer survivors bolster those criticisms with testimonials and appeals to common sense. Supporters of the study are drawn from the public health community, and they tend to focus on overdiagnosis and health economics.

The report at issue is not the first emerging from the nbss. Earlier reports9,10 were criticized for not having allowed adequate follow-up time. But the 25-year results resemble the early results, and the authors are no longer criticized for premature disclosure. None of the first-generation critics have acknowledged the consistency; instead, they look elsewhere and point out other weaknesses. They claim that high-risk women were assigned to the mammography arm in violation of the principle of randomization. In his bestseller The Emperor of All Maladies, Siddhartha Mukherjee says, as a matter of fact, that high-risk women were assigned surreptitiously to the mammography arm, which explains the lack of observed benefit11.

The most recent nbss report1 tallied the breast cancers that occurred in each of the two study arms after the screening period ended (that is, between years 6 and 25), counting 2584 cancers in the screening arm and 2609 cancers in the control arm. If the screening arm had been enriched for women at “high risk,” that enrichment must have been performed in a peculiar fashion, using only risk factors that have a transient effect. Perhaps Dr. Mukherjee would care to explain what those factors were. It follows that the excess of cancers seen in the screening period (years 1–5: 666 vs. 524) was a result of early diagnosis and not from stacking the deck.

In any case, compelling evidence against the criticism of assignment of high-risk women to the screening arm is provided in the most recent analysis1, and that criticism is no longer raised (although no one has retracted or apologized). Instead, critics now insist that many women with palpable lesions were sent directly to the screening arm by duplicitous research assistants. There is no reason to believe that such actions (which would involve a national conspiracy of dozens of coordinators who spoke two official languages) were taken, but even if they had been, the study and its conclusions would not necessarily be invalidated. Even if all the women with prevalent cancers had been shunted to the screening arm, the situation could still be remedied by ignoring all cancers found at the first screening round (prevalent cancers) and focusing instead on the incident cancers. Such a strategy is not uncommon in screening studies. In the nbss, no woman had the opportunity to “cross the floor” from one study arm to the other after initial assignment. Therefore, if we exclude all prevalent cases from the analysis and focus on women with no cancer at study entry, we can re-evaluate the benefit of mammography thereafter. The hazard ratio for death from breast cancers detected in screening rounds 2–5 was 0.90 (95% confidence interval: 0.69 to 1.16;p = 0.40).

But what about crossover? It is claimed that a certain proportion of the women in the control arm—perhaps as high as 20%—opted for screening off-study, in particular after the screening period was over. That crossover will, some say, eclipse a benefit of screening that might otherwise have ensued. That is, the benefit of mammography (which might well have been substantial) was nullified by a subcohort of independently-minded women who went for mammography at the end of the 5 years. That speculation is fanciful, but if true, should be welcomed, because it can now be said to a patient who, at age 40, requests a mammogram, that there is no hurry; she can come back in 5 years for a mammogram and achieve the same net benefit. And when she comes back at age 45, she can be reprieved again until age 50.

Crossover is a form of contamination that results in misclassification of the exposed and unexposed groups. In a trial, it will tend to bias the result toward the null. The best way to avoid misclassification is to randomize the patients after they agree to participate—as the nbss did. In contrast, in the Swedish two-county trial (discussed in more detail a little later in this article), the subjects were randomized by intention-to-treat—that is, by whether they received or did not receive an invitation to mammography1215. Of the 78,085 women in Sweden who were offered screening, 69,645 accepted and 8440 declined. In effect, then, 8440 women in the Swedish study were de facto misclassified (versus an undisclosed number of hypothetical crossers-over in the Canadian study). The proponents of the Swedish study do not see that misclassification as a shortcoming, but instead use it to buoy their argument in favour of screening. They say that if everybody invited for screening came for screening, then the protective effect would have been more profound. In the Swedish study, all women in the control group were offered a screening test after the screening period ended (a reasonable thing to do); but those authors were not criticized for “contaminating” their study.

The second issue raised concerns the quality of the mammography. After all, the nbss tests were completed 30 years ago using 30-year-old technology. I still wonder how things might have been done differently. Mammography screening identified 212 women with breast cancer who would otherwise have been missed. They had cancers that were, on average, 1.4 cm in size, with 67% being node-negative. The survival of those women was very good. At the end of the study period, 170 women with a nonpalpable mammography-detected breast cancer were alive or had died of other causes. How many of those lives did screening save? Fifty? Twenty-five? Ten? Unfortunately, all we can say is that the number was too few to be noticed. If a significant number of those 170 lives had, in fact, been saved, surely the difference between study arms would have been noticeable. Breast cancer deaths numbered 180 in the mammography group and 171 in the control group. Perhaps some of the survivors believe that their lives were saved. They might perhaps have written a letter to the editor of their local newspaper extolling the virtues of mammography. But 42 women with a nonpalpable mammography-detected cancer died (none of whom has written a letter to the editor).

I am also among the authors of several publications on the benefits of screening by magnetic resonance imaging (mri) in high-risk women1618. Those studies were greeted as successes, given that they demonstrated how, with the use of mri, breast cancers could be downstaged. Those studies were accepted by the radiology community as being supportive of screening. Whether mri reduces mortality has not yet been shown. I cannot predict whether  mri screening will be effective in reducing mortality 10 years down the line, but I fully expect that if a mortality benefit fails to materialize, the studies will be criticized for using 30-year-old equipment and a poor study design.

Much of the criticism of the nbss has come from Drs. Daniel Kopans and László Tabár, and fellow travellers such as Siddhartha Mukherjee and Patrick Borgen27,11. They use the Swedish two-county trial as evidence of a good study that supports the use of mammography and quote a 30% reduction in mortality. Naturally, they do not criticize their canonical study, but it is time to take a closer look.

In the nbss, women were randomized on an individual basis after they had attended the study centre. The result was two groups of equal size and 100% compliance with the first screen. In Sweden, the two counties were divided into 19 geographic strata that were then divided into either 2 blocks (Östergötland) or 3 blocks (Kopparberg). The resulting 45 blocks were randomized, and women in more than half the blocks were sent a letter of invitation to screening. Of the 59% of women who received an invitation, 89% came for the first screen and 83% came for the second screen14.

The Canadian women were offered 5 mammograms 1 year apart. The Swedish women were offered mammograms every 2 years (ages 40–49) or every 3 years (ages 50–74) for up to 8 years. They underwent fewer screens (Table i). The cancers detected by mammography in Canada were similar in size to those detected in Sweden (Table i), but the size of the cancers occurring in the control group were very different. Those comparisons suggest that physical examinations or breast cancer awareness (or both) were important contributors to the size of cancers detected in Canada. A diminution of cancer mortality would not be expected to be associated with a 0.2 cm mean difference in tumour size, but might be expected with a net reduction of 0.7 cm in size19. Of the cancers detected in the screening arm of the Canadian trial, 68% were palpable. That fact has been a source of criticism. But a physical examination was not conducted as part of the screening protocol in Sweden, and the comparable number of palpable tumours was not given. Therefore, given the much longer mean time between screening visits in Sweden, and the high proportion of women in the screening arm that were never screened, I estimate that between 70% and 80% of the cancers in the mammography arm in Sweden would have been palpable and could have been detected by physical examination—had it been done. The fact that the relevant number is not given is a critical lapse. Suppose, for the sake of argument, that 100% of the cancers detected in the screening arm in Sweden were in fact palpable (not a gross exaggeration). What then would be the point of mammographic screening? And if that number (the palpable fraction) is not available, how can the results be judged? Neither the Swedish nor the Canadian trial can exclude the possibility that the benefit from invitation to mammography might have been restricted to women with palpable cancers.

A comparison of key parameters in the Canadian National Breast Screening Study (nbss) and the Swedish two-county trial

The Canadian study reports the number of cancers detected in the follow-up period after the end of the screening period and the number of subsequent deaths from breast cancer. From year 6 to year 25, 2584 incident cancers occurred in the screening group, resulting in 298 deaths (11.5%), and 2609 incident cancers occurred in the control group, resulting in 321 deaths (12.3%). Those data are important because they confirm that, in the absence of screening, the cancer incidence and mortality are equal in the study groups. Where are the comparable numbers for the Swedish study? Again, they are not given. But in looking at the extraordinary Figure 1 from the most recent report of the Swedish study12, the mortality curves are seen to continue to separate at 25 to 29 years after the initiation of screening, and long since screening had stopped.

Tabár and colleagues ask readers to believe that the benefits of mammography are everlasting (or at least for 20 years beyond the end of screening). They make that claim despite having no surety about whether the deaths from breast cancer in years 25–29 were the result of cancers diagnosed during the screening period or diagnosed after screening had stopped. They claim that most of the deaths from breast cancers diagnosed in the control arm occurred more than 10 years after diagnosis. Thus, the reader is asked to accept that a mean of 2.3 mammograms obtained in year 1–7 are more likely than a baseline imbalance in breast cancer risk to lead to a reduction in breast cancer mortality of 30% in years 25–29!

The incidence and mortality rates corresponding to cancers that were diagnosed after the screening trial was stopped are unavailable. Seeing the survival curves corresponding to cases detected in the screened and unscreened cohorts would be interesting. In the nbss, most cancer deaths occurred, as expected, within 10 years from diagnosis1. When the nbss was challenged as to having achieved an even balance in the study groups, the authors provided the relevant data. The Swedish authors should do the same. Patrick Borgen has stated that the  nbss is the “worst clinical trial ever done”5—an extraordinary statement. Either he has devoted his life to poring over medical tracts with the zeal of a Talmudic scholar, or he is speaking nonsense. But refuting his claim is easy: it takes merely the time required to read the Swedish papers.

Once the facts are accepted (that screening mammography fails to do what it was intended to do, and that overdiagnosis is real and substantial), then the most interesting questions can begin to be addressed. Did the nbss  fail because mammography is not a sufficiently sensitive imaging technique? Or has the screening community been working under false premises?

Consider sensitivity. Proponents of mammography say that the technique is currently better than it was in the 1980s, largely because it is more sensitive. (Specificity is also important, but is not at issue here.) They argue that “the more sensitive, the better.” The earlier a cancer can be identified and managed, the better. The smaller, the better. But those contentions generate an interesting paradox. Consider a woman with a small early-stage breast cancer. The recommendation is that this woman be followed with annual bilateral mammography for 5 or more years to identify recurrences and contralateral cancers20. That recommendation is based on the knowledge that the risk of contralateral cancer is between 0.5% and 0.8% annually21 and that a diagnosis of contralateral cancer is associated with an increase in mortality from breast cancer22. (It has not been shown that screening for contralateral cancer reduces mortality.) But mri is a much more sensitive screening tool than mammography, and by using mri in that setting, a small contralateral breast cancer can be identified in 4% of women with newly-diagnosed breast cancer23. And yet routine mri of the contralateral breast is not recommended, because it has not been shown to improve survival. Instead, the recommendation for follow-up with annual mammography continues. The paradox is this: If 8 years’ worth of incident breast cancers can be identified in one shot, why bother to pick them up in dribs and drabs? The mri-detected occult lesions are understood not to be clinically meaningful because they do not adversely affect mortality (overdiagnosis); however, if a similar lesion were to be found as a primary cancer in the ipsilateral breast, the radiologists insist that it is clinically meaningful. Once the paradigm that an increase in sensitivity increases overdiagnosis is accepted (that is, not all lesions are clinically meaningful), then it is the responsibility of clinicians to try to determine the ideal level of sensitivity.

The nbss has been berated for working with 30-year-old machinery, but I think that the greater problem is that clinicians are still working under 30-year-old assumptions. How much is really known about the relationship between size and survival? How confident is our community about early detection? It is universally accepted that tumour size and survival are inversely related for women diagnosed with palpable breast cancer24. That understanding is the rationale for early detection by mammography or other means. But it does not logically follow that a decrease in tumour size will necessarily lead to a decrease in mortality.

Consider two analogous situations. First, among women with breast cancer who experience a local recurrence, the strongest predictor of death is a short time from diagnosis to local recurrence25. However, that finding does not imply that a further shortening of the time from diagnosis to recurrence through intensive imaging would worsen survival. Second, studies of children with neuroblastoma noted that the children diagnosed in the first year of life experienced much better survival than those diagnosed thereafter26. That observation encouraged physicians to consider that screening for neuroblastoma by measuring urinary metabolites would increase the proportion of children diagnosed in the first year and thereby reduce mortality. The resulting clinical trial unfortunately found no benefit27. Neuroblastoma with a favorable prognosis is detectable by screening, but those cases are associated with a very high rate of spontaneous regression or maturation of the neuroblastoma into benign ganglioneuroma. Very few cases of neuroblastoma detected by screening have unfavourable biologic features such as N-Myc amplification28.

The relationship between breast cancer size and survival is not fixed, and the slope of the curve that defines the relationship varies according to the stage and pathologic features of the breast cancer24. The strongest relationship is seen with large cancers and node-positive cancers29. The relationship is attenuated among women with triple-negative cancers, with her2 (human epidermal growth factor receptor 2)–positive cancers, and with BRCA1-positive cancers19,30. Size does not predict mortality well for women with nonpalpable cancers29. Is it possible that there are additional categories wherein the size–survival relationship does not hold, and that eventually every woman with breast cancer will be able to be assigned to one of those categories? If more specific categorization were to be possible, then there would be no expectation of benefit from early detection—through mammography or any other means. In statistical terms, the question is “Are there variables n1, n2, n3, … nx, such that, after adjusting for n1, n2, n3, … nx in a follow-up study, size is no longer predictive of survival?” For example, in a study of 5423 women with cancers of less than 2.0 cm, tumour size was not predictive of survival after adjustment for grade, hormone receptor status, and her2 expression30. Those data suggest that, as the mean size of breast cancers in a population diminishes, further reductions in size can achieve only marginally less benefit. The lesson of mammography should be used to rethink the fundamentals of breast cancer and its natural history so that planning can commence for the experiments and clinical studies that will lead to better outcomes in the future.

 

Curr Oncol. Oct 2014; 21(5): 215–216.  re: Reflections on screening mammography and the early detection of breast cancer   Baum, MD ChM* *Professor Emeritus of Surgery &  Medical Humanities, University College, London, U.K.

I welcome this opportunity to comment on the piece by Dr. Steven Narod in this issue of Current Oncology. His commentary systematically responds to, and rebuts, the near-hysterical reactions to the recent publication of the 25-year follow-up results of the Canadian National Breast Cancer Screening Study1. I admire his restraint in the face of criticisms that go way beyond the boundaries of polite scientific disputation.

Much of the criticism the authors of the trial have faced goes so far as to accuse them of being guilty of scientific misconduct and fraud. Those charges are libellous, but I’m sure that Narod et al. are wise enough not to resolve their differences in a court of law, but simply to open their books to scientific scrutiny, in a way that fair-minded clinicians can judge who are the real culprits. Narod has achieved precisely that end in his timely and measured response. My only criticism is minor … in that he doesn’t go far enough. For example, it could easily be pointed out that the results of the National Breast Cancer Screening Study sit comfortably within the confidence intervals of a Cochrane Collaboration overview of the screening trials, with no hint of heterogeneity2. If anything, the trial in that overview that is closest to being an outlier is the Swedish two-county trial, whose authors are the shrillest of all the critics3.

The debate is so polarized that, leaving aside possible conflicts of interest, the only assumption that can be made is that the clash is one of ideology rather than scientific discourse. In other words, the true believers in the screening dogma will never be persuaded of the error of their ways by data alone, and so when facts don’t fit their prejudice, they resort to ad hominem attacks.

I was one of those who established the first screening centre in London and South East England in 1988, but as an open-minded clinical scientist, I allowed the emerging new data to change my mind. With all due modesty, that is what is called an expression of scientific integrity. Of course, as Narod points out, the prolonged and futile debate merely inhibits real progress on the subject. The importance of breast screening programs lies not in their success, but in their failure. As Huxley put it, “The tragedy of science is the slaying of a beautiful hypothesis by an ugly fact.”

The national breast screening programs around the world have provided us with a natural experiment of the greatest historical importance, not because of their success in reducing breast cancer mortality, but because of the observations that have emerged concerning overdiagnosis of the disease4,5. About two hundred years ago, cancer was defined by its microscopic appearance. With the discovery and use of the modern microscope, the nineteenth century saw the birth of scientific oncology. Rudolf Virchow, often called the founder of cellular pathology, provided the scientific basis for the modern pathologic study of cancer6. As earlier generations had correlated autopsy findings observed with the unaided eye with the clinical course of cancer one hundred years earlier7, so Virchow correlated the microscopic pathology of the disease. However, the material he was studying came from the autopsies of patients dying from cancer. In the mid-nineteenth century, pathology correlations were performed either on cadavers or on living subjects presenting with locally advanced or metastatic disease who were almost always predetermined to die in the absence of effective therapy. Since then, and without pause for thought, the microscopic identification of cancer according to those classical criteria has been associated with the assumed prognosis of fatal disease in the absence of treatment.

A syllogism at the heart of the diagnosis of cancer therefore runs like this: People frequently die from malignant disease. Under the microscope, this malignant disease has many histologic features that we will call “cancer.” Ergo, anything that looks like “cancer” under the microscope will kill you. The screening debacle therefore suggests that some of the earliest stages of “cancer,” if left unperturbed, will not progress to a disease with lethal potential. Those pathologic entities might have microscopic similarity to true cancers, but their appearances alone are insufficient to predict a life-threatening disease.

Conventional mathematical models of cancer growth are linear or logarithmic—in other words, completely predictable at the outset. They predict transition from in situ phases to early invasive, and from early invasive to late invasive over time. Most natural biologic mechanisms are nonlinear or are better described by chaos theory8. Prolonged latency followed by catastrophe should not be all that surprising. We accept the case for prostate cancer, because we know that most elderly men will die with prostate cancer in situ and not of prostate cancer. In fact, the United Kingdom’s national prostate-specific antigen screening trial (protect) is predicated on that fact, with two a priori outcome measures defined: deaths from prostate cancer, and the number of cancers over-detected and treated unnecessarily9.

Next, it is worth noting that, contrary to all common-sense predictions, the increased detection rate of ductal carcinoma in situ has led to an increase in the mastectomy rate for the screened population4,5. Up to 45% of women with a screen-detected case of ductal carcinoma in situ end up undergoing mastectomy because of the multicentricity of the disease10. And yet the paradox is that clinically detected multicentric invasive breast cancer is relatively uncommon11. Surely that is proof enough that at least half the foci of ductal carcinoma in situ will regress if left alone; of course, determining which half remains the problem.

In conclusion, then, it can be stated with a great deal of conviction that a large proportion (on the order of 50%) of screen-detected (preclinical) foci of breast cancer are not programmed to progress if left unperturbed. That observation is of seismic importance and could set the agenda for breast cancer research into the next decade. The choice to ignore those observations, either because they do not support personal prejudice or because of some sleazy political agenda, will result in our community missing an opportunity of a life-time—and that would be unforgivable.

Narod is to be congratulated for his systematic and robust rebuttal of the unjustified attempts to destroy the credibility of the Canadian trial by a small group of vociferous critics who provide a background noise so loud that it nearly drowns out the true signal of the 25-year experiment of population screening for breast cancer.

“There’s non so blind as those that will not see.”— Jonathan Swift, Polite Conversation

Curr Oncol. Oct 2014; 21: 205–207. Screening mammography: the turning of the tide?  W.D. Foulkes, MBBS PhD McGill University, Montreal, Quebec     This issue of Current Oncology features a Counter-currents article by Dr. Steven Narod, “Reflections on screening mammography and the early detection of breast cancer”1, that is accompanied by a commentary from Professor Michael Baum2 supporting Narod’s thesis. Indeed, in Baum’s view, Narod’s only error was not to push home the point that the Canadian National Breast Cancer Screening Study (nbss) is not an outlier among mammography screening studies. He commends Narod for a measured response to the widespread criticism that followed publication of the 25-year follow-up results of the by now notorious nbss.

It seems as if almost everyone has an opinion on screening mammography. Everyone is entitled to an opinion, of course; but discussions about mammographic screening tend to take on a special, almost unique, quality—which perhaps speaks to the investments (financial, psychological, and career) made by many of the protagonists, which Professor Baum fleetingly mentions as potential conflicts of interest in his editorial. Baum prefers to see the ongoing debate—if that is what it is—as a clash of ideologies. But what are these ideologies that are so opposed?

Essentially, Baum’s argument is that the proponents of screening are not really scientists, in the sense that they do not accept refutation of data by data. He could be right, but I think the more parsimonious and psychologically more plausible explanation is that the aforementioned investments are simply too great: the stakes are too high. That the stakes are high is, in my view, very clear. Breast cancer is a common disease, and if population-based screening mammography is shown to have failed and is therefore no longer offered, billions of dollars would be saved every year in the United States alone3.

Narod contrasts the results of two large trials of mammography (one carried out in Sweden, the two-county study) with the nbss data. Having read these carefully laid out arguments, I think that most disinterested, but informed, readers will accept that many of the legion of criticisms that have been placed at the door of the nbss simply do not hold up to scrutiny. But mud sticks, and so many observers who do not like the results of the nbss point again and again to the same “flaws.”

One of Narod’s most telling points is that the survival curves for the two arms of the Swedish trial continue to remain separate up to 29 years after the trial was started. That observation is not consistent with any known effect of mammographic screening. It is much more likely that the populations were simply different to start with.

Further discussion of the pros and cons of these two trials is now fairly pointless. There are not much new data to be had, and I can’t see Drs. Kopans and Tabár, on reading Narod’s article, deciding that perhaps the benefits of mammography have, after all, been overestimated. Without new data, we can’t resolve this critical issue. So perhaps we need to stop the current process and actually do some new research to gather the required data.

A recent Perspective article in the New England Journal of Medicine4 noted the presence of a deep chasm separating women’s views of the likely benefit of mammographic screening and the actual data available. The nongovernmental Swiss Medical Board subsequently determined that women could not make informed decisions about screening without access to more nuanced information. Moreover, the Board felt that the benefits of mammographic screening were likely to be so small that no new screening programs should be introduced and existing programs should be allowed to run down. Their decision caused the expected uproar, but it is interesting to note that the results of a reader poll after a Clinical Decisions article 2 years earlier in the New England Journal of Medicine5 showed that a clear majority did not think that screening mammography should be started at age 40. Those results are contrary to the recommendation of many breast cancer organizations. But on the basis of these newer findings, it seems to me that the tide has turned, insofar as there are now enough interested parties prepared to question the benefits of mammography.

One of the points that Narod makes bears some discussion: He sees the problem not in terms of 30-year-old mammography machines in nbss study, but in 30-year-old thinking about the biology of breast cancer on the part of those who support screening. Logically, it can be seen that, as breast cancers enlarge, the number of cancer cells within them increases, which can provide opportunities for more malignant clones to emerge. Earlier detection will thus prevent those emerging clones from worsening outcomes. This quasi-Halstedian view, that a breast cancer makes a stately progression through biologically distinct and distinguishable stages and that the grade worsens as the tumour enlarges (assumptions that are at the heart of the original explanation of how mammography “works”6), are no longer part of mainstream thinking about breast cancer biology. Even ductal carcinoma in situ seems to possess many of the molecular changes found in invasive breast cancers, albeit at lower frequencies7,8. It seems as if the “die is cast” fairly early in the life of a breast cancer9. Intrinsic subtypes hold true as cancers grow and metastasize10, and the sojourn time varies from subtype to subtype11. Some breast cancers regress12. Others grow very rapidly13. These are not ideal biologic circumstances for the success of an “across the board” screening program. That conclusion is even borne out by a careful examination of the two-county study data14. The one group for whom screening mammography would be hoped to work—women between 40 and 49 years of age with a grade iii breast cancer (a group likely to contribute disproportionately to the observed mortality from breast cancer)—does not seem to achieve any mortality savings (see Figure 20 in Tabár et al.14). Survival at 16 years from randomization was identical in the invited and screened groups (relative risk: 0.95; 95% confidence interval: 0.55 to 1.64). One wonders if, in fact, the shoe is on the other foot. What has been learned about interpreting screening data from the current understanding of the natural history of breast cancer?

On the other side of the ledger, overdiagnosis has emerged in the past several years as a major issue in breast cancer screening. Quantifying the benefits and harms of mammography make for sobering reading by disinterested parties. If one starts with a sample of 1000 U.S. women 50 years of age, and if those women are screened annually for a decade, fewer than 4 women will avoid a breast cancer death; 3–14 women will suffer the consequences of over-diagnosis; and many hundreds will have at least 1 false alarm15. Work by Welch and Frankel suggests that women would think differently about mammographic screening for breast cancer if they were made aware of those figures at time of invitation for screening. Using best estimates, only 1 woman in 4 who develop a screen-detected breast cancer will avoid a breast cancer death16. The other 3 will do just as well, or just as poorly, without screening—or, of more concern, will have been diagnosed with a cancer that was not destined to ever present clinically. In the observational Norwegian study, only one third of the reduction in deaths from breast cancer could be attributed to mammographic screening per se17. Most women with a screen-detected breast cancer are therefore either diagnosed early (but with no effect on outcome) or are overdiagnosed.

We have been here before. Maureen Roberts, director of the Edinburgh breast screening project, died of breast cancer in 1989. While hopeful that mammographic screening would benefit women, she concluded from an analysis of the Edinburgh trial results that it did not. Before she died, she wrote “Breast screening: time for a rethink?” for the British Medical Journal18, concluding, “I feel sad to be writing this; sad because naturally after so many years I am sorry that breast screening may not be of benefit. I am also sad to seem to be critical of the many dear and valued colleagues I’ve worked with over the years, particularly those who have made such a magnificent contribution to the care and welfare of women with breast cancer. But they will recognise that I am telling the truth.”

It is time to work toward a trial of screening mammography that will incorporate variable thresholds, molecular markers, genetic testing, and psychological and physical measures of the effect of overdiagnosis. One of the two authors of the New England Journal of Medicine Perspective article discussed earlier, an ethics representative on the Swiss Medical Board, has argued that there is a moral requirement for a randomized controlled trial of mammography19 based on Welch’s idea of differing detection thresholds. I believe that women will be interested in such a study. But because almost every major U.S. medical organization focusing on breast cancer prevention, diagnosis, or treatment has stated that women should begin undergoing mammography annually from the age of 40 years, will any agency have the courage to fund it?

 
October 07, 2014  Dr. Joe Mercola DC  does a nice review of recent critiques  in   Why So Many Mixed Messages on Mammogram Benefits?
                       Earlier this year, one of the largest and longest studies of mammography to date — involving 90,000 women followed for 25 years — found that mammograms have no impact on breast cancer mortality. The Canadian Breast Screening Trial ll Miller ea 
Over the course of the study, the death rate from breast cancer was virtually identical between those who received an annual mammogram and those who did not, while 22 percent of screen-detected invasive breast cancers were over-diagnosed, leading to unnecessary treatment. The researchers concluded “the data suggest that the value of mammography screening should be reassessed.”2
A Cochrane Collaboration review also found no evidence that mammography screening has an effect on overall mortality, which, taken together, seriously calls into question whether mammography screening really benefits women.3
Public health agencies, however, have been slow to update their recommendations. The American Cancer Society recommends annual mammograms for average-risk women starting at the age of 40, while the US Preventive Services Task Force recommends mammograms every other year starting at age 50
The conflicting recommendations send women mixed messages on whether screening is helpful or harmful, yet, earlier this year the Swiss Medical Board made a clear-cut recommendation: no more systematic mammography.  
Why Did the Swiss Medical Board Do Away with Routine Mammograms? 
After a year of reviewing the available evidence and its implications, the Swiss Medical Board, an independent health technology assessment initiative, noted they became “increasingly concerned” about what they were finding. The “evidence” simply did not back up the global consensus of other experts in the field suggesting that mammograms were safe and capable of saving lives.
        On the contrary, mammography appeared to be preventing only one death for every 1,000 women screened, while causing harm to many more. Their thorough review left them no choice but to recommend that no new systematic mammography screening programs be introduced, and that a time limit should be placed on existing programs.  
In their report, made public in February 2014,4 the Swiss Medical Board also advised that the quality of mammography screening should be evaluated and women should be informed, in a “clear and balanced” way, about the benefits and harms of screening.  
Unfortunately, many women are still unaware that the science backing the health benefits of mammograms is sorely lacking. Instead of being told the truth, women are guilt-tripped into thinking that skipping their yearly mammogram is the height of medical irresponsibility. It can be hard to stand your ground against such tactics.  
      When it comes to cancer prevention, however, many doctors are just as confused and manipulated as the average person on the street because of the relentless industry and media propaganda that downplays or ignores research that dramatically contradicts their profit-based agenda.
Five Facts About Mammograms That Every Woman Should Know
Before your next (or first) mammogram, you may be interested to know the following:

1. Mammograms May Offer Less Benefit Than You Think:

In one survey, most women said they believed mammography reduced the risk of breast cancer deaths by at least half and prevented at least 80 deaths per 1,000 women screened.5 In reality, mammography may, at best, offer a relative risk reduction of 20 percent and prevent in absolute terms only onebreast-cancer death per 10,000 women.

2. Mammography May Increase the Risk of Breast Cancer in Women with a BRCA 1/2 Mutation:

Results published in the British Medical Journal (BMJ) show that women carrying a specific gene mutation called BRCA1/2 (which is linked to breast cancer) are particularly vulnerable to radiation-induced cancer.6

Women carrying this mutation who were exposed to diagnostic radiation (which includes mammograms) before the age of 30 were twice as likely to develop breast cancer, compared to those who did not have the mutated gene. They also found that the radiation-induced cancer was dose-responsive, meaning the greater the dose, the higher the risk of cancer developing.

3. False Positives are Common (and Dangerous)

In the US, the risk of having a false-positive test over 10 mammograms is a concerning 58 percent to 77 percent!78 When a woman is told she may have breast cancer, it causes considerable anxiety and psychological distress. Meanwhile, you will be subjected to more testing, such as biopsy or surgery, which carry their own set of risks, unnecessarily.

4. Mammograms May Not Work if You Have Dense Breasts

Up to 50 percent of women have dense breast tissue, which makes mammograms very difficult to decipher. Dense breast tissue and cancer both appear white on an X-ray, making it nearly impossible for a radiologist to detect cancer in these women. It’s like trying to find a snowflake in a blizzard.

Breast density laws have been passed in California, Connecticut, New York, Virginia, and Texas, making it mandatory for radiologists to inform their patients who have dense breast tissue that mammograms are basically useless for them. A law is now being considered at a federal level as well.

5. There are Other Screening Options

There are other screening options, each with their own strengths and weaknesses, and you have a right to utilize those options.  Remember, only a biopsy can confirm cancer.  Screening tools only aid in the process of showing concern.  

Your Waist Size Is Linked to Your Breast Cancer Risk It’s important to remember that getting a mammogram, if you choose to, is not the same as prevention. In order to truly avoid breast cancer, you need to focus your attention on actual prevention and not just early detection, and one way to do this is by maintaining a healthy weight, and, particularly, a healthy waist size.

Researchers analyzed data from 93,000 mostly overweight post-menopausal women. This included data such as their general health, cancer status, and skirt size (which was used as a gauge of waist size). The latter – skirt size – was strongly linked to breast cancer risk.9 As TIME reported:10

An increase in skirt size was the single most predictive measure of breast cancer risk, the study concluded. When women went up a single skirt size over a 10-year span between their mid-20s and mid-60s, they were shown to have a 33% greater risk of developing breast cancer after menopause. Buying two skirt sizes up during that same period was linked to a 77% increased risk.”

Clothing sizes can be quite ambiguous, of course, with a size 8 in one brand equal to another’s size 10. Yet, the premise that increasing waist size might increase cancer risk is sound. Breast cancer is the most common cancer in women, and obese women are thought to be up to 60 percent more likely to develop cancer than those of normal weight.

The reason for this increased risk is because many breast cancers are fueled by estrogen, a hormone produced in your fat tissue. So the more body fat you have, the more estrogen you’re likely to produce. However, excess fat around your mid-section may be particularly dangerous.

Why Your Waist-to-Hip Ratio Matters     If you have a high waist-to-hip ratio, i.e. you carry more fat around your waist than on your hips, you may be at an increased risk for certain chronic conditions. Certain body compositions do tend to increase your risk of chronic disease, and carrying extra inches around your midsection has been repeatedly shown to increase cardiovascular health risks. Your waist size is also a powerful indicator of insulin sensitivity, as studies clearly show that measuring your waist size is one of the most powerful ways to predict your risk for diabetes, and this could also play a role in cancer as well.

To calculate your waist-to-hip ratio, measure the circumference of your hips at the widest part, across your buttocks, and your waist at the smallest circumference of your natural waist, just above your belly button. Then divide your waist measurement by your hip measurement to get the ratio. (The University of Maryland offers an online waist-to-hip ratio calculator11 you can use.) To determine your waist-to-hip ratio, get a tape measure and record your waist and hip circumference. Then divide your waist circumference by your hip circumference. For a more thorough demonstration, please review the video below.

Waist to Hip Ratio Men Women
Ideal 0.8 0.7
Low Risk <0.95 <0.8
Moderate Risk 0.96-0.99 >0.81 – 0.84
High Risk >1.0 >0.85

  The Sugar Connection  Obesity, including abdominal obesity, is driving up rates of breast cancer in many developed countries. And what is driving up rates of obesity? Many factors, actually, but sugar certainly plays a primary role. There is no shortage of research linking excessive sugar consumption with obesity, and the intake of sugar-sweetened beverages appears to have a particularly strong link. It was more than five years ago when UCLA researchers found that adults who drank at least one sugar-sweetened beverage a day are 27 percent more likely to be overweight or obese.12 Even those who only drank soda occasionally had a 15 percent greater risk.

This is far more than simply an issue of consuming “empty calories,” as sugary drinks, soda, and even fresh-squeezed fruit juice contain fructose, which has been identified as one of the primary culprits in the meteoric rise of obesity and related health problems—in large part due to its ability to turn on your “fat switch.” Alarmingly, research presented at the American Heart Association’s Epidemiology and Prevention/Nutrition, Physical Activity and Metabolism 2013 Scientific Sessions suggested sugary beverages are to blame for about 183,000 deaths worldwide each year, including 133,000 diabetes deaths, 44,000 heart disease deaths, and 6,000 cancer deaths.

About 77 percent of food items in US grocery stores contain added sugar. So it’s no wonder that, while the American Heart Association recommends a daily sugar limit of six teaspoons for women and nine for men, the average American consumes more like 22. If health agencies really wanted to make a dent in breast cancer, they would focus on sharing the truth about sugar (and grains), and their role in obesity and cancer. Unfortunately, breast cancer is big business, and mammography is one of its primary profit centers. This is why the industry is fighting tooth and nail to keep it, even if it means ignoring (or downplaying) the truth.

Avoiding Sugar and Other Top Breast Cancer Prevention Tips   I believe the vast majority of all cancers, including breast cancer, could be prevented by strictly applying basic, commonsense healthy lifestyle strategies, such as the ones below. No available screening method, whether mammography or otherwise, is going to lower your risk of breast cancer… but the tips that follow will:

    • Avoid sugar, especially fructose, and processed foods. All forms of sugar are detrimental to your health in general and tend to promote cancer. Refined fructose, however, is clearly one of the most harmful and should be avoided as much as possible. This automatically means avoiding processed foods, as most are loaded with fructose.
    • Optimize your vitamin D levelsVitamin D influences virtually every cell in your body and is one of nature’s most potent cancer fighters. Vitamin D is actually able to enter cancer cells and trigger apoptosis (programmed cell death). If you have cancer, your vitamin D level should probably be between 70 and 100 ng/ml. Vitamin D works synergistically with every cancer treatment I’m aware of, with no adverse effects. Ideally, your levels should reach this point by exposure to the sun or a tanning bed, with oral vitamin D used as a last resort and balanced by other nutrients like vitamin K2 and magnesium.
    • Limit your protein. Newer research has emphasized the importance of the mTOR pathways. When these are active cancer growth is accelerated. One way to quiet this pathway is by limiting your protein to one gram of protein per kilogram of lean body mass, or roughly a bit less than half a gram of protein per every pound of lean body weight. For most people, this ranges between 40 and 70 grams of protein a day, which is typically about 2/3 to half of what they are currently eating. You can eat 25% more if you are exercising or pregnant.
    • Avoid unfermented soy productsUnfermented soy is high in plant estrogens, or phytoestrogens, also known as isoflavones. In some studies, soy appears to work in concert with human estrogen to increase breast cell proliferation, which increases the chances for mutations and drives the phenotype associated with cancer.
    • Improve your insulin and leptin receptor sensitivity. The best way to do this is by avoiding sugar and grains and restricting carbs to mostly fiber vegetables. Also make sure you are exercising, especially with Peak Fitness.
    • Exercise regularly. One of the primary reasons exercise works to lower your cancer risk is because it drives your insulin levels down, and controlling your insulin levels is one of the most powerful ways to reduce your cancer risks. It’s also been suggested that apoptosis (programmed cell death) is triggered by exercise, causing cancer cells to die in the way nature intended. Studies have also found that the number of tumors decrease along with body fat, which may be an additional factor. This is because exercise helps lower your estrogen levels, which explains why exercise appears to be particularly potent against breast cancer.

In addition to exercise, try to limit your sitting time to three hours a day while taking 10,000 daily steps during your non-exercise hours.

  • Maintain a healthy body weight. This will come naturally when you begin eating right and exercising. It’s important to lose excess body fat because fat produces estrogen, creating a vicious self-perpetuating cycle.
  • Drink a pint to a quart of organic green vegetable juice daily. This is a simple way to get more cancer-fighting nutrients into your diet. Please review my juicing instructions for more detailed information.
  • Get plenty of high-quality, animal-based omega-3 fats, such as krill oil. Omega-3 deficiency is a common underlying factor for cancer.
  • Curcumin. This is the main active ingredient in turmeric and in high concentrations can be very useful adjunct in the treatment of cancer. It actually has the most evidence-based literature supporting its use against cancer of any nutrient, including vitamin D.13 For example, it has demonstrated major therapeutic potential in preventing breast cancer metastasis.14 It’s important to know that curcumin is generally not absorbed that well, so I’ve provided several absorption tips here. Newer preparations have also started to emerge, offering better absorption. For best results, you’ll want to use a sustained-release preparation.
  • Avoid drinking alcohol, or at least limit your alcoholic drinks to one per day.
  • Avoid electromagnetic fields as much as possible. Even electric blankets may increase your cancer risk.
  • Avoid synthetic hormone replacement therapy, especially if you have risk factors for breast cancer. Many forms of breast cancer are estrogen-fueled, and according to a study published in the Journal of the National Cancer Institute, breast cancer rates for women dropped in tandem with decreased use of hormone replacement therapy. (There are similar risks for younger women who use oral contraceptives. Birth control pills, which are also comprised of synthetic hormones, have been linked to cervical and breast cancers.) If you are experiencing excessive menopausal symptoms, you may want to consider bioidentical hormone replacement therapy instead, which uses hormones that are molecularly identical to the ones your body produces and do not wreak havoc on your system. This is a much safer alternative.
  • Avoid BPA, phthalates, and other xenoestrogens. These are estrogen-like compounds that have been linked to increased breast cancer risk.
  • Make sure you’re not iodine deficient, as there’s compelling evidence linking iodine deficiency with certain forms of cancer. Dr. David Brownstein, author of the book Iodine: Why You Need It, Why You Can’t Live Without It, is a proponent of iodine for breast cancer. It actually has potent anticancer properties and has been shown to cause cell death in breast and thyroid cancer cells. For more information, I recommend reading Dr. Brownstein’s book. I have been researching iodine for some time ever since I interviewed Dr. Brownstein, as I do believe that the bulk of what he states is spot on. However, I am not at all convinced that his dosage recommendations are correct. I believe they are far too high.
  • Avoid charring your meats. Charcoal or flame-broiled meat is linked with increased breast cancer risk. Acrylamide—a carcinogen created when starchy foods are baked, roasted, or fried—has been found to increase cancer risk as well.
 
 27 Sept 2014   Three  thoughtful  new reviews, from Universities in Australia (Robin Bell),  Kuwait (Yusuf Luqmani) and Cape Town (Tim Noakes),  highlight the deadly ethical  problem of the myth-based zealous profiteering  Disease Industry promotion in the well of cancer screening,  and the high carbs low fat-low cholesterol  diet, and “statin deficiency” – iatrogenic  “OBSESSIVE-COMPULSIVE DISORDERS ” that profiteers cultivate in the guileless.
       It is not coincidence that the Food and Disease Industry insist that the dangerous high carbs low fat diet they have promoted for the past 40 years, and mass cancer screening for the past >20years , are correct- for the simple perverse reason that such lies pay ie Only Disease Pays. This brings us via  Lupton’s question of Ethics vs Science  in the fraught  narrow parenting domain,  to our everywhere dilemma:  Can Health Science , Human,  Animal and plant  Rights Survive the Onslaught of ruthless commerce and politics?

           Breast screening: an obsessive compulsive disorder.  in Cancer Causes Control. 2014 Jul 11.  Prof Yunus Luqmani  a British oncology biochemist,  Kuwait University writes   “Mammographic screening was  founded on the premises that “it  saves lives”, early is better than late,’  which prevails  in several countries but  controversial since its inception. Findings and interpretation of clinical trials data vary considerably, with disagreement on the outcome and value of such  procedure, not just about the benefits but about the potential harms of mass screening. Many are being screened for the benefit of the few. Even this might be acceptable  but  for concern for many  women with screen detected cancers that will potentially not cause them harm, and who are very likely receiving unnecessary treatment. Many  call for complete cessation of indiscriminate screening if not re-assessment of  age  and periodicity . Of great concern is that screening is being vigorously advocated by many healthcare workers, the media, and lay persons alike without proper awareness or appreciation of the consequences. Although some National leaflets  now present a truer picture, there is   distinct lack of transparency to allow women to distinguish perception from reality and to make informed choices. How many would elect to be screened if they knew that for every one woman who is notionally saved by early detection, anywhere from 2 to 10 otherwise healthy women are being turned into breast cancer patients?  

          Screening mammography – early detection or over-diagnosis     Climacteric. 2014 Sep 16:1-7. Epidemiologist  Prof Robin Bell  Monash University,  Australia examines  benefits and harms of organized screening mammography. Most  recent reduction in breast cancer-specific mortality is explained by use of adjuvant therapy rather than screening mammography. Impact of screening mammography in countries where women present with early disease and have access to adjuvant treatment is modest. There is a wide range of estimates for the magnitude of over-diagnosis. All-cause mortality (rather than breast cancer-specific mortality) should be used when assessing impact of screening as otherwise the harm of cancer treatment in those  over-diagnosed will be missed. Conclusions The benefits and harms of screening mammography are finely balanced. The impact of screening mammography is at best neutral but may result in overall harm. Women should be informed of the issue of over-diagnosis. It is time to review whether organized mammographic screening programs should continue.  
        AND ON DIET:             It is common cause that humans consume their energy requirements from what they can get- and since animal protein is the most costly,  and excess harmful, this means from carbs or fat, of which natural  animal/ dairy/ nut  fat is the most satisfying. So while keeping energy output and adequate animal protein intake  stable, needed energy intake comes from balance of fat and carbs.
       A  major bone of contention locally is the merits of the Banting diet –  in his words,  ‘four meals per day, consisting of meat, greens, fruits, and dry wine’- before the age of mass refined and chemically-and genetically-polluted food and maize-fed livestock.
        Cereals-carbohydrates in his time 160 years ago were thus largely replaced by fresh meat fats and fresh produce. Considering he was born in 1796, his life of  82 years was   almost double the then average lifespan despite his having been severely obese until he found his optimal diet advised by Dr William Harvey based on Professor Claude Bernard’s work on diabetes.
        But Banting was a businessman  of the pre-automobile  era:  unlike labourers, you walked, or you saddled up- without tarmac, coaches were slow. With modern understanding of the importance of avoiding the sedentary lifestyle and overload of both alcohol, salt, refined carbohydrates, protein, and synthetic ie transfats (margarine) , the Banting diet has adapted in modern times  to be optimal for many people for both energizing and keeping slim and well – with its accent on minimal refined/ processed carbs including concentrated cereals,  pure starches, cooked fatty pastries, and commercial fruit juice;
        with high natural fat 50+% as the  ideal brain-muscle-metabolic energy source- from unprocessed meat,  fish, eggs, cream, coconut, butter, cheese;  and modest mixed nuts; matched with copious  greens and other lowstarch rainbow vegetables.
     The futility of low fat (ie high carbs) diet was borne out in the biggest and costliest   -$billion – trial ever- the Women’s Health Initiative  WHI, published in 2006 (Rossouw ea)  and for cancer,  this week (Thomson ea)“Randomized controlled trial of 48,835 postmenopausal women aged 50 to 79 years,  who participated in the WHI Dietary Modification Trial;  randomly assigned to  intervention [40%]) or comparison group  [60%]) in a free-living setting,  enrollment between 1993 and 1998 in 40 US clinical centers; mean follow-up in this analysis was 8.1 years.  Intensive behavior modification in group and individual sessions designed to reduce total fat intake to 20% of calories and increase intakes of vegetables/fruits to 5 servings/d and grains to at least 6 servings/d. The comparison group received diet-related education materials.    “Dietary advice to reduce fat for cancer and cardiovascular disease, stroke or coronary heart disease   prevention after menopause  was not supported in the  WHI.   The diet had no effects on incidence of CHD , stroke ,  or CVD.  In fact  Women with higher baseline fat intake (quartile) had breast cancer risk only  HR-0.76; 0.62, 0.92 during intervention). Thus the highest  fat intake lowered breast cancer risk by 24%There were no intervention effects   ie no benefits of low fat diet on invasive breast 1.08  or colorectal cancer, other cancers, cancer-specific or overall mortality.
 
        and  the WHI (Shikany ea 2006 and 2011further showed direct association of  higher Dietary carbs (glycemic load GL  glycemic index)   and risk of breast cancer and cardiovascular disease risk factors .There was a trend toward significance for the positive association between GL and in situ cancers (1.40, 0.94-2.13; P = 0.07).   GL inversely associated with high-density lipoprotein HDL  cholesterol (P for trend = 0.004) and positively with triglycerides,  total cholesterol (P = 0.018) and low-density lipoprotein cholesterol.
             Professor Tim Noakes  Cape Town keeps on pointing out the lack of science in the perverse western (Ancell Keys)   paradigm of high carbs low fat processed diet (as in the WHI) , with  futile overreliance on  synthetic drugs eg statins,  and appliances, surgery  to reverse the consequent epidemic degenerative diseases- and keep the medical disease industry profitable. .

This brings us to the cutting edge of modernity: Can  Ethics Survive the Onslaught of Science ? (Prof Michael Lupton, Bond University, Australia  2013)?  Can health science  survive the onslaught of perverse incentives, profiteering- the Semmelweis Reflex that denies what is cheap, natural and best?
24 Sept 2014  update after the Angela Jolie hype: This month’s JAMA say it all: the less breast  surgery the better:
                              Use of and Mortality After Bilateral Mastectomy Compared With Other Surgical Treatments for Breast Cancer in California, 1998-2011. Kurian &  Gomez    Stanford Univ.  JAMA. 2014;312:902-914.                Bilateral mastectomy is increasingly used to treat unilateral breast cancer. Because it may have medical and psychosocial complications, a better understanding of its use and outcomes is essential to optimizing cancer care. Conclusions and Relevance  Use of bilateral mastectomy increased significantly throughout California from 1998 through 2011 and with median follow-up of 89 months  was not associated with lower mortality than that achieved with breast-conserving surgery plus radiation. Unilateral mastectomy was associated with higher mortality than were the other 2 surgical options.
Contralateral Prophylactic Mastectomy   Is It a Reasonable Option?         Editorial|Sept 3, 2014     Lisa Newman, Univ Michigan,   JAMA. 2014;312:895-897 The professional oncology community has worked diligently to generate data that facilitate surgical planning and the decision-making process for patients with newly diagnosed breast cancer. Several lines of evidence support the importance of prioritizing treatment of the known cancer over and above consideration of a risk-reducing mastectomy for the unaffected breast (contralateral prophylactic mastectomy [CPM]). For example, the equivalent overall survival for breast-conserving surgery (BCS) and mastectomy makes CPM an unnecessary option for women who are eligible for lumpectomy and desire breast preservation. Incidence of metachronous contralateral breast cancer (ie, contralateral cancer detected several months after initial breast cancer diagnosis) is relatively low, at 0.25% to 1% per year,1,2 and these cancers are usually detected at early, highly curable stages. Synchronous occult contralateral breast cancer is uncommon, as documented by studies revealing incidental cancer in only 1% to 3% of CPM specimens.3,4 Survival is comparable for patients with unilateral vs metachronous bilateral breast cancer5,6 and typically is associated with the stage of first cancer, consistent with the concept that the initially presenting tumor has a lead-time advantage in establishing distant organ micrometastases.
The corollary is obvious:    Less Informed Women With High Anxiety Are More Likely to Choose Bilateral Mastectomy for Breast Cancer  San Francisco Cancer Symposium  PracticeUpdate Editorial Team, 2014 Sept   Women with higher anxiety levels and less knowledge about breast cancer recurrence and survival are more likely to choose bilateral mastectomy ,    Katharine Yao, MD, of  University of Chicago  stated, “There is so much information about breast cancer that it’s easy for patients to get overwhelmed. As doctors, we have to be aware of each patient’s knowledge level and the concerns and worries he or she has. We need to do a better job of educating patients that the risk of developing contralateral breast cancer is actually low and that breast cancer can come back in other parts of the body no matter what type of surgery they have.”    Overall, 59% of patients chose lumpectomy, 32% unilateral mastectomy, and 9% CPM. Eighty-three (58%) considered CPM, and 12 (21%) of this latter group chose CPM contralateral prophylactic mastectomy.
 
11 August 2014  The current SA Menopause Society newsletter says:

Benefits of mammography

“the benefits of screening mammography are modest at best” (Elmore & Harris BMJ 2014;348:g3824). This is the conclusion after the latest research to come out of Norway where the introduction of screening has been gradually introduced over the last 2 decades (Weedon-Fekjaer et al BMJ 2014;348:g3701).The Norwegian authorities invited women between 50 and 70 years old to attend for screening every second year and looked at before and after death rates from breast cancer. They found RELATIVE risk reduction of 28% in those invited compared with those not invited to be screened. Without knowing the ACTUAL risk reduction or the harms of screening this sounds like a “good deal”. However it is an observational study not a randomised trial and therefore susceptible to various biases.For women to make up their own minds about screening, actual figures of benefits and harms need to be given because without accuracy perceived dangers and benefits are very far from reality. For example in the US or UK asking women about their estimates of breast cancer deaths – taking 1000 women aged 50 and following them for 20 years – gave the following results:

Of 1000, number
alive after 20 years
Deaths from
breast cancer
Deaths from
other causes
Women’s estimates
without screening
801 160 39
with screening 881 80 39
In reality
without screening
956 5 39
with screening 956-7 4 39-40

Women believe that breast cancer is a far greater threat than it really is. They also believe that screening halves such risk.

If actual death reductions from breast cancer are taken into account, screening benefits are modest at best and if all cause deaths are taken into account the benefits all but disappear.

20 July 2014 Two new papers from Scandinavia highlight the harms of screening mammography.:

Clin Adv Hematol Oncol. 2014 June;12:407-11    Screening mammography:   do the benefits always outweigh the harms?  Brodersen J, Jørgensen KJ, Brawley OW.

APMIS. 2014 May 26. doi: 10.1111/apm.12278.
Overdiagnosis: How cancer screening can turn indolent pathology into illness.    Brodersen J1, Schwartz LM, Woloshin S. The shift from illness to disease has had a profound impact on modern medicine – particularly in the realm of cancer screening. In screening, it is not patients with illness who seek help from the healthcare system; it is asymptomatic healthy individuals who are invited into the healthcare system to be examined for pathology. The underlying assumption of screening is that abnormalities and pathology always progress. If this were true, it would always make sense to look for disease even when people feel well. The million (or more accurately multi-billion) dollar question is whether the fundamental assumption that disease invariably leads to illness is valid. This is the question that the present paper will try to explore and answer.
The current Wiki article on Cancer Screening    firmly denies benefit for screening for silent prostate cancer;  and for xray screening mammography it  firmly questions  the benefit in lives saved versus the harms of screening.  The balance for screening mammogram is summed up by Wiki : “The phenomenon of finding pre-invasive malignancy or nonmalignant benign disease is commonplace in all forms of cancer screening, including pap smears for cervical cancer, fecal occult blood testing for colon cancer, and prostate-specific antigen testing for prostate cancer. All of these tests have the potential to detect asymptomatic cancers, and all of them have a high rate of false positives and lead to invasive procedures that are unlikely to benefit the patient.”
                Reality  remains that, in average  lean  well adults ie without obvious risks , the only screening justified is regular noninvasive SELF- EXAMINATION of breast, skin, testes, electronic bloodpressure; and professional optometric, dental,  skin and bloodpressure screening and, if suspicious, urine multistix exam.  By contrast, regular xray (chest or  mammogram- cumulative radiation risk) and pelvic  internal exams are highly invasive, thus indicated only for symptomatic or familial-risk cases. .
PEER (perverse) PRESSURE, Beliefs, perceptions, indoctrination –  by peer bodies, Corporates like Hospitals and Big Pharma, Regulators,  Accredition Bodies and dangled incentives – which obviously have commercial group vested self-interests  –  die hard:                                     Prev Med. 2014 Jul 16.Miller JW1,  Goff BA ea .  CDC & Washington State University, USA,   studied Physicians’ Beliefs about Effectiveness of Cancer Screening Tests: National Survey of Family Physicians, General Internists, and Obstetrician-Gynecologists(excluding breast radiologists, pathologists,  and oncologist/surgeons). RESULTS: of   1574 respondents-   62% response rate- the majority agreed with the effectiveness of: mammography aged 50-69 years, Pap tests  aged 21-65 years, and colonoscopy for aged ≥50 years.  Physicians typically listed their respective specialty organizations as a top influence for screening  recommendations.  CONCLUSIONS: There were several substantial inconsistencies between physician beliefs in the effectiveness of cancer screening tests and the actual evidence of these tests’ effectiveness which can lead both to underuse and overuse of cancer screening tests.
    This outcome obviously damns professional bodies in respect at least of the evidence discouraging  screening mammography of well breasts.
   Its as Soren Kierkegaard wrote 150 years ago about religious conviction- the difficulty of following ethical theistic belief against the majority tide of convenience and venality;
  and Steven Jay Gould’s Non-Overlapping Magisteria of Science and Religion- for some (but not all), the difficulty of reconciling apparent scientific medical evidence (is it ever immutable? ) with belief, dogma- whether from mythical (is it always?)  religious belief, or simply vested interest.
       As we were taught 50 years ago, if new medical discoveries stand the test of time – they often dont-  it takes a generation for  the majority to accept, apply them. Almost two generations of women have now been martyred by repetitive screening xray mammography. Must it take yet another generation before such barbaric screening is abandoned? As Winwood Reade  and AC Grayling philosophized, countless millions have suffered genocide, holocaust in the post-Greko-Roman “enlightened”  two  millennia for vested interests in the guise of religious let alone medical dogma  .
14 July 2014:  BASTILLE DAY CLARION CALL FOR TRUTH TO PROTECT WOMEN:      Screening mammography & Bambi  This column reported these issues a few months ago (see Dr Gerd Gigerenzer PhD  below in May, and April 16, 2014  from the Swiss Medical Board: Abolishing Mammography Screening Programs? ), but they are worth repeating from Groote Schuur Hospital.  A professor of Obstets and Gyne there writes in the current South African Menopause Matters  news email (“an  editorial opinion that does not necessarily represent the views of  SAMS”) :
(the answer to his question: Whatever happened to Evidence-Based medicine? is quite simple: if  it doesnt pay, then evade, deny and mock the evidence, or better, shoot the messenger who dares blow the whistle on  inconvenient truth. )

The Professor writes: “Screening mammography is an emotive subject. Correctly so, because if it did clearly have more benefits than harms then it should be advocated, promoted and sold as an intervention in every woman’s interest.

      Regrettably screening mammography does not clearly have more benefits than harms and given that it is an unpleasant and costly process it should not be promoted. Both the protagonists and the antagonists claim ample facts supporting their arguments while finding fault with the others’ data. One of the latest trial outcomes from Canada (Miller et al BMJ 2014;348:g366) reports on a large group of women (nearly 90 000) who were randomised to mammography annually for 5 years or annual physical breast examination. This took place in the 1980s and the women were in their 50s and were followed up for 25 years.

Diagnoses of breast cancer and deaths from the disease were collected from national databases, as were all-cause mortality figures. The researchers showed that during the 5 years of mammography (or not) more women were diagnosed with breast cancer in the mammography arm (and treated) but the deaths were not significantly different in the two groups. Similarly over the entire study period there were more cancers diagnosed in the mammography arm but the number of deaths were similar, with the conclusion that mammography was not superior to annual examinations and resulted in overdiagnoses.

This is essentially a negative outcome if “deaths avoided” or “lives saved” are taken as the end points. Maybe modern screening techniques work better but also maybe better treatments have reduced mortality rates. The most recent Cochrane Review suggests that if 1000 women aged 50 were screened for 10 years then 4 women would die from breast cancer. Without screening 5 would die.

If the group’s deaths from any cancer are counted then the results are 21 per 1000 with or without mammography. So does mammography screening save lives? The supposed benefit?

If the harms are tallied for the same 1000 women then 100 in the mammography arm would have a false positive-evaluation and 5 would have an unnecessary partial or complete breast removal (Gøtzche et al Cochrane Reviews 2013;6:CD001877). The financial and convenience costs are not commented on.

Yet screening mammography is treated like a religion. Any suggestion to curtail its promotion is seen as “unfair to women” or not doing “the right thing”. A bit like Bambi bashing. How can something so obviously right be challenged?

Nowhere are the facts more disguised than in breast cancer screening pamphlets (Gigerenzer BMJ 2014;348:g2636). The data are presented without numbers ”Most doctors feel that early detection tests for breast cancer save thousands of lives each year” or as relative risk reduction with the difference between 4 and 5 deaths per 1000 being a “20% reduction in deaths”. A final fallacy of the leaflets is extrapolating ahead where 1 life saved over a decade means 2.5 lives over 25 years which is not supported by the data.

No wonder 98% of women in France, Germany and the Netherlands overestimate the benefit of screening by a factor of 10, 100 or more, or do not know. They get much of their information from leaflets – put out by people whose likelihoods depend on screening – which are blatantly misleading. Advertising of medicines is not allowed to make claims that cannot be backed up by evidence, so why can screening pamphlets?

These semi-facts promote beliefs that screening prevents or reduces the risk of breast cancer and saves many lives through the early detection of aggressive tumours. These beliefs are not valid according to an independent Swiss group reporting in a lead article in NEJM (Biller-Andorno & Jüni 2014;370:1965-7) which states that public health programmes that do not produce more benefits than harms are hard to justify ethically – like mammography screening.

Their report caused an uproar because it challenges a tightly held myth – like the existence of Bambi.    What has happened to evidence-based medicine?

Menopause Matters is a monthly review of matters menopausal that have recently appeared in the journals. It is produced for the South African Menopause Society by Athol Kent and the summaries concentrate on clinical issues although some underlying patho-physiology will be included to ensure a scientific basis for the work. It does not necessarily reflect the views of SAMS or its managementf
15 June 2014 this month:  SMALL BENEFITS, SUBSTANTIAL HARMS WITH MAMMOGRAPHY SCREENING  is a trenchant review by Prof Cornelia Baines breast clinician from Canada on why xray screening mammography does well breasts and women far more harm than good.                Prof Stephen  Duffy statistician at UCL argues the reverse.

DIET RISKS FOR BREAST CANCER:

already 30 years ago Seely and Horrobin in Diet and breast cancer: possible connection with sugar consumption hypothesized: younger and older women (possibly pre- and post-menopausal women) differ with respect to such correlations. In older women a strong correlation was found between breast cancer mortality and sugar consumption (correlation coefficient = 0.9).. In younger women the correlation with diet is weak. A possible connecting link between sugar consumption and breast cancer is insulin. This is an absolute requirement for the proliferation of normal mammary tissue and experimental mammary tumours may regress in its absence. Insulin secretion occurs in response to blood glucose level and could be excessive if the regulatory mechanism is overtaxed by large sugar intake. The same mechanism might account for the increased risk of mammary cancer in diabetics.
  A  major Nurses’ Health decades-long Study  review from Harvard shows no relationship between fat intake and breast cancer.
By contrast, studies from  Mexican  2004,  Canada 2005, Italy 2006 , and New York  2009 confirm direct association between sugar intake and breast cancer. . Only a study from Denmark 2005  shows no relationship.
Hence the HighFat LowCarbs (William Banting 1863) diet is now established by the rigorous scientific references of the past 150 years  assembled by science writer Gary Taubes in The Diet Delusion ,  and advised to all  for prevention and management of obesity and all other common major diseases including breast and all cancers.
      As investigative journalists write recently, like Taubes and rational scientists the past 50years,  the major cause of all common chronic degenerative disease including cancer and immunoincompetence is not fat but refined carbs – the root cause of the SACCHARINE DISEASES  that Cleave, Campbell, Burkitt reported occurring in pastoral tribes converting to the western commercialized diet of sugar, refined cereals and rice .                   They note that in the Mouse Cancer Study in cancer-prone mice, 2011,  which claimed that high (fat)cholesterol intake promotes breast cancer, the control mice  (not major carnivores but omnivores) were fed a balanced natural chow with 4.5% fat, 23% protein, and 50% carbohydrate, whereas the test mice were fed a totally synthetic chow meant to represent a western human  cholesterolemic  diet: 20% fat, 17% protein, and 48% carbohydrate. So in fact the high risk factor for cancer and all disease was not the higher fat intake (20%  as dairy fat) vs 4.5%- from fish meal and soy/cereals) but the 48% carbs (2/3  sucrose, 15% (malto)dextrins -which absorb as rapidly as glucose) intake and 19% casein (a major health problem)   in the test chow. They failed to include a control group on what is natural mouse diet ie free of refined carbs and milk :  “RSPCA 2014:   Wild mice – opportunistic omnivores- will eat a wide variety of seeds, grains, and other plant material as well as invertebrates, small vertebrates and carrion”. Thus plenty of natural seed/grain fats and mixed protein and plant carbs,  zero sugar or refined carbs- ie the Banting diet. ..
A new 18year observational  followup  study from Sweden last year in 62000 people assessed total energy intake – carbohydrate  from median 61 to 39% , protein 11 to 19% , and  fat 27 to 42% . LCHP scores were positively related to intake of animal protein, but negatively related to plant protein. For carbohydrate and fat, associations were consistent in sucrose and whole grain and saturated and unsaturated fat, respectively. Across the range of macronutrients, there was no clear significant trend for particular cancers. This is not surprising as the intake of carbs range d from 40 to 60% and fat from 27 to 42%. Thus no cohort was on a highfat low carbs ketogenic diet as Banting, Noakes  et al find successful. . the lowest % carbs group at best had similar fat % intake ie there was no low-carbs cohort taking below 30% carbs..There is a vast difference in calorie intake  between their “optimal’  LCHP 42:40 fat:carbs ie 1:1  , versus the  true ketogenic HifatLowcarbs diet of eg 50:<30 fat:carbs ie >1.66:1.
       Allowing up to 20% protein in total energy intake, fat may need to  be  close to 50% energy and carbs below 30%, thus ensuring ketogenesis to shed excess fat and avoid depositing more glycogen and adiposity ; so eg for a 2000kcal/day  diet, thats  up to 100gms protein 400kcal mostly from flesh and nuts; carbs below 150gms 600kcal (in nuts and  rainbow vegs) , and fat up to 1000 kcal ie 110gms from cream (not milk), nuts, avo, eggs, butter, cheese and fatty flesh. .

It is no wonder the public is confused.

The truth of more than four decades worth of research is now very clear: the potential benefit of mammography screening is small and the harms are substantial at all ages, but especially so for women in their 40s.

The bottom line is that mammography screening, implemented to reduce breast cancer deaths due to earlier detection of breast cancer, has been eclipsed by therapy and increased awareness.

- See more at: http://umanitoba.ca/outreach/evidencenetwork/archives/4490#sthash.rf9YcMYp.dpuf

It is no wonder the public is confused.

The truth of more than four decades worth of research is now very clear: the potential benefit of mammography screening is small and the harms are substantial at all ages, but especially so for women in their 40s.

The bottom line is that mammography screening, implemented to reduce breast cancer deaths due to earlier detection of breast cancer, has been eclipsed by therapy and increased awareness.

- See more at: http://umanitoba.ca/outreach/evidencenetwork/archives/4490#sthash.rf9YcMYp.dp

VITAMIN INTAKE AND BREAST CANCER:

VITAMIN C  each 100mg/day increment reduces allcause mortality by 27%, and breast cancer mortality by 22%:   a metaanalysis by the Karolinska- Harris ea   last month found 10 trials of vitamin C use and intake  in breast cancer, included 17,696 breast cancer cases, 2791 total deaths, and 1558 breast cancer-specific deaths. The summary RR (95% CI) for post-diagnosis vitamin C supplement use was 0.81 (95% CI 0.72-0.91) for total mortality and 0.85 (95% CI 0.74-0.99) for breast cancer-specific mortality. The summary RR for a 100mg per day increase in dietary vitamin C intake was 0.73 (95% CI 0.59-0.89) for total mortality and 0.78 (95% CI 0.64-0.94) for breast cancer-specific mortality- ie 25% lower mortality for every 100mg higher daily vit C intake..

VITAMIN D AND BREAST CANCER:
20 years  ago Newmark from Sloan Kettering NY wrote :  High dietary fat increases mammary epithelial cell proliferation, particularly the “hormonally driven” hyperproliferation during breast growth and development in young animals. Increased dietary calcium (and probably vitamin D) lessens the increase of proliferation induced by high fat. These data, although limited, suggest that the maximum effect of diet (high fat increase, as well as calcium and vitamin D modulation) on eventual breast cancer may be during puberty, and adolescence, when the mammary gland is actively growing and developing. (3) An inverse epidemiological correlation exists between sunlight availability as a source of vitamin D and the risk of breast cancer in the U.S. and Canada. (4) Current vitamin D and calcium dietary intake in the U.S. is far below the RDA in all female age groups, particularly for the elderly. (5) Reduction of breast cancer risk, and simultaneously osteoporosis, might be achieved by increasing dietary intake of calcium and vitamin D to RDA levels. This may be particularly applicable to females during puberty and adolescence.
                    20 years later we now still find:                 Vitamin D and Cancer: The promise not yet fulfilled(California) ; and is there a link (France)?

BUT The Vitamin D Council    sums up the study evidence eg in a major Brit J Cancer metaanalysis last month of 30 prospective studies in 32000 BRCA  patients, and a Chinese study a year ago,   show  that  those with highest  vitamin D levels have 50-90% lower risk of  breast cancer risk, and mortality, and the chance of breast cancer spreading.  so far all they can recommend is that  vitamin D dose should for a robust adult not exceed        10 000iu/day, or pro rata at longer intervals eg 150 000iu a fortnight.  Compared to those with the lowest quartile of plasma 25(OH)D level, women with highest quartile 25(OH)D level showed a significant decreased breast cancer risk (Q4 vs.Q1: OR = 0.10, 95% CI = 0.06–0.15) and every 1 ng/ml increment of plasma 25(OH)D level led to a 16% lower odds of breast cancer.

         It is likely that- given the limits on vitamin C intake due to diarrhoea, and cost, and bloating-  increments in vit D3 intake above the current mediocre 400iu/d norm- up to the generally well-tolerated 10 000iu/day, with supplement of vitamin K2-  will give even better benefit against breast cancer than vitamin C.     
                                                                                                                               
20 May 2014 BREASTS TO KILL: KILLER BRAS
          For the past 4 years, Sure Touch examiners  have observed that many women who wear underwired bras have a string of pearl – fibrous lumps- where the bra wire cuts into them inferiorly; and sometimes radially under the ‘ spokes’ of the bra cups.  We have not yet detected a cancer in such symmetrical  lumpiness, which we find diminishes with change to a soft bra and healing massage with Lugols iodine, coconut oil and DMSO.
          This bra risk   was postulated  in  the book  Dressed To Kill: The Link Between Breast Cancer and Bras(1995, 2005), (NaturalNews).     
Dr Joe Mercola muses: ” Would you believe that two of the nation’s most prominent cancer organizations are completely disinterested in a common wardrobe practice that studies suggest could be a leading cause of breast cancer in women? Wearing bras, says the book  ,appears to be a common trigger of this harrowing disease, yet the American Cancer Society (ACS) and the Susan G. Komen Foundation continue to deny any link between the two.
            ” Authors Sydney Ross Singer and Soma Grismaijer, husband and wife medical anthropologists, have conducted extensive research into the link between bras and breast cancer. They are convinced that the lymphatic constriction imposed by wearing bras prevents women’s bodies from effectively clearing out toxins and other waste, leading to an accumulation of these cancer-causing substances. Bras can also cut off circulatory flow within the body, leading to other health problems.
              “[B]ecause lymphatic vessels are very thin, they are extremely sensitive to pressure and are easily compressed,” the Singers are quoted as saying, noting that the perpetual use of bras over the course of several decades can eventually lead to cancer. “Less oxygen and fewer nutrients are delivered to the cells, while waste products are not flushed away.”
             These are powerful claims, and science seems to back them. Based on an analysis comparing women who wear bras to those who don’t, breast cancer risk was found to be significantly higher among women in the former group. At the same time, women who do not wear bras have about the same risk of developing breast cancer as the average man does, which is not very high.
               Beginning in 1991, the Singers initiated a 30-month “Bra and Breast Cancer” study that evaluated roughly 4,000 women from five major U.S. cities. All the women were Caucasian and came from mostly middle-income homes, ranging in age from 30 to 79. About half of them had previously been diagnosed with breast cancer.After determining the bra-wearing habits of all the women, the Singers determined that wearing a bra increases a woman’s risk of developing breast cancer by double. Shockingly, wearing a bra to sleep at night is even worse, with three out of four, or 75 percent, of women who engage in this practice regularly developing the condition.
                 “Women who want to avoid breast cancer should wear a bra for the shortest period of time possible — certainly for less than 12 hours daily,” said Sydney Singer, as quoted by HealingCancerNaturally.com.     One would think that such information would be pertinent to Komen and other cancer organizations, which are purportedly raising money to find a cure. But the Singers and others have never been able to get their attention, with both Komen and the ACS denying any link between bras and breast cancer.So the Singers are calling on women everywhere to not only boycott supporting these organizations, but also to send over their bras whenever they are asked for money. Awareness about the potential dangers of wearing bras should at least be acknowledged by these groups that claim to support cancer awareness, and yet the response of ACS and Komen on the issue has been less than acceptable.
           “Because of this unscientific stonewalling of this information,” Singer wrote, “over the past 20 years 2,000,000 women in the US alone have gotten breast cancer who may have prevented it by simply loosening their bra and wearing it less time each day.”
             To learn more about Dressed To Kill, visit:
http://www.killerculture.com.
19  May 2014 update:  Dr Gerd Gigerenzer PhD, professor at a number of top USA and German institutions and expert in uncertainty, heuristic problem-solving, writes: This One Graphic Will Change the Way You Look at Breast Cancer Screening:  The most trenchant reasoning against screening xray mammography this year is in  Time Magazine 1 May 2014;  which he argues definitely applies to screening mammography: he details four tricks used by zealous proponents of screening mammography to infamously  persuade gullible women why ““If you haven’t had a mammogram, you need more than your breasts examined.”  These tricks are as follows, but are debunked  by the absolute facts in his Fact Box below. He says:

“First, look at the benefit. Out of every thousand women aged 50 and older, five without screening died from breast cancer, compared to four in the screening group. This is an absolute reduction of 1 in 1,000. In fact, it might even be an optimistic estimate because the Canadian follow-up study of women for 25 years after these trials found no reduction at all. But the exact number is not my point here. What I want to explain is how women are being misled.

Trick #1: State that screening reduces breast cancer mortality by 20% or more, because it sounds more impressive than explaining that the absolute risk reduction is 1 in 1,000.   This trick has been used for years in pamphlets. You might think, well, it’s not much, but at least one life is saved. But even that is not true. The number of deaths from all cancers, breast cancer included, is the same in both groups, as seen in line two of the fact box.            And that leads us to                                                                                                                             trick #2: Don’t mention that mammography screening doesn’t reduce the chance of dying from cancer. Talk only about the reduction in dying from breast cancer.      Often, and particularly if a person had multiple cancers, the exact cause of death is unclear. For this reason, total cancer mortality is the more reliable information when you look at it in terms of the larger goal: saving lives. In plain words, there is no evidence to date that routine mammography screening saves lives.             Now let’s look at the harms.

Trick #3: Don’t tell women about unnecessary surgery, biopsies and other harms from overtreatment. If you are asked, play these down.            The first way a mammogram can harm women is if it comes back with a false positive, leading to invasive and unnecessary biopsies. This isn’t the rare fluke most people seem to think it is. This happens to about a hundred out of every thousand women who participated in screening. Legions of women have suffered from this procedure and the related anxieties. After false alarms, many worried for months, developing sleeping problems and affecting relationships with family and friends.

Second, not all breast cancers are life-threatening. Women who have a nonprogressive or slowly growing form that they would never have noticed during their lifetime often undergo lumpectomy, mastectomy, toxic chemotherapy or other interventions that have no benefit for them and that are often accompanied with damaging side-effects. This happened to about five women out of a thousand who participated in screening.

The final trick #4    Tell women about increased survival. For instance, “If you participate in screening and breast cancer is detected, your survival rate is 98%.” Don’t mention mortality.

1 May 2014 update:  Dr Iona Heath FRCP, past president of the New Zealand Royal College of GPs ,  says in March that  Breast cancer mammography screening causes more harm than good.  Dr Kurt Kroenke from Univ Indiana two weeks ago  wrote That most screening test results will be normal or negative is commonplace, but the reality that abnormal results are frequently false-positive is not always well appreciated, nor is it fully conveyed to patients. How does a patient feel after a false-positive test result? Tosteson and colleagues1 concluded from their longitudinal study that “false-positive mammograms are associated with a measurable, small, and transient effect on personal anxiety.” However, a closer look at all the outcomes assessed in this well-done study reveal some adverse consequences that, although not serious, may nonetheless be meaningful.
          Given the harms of  screening, the Spanish consortium sum it up nicely last February:  Optimal (mammography)  screening is characterized by quinquennial or triennial periodicities for the low or moderate risk-groups and annual periodicity for the high-risk group.   This last group  is in reality tiny.                                                                                                                                                                    
        As this ongoing Woman’s Care column  stresses, very few well women at any age justify screening mammography, or any screening beyond thorough annual review and bloodpressure  and breast exam check. Only if the annual checkup, with  the examining clinician’s concern about clinical breast feel, or the woman’s  breast symptoms (which in fact rarely originate in the breast and are mostly easily resolved) raise suspicions, may some sort of  no-xray breast imaging be justified- soft SureTouch or ultrasound, or no-touch thermography .  No woman without an obvious  growing solitary breast lump or nipple bleeding/ discharge warrants the harms of initial xray screening mammogram.
                                                                                                                                                                        Unlike Bone Density  Screening available on request,  Sure Touch Breast screening is not charged for since it is part of a proper professional clinical consultation- which can be booked for any regular workday. It is the expert clinical consultation, and any necessary advised evidence-based   natural breast supplements and other changes for prevention, that are billed- obviously at viable market rates, but reduced on justified request based on usual means test.
Breast imaging on its own, without expert clinical assessment and advice , is hazardous because it may cause unwarranted concern and lead to the fearsome  and costly invasive cascade; and because breast imaging without thorough risk factor assessment including expert clinical exam may miss disease that justifies further steps if not immediate resolution.
                                                                                                                                                                HOW TO AVOID UNSETTLING, HARMING WOMEN?  As applies to unjustified mass prostate screening of well men, two new relevant publications below this month highlight the widening gap around MASS BREAST MAMMOGRAPHY SCREENING, between realist  holists- independent  Swiss reviewers  looking at the welfare of women and the real cost-benefits  of  breast screening till now – versus the burn & cut-at-any-cost  screening-industry Dutch career  radiologists’ and cancer experts’  vested-interest view looking solely at breast cancer deaths 2004-5, like most for-profit breast -career specialists   targeting every last well breast from 40years upwards.
The latest Cochrane metanalysis  2013   “found that breast cancer mortality was an unreliable outcome that was biased in favour of screening, mainly because of differential misclassification of cause of death.”
                                                                                                                                                                       Boston San Francisco- Illinois and Spanish- Catalonia-  universities’  reviewers recently make a less in-your-face case  against universal mass mammography screening,  rather selective screening frequency based on individualized risk factors and  potential harms.. But they dont refer to equally effective non-xray imaging techniques; or the fact that no imaging techniques except tissue histology can confirm or exclude cancer. .
                                                                                                                                                                against: DO NO HARM:  April 16, 2014 / NEJM  Perspective   from the Swiss Medical Board: Abolishing Mammography Screening Programs?          Nikola Biller-Andorno, and Peter Jüni, http://www.nejm.org/doi/full/10.1056/NEJMp1401875?query=TOC      In January 2013, the Health Ministers of the Swiss Cantons, the Swiss Medical Association, and the Swiss Academy of Medical Sciences mandated the Swiss Medical Board (a medical ethicist,  a clinical epidemiologist, a clinical pharmacologist, an oncologic surgeon, a nurse scientist, a lawyer, and a health economist), an independent health technology assessment initiative,  to prepare a review of mammography screening.We were aware of the controversies that have surrounded mammography screening for the past 10 to 15 years. When we reviewed the available evidence and contemplated its implications in detail, however, we became increasingly concerned.
          First, we noticed that the ongoing debate was based on a series of reanalyses of the same, predominantly outdated trials. The first trial started 50 years ago in New York City and the last  in 1991 in the United Kingdom.1 None of these trials were initiated in the era of modern breast-cancer treatment, which has dramatically improved the prognosis of women with breast cancer. Could the modest benefit of mammography screening in terms of breast-cancer mortality that was shown in trials initiated between 1963 and 1991 still be detected in a trial conducted today?
                                                                                                                                                                      
             Second, we were struck by how nonobvious it was that the benefits of mammography screening outweighed the harms. The relative risk reduction of approximately 20% in breast-cancer mortality associated with mammography that is currently described by most expert panels2 came at the price of a considerable diagnostic cascade, with repeat mammography, subsequent biopsies, and overdiagnosis of breast cancers — cancers that would never have become clinically apparent. The recently published extended follow-up of the Canadian National Breast Screening Study is likely to provide reliable estimates of the extent of overdiagnosis. After 25 years of follow-up, it found that 106 of 484 screen-detected cancers (21.9%) were overdiagnosed.3 This means that 106 of the 44,925 healthy women in the screening group were diagnosed with and treated for breast cancer unnecessarily, which resulted in needless surgical interventions, radiotherapy, chemotherapy, or some combination of these therapies.
      In addition, a Cochrane review of 10 trials involving more than 600,000 women showed no evidence of mammography screening benefit  on overall mortality.1 In the best case, the small reduction in breast-cancer deaths was attenuated by deaths from other causes. In the worst case, the reduction was canceled out by deaths caused by coexisting conditions or by the harms of screening and associated overtreatment. Did the available evidence, taken together, indicate that mammography screening indeed benefits women?
                                                                                                                                                                        
      Third, we were disconcerted by the discrepancy between women’s perceptions of the benefits of mammography screening and the benefits to be expected in reality. The figure  Women’s Perceptions of the Effects of Mammography Screening on Breast-Cancer Mortality as Compared with the Actual Effects. shows the numbers of 50-year-old women in the United States expected to be alive, to die from breast cancer, or to die from other causes if they are invited to undergo regular mammography every 2 years over a 10-year period, as compared with women who do not undergo mammography. The numbers in Panel A are derived from a survey about U.S. women’s perceptions,4 in which 717 of 1003 women (71.5%) said they believed that mammography reduced the risk of breast-cancer deaths by at least half, and 723 women (72.1%) thought that at least 80 deaths would be prevented per 1000 women who were invited for screening. The numbers in Panel B reflect the most likely scenarios according to available trials1-3: a relative risk reduction of 20% and prevention of 1 breast-cancer death. The data for Switzerland, reported in the same study, show similarly overly optimistic expectations. How can women make an informed decision if they overestimate the benefit of mammography so grossly?
                                                                                                                                                                        
      The Swiss Medical Board’s report was made public on February 2, 2014 . It acknowledged that systematic mammography screening might prevent about one death attributed to breast cancer for every 1000 women screened, even though there was no evidence to suggest that overall mortality was affected. At the same time, it emphasized the harm — in particular, false positive test results and the risk of overdiagnosis. For every breast-cancer death prevented in U.S. women over a 10-year course of annual screening beginning at 50 years of age, 490 to 670 women are likely to have a false positive mammogram with repeat examination; 70 to 100, an unnecessary biopsy; and 3 to 14, an overdiagnosed breast cancer that would never have become clinically apparent.5 The board therefore recommended that no new systematic mammography screening programs be introduced and that a time limit be placed on existing programs. In addition, it stipulated that the quality of all forms of mammography screening should be evaluated and that clear and balanced information should be provided to women regarding the benefits and harms of screening.
The report caused uproar and was emphatically rejected by a number of Swiss cancer experts and organizations, some of which called the conclusions “unethical.” One of the main arguments used against it was that it contradicted the global consensus of leading experts in the field — a criticism that made us appreciate our unprejudiced perspective resulting from our lack of exposure to past consensus-building efforts by specialists in breast-cancer screening. Another argument was that the report unsettled women, but we wonder how to avoid unsettling women, given the available evidence.
The Swiss Medical Board is nongovernmental, and its recommendations are not legally binding. Therefore, it is unclear whether the report will have any effect on the policies in our country. Although Switzerland is a small country, there are notable differences among regions, with the French- and Italian-speaking cantons being much more in favor of screening programs than the German-speaking cantons — a finding suggesting that cultural factors need to be taken into account. Eleven of the 26 Swiss cantons have systematic mammography screening programs for women 50 years of age or older; two of these programs were introduced only last year. One German-speaking canton, Uri, is reconsidering its decision to start a mammography screening program in light of the board’s recommendations. Participation in existing programs ranges from 30 to 60% — variation that can be partially explained by the coexistence of opportunistic screening offered by physicians in private practice. At least three quarters of all Swiss women 50 years of age or older have had a mammogram at least once in their life. Health insurers are required to cover mammography as part of systematic screening programs or within the framework of diagnostic workups of potential breast disease.
                                                                                                                                                                              

     It is easy to promote mammography screening if the majority of women believe that it prevents or reduces the risk of getting breast cancer and saves many lives through early detection of aggressive tumors.4 We would be in favor of mammography screening if these beliefs were valid. Unfortunately, they are not, and we believe that women need to be told so. From an ethical perspective, a public health program that does not clearly produce more benefits than harms is hard to justify. Providing clear, unbiased information, promoting appropriate care, and preventing overdiagnosis and overtreatment would be a better choice.

from the  Universities of Zurich &  Bern,  Switzerland; and   Harvard Medical School, Boston . Dr. Biller-Andorno is a member of the expert panel of the Swiss Medical Board; Dr. Jüni was a member of the panel until August 30, 2013

                                                                                                                                                                      FOR-SCREENING- FOR CAREER/PROFIT :  do the maximum: 
Breast. 2014 Apr 5.  Breast cancer screening halves the risk of breast cancer death: A case-referent study. Paap E, Verbeek AL,Broeders MJ ea.  Netherlands Breast Screening Centres.   Large-scale epidemiologic studies have consistently demonstrated the effectiveness of mammographic screening programs, however the benefits are still subject to debate. We estimated the effect of the Dutch screening program on breast cancer mortality. In a large multi-region case-referent study, we identified all breast cancer deaths in 2004 and 2005 in women aged 50-75 who had been invited for screening (cases). Cases were individually matched to referents from the population invited to screening. A total of 1233 cases and 2090 referents were included in this study. We found a 58% reduction in breast cancer mortality in screened versus unscreened women (adjusted OR = 0.42, 95% CI 0.33-0.53). Screening, i.e. early detection and treatment, has resulted in a substantial reduction in breast cancer mortality, indicating that the Dutch breast cancer screening program is highly effective.
                                                                                                                                                                 update  23 March 2014: Caroline Huang at the  Ethox Centre at Oxford writes in   Screening mammography: benefits, harms, and evidence-based guidelines in the US and UK:   The Ethox Centre is a multidisciplinary bioethics research centre in the University of Oxford’s Nuffield Department of Population Health.“Authors Bleyer and Welch claim there has been only an 8% reduction in late-stage breast cancer diagnoses (an absolute reduction of 8 cases per 100,000 women), and while mortality has decreased, it appears that most of the benefit has come from better treatment rather than better screening. (For cancer screening to be considered effective, the US National Cancer Institute says that cancer deaths and late-stage cancer diagnoses should decrease, while early-stage cancer diagnoses should increase.[2])
Contrast these findings to another mammography study published the same week in The Lancet, conducted by an independent panel in the UK as a meta-analysis of 11 randomized trials.[3] The panel estimated overdiagnosis of early-stage breast cancers in the UK to be between 11 and 19%. Crucially, though, there appeared to be a 20% mortality benefit from screening alone.What might account for these significantly different estimations of breast cancer screening effectiveness? The most obvious factor is the frequency and age at which average-risk women are offered mammography. In the UK, women ages 50-70 are offered screening every three years through the NHS Breast Cancer Screening Programme. In the US, women ages 40-70 are typically offered screening every one or two years.      
                      Though a 2009 US Preventive Services Task Force (USPSTF) report recommended that average-risk women should receive screening from ages 50-74 every two years,[4] this recommendation has been not been adopted by professional organizations such as the American Cancer Society, the American College of Radiologists, and the National Cancer Institute. In fact, a study published in November in Preventive Medicine showed that there has been no difference in mammograms provided across any age groups in the US since the 2009 USPSTF report was published.[5]These two studies (and many others preceding them) raise plenty of practical questions about diagnostic thresholds, benefits of population screening, limitations of current radiology technologies, and understanding of which cancers do and do not become invasive. But I want to raise a broader question: should there be an ethical imperative compelling different US professional groups that address the same disease or disorder to adopt a common set of evidence-based guidelines?                                                                                                                                                       
          And if there isn’t, then what is the value of having a group like the USPSTF to issue recommendations that may ultimately be ignored by its target audiences?A few reasons for adopting a common set of evidence-based guidelines might be reducing patient and provider confusion, enhancing low-cost access to care, and potentially redistributing funds to further the reach of proven services or improve research. While the National Breast Cancer Screening Programme requires only the NHS to adopt and implement new recommendations, the more fragmented US system means that screening is not organized by a single body and thus involves competing recommendations that could confuse patients trying to make informed choices and providers trying to assist them in doing so. Additionally, because US insurers are increasingly moving towards funding only evidence-based services, having a common set of guidelines would help ensure that providers’ recommended services are covered under patients’ insurance rather than falling into a category of services with questionable benefit that might not be covered. This is perhaps not the optimal ethical consideration to have to make, but it is a necessary component of realistic preventive care. Finally, at the health system level, providing mammograms only to women ages 50-74 might mean that resources currently allocated to mammograms for women ages 40-49 could be put towards more mammograms for women ages 50-74 or other related preventive health services or research.Despite these reasons, however, it would be equally problematic to remove clinical groups’ ability to disagree with recommendations that they believe result from poor statistics or faulty logic. It also does not seem like there is intrinsic opposition to adopting recommendations produced by independent panels or other clinical groups.   
                                                                                                                                                                        The same Preventive Medicine study discussed above references two cases in which recommendations resulted in immediate changes to screening patterns: (1) the National Cancer Institute and American Cancer Society’s 1997 recommendation that mammography be expanded to women ages 40-49 resulted in increased screening, and (2) the USPSTF’s 2008 recommendation against prostate cancer screening in men ages 75 and older resulted in fewer early-stage prostate cancer diagnoses. So the USPSTF has not always been unsuccessful in having its recommendations taken seriously, even in a case where less screening is recommended, and at least one breast cancer screening recommendation has previously had a quick adoption in practice.These cases – as well as the USPSTF 2002 recommendation that originally suggested offering mammography to women ages 40-49 once every 1-2 years, which is reflected in current clinician groups’ guidelines – suggest that the USPSTF’s target audiences aren’t willfully ignoring meta-analyses of available data. Rather, clinicians, advocacy groups, and patients have questioned the methodology behind the 2009 USPSTF recommendation, in a similar fashion to the critiques being raised over the NEJM study.                                                                                
                                                                                                                                                                        
               For example, the American College of Radiology suggested that Bleyer and Welch failed to properly account for an increasing incidence of invasive late-stage breast cancers unrelated to screening uptake.[6] In light of this information, we might reframe the second question to ‘How do we ensure that groups like the USPSTF incorporate the right kind of data into their analyses and recommendations?’ That answer might have to do with rethinking how consultation with relevant clinical and patient advocacy groups is carried out, as well as examining a broader range of data sources. To circle back to the contrast between the NEJM and Lancet findings, it is important to think about how and why the UK’s National Breast Cancer Screening Programme seems to have lower rates of overdiagnosis and greater mortality benefit from screening relative to the US screening system.                                                                                                                                                                                                                                                                             At the very least, these kinds of contradictory non-US outcomes should prompt a re-evaluation of which kinds of evidence we have chosen to evaluate.We might also point to the discourse around prostate-specific antigen (PSA) testing – which has been linked to overdiagnosis of early-stage, non-invasive prostate cancer – as one model for where breast cancer screening recommendations may go. Importantly, while clinical organizations have not reached consensus in whether PSA testing should be recommended as a yearly exam for men over 50,[7] they do agree that a careful discussion of PSA testing’s potential harms and benefits is always appropriate.Indeed, the authors of both the Lancet and NEJM articles conclude with similar thoughts: physicians must initiate conversations about the pros and cons of mammography so that patients can make informed choices. That assertion seems uncontroversial enough to be accepted by the various professional groups involved – so perhaps any common set of guidelines we should expect groups to adopt should relate to the communication of evidence rather than potentially controversial or insufficient evidence itself.”
                                                                                                                                                                      15/3/ 2014 update: Great Mammography Debate :  Dr. Patrick Borgen, Chairman of Surgery at Maimonides Medical Center in Brooklyn, New York, talks about the role of screening mammography, a topic bracketed by strong opinions. It has been a particular focus of discussion at the 31st Annual Miami Breast Cancer Conference, held March 6 through March 9, 2014, in Miami, Florida.

               Commentary  The mammography debate is one of the facets of the Miami Breast Cancer Conference this year.   It seems as though the field of breast cancer has always been controversial, going back half a century, and breast cancer is a disease that, more than most others, is very polarizing. This disease engenders great passion—and great debate, which has been ongoing about the role of screening mammography.

            A few weeks ago, The New York Times covered an article that was published in the British Medical Journal 1 about the Canadian National Breast Screening Study. On the surface, this study failed to show any benefit from mammography. That was the story that the writer, Gina Kolata, picked up and ran with. Ms. Kolata had written about her own experience with breast cancer a number of years ago; her breast cancer had not been picked up on a mammogram, and so she is somewhat biased.

               In short, the Canadian study evaluated mammograms from more than 90,000 women who had very primitive mammograms between 1980 and 1984, and that is really the first problem with this study: the technology and the equipment then was incredibly limited, such that the mammograms only showed 30% of breast cancers; whereas, today, mammography detects 70% to 80% of breast cancers. Thus, taking results generated by technology from 34 years ago and making a conclusion about them in today’s world is a stretch.

One of the fundamental flaws of the Canadian study, besides the dated technology on which the conclusions were based, was that it was not randomized. Nurses, and, in some provinces in Canada, doctors, did a clinical breast exam, and, if they felt a mass or a lump, they preferentially put the patient into the mammography arm. That is what I would have done in their place; if I felt a lump, I would not be willing to send someone home.

By the end of the study, there were more than 100 extra breast cancers in the mammography arm and more breast cancers that had spread to lymph nodes in the mammography arm. And, in fact, the chance of dying of breast cancer was higher in the mammography arm.

All of the authorities with whom I have ever spoken or read who have reviewed this study dismiss it as very flawed. A number of the doctors who were involved with the study resigned their positions in protest. Despite all of that, The New York Times ran an article headlined, “Vast Study Casts Doubts on Value of Mammograms” (February 11, 2014).

Well, it is a vastly flawed study, and, in fact, there are six other, much larger and much better controlled studies, all of which showed a reduction in breast cancer mortality from 20% up to 40% in women who have mammograms—and that is certainly what we observe clinically.

We felt that it was important to really highlight this at the Miami Breast Cancer Conference this year. My guess is that our audience already knows this; but, what we would like to give them is the science about why the Canadian study was flawed so that they can talk to their patients and talk to their colleagues who may not be in the breast cancer field. That is really what I think our mission is for part of this year’s conference.

We think that this is dangerous information. We think that women will unnecessarily lose their lives to breast cancer if they forego mammography, which this study frankly says one should. I have a busy practice in Brooklyn, New York, and, at least once or twice a week, I see someone, without any question, whose life was saved by a mammogram.

I think that we all agree we need something better than mammography. We all agree that mammography can lead to over-diagnosis of breast cancers, and over-diagnosis happens, of course, when we screen for diseases in other areas of the body. We all accept this limitation.

But, for a major media outlet to take a single study that was deeply flawed and not even mention the existence of other studies, even as a point–counterpoint, I think was a bit outrageous!

12 March 2014 this publication on the Huffington Post website  today under screening mammography is as appropriate as when it was published in 2010:

The NBCAM has assured women that “early (mammography) detection results in a cure nearly 100 percent of the time.” More specifically, the NBCAM is directed to claims for reducing the incidence and mortality of breast cancer through early detection by annual mammography starting at age 40. Moreover, mammograms can miss cancers in premenopausal women due to the density of their breasts, and also fail to detect cancers smaller than half an inch.

Still denied by the ACS is clear evidence that premenopausal mammography poses significant risks of breast cancer. The routine practice of taking two films annually for each breast results in approximately 0.5 rad (radiation absorbed dose) exposure. This is about 500 times the dose from a single chest X-ray and is broadly focused on the entire chest rather than narrowly on the breast. This is also 25 times higher than is allowed by the Environmental Protection Agency for whole-body radiation from local nuclear industries (0.02 rad). Moreover, the breast is the most sensitive organ to ionizing radiation.

As warned by the prestigious National Academy of Sciences in 1972 but still ignored by the ACS, the premenopausal breast is highly sensitive to the risks of cancer from mammography, as each rad exposure increases the risks of breast cancer by 1 percent. This results in a cumulative 10 percent increased risk for each breast following a decade of routine screening. This can also accounts for the 19-percent increased incidence of breast cancer since 1975. Not surprisingly, the prestigious U.S. Preventive Task Force, supported by the National Breast Cancer Coalition, warned last year against routine premenopausal mammography. Also, not surprisingly, routine premenopausal mammography is practiced by no nation other than the U.S.

Risks of premenopausal mammography are some four-fold greater for the 2 percent of women who are carriers of the A-T gene (ataxia telangiectasia) and are highly sensitive to the carcinogenic effects of radiation. By some estimates, this accounts for up to 20 percent of all breast cancers diagnosed annually. Compounding these problems, missed cancers are common in premenopausal women due to the density of their breasts.

That most breast cancers are first recognized by women was admitted by the ACS in 1985. “We must keep in mind that at least 90 percent of the women who develop breast cancer discover the tumors themselves.” Furthermore, an analysis of several 1993 studies showed that women who regularly performed breast self-examination (BSE) detected their cancers much earlier than women failing to examine themselves. The effectiveness of BSE, however, depends on training by skilled professionals, enhanced by an annual clinical breast examination. Nevertheless, in spite of such evidence, the ACS dismisses BSE, and claims that “no studies have clearly shown [its] benefit.”

As reported in our 1999 publication in the International Journal of Health Services, an article in a leading Massachusetts newspaper featured a photograph of two women in their twenties. The article promised that early detection by mammography results in a cure “nearly 100 percent of the time.” Questioned by journalist Kate Dempsey, an ACS communications director responded: “The ad isn’t based on a study. When you make an advertisement, you just say what you can to get women in the door. You exaggerate a point — Mammography today is a lucrative [and] highly competitive business.”

If all 20 million U.S. premenopausal women submitted to annual mammograms, the minimal annual costs would be $2.5 billion. Such costs would be increased some fourfold if the industry, supported by radiologists, succeeds in its efforts to replace film machines, costing about $100,000, with high-tech digital machines, costing over $400,000, even in the absence of any evidence for their improved effectiveness.

With this background, it is hardly surprising that the National Breast Cancer Awareness Month neglects to inform women how they can reduce their risks of breast cancer. In fact, we know a great deal about its avoidable causes which remain ignored by the ACS. These include:

    • Prolonged use of the Pill, and estrogen replacement therapy.
    • Prolonged consumption of milk from cows injected with a genetically engineered growth hormone to increase milk production. This milk is contaminated with high levels of a natural growth factor, which increases risks of breast cancer by up to seven-fold.
    • High consumption of meat, as it is contaminated with potent natural or synthetic estrogens. These are routinely implanted in cattle before entry into feedlots, about 100 days prior to slaughter, to increase muscle mass and profits for the meat industry.
    • Prolonged exposure to a wide range of hormonal ingredients in conventional cosmetics and personal care products.
  • Living near hazardous waste sites, petrochemical plants, power lines, and nuclear plants.

The enthusiastic and continuing support of premenopausal mammography by the ACS is hardly surprising in view of its major conflicts of interest that still remain unrecognized. Five radiologists have served as ACS presidents. In its every move, the ACS promotes the interests of the major manufacturers of mammogram machines and films, including Siemens, DuPont, General Electric, Eastman Kodak and Piker. The mammography industry also conducts research for the ACS, serves on its advisory boards, and donates considerable funds. DuPont is also a substantial backer of the ACS Breast Health Awareness Program. It sponsors television shows touting mammography; produces advertising, promotional materials and literature for hospitals and doctor; and lobbies Congress for legislation promoting the availability of mammography. The ACS has been and remains strongly linked with the mammography industry, while ignoring or criticizing the value of breast self-examination, even following training by a qualified nurse or clinician.

The ACS conflicts of interest extend well beyond the mammography industry. The ACS has received contributions in excess of $100,000 from a wide range of “Excalibur (industry) Donors,” who manufacture carcinogenic products. These include petrochemical companies (DuPont, BP and Pennzoil), Big Pharma (AstraZenceca, Bristol Myers Squibb, GlaxoSmithKline, Merck & Company and Novartis), and cosmetic companies (Christian Dior, Avon, Revlon and Elizabeth Arden).

Samuel S. Epstein, M.D. is professor emeritus of Environmental and Occupational Medicine at the University of Illinois at Chicago School of Public Health; Chairman of the Cancer Prevention Coalition; and a former President of the Rachel Carson Trust. His awards include the 1998 Right Livelihood Award and the 2005 Albert Schweitzer Golden Grand Medal for International Contributions to Cancer Prevention. Dr. Epstein has authored 270 scientific articles and 20 books on cancer prevention, including the groundbreaking “The Politics of Cancer” (1979), and most recently “Toxic Beauty” (2009, Benbella Books: http://www.benbellabooks.com) about carcinogens, besides other toxic ingredients, in cosmetics and personal care products. Email: epstein@uic.edu. Web: http://www.preventcancer.com.

update 6 March 2014    Switzerland debates dismantling its breast cancer screening programme   BMJ 2014;348:g1625   “A row has erupted in Switzerland after the Swiss Medical Board  recommended that the country’s mammography screening programme for breast cancer be suspended because it leads to too many unnecessary interventions.
              In a report made public on 2 February, the board said that while systematic mammography screening for breast cancer saved 1-2 women’s lives for every 1000 screened, it led to unnecessary investigations and treatment for around 100 women in every 1000.1 “The desirable effect is offset by the undesirable effects,” said the report, which was based on study data from 1963 to 1991   comparing 1000 women who were screened with 1000 women who were not. The report also concluded that screening was not cost effective.…”

update 1 Mar 2014   Supporting informed decision making when clinical evidence and conventional wisdom, clash.   The nub of the screening mammography war – and all hard-sell marketing hype-  is elegantly analyzed by a USA multiUniversity Communications team in Against conventional wisdom: when the public, the media, and medical practice collide.       Jakob Jensen ea argue that “the screening mammography  controversy was driven by the systematic removal of uncertainty from science communication. To increase comprehension and adherence, health information communicators remove caveats, limitations, and hedging so science appears simple and more certain. This streamlining process is, in many instances, initiated by researchers as they engage in dissemination of their findings, and  is facilitated by public relations professionals, journalists, public health practitioners, and others whose tasks involve using the results from research for specific purposes.   Uncertainty is removed from public communication because many communicators believe that it is difficult for people to process and/or that it is something the audience wants to avoid. Uncertainty management theory posits that people can find meaning and value in uncertainty.                  CONCLUSIONS: Science is routinely simplified as it is prepared for public consumption.     In line with the model of information overload, this practice may increase short-term adherence to recommendations at the expense  of long-term message consistency and trust in science”. 

          The Mammography Saves Lives  screening campaign  was and is to recruit all older women to regular screening; it  was progressively oversold   by removing, ignoring the science uncertainty. “Science is routinely simplified as it is prepared for public consumption. In line with the model of information overload, this practice may increase short-term adherence to recommendations at the expense of long-term message consistency and trust in science”.


We see the same collusion between corporate marketeers and government regulators in so many high-profit industries:
  on Pubmed,  screening mammography features for 50 years, and continued to expand exponentially without hindrance until enough epidemiologists – led by the Cochrane Group- collectively  rang enough alarm bells the past decade. The zealous huge-profit USA  radiology-oncology industry simply shouted down the negative result of the massive Canadian Screening Mammography trial outcome   30 years ago in 90 000 women, and continue to do so with the 25year results now reported. The huge Breast Industry retaliates by threatening whistle blowers.

*at the same time around 50years ago, as many of us were starting medical studies, Keys and Stamler  et al in USA did bad epidemiological studies that subverted the facts of  healthy indigenous diets around Europe, Africa and Asia, and the healthy traditional English-speaking (USA and the British Empire) working population’s mainly fresh meat/fish  fat and farm produce diet,
      to claim that the reverse be promoted-  factory-produced low fat low cholesterol high carbohydrate (cereals, potato, white flour and white rice) –  and worse, quadrupling of fructose and sucrose intake, with increasing obesity;   and then noxious statins- for-all for the resultant carbs-inducedlipidemia “epidemic”;  and the  dangerous hypoglycemic drugs for mushrooming type 2 diabetes, and NSAIDs for arthritis; and numerous wannabe antiobesity drugs; and finally the new industry of bariatric surgery!.
        see the classic expose books: John Gofman’s  Preventing Breast Cancer 1996; James le Fanu ‘s  The Rise and Fall of Modern Medicine 1999 ; Gary Taubes’ The Diet Delusion (2007);  Ben Goldacre’s Bad Pharma 2012 and Peter Gotzsche’s Mammography Screening: Truth, Lies and Controversy 2013

*and as a result,  the past 30years,- against all rational food  science and biology – Montsanto’s Government- approved  rape  of healthy food agriculture by genetically modified crops laced with toxic environmentally persistent glyphosate C3H8NO5P- Roundup.

It is no irony that one of the leading medical scientists of the 20th century Dr John Gofman took part in  the Manhattan  nuclear Project, was a pioneer of VLDL lipidology, and then an activist for protecting women against the accumulating harm of mammography – “there is no safe dose of radiation”.

 at Exam. Resulting Risk of Mammogram-Induced Breast Cancer. 1998
Any age in 1 exam: 1 chance in about 1,100.
30-34 range. 5 exams: 5 chances/1100, or 1 chance in 220.
Any age in 1 exam: 1 chance in about 1,900.
35-49 range. 10 exams: 10 chances/1900, or 1 chance in 190.
Any age in 1 exam: 1 chance in about 2,000.
50-64 range. 15 exams: 15 chances/2,000, or 1 chance in 133.

Dr Emily Transue MD eloquently describes her personal disillusionment with screening mammography.

                                                                                                                                                                                     update 23 Feb 2014     Like Wikipedia on breast screening, Karen Kaplan in the L.A.Times this week challenges mammography radiologists: stop lying to patients about the benefits of screening mammography. As Dr David Katz in the Huffington Post muses, can we unmuddle mammography?                                                                            The USA National Cancer Association promotion conspicuously avoids mentioning the equal balance between benefits and risks of screening mammography, 
and Dr Charles Wright in the Toronto Globe and Mail  says   “It’s time for a new approach to mammograms  
     The New York Times review this week turns the report of the Canadian trial to focus on the importance of breast self-examination; their other review  agrees that  Vast Study Casts Doubts on Value of Mammograms.
It is damning that Cochrane studies   (which date from about 1994) -for mammography published only since year 2000 – have consistently found that screening mammography imaging has no material longterm survival benefit for women with apparently normal breasts, with numerous potential harms.
      The question remains, should people  without suspicious cancer  symptoms or bad family history  have any invasive screening (of breast and prostate) beyond regular appropriate physical examination? when all of us should follow  sensible lifestyle, diet and appropriate supplements to minimize both acute and chronic diseases, and thus die well in old age.
                If women without apparent high risk  will not be satisfied by clinical reassurance, prescreening  image recording without compression irradiation will depend on what is locally available.
The USA National Cancer Institute at the NIH , while dutifully promoting regular screening mammography, negates their promotion by listing  precisely  7 lines,  one benefit : Early detection of breast cancer with screening mammography means that treatment can be started earlier in the course of the disease, possibly before it has spread. Results from randomized clinical trials and other studies show that screening mammography may  reduce the number of deaths from breast cancer among women ages 40 to 70, especially for those over age 50..
            But it lists 46 lines of potential harms:” What are some of the potential harms of screening mammograms?      
1. “Finding cancer early doesnt  reduce a woman’s chance of dying from breast cancer or any cause. Even though mammograms can detect malignant tumors that cannot be felt, treating a small tumor does not always mean that the woman will not die from the cancer. A fast-growing or aggressive cancer may have already spread to other parts of the body before it is detected.                                                              
2. Fear: “Women with such detected  early tumors live a longer period of time fearing that they likely have a fatal disease… screening mammograms dont help prolong the life of a woman who is suffering from other, more life-threatening health conditions. Depression anxiety let alone suicide are increased .
3. “False-negative results occur when mammograms appear normal even though breast cancer is present. Overall, screening mammos miss about 20% of breast cancers that are present at the time of screening.. from  high breast density i.e., glandular tissue and connective tissue, together known as fibroglandular tissue) and fatty tissue.  Because fibroglandular tissue and tumors have similar density, tumors can be harder to detect in women with denser breasts more often among younger women than among older women because younger women are more likely to have dense breasts. As a woman ages, her breasts usually become more fatty, and false-negative results become less likely. False-negative results can lead to delays in treatment and a false sense of security for affected women.                              
4. “False-positive results occur when radiologists decide mammograms are abnormal but no cancer is actually present. All abnormal mammograms should be followed up with additional testing (diagnostic mammograms, ultrasound, and/or biopsy) to determine whether cancer is present… more common for younger women, women who have had previous breast biopsies, women with a family history of breast cancer, and women who are taking estrogen (for example, menopausal hormone therapy).        False-positive mammogram results can lead to anxiety and other forms of psychological distress in affected women. The additional testing required to rule out cancer can also be costly and time consuming and can cause physical discomfort. .                                                                                                            
5. “Overdiagnosis and overtreatment. Screening mammograms can find cancers and cases of ductal carcinoma in situ (DCIS, noninvasive tumor  cells that may become cancerous build up in the lining of breast ducts) that need to be treated. However, they can also find cancers and cases of DCIS that will never cause symptoms or threaten a woman’s life, leading to “overdiagnosis” of breast cancer. Treatment of these latter cancers and cases of DCIS is not needed leads to “overtreatment.” Overtreatment exposes women unnecessarily to the adverse effects associated with cancer therapy.      Because doctors often cannot distinguish cancers and cases of DCIS that need to be treated from those that do not, they overtreat .                                                                                                                              
6. “Radiation exposure. Mammograms require very small doses of radiation. The risk of harm from this radiation exposure is extremely low, but repeated x-rays have the potential to cause cancer. 

They fail to list other adverse effects:                                                                                       7. Pain and bruising of crush mammography- sometimes prolonged;                     8. spreading early and likely dormant cancer.                                                                   9. Increased incidence of breast cancer and thus more irradiation, mastectomy and all-cause mortality, and                                                                                                              10. complications of surgery, radiotherapy and chemotherapy.                                                 ………………………..

           the Rapid Responses to the 25year  Breast cancer incidence and mortality of the Canadian National Breast Screening Study show again the Great Divide between objective  epidemiological evidence,  and vested-interest belief by those whose careers and incomes depend on zealous pursuit of early (pre)cancers.
                 Prof Michael Baum as a former UK Screening Mammography leader again trenchantly quotes reality to protect women from terrorism by screening mammography and mastectomy, in particular urging the same policy of watchful waiting to see the natural course of early  cancer-   that has saved so many men from harmful diagnostic and therapeutic invasion of asymptomatic prostate cancer.
                  We must stress that, if the patient refuses or is denied conventional oncotherapy, Watchful Waiting should always be supported including by all possible improvements in multibeneficial diet, lifestyle and supplements, and avoidance of cancer-promoting estrogenics .
…………………………………….
     Women who choose not to have mammography and oncotherapy for highly suspicious lumps or even advancing cancers, or have been classified by cancer clinics  as too advanced for oncotherapy- told they have very short life expectancy- illustrate the lesson of watchful waiting with active intervention. We  see surprising regression in breast lumps, breast cancer and quality life extension in those who refuse to accept the oncologists’  death predictions  and who apply strong faith and  some of the many evidence-based changes and preventative natural supplement remedies we have  collated,    before or  even after the gamut /  gauntlet  of crush mammography, biopsy, surgery and radio-chemotherapy.
                                                                                                                                                           update 21 Feb 2014 The Oncologist publishes epidemiologist Archie Bleyer’s   “Were Our Estimates of Overdiagnosis With Mammography Screening in the United States Based on Faulty Science”?   rebuttal of radiologist Prof Daniel Kopans’  denial of the overdiagnosis of breast cancer.
        The point Bleyer again makes is that women have the choice provided they are fully informed of the pros and cons, and the options to screening mammography  and biopsy.
                 16 Feb 2014 update:   a slew of new papers reinforces the futility and hazards of mammography screening for early breast cancer- and the divide between the vested interests of mammographers/ oncologists – those who make their living from finding every possible cancer-  and the welfare of women:
                    Natural News today reviews criticisms of mammography from USA.
   in  NEJM 13 Feb , 2014,       Lisa Rosenbaum MD , Univ Pensylvania:  sums up the dilemma of real but unprofitable evidence vs profiteering, culture  and feeling  : Misfearing” — Culture, Identity, and Our Perceptions of Health Risks  Despite knowing that heart disease kills more women each year than all cancers combined, most women fear breast cancer far more — and their health-related behavior reflects this difference. If our sense of risk is less about fact than about feeling, how do we adjust it?
                
BMJ Feb 11,  2014: 25year  Breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial   Anthony  Miller, Cornelia  Baines, Steven  Nar ea,  compared breast cancer incidence and mortality up to 25 years later  in 89 835 volunteer women aged 40-59 randomly assigned to mammography (five annual mammography screens) or control (no mammography) in 15 screening centres in six Canadian provinces, 1980-85 . .  Women aged 40-49 in the mammography arm and all women aged 50-59 in both arms received annual physical breast examinations. Women aged 40-49 in the control arm received a single examination followed by usual care in the community.  Main outcome measure Deaths from breast cancer.  Results During the five year screening period, 666 invasive breast cancers were diagnosed in the mammography arm (n=44 925 participants) and 524 in the controls (n=44 910), and of these, 180 women in the mammography arm and 171 women in the control arm died of breast cancer during the 25 year follow-up period. The overall hazard ratio for death from breast cancer diagnosed during the screening period associated with mammography was 1.05 (95% confidence interval 0.85 to 1.30). in those aged 40-49 and 50-59 . During the entire study period, 3250 women in the mammography arm and 3133 in the control arm had a diagnosis of breast cancer, and 500 and 505, respectively, died of breast cancer. Thus the cumulative mortality from breast cancer was similar between women in the mammography arm and in the control arm (hazard ratio 0.99, 95% confidence interval 0.88 to 1.12). After 15 years of follow-up a residual excess of 106 cancers was observed in the mammography arm, attributable to over-diagnosis.   Conclusion Annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available. Overall, 22% (106/484) of screen detected invasive breast cancers were over-diagnosed, representing one over-diagnosed breast cancer for every 424 women who received mammography screening in the trial.
                        Editorial Too much mammography  11 February 2014   BMJ 2014;348:g1403 http://dx.doi.org/10.1136/bmj.g1403  Mette Kalager,Hans-Olov Adami, Michael Bretthauer, Norway.                                     Long term follow-up does not support screening women under 60.   Before being widely implemented, mammography screening was tested in randomised controlled trials in the 1960s to 80s. Meta-analyses of these trials showed a relative reduction in deaths from breast cancer of between 15% and 25% among women aged 50 to 69.1 2 3 Only the Canadian National Breast Screening Study showed no reduction in breast cancer mortality.1 2 3 This large randomised controlled trial compared physical breast examination with combined physical breast examination and annual mammography in women aged 40 to 59.1 2 3    In a linked paper (doi:10.1136/bmj.g366), Miller and colleagues present the results for up to 25 years of follow-up in the Canadian study.4 No difference in breast cancer mortality was observed between the mammography and control arms, whereas a significant excess incidence of invasive breast cancer was observed in the mammography arm, resulting in 22% overdiagnosis. This means that 22% of screen detected invasive cancers would not have reduced a woman’s life expectancy if left undetected. The major strengths of this study include its randomised design, intense intervention with five annual mammography screenings, high compliance, and complete, long term follow-up. The lack of mortality benefit is also biologically plausible because the mean tumour size was 19 mm in the screening group and 21 mm in the control group. This 2 mm difference—which might be even smaller if overdiagnosed cancers could be excluded from the screening group—represents a minimal proportion of the entire clinical course for breast tumours.  But the trial also has some potential limitations. No quantitative data are available on the degree of contamination in the control arm or possible confounding by screening mammography after the trial. It seems unlikely, however, that such potential limitations would conceal a clinically important benefit. The rate of overdiagnosis did not include ductal carcinoma in situ, and the trial provides no data for women older than 60.

               The Canadian study, launched in 1980, is the only trial to enroll participants in the modern era of routine adjuvant systemic treatment for breast cancer, and the women were educated in physical breast examination as advocated today.4 These important features may make this study more informative for a modern setting, compared with other randomised trials. The results of the study are strikingly similar—for both lack of efficacy and extent of overdiagnosis—to recent studies evaluating today’s screening programmes.5 6 7 The real amount of overdiagnosis in current screening programmes might be even higher than that reported in the Canadian study,4 because ductal carcinoma in situ, which accounts for one in four breast cancers detected in screening programmes,8 was not included in the analyses.

                Other studies also indicate that improved treatment rather than screening is the reason for the decline in breast cancer mortality during the past four or five years.5 7 Even though different studies arrive at different reductions in breast cancer mortality (from 10% to 25%), these benefits translate to only marginal differences in absolute effects. Much larger variation is seen in the estimates of overdiagnosis.6 In studies based on statistical modelling, overdiagnosis was less than 5%.6 By contrast, most observational studies report higher estimates of overdiagnosis, ranging from 22% to 54%,6 depending on denominator used.9 When the number of breast cancers detected at screening is used as the denominator (as in the Canadian study), the amount of overdiagnosis observed in the previous randomised controlled trials is strikingly similar (22-24%).4 10

How do the data on mammography screening compare with data on prostate cancer screening by prostate specific antigen, which is currently not encouraged in the United Kingdom and other countries owing to its small effect on mortality and large risk of overdiagnosis (www.screening.nhs.uk/prostatecancer)? The figure on bmj.com shows that the absolute harms (overdiagnosis) and benefits (mortality reduction) are not very different between the screening types. The 20 year risk of breast cancer for a 50 year old woman is 6.1% with screening (including 22% overdiagnosis 4),11 and 5.0% without screening; and the corresponding numbers for prostate cancer in a 50 year old man are 3.9% with screening (including 45% overdiagnosis 12) and 2.7% without screening.11 The 20 year risk of death from cancer for a 55 year old woman is 1.5% with screening (assuming a 20% reduction in mortality2)11 and 1.9% without screening; and the corresponding numbers for prostate cancer in a 55 year old man are 1.0% with (assuming a 20% reduction in mortality12) and 1.3% without screening.11

           Nevertheless, the UK National Screening Committee does recommend mammography screening for breast cancer but not prostate specific antigen screening for prostate cancer, stating that the “aim is to only implement programs that do more good than harm and that the informed choice is a guided principle of screening” (www.screening.nhs.uk/screening). Because the scientific rationale to recommend screening or not does not differ noticeably between breast and prostate cancer, political pressure and beliefs might have a role.

             We agree with Miller and colleagues that “the rationale for screening by mammography be urgently reassessed by policy makers.” As time goes by we do indeed need more efficient mechanisms to reconsider priorities and recommendations for mammography screening and other medical interventions. This is not an easy task, because governments, research funders, scientists, and medical practitioners may have vested interests in continuing activities that are well established.

                RESPONSES:  12 February 2014  BMJ 2014;348:g366 :                     1. rebuttal by USA  radiologists : Daniel B. Kopans, Professor of Radiology Harvard Medical School.  Having been one of the experts called on in 1990 to review the quality of their mammograms I can personally attest to the fact that the quality was poor (1). To save money they used second hand mammography machines. The images were compromised by scatter since they did not employ grids for much of the trial. They failed to fully position the breasts in the machines so that cancers were missed because the technologists were not taught proper positioning, and their radiologists had no specific training in mammographic interpretation.   

The CNBSS’s own reference physicist wrote:“..in my work as reference physicist to the NBSS, [I] identified many concerns regarding the quality of mammography carried out in some of the NBSS screening centers. That quality [in the NBSS] was far below state of the art, even for that time (early 1980’s). ” (2)

In this latest paper (3) the authors gloss over the fact that only 32% of the cancers were detected by mammography alone. This extremely low number is consistent with the poor quality of the mammography. At least two thirds of the cancers should be detected by mammography alone (4). In their accompanying editorial (5) Kalager and Adami admit that ” The lack of mortality benefit is also biologically plausible because the mean tumour size was 19 mm in the screening group and 21 mm in the control group….a 2 mm difference.” Poor quality mammography does not find breast cancers at a smaller size and earlier stage and would not be expected to reduce deaths.

The documented poor quality of the CNBSS mammography is sufficient to explain their results and all of the above disqualifies the CNBSS as a scientific study of mammography screening, but it was even worse than that. In order to be valid, randomized, controlled trials (RCT) require that assignment of the women to the screening group or the unscreened control group is totally random. A fundamental rule for an RCT is that nothing can be known about the participants until they have been randomly assigned so that there is no risk of compromising the random allocation. Furthermore, a system needs to be employed so that the assignment is truly random and cannot be compromised. The CNBSS violated these fundamental rules (6). Every woman first had a clinical breast examination by a trained nurse (or doctor) so that they knew the women who had breast lumps, many of which were cancers, and they knew the women who had large lymph nodes in their axillae indicating advanced cancer. Before assigning the women to be in the group offered screening or the control women they knew who had large incurable cancers. This was a major violation, but it went beyond that. Instead of a random system of assigning the women they used open lists. The study coordinators who were supposed to randomly assign the volunteers, probably with good, but misguided, intentions, could simply skip a line to be certain that the women with lumps and even advanced cancers got assigned to the screening arm to be sure they would get a mammogram. It is indisputable that this happened since there was a statistically significant excess of women with advanced breast cancers who were assigned to the screening arm compared to those assigned to the control arm (7). This guaranteed that there would be more early deaths among the screened women than the control women and this is what occurred in the NBSS. Shifting women from the control arm to the screening arm would increase the cancers in the screening arm and reduce the cancers in the control arm which would also account for what they claim is “overdiagnosis”.                                                                                                                                          The analysis of the results from the CNBSS have been suspect from the beginning. The principle investigator ignored the allocation failure in his trial and blamed the early excess of cancer deaths among screened women on his, completely unsupportable, theory that cancer cells were being squeezed into the blood leading to early deaths. This had no scientific basis and was just another example of irresponsibility in the analysis of the data from this compromised trial and he finally retracted the nonsense after making front page headlines (6).

      The compromise of the CNBSS trial is indisputable. The 5 year survival from breast cancer among women ages 40-49 in Canada in the 1980’s was only 75%, yet the control women in the CNBSS, who were supposed to represent the Canadian population at the time, had a greater than 90% five year survival. This could only happen if cancers were shifted from the control arm to the screening arm. The CNBSS is an excellent example of how to corrupt a randomized, controlled trial. Coupling the fundamental compromise of the allocation process with the documented poor quality of the mammography should, long ago, have disqualified the CNBSS as a legitimate trial of screening mammography. Anyone who suggests that it was properly done and its results are valid and should be used to reduce access to screening either does not understand the fundamentals, or has other motives for using its corrupted results.

        2.  confirmation:   http://www.bmj.com/content/348/bmj.g366?tab=responses  Per-Henrik Zahl, MD & statistician   Norwegian Institute of Public Health.   In this 30-year old study, the authors report no mortality reduction when screening with mammography and 22% overdiagnosis (1). The sensitivity of the mammography technique has improved tremendously in the last three decades. Ten years ago we got digital mammography and recently we have got tomosynthesis (2). The detection rate at mammography in the Canadian study was about 3 per 1000 in the second and later screening rounds (3). In digital mammography, the corresponding detection rate is 6 per 1000 screened woman and in tomosynthesis, the detection rate is 8 per 1000 (2). It could even have been higher if the pathologists had time to perform more biopsies (personal communications). In tomosynthesis a large number of stellate lesions appear, many more than in traditional mammography, and they are probably representing a reservoir of overdiagnosed breast cancers. In the last 15 years, the rate of interval cancer has been constant and is at the same level as in Canada 30 years ago (4). Thus, the level of overdiagnosis is far much bigger today than in Canada 30 years ago.

             update 6 Feb 2014 This column has noted  that in the 2012 report of the the giant ATLAS (and aTTom) trials in 37  countries the past decade (discussed in detail below), despite the claimed 80% cure rate of early silent  breast cancer (diagnosed by mammography screening at around 55yrs),   by 15 years after repeated screening mammography- surgery-radiotherapy,  tamoxifen for 5 or 10 years and annual screening mammography followup,   of the women who had died by age 70yrs and had autopsy,   some 43% had (silent) recurrence of breast cancer- although this had been detected in far fewer living women. The 15 year ATLAS results overall were depressing- in those originally early silent estrogen-receptor positive breast cancers, although only about 20% had clinical recurrence by a mean age of 70yrs, of the 22% who had died by then,  almost half ie 43% had recurrence of breast cancer at autopsy.
How successful was tamoxifen versus placebo?
Why was  the Atlas trial  felt not to justify a no-tamoxifen control group?
               Sir Richard Peto’s earlier Oxford review (Horm Res 1989;32:165) Effects of Adjuvant Tamoxifen and of Cytotoxic Therapy on Mortality in Early Breast Cancer. An Overview of 61 Randomised Trials Among 28,896 Women  sought information worldwide on mortality according to assigned treatment in all randomised trials that began before 1985 of adjuvant tamoxifen or cytotoxic therapy for early breast cancer (with or without regional lymph node involvement). Coverage was reasonably complete for most countries. In 28 trials of tamoxifen nearly 4,000 of 16,513 women had died,  reductions in mortality due to treatment  were significant when tamoxifen was compared with no tamoxifen (p < 0.0001), any chemotherapy with no chemotherapy (p=0.003), and polychemotherapy with single-agent chemotherapy (p=0.001). In tamoxifen trials, there was a clear reduction in mortality only among women aged 50 or older, for whom assignment to tamoxifen reduced the annual odds of death during the first 5 years by about one fifth. In chemotherapy trials there was a clear reduction only among women under 50, for whom assignment to polychemotherapy reduced the annual odds of death during the first 5 years by about one quarter. Direct comparisons showed that combination chemotherapy was significantly more effective than single-agent therapy. Because it involved several thousand women, this overview was able to demonstrate particularly clearly that both tamoxifen and cytotoxic therapy can reduce five-year mortality.
         A decade later  the 1998 Tamoxifen for early breast cancer: overview of the randomised trials:  Oxford Early Breast Cancer Trialists’ Collaborative GroupCorresponding Author (The Lancet, 1998: 351,: 1451 – 1467) confirmed Peto’s review:  In 1995, information was sought on each woman in any randomised trial that began before 1990 of adjuvant tamoxifen versus no tamoxifen before recurrence on 37 000 women in 55 such trials, comprising about 87% of the worldwide evidence. Compared with the previous such overview, this approximately doubles the amount of evidence from trials of about 5 years of tamoxifen and, taking all trials together, on events occurring more than 5 years after randomisation.
                Nearly 8000 of the women had a low, or zero, level of the oestrogen-receptor protein (ER) measured in their primary tumour. Among them, the overall effects of tamoxifen appeared to be small, and subsequent analyses of recurrence and total mortality are restricted to the remaining women (18 000 with ER-positive tumours, plus nearly 12 000 more with untested tumours, of which an estimated 8000 would have been ER-positive). For trials of 1 year, 2 years, and about 5 years of adjuvant tamoxifen, the proportional recurrence reductions produced among these 30 000 women during about 10 years of follow-up were 21% (SD 3), 29% (SD 2), and 47% (SD 3), respectively, with a highly significant trend towards greater effect with longer treatment (χ21=52·0, 2p<0·00001). The corresponding proportional mortality reductions were 12% (SD 3), 17% (SD 3), and 26% (SD 4), respectively, and again the test for trend was significant (χ21= 8·8, 2p=0·003). The absolute improvement in recurrence was greater during the first 5 years, whereas the improvement in survival grew steadily larger throughout the first 10 years. The proportional mortality reductions were similar for women with node-positive and node-negative disease, but the absolute mortality reductions were greater in node-positive women. In the trials of about 5 years of adjuvant tamoxifen the absolute improvements in 10-year survival were 10·9% (SD 2·5) for node-positive (61·4% vs 50·5% survival, 2p<0·00001) and 5·6% (SD 1·3) for node-negative (78·9% vs 73·3% survival, 2p<0·00001). These benefits appeared to be largely irrespective of age, menopausal status, daily tamoxifen dose (which was generally 20 mg), and of whether chemotherapy had been given to both groups. In terms of other outcomes among all women studied (ie, including those with “ER-poor” tumours), the proportional reductions in contralateral breast cancer were 13% (SD 13), 26% (SD 9), and 47% (SD 9) in the trials of 1, 2, or about 5 years of adjuvant tamoxifen. The incidence of endometrial cancer was approximately doubled in trials of 1 or 2 years of tamoxifen and approximately quadrupled in trials of 5 years of tamoxifen (although the number of cases was small and these ratios were not significantly different from each other). The absolute decrease in contralateral breast cancer was about twice as large as the absolute increase in the incidence of endometrial cancer. Tamoxifen had no apparent effect on the incidence of colorectal cancer or, after exclusion of deaths from breast or endometrial cancer, on any of the other main categories of cause of death (total nearly 2000 such deaths; overall relative risk 0·99 [SD 0·05]).
            So, for corroboration we need the autopsy results of the women in the earlier tamoxifen vs placebo studies; and the 20 year results of the Atlas study. The ATLAS study reports clearly that silent breast cancer was more than twice as high in autopsied cases as in screening mammography during life. The conundrum remains whether  early cancer detection by regular repeated screening mammography, and early treatment by biopsy, surgery, radiotherapy and tamoxifen, is more beneficial or more harmful to women long term?
24 Jan 2014   Overdiagnosis    Overtreatment of Breast Cancer   .Am Soc Clin Oncol Educ Book. 2012;32:e40-e45. doi:  Alvarado M, Ozanne E, Esserman L. meetinglibrary.asco.org/sites/meetinglibrary.asco.org/files/Educational Book/PDF Files/2012/zds00112000e40.pdf  Dept Surgery Univ Calif San Francisco. write:   “Breast cancer is the most common cancer in women. Through greater awareness, mammographic screening, and aggressive biopsy of calcifications, the proportion of low-grade, early stage cancers and in situ lesions among all breast cancers has risen substantially. The introduction of molecular testing has increased the recognition of lower risk subtypes, and less aggressive treatments are more commonly recommended for these subtypes. Mammographically detected breast cancers are much more likely to have low-risk biology than symptomatic tumors found between screenings (interval cancers) or that present as clinical masses.                                                                                                                                
        Recognizing the lower risk associated with these lesions and the ability to confirm the risk with molecular tests should safely enable the use of less aggressive treatments. Importantly, ductal carcinoma in situ (DCIS) lesions, or what have been called stage I cancers, in and of themselves are not life-threatening. In situ lesions have been treated in a manner similar to that of invasive cancer, but there is little evidence to support that this practice has improved mortality. It is also being recognized that DCIS lesions are heterogeneous, and a substantial proportion of them may in fact be precursors of more indolent invasive cancers. Increasing evidence suggests that these lesions are being overtreated. The introduction of molecular tests should be able to help usher in a change in approach to these lesions. Reclassifying these lesions as part of the spectrum of high-risk lesions enables the use of a prevention approach. Learning from the experience with active surveillance in prostate cancer should empower the introduction of new approaches, with a focus on preventing invasive cancer, especially given that there are effective, United States Food and Drug Administration (FDA)-approved breast cancer preventive interventions.”                                                                                                                                                                                             5 January 2014:      Quantifying the Benefits and Harms of Screening Mammography.  H Gilbert Welch & Honor Passow  , Dartmouth Geisel school of medicine, NewHampshire  write:  JAMA Intern Med. 2013 Dec 30.                   Like all early detection strategies, screening mammography involves trade-offs. If women are to truly participate in the decision of whether or not to be screened, they need quantification of its benefits and harms. Providing such information is challenging, however, given the uncertainty-and underlying professional disagreement-about the data. In this article, we attempt to bound this uncertainty by providing a range of estimates-optimistic and pessimistic-on the absolute frequency of 3 outcomes important to the mammography decision: breast cancer deaths avoided, false alarms, and overdiagnosis. Among 1000 US women aged 50 years who are screened annually for a decade,                                                                        0.3 to 3.2  ie ~0.17%  will avoid a breast cancer death                                                490 to 670  ie ~58% will have at least 1 false alarm recall, and                               3 to 14 ie         0.85%  will be overdiagnosed and treated needlessly.                                            We hope that these ranges help women to make a decision: either to feel comfortable about their decision to pursue screening or to feel equally comfortable about their decision not to pursue screening. For the remainder, we hope it helps start a conversation about where additional precision is most needed
                                                                                                                                                                     A recent review of a new book by journalist Rolf Hefti- The Mammogram Myth-  consolidating the controversy for and against screening mammography is reviewed by Cape Ray. The book relies heavily on Dr John Gofman (1919-2007), a distinguished medical scientist,  a key member of the Manhattan Project that developed the first atomic bomb used on Nagasaki. In 1996 Gofman published a book entitled Preventing Breast Cancer: The Story of a Major, Proven, Preventable Cause of This Disease, in which he made the astonishing claim that 75% of all breast cancers were caused by women being exposed to ionising radiation from X-rays. As highlighted in a review in JAMA, Gofman’s claim — based on an extensive literature review and certain critical assumptions — was at variance with every other authority, including the National Academy of Sciences and the National Council on Radiation Protection.  Martin Yaffe of Toronto has recently shown that the risk of radiation-induced breast cancer from mammographic screening is not negligible, but this risk is small when compared to the expected reduction in mortality achieved through screening.
                                                                                                                                                                   So the dilemma for health professionals, and for  the target of the zealous Cancer Screening Industry-  healthy women in their prime-of-life middle years- remains:  why have xray mammography screening when the independent evidence from expert epidemiologists is that screening mammograpy  to find preclinical ie precancer does not in fact  meaningfully save lives, entend health or reduce breast surgery and cancer therapy, it actually increases all these risks compared to waiting till cancer presents clinically.                                                                                                                                             Zahl Jorgensen and Gotzsche  in their latest review show that Overestimated lead times in cancer screening has led to substantial underestimation of overdiagnosis.
and Gotzsche’s new book is an expose  of  Deadly Medicines and Organised Crime.  
                                                                                                                          20 July 2013   HUMAN PROGESTERONE  BREASTCANCER RISK  REVISITED: Its 3 years since this column last reviewed progesterone, in the context of osteoporosis,  bone building.   While the first Pubmed report on progesterone implants  is apparently sixty years ago (probably in veterinary reproductive use), Drs John Lee and Kathy Dalton promoted use of solo human progesterone P4 for (post)menopausal protection,  also  against cancer including breast cancer; which l’Hermite 2013 from France, and eg David Sturdee from UK, have recently favourably  summarized in respect of balanced transdermal estrogen and oral micronized progesterone P4. The evidence for P4 as  almost global protection as HRT   has largely been confirmed provided progesterone is used in moderation – ideally transdermally/ transvaginally  like estrogen (Genazzani ea);  some believe in the basal physiological bloodlevel of about 1 to 2 nmol/L,  in balance with basal levels of human estrogen and androgens.                                                                                                                                Vanadin Seiffert-Klauss ea in Munich have recently (2012) confirmed that “women in the (~10year) menopause transition lose trabecular bone at a rapid rate despite intermittently high and usually normal estrogen levels –  especially the lean women (BMI<20kg), and those with family fracture history”.  And in their PEKNO study, “Decreasing rates of ovulation, hormonal changes, and increasing bone loss pre-date menopause by several years.;  in addition to estradiol, progesterone may play a significant role in the interrelationship between the ovaries and the skeleton in women.  differentiation of human osteoblasts from perimenopausal women has been shown to be dose-dependent on progesterone at physiological concentrations.  Higher progesterone levels, as seen in the luteal phase of ovulatory cycles, may be associated with more bone formation and with slightly less bone resorption than anovulatory cycles in which progesterone levels are low (< 5.8 ng/ml)”.                 These data led to the initiation  in perimenopausal women of a large, prospective, 2-year observational PEKNO study – from which interim data indicate that a decrease in ovulation correlated with an increase in the loss of bone mineral density (BMD). A meta-analysis in women *with normal ovulation estimated a BMD increase of 0.5% per year, vs *with ovulatory disturbances (anovulation or short luteal phase) a BMD decrease of 0.7% per year in young women ; but * in postmenopausal women a 1.3% increase per year in BMD when receiving hormone replacement therapy with unopposed estrogens, and a further 0.4% increase in BMD in women receiving estrogens plus progestogens. The role of progesterone in bone metabolism in perimenopausal women who are estrogen-replete requires further study.”  
                                   Thus they show that postmenopausally, addition of progestin may boost BMD by 31% more than ERT alone. But currently some experts eg Kuhl and Schneider and David Zava   feel that evidence warrants caution, that oral human progesterone P4  may have a  role in breast cancer promotion;  although it has protective benefit against estrogen dominance in most circumstances eg against endometrial cancer. As this column has previously reviewed, longterm experience of experts like Greenblatt & Gambrell, Gelfand,  Lee Vliet  in N America;   Schleyer-Saunders, Whitehead & Studd (London) , Burger & Davis (Australia) ; and Davies ea (Cape Town) showed no increase but reduction in all postmenopausal morbidity including cancer with  non-oral eg implants of BIDHRT (estradiol balanced  with human antiestrogen eg testosterone and/or progesterone).
                                                                                                                                                              Now Stephenson ea  at the Tyler Women’s Wellness Center, Texas publish a 3  year study showing multiple benefits and no adverse effects of balanced   compounded bioidentical transdermal hormone therapy BIDHRT on hemostatic, inflammatory, immune factors; cardiovascular biomarkers; quality-of-life measures in peri- and postmenopausal women. Conventional  nonhuman hormone therapy HT eg CEE and medroxyprogesterone results in increased thrombotic events, and an increased risk of breast cancer and dementia  in large prospective clinical trials including the HERS and the Women’s Health Initiative studies.  Physiologic human sex steroid therapy with transdermal delivery for peri/postmenopausal women may offer a different risk/benefit profile, yet long-term studies of this treatment model are lacking.  In a  prospective, approved closed-label study, 75  women who met strict inclusion/exclusion criteria were enrolled; following baseline hormone evaluation,  women received compounded transdermal bioidentical hormone therapy of BiEst (80%Estriol/20%Estradiol), and/or Progesterone to meet established physiologic reference ranges for the luteal phase.          Subjects receiving  BIDHRT in doses targeted to physiologic reference ranges administered in a daily dose showed significant favorable changes in  menopausal symptoms, cardiovascular biomarkers, inflammatory factors, immune signaling factors, and health outcomes, despite very high life stress, and home and work strain in study subjects. There were no associated adverse events. This model of care warrants consideration as an effective and safe clinical therapy for peri/postmenopausal women especially in populations with high perceived stress and a history of stressful life events prior to, or during the menopausal transition.
                                                                                                                                                              This Texas   study supports the 2009 metanalysis by Holtorf: The bioidentical hormone debate: are bioidentical hormones (estradiol, estriol, and progesterone) safer or more efficacious than commonly used synthetic versions in hormone replacement therapy?   Patients report greater satisfaction with HRTs that contain progesterone compared with those that contain a synthetic progestin. Bioidentical hormones have some distinctly different, potentially opposite, physiological effects compared with their synthetic counterparts, which have different chemical structures. Both physiological and clinical data have indicated that progesterone is associated with a diminished risk for breast cancer, compared with the increased risk associated with synthetic progestins. Estriol has some unique physiological effects, which differentiate it from estradiol, estrone, and CEE. Estriol would be expected to carry less risk for breast cancer, although no randomized controlled trials have been documented. Synthetic progestins have a variety of negative cardiovascular effects, which may be avoided with progesterone.  Physiological data and clinical outcomes demonstrate that bioidentical hormones are associated with lower risks, including the risk of breast cancer and cardiovascular disease, and are more efficacious than their synthetic and animal-derived counterparts. Until evidence is found to the contrary, bioidentical hormones remain the preferred method of HRT. 
                                                                                                                                                                          And of course the recent 4year Kronos KEEPS study by Harman ea 2012 confirms that in early postmenopausal woemen, parenteral physiological-dose  estradiol has subtle benefits over oral premarin, with or without  parenteral progesterone, with no significant adverse effect..                                                                                                                                                                                                                                                                                                                                                                                                                  17 June 2013  SHOULD WE EVER TELL A PATIENT WITH A BREAST LUMP THAT IT’S CANCER?  or THAT IT MAYBE PRECANCER?  This was and is a  major dilemma in medicine. One of the big  lessons arising out of the high technology in living memory ie the past >century-our grandparents’ time-  is that before modern laboratory, imaging and surgical diagnostics, all we could do was wait and see, the trial of observation and therapy, prayer, meditation. Now we have gone to the other extreme in the aging,  bullying them to have risky invasive screening on the crass assumption that screening and early radical – invasive ie potentially  harmful-  treatment of silent ie precancer saves lives- when the evidence has become progressively clearer that unselective invasive screening of asymptomatic prostates and breasts simply creates worried well,  overdiagnoses silent disease which may never cause illness or death ,  and may hasten misery; whereas combining natural preventative remedies may benefit all systems  including regress cancer.
                                                                                                                                                             Silent hypertension and unrealised overweight/ metabolic syndrome  are radically different from cancer. With simple measurement  of asymptomatic arterial hypertension, visceral obesity and eg glycosuria, the earlier that risk factors are defined and addressed, and the earlier the adiposity/glycosuria/ hypertension corrected with lifestyle, abolishing smoking and boozing,  and diet improvements, supplements and if necessary the safest prescription drugs-  initially fish oil,  lowdose amiloretic and reserpine, metformin, and the basket of vitamins and minerals especially magnesium, zinc,  vits C and D3 –  the sooner is the progressive  risk  reversed to the heart, brain, mind, vision, lungs, digestive and excretory system, joints and legs, let alone to fertility, carcinogenesis and other immunoendocrine  functions                                                                                                                                                           So instead of driving well aging women witless with disease-mongering-  forced regular invasive xray screening mammography-  we should  instead respect the power of the mind over disease, and use simple careful history, and physiological  biometrics including behaviometrics to persuade and condition those at risk to take sensible precautions including if necessary supplements, exercise and corrective diet/psycho/hypnotherapy. The lesson of screening breasts and prostates for silent cancer  the past 20 years is that so many cases of silent dormant cancer regress spontaneously if left well alone, especially if they are left undiagnosed and instead just the score of common risk factors for  all common diseases addressed as this column keeps exploring. So when asymptomatic changes and lumps in breasts are detected by noninvasive means eg clinical or Sure Touch or thermal exam, there is no need to alarm the woman by labelling her a patient with breast disease – it is more than healing for her to show her that within a month, these changes can be reversed with  all the appropriate natural  steps as described in Combatting Breast Cancer , including the Magic Oils. If there were indeed (pre)malignant changes present, they too regress as normally happens in so many – so  leave well alone. As reviewed below,  up to  45% of apparently well adults who are killed  have silent cancers;    and in the giant ATLAS and aTTom trials in 37  countries the past decade (discussed in detail below), despite the claimed 80% cure rate of early silent  breast cancer (diagnosed at around 55yrs)  by 5 and 15 years after repeated screening mammography- surgery- and radiochemotherapy,  and annual screening mammography followup,   of the women who had died by age 70yrs and had autopsy, the similar 43% had (silent) recurrence of breast cancer. So  like men,  asymptomatic women should be discouraged from invasive screening; but the higher their risk score, the more readily they should be offered simple noninvasive breast screening, and thereby encouraged to optimize diet, habits, lifestyle, body build-fitness,  including with the battery of multibenefit preventative supplements . Like millions of partisans have sung in bitter wars and holocausts, Hirsh  Glik’s “Never Say that You Are Trodding the Final Path“- remains the hope-givimg mantra that all patients and caregivers  must hold to – the power of positive thought and action  if not prayer. Both mistakes and miracles happen.                                                                                                                                                                                                                                                                                 upate June 14 2013: a new review from Oxford University  Breast cancer mortality trends in England (1979-2009) and the assessment of the effectiveness of mammography screening concludes: In the Oxford region,  For all ages combined, mortality rates peaked for both underlying cause and mentions in 1985 and then started to decline, prior to the introduction of the NHSBSP in 1988.  There was no evidence that declines in mortality rates were consistently greater in women in age groups and cohorts that had been screened at all, or screened several times, than in other (unscreened) women, in the same time periods. Conclusions Mortality statistics do not show an effect of mammographic screening on population-based breast cancer mortality in England. update June 10 2013  a  review published today  by Coldman and Phillips on   Incidence of breast cancer and estimates of overdiagnosis after the initiation of a population-based mammography screening program   in Canada over 40years showed that ” the extent  of overdiagnosis of invasive cancer  was modest and primarily occurred among women  over the age of 60 years. However, overdiagnosis of ductal carcinoma in situ was elevated  for all age groups.”                                                                                                                                                                                                                                                                                                                    update 9 June 2013:    THE HARMFUL COERSIVE PRESSURE APPLIED ON WOMEN,  AND ON THEIR BREASTS, WITH SCREENING  XRAY  MAMMOGRAPHY:      Womens’ wishes must be respected when they  prefer no-xray no-squeeze prescreening, choose not to have xray mammography. Breast discomfort and breast trauma from xray mammography -breast sandwiching –   vary greatly between women and especially in young more hormonally-driven  breasts.. The pressure is manyfold:  not just in crushing the breasts, but in PTSD- post-traumatic stress disorder: Oxana Palesh & Cheryl Koopman report this month Breast cancer: PTSD—prevalent and persistent:  Receiving a diagnosis of breast cancer is likely to have aconsiderable impact on the psychological wellbeing of the patient. In a recent observational study, Vin-Raviv et al.1 reported that 23% of 1,139 women with newly diagnosed localized breast cancer experienced post-traumatic stress disorder (PTSD) symptoms. This is not to deny that many women experience post-traumatic character growth, as a recent Greek study discusses.   Posttraumatic stress disorder and posttraumatic growth in breast cancer patients.  But Elklit and Blum and O’Connor ea in Denmark a year earlier highlight  PTSD   as being highly relevant in oncology settings after early breast cancer.. This awareness has been reviewed on Pubmed from before 1997. A recent report says the physical crushing force applied in such breast compression  – snackwiching –  is briefly up to about  130 Newtons, ie 13 kg or  25 pounds force.    This compares to the gentle 1.5 to 2kg force applied briefly when having a mechanical tactile Sure Touch surface breast anatomical mapping, or professional clinical breast exam; or zero force with a no-touch infrared thermomammogram. Hence some  women report breast pain, bruising and discomfort for weeks after a compression xray mammogram. And because oncologists insist on followup regular xray mammography after cancer therapy with breast-conserving surgery & radiochemotherapy, women increasingly ignore breast lumps let alone any screening breast exams at all. It is common cause that stress, anxiety  increase cortisol, insulin  and thus estrogenic stimulation, and thus cancer risk to  breasts.  It is still unknown how much the longterm risk of breast problems and cancer is increased from rupturing breast cells (let alone spreading cancer cells) with repeated successive compression xray mammography and the cumulative xray dose used – especially when perhaps 1 in 10 women screened is recalled  by radiologists for more compression views, to find (by biopsy of perhaps 10 to 20 women per 1000) the 2 to 4 clinically undetected tiny breast (pre)cancers in each 1000 women so screened preventatively… And it is obvious that with denser more active breasts in young women- monthly high-turnover glandular cells (especially in those on cyclic synthetic estrogen-progestin contraception) –  both breast fragility and sensitivity are higher the earlier that xray mammography is commenced as radiologists insist.

              Hence Regulators in most countries have reduced recommendations for routine screening mammography to starting at age >50yrs and stopping by 70-75years (ie 10-12 times on average through midlife); whereas Radiology Associations ignore the risks and still advise screening annually from age 40 years,  for life  –   ie at least THREE times as many times from age 40years. So women are doubly exposed to harmful pressure both in being bullied that they need screening xray mammography – the lie that  ” screening mammography saves lives”  when the benefit of this is unproven, and in being forced to undergo breast crushing repeatedly. A woman who recently attended for Sure Touch in Port Elizabeth   objected to having her breasts snackwiched again by compression mammography. The flippant analogy is eerie when one considers how such women are expected to attend annually to have their breasts both flattened and irradiated – and more so with cumulative frying after therapeutic radiotherapy. No wonder some end up with a hard breast. . So while the young at heart may   love nudging breasts-,  and massage  heals, (and Bissell and Fletcher at the Berkley lab show that gentle nudging with about 50 gm pressure knocks errant breast ductal cells back into healthy behaviour) –   crushing force and coersion do women harm, not good; in contrast to men where forceful digital massage may (also with putative risk) relieve the infected painful prostate.. .

And Gøtzsche   and Jørgensen in  .Cochrane Database Syst Rev. have Jun 4 published update stats against Screening for breast cancer with mammographyfrom  PubMed and the WHO ‘s International Clinical Trials Registry  (to November 2012).  Eight eligible trials  included 600,000 women  in the age range 39 to 74 years. Three trials with adequate randomisation did not show a statistically significant reduction in breast cancer mortality at 13 years (relative risk (RR) 0.90); four trials with suboptimal randomisation showed a significant reduction in breast cancer mortality with an RR of 0.75 (95% CI 0.67 to 0.83). The RR for all seven trials combined was 0.81 (95% CI 0.74 to 0.87). We found that breast cancer mortality was an unreliable outcome that was biased in favour of screening, mainly from differential misclassification of cause of death. The trials with adequate randomisation did not find an effect of screening on total cancer mortality, including breast cancer, after 10 years (RR 1.02, 95% CI 0.95 to 1.10) or on all-cause mortality after 13 years (RR 0.99, 95% CI 0.95 to 1.03).  Surgeries – Lumpectomies and mastectomies (RR 1.20-1.31, 95% CI 1.08 to 1.42) were significantly more in the screened groups . The use of radiotherapy was similarly increased whereas there was no difference in the use of chemotherapy.              AUTHORS’ CONCLUSIONS: If we assume that screening reduces breast cancer mortality by 15% and that overdiagnosis and overtreatment is at 30%, it means that for every 2000 women invited for screening through 10 years, one will avoid dying of breast cancer and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 10%  will experience important psychological distress including anxiety and uncertainty for years because of false positive findings.        To help ensure that the women are fully informed before they decide whether or not to attend screening, we have an evidence-based lay  leaflet http://www.cochrane.dk. Because of substantial advances in treatment and greater breast cancer awareness since the trials, it is likely that the absolute effect of screening today is smaller than in the trials. Recent observational studies show more overdiagnosis than in the trials and very little or no reduction in the incidence of advanced cancers with screening”.                                                                                                              

update 26 May 2013  Apart from the strident promotion of preventative mastectomy by a film star,  reports the past week prompt review of :  why and whether  aggressive breast cancer may have doubled  in young women 25-39years old; and  it’s prevention by natural steps.

update 22 May 2013:   WHY DO SO MANY  WOMEN HAVE  RELAPSE OF BREAST CANCER BY 25 YEARS AFTER  DIAGNOSIS AND APPARENTLY CURATIVE TREATMENT OF EARLY SILENT BREAST CANCER?: three landmark new papers shine more light on why 43% of women who died by 15 years after aggressive treatment of  initial silent preclinical breast cancer had relapse/recurrence  of breast cancer at autopsy  – the  depressing result of the monumental 180 000 women-year  ATLAS trial:

Lisa Willis, Karen Page, Trevor Graham, Tomás Alarcón, Malcolm  Alison    & Ian  Tomlinson  from Universities of London, Oxford, Cambridge, and Barcelona  this month dissect  “What Can Be Learnt about Disease Progression in Breast Cancer Dormancy from Relapse Data?   why Breast cancer patients have an anomalously high rate of relapse up to 25 years  after apparently curative surgery removed the primary tumour. Disease progression during the intervening years between resection and relapse is poorly understood. There is evidence that the disease persists as dangerous, tiny metastases that remain at a growth restricted, clinically undetectable size until a transforming event restarts growth. This suggests a natural question and  a surprising answer: why are interesting trends in long-term relapse data not more commonly observed?”       But they are observed: another recent  15 year followup study, from Denmark (Grantzau ea), furthermore shows that DXRT after early breast cancer almost doubles the risk of radiotherapy-associated second cancer to 1:200 of women so treated..

       Thus at least dangerous dormant micrometastases, and the enormous cumulative  radiation exposure from both screening mammography over decades, and DXRT itself, will explain much of the 43% recurrence rate of breast cancer by 15 years (at autopsy in those who had died by then, at a  mean of only 70 years) seen in the ATLAS trial.

  These reports raise yet further doubts about the wisdom  of  regular mass xrayscreening of well breasts from age 50 years let alone 40years, and worse-  zealous major surgery and DXRT for preclinical disease, and then even worse, ongoing xray mammographic surveillance into old age.

      They point in the opposite direction:  that xray screening of well breasts should be avoided;  DXRT avoided in localized early breast cancer; and surveillance for breast cancer limited to the many available non-xray methods;

     and that women must be encouraged instead to maintain prevention with combination of safe natural (and multisystem-protecting)  means as discussed repeatedly in this column – lifestyle, diet, exercise, and massage and oral use of safe natural preventative supplements. Anticancer antiangiogenesis factors from our diet  are legion, include  cannabis, mushrooms, resveratrol, green tea, black rasberry  and Royal jelly. One would not recommend soya against breast cancr because of its phytoestrogen potential.

               Xradiation has been known for decades eg 1978   1990 to be both an angiogenic and an antiangiogenic factor in tumour growth angiogenesis (Judah Folkman 1971) . so it is  obviously a double-edged sword that should certainly not be used in the witchhunt for silent and usually irrelevant precancer in well breasts.

                   So we have the ludicrous situation reported today in JAMA  that despite all the evidence for 20 years now to stop or at least halve  mass xray screening and thus (over)treatment of silent early breast cancer, Physicians, Patients Not Following Advice From USPSTF on Mammography Screening: In 2009, the US Preventive Services Task Force (USPSTF) recommended against routine screening mammography for women under 50 years and advised biennial rather than annual screening for women aged over 49yrs. But women and physicians ignored these recommendations.  A new study from Harvard  found that in 2005 to 2011, the percentage of women aged 40 to 49 years reporting that they had undergone mammography screening in the previous year was the same, about 47%. As for women aged 50 to 74 years, the percentage reporting mammography screening in the previous 12 months for each year analyzed also remained essentially the same, in the upper 50% range.”

        Update 21 April 2013FIFTEEN YEAR FOLLOWUP STUDIES OF BREAST CANCER AND ALLCAUSE  MORTALITY FROM MENOPAUSE ONWARDS:                                                                           Overall, long-term studies do not favour invasive breast screening or adjuvant therapy of early breast cancer,  but actually argue  against  early diagnosis and treatment of both silent breast and prostate  cancer.  Rather, the focus must be on safe natural prevention to reduce the occurrence of all common degenerative diseases of aging.

       It is instructive to juxtapose  the diverse 15 year followup studies in 14 countries (Nordic Cochrane- Gotzsche, Jorgensen ea) of women routinely xray- mammography screened or not, with the 15 year ATLAS study  (that ended in 2010)  reviewed below in 36 countries,  of women zealously xray- screened for early breast cancer, prompt  biopsies and surgical/  radiotherapy treatment- the majority mastectomy-  and then randomized to tamoxifen for up to  10 years. and it is reported by the ATLAS authors that there was a major breach of protocol - The protocol stated that 20 000 patients would need to be randomised in ATLAS and the other trials of tamoxifen duration to detect reliably an absolute difference of 2–3% in mortality. Entry to ATLAS was halted in 2005 (with 12 894 patients, including 6846 with ER-positive disease) because the MA.17 trial  showed benefit from continued endocrine treatment after 5 years of tamoxifen..   Yet the MA17 trial was with a different drug- letrozole;  and bizarely, the trial conclusion was that “the results from the analyses based on the Cox model with time-dependent covariates  were similar for letrozole and placebo.”  ie that letrozole was no better than placebo.. Thus, like the Womens’ Health Initiative misguided early termination,  it is unclear why MA17 was used as reason to terminate the ATLAS trial.
             The 15 year ATLAS results overall were depressing- in those originally early silent estrogen-receptor positive breast cancers, although only about 20% had clinical recurrence by a mean age of 70yrs, of the 22% who had died by then,  almost half ie 43% had recurrence of breast cancer at autopsy.              Many new such trials are under way.
             The aTTom trial  the UK arm of the ATLAS trial similarly “followed women with early breast cancer after initial treatment  for about 15 years:  it  randomly assigned 6934 women (39% ER-positive, 61% ER-untested) at the completion of 4 or more years of tamoxifen therapy to either 5 additional years of tamoxifen or cessation of tamoxifen therapy. With a median follow-up of 4.2 years, there was a slight, non-significant advantage for the 10-year tamoxifen arm (RR, 0.94; 95% CI, 0.81–1.09; P = .4). Thus, the optimal duration of therapy is not known, but it is at least 5 years”. For undisclosed reasons this trial has apparently  never been published in full although it was first reported in 2008- this raises the usual question by eg Booth and Tannock 2008  of bias against negative results, whether there was suppression by sponsors…  And the aTTom trial design was heavily criticised at the outset in 1996.
                The meta-analysis published the past week by Heidi Nelson ea for the USPSTF  confirms the ATLAS study, showed that tamoxifen/ raloxifen for 5 years reduced absolute mortality from breast cancer by about 0.16% per year. Neither reduced breast cancer-specific or all-cause mortality rates. Both reduced the incidence of fractures, but tamoxifen increased the incidence of thromboembolic events more than raloxifene by 4 cases in 1000 women. Tamoxifen increased the incidence of endometrial cancer and cataracts compared with placebo and raloxifene. Trials provided limited and heterogeneous data on medication adherence and persistence. Many women do not take tamoxifen because of associated harms.
         It then becomes apparent  that  having early breast cancer detected – without the adverse risk factors of xray mammography of repeated breast crushing, radiation,  biopsies and overtreatement,                             but with better application of safe preventative measures including vitamin D3, melatonin, metformin, iodine, DMSO, coconut oil,  fish oil, sutherlandia, I3C/DIM, vitamins and minerals                  – while women will live healthy longer,  few women  (perhaps <5% of all deaths) will die of breast cancer.  The common risk factors (for all common premature disease and deaths) are  m   anaged with the same basket of safe natural effective preventatives including supplements like appropriate balanced hormone replacement -that this column addresses.                                                                                                                                                                                                                                                    
Dr.  Northrup says “[Gilbert Welch] pointed to a study [from] way back, of women who died in car accidents in their 40s. They sectioned their breast tissues and found that 40 percent of them – this is normal healthy women dying in car accidents – had evidence of ductal carcinoma in situ that was never going to go anywhere. This is the big dilemma,” .   Welch and Black 1997 reported Among seven autopsy series of women not known to have had breast cancer during life, the median prevalence of invasive breast cancer was 1.3% (range, 0% to 1.8%) and the median prevalence of DCIS was 8.9% (range, 0% to 14.7%). Prevalences were higher among women likely to have been screened (that is, women 40 to 70 years of age).

     Erbas ea at Univ Melbourne studied all sources for the prevalence of ductal carcinoma in situ. “The reported prevalence of undiagnosed DCIS in autopsy studies, of approximately 9%, has been used to suggest a larger reservoir of DCIS may exist in the population”.

      Update 18 April 2013:  a  new study from  Italy   graphically illustrates the lower sensitivity of xray screening – U/S ie  ultrasound picked up ‘significantly’ more tiny asymptomatic breast cancers  missed in 22,131  women with negative mammography.  “The overall U/S detection was 0.185%, but 0.55% with previous cancer vs 0.145% in women without cancer history (p = 0.0004),  0.22% in dense breasts (p = 0.17) vs .156% in fatty breasts. The U/S- generated invasive assessment was 0.19%  The benign to malignant open surgical biopsy ratio was  thus 0.17.”  This is likely more overdiagnosis unless the women simply apply the preventative measures recommended below.

             But while no screening method can diagnose cancer (only invasive biopsy can), and none can guarantee there arnt cancer cells busy germinating especially if stirred up by severe anxiety,  radiation, crushing, biopsy etc, Sure Touch mapping is more accurate than even U/S for  reassuring while reducing referral rate for U/S.

UPDATE 14 APRIL 2013: Because of the evidence the past score years set out below  that xray screening actually does more harm than good, integrative  medical clinics world wide do not promote xray screening mammography. But such clinics including in Cape Town generally offer regular safe and lower-cost  anatomical eg Sure Touch mechanical tactile if not ultrasound or MRI, and physiological no-touch eg thermography ie bloodflow studies,  –  for those who need peace of mind. Some women choose to alternate Sure Touch and thermomammography.

     While only 1 in 200 women have the familial gene risk,  the majority of older women have  the common multiple risk factors eg longevity, estrogenic and heavy metal pollution, stress, overweight density, smoking, alcohol; and  there are many simple remedies described in these  columns that can reverse most of the risk factors – not just of even genetic breast cancer and increasing overweight,  but of all the major diseases of aging.

The problem remains the stubbornness of third party payers including governments to listen to both the evidence and to womens’ wishes, and pay for such safe, cheaper and arguably more accurate prscreening than crush xray mammography, if any is desired or desirable .

Dr Johnnie Ham MD MSc MBA Californian ObGyn discusses why xray screening mammography and aggressive medical assault on  well breasts- the witchhunt for the pot of hidden gold,  silent preclinical breast cancer –  is a giant  con by the  for-profit high-tech medical goliath  industry   terrorizing and mutilating  naive women.

Governments -WHO  silence on harms of screening mammography : What is tragicomedy is that worldwide, government Regulators seem to be standing silently firm, not saying a word about the harm likely exceeding the medical benefit- the screening and cancer  industry is far too profitable in jobs, taxes and votes. Search on the internet for Government warnings on harms of screening mammography does not yield a word of warning. Regulators and Medical Schemes piously promote quality screening, but say nothing about the harms versus benefits. The FDA still promotes annual screening mammography  on line without a word about the risks and harms of mammography; others like the UK NHS promote it every 2 to 3 years.    Yet the US Senate is actually considering a Republican Act to promote more xray breast imaging.

UPDATE 12 April 2013  The Wiki entry on breast cancer prognosis says now: “One result of media hype- breast cancer’s high visibility -(compared to other cancers in eg men, and other common major diseases) is that statistics may be misinterpreted, such as the claim that breast cancer will be diagnosed in one in eight women during their lives—a claim that depends on the unrealistic assumption that no woman will die of any other disease before the age of 95.[132] This obscures reality that about ten more women will die from heart disease or stroke than from breast cancer.[133]The emphasis on breast cancer screening may be harming women by subjecting them to unnecessary radiation, biopsies, and surgery. One-third of diagnosed breast cancers might recede on their own.[134] Screening mammography efficiently finds non-life-threatening, asymptomatic breast cancers and pre-cancers, even while overlooking serious cancers. According to Prof Gilbert Welch of  Dartmouth Institute, research on screening mammography has taken the “brain-dead approach that says the best test is the one that finds the most cancers” rather than the one that finds dangerous cancers.[134]

The latest  report  Lancet 2011) on the Relevance of breast cancer hormone receptors and other factors to efficacy of Tamoxifen protection after breast cancer looked at 20 trials (n=21,457) in early breast cancer . In oestrogen receptor (ER)-positive disease, about 5 years of tamoxifen halved recurrence rates throughout the first 10 years but  no further gain or loss after year 10; risk was approximately independent of progesterone receptor status (or level), age, nodal status, or use of chemotherapy. Breast cancer mortality was reduced by about a third throughout the first 15 years. Overall non-breast-cancer mortality was little affected, despite small absolute increases in thromboembolic and uterine cancer mortality (both only in women older than 55 years), so all-cause mortality was substantially reduced. In ER-negative disease, tamoxifen had little or no effect on breast cancer recurrence or mortality.

       This is not surprising as tamoxifen like  all synthetic  sex hormones  /blockers has  a long list of adverse effects on bone, brain, cardiovascular, bladder, mood, immunity, body weight and metabolism,  womb etc.

But the Oxford UK-led (Davies ea)  landmark monumental  ATLAS trial (2012)  from 1996 -2010 in 36 countries and 180 000 women-years (mean presentation  age mid 50s, ER+ breast cancer about 1 cm size,   2/3 had mastectomy – which is now known to increase mortality) showed that after 6846 women taking tamoxifen  for up to 10 years, at about 15 years from diagnosis, tamoxifen in absolute terms  was only marginal benefit- marginally reduced the risk for breast cancer recurrence, compared with stopping tamoxifen (617 vs 711; P = .002), reduced breast cancer mortality  relatively by 8% (331 vs 397 deaths; P = .01) but that’s only about 1% in absolute terms, and reduced overall mortality by 10% (639 vs 722 deaths; P = .01). Over all, approximately 1/5 clinically relapsed,  1/7 deaths were from breast  cancer; but of those who died, webfigures 4a and 4b of  the supplementary appendix   of the main ATLAS  report showed that at autopsy almost half  (43%) indeed had recurrent breast cancer. This gives the lie to early screening and treatment-  15 years later, even with tamoxifen for  10 years, early xray mammography detection and conventional surgical-radio-chemotherapy treatment does not cure much more than half of women with preclinical ER+  breast cancer that screening detects.The risk for recurrence by year 15 was 21.4% in the continuers group and 25.1% in the control group. ie only 3.7% absolute reduction. In addition, breast cancer mortality by year 15 was significantly reduced by nearly 3%; it was 12.2% in the continuers group and 15.0% in the control group. ie only 2.8% absolute reduction. Thus even in these women with early breast cancer, the cure rate even with tamoxifen was poor- slight reduction in the 25% recurrence  and 15% breast cancer mortality rates. But almost  half of the women who died had recurrence.  Once again, the actual results published 4 months ago in the final Lancet report were much less impressive than the media release published 5 days later. Of these >6000 women allocated after initial surgery/ radio/chemotherapy to the tamoxifen or placebo  trial, 85% did not die of breast cancer. But the cure rate was at best still only about 75%, and only  half of those who died -by a mean of age 70 years – of any  causes were free of breast cancer.

11 April 2013  the SA Menopause Society Menopause Matters today  also features The Great Mammography Debate- concluding “The point being that the treatments of breast cancer are not benign and need to be drawn into the calculations when assessing the harms of screening mammography. If these treatments are carried out on a significant number of people who are not in danger of being harmed by their breast cancer in the first place (those over-diagnosed) then the scales of benefit versus harm from routine mammography may well tip in favour of harm. If so it may be unwise or even unethical to recommend screening by mammography.”

9 April 2013  Robert Stern at University of Arizona writes that “xray mammography alone is not a very good screening modality and has strikingly variable false positive, false negative, specificity, and efficacy rates, depending on what you read and who you believe.

   Worldwide, the days of simple repetitive yearly/ biannual mammograms for every living woman over some arbitrary age may be over soon.. breast cancer screening is about to evolve into a personalized, patient-centered program. It means you can’t just  order a mammogram when a  flag pops up saying it’s time.  It means understanding fairly complex risk stratification, the indications for these new technologies, and the clinical context for various imaging strategies”, mostly still based on irradiation;  as detailed in the American Medical Journal by Drukteinis ea at the Florida Mofitt Cancer Centre ..

8 April 2013: UPDATE:  see  vitamin D3 and Breast Cancer.

JAMA publishes on line from University Basel  Switzerland,   Shaw and Elger’s viewpoint on Evidence-Based Persuasionoften  an ethical imperative to  forcefully guide a hesitant patient into what seems to be the best decision, using arguments from Removal of Bias to Recommending Options and occasionally even Creating New Biases.      The eternal problem remains, what is truly right? Is mass flu vaccine right? Is screening xray  mammography truly lifesaving? especially if one quotes impressive but misleading relative risk reduction rather than in fact the crucial trivial absolute reduction?  Is Directive Counselling however well-meant exercising undue influence? They conclude that it  is an essential part of modern medical practice, without which it may be impossible to respect patients’ autonomy. Such necessary persuasion needs to meet 6 criteria.

A month ago BCAction held a webinar reported by Manie Clark

updating the risks and futility of screening xray mammography.

24 Mar 2013. THE COVERUP OF HARMS AND FUTILITY OF XRAY BREAST SCREENING CONTINUES IN USA Many opinions from around the world in recent NEJMs say it all about screening mammography:  most are subjective, emotive. There is no impartial objective evidence to support the gold standard xray mammography at all (except arguably  in cases of obvious cancer- when biopsy, and MRI scan is better and safer).   When there are acceptable prescreenings that do no harm and when combined,  give good sensitivity and specificity eg any two of  mechanical tactile imaging, thermomammography, breast ultrasound and (if affordable) MRI.
         Karla Kerlikowske ea  co-author already four peer-reviewed Pubmed-listed studies on xray  mammography this year..  the latest on screening well women from the  Breast Cancer Surveillance Consortium asks: Screening Outcomes in Older US Women Undergoing Multiple Mammograms in Community Practice: Does Interval, Age, or Comorbidity Score Affect Tumor Characteristics or False Positive Rates?Uncertainty exists about appropriate use of screening mammography among older women because comorbid illnesses may diminish the benefit of screening. We examined the risks from 1999 to  2006 on 140000  women aged 66 to 89 years at study entry undergoing mammo     . About 7% had  breast cancer,  in a data linkage between the Breast Cancer Surveillance Consortium and Medicare claims.  Cumulative probability of a false-positive mammo result was higher among annual screeners than biennial screeners irrespective of comorbidity: 48% of annual screeners aged 66 to 74 years had a false-positive result compared with 29% of biennial screeners. These women  who undergo biennial screening mammo had similar risk of advanced-stage disease and lower cumulative risk of a false-positive recommendation than annual screeners, regardless of comorbidity.
But their abstract abysmally fails to ask and answer the obviously far more important question:  – did screening mammo  give any  significantly lower mortality, surgery   or  radiotherapy at 15 or 20year followup compared to a matched  randomly selected cohort not screened over the same period, or compared to women who were screened only once at the outset??
   All independent studies show that women regularly screened by xray mammogram  do no better and sustain far more harms, in fact may die sooner than those not screened. Why did they not say this in their abstract, that xray mammo screening is unethical abusive harmful exploitation of women?
    The BCSC website registers over 8million screening mammograms done there 1996-2009 – 24% of women had 5 or more xray screens- ` yet similarly  fails to mention the crucial harms and mortality data in screened versus unscreened women.  The reason is obvious:  admitting the truth, that xray screening mammo is not only futile but harmful, would kill what must now be a $10billion a year   industry in USA for xray manufacturers, radiologists, breast surgeons, hospitals, medical schemes, oncologists and Big Pharma in the Find a Hidden  Breast Cancer Conspiracy against older women. . Indeed, the endgame would be that lawyers will swarm to call on women to sue the Breast Cancer Industry for wrongful assault.
23 Mar 2013  Dr Enza Ferreri is a London-based  Italian journalist philosopher of science, christian human and animal  rights activist, including saving  Britain from an Islamist President Charles Windsor.. She yesterday wrote a devastating critique of screening xray mammography, its profiteering  oversell by  Scandinavian and English-speaking governments’ propaganda that omit  to explain all the risks and lack of benefits. “On one side you have the stories about women whose ” life  was saved” by breast screening, on the other  women whose life was made hell by discovery of a possibly benign DCIS, and those who endure a nightmare of false positives believing that she has breast cancer when she hasn’t. “
22 Mar 2013 Even this month’s  European Radiology Congress, and the South African Menopause Society  SAMS newsletter Menopause Matters, and the Annals of Family Medicine - a new Copenhagen study- now question  screening xray mammography, including cumulative radiation damage to heart and lungs; and chronic psychological trauma from false positive reports.
False-positive findings on screening mammography causes long-term psychosocial harm: 3 years after a false-positive finding, women experience psychosocial consequences that range between those experienced by women  with a normal mammogram and those with a diagnosis of breast cancer. Not even a “positive” breast biopsy is a guarantee that it is cancer that needs treatment -apparently 4% of breast biopsies may be misread. so 2nd opinions are advised.
     the  SAMS author says: ”   the fundamental question  is “Does screening for cancer improve length or quality of life?”  The latest arguments from the UK ask if screening saves lives, if you take all causes of death into account (Baum BMJ 2013;346:f385).  Firstly, the author accepts that screening saves lives. If 10 000 women are screened for a decade then 4 deaths will be avoided. As treatments improve as they are doing all the time, then deaths avoided become lower, maybe 2 per 10 000 in the near future and thus screening becomes less valuable… current data about survival need to be used when making calculations about prolonging life.
     Secondly, overdiagnosis is important because if some women who do not have life-threatening disease are treated, they may die from the treatment. Mastectomy, radiation, chemo- or endocrine therapy are not trivial treatments. Surgery carries anaesthetic and sepsis possibilities, especially in obese patients.   Radiation is not without its risks, raising the incidence of ischaemic heart disease 27%  and of lung cancer 78%. These risks would be worth taking if there were no cases of overdiagnosis – but there are – somewhere between 10% and 50% -so any lives saved may be cancelled out by deaths caused.     So with all-cause mortality no longer showing benefit, it devolves to other factors such as the positive peace of mind screening provides or the negative over-investigation of false positives to sway decisions for or against screening. No wonder the editor of the BMJ (26th January 2013) asks “At what stage must we seriously consider whether this screening is a good use of £96m of  NHS budget?”  So how should we advise our patients? The statistics show the “lives saved” argument is neutralized. The cost of screening, time involved and morbidity from false positive tests are all non-fatal harms so these have to be weighed against  peace of mind of a negative result and these calculations are in the mind of the beholder.     The parallels with prostate specific antigen screening are uncanny and PSA testing is rapidly falling into disfavour or even disrepute. It seems those with vested interests are those promoting mammography screening. The moral position of doctors is becoming increasingly complex – can it be correct to say mammography screening in low-risk women is “the right thing to do”?
16 Mar 2013   Recently Bateman in Cape Town suggests  “PinkDrive intervention ‘over-rated’ : Breast health professionals are questioning the life-saving impact of the high profile non-profit breast cancer organisation PinkDrive.
      The Pink Drive website opens with some  fallacies eg  that:                                         xray mammo 23kg breast compression causes no pain or damage – wrong; that     It is a tool to diagnose breast cancer“-      wrong-only  histology does; and that diagnostic breast irradiation is no risk after age 40years ;  wrong- this column has quoted authoritative opinion and research eg Lemay,  Sherbrooke Univ 2011  to the contrary, the linear no-threshold model, although Mina Bissell’s  Berkley Lab 2011 research paper perhaps contradicts this – the jury is still out . .
          It is significant that of the seven Platinum Pink Drive sponsors, two are private Hospital chains with  major vested interest in the Breast Cancer Surgery and Reconstruction  Industry.
Contrary to the Pink Drive website stating  that mammograms diagnose breast cancer, a major new  study from Japan on xray mammography of almost 120000 women found histological cancer in 0.22% of those  who underwent mammography alone, 0.37% of those who underwent ultrasonography alone, and 0.5% of the 974 participants who underwent both mammography and ultrasonography. Recall rate due to mammographic abnormalities was 4.9% for women screened only with mammography and 2.6% for those screened with both modalities. The cancer detection rate was 0.22% for women screened only with mammography  and 0.31% for those screened with both modalities. Their conclusion that It is possible to reduce the recall rate in screening mammography by combining mammography and ultrasonography for breast screening is precisely the point, that  hazardous xray mammography screening with its immediate and  longterm risks is not needed when any two of the three well-tested lowcost zero-risk portable facilities are available eg Sure Touch Mechanical Tactile imaging, thermomammgraphy, and ultrasound, and two  combined give high sensitivity and specificity.
Neither of the above new abstracts raised the issue of overdiagnosis or longterm hazards.. In fact the NCI Nat Cancer Institute Journal itself published a study this month  from San Fran  University California showing that  in 140 000  women from 66years upward screened  between 1999 and 2006, Cumulative probability of a false-positive mammography result was higher among annual screeners than biennial screeners irrespective of comorbidity: 48%  of annual screeners aged 66 to 74 years had a false-positive result compared with 29%  of biennial screeners. Women aged 66 to 89 years who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of a false-positive recommendation than annual screeners, regardless of comorbidity. Thus  even cancer comes and go. Reducing xray screening  in USA   to every second year reduced the frequency of false positive recall – overdiagnosis – from almost half – 48% – by above one third, without increase in advanced cancer.
A Comparative Table shows the many methods, procedures  for objective breast imaging (mammography) available.  Of the established procedures  it lacks only comparison with the gold standard- the oldest ie  manual clinical examination-  and with forty year old Infrared Thermography. As this column has stressed previously, mammography is not a patented word for xray breast imaging, it is simply a generic description of breast (mammo-) and image (-gram) . Any image of the breast is thus a mammo-gram, and the process is mammo-graphy.SCREENING METHODS COMPARATIVE TABLE:                   this table shows the relative merits of some different methods of breast imaging. Mechanical Tactile Sure Touch Imaging leads the field  for combined sensitivity and specificity, portability, all-age utility without problems of breast density interference, cost, risks and reproducible mapping. Like a photograph, a  plaster or other cast of the bust would thus also be a mammogram image- and unlike plastic surgeons,  dermatologists and thermographers, other health professionals and patients alike too often forget to record a photograph to compare changes in the skin and breast serially. .
NEJM 28 Feb from Harvard, Adler and Colbert’s  “Mammography Screening Poll Results”  is a sobering commentary  on the health professionals’ wrong perceptions about routine X-ray mammography screening of all well breasts from midlife. What do readers say about the indisputable overwhelming independent evidence against routine X-ray screening mammography?
One has to question  the rationality of most NEJM readers – surprisingly few in total – who responded to the poll after Bleyer and Welch’s  , Mette Kalager’s  , Baum, Jorgensen and Gotzsche’s publications last year, that the majority of NEJM readers polled still  promote X-ray screening despite the hard evidence, the absence of benefit from screening irradiation of well breasts- significant reduction in mortality in such women – in the face of multiple hazards of such screening.
The risks, the  list of hazards – in five broad categories – is so great that as pointed out below last month, not even the NCI National Cancer Institute itself any longer clearly  promotes routine  X-ray mammography screening. As Colbert and Adler and the 2nd Canadian mammography trial 20 yrs ago noted (Miller and Baines) , the evidence for presymptomatic screening X-ray mammo is no better than clinical digital exam. Early diagnosis of silent  breast precancer by xray screening and biopsy does not save lives, it is a vast waste of money except for the career Breast Industry, that has been characterized as  terrorizing and damaging gullible submissive women (Winifred Cutler, Athena Inst).

There are certainly many safe natural ways we  reviewed recently of  reversing the  risks of breast  proliferation and cancer, thus justifying periodic safe low cost breast screening  – mammo-imaging – by independent  eg digital, mechanical tactile  ” Sure Touch ” , ultrasound and/ or thermo- means.26 Feb 2013. There is a flood of new progress against breast disease , breast cancer and  xray screening mammography: Contrary to  the for-profit Breast industry,  like all independent authorities including the Cancer Association of South Africa CANSA , the National Cancer Institute of America in 2013 no longer recommends routine xray mammography   screening-          it rates  the EVIDENCE on X-ray screening mammography          as FAIR evidence for its sole and arguable benefit –  Decrease in total and breast cancer mortality –        -*Consistency of studies is only Fair. External Validity: Good.  Internal Validity: Variable,.           But as GOOD evidence for the FIVE major  HARMS of  xray  screening    -* both  consistency, internal & external validity -are good -

  • Discomfort if not cellular rupture and bruising from violent 23 kg 50 lb crushing,
  • Overdiagnosis and Resulting Treatment – including mastectomy or radiochemotherapy- of Insignificant Cancers:
  • False-Positives with Additional Testing and Anxiety.
  • False-Negatives with False senseof Security and Potential Delay in Cancer Diagnosis.
  • Radiation-Induced Breast Cancer.

Winifred Cutler’s Athena Institute  team warns again that screening X-ray mammography on well women is dangerous , inflicts terror,  it does not reduce but may worsen the occurrence of invasive breast cancer. The  Berkeley  Institute’s  Dr Venugopalan  under profs Mina Bissell and Daniel Fletcher  show that simply gentle massage  helps – Compressing Breast Cancer Cells Can Stop Out-of-Control Growth  Shelley Hwang ea show that in California simple lumpectomy for early breast cancer reduced deaths (up to 2009) by 28% compared to mastectomy. Belinski & Boyages at the  Westmead Centre in Australia show again that common very low vitamin D levels more than double the risk of breast cancer let alone colon and all other cancers. A  Harvard team (Liu ea) has just shown that the carnage of legalized poisoning (smoking  – lungcancer, vascular;  alcohol -liver disease, violence;  adulteration with refined sugar/fructose - diabetes, vascular disease, cancer)  aside,  breast cancer far outstrips the other common cancers (colon, prostate cancer) in  preventible  life years lost. Willaims ea show again the major benefit of metformin against lethal breast cancer. Amadou ea in France confirm again the strong  link between abdominal obesity and breast cancer from childhood throughout life. This again highlights the criminal stupidity of delaying metformin use till obesity let alone infertility or diabetes are established. Metformin can safely be introduced at any stage of life provided it is started at very low dose eg below 250mg/day and cautiously titrated to the maximum well-tolerated dose to avoid nausea and diarrhoea- and temporarily halved or stopped in case of intercurrent gastrointestinal upset. . Grani et al from Rome, Italy    and many others remind us that both thyroid and breast malfunction are common by middle age and need to be sought and managed together.    We know that in most aging populations, deleterious deficiency of especially  magnesium, iodine, selenium, sulphur, and  vits B, C, D and K , and melatonin and sex hormones is very common along with crippling multitoxic carcinogenic overload. So it is logical to use multisupplements, and massage anti- inflammatory anti-cancer antioxidant  chelating antiestrogenic deep – penetrating iodine, coconut oil and DMSO – into the breasts as multidisease prevention and part of treatment. Oz ea in Turkey show that DMSO is  more effective against breast cancer than thalidomide.  But more importantly, DMSO enhances transport of any anticancer  agents into cancer cells. Already in 2008 Frederick ea showed that Lugol’s Iodine is an important antiestrogen adjuvant against breast cancer. Hence we advise  the harmless combination of natural multisystem micronutrients- especially  fish oil, coconut oil, DMSO,   vitamin C, D, K, melatonin, metformin, selenium, Lugol’s iodine and appropriate progesterone/ testosterone/ DHEA  – as nutrient supplements against all chronic aging diseases especially in women at risk of breast cancer.  . At Univ  Newcastle on Tyne,   Dr Dorota Overbeck-Zubrzycka’s  landmark  PhD  thesis just published on    FOXP3 regulates metastatic spread of breast cancer via control of expression of CXCR4 chemokine receptor promises new gene therapy in future. and her parallel study with Harvey,  A. Griffiths & C. Griffith,  Randomised control trial of Breast Tactile Imaging as an assessment tool for diagnosis of breast lumps in 2009/10 is now being published in full in a leading UK journal, validating this ( Sure Touch) bedside and outpatient clinic procedure as an established no-risk screening procedure, objective breast mapping  record for anxious women as shown in USA, Indian and Chinese studies. Thus increasingly Authorities are accepting that screening X-ray mammography harms far outweigh trivial if any improvement in survival. But screening – by eg regular clinical exam and mechanical tactile mapping –  for early signs of breast degeneration allows gentle safe self – treatment of all multisystem diseases that reverses both the breast degeneration and multisystem risk factors.

4 Feb 2013 UPDATE: BREAST SCREENING: Time lag to benefit after screening for common internal problems:   routine high-tech mass screening is inappropriate insurance.
a lot of the prestigious British Medical Journal last issue of 23 January 2013 is dedicated to the Breast Screening controversy; with a number of critics questioning the November 2012 Government  (Marmot) whitewash of the gigantically costly- and risky- NHS  screening mammography program. Professor Michael Baum of London University in particular has argued against this process for the past decade, after being the lead UK breast surgeon to set up this program in the 1990s and realizing it’s folly and risks.

Editorial: Breast cancer screening: what does the future hold?

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f87  Cite this as: BMJ 2013;346:f8    Cliona C Kirwan, National Institute for Health Research clinician scientist in surgical oncology          :  “Overdiagnosis remains a problem; quantifying its effects and minimising its impact are priorities.
The role of national breast screening programs and the quality and transparency of information given to participating women are increasingly the subject of heated debate. In the past 12 months alone, the BMJ, the Lancet, and the New England Journal of Medicine have published 24 articles debating the value of breast cancer screening. After calls for an impartial review of the value of breast screening in the United Kingdom, the findings of an independent panel of experts, led by Professor Marmot, were published in November 2012.1 Currently in the UK, women aged 50-70 years are invited for screening every three years; 2.3 million women were invited during 2010-11. The rate of uptake currently stands at 73.4%, having steadily increased in the past decade.2 The primary aim of screening is to reduce mortality from breast cancer. Reduced breast cancer related mortality is balanced against the cost of screening in terms of physical and psychological harm to women and the financial impact on health services. Much recent debate has concerned overdiagnosis—that is, diagnosis of a condition that would never cause symptoms or death during a patient’s lifetime. Although over-investigation can cause harm (pain and anxiety from mammography and biopsies), this is usually …”

Personal View     Harms from breast cancer screening outweigh benefits if death caused by treatment is included : Prof Michael Baum

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f385 (Published 23 January 2013)      Cite this as: BMJ 2013;346:f385

13 Jan  2013   As this column has long noted, routine high-tech mass screening is inappropriate insurance/prevention. Contrary to the gospel of the American Radiology, Breast and endoscopy costly screening industry,  and Curves International,  no human  survives   for  > 10 000 years to benefit from routine hightech screening  to avoid premature disease and death ie ‘save a life’ . . There is still grave doubt about the risk:benefit of routine prostate screening in the well.
A new January 2013 BMJ paper by a California University team Lee et al    looks at  ‘noninvasive’ cancer  screening of  breast (xray mammography) and colon (testing stool for occult blood)   in Europe and USA.  It found that  at least 1000 patients must be screened for at least 10 years – ie >10 000 patient-years of screening- before screening for either cancer could be claimed to save  a life. The corollary is that such screening of the well has a very low  chance – below 1:10 000 in any year, ie  0.01%  –  of finding a silent killer cancer that will save/  extend a life.

Thus they advise against screening people with an expected lifespan of below about 10 years.   But who would undergo such bothersome risky screening even over 10  years for a proposed benefit  (in death risk reduction)  of 0.1% a decade ? They found the reasons against routine screening of those not at high risk ( ie no suspicious personal symptoms or familial history) are as usual   those of the ensuing anxiety, the  procedures – radiation and colonoscopy and biopsies – and overdiagnosis. The worst is of course the cumulative risk of breast irradiation, and perforation death from colonoscopy:        “For cancer screening,  about one in 10 patients who are screened (with xray mammography , or with fecal occult blood testing) will have a false positive result,  leading to recall worry and likely biopsy/  colonoscopy.  Serious complications (such as perforation, major bleeding, and death) occur in 3.1 colonoscopies per 1000 screened.  One in 100 routinely mammography-screened  women will be  biopsied, and one in 1000 will be subject to overdiagnosis (that is, diagnosed with a breast cancer that was unlikely to have been clinically evident during their lifetime) and possibly unnecessary treatment.”

The same arguments apply strongly against routine screening of men for prostate cancer, or smokers for lung cancer,  in the absence of symptoms. . It should be noted that even the Wikipedia Mammography review now strongly highlights the arguments against mass screening mammography. The introduction sums it up bluntly: “task force reports point out that in addition to unnecessary surgery and anxiety, the risks of more frequent mammograms include a small but significant increase in breast cancer induced by radiation.[3][4] The Cochrane Collaboration (2011) concluded that mammograms reduce mortality from breast cancer by an absolute amount of 0.05% or a relative amount of 15%, but also result in unnecessary surgery and anxiety, resulting in their view that it is not clear whether mammography screening does more good or harm.[5] They thus state that universal screening may not be reasonable.[6]     Mammography has a false-negative (missed cancer) rate of at least 10 percent. This is partly due to dense tissues obscuring the cancer and the fact that the appearance of cancer on mammograms has a large overlap with the appearance of normal tissues. A meta-analysis review of programs in countries with organized screening found 52% over-diagnosis.[6]

It can be argued that noninvasive screeing that finds suspicious premalignant signs can then motivate prevention by natural means- lifestyle diet and appropriate supplements. But since these preventative steps (including blood-pressure and waist/breast  girth measurements and monthly self-exam for breast changes)    hugely  reduce the risks of all serious  acute and  chronic diseases, accidents and premature disability and death, routine mass screening for common ‘silent’  internal cancers eg breast, prostate  colon lung womb and ovary , is irrelevant, risky and huge waste of resources for no benefit. Not applying sensible diet,  lifestyle, blood-pressure checks   and supplements is like failing to maintain  your car, house, computers and electrical appliances etc , until  these  crucial assets  break  down. The evidence against hightech screening of the well of course does not  stop the anxious well  from worrying. As a heavy cigarette-smoking prof  of lung medicine  said 30 years ago, if an anxious patient demands a scope despite reassurance that the risk:benefit doesnt justify it, it is wise to do it.  Or someone else will. At least in the context of the younger adult who will thereby be more motivated to apply prevention, non-xray non-invasive screening by eg Sure Touch breast mapping- from onset of menopause, or younger  in eg diabetics   and others more prone to cancer eg in AIDS,  – and ultrasound quantitative bone-density risk measurement  from toddlers upwards , in exercising ie sportspeople,  and in any serious chronic disease especially with hormone overtones  eg thyroid,  diabetes, COPD/ asthma, cancer, arthritis, paralysis, AIDS,TB, cardiacs, renal, liver disease –  are relatively low cost  and safe compared to the traditional  xray screening procedures. The brilliant new French movie The Intouchables is all about choices  of lifestyle and the risks entailed.  Thats what screening, and voluntary prevention, are about.  No  adult  should be pressurized – by vested interests –  into having hightech eg xray (breast, bone)  or more invasive (eg scope, biopsy) screening without understandable explanation of the possible  although  infrequent immediate and distant risks,  and remote if any  benefits. Only the frequent  incidental unexpected screening discovery of hypertension,  increased breast lumpiness/density,  and low bone density, and initiation of simple lifestyle diet changes  and safe supplement  therapy- the below- listed scores of supplements against all common degenerative diseases  (and if needed the best primary antihypertensive  – lowdose reserpine and co-amilozide – costs perhaps  $1  a month to control  most; and simple (breasts, arthritis, wound   or elsewhere)  antiinflammatory  self massage if indicated with Lugol’s iodine, and analgesic antioxidant coconut oil and DMSO),  gives huge early and permanent preventative  pain and inflammatory benefits without risks.  There are also  promising studies on Pubmed between 1989 and 2011 of the benefits of DMSO in management of prostate problems in rats, and humans for transrectal procedures  and intravenously as cancer adjuvant palliation. DMSO-MSM is cheaply and safely available . It comes back to basics that are anathema to politicians,  Government, profiteers, Big Business Pharma and the Disease Industry.  Motivating and enforcing better lifestyle and natural diet (minimizing sugar , aspartame, alcohol, processed food especially cornstarch) , and healthgiving realistic doses of supplements – vits (all –  especially B, C,  D3 and K), minerals  (especially Mg, Zn, I2, Se, P, Bo,) and biological (plant  and sealife – not land animal) extracts,  (including fish oil, metformin, bioidentical human hormones, tryptophan, MSM, DMSO, chondroglucosamine,  coconut oil, cinnamon, pepper, curcumin, arginine, carnitine, carnosine, ribose, coQ10, proline, rauwolfia) – reduces the occurrence of serious disease drastically with decades of health extension. This vastly reduces  profit to the Disease Hospital-Drug  and processed food- alcohol – tobacco industry in delayed disease till very old age, and thus loss of  skilled workers’  jobs – that need to be taken up  elsewhere. That’s called reinvention, recycling…

SPECIALIST NATURAL MEDICINE CLINIC 2014

SPECIALIST NON-XRAY PAIN, BONE, BREAST, BRAIN,  HEART, CHEST, GENITOURINARY, HORMONE RISK SCREENING  @ NATURAL MEDICINE CLINIC

WOMAN’S MONTH  DISCOUNT

for appointments for consultations,   or non-xray procedures by registered practitioners :  Sure Touch breast prescreening on  Saturday mornings   1 Nov then 5 Dec  by Sister Zeneath Ismail – cash R600 (then R400 if followup scan desired within 3 months);   – bone density  cash R450 -tariff item 3612-  anytime;  Unlike radiologists’  and thermography reports (which describe only  the imaging finding), the rates quoted include relevant breast or bone consultation and management planning  by a specialist physician.

or any health problems: heart- ECG,  fatigue, HRT, sexual health, hypertension, depression, memory/dementia, lung & lungfunction, anaemia-haematology; kidney/bladder/pelvic, hormone-endocrine, depression, osteoporosis, sleep, diabetes, thyroid, adrenal; cramp; skin,  infection including STDs & HIV/AIDs, stroke, epilepsy-neurology, dizziness, heartburn/digestive/liver,  neuropathy,  sexual health, menopause, HRT, genotourinary; immune problems, or arthritis/backache/pain/headache relief;

Thermography no-touch infrared screening  for suspicious  cancer /inflammatory  changes:  by Radiographer Melinda-next in March 2015.   R900 breasts; R1100  head and  upper;  or lower body & pelvis;  R1300 whole body.

Bookings/queries contact Evelyn/ Reyhana / Val at  the Natural Medicine Clinic, 1st Floor no 15, Grove Medical Bldg, opp ABSA (ABSA Parkade parking)  near Warwick/Cavendish  Square Claremont Cape Town RSA, ph +27216831465 or a/h +2783 4385248 or reyhanadaya@yahoo.com  .

For the disabled – by arrangement  drive  up the ramp  to the Clinic door on the Grove Bldg 1st floor  parking deck.

Under CMS Council for Med Schemes Rule 10(6), open Medical schemes eg hospital plans  have to pay from their own funds (not members’ savings) for appropriate outpatient consultation (tariff item 0191) for  PMBs ie major conditions eg  cancer,   depression, neck/spinal problems, serious heart, lung, other disease., etc. Breast and osteoporosis concerns are generally part of menopause consultations N95.9  (if not already eg breast cancer code C50) and thus are often billable  med scheme benefits.

On patients’ requests, appropriate invoice can be prepared and submitted to your scheme for refund of your due benefits. Some schemes eg hospital plans  falsely deny due benefits until reported to their regulator  CMS. For medical plans where the billable tariff benefit rate is higher than the breast screening fee paid, the med plan rate 0191  will be charged eg R747.50 by the contracted  specialist,  and refundable by Discovery to the member. some basic schemes eg Keycare, Bonitas require preauthorization, or referral by their contracted GP  .

 

DIET- NUTRITIONAL – RISKS AND BENEFITS FOR INFECTION, CANCER, VASCULAR, SKELETAL, MOOD & ALL ELSE::

neil.burman@gmail.com

20 July 2014 HIGH CARBS OR LOW CARBS?  THE BIG FAT SURPRISE  – which is best for weight loss?  a collaborative literature metanalysis study  July 2014 by Naude ea the universities of Stellenbosch, Cape Town and Liverpool (UK)  claimed to compare the effects of low CHO and isoenergetic balanced weight loss diets in overweight and obese adults,  stratified by outcomes at 3-6 months and 1-2 years.  Of nineteen trials  (n = 3209), 3 had adequate allocation concealment. In non-diabetic participants, analysis showed little or no difference in mean weight loss in the two groups at 3-6 months (MD 0.74 kg) or  for blood pressure, LDL, HDL and total cholesterol, triglycerides and fasting blood glucose. In diabetic participants, findings showed a similar pattern.  CONCLUSIONS: Trials show weight loss in the short-term irrespective of whether the diet is low CHO or balanced. There is probably little or no difference in weight loss and changes in cardiovascular risk factors up to two years of follow-up when overweight and obese adults, with or without type 2 diabetes, are randomised to low CHO diets and isoenergetic balanced weight loss diets.

‘But  Noakes points outLow-fat, high-carb, high-sugar diet a likely cause of obesity/diabetes  “I refer to the report in the Cape Times of July 10,  “Noakes’s popular low-carb diet is not healthier, better for weight loss – study “. Since the authors of that study (Naude ea) do not understand either what constitutes a low-carbohydrate diet or the unique biological effects of such diets, they were predisposed to produce a biased report that comes to exactly the wrong conclusion.

‘First, the conclusion of their study was predictable since the authors chose to review only studies in which subjects ate the same number of calories on both diets. It is not clear how the authors conceived that diets that provided exactly the same number of calories would produce different outcomes. Indeed, a core teaching of these nutritional scientists is that the degree of weight loss is determined by the reduction in calorie consumption. Thus the authors knew the outcome of their study even before they undertook it. This is not good science.

‘Second, the studies included in their meta-analysis are not of the low-carbohydrate diet described by either Dr Robert Atkins or ourselves in Real Meal Revolution. Dr Atkins realised in the 1970s that the majority of overweight/obese persons can only reduce their weights successfully, and keep that weight off in the long term, if they eat less than 60g carbohydrate/day for the rest of their lives. Higher intakes are increasingly less effective. In Real Meal Revolution we stress that those with insulin resistance/ type 2 diabetes need to keep their carbohydrate intakes even lower, ideally to about 25g/day. The  “low-carbohydrate ” diets included in the meta-analysis provided a minimum of 200g carbohydrate/day (or 4-8 times higher than the carbohydrate content that is known to be effective). As a result this is a meta-analysis of studies providing a high, not a low-carbohydrate load for those with obesity/insulin resistance/type 2 diabetes.

‘Third, the extent of weight loss in the studies included in he meta-analysis is small, the greatest values being about 10kg. For most people with significant weight problems, such small weight losses are probably relatively meaningless and should be classified a diet failure, not a success. But freeliving persons who follow individually prescribed carbohydrate diets providing about 25g carbohydrate/day report quite remarkable degrees of weight loss, not infrequently up to 40-80kg, usually achieved effortlessly if the low-carbohydrate rules are followed.

‘Fourth, the unique biological effects of the properly-defined low-carbohydrate is that (i) It reduces hunger, allowing subjects to eat fewer calories without experiencing continual hunger. The point, as stressed by Dr Atkins, is that the low-carbohydrate diet is a low-calorie, no-hunger diet. (ii) The diet lowers blood insulin concentrations. In those with obesity/insulin resistance/metabolic syndrome, it is continually elevated blood insulin concentrations that cause ill-health (as clearly established by the work of Dr Gerald Reaven of Stanford University over the past 50 years).

‘The authors  found that health benefits were no different on either diet.    A number of properly designed, peer-reviewed meta-analyses of the real low-carbohydrate diets show that weight loss and health benefits are superior compared with higher-carbohydrate diets. Unfortunately, the authors appear to be ignorant of those studies since neither they nor your reporter refers to them. This implies the presence of bias, questioning the true intent of the report.

‘The report also includes the statement of the Heart Foundation of South Africa (HFSA) to the effect that a diet high in saturated fat causes heart disease. Unfortunately, the HFSA spokesperson appears unaware of Nina Teicholz’s recentbook, The Big Fat Surprise: Why Butter, Meat, Cheese Belong in Healthy Diet, and the  June 23 Time Magazine  Ending the War on Fat, which show that this dogma is false and is not based on any credible science.     It is  time  the HFSA updated its understanding of what actually causes heart disease. They might also want to consider whether their promotion of their unproven low-fat, high-carbohydrate, high sugar diet for the past 37 years is the most likely direct cause of the obesity/diabetes epidemic that has since engulfed South Africans.

‘Indeed on a practical side, I wonder if the authors have ever considered studying the dietary intakes of the obese diabetic patients they treat at Tygerberg and Groote Schuur hospitals. Do patients with these diseases eat either high- or low-carbohydrate diets? Why is is that these twin diseases, which are crippling the health services of the Western Cape, began to increase exponentially only after the 1977 Dietary Guidelines that institutionalised the low-fat, high-carbohydrate diets? Surely these are the critical questions that should really be exercising the minds of the Western Cape’s nutritional scientists? The best conclusion that can be drawn from this study is that diets providing more than 10 percent of daily calories in the form of carbohydrate are equally ineffective in producing meaningful degrees of weight loss in those with obesity/insulin resistance/type 2 diabetes.”

15 June 2014    DIET RISKS FOR BREAST CANCER, INFECTION & ALL ELSE:   Sugar? Fats? Vitamins?

already 30 years ago Seely and Horrobin in ‘Diet and breast cancer: possible connection with sugar consumption’ hypothesized: younger and older  (possibly pre- and post-menopausal )women differ with respect to such correlations. In older women a strong correlation was found between breast cancer mortality and sugar consumption (correlation coefficient = 0.9).. In younger women the correlation with diet is weak. A possible connecting link between sugar consumption and breast cancer is insulin. This is an absolute requirement for the proliferation of normal mammary tissue and experimental mammary tumours may regress in its absence. Insulin secretion occurs in response to blood glucose level and could be excessive if the regulatory mechanism is overtaxed by large sugar intake. The same mechanism might account for the increased risk of mammary cancer in diabetics.
  A  major decades-long Nurses’ Health  Study  review from Harvard shows no relationship between fat intake and breast cancer.
By contrast, studies from  Mexican  2004,  Canada 2005, Italy 2006 , and New York  2009 confirm direct association between sugar intake and breast cancer. . Only a study from Denmark 2005  shows no relationship.
Hence the HighFat LowCarbs (William Banting 1863) diet is now established by the rigorous scientific references of the past 150 years  assembled by science writer Gary Taubes in The Diet Delusion ,  and advised to all  for prevention and management of obesity and all other common major diseases including breast and all cancers.
      As investigative journalists write recently, like Taubes and rational scientists the past 50years,  the major cause of all common chronic degenerative disease including cancer and immunoincompetence is not fat but refined carbs – the root cause of the SACCHARINE DISEASES  that Cleave, Campbell, Burkitt reported occurring in pastoral tribes converting to the western commercialized diet of sugar, refined cereals and rice .                   They note that in the Mouse Cancer Study in cancer-prone mice,

Gemma Llaverias ea, Jefferson University, Philadelphia   2011,  which claimed that high (fat)cholesterol intake promotes breast cancer, the control mice  (not major carnivores but omnivores) were fed a balanced natural chow with 4.5% fat, 23% protein, and 50% carbohydrate, whereas the test mice were fed a totally synthetic chow meant to represent a western human  cholesterolemic  diet: 20% fat, 17% protein, and 48% carbohydrate. So in fact the high risk factor for cancer and all disease was not the higher fat intake (20%  as dairy fat) vs 4.5%- from fish meal and soy/cereals) but the 48% carbs (2/3  sucrose, 15% (malto)dextrins -which absorb as rapidly as glucose) intake and 19% casein (a major health problem)   in the test chow. They failed to include a control group on what is natural mouse diet ie free of refined carbs and milk :  RSPCA 2014:   Wild mice – opportunistic omnivores- will eat a wide variety of seeds, grains, and other plant material as well as invertebrates, small vertebrates and carrion“. Thus plenty of natural seed/grain fats and mixed protein and plant carbs,  zero sugar or refined carbs- ie the Banting diet. ..
A new 18year observational  followup  study from Sweden last year in 62000 people assessed total energy intake – carbohydrate  from median 61 to 39% , protein 11 to 19% , and  fat 27 to 42% . LCHP scores were positively related to intake of animal protein, but negatively related to plant protein. For carbohydrate and fat, associations were consistent in sucrose and whole grain and saturated and unsaturated fat, respectively. Across the range of macronutrients, there was no clear significant trend for particular cancers. This is not surprising as the intake of carbs ranged from 40 to 60% and fat from 27 to 42%. Thus no cohort was on a highfat low carbs ketogenic diet as Banting, Noakes  et al find successful. . the lowest % carbs group at best had similar fat % intake ie there was no low-carbs cohort taking below 30% carbs..There is a vast difference in calorie intake  between their “optimal’  LCHP 42:40 fat:carbs ie 1:1  , versus the  true ketogenic HifatLowcarbs diet of eg 50:<30 fat:carbs ie >1.66:1.
       Allowing up to 20% protein in total energy intake, for real weight loss- especially with insulin resistance- diet  fat needs to  be  >50% energy and carbs <30%, thus ensuring ketogenesis to shed excess fat and avoid depositing more glycogen and adiposity ; so eg for a tall fat person, thats  up to 80gms protein 320kcal mostly from flesh; carbs below 50gms 200kcal (  rainbow vegs) , and fat ~1480 kcal ie ~160gms from cream (not milk),   eggs, butter, cheese, avo, and fatty flesh; and mixed nuts cautiously due to their ~20% carbs content. .

It is no wonder the public is confused.

The truth of more than four decades worth of research is now very clear: the potential benefit of mammography screening is small and the harms are substantial at all ages, but especially so for women in their 40s.

The bottom line is that mammography screening, implemented to reduce breast cancer deaths due to earlier detection of breast cancer, has been eclipsed by therapy and increased awareness.

- See more at: http://umanitoba.ca/outreach/evidencenetwork/archives/4490#sthash.rf9YcMYp.dpuf

It is no wonder the public is confused.

The truth of more than four decades worth of research is now very clear: the potential benefit of mammography screening is small and the harms are substantial at all ages, but especially so for women in their 40s.

The bottom line is that mammography screening, implemented to reduce breast cancer deaths due to earlier detection of breast cancer, has been eclipsed by therapy and increased awareness.

- See more at: http://umanitoba.ca/outreach/evidencenetwork/archives/4490#sthash.rf9YcMYp.dp

VITAMIN INTAKE, INFECTION, BREAST CANCER:

VITAMIN C  each 100mg/day increment reduces allcause mortality by 27%, and breast cancer mortality by 22%:   a metaanalysis by the Karolinska- Harris ea   last month found 10 trials of vitamin C use and intake  in breast cancer, included 17,696 breast cancer cases, 2791 total deaths, and 1558 breast cancer-specific deaths. The summary RR (95% CI) for post-diagnosis vitamin C supplement use was 0.81 (95% CI 0.72-0.91) for total mortality and 0.85 (95% CI 0.74-0.99) for breast cancer-specific mortality. The summary RR for a 100mg per day increase in dietary vitamin C intake was 0.73 (95% CI 0.59-0.89) for total mortality and 0.78 (95% CI 0.64-0.94) for breast cancer-specific mortality- ie 25% lower mortality for every 100mg higher daily vit C intake..

Johnston CS1,ea., Arizona State University.            The early indications of vitamin C deficiency are unremarkable (fatigue, malaise, depression) and may manifest as a reduced desire to be physically active; moreover, hypovitaminosis C may be associated with increased cold duration and severity.. Healthy non-smoking adult men (18-35 years; BMI < 34 kg/m2; plasma vitamin C < 45 µmol/L) received either 1000 mg of vitamin C daily (n = 15) or placebo (n = 13) in a randomized, double-blind, eight-week trial. In the final two weeks of the trial, the physical activity score rose modestly for the vitamin C group vs. placebo after adjusting for baseline values: +39.6% p = 0.10). The number of participants reporting cold episodes was 7 and 11 for the vitamin C and placebo groups respectively during the eight-week trial (RR = 0.55;  p = 0.04) and cold duration was reduced 59% in the vitamin C versus placebo groups (-3.2 days; 95% CI [-7.0,0.6]; p = 0.06). These data suggest measurable health advantages associated with vitamin C supplementation in a population with adequate-to-low vitamin C status.

A 49-year-old man presented to hospital with severe orthostatic hypotension, gingival dysplasia and a purpuric rash involving his extremities. The orthostatic hypotension failed to respond to fluids and, on the basis of physical examination and dietary history, the patient was given a preliminary diagnosis of scurvy (ascorbic acid deficiency). Serum ascorbic acid levels were undetectable and the orthostasis resolved within 24 h of ascorbic acid replacement. The pathogenesis of orthostatic hypotension in the setting of scurvy appears to involve impaired catecholamine synthesis and attenuated vasomotor response to α-adrenergic stimulation. We believe that this case describes a rare presentation of scurvy and highlights a previously under-reported connection between scurvy and vasomotor instability.         

Br J Community Nurs. 2013 Suppl:S6, S8-11.Vitamin C: a wound healing perspective.   Moores JVitamin C, also known as ascorbic acid (AA), is involved in all phases of wound healing. In the inflammatory phase it is required for neutrophil apoptosis and clearance. During the proliferative phase, AA contributes towards synthesis, maturation, secretion and degradation of collagen. Deficiencies affect the maturation phase by altering collagen production and scar formation. The body strives to maintain homeostasis of AA, thereby ensuring availability for collagen synthesis. After wounding, plasma and tissue levels of AA diminish and, as a consequence, supplements may be useful for healing, although levels beyond saturation are excreted. Clinicians need to be aware of both the nutritional status of patients with either acute or chronic wounds and the possibility of any AA deficiency which may hinder healing.
Nat Commun. 2013;4:1881. Mycobacterium tuberculosis is extraordinarily sensitive to killing by a vitamin C-induced Fenton reactionVilchèze C1,ea .Einstein College New York.  Drugs that kill tuberculosis more quickly could shorten chemotherapy significantly.  we show that vitamin C, a compound known to drive the Fenton reaction, sterilizes cultures of drug-susceptible and drug-resistant Mycobacterium tuberculosis, the causative agent of tuberculosis. While M. tuberculosis is highly susceptible to killing by vitamin C, other Gram-positive and Gram-negative pathogens are not. The bactericidal activity of vitamin C against M. tuberculosis is dependent on high ferrous ion levels and reactive oxygen species production, and causes a pleiotropic effect affecting several biological processes. This study enlightens the possible benefits of adding vitamin C to an anti-tuberculosis regimen and suggests that the development of drugs that generate high oxidative burst could be of great use in tuberculosis treatment.
VITAMIN D AND BREAST CANCER:
20 years  ago Newmark from Sloan Kettering NY wrote :  High dietary fat increases mammary epithelial cell proliferation, particularly the “hormonally driven” hyperproliferation during breast growth and development in young animals. Increased dietary calcium (and probably vitamin D) lessens the increase of proliferation induced by high fat. These data, although limited, suggest that the maximum effect of diet (high fat increase, as well as calcium and vitamin D modulation) on eventual breast cancer may be during puberty, and adolescence, when the mammary gland is actively growing and developing. (3) An inverse epidemiological correlation exists between sunlight availability as a source of vitamin D and the risk of breast cancer in the U.S. and Canada. (4) Current vitamin D and calcium dietary intake in the U.S. is far below the RDA in all female age groups, particularly for the elderly. (5) Reduction of breast cancer risk, and simultaneously osteoporosis, might be achieved by increasing dietary intake of calcium and vitamin D to RDA levels. This may be particularly applicable to females during puberty and adolescence.
                    20 years later we now still find:                 Vitamin D and Cancer: The promise not yet fulfilled(California) ; and is there a link (France)?

BUT The Vitamin D Council    sums up the study evidence eg in a major Brit J Cancer metaanalysis last month of 30 prospective studies in 32000 BRCA  patients, and a Chinese study a year ago,   show  that  those with highest  vitamin D levels have 50-90% lower risk of  breast cancer risk, and mortality, and the chance of breast cancer spreading.  so far all they can recommend is that  vitamin D dose should for a robust adult not exceed  10 000 iu/day, or pro rata at longer intervals eg 150 000iu a fortnight.  Compared to those with the lowest quartile of plasma 25(OH)D level, women with highest quartile 25(OH)D level showed a significant decreased breast cancer risk (Q4 vs.Q1: OR = 0.10, 95% CI = 0.06–0.15) and every 1 ng/ml increment of plasma 25(OH)D level led to a 16% lower odds of breast cancer.

         It is likely that- given the limits on vitamin C intake due to diarrhoea, and cost, and bloating-  increments in vit D3 intake well above the current mediocre antirachitic 400iu/d norm- up to the generally well-tolerated 10 000iu/day, (after a loading dose of 200 000 to 600 000iu).  with supplement of vitamin K2-  will give even better benefit against breast cancer than vitamin C.     

 

IT IS COMMON CAUSE THAT ONE DOESNT, CANNOT   PREVENT OR TREAT INFECTION BY POOR NUTRITION OR LOWDOSE ANTI- MICROBIALS- such policy is futile if not dangerous for breeding resistance as well as disease extension.   The studies below confirm the obvious, (as Klenner, Pauling,  Cameron ea showed the past 50 years with highdose vit C injection), that  vitamin D3 orally also works as a multiantimicrobial agent if given as early as possible in safe very high dose and bloodlevel eg 600 000iu monthly (in the first month, – in Salhuddin’s  Pakistan PTB patients (presumably also Sunni muslim) initially mean wt 45kg, thats vit D3 ~440iu/kg/d) for two doses ie a mean of 300iu/kg/day over 90days;   not the current preventative recommendation of 80iu/kg /day to a safe blood level of around 50-60ng/ml. As Holick has said, with adequate water intake  even 50 000iu vit D3 a day ie 1.5million iu/month for months causes no toxicity. Given the 40% mortality rate in the frail Saudi MERS patients, and in acute severe influenza and other serious viral infections, it can be expected that such  highdose immediate vitamin D3 therapy orally with eg 600 000iu, combined with highdose vitamin C, zinc and some multivite,  (never mind appropriate antibiotics in acute bacterial infection) will similarly virtually eliminate mortality.

 

But no KSA Govt website mentions this- except the Saudi Gazette a year ago which strongly urged vitamin D supplement in the KSA as even daily sun exposure does not bring most Saudi women above the vitamin D deficiency threshold. It says Since Muslim women can only reveal the hands and face, they may need to be out in the sun for longer than 30 minutes. But the review conspicuously  fails to mention that in public outdoors in KSA, women must have even the head and face covered. It also  propagates surprising  dangerous  nonsense that “severe deficiency needs monthly vitamin D injectionMom, have you taken your vitamin D injection this month?, when all it requires is an oral daily, weekly  or fortnightly  dose vitamin D3  at trivial cost.” It does stress  “One of the main reasons why vitamin D deficiency is so common in the Kingdom is because there are very few food sources of vitamin D. Foods which have fairly good amounts of vitamin D are fish liver oil, sweet potatoes, egg yolks, vegetable oils, butter, and fatty fish such as salmon, sardines, and tuna,” said Dr. Rasha Jameel, a consultant in family medicine at a local hospitalIn the United States, all milk and dairy products are fortified with vitamins A and D, but no such measures are in place in the Kingdom“.

 

This correlates with a new metaanalysis (in the  BMJ this month) of observational studies from Europe and USA, that all-mortality hazard ratio over a mean of 10 years  increases by 57% as vit D level falls from the highest to the lowest level. The KSA apparently chooses to ignore that, as this column reported recently from WHO data, despite  apparently being the wealthiest country per capita  of bigger populations  in the world,  KSA’s population life expectation is about 5 years lower than eg far less sunny Britain’s; ie KSA  all-cause mortality rate is avoidably materially higher. Despite KSA medical professors  having reported in studies  that most of the KSA population is deficient in vits D and C, the  KSA Govt website  chooses to ignore this on official websites;  unlike other even Middle-Eastern governments promoting vit D fortification or meaningful safe supplements costing trivial amounts.

 

Even a new study last year from KSA universities confirmed that ” Most commonly consumed food products by Saudi population which are supposed to be fortified by vitamin D are either not fortified or contain an amount less than  (apparently  from their table 2 ~ half of)  recommended by guidelines set for US marketplace”. Even a UAE authority recently stressed “Can fortified milk fight Vitamin D deficiency? Shockingly low levels of D3 among UAE population cannot be rectified by milk alone.” As Holick ea, including  a Turkish University 2010  trial report,  oral vitamin D3 is far more  effective , and safer than,   either vitamin D2, or vitamin D injection -never mind much cheaper. This current ostrich-head-in-the-sand denialism by the KSA government is like that of the RSA govt under Presidents Mbeki and Zuma 10-15 years ago about preventing and treating HIV-AIDS  – considering that the safe and beneficial daily intake of vitamin D3 is now universally recognized as 4000 if not 10 000iu/day (ie about 80iu/kg/day or pro rata up to perhaps fortnightly) , to a mean blood vit D  level of about 60 to 80ng/ml. .

As Prof Mike Holick pointed out a few years ago, “Even in Saudi Arabia, Qatar and South Africa, more than 50% of the population is deficient in vitamin D, all because of their avoidance of sun. Based on some of the literature, it seems that we could probably decrease health care costs across the board by 25% if everybody had optimal vitamin D status.” As Al Faraj ea reported in Riyadh in 2003,   Prof Zahid Naeem from a KSA university wrote in 2010,Vitamin D deficiency is an ignored epidemic in KSA  and globally“; confirmed by a KSA study by Ali ea in 2012: “Even in a sunny country like Saudi Arabia the prevalence of vitamin D deficiency in young female is high“..  One does not need to  speculate why the KSA and all governments globally choose to ignore this inconvenient truth,  downplay effective vigorous  vitamin C and D3 (sunshine) supplements-  such widespread vitamin D and C deficiencies, like cigarette smoking and alcohol abuse,   suit governments and Big Pharma-  the Disease Industry- in reducing populations growths and creating jobs for the highly profitable Disease Industry and it’s shareholders-   for whom Only Disease Pays. Cheap safe natural  Prevention Does not Pay since it at least halves sickness never mind disease industry jobs, taxes  and profiteering in the global $multitrillion Disease and Diet and Vaccine and Invasive Screening Industry scams.

 

And Karen Hansen ea at Univ Wisconsin 2014 have  just shown  that  giving vitamin D2  (not D3)  50 000iu fortnightly for a year is actually adverse – as Holick and others have  show – IT DEPRESSES – perhaps halves – THE BIOLOGICALLY ACTIVE blood 25OHVIT D3 while boosting perhaps 5 fold the far less active blood 25OHvit D2 levels , and actually worsens  rheumatoid arthritis clinically and serologically . One can speculate whether vit D2 actually blocks optimal function of VDRs vitamin D receptors. Trials published 2012 from Japan and Netherlands showed that vitamin D3 – blood 1,25(OH)2D3 (but not TNFalpha blockers) blocked  inflammation (ie TNF tumour necrosis factor alpha activation of vascular calcification).                                                 

Salahudfin ea’s new randomized controlled trial  from Pakistan Vitamin D3 injection accelerates clinical recovery from tuberculosis  shows “impressive clinical (weight gain, chest xray and sputum clearing)  improvement  over 3 months on outpatient TB therapy (Directly Observed Therapy (DOTS) with 2 months of 4 antituberculous drugs [Isoniazid, Rifampicin, Ethambutol and Pyrazinamide] followed by 6 months Isoniazid and Ethambutol)  with two doses 600 000iu vit D3 imi  (vs placebo inj)  a month apart-  ie equivalent to about 7 000iu/day over the 3 months treatment period . This dose  of vitamin D is as recommended for vitamin D supplement by the Pakistan Endocrine Society.  Trough  25OH vit D levels increased from about 20 to 90ng/ml.    After 12 weeks, the vitamin D supplemented pts (mean 28 yrs, BMI 17.2kg, 85% moderate to far advanced lung disease)  had  significantly greater mean weight gain (kg) + 3.75, (3.16 – 4.34) versus + 2.61, p 0.009; lesser residual disease by chest xxray-  30% fewer zones involved 1.35 v/s 1.82 p 0.004,   and 50% or greater reduction in cavity size 106 (89.8%) v/s 111 (94.8%), p 0.035. Vitamin D supplementation led to significant increase in MTBs-induced IFN-g secretion in patients with baseline ‘Deficient’ vitamin D serum levels (p 0.021). Patients in the vitamin D arm and serum < 30 ng/mL (‘Insufficient’ and ‘Deficient’ groups) at enrollment had significantly greater improvements in TB severity scores compared to patients with normal baseline vitamin D levels; p 0.014. This corresponds with the earliest reports of the benefits of vitamin D in TB patients published in 1848 [21] that describes disease arrest, weight gain and reduction in mortality in patients with TB treated with cod liver oil compared to standard therapy alone. More recently, Martineau et al  [7]  demonstrated that a single oral dose of 2.5 mg (100,000 IU) of vit D2 significantly reduced growth of mycobacteria . A randomized, placebo controlled study on 67 Indonesian patients, by Nursyam et al , Jakarta  [22] reported that pulmonary TB patients given 420,000 IU of vitamin D over 6 weeks  ie 10 000iu/day had significantly higher sputum conversion rates as compared to placebo (p 0.002). Martineau et al. [8] showed that 100,000 IUs of 25-hydroxyvitamin D3 supplementation significantly improved sputum conversion rates in patients with the Taq1 25-hydroxyvitamin D receptor polymorphism of the tt genotype.                                                                     .        

            As Salahuddin ea note, the good results in Pakistan in only 3 months with vigorous  INITIAL dose vit D3  contrasts with Two recently published large randomised, controlled trials of conservative vitamin D3 over months  that achieved far lower blood vitamin D levels found no difference in clinical outcomes or mortality after 400,000 IU of 25-hydroxyvitamin D3 or placebo were given by   Martineau ea  in London, UK to 146 pulmonary TB patients – where mean (trough  or midpoint)  vit D level  (after 100 000iu vitamin D(3) or placebo at baseline and 14, 28, and 42 days after starting standard tuberculosis treatment) – was surprisingly only  40ng/ml at 56days – ie after a mean of 7000iu/d by  56 days,  vs 10ng/ml  on placebo)- less than half of the bloodlevel  achieved on vit D3  in the Pakistan trial ;      

 

        and  by Wejse et al  2009  in  Guinea-Bissau to 365 TB patients  – who received  300,000 IUs of vit D3   ie only 100,000 IU or placebo at inclusion and again 5 and 8 months after the start of treatment,  ie below 1000iu vit D3 per day over the 12 month trial period “. The Guinea-Bisseau pts thus might have achieved a mean blood vit D level boost of only  10ng/ml.. and now Havers ea (Baltimore)   show Low 25(OH)D is common in diverse HIV-infected populations and is an independent risk factor for clinical and virologic failure; Low 25(OH)D was associated with high body mass index (BMI), winter/spring season, country-race group, and lower viral load. Baseline low 25(OH)D was associated with increased risk of human immunodeficiency virus (HIV) progression and death (adjusted hazard ratio (aHR) 2.13; 95% confidence interval [CI], 1.09–4.18) and virologic failure (aHR 2.42; 95% CI, 1.33–4.41). and Shepherd ea (Eurocoord) Low Vitamin D predicts short term mortality in HIV-positive persons Odds of death decreased by 46.0%( P = .04) for a 2-fold increase in latest 25(OH)D level.. In patients with current 25(OH)D <10 ng/mL, hsIL-6 concentration increased by 4.7%(95% CI, .2,9.4, P = .04) annually after adjustment for immunological/inflammatory markers, and no change in hsCRP rate was observed (P = .76)

COMBATTING THE INCREASING OCCURRENCE OF BREAST CANCER IN YOUNGER WOMEN.

UPDATE: 2 Mar  2014: PARACETAMOL ACETAMINOPHEN, DIGOXIN AND SPIRACTIN are ESTROGENIC: even the most popular and perhaps safest synthetic designer painkiller paracetamol acetaminophen (Tylenol, Panado) discovered in 1877   has again been shown  (Harvard University 2014- the Nurses’ Health Study from 20 years ago) to be ( like the 250year old biological human hormone digitalis/digoxin, and the 50year old synthetic antihormone  spironolactone), a weak estrogenic ie they proliferate the breasts and thus cancer potential.                       Acetaminophen use was positively associated with total Estrogen Metabolites (2+ days/week vs. non-use: 236 vs. 198 pmol/mg creatinine; p difference = 0.02, p trend = 0.11),  Thus like its cousin phenacetin (never mind alcohol and smoking)  after decades of fraudulent promotion as safe,  paracetamol’s harms outweigh its utility

     Thus while it  is fairly safe in adults in moderation,  like all designer synthetic drugs eg NSAIDs and synthetic/xenohormones,  like even lowdose aspirin, paracetamol  has many risks (even for the eyes)  and doesnt cure anything- whereas digoxin and spiractin may have lifesaving benefits in serious heart/ hypertensive disease. .

As always, for pain best stick to physical cure by eg manipulation, massage, rest and exercise, heat or cold, acupuncture; or some natural safe biological analgesic/antipyretic combination- massage with   arnica/menthol/coconut oil/ DMSO/cayenne/Lugol’s iodine/magnesium oil;     or these orally with eg fish oil; vitamins C (eg citrus), D3 (sunshine) and B esp B5 (meat, whole grain, avocado, brassica);  magnesium, manganese, copper, iodine, selenium; GABA (but not gabapentin and pregabalin – Bad Medicine);  plant extracts eg  boswelia, bromelain, buchu,  catsclaw, curcumin, dandelion,  MSM, nettle, ginger, caffeine, ecchinacea, sage, cherries, Oregano, rosemary, thyme, mint, cannabis, angelica, valerian;  and  cartilage eg glucosamine-chondroitin .

Oct 2013:  BREAST PAIN,  CHEST PAIN AND HORMONE CONTRACEPTION.

CHEST/BREAST  PAIN: In men and women, nontraumatic pain in the front , back and sides  of the chest (and abdomen)  is mostly neuromusculoskeletal, and easily diagnosed  by  the history (absence of cough, central deep pain radiating especially to the jaw , back  or left shoulder, breathlessness, fever, heartburn),  and  physical examination –absence of  systemic signs or  significant  changes in pulse and bloodpressure);

and appropriate assessment of the neck and thoracic spine since these are so often where root pain (around the shoulder girdle, trunk and limbs)  originates and can be simply relieved ie cured and thus diagnosed.

    This is crucial in daily busy  primary care ie general practice where patients –especially the younger fitter ones without the common high  risks – want a quick opinion and fix so they can move on, not have to undergo xrays,  heart-  and blood-tests that specialists and hospitals, medical schemes, politicians and civil servants  thrive on..

    Older women of  course  usually have the   major extra anterior chest organs – pendulous  breasts – to  consider.  But the same  history and physical exam as in men  quickly mostly  sorts out the source and thus the cause of the pain:  a mammary cause eg hormonal congestion diffuse tenderness,  discharge, or tender  lump or gland, or root cause, is  quickly  apparent.

CASE REPORTS: at yesterday’s breast clinic we saw the usual spread of middle-age issues  in the eight  (mean age 45yrs, 32 to 65yrs) who booked  for breast prescreening imaging :

HORMONE CONTRACEPTION vs NECESSARY (PRO)HORMONE SUPPLEMENTS:

TWO IN THEIR FORTIES  ON DEPOT PROGESTINS:

CHEST PAIN: clerk Ms  booked herself for screening with almost constant  discomfort in her left breast for about 10weeks.. Like her and her doctors’ examinations, mammography a  month earlier found nothing abnormal.. She had no history of trauma or pain elsewhere, just slight neck discomfort. Her last period was years earlier, still on contraception  progestin injections. Examination and  mechanical tactile breast imaging confirmed tender full breasts; with maximal palpation tenderness midthorax laterally  at the site of her complaint.          Pressure and rotation elicited no discomfort elsewhere.  Gentle traction manipulation of her neck halved the ‘breast’ discomfort, which disappeared with a final satisfying click with gentle prone rotational pressure on her appropriate upper thoracic vertebra – confirming the root  source of her pain had been cured; and obviated further concern , tests and  analgesia.

 Manageress  also on  longterm depot hormone contraception (Mirena), with growing breasts,    rising weight despite careful diet,   and  concern about hip osteoporosis on DXA screening that was not improving but worsening the past 3 years on some routine vitamins C, D3  2000iu/day. K2 and calcium supplements. Her husband (not she) observed that she had severe night sweats.

       Both of the  ladies on synthetic progestin contraception   were reminded that such depot synthetics  suppress the ovaries ie cause artificial menopause with all its longterm subtle adverse effects, and that such hormones are known to slightly increase the risk of breast cancer, fattening and osteoporosis.    Both   were recommended progesterone cream, vitamin D and metformin as well as the other almost 20 bone supplements, for (pro)hormone balance and to assist with body fat  and thus all-risk reduction

        Ms   mid-60s with no complaints except stress vertebral fracture from osteoporosis now on opioid patch!  mother died of breast cancer at 78yrs; she has had 10 mammograms;  just dense lumpy breasts;; advised vigorous vit D, Super C, K2; Triple Bone-Pain – antiarthritic blend; metformin; DHEA and melatonin 20mg/d;

    Ms  early  50s  with menopausal symptoms, hypertension ( on perindopril)   and lumpy breasts, now off Nuristerate, ,   was advised to take appropriate supplements including progesterone cream. There is a new report from Holmes ea Canada http://www.ncbi.nlm.nih.gov/pubmed/24075077  that ACEi/ARBs use eg perindopril  was associated with significant 22%  increased deaths from  breast cancer (95% CI: 1.04-1.44), let alone the risk with such drugs of recurrent persistent cough and insidious nephropathy; so is advised to swop over to the safest best and cheapest 1st-line antihypertensive regime of lowdose  reserpine with low dose amilozide,

Ms  mid-30s with a child despite endometriosis and  PCOS , 4 years after removal of Mirena (7 years) , had lumpy breasts. Advised metformin,  vits  D and Supervit C, minerals and vitamins.

Ms  early 30s with PCOS , two aunts in their 50s with breast  cancer, her granny from the other parent having died of breast cancer at 76years.. with  lumpy breasts; she was advised the supplements including progesterone cream, melatonin, and metformin.

TWO IN THEIR 30S HAD KNOWN BREAST CANCER:

 Ms   mastectomy and DXRT 2011, now off Nuristerate ,  given weeks to live 18 mo ago with brain metastases that have shrunk with chemoradiotherapy and her zealous work as a cancer counselor;  lumpy other breast; now advised metformin, sutherlandia, melatonin 20mg/d,  vigorous vit  K2,  D and Supervit C, DIM, mushroom, astragulus, selenium, minerals and vitamins within her means.

Ms   had lumpectomy and 3 positive glands/12 removed in 2011, refused further oncology/ radiochemotherapy.   Lumpy breasts confirmed . Advised metformin,  sutherlandia, melatonin 20mg/d,  vigorous vits K2,  D and Supervit C, DIM- I3C, mushroom, astragulus , selenium, minerals and vitamins;  if not Iscador, cesium, TCM,  and pancreas/gene therapy  within her means.

BREAST PREVENTION REGIME: apart from optimizing diet and lifestyle with appropriate obesity-reducing diet and avoidance of estrogenic foods and drugs,

Based on published evidence and our experience from patients of analgesics and anticancer benefit, all were advised to try  triple breast massage daily with coconut oil, Lugols iodine then DMSO  for a few weeks, and if they want reassurance, return in a month or two  for followup breast imaging to show the shrinkage in all lumps that  most show. Those with higher risks are advised to take the oils by mouth as well, and if iodine depleted, oral iodine , for their global benefits.

      However, short of  avoiding  sex, or use condoms and barrier creams, or ill-advised sterilization or dependence on coitus interruptus,  their contraceptive method is hard to improve, short of relying on the oldfashioned intrauterine device without any contraceptive hormone. The oldest naturally occurring pregnancy we have seen was at 55 years, so women have to take care past this age…Natural human contraception with depot human progesterone and estrogen was developed decades ago, but naturally not made available commercially because only synthetics are patentable and thus commercially viable raincheck drugs that profit Big Pharma, health professionals and politicians. .

     Instead, women are advised simply to protect the breasts, womb, brain, heart, skeleton,  face etc, and stop menopause symptoms, by adding just enough human  progesterone cream daily to their face makeup (+- vaginally); (testosterone cream sparingly  if indicated for frailty, depression  and poor sex) , and take a sensible daily blend of the twenty other natural bone and multisystem antioxidant anabolics  (as this website www.healthspanlife.wordpress.com details under osteoporosis) including vitamin D about 2500iu/kg/month ie about 150 000 to 200 000 iu/month for an average size adult.

         In people rapidly fattening due to lifestyle, stress and the bad marketed adverse food chain, wiser choices have to be promoted-which does not suit most  politicians, Big Business or the Disease Industry for whom Only Disease Pays-  Prevention Doesn’t Pay.. So to protect against fattening and insulin resistance perils, metformin to sensible tolerance is also an inevitable recommended  natural albeit prescription supplement until healthy robust lean weight can be maintained without it.

      The supplements listed  above – (fish oil, appropriate parenteral human sexhormone replacement and the other antioxidants/anabolic vitamins, minerals and natural biologicals including the prohormones metformin and vitamin D) also mostly obviate the deplorable high-risk use (for commercial profiteering) of risky synthetics eg  statins, bisphosphonates, psychotropes, analgesics, NSAIDS, patented xenohormones and chemotherapy   etc – none  of  which address the underlying stress, deficiency  and pollution ie primary causes of  disease.

UPDATE: FIGHTING THE TIDE  OF  BREAST CANCER, DISEASE  in YOUNGER WOMEN: 

16 June 2013 A new review by Carolanne Wright reviews how to combat estrogen overload – How environment and lifestyle contribute to hormonal imbalance while devastating the health of both men and women.

27 May 2013 Wikipedia reports that in 2008,  about half a million women   died from  breast cancers (out of some billion older women worldwide ie 0.5 per 1000 women, an annual deathrate of 0.05% pa),  23% of cancer deaths in women; with cancer overall accounting for about 13% of deaths -the commonest being stomach-colon-liver 2.8%;  lung cancer 1.4%, then breast 0.46%  of deaths. So breast cancer – mostly undetected globally  by the luxury of mammography till it presents clinically-  kills only perhaps  1:2000 older women per year, ie perhaps <25%  of the  perhaps  1:500 older women who develop clinical breast cancer-  995/1000 of older women’s deaths being from other causes than breast cancer.

These figures dispel the  dangerously fraudulent  fearmongering  lie  of the USA Radiological and Breast Cancer Associations and Curves International that “(screening) mammography saves lives”. Its good to see in the current Curves South Africa website that in this Celebrating Mothers’ Week at Curves, they have dropped the Mammography saving lives myth of 3 years ago that started this particular theme column.  That hasnt stopped USA doctors  from continuing to propogate the lie.

But some there  eg Dr Lissa Rankin MD – daughter of a mammography radiologist- are still brave enough to refute the lie. And even the American Cancer Society chief medical officer doesnt make such ludicrous  claims but points out how complex the issue of prescreening detection is. .

Johnson and Bleyer reported Feb 2013    from the SEER study  that advanced breast cancer in young USA  women 25-39yrs has doubled between 1976 and 2010.

South Africa (religion mostly African Christian) has the distinction  of being one of Earth’s  most corrupt and illiterate  countries,  with strange bedfellows –  Latin  America (mostly Catholic),  Egypt Lebanon & Pakistan(Islamic), and  South Korea(mixed religions)-  that follow the USA in defying evidence – in this case  of danger to cows and humans – and allow the use of rBGH recombinant Bovine Growth Hormone ; and  sex hormones   in dairy and meat production. The evidence of harm, eg  carcinogenicity and feminization  is so strong that such  use has been banned in many  countries for decades .

MORTALITY TREND AND CANCER IN RSA AND GLOBALLY: Breast cancer is usually a disease of postmenopausal women-who till a centry ago on average barely lived to that age. In South Africa at the   peak of the untreated AIDS epidemic around 2000, with average lifespan drastically fallen, of all deaths, overall infections (HIV  TB, pneumonias etc)  caused about 39%, external causes  12%, cardio/vascular disease 11%,  cervix cancer 1.4% and breast cancer 1.3%.    But Statistics SA report last month that by 2010, with antiretrovirals, life expectancy  had risen about 5years, and that of all deaths,  HIV+TB  deaths had  at least halved   to  15% (17% in Africans, 9% in coloureds, 2.4% in Indians), cardio/vascular deaths were 12% in blacks but 27.8% in whites; external causes down to 9%, cancers 9% (mostly digestive and respiratory); with only 20 breast cancer deaths ie 0.00% reported in RSA.

Breast cancer is still rare in a mostly young population with mean age of survival of women still half of that of the first world,  with virtually a generation gap due to the carnage of the untreated AIDS era and institutionalized male violence especially against women, children and minorities- xenophobia.

But meat  and dairy milk (in South Africa widely containing added rBGH and sex hormones) are  among widely used foodstuffs likely contributing, as Joe Mercola notes,  to the increasing occurrence of breast cancer in younger women. Never mind deadly  sugars, smoking and alcohol consumption on the rise here in RSA.

AVOIDING CANCER AND MASTECTOMY:
To   improve immunity,  insulin receptor sensitivity
,  lessen obesity and excessive estrogenization (from both outside your body,  and your own fat production):

  • Exercise;  Maintain a healthy body weight  -BMI < 24kg; waist girth<about 85- 90 cm; earthing- walk barefoot.
  •    AVOID:- added or concenrated sugar, (especially fructose- commercial fruitjuice; cornstarch, white flour); charred fats; smoking; alcohol;  unfermented soy products; licorice; GE genetically engineered foods. .  
  • BUT those with asthma, leaky gut/IBD, epilepsy or bad arthritis should also try excluding for a few weeks WHEAT; DAIRY; AND NIGHTSHADEs (potato, tomato, peppers/cayenne, eggplant).
  •              –synthetic sexhormones (progestins, xenoestrogens eg in meat, commercial milk, birth control and HRT,   BPA, phthalates, pesticides); spironolactin Spiractin; digoxin; and . 
  •              -physical trauma eg underwire bras;                        xray (eg airports and xray screening mammography), electromagnetic fields eg electroblankets.
  •              -other toxin overload aspartame,  marketed designer drugs (eg  painkillers, statins, psychotropes, bloodthinners, antiinflammatories- even paracetamol Panado acetaminophen Tylenol);                         and      -overload metals  (eg iron, fluoride, bromide, chloride,  aluminium, lead, mercury, - consider detox.
  •    Do (Lymphatic) breast massage with eg anticancer coconut oil, DMSO, Lugols iodine; 
  •   Breastfeed your babies;
  • &  To avoid common deficiencies (on our depleted polluted GMO-fastfood diet, especially with increasing longevity), which contribute to all common diseases,                             take plenty of
  •      -sunlight; melatonin & enough restful natural sleep and relaxation!
  •      -organics eg green/coloured  vegetables/ juice daily. .
  •      -fish oil ie marine  omega-3  (dont fry  in  Om6 plant oil)
  •      -for lipidemia,  overweight, diabetes, the prime insulin sensitizer-weight/appetite reducer galega/metformin to tolerance;
  •      -iodine as eg kelp, or Lugol’s iodine.
  •      -vitamin D3:  with cancer, target  blood vitamin D level 70 to  100 ng/ml ie we need about  70-100iu/kg/day – and   sunshine and food cant provide this. . .
  •      -natural vitamin A - organic eggs, raw butter, raw whole milk, and beef or chicken liver, or a supplement.
  •      -buffered vitamin C about 50mg/kg/day    up  to tolerance;- with acute infection/inflammation/cancer  in an  adult, this may be 1/2 up to >2gm hourly till better, or diarrhoea, then (like metformin) just enough to avoid diarrhea;
  •      -virgin coconut oil & DMSO each 1(-15) tsp/day;
  •      -magnesium about 5 mg/kg/d; calcium phosphate;
  •      -zinc, chromium, selenium, manganese, boron;  and
  •      -vits Bco, CoQ10, &  K2.
  •      -natural estrogen-aromtase inhibitors to lower adverse estrogen dominance, raise  the  2OH:16OH estrone balance to about 2:1 – eg exercise; lecithin/choline (from eg  eggs/seeds);  oranges/lemons, red grapes, passionfruit;  celery, parsley, basil, artichokes, avocado,coconut, onions, garlic, olives, olive leaves; asparagus, squash, cauliflower, broccoli/cabbage/spinach/Brussels (provide I3C/DIM di-indole methane), yams, milk thistle,  sawpalm, diet fibre,  black radish, mushroom-astragulus, sutherlandia, beet, dandelion, curcumin turmeric, cinnamon, ginger, honey, garlic,  black pepper; taurinemethionine; zinc, selenium, vits C/D3/E/K2; and/or balancing  progesterone/ testosterone – or just 7ketoDHEA in the elderly..

Just this  month, a major trial from UCLA (Smith, Kurzer ea) confirmed that in healthy sedentary young women, moderate exercise 2.5 hour a week significantly beneficially  lowered the risky  estrone level  and raised  the             2OH:16OH estrone ratio.

These preventative steps may remove justification for therapeutic mastectomy (which is known to reduce survival)  for localized breast cancer , let alone preventative bilateral mastectomy even in women with high penetration BRCA genes, as publicized this month  by filmstar Angela Jolie .

WHAT FOOD SHOULD YOU EAT?

28 January 2014    guest author  orthopaedic surgeon and instructor  Dr Jon Driver-Jowitt FRCS  orthopaediciq.org   opined:

This is not scientific precision.  This is not peer reviewed.  This might not resist the rigor of an editor.  These are simply observations intended to spur thought and look laterally.

Much advice about food appropriate for health has been given. Much of that has been based upon (often marginal) statistics. Many are deduced from self-reporting surveys. However the variables are so great that it is impossible to accommodate these into meaningful statistics. A few of these variables include quantum of food, types of mixtures of food, frequency of these foods, plus multiple variables related to micro-nutrients ingested simultaneously, and more.

When in doubt, it has been said, look in the instruction book. The instruction book for  animals (including the human)  exists in the animal. It is the inclination to eat some foods and the abhorrence of others.

Without the instruction book, one has to look at design specifications. Unfortunately the animal-machine-design did not consider the possibility of limitless food, or great food variety, or types of current cultivars. So selection by appetite might be flawed, and one is left guessing (somewhat) about the design specification. That is what is addressed here.

But before that, if one wants to live longer, the method has been (scientifically) available for the better part of a century. Simply, eat less. Eat less than your appetite drive. Eat less than your cohorts.

But let us look at design. Suppose humans were to be designed from scratch, which fuels (i.e. foods) should be selected, bearing in mind the limitations of availability, and knowing that the human is a mobile device with defined functional requirements and a limited life-span? Consider these options, and consider how they fit with current eating patterns:

Fat is probably the most desirable and quintessential food for humans.  It is the supreme appetiser.  It carries essential vitamins. Fat the highest calorific gain of all foodstuffs whilst it has a low energy cost for ingestion and digestion. It is the most cost effective source of energy. Yet fat has powerful negative feedback mechanisms.  Therefore, although fat stimulates appetite it also produces satiation relatively rapidly. Rapid satiation allows food to be spread to the entire pack, in keeping with expectations of le milieu exterior which demands survival of the group, not the greedy individual. However the satiation of fat can be strongly altered by salt.  Therefore, salted fat and perhaps salted protein can become “compulsive” foods, inducing the eater to keep eating until gorged.  So we have yet another factor, the “additions” to food which induce compulsive feeding, prompted by those intent on making money out of food.

Protein is probably neutral tasting without the fat and salt, is not particularly palatable and does not have the “addictive” quality of carbohydrate. But it contains “essential” components which the human cannot manufacture, including amino-acids and vitamin C (curiously a “water-soluble” vitamin). It is also heavily mechanically bound to fat, and often inseparable.

Carbohydrate, on the other hand, was never particularly attractive to early humans.  Yes, I know well enough that some carbohydrates, the sugary carbohydrates, are exceedingly attractive.  But in primitive societies, all carbohydrates were not attractive.  Pure sugar is a relatively new evolution. The current sweet fruits and even potatoes are the product of intentional selective breeding to make those carbohydrates more palatable.

The metabolisms of carbohydrate, the sugars, are again very different from fat, in that the same metabolic pathways are used for both the anabolism and the catabolism of carbohydrate. The control of carbohydrate metabolism lies outside the direct metabolic pathways, relying on end-organ control. These includes insulin receptors.   This is distinct from fat where the anabolic and catabolic pathways are different, and so allowing feed-back to curb appetite and metabolic direction.

Carbohydrate’s prime quality is that it is cheap.  As a consequence commerce has “wrapped” carbohydrate in both fats and sugar in order to make it compulsive eating at a cheap price.  Amongst the most tempting ingestants are those that have both sugar and fat, as in chocolate.

Refined and manufacturer altered carbohydrate once ingested, prompt the desire to keep on eating it. Carbohydrate can have a long shelf life, is easily stored and so lends itself to easy snacking. No surprise that it is perfect to fuel “habituation eating”, and ultimately obesity.

Sugar is impregnated into cake carbohydrate or spread on the top as icing.  Fat is used as a layer to make bland carbohydrates or even carbohydrates and protein more palatable, as in deep fried foods – where salt is added for good measure. Cheap beans are made more palatable for sale by adding the salt and sugar of ketchup.Salt is impregnated into carbohydrate ( chips and French fries).

Water, the foundation nutrient.  Many children are metabolically confused because the water offered to them is laced with calories, primarily sugar and some metabolically noxious colourants. They then lose the distinction between thirst and hunger. When thirsty they might attempt to satisfy themselves  by choOsing “food” rather than fluid (sugar laden drinks, iced cream ). The outcome is hypercaloric habituation.

It therefore might not be what you eat, but which combination one eats, that influences the health or disease of individuals.  There is some evidence that individuals like to eat the same food and will repeat eating that ingestant by choice.

“Humans like variety, humans need variety, and humans need a balanced diet”.  This may not have been the case with evolutionary man and it is certainly not the case with many animals.  Those animals can adapt to a particular foodstuff (obviously one that is available) and then continue eating that foodstuff by choice, even where alternatives become available.

The legend has arisen that individuals need a “mixed and balanced” diet.  As far as I am aware there is no evidence that this mixing needs to occur in the same meal.  True enough, one needs the vitamins and one needs the different proteins, fat and carbohydrate.  But does one need them simultaneously, wrapped around each other and made into tempting compotes?

Editorial comment:  The science concurs:

The evidence  for higher water intake, moderate protein and low sugar/salt no-smoking   intake is self-evident except to sugar, beverage  and cigarette manufacturers, marketeers and addicts.          But the fraudulent promotion of the low saturated fat (ie meat), low-cholesterol , high carbs regime for all remains a big problem.

Dr Ancel Keys  PhD (1904-2004) was a revered polymath  traveler, oceanographer biologist turned physiologist nutritionalist (Biology of Starvation; the K Ration) , who correctly  recognized and  promoted the Mediterranean Diet (>35% fat), and long outlived his critics. But he and his followers  set USA-led  nutrition and health  back 50 years with his  wrongly interpreted Seven Countries study  claiming that atheroma was caused by saturated fat- related hypercholesterolemia, thus   promoting  the Omega6PUFA low cholesterol diet and cholesterol-busting statins- but not explaining the question  of fatal sudden death- coronary thrombosis posed by Sir George Pickering in 1964.

Keys  may  still be laughing  his head off at the  $billions he made  for the  Fast-Food industry & Big Pharma, and the millions  of quality health years he cost gullible Americans and their ilk  with his wrong  high-omega6 diet and thence  the money-spinning statins-for-all poison myth.

After the decades of derision poured  as a result on the ketogenic high-fat-protein  low sugars Atkins diet, the Disease-monger (Food,  Sugar, Disease, Big Pharma)  Industries  will scoff,  as they recently mocked  sports physiologist  Prof Tim Noakes’ conversion to high-fat ketogenic diet for those  with the appropriate physiology, his Real Meal Revolution . .   Some cardiologists and dieticians even attacked him publicly for promoting scientific evidence against the  high-carbs lowfat  diet, including the Womens Health Initiative , not Big Pharma wishful thinking  taught  by the academics  and clinicians  whose livelihoods depend on their promoting Big Pharma and other new-tech products.. 

Read Noakes’ modern  nutrition bible, the American science writer   Gary Taubes’  The Diet Delusion(2009);  and read  the British Dr James le Fanu’s earlier Rise and Fall of Modern Medicine (1999 London pp 323-376),  that dissected Keys’  toxic cholesterol-busting mythology,  including statins  that are now promoted for all seniors.

Its not a question of statin denialism  since such drugs may have an appropriate  place in severe hypercholesterolemia. Over all, the majority of hypercholesterolemic and CVD patients will do better on multisystem-beneficial metformin (antioxidant, antiinfective, antithrombotic, antidiabetic, insulin-sensitizing, appetite-reducing, weighloss-promoting),  titrated to tolerance; with modest other essential multibeneficial  supplements- (water; fish oil, coconut oil,   DMSO, all vitamins especially BCo, C,D and K2;  minerals especially magnesium, zinc, chromium, selenium and iodine; and other aging-and -diet-conditioned deficiencies of eg CoQ10, arginine, alphalipoic acid, carnitine, ribose, carnosine, acetylcystine, garlic, cinnamon, proline  etc.  )  than  a multisystem-toxic statin.

THE SYDNEY HEART DIET STUDY    And now the truth emerges yet again, that debunked Keys’ high Omega6 diet theory: as it did in the original ignored  but landmark  Sydney Heart Diet Study report in an elite 1978 journal (Adv Exp Med Biol.)  aboutLinoleic Acid with Low fat, low cholesterol diet in secondary prevention of coronary heart disease. Woodhill JM, Leelarthaepin B, ea) discrediting  Keys’ (and the USA Govt) postulate.                                                                                                                                The new 35year followup  2013 BMJ multicentre  paper (Ramsden,  Leelarthaepin B ea) from the Universities of Sydney, N Carolina and  Illinois and the  USA NIH :    Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovered data from the Sydney Diet Heart Study  reevaluated effectiveness of replacing diet saturated fat (from animal fats, margarine,  shortenings)  with omega 6 linoleic acid Om6LA  (safflower oil/margarine )  for a mean of 39months;  in a  single blind, parallel  randomized controlled trial  in 1966-73  in 458 men 30-59 years, with recent coronary event. Controls received no specific diet instructions. Non- dietary aspects equivalent in both  groups.                                  Results The intervention group (n=221) after only 3.25 years  had 62-70% higher rates of death  and CHD and CVD than controls (n=237; P=0.04-0.05)) (all cause 17.6% v 11.8%),                  Conclusions Advice to substitute PUFA for saturated fats is a key component of worldwide dietary guidelines for CHD risk reduction. However, clinical benefits of the most abundant PUFA Om6LA , have not been established. In this cohort, substituting dietary  LA  in place of saturated fats increased the rates of death from all causes, CHD and CVD. Updated meta-analysis of linoleic acid intervention trials showed no evidence of CVD benefit. These findings (could) have important implications for worldwide dietary advice to substitute Om3LA , or PUFA  in general, for saturated fats.

THE MESA STUDY:  The Sydney Diet Heart Study outcome  has just been confirmed again by the Dec 2013 Harvard USA MESA study (de Olivera, Mozaffarian  ea J Am Heart Assoc.) Circulating and Dietary Omega-3 and Omega-6 PUFA  and Incidence of CVD in the Multi-Ethnic Study of Atherosclerosis. in 6 USA centres,  which confirms that  higher intake and levels of fish oil (but not ALA or Om6PUFA) halves CVD: Over 10 years, in a multiethnic cohort of 2837 US adults- mean  age 61.4yrs at outset-  plasma  PUFAs  measured at baseline (2000-2002),  and dietary PUFAs ,  through 2010 during 19 778 person-years of follow-up,  circulating n-3 eicosapentanoic acid EPA and docosahexanoic acid  DHA inversely associated with incident CVD, with extreme-quartile hazard ratios (95% CIs) of 0.49 for EPA  (0.30 to 0.79; Ptrend=0.01) and 0.39 for DHA (0.22 to 0.67; Ptrend<0.001).  No significant associations with CVD were observed for circulating n-3 alpha-linolenic acid ALA or n-6 PUFA (linoleic acid, arachidonic acid). Associations with CVD of self-reported dietary PUFA were consistent with those of the PUFA biomarkers. Both dietary and circulating eicosapentaenoic acid and docosahexaenoic acid, were inversely associated with CVD incidence. These findings suggest that increased consumption of n-3 PUFA from seafood (but not alpha-linolenic acid or n-6 PUFA), may prevent CVD development in a multiethnic population.

But then we senior medics born around WW2  were schooled  in the English /Scottish (not American) medical tradition of Drs Cleave, Burkitt,  Painter & Campbell’s  Saccharine Diseases, refined sugar, boozing,  smoking  and physical indolence-TV sloth as the chief causes of the burgeoning post-WW2 epidemic of obesity, diabetes, vascular disease, cancer and violence. 

Humans rarely  need what Big Pharma, science  invents for megaprofits. We have known for 50 years that  the current pandemic of degenerative and modern infectious diseases  is due to bad diet – fast-food  – and slothful lifestyle,  tampering for megaprofit with food production and the environment, and reversible by correcting these factors with exercise, fresh whole food and organic farming, and avoidance of boozing,  smoking, TV sloth, and continuous wars for profit, especially the Breast-and -Prostate Screening wars for the $billions  to be made from screening aging men and women for early ie silent cancer. 

The Sydney and MESA studies quoted thoroughly debunk  the fast-food high  Om6/carbs  low fat  diet promoted the past 50 years by the Food and Disease Industry, and by  the Peskin-Rowen Om6 PEO  and the statins-for-all hypotheses;  and the nonsensical UK Wald and Law Polypill including high-risk statin-aspirin-betablocker -diuretic-ACEI   for all senior citizens. . Even an advertorial Wikipedia entry promoting  such nonsense has been allowed…

BALANCING INTAKE OF ANIMAL/DAIRY  PROTEIN -SFA WITH MARINE Om3 PUFA, PLANT MCT & Om6, without added refined/concentrated  sugars like fructose and cornstarch:                                                              As Mike Howard the Health Ranger writes this week, healthful pasture-fed butter is back, and margarine debunked even by its manufacturers; and almost half the USA states moving to enforce labeling of GMO foodstuffs so that consumers can choose what they buy. .

and biochemist  GD  Lawrence from Dept  Biochemistry, Long Island University, NY  writes in  May 2013 Adv Nutr.   Dietary fats and health: dietary recommendations in the context of scientific evidence:  Early studies showed that saturated fat SFA  diets with very low levels of PUFAs increase serum cholesterol, whereas other studies showed high serum cholesterol increased the risk of coronary artery disease (CAD). The evidence of dietary SFA  increasing CAD or causing premature death was weak. Over the years, data revealed that dietary SFAs are not associated with CAD and other adverse health effects or at worst are weakly associated in some analyses when other contributing factors may be overlooked. Several recent analyses indicate that SFAs, particularly in dairy products and coconut oil, can improve health. The evidence of ω6 polyunsaturated fatty acids (PUFAs) promoting inflammation and augmenting many diseases continues to grow, whereas ω3 PUFAs seem to counter these adverse effects. The replacement of  SFA in the diet with carbohydrates, especially sugars, has resulted in increased obesity and its associated health complications. Well-established mechanisms have been proposed for the adverse health effects of some alternative or replacement nutrients, such as simple carbohydrates and PUFAs. The focus on dietary manipulation of serum cholesterol may be moot in view of numerous other factors that increase the risk of heart disease. The adverse health effects that have been associated with SFA  in the past are most likely due to factors other than SFAs.  This review calls for a rational reevaluation of existing dietary recommendations that focus on minimizing dietary SFAs,   for which mechanisms for adverse health effects are lacking.

The University Oregon Linus Pauling Micronutrient Centre website on EFAs has not apparently been updated with the latest MESA and Sydney trial reports; but it advocates (from Japan, and American Heart Association recommendations) Om3 fishoil intake of 2-4gm/day and Om6LA perhaps three times that- rather than the Keys-based 20:1 Om6:Om3 low SFA high carbs  balance that has done so much harm in our lifetime. 

BENEFITS OF FISH OIL AND COCONUT  (MCT) OIL:           are  achieved by taking a tsp of clean (eg Baltic) codliver oil or a gm of fish oil concentrate a day; and no Om6LA supplement other than as a salad/pasta dressing; combined with liberal virgin coldpressed coconut oil for massage, cooking, and food dressing, or as a desertspoon+  a day.. 

The Wiki Health entry for coconut oil usefully still notes the historical deliberate- profiteering- fallacious marketing bias against coconut oil- SFA- which has now been again debunked by the Sydney and MESA studies:  Advocacy against coconut and palm oils in the 1970s and 1980s due to their perceived danger as a SFA saturated fat caused companies to substitute trans fats instead of  them.  Many health organizations (still) advise against the consumption of high amounts of coconut oil due to its high levels of SFA, including the USA FDA & ADA, the UK NHS,  the WHO,[3] International College of Nutrition, and American Heart Association,[7]  Coconut oil contains a large proportion of lauric acida SFA that raises blood cholesterol levels by increasing the amount of high-density lipoprotein (HDL) cholesterol and low-density lipoprotein (LDL) cholesterol. Most of the increase is however  HDL cholesterol, hence the ratio of total to HDL cholesterol is decreased.[30] A decreased ratio indicates reduced risk for heart disease.[31] It is also found in significant amounts in laurel oil, palm kernel oil (not to be confused with palm oil), and human and animal breast milk. This may create a more favourable blood cholesterol profile… Because much of the saturated fat of coconut oil is in the form of lauric acid, coconut oil may be a better alternative to partially hydrogenated vegetable oil when solid fats are required.[34] In addition, virgin coconut oil (VCO) is composed mainly of medium-chain triglycerides,[35] which may not carry the same risks as other saturated fats.[34][36

Similarly, the Wiki entry on  Medium-chain triglycerides ie coconut oil-  states its nutritional benefits without any harms: MCTs are  considered good biologically inert source of energy that the humans find reasonably easy to metabolize. MCTs have potentially beneficial attributes in protein metabolism … and..  their tendency to induce ketogenesis Due to their ability to be absorbed rapidly by the body, MCT have use in the treatment of malabsorption ailments. and  neurodegenerative disorders (e.g. Alzheimer’s, Parkinson’s disease)[14] and epilepsy through the use of ketogenic dieting.[15][16] Serum high-density lipoprotein is increasingly elevated as the chain-length of triglyceride decreases.[17]

We should not be relying  on heavily marketed,  factory-processed and poison-laced (margarines, Roundup GMO, exogenous sexhormone -laden meat ) foods, TV-armchair  lifestyle; exploiting and burning fossil fuels; and Big Pharma’s synthetic new designer wannabe drug $$$ rainchecks-  like statins, antidiabetics, antiobesity, antianxiety, antiosteoporosis, antiplatelet, antidepressant, antiinflammatory,  antihypertensive, memory, analgesic  and antibiotic  drugs  for quick fixes, which treat symptoms but not causes, do not reverse the consequences of environmental destruction, bad and deficient diet and unhappy slothful lifestyle.

Dr Driver-Jowitt pragmatically  and succinctly puts healthy diet balance in perspective.

ndb.

THE 2014 VIRUS SEASON DAWNS: URGENT UPDATE: AVOIDING THE SEMMELWEIS REFLEX; natural antibiotics- Vitamins C & D3 – avoiding vitamin denialism.

update 22/3/2014the March equinox:Vaccines and antivirals for preventing   and  treating  influenza in healthy adults have  very modest benefit.  as  the seasonal flu epidemic wanes in the northern hemisphere and approaches in the south, Authorities eg the US CDC  continue relentlessly to promote mass flu vaccination. The South African Authority NICD recommends vaccination for anyone at high risk ie the elderly, infants or the sick, and carers. It also recommends antivirals eg Tamiflu for infection- but the BMJ recently publishes  Study claiming Tamiflu saved lives was based on “flawed” analysis. a 2012 BMJ  report by the samemedical journalist   Zosia Kmietowicz   notes Cochrane group rejects Roche’s offer of “advisory board” to discuss analysis of oseltamivir data. The 2011 Cochrane question remains unresolved:  Does Oseltamivir Tamiflu  Really Reduce Complications of Influenza?

But current Cochrane review of controlled trial publications to 2013 confirms  Vaccination of pregnant women is recommended internationally, while healthy adults are targeted in North America. The overall efficacy of inactivated vaccines in preventing confirmed influenza has a NNV of 71 (95% CI 64 to 80). . Live aerosol vaccines have an overall effectiveness corresponding to a NNV 46 (95% CI 29 to 115). Vaccination had a modest effect on time off work and had no effect on hospital admissions or complication rates. Inactivated vaccines caused local harms CONCLUSIONS: Influenza vaccines have a very modest effect in reducing influenza symptoms and working days lost in the general population, including pregnant women.  This review includes 90 studies, 24 of which (26.7%) were funded totally or partially by industry. Out of the 48 RCTs, 17 were industry-funded (35.4%).

A current German review  Methodological quality of systematic reviews on influenza vaccination.   Fourty-six systematic reviews fulfilled the inclusion criteria. Average methodological quality was high  but variability was large (AMSTAR range: 0-11). Quality did not differ significantly according to vaccination target group. Cochrane reviews had higher methodological quality than non-Cochrane reviews (p=0.001).  this was due to better study selection and data extraction, inclusion of unpublished studies, and better reporting of study characteristics (all p<0.05).

20/1/2014   Protecting us from the new year northern hemisphere viruses:   natural antibiotics- Vitamins C & D: avoiding vitamin denialism as cause of more deaths.

Abstract: The Semmelweis  Reflex is about rejecting, deriding important new scientific discoveries or any serious sincere statement/action.    I didnt  fully appreciate the importance of that  age-old human  (mostly male) evil – mocking, martyrdom  and murder by denialism-  until I started this review of the current flu season threat and the role of supplements, and researched  pioneer medical martyrs Drs Ignaz Semmelweis, Jack Drummond  and Linus Pauling  as  paradigms of the scourge of modern vested-interest denialism and falsehoods, in medicine as much as politics, religion etc..

In fact,  just as it is negligence to deny (as Semmelweis’s persecutors did) gloving up or  properly washing  hands between examining patients , or ensure that every adult has bloodpressure checked occasionally, it is clearly bad practice  not to ensure that everyone – especially the young and old,  takes a multinutrient plus extra vigorous dose vitamins D3 and C, plus some protective herbs- garlic, cinnamon, ginger, origanum; and fish oil and/or coconut oil if not both; and drastically cut down sweetness intake- especially fructose, sucrose  and aspartame that now pervade all mass- produced food and drinks..

update 21 January 2014 : URGENT: THE 2014 FLU EPIDEMIC:     “High H1N1 prevalence and mortality rates a concern:    Type A (H1N1) influenza, the  commonest flu virus in Canada this year, has a higher  than anticipated mortality rate  causing some to wonder if it’s virulence has increased.             The worrisome factor  “is the reported mortality rate,” says  McGill University. As of Jan. 13, there were twenty confirmed deaths in Canada   attributed to H1N1. “There are more deaths than what we expect for the regular H1N1 influenza, The strain this year could be more virulent . 96% of this year’s lab -confirmed influenza is H1N1. The virus is unusual in that it appears to affect younger people more than other strains of seasonal influenza. People  20 to 65 are being hit harder than usual, comprising 52% of flu cases.                                  However, if you look at Europe,  it’s still H3N2. Its an example of how   you never know what the flu is going to do.”           Alberta confirmed a death  on Jan. 8, due to the virus H5N1, an avian virus. The  deceased woman had recently returned from China. The mortality rate is higher with H5N1 than H1N1, “but fortunately, it’s not an easy virus to transmit”. So far, it seems that there are no cases of H5N1 transmission from human-to-human. It seems   like the cases of H5N1 are few and far between and related to contact with birds in  China.     Patrick Janukavicius, Montréal, Quebec.  In the same period, at least 20 children have reportedly died of the same strain in USA.

update 12 Jan 2014  THE ANTIFLU VACCINE DECEPTION: this review by Doc Joe Mercola     stresses the disease-mongering myths,  futility and risks in real life of flu vaccination  and antiflu drugs eg Tamiflu ; and the overwhelming importance of natural immune boosters like Vit D3 & C, zinc, selenium,  herbs, and hygienic prevention.

1 Jan 2014  CURRENT INFLUENZA STATUSThe  22 December  solstice is the sun at its southern nadir seen from planet Earth, the onset respectively of real winter in the Northern hemisphere, and real summer in South Africa. Last year   the Gregorian New Year heralded a fierce flu season in the northern hemisphere, and as usual feathered- and jet-propelled  air travel brought the corresponding surge at the bottom of Africa.

And ominously, the Plagues & Pandemics   (Howard Phillips 2012) of temperate climates  that did so much historically  to mould global demography not least  the past 360 years in South Africa ( -STDS- pox, bubonic, polio, cholera, influenza, and now  tuberculosis, Mad Cow disease, and   HIV-AIDS). and especially antibiotic-resistant germs – are all on the increase despite (or because of) the increasingly futile $trillion armamentarium of 20th century designer vaccines and other antimicrobials.. 

Pneumonia is a welcome   friend of the old, often rapidly relieving prolonged degenerative incapacity;  such ending mostly by virus respiratory infection  the gateway for the  final bacterial infection.  

Unlike the  selflimited coronavirus common cold, breath-and hand-borne type A  influenza, although usually mild in the well,  is the commonest trigger in the frail.  Many  of us in our (grand)parents’ time lost relatives in the 1918/1919 “Spanish”  H1N1  flu pandemic. But that was a unique  global catastrophe because it killed mostly  armies  of healthy men, and then  young working adults, apparently from cytokine storm, with 30 % of the workforce out for up to3 weeks if not  20% mortality.  This is harrowingly described in the recently published   Letters ( to his Mother) of Dr Arthur Conan Doyle, who lost – apart from his first wife to TB- more young relatives to the  flu  than to warfare.

The recent spring  months here – apart from seasonal allergies -have seen declining viral respiratory illness in Cape Town, with the  upper respiratory accent often shifted down to more gastritis-enteritis .

But New Year 2014   UK and northern North America forecast  and are having a  wet if not white New Year.  ‘Flu rates are reported already high  and rising  in USA and Canadamostly influenza A H1N1(swine-avian flu-the main 1918/19 killer); including already 6 deaths in USA and 3 in Canada.

but not in Europe, where  the influenza (A > B) prevalence is still low and slightly more H3N2 than H1N1;  in UK there has rather been been increase in RSV respiratory syncytial virus bronchitis in infants. .  .

In fact by 28 December the exploding H1N1 deathtoll had hit 13 in Texas alone; especially in youths; with increasing Tamiflu resistance reported eg in Missisippi.. On 24 Dec the USA CDC mailed an emergency Advisory Notice to Clinicians: Early Reports of pH1N1-Associated Illnesses for the 2013-14 Influenza Season: From November through December 2013, CDC has received a number of reports of severe respiratory illness among young and middle-aged adults, many of whom were infected with influenza A pH1N1 pdm09 virus. Multiple pH1N1-associated hospitalizations, including many requiring intensive care unit (ICU) admission, and some fatalities have been reported.  While it is not possible to predict which influenza viruses will predominate during the entire 2013-14 influenza season, pH1N1 has been the predominant circulating virus so far. For the 2013-14 season, if pH1N1 virus continues to circulate widely, illness that disproportionately affects young and middle-aged adults may occur. 

Our  regional  South African Communicable Diseases Institute says H1N1 was documented here from April to September. But of 2566 pts with severe respiratory illness for January to October 2013 enrolled and tested at the five sentinel sites, only 6% were positive for influenza – mostly virus -H1N1. A pneumonia case in Cape Town was found to be due to Leigionnaire’s.

Now from China 147 human cases of avian influenza H7N9 have been confirmed including 48 deaths. – especially from poultry contact. No vaccine is currently available for avian influenza (H7N9) virus.

SAPA–AFP, 10 December 2013:  Resistant flu virus keeps contagiousness.  A mutant form of the H7N9 flu virus that is resistant to frontline drugs is just as contagious as its non-resistant counterpart, according to a study, published inthe journal Nature Communications.  The virus has claimed dozens of  lives since its outbreak in February. H7N9 is believed to have spread to humans from poultry, where it circulates naturally. The World Health Organisation (WHO) said on its website that “so far”, no evidence has emerged of  “sustained” transmission of H7N9 among people.

And H7N1 and H7N7 has broken out in ostriches in South Africa,

So never mind the  common cold  coronaviruses and many other prevalent infections, increased caution is due against all common diseases at this season- both the USA H1N1 swine flu circulating the past few years,  and now the Chinese H7N9 flu. . And the MERS-Co Virus Middle-East SARS-type outbreak has not gone away… 9 new cases reported the past week or two  from the KSA alone .-the-deadly-middle-east-coronavirus-outbreak/

A  current NEJM  has a new report of a trial of quadrivalent Vaccine for Prevention of Mild and Moderate-to-Severe Influenza in Children by vaccine manufacturers GSK. The vaccine reduced severity by perhaps 70%- but at a cost of 1.5% serious adverse events, 50% more than the control group (hepatitis A vaccine only).                                                                                    The question remains- why risk  flu vaccine’s ~1.5% serious adverse events when a single high dose of vitamin D3  300 000iu  even just annually, and regular vitamin C with a multivite  including zinc and selenium (at trivial cost ) largely cover one  against a multitude of infections including AIDS and TB, and all degenerative health   problems?

PRECAUTIONS:

Is it coincidence, or divine evolution, that we have had available at low cost  for about 60 year (never mind zinc,  selenium, iron, iodine, vitamins A and vitamin E) two safe natural major antimicrobials in vigorous safe dose   –  vitamins  C and D3?  Medico-Pharma Big Business and governments have been heavily discrediting and ruthlessly suppressing these  for their own profiteering vested interest  even as plagues of HIV, TB,  influenza rage, and Big Business determinedly profits hugely from killer  smoking and alcohol sales despite increasing  marketing restriction?   South Africa- a major producer of alcohol and tobacco-smoke, and fossil-fuel-burning power stations, factories and motorvehicles – continues to lead the world with  the highest road and respiratory death rates  despite zealous attempts to reduce their lethal  use.

Apart from optimal hygiene including  avoiding livestock  and poultry contact, smoking, alcoholism and pollution including  swimming and sick buildings- air-conditioning-           what can we take  to minimize avoidable influenza  ie immune depletion risk? apart from enough  sunshine, exercise, rest, sleep, walking barefoot, not carrying a cellphone,   and good mixed fresh organic diet? The clinical benefit of influenza vaccines is anything but proven, and the adverse risks appreciable.

Big Business and thus governments  and the media  profit from illness, so they keep publishing articles promoting Big Business: new antibiotics, vaccines  and other synthetic drugs that do not prevent or cure but if anything perpetuate chronic degenerative obesity-diabetes-vascular-respiratory,- digestive-arthritic-cancer diseases; – and  GMO-genetically modified preserved  food  and bottled drinks stuffed with slow poisons like refined cornstarch – fructose; salt; sucrose and cereals, soya,  Roundup, antibiotics, preservatives, estrogenics,  aspartame,  and especially boiled and baked omega6 and sugars;  instead of marine omega3 and MCT- medium chain triglyceride virgin coconut oil, and unrefined cereals eg oats, wholewheat bread etc..  

Big Business and it’s cash-cow  Disease Industry decries  the natural healthgiving lowsugar Asian/ Mediterranean  diet-organically pastured and grown livestock meat and dairy products, lightly cooked if not raw (oily)  fish,  fruit and nuts, coloured veggies,  and plenty of  oils in their natural plant form. These were  the norm till food processing became Big Business in our lifetime post WW2, and the developed world was bluffed by Organized Medicine, the Food Barons and Big Pharma  with the masterly fiction of Ancel Keyes, into jettisoning the natural longevity “sea and farm” diet of the east eg Japan, and West eg Mediterranean (fresh produce & cholesterol-rich dairyproducts, meat and fish)  for the Diet Deception (Gary Taubes, Tim Noakes) and Bad Pharma ( James le Fanu, Ben Goldacre) of Ancel Keyes‘  low-fat high-refined cereals, margarine; and  the cholesterol -busting and psychotropes/ painkillers /antidementia/antivascular/ antidiabetic disease Designer Drugs-for-all  myths.

It spends multimillions promoting alcohol,  smoking and ever-newer designer prescription drugs and vaccine, and  disinformation on old well-proven cheap drugs like  reserpine, amilozide, metformin,  natural physiological  human hormone replacement,  natural antioxidants and anti-inflammatories ,  and decrying  ineffective but deliberately lowdose and isolated or imbalanced  vitamins and minerals .

The ATBC vits A+E trial  (isolated highdose vits A and E) was  one such  farce in very high risk smokers in an icy climate. . Others have been the recent Norwegian trial using only up to 1000iu vit D supplement a day,

and the current Annals Int Medicine editorial  review of three new articles condemning multisupplements: , on which Mike Howard publishes a scathing critique -

*a commercial multisupplement in the TACT  post-heart attack trial - but the composition of the multisupplement  included only deficiency-disease prevention microdoses of micronutrients including 100iu vitamin D3/d and equally negligible vitamin K-  not pharmacological doses of key vitamins eg vits B, C, D & K2 that are well proven to greatly reduce infections and chronic degenerative diseases ;

* the  Physicians’ Health Study  randomized elderly professional men  to placebo or combinations of vitamin C (500 mg synthetic ascorbic acid), vitamin E (400 IU of synthetic alpha-tocopherol), beta-carotene (50 mg Lurotin), and a multivitamin (Centrum Silver - this included  anti-deficiency disease low dose of all common vits and minerals BUT   only 400iu Vit D3),   .

* The third study- on lowdose (traditional anti-deficiency disease) Vitamin and Mineral Supplements in the Primary Prevention of Cardiovascular Disease and Cancer was simply a literature review of 26 best-quality  published trials of microdoses – not pharmacological safe macrodoses.

ie these  three trials published in this  Annals Internal Medicine issue to please Big Pharma advertisors to discredit supplements shared the usual problem of now well-known futile lowdose supplement doses  at least of vitamins D3 and K, if not also vitamin C in the multigram dose scientifically promoted by the Drs  Stone- Klenner-Pauling followers.

Sir Jack Cecil  Drummond (1891-1952) was one of the world’s pioneer 20th century  biochemists and nutritionists in UK,  from  1916- 1952 discovering or defining  and promoting  under his world-famous biochemist professors Rosenheim, Halliburton and Funk the role especially  of vits A, B, C  and E. Thanks to his and Churchill’s forceful vision and foresight, he oversaw  food supply and diet  and thus keeping Britons healthy through and after WW2. He was  so successful in promoting healthy cheap and unpatentable micronutrients and natural fresh food  (in the face of the mushrooming megaprofit  processed food  and designer drug industry) that it  speculatively led to his and his family’s  1952 assassination by competing interests  in France -The Vitamin Murders, Fergusson 2007. .

        MURDER BY DENIALISM: It is incontrovertible   common cause that irrational and often jealous medical denialism costs endless lives:
* Scurvy prevention:  Dr James Lind (who did the first ever recorded clinical trial) showed by 1750 that sailors’ scurvy on long sea voyages  was preventable; but  despite his pioneer discovery, the British navy cost the lives of thousands more seamen from scurvy when the Admirals  neglected for 50years until the Napoleonic Wars to supply the fresh produce-  eg limes – that rapidly cured and prevented the lethal scourge.

This despite the fact that another UK navy surgeon Dr John Woodall had already over 130 years earlier- by 1617 – published in UK  The Surgeon’s Mate stating We have in our owne country here many excellent remedies generally knowne,- Scurvy-grasse, Horse-Reddish roots, Nasturtia Aquatica, Wormwood, Sorrell, and many other good meanes… to the cure of those at home…and Sea-men returned from farre who by the only natural disposition of the fresh aire and amendment of diet, nature herselfe in effect doth the Cure (of scurvy- for which antiscorbutic citrus had been known since antiquity) without other helps. the Lemmons, Limes, Tamarinds, Oranges, and other choice of good helps in the Indies… do farre exceed any that can be carried tither from England.

* Childbed fever prevention:  in 1865  Dr Ignaz Semmelweis (1818 -’65) an AustroHungarian Roman Catholic ob-gyne in Vienna, was locked up, and beaten to death  within weeks, because he showed – to the outrage of his peers- that handwashing with chlorinated lime eradicated the epidmic puerperal fever (three times that in the midwives’ ward)  in  the  doctors’ labour wards; 70years before Thir Reich terrorists took charge, his senior colleagues reacted violently to his progressive promotion of (what was already more advanced British and  French) hygiene and science, and his urging them to wash their hands after examining corpses before examining women in labour..  .  Tragically for Semmelweis and new mothers in the Hapsburg empire then,  Pasteur (b 1822) and Lister (b 1827) ‘s germ antiseptic discoveries  were already being implemented further west, but  had not yet been publicized.

    *metformin after centuries of use as an antidiabetic herb galega officinalis,  and its extraction as an antidiabetic in 1922, came into increasing use globally from the 1950s as the best treatment for type 2 diabetes, but the USA- to protect their own new patent antidiabetic  drugs – ruthlessly suppressed  its use there (like that of the natural salt lithium for manic depression)  for 40years till the mid-1990s.

     *AIDS and ART denialism: until  5 years  ago in South Africa   the  overwhelming-majority “people’s”  government  (with the country’s vast resources),  and its successive  “health”  ministers,   cost the lives of an estimated 300 000  AIDS victims through sufferers  – indigent state dependents-  being denied  antiretroviral ART  drugs, (never mind still till now denied quality education and civil  security,  and thus    adequate basic nutrition, and meaningful housing,  jobs and thus hope.)  Genocidal AIDS denialism about which the still-ruling (since 1994) leadership cadre did nothing until under  intense  international pressure and repeated Constitutional Court orders, combined with political rival factioneering in the ruling party,   they  ousted the denialist president and his denialist Disease Minister in 2008.

DENIALISM TARGETS IN NUTRITION: 

VIGOROUS VITAMIN C ASCORBIC ACID  PHARMACOTHERAPY : Much effort and Big Pharma money  has been  spent to denigrate the irrefutable science-based work   (between their advocacy years shown) of Drs Irvine Stone (1934-1984), Fred Klenner(1948-74) and Linus Pauling (1970-1991) of  antibiotic dose >50 to 1000 mg/kg/d pure vitamin C (not the antiscurvy  10mg/d)  – as a universally needed essential in primates. We primats,  like guineapigs and a few birds and fish species,  are among the few  that do not make their own since we  lost the needed gene and thus enzyme in our evolution..

It took about 150 years after Lind’s publication for the antiscorbutic factor to be named as vitamin C by Dr Jack Drummond, another 10 years for it to be assayed and its structure proven- but despite the pioneering clinical work of Dr Fred Klenner in the 1950s proving the lifesaving benefit of tens of grams a day intravenously, it took another 20 years before Dr Linus Pauling  took up Dr Irvine Stone’s conviction and put highdose vitamin C  on the world Nobel prize map; just on Pubmed,  vitamin C has >51 000 citations  since 1921, and intravenously in 763 entries  since 1946, with  Dr Fred  Klenner reporting  it intravenously  asmajor antibiotic in the Southern Medical journal from 1948..

The 2009 book  Injectable Vitamin C and the Treatment of Viral and Other Diseases collection  of  medical journal papers from the 1930s to 2006 details the exhaustive scientific evidence proving the uniform benefit of even 1gm a day vit C both as an antimicrobial antiinflammatory antioxidant  and immunomodulator against major crippling / lethal diseases from polio to tuberculosis, pneumonia, hepatitis, rabies, encephalitis, neuritis, poisoning, cancer, and pancreatitis;                                                                                   

          and the persistent resistance of the FDA and other multinational Regulators to recognize (so as to protect their domestic patent drug manufacturers- Big Pharma and their politician and civil service lobbyists )- such uniquely safe and effective natural drug therapy.         The final chapters of that 2009 book pose the crucial questions of overwhelming vested interest by the organized medical – hospital -pharmaceutical mega-industry and governments in not eradicating preventable disease, the Big Pharma banning of natural effective remedies-  The Origin of the 42-Year Stonewall of Vitamin C, and Medical Resistance to Innovation,

The  University of Oregon,  the  Riordan-Gonzalez group and more recently Hemila and Chaker‘ and Ullah et al’ s 2012 reviews have  published much  validating what Drs Goodall, Lind, Drummond, Stone, Klenner, Pauling and Cameron started.

VIGOROUS   VITAMIN D3 CHOLECALCIFEROLPHARMACOTHERAPY  costing wholesale ~ <US$0.5/month for ~200 000iu /month  in South Africa)  reduces serious infection by perhaps 90% ie 9fold: . eg 80iu/kg/d – 500iu/d (15000u/month) for an infant, 50 000iu/wk or 200 000iu/mo for an adult; who if obese, may need two  to three times the average dose, to achieve the (?) optimal 25OH vit D level of around 70ng/ml for health, higher for any acute or chronic chronic illness.

The modern prophets of vitamin D3 have been the three pre-WW2 doyens :

Prof Chris E Nordin (MB ChB 1950) working in bone physiology for 60 years now; 84 papers on vitamin D on Pubmed 

Prof Walter Stumpf (1927-2012; MD 1952) the recently deceased  professor at North Carolina University, neuropsychiatrist and radiobiologist  in his 60year medical career with over 500 publications (76 on Vit D on Pubmed) including early discovering that vitamin D targets all systems and diseases; professor-walter-e-stumpf-ahead-of-his-time/ and http://healthspanlife.wordpress.com/tag/stumpf-dr-walter/

paralled by Prof Robert Heaney (MD 1951) at Creighton University, osteoporosis and nutrition authority with 119 vitamin D papers on Pubmed since 1982, over 400 publications to date;

succeeded by Prof Mike Holick (PhD 1971, MD 1976) with 391 publications on vitamin D since 1970 on Pubmed, who has done more than most to show that the maximum daily body production of vitamin D3 with plenty of sunlight is enough to prevent rickets and reduce all disease, but nowhere near the pharmacologically therapeutic 80iu/kg/d needed to maintain a vigorous all-disease protective bloodlevel of 60-100ng/ml.

and Dr John Cannell (MD 1976, registered psychiatrist from 1993, nutritionalist), a  legendary whistleblower .   who successively campaigned against  #cigarette smoking; and  uncovered:   # the cigarette-smoking  (Black Lung) compensationitis fraud of miners’ pneumoconiosis;          #the fictitious inflated “above national average” school results (Lake Woebegone)  that all states were inventing and  reporting (as is still happening – mass government deception- in South Africa) ;  then the  
# recovered memory therapy (RMT) scandal – a form of psychotherapy in which patients recovered memories of abuse that they had no previous memory of. Such therapy resulted in false memory syndrome (FMS) of events that never occurred as well as an epidemic of multiple personality disorder (MPD), a rare disorder historically conceived of as being a hysterical disorder.  Unfortunately, many MPD patients believed the psychiatrist conducting the RMT and went home to falsely accuse their parents and others of horrendous acts that never occurred. Cannell teamed up with two Harvard professors to write a peer reviewed paper on RMT, debunking the witch-hunt;                                                                               then since the 1990s researching and promoting  # vitamin D deficiency as major cause of much psychopathology including autism, and vigorous vitamin D therapy to correct multiple diseases, through the Vitamin D Council. He has (co)authored some 13 papers, and published a book. .

Now a major longterm German Cancer Research screening program has just publishd   the 2002-2013 ESTHER study (Perna ea) of 10 000 citizens followed with serial 25OH vit D  levels; to assess the association of apparently unsupplemented vit D levels with fatal and nonfatal CVD in the same study population.  Follow-up data, including survival status, up to over 9  years. Comparing subjects with 25(OH)D levels below 12ng/ml and above 20ng/ml resulted in the lower vitamin D level cohort showing a higher hazard ratio of 1.27 (95% confidence interval = 1.05-1.54) for total CVD and 1.62 (1.07-2.48) for fatal CVD in a model adjusted for important potential confounders. No significant association for nonfatal CVD was observed. In dose-response analysis, we observed an increased cardiovascular risk at 25(OH)D levels below 30ng/ml. Results for CHD and stroke were comparable to the results obtained for the composite outcome CVD. Our results support evidence that low 25(OH)D levels are associated with moderately increased risk of CVD, BUT  the observed association is much stronger for fatal than for nonfatal events.

But the benefit of sunlight in healing tuberculosis has been used for well over a century; while the Google antibiotic benefit of calciferol on Pubmed goes back at least to 1950.

In a prospective 16 mo trial in press from Australia, vit D3 even just 60 000iu/month (ie 2000iu/day) halved antibiotic use in seniors.  (Tran, Neale  ea 2014) Effect of vitamin D supplementation on antibiotic use: a randomized controlled trial.

Since the toxic dose of vitamin D long term  reportedly may be as high as 600 000iu/day or a blood level well >150ng/l , imagine how much better the antimicrobial benefit of vitamin D3 at 80 to 100iu/kg/day or pro rata – even higher eg 10 000+iu/day for obese people who sequester more vit D in fat. .

Dr Robert F  Cathcart wrote 30 to 20 years ago in  Med Hypotheses. 1981 Vitamin C, titrating to bowel tolerance, anascorbemia, and acute induced scurvy   The amount of oral ascorbic acid tolerated by a patient without producing diarrhea increase somewhat proportionately to the stress or toxicity of his disease. Bowel tolerance doses of ascorbic acid ameliorate the acute symptoms of many diseases. Lesser doses often have little effect on acute symptoms but assist the body in handling the stress of disease and may reduce the morbidity of the disease. However, if doses of ascorbate are not provided to satisfy this potential draw on the nutrient, first local tissues involved in the disease, then the blood, and then the body in general becomes deplete of ascorbate (Anascorbinemia and Acute Induced Scurvy). The patient is thereby put at risk for complications of metabolic processes known to be dependent upon ascorbate.                     1984 Vitamin C in the treatment of acquired immune deficiency syndrome (AIDS). evidence is that massive doses of ascorbate (50-200 grams per 24 hours) suppress the symptoms of the disease and can markedly reduce secondary infections. In combination with usual treatments for the secondary infections, large doses of ascorbate will often produce a clinical remission which shows every evidence of being prolonged if treatment is continued. .. despite continuing laboratory evidence of helper T-cell suppression. There may be a complete or partial destruction of the helper T-cells during an initial infection that does not necessitate a continuing toxicity from some source to maintain a permanent or prolonged helper T-cell suppression. However, it is possible ascorbate may prevent that destruction if used adequately during that prodrome period. Emphasis is put on the recognition and treatment of the frequent intestinal parasites. Food and chemical sensitivities occur frequently in the AID syndrome and may aggravate symptoms considered to be part of the AID syndrome. A topical C-paste has been found very effective in the treatment of herpes simplex and, to a lesser extent, in the treatment of some Kaposi’s lesions.  Increasingly, clinical research on other methods of treating AIDS is being “contaminated” by patients taking ascorbate.                                                     1991 A unique function for Vitamin C is as reducing substance,  electron donor. When vitamin C donates its two high-energy electrons to scavenge free radicals, much of the resulting dehydroascorbate is re-reduced to vitamin C and therefore used repeatedly. Conventional wisdom is correct in that only small amounts of vitamin C are necessary for this function because of its repeated use. The point missed is that the limiting part in nonenzymatic free radical scavenging is the rate at which extra high-energy electrons are provided through NADH to re-reduce the vitamin C and other free radical scavengers. When ill, free radicals are formed at a rate faster than the high-energy electrons are made available. Doses of vitamin C as large as 1-10 g per 24 h do only limited good. However, when ascorbate is used in massive amounts, such as 30-200+ g per 24 h, these amounts directly provide the electrons necessary to quench the free radicals of almost any inflammation, and reduces NAD(P)H and therefore  provide the high-energy electrons necessary to reduce the molecular oxygen used in the respiratory burst of phagocytes. In these functions, the ascorbate part is mostly wasted but the necessary high-energy electrons are provided in large amounts.

A recent review from Atlanta Kearns ea found 30 papers which aggregate to show that annual vitamin   D3 dose (not D2) of  optimally 300 000 to 500 000iu (wholesale cost ~R5 in South Africa)  for deficient adults is best for avoiding poor patient compliance with minimal risk and major benefit.

THE INFERIORITY OF VITAMIN D2 SUPPLEMENT: It should be noted that the long-used Lennon’s Strong Calciferol datasheet  (1974 updated 2004) does not indicate that this 50 000iu tablet labelled ‘calciferol’  is in fact vitamin D2 (ergocalciferol), not the fourfold more potent cholecalciferol D3 formed by sunlight in the skin. This is disclosed only on the Lennons website.. and in the South African Medicines Formulary.  So ‘Strong Calciferol’ in South Africa (actually  the D2 not D3 form of calciferol) is convenient but seriously deceptive mislabeling-  much weaker than the ideal vitamin D3, and therefore its effect unpredictable compared to D3- in fact Dierkes ea Norway show that  giving D2 may actually lower 25OH vit D level in the blood..   Sadly, despite this being reported to the local manufacturers and authorities, no correction of the clinically serious misperception created by the Strong Calciferol label and insert has been issued  to health practitioners by the Medicines Control Council and the manufacturer Aspen-Lennons. 

A recent 8yr study in Cape Town blacks   Reciprocal seasonal variation in vitamin D status and tuberculosis notifications in South Africa Martineau, Nhamoyebonde ,Wilkinson ea   confirmed that vitamin D deficiency (serum 25(OH)D <20 mg/L) is associated with susceptibility to tuberculosis (TB) in HIV-uninfected people in Cape Town as it is Europe. Vitamin D deficiency was present in 62.7% of 370 participants and was associated (OR ~5.4)  with active TB in both HIV-uninfected  and HIV-infected -(P < 0.001) people. Vitamin D status varied according to season:  25(OH)D concentration was double in summer-January- March compared to winter (23 vs 12ng/l; P < 0.001). Reciprocal seasonal variation in TB notifications was observed:lowest in autumn  and highest in spring October through December (4,2 vs. 5; P < 0.001). Vitamin D deficiency is highly prevalent among black Africans in Cape Town and is associated with susceptibility to active TB both in the presence and absence of HIV infection.

Antimicrobial implications of vitamin D is detailed by Youssef,  Peiris ea (USA  Dermato-Endocrinol  2011)   against all microorganisms – viruses, fungi, bacteria, protozoa  (except perhaps leishmaniasis)  as both profound prevention and therapy; in many cases without commercially invented marketed antimicrobials to which there is growing and deadly  microbial resistance, let alone toxicity.. There is evidence that seasonal vitamin D deficiency  status contributed greatly to the 1918/19 flu-pneumonia pandemic (Grant & Giovannucci 2009).

and finally, a month ago JAMA published from Marianna  Baum,  Richard Marlink ea the universities of Miami, Harvard and Florida  Effect of Micronutrient Supplementation on Disease Progression in Asymptomatic  Antiretroviral-Naive HIV-Infected Adults in Botswana A Randomized Clinical Trial,  that Micronutrient deficiencies occur early in human immunodeficiency virus (HIV) infection, and supplementation with micronutrients may be beneficial; however, its effectiveness has not been investigated early in HIV disease among adults who are antiretroviral therapy (ART) naive.  2 year supplementation with either daily vitamins BCo,  C and E, selenium alone, or B,C,E with selenium vs placebo: study  conducted in 878 patients infected with HIV subtype C with a CD4 cell count greater than 350/μL who were not receiving ART between  2005 and July 2009.  Results  participants receiving the combined supplement of vitamins plus selenium vs placebo had half the  risk of reaching CD4 cell count 250/μL or less (adjusted hazard ratio [HR], 0.46); and secondary events of combined outcomes for disease progression  or AIDS-related death, whichever occurred earlier [adjusted HR, 0.56); . There was no effect of supplementation on HIV viral load. Multivitamins alone and selenium supplementation alone were not statistically different from placebo for any end point. Reported adverse events were adjudicated  unlikely  related to the intervention, and there were no notable differences in incidence of HIV-related and health-related events among study groups.Conclusions and Relevance  In ART-naive HIV-infected adults, 24-month supplementation with a single supplement containing vitamins BCo,C,E and selenium was safe and significantly reduced the risk of immune decline and morbidity. Micronutrient supplementation may be effective when started in the early stages of HIV disease.

THE PARADOX OF THE GLUCOSE- ASCORBIC ACID- CHOLESTEROL- STEROID CASCADE:              Is it coincidence, or  evolution, that the basic animal fast-energy circulating anabolic substrates are glucose, fatty acids and aminoacids?   from which basic glucose C6H12O6 ( from ingested  fructose C6H12O6 and sucrose C12H22O11, or fats or protein)  the liver manufactures the basic cardinal steroid  cholesterol C27H46O.     Then from cholesterol we metabolize by adding or splitting off carbon molecules  the crucial anabolic and regulating  human hormones-                                                                                                                    1. ouabain C29H44O12  the  adrenal hormone  made also  in the hypothalamus and heart ; adrenal),                                                                                                                                           2.  active calciferol C27H44O the strengthening and reproductive secosteroid;                                                                                                                                   3 the prime sex/ reproductive steroids  pregnenolone C21H32o2,  and thence progesterone C21H30O2,  testosterone C19H28O2, DHEA C19H24O2. and thence estradiol C18H24O2. and                                                       4 the prime adrenal mineralo/glucocorticoid steroids  cortisol C21H30O5, aldosterone C21H28O5.

But we primates and a few other species lost the ability to synthetise on demand in quantities of grams a day the crucial vitamin C ascorbic acid C6H8O6 that is key to all the above.                                                                                            And vested interests in the Disease Industry want us to believe the biological nonsense  heresy  that we must ingest minimal unprocessed foods- cholesterol, fats (especially dairy, marine oil Omega3 and medium-chain triglyceride- coconut oil)   and abundant vitamins C and D3, but eat abundant processed foods-  refined plant Omega6,  refined carbs- fructose,  sucrose, fruit juice,  cooldrinks, cereals, confections- which overload causes insulin resistance and thus lipidemia,  obesity- metabolic syndrome -diabetes, cancer and cardiovascular disease.

The Semmelweis reflexA current Wiki essay sums up the current genocidal problems of deliberate deceptions/denialism in Diet, Vitamins and causality  – for ruthless profit and possibly cynical eugenics: “The Semmelweis  effect is a metaphor for the reflex-like tendency to reject new evidence or new knowledge because it contradicts established norms, beliefs or paradigms.The term originated from the saga of Dr Ignaz Semmelweis, who discovered that childbed fever mortality rates reduced ten-fold when doctors washed their hands with a chlorine solution before examining  patients. His hand-washing suggestions were rejected by his contemporaries, often for non-medical reasons. For instance, some doctors refused to believe that a gentleman’s hands could transmit disease (see Contemporary reaction to Ignaz Semmelweis).   In his book The Game of Life, Timothy Leary provided the following polemical definition of the Semmelweis reflex: “Mob behavior found among primates and larval hominids on undeveloped planets, in which a discovery of important scientific fact is punished”. The expression has found way into philosophy and religious studies as “unmitigated Humean skepticism concerning causality“.[2]“

Idealism, ethics may evolve; but the  problem of  human bigotry, self-interest and subjective ie personal bias do not diminish, they spread.  It is classic that Semmelweis  (1818-1865) the observant innovative  Catholic medical scientist of his time (before microbes and antiseptics   were known) was fatuously condemned  not just by his jealous  competing Vienna colleagues,  but even by his progressive and reformist  Copenhagen  contemporary obgyn Prof Carl Levy (1808-1865)- who outlived him by only 4 months;

ironically at the same time that their Copenhagen contemporary Dr Soren Kierkegaard (1813-1855) was increasingly  isolating himself on the lonely ethical journey  against the convenience lazzez- faire  tide, writing for ethical life and religion against the hypocrisy  of the Church and becoming the father of both reformist theology and psychology. But unlike Semmelweis who was way ahead of the bioscience  and humanity of his time, Kierkegaard stuck to and isolated himself in   promoting the incompatible ie  blind-faith-based   religion – the dilemma of Abraham’s conviction (or delusion)  to sacrifice his son-  and ethical morality;

and closely followed by    Rudolph Steiner (1861-1925) another more  profound European  thinker who bridged  science, spirituality, progressive education, architecture, agriculture, natural medicine, nutrition,    and   social  reform;

contrary to the rationalists of the 19th Century “Age of Enlightenment” and since, like   British historian-philosopher -ethicist  Winwood Reade (1838 – 1875)  who published the enduring secularist’s bible The Martyrdom of Man (1872), of which  Churchill wrote  25 years later  “he was right but wrong to say it” on the book’s critique of the wrongs of war and religion, of mankind’s selfishness, corruption  and destructiveness (by the greedy aggressive acquisitive minority)  against the  weak masses and the environment) that carries on worse in the 21st century than even the 20th century;                                                                                                                                          and    150 years later bioscientist and philosopher Stephen Jay Gould (1941-2002) rationalized sadly   the non-overlapping Magisteria of Science and Faith, objective “provable” science – which in fact is seldom immutably constant as is mathematics-  and purely faith-based  “unprovable” religious belief.

It was only a year ago that Richard Conniff published his column on   Strange Behaviours, The Medical Martyrs. And the medical  hero martyrs in this review-  Semmelweis,  Margaret Sanger, Drummond  and Pauling –  never made it onto his list.

But then nor did  the modern medical  freedom fighters  Steve Biko,  Agostinho Neto,  Che Guevera. Jonas Savimbi, Neil Aggett, and the living spouse of Steve Biko, Dr Mamphele Ramphele….

Women of the Century apart (like Margaret Sanger, Marie Curie, Eleanor Roosevelt, Golda Meir, Indira Gandhi,  Helen Keller, Benazir BhuttoMother Theresa, Aung San Suu Kyi -many of whom have been martyred),                 it is a philosophical debate whether among the men  the medical martyr  Semmelweis (1818-1865) ranks with  his  19thC contemporaries-   Lincoln (1809-1865), Kierkegaard(1813-1855), Pasteur (1822-95), Lister (1827-1912)  ;  and his successors (and 20th C  leading achievers): Koch(1843-1910), Edison(1847-1931), Steiner (1861-1925), Gandhi(1869-1948),  Weizmann(1874-1952), Churchill (1874-1965), Einstein (1875-1955), Jung (1875-1961), FD Roosevelt(1882-1945), JK Galbraith(1908-2006), Martin Luther King (1929-68), Pauling and Mandela   as arguably giant enduring male leaders -innovators-  teachers and achievers  of the past two centuries.

Unlike eg Socrates, Hippocrates  and Jesus of Nazareth, one of the  five greatest polymath medical and ethical sages of all time Rabbi Dr Moses Maimonides (RamBam)  avoided martyrdom by burying himself in practicing selfless medical service for sultan and peasants alike, and jurisprudence   for his GreekoRoman based  Islamic-Sephardic   times and philosophy, like his guru predecessor Avicenna and his contemporary savant Averroes. .

CONCLUSION:   Today it can  be argued that the denial of effective phamacotherapeutic doses of especially  vitamins C and D3, let alone supportive doses of balancing vits (A, B1,3,5,6,9 & 12, E and K2); the often-crucially  deficient minerals (eg magnesium, sulphur, phosphate, iodine, zinc and selenium), and biologicals like human transdermal balanced HRT, coenzyme Q10, alphalipoic acid, milk thistle, cinnamon, fish oil, chondroglucosamine, DMSO, coconut oil,  is a repetition of denialism of the germ theory,  and of optimal physiological human micronutrition as well as macronutrition. .

      – especially when patients are poor and thus malnourished, and plagued by diarrhoea and stress, TB, lipidemic vascular disease and cancer; and when antiretroviral ART- although life-saving- is even more diabetogenic and neurotoxic  than untreated AIDs.

Even transdermal administration is  better than nothing, perhaps  better  (for the frail and noncompliant eg oldies) than oral or injection eg of vitamins D3 & C and progesterone , metformin, (in addition to the usual magnesium chloride, vits A, BCo & E)  may be beneficial whether by patch or cream for both healing, infection, calming,  heart, circulation, infection, arthritis, osteoporosis,   and neuritis, applied under coconut oil,  codliver oil and DMSO as further analgesic, anti-inflammatory,  memory and absorption enhancers.

REFERENCES:     New reviews bear out the major benefits of micronutrient supplements selenium,  zinc, silver, vits A, B, C, D, E;  and DMSO, sutherlandia and aloe  against HIV-AIDs. and co-infection;

Micronutrient supplementation for children with HIV infection. Irlam JH,  Rollins NC ea . Cochrane Database Syst Rev. 2013 Oct 11;10:CD010666.

Effect of micronutrient supplementation on disease progression in asymptomatic, antiretroviral-naive, HIV-infected adults in Botswana: a randomized clinical trial.Baum MK,  Marlink R ea .JAMA. 2013 Nov 27;310(20):2154-63. .

Preliminary trial of aloe vera gruel on HIV infection.Olatunya OS,  Oyelami OA. ea, J Altern Complement Med. 2012 Sep;18(9):850-3. doi: 10.1089/acm.2010.0735.

In vitro effects of Sutherlandia frutescens water extracts on cell numbers, morphology, cell cycle progression and cell death in a tumorigenic and a non-tumorigenic epithelial breast cell line.Stander A,  Joubert AM. ea, J Ethnopharmacol. 2009 Jul 6;124(1):45-60

Sulfur in human nutrition and applications in medicine.Parcell S.Altern Med Rev. 2002 ;7(1):22-44.

Coconut (Cocos nucifera L.: Arecaceae): in health promotion and disease prevention.DebMandal M, Mandal S.Asian Pac J Trop Med. 2011 Mar;4(3):241-7

below  are some of the  most recent  94 studies  of vitamin D and human infectionin   published just  in 2013:

New insights on the role of vitamin D in the progression of renal damage: Kidney Blood Press Res. 2013;37:667-78. . Lucisano S, Santoro D.ea  Many studies indicate relationship between hypovitaminosis D and survival, vascular calcification, bone mineral metabolism, immune, cardiovascular and endocrine. Vitamin D analogs reduces proteinuria, in particular through suppression of the renin-angiotensin-aldosterone system (RAAS) and exerts anti-inflammatory and immunomodulatory effects. In particular vitamin D deficiency contribute to an inappropriately activated RAAS, as a mechanism for progression of chronic kidney disease (CKD) and/or cardiovascular disease. Human and experimental models of CKD showed that vitamin D may interact with B and T lymphocytes and influence the phenotype and function of the antigen presenting cells and dendritic cells, promoting properties that favor the induction of tolerogenic T regulators rather than T effectory. Interstitial fibrosis may be prevented through vitamin D supplementation. .

Should vitamin D supplementation be a regular part of asthma care? Gordon BR.Otolaryngol Clin North Am. 2014 Feb;47:97-108. .Vitamin D (vitD3) deficiency occurs frequently and has profound effects on health, especially asthma.

Vitamin D in asthma and future perspectives.Huang H,  Zarogoulidis K. ea Drug Des Devel Ther. 2013 Sep 23;7:1003-13.

 vitamin D deficiency associated with development of Acinetobacter baumannii infections in critically ill patients?; Türkoğlu M, Aygencel G et al.; Journal of Critical Care 28 (5), 735-40 (Oct 2013)

Association between vitamin D and hepatitis C virus infection: a meta-analysis. Villar LM, Romero-Gomez M. ea World J Gastroenterol. 2013 Sep 21;19(35):5917-24.

Association between prehospital vitamin D status and hospital-acquired bloodstream infections. Quraishi SA, Christopher KB. Ea, Am J Clin Nutr. 2013 Oct;98(4):952-9.

Human parvovirus B19 associated dilated cardiomyopathy. Jain P, Jain A, Khan DN, Kumar M. BMJ Case Rep. 2013 Aug 5;2013.

The role of vitamin D supplementation in the risk of developing pneumonia: three independent case-control studies. Remmelts HH,  van de Garde EM ea  .Thorax. 2013 Nov;68(11):990-6.

Correlation between serum vitamin D level and severity of community acquired pneumonia in young children   Ren J, Sun B, Miao P, Feng X. Zhongguo Dang Dai Er Ke Za Zhi. 2013 Jul;15(7):519-21. Chinese. http://www.ncbi.nlm.nih.gov/pubmed/23866270

Role of vitamins D, E and C in immunity and inflammation. Shaik-Dasthagirisaheb YB, Pandolfi F. J ea Biol Regul [Correlation between serum vitamin D level and severity of community acquired pneumonia in young children].Homeost Agents. 2013 Apr-Jun;27(2):291-5.

Pre-hospital vitamin D concentration, mortality, and bloodstream infection in a hospitalized patient population.Lange N, Christopher KB ea. Am J Med. 2013 Jul;126(7):640.e19-27.

Vitamin D deficiency in HIV infection: an underestimated and undertreated epidemic. Pinzone MR, Nunnari G. eA Eur Rev Med Pharmacol Sci. 2013 May;17(9):1218-32.

Vitamin D deficiency and sudden unexpected death in infancy and childhood: a cohort study.Cohen MC, Offiah A, Sprigg A, Al-Adnani M. Pediatr Dev Pathol. 2013 Jul-Aug;16(4):292-300.

Serum 25-hydroxyvitamin D3 and the risk of pneumonia in an ageing general population.Aregbesola A, Tuomainen TP. ea J Epidemiol Community Health. 2013 ;67:533-6.

Treatment of pulmonary tuberculosis.Nunn A, Phillips PP, Abubakar I.Curr Opin Pulm Med. 2013 ;19(3):273-9.

Role of vitamin D in children with respiratory tract infection.Esposito S, Baggi E, Bianchini S, Marchisio P, Principi N. Int J Immunopathol Pharmacol. 2013 J26(1):1-13.

Tuberculosis incidence correlates with sunshine: an ecological 28-year time series study.Koh GC, Dedicoat M. PLoS One. 2013;8:e57752.

Improving outcomes in patients with psoriasis.Tidman MJ. Practitioner. 2013 ;257:27-30, 3.

vitamin C refs & infection:

Authors’ perspective: What is the optimum intake of vitamin C in humansFrei B, Birlouez-Aragon I, Lykkesfeldt J.  Crit Rev Food Sci Nutr. 2012;52(9):815-29.

Micronutrients at the interface between inflammation and infectionascorbic acid and calciferol. Parts 1 & 2: .Ströhle A, Wolters M, Hahn A. Inflamm Allergy Drug Targets. 2011 ;10:54-74- FULL TEXT IS ON LINE. .

Vitamin C for preventing and treating tetanus Cochrane Database Syst Rev. 2008 Apr 16;(2):

TOURISM HEALTH: SAFARI HEALTHSPANLIFE HEALING CAPE TOWN HOLIDAY 2013.

Health- slante, l’chaim!, hayah, sawubona! – in any country or language  is a blessing, a gift- not a right. It is insurance that has to be planned and enforced. Leaving it to fate, illness and hoping for a cure is often too late, sometimes crippling if not often  fatal. With comprehensive natural supplements, we can and should all die peacefully at an  active fit advanced  age  90years +  –   not old, incapacitated and demented. We owe this prevention to both ourselves, our  kids and our aging seniors.

So sensible lifestyle aside, promoting health  includes simple low-cost  (no-xray/no-laboratory) periodic screening:  for all,  from childhood:  of weight,  girth, eyes, teeth, bloodpressure, brainfunction- memory; and ultrasound bones – at any pharmacy/ optometrist, school or clinic;                         and  for women:  checking the breasts and pelvis for risk of  cancer.

The HealthSpanLife  South African Natural Medicine Clinic SANMC next to Cavendish Mall on the slopes of Table Mountain in beautiful Cape Town – one of the favourite world tourist  and heritage centres-  is a specialist clinic  staffed by experienced  registered professional practitioners- a medical internist specialist  (also UK registered);  a homeopath;  and a Muslim nursing sister.

It provides  one-stop holistic screening and diagnostics, and – uniquely-  evidence-based  natural remedies- nutritional support for all symptoms and chronic conditions-  also  for menopause-andropause-genitourinary- breast-sexual dysfunction- obesity-pain/headache –chiropractic  and detox ,

as well as if needed  appropriate modern specialized  testing and prescription medicines for all chronic major conditions including bio-identical hormone replacement for both genders (including implants);

and integrated referrals nearby (and in Gauteng)  as patients desire eg for autism, acupuncture, aromatherapy, physiotherapy, aquarobics,  advanced scopes, delicate restorative micro (eg hands, toes)-as well as major (eg bariatric, spinal,eye-, ear- neuro-)  surgery, infertility, xray/other scans, cancer, hyperbaric oxygen, spiritual intervention, psychiatric-hypno- therapy, and eg genetic profiling and counselling,   dialysis and transplantation, and stem cell therapy. …

Gentle Non-xray  ultrasound bone-density measurement (recommended by Cape Town , UK, and USA universities),  and tactile mechanical breast mapping (recommended by CANSA, UK, USA, Indian and Chinese studies) are available at SANMC (and in Gauteng) by appointment, and are covered by some medical aid plans;  whereas menopause consultations are covered by all open plans.

As typified by a new review last month,    World opinion is to use xray  mammography and  xray bone density imaging  only as last resort and only  in the elderly – or in staging those with breast cancer- because of the major problems and risks of xray imaging..   As world experts Profs Cornelia Baines epidemiologist in Canada, Mike Baum breast surgeon  in London and Peter Gotzsche epidemiologist  in Denmark  say,  there never has been any independent scientific evidence to support hazardous routine mass mammography crush xray screening of well women, let alone any repeated mass xray screening for decades, or the dangerous fictitious marketing hype of the American radiology-Breast Surgeons and Curves International nonsense  that xray mammo screening saves lives ..

While health tariffs must rise with inflation,  where med aid doesn’t cover, New Year 15% discount applies through January on cash-paid clinic services and in-house products. . .

For out-of-town/ overseas  visitors, accommodation and travel locally and throughout Africa and beyond can be arranged by outside experts around  clinic appointments. .  http://www.capetown.gov.za/en/visiting/Pages/default.aspx

For appointments visit  the SANMC at 1st floor no.  15 Grove Medical Bldg on Pearce St  cnr Grove Ave (parking opposite at ABSA on Grove);    or  phone +2721-6831465/  -6717415; or fax  +27865657215; or email the manageress, doctors or Sister at   sales@healthspanlife.co.za  to discuss needs,  timing and preliminary costing. For details, references  and rationale for screening and prevention,  see https://healthspanlife.wordpress.com/?s=screening.

UPDATE: WHAT’S THE PROBLEM WITH BONE DENSOMETRY AT ALL AGES AND SEXES??

neil.burman@gmail.com

WHAT’S THE PROBLEM WITH BONE DENSOMETRY?

Answer: none provided it is safely and economically measured and safely and economically corrected at all ages from small children to dotage. It is so cheap and easy to halve  the fracture risk and rate in all, and thus save vast suffering, costs and especially deaths.

A spinal surgeon laments as we all do  the poor correlation between dual xray bone density analysis DXA and fracture risk.
The simple answer is that bone density is not the top risk factor for fractures,

The chief risk for fractures in the aging is falls and fragility ie global health balance  including agility-co-ordination, balance, and strength- muscle mass.

As this column has previously detailed, DXA is valuable for looking at risk areas in the hip or a vertebra;
but just as screening X-ray mammography overdiagnoses clinically relevant breast cancer,   trunkal DXA measurement  increasingly overreads bone density  as we age because of false densification- vascular calcification overlying hips and spine, and progressive collapse wedging of vertebrae.

That’s why,  as  this column has previously referenced,  QUS -quantified ultrasound – done mostly at the heelbone, has become the international gold standard for monitoring global fracture risk, since that bone measured in its long axis  is generally free of overlying vascular calcification and collapse wedging. It is recommended by  international bodies, many leading universities from Cape Town to Cambridge to Scotland, Japan and USA. .

There is generally  good  correlation between true DXA measurement at hip and spine, and heel QUS measurement.
And QUS lacks the cumulative radiation risks of DXA.
That’s why QUS bone density  is increasingly recommended from childhood, for monitoring and thus simple prevention of frailty   – thus avoiding  the mushrooming  fracture and frailty risk in later life

http://www.ncbi.nlm.nih.gov/pubmed/22878531 Osteoporos Int. 2012 Aug  Quantitative ultrasound and fracture risk prediction in non-osteoporotic men and women as defined by WHO criteria.Chan ea  Garvan Institute of Medical Research,Sydney,  Australia.

http://www.ncbi.nlm.nih.gov/pubmed/22037972 Osteoporos Int. 2012 Jan:143-53.Quantitative ultrasound of  heel and fracture risk. Moayyeri ea .University Cambridge  UK. Metanalysis: 21 studies with 55,164 women and 13,742 men were included  with a total follow-up of 279,124 person-years. All QUS parameters were associated with risk of different fracture:  1 SD decrease in BMD associated with almost doubling of  hip fracture risk.  (RR by BUA  1.69, SOS was 1.96). There was marked heterogeneity among studies on hip and any clinical fractures but no evidence of publication bias amongst them. Different validated devices predicted fracture risks with similar performance; with  similar performance in men and women. This study confirms that heel QUS, using validated devices, predicts risk of different fracture outcomes in elderly men and women.

Oct 30, 2010.

FRAILTY FRACTURES- OSTEOPOROSIS- ARE ALSO COMMON- AND EASILY PREVENTED-  IN AGING MEN

The just-published Champ study of osteoporosis in men over 70yrs in Australia shows the high risk for older men as well: 25% had vertebral fractures, but only 77% of the men with fractures had even osteopenia let alone osteoporosis on DXA screening. and this does not factor in the overreading by DXA at the spine and hip owing to the high prevalence of both calcinosis and vertebral collapse. And abysmally few of the men were taking realistic preventatives.

The study bears out:

that frailty,  usually from aging  – is the chief risk factor for non-violent fractures;

and  the low sensitivity of especially  DXA screening, never mind the folly of waiting for fractures or dementia or worse before doing safe lowcost (QUS bone risk) screening as one incentive to starting multipreventative supplements.

As the GIOS Project in Spain yet again confirms, simple  diagnosis and safe  treatment of those at risk of non-violent fractures is scandalously neglected.

And it does not require costly risky high technology – xray screening  bisphosphonates or strontium ranelate..

Like doctors, men are far more resistant than even women to heeding warning to start screening and supplements early enough.

The  CHAMP  study again highlights the importance of asymptomatic middleaged men never mind women having periodic no-xray ultrasound quantitative bone strength scans  routinely as the gold standard so as to prompt them to take the appropriate blend of the fewscore supplements effective against both frailty fractures as well as the associated lipid- diabetes- vascular -respiratory- dementia- cancer diseases.

question: WHAT IS THE PROBLEM WITH MAMMOGRAMS?

A: THERE IS NO PROBLEM PROVIDED THEY ARE APPROPRIATE.

update 20/12/12      Dr Giske Ursin of the Norwegian Cancer Registry has just published   thoughts on collaboration – not anger for and against risky xray mammography – needed to move the field forward on avoiding breast cancer, to defend the integrity of women’s breasts. http://www.ncbi.nlm.nih.gov/pubmed/23234258 

this column has previously reviewed mammography screening  http://healthspanlife.wordpress.com/2011/11/06/negligent-promotion-of-screening-xray-mammography-as-saving-lives/

and   http://healthspanlife.wordpress.com/2011/10/16/the-evidence-against-xray-screening-mammography-grows-after-20-years/

A new paper – from the USA National Cancer Institute no less- writes about the fraud of alarmist marketing of cancer screening/treatment. http://www.nejm.org/doi/full/10.1056/NEJMp1209407

Another new paper, from Wisconsin University,   What Is the Optimal Threshold at Which to Recommend Breast Biopsy? notes that with an annual incidence of breast biopsy  of 0.626% there (ie about 6 per 1000 women of the ~18 000 screened over 5 years ),  1 in 4 biopsied  ie about 0.15% of those screened will be proven to have some degree of (pre)cancer..  They confirm the 2% risk threshold at which radiologists recommend biopsy.   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3492229/

Of well women, perhaps <1 in 20 justify screening breast imaging except in those women with relevant anxieties ie the worried well.

But screening xray mammography often uncovers clinically silent ie preclinical breast cancer which otherwise might never cause problems in lifetime; and such irradiation and crushing may activate and  spread dormant precancer cells.
Just as cardiograms are electrical-, echo- or angio- images of the heart, mammograms MGMs are widely different technology images of the breasts.

But unlike heart disease, no living imaging technique diagnoses with certainty cancer that is not already clinically pretty obvious.

The breast carcinogenic radiation risks from X-rays have been known for a century and yet it’s heavy usage is often inappropriate, profit-driven.

When patient’s history and  physical  exam suffice to exclude significant risk of breast cancer with practical certainty, it is unnecessary to crush, irradiate, needle or cut. Low risk women expose themselves to a greater risk with lower-dose  screening X-ray MGMs and more invasive costly tests. For the common “silent” cancers (e.g. prostate/breast), statistics do not support that routine invasive screening of the apparently healthy saves lives.

As with all technology, many ‘grams – imaging methods – have evolved for the breasts. Like the infants they are built to nourish, breasts are extremely sensitive to irradiation. The lower the X-ray dose, the worse the subtle genetic damage that may occur – even decades later. We know this from follow-up consultations with women with initially healthy breasts >15 years earlier who had repeated xray mammograms, versus their sisters who had xray mammograms only when suspicions arose; and from controlled laboratory experiments on rodents and human breast cells.

Objective statistical analyses since the Canadian breast X-ray screening trial more than 20 years ago, show no benefit, but show instead an increasing risk of more breast cancer, more breast surgery and more premature deaths in well women repeatedly xrayed. .

ALTERNATIVE BREAST SCANS available include no-touch photographic thermo-mammography, gentle ultrasound;

and gentle mechanical tactile imaging (MTI), which may be  better than xray or ultrasound MGM show early warning signs such as thickening of tissue and lumps. These signs may be reversed with diet, supplements and lifestyle changes.

From international studies and  local experience, MTI (e.g. Sure Touch Mammography) has become the best at outpatients, to document the physical exam findings with three-dimensional characteristics mapped.. With this simple process, perhaps  < 1 in 30 healthy women may need referral for ultrasound, and perhaps < 1 in 100 cases justify biopsy, and as the Wisconsin study shows, <1 in 1000 found to have significant breast cancer. It has been validated as at least as effective as (if not better than) other breast imaging  in studies in USA, England, China and India.
MTI is recommended by CANSA, which says that from 2005 data    about 1:29 women will be diagnosed in their lifetime with breast cancer. .

Studies confirm the obvious, that the more experts with vested interests (in XRMGM and breast cancer management) who draw up Guidelines, the more likely that Panel is to encourage mass XRMGM and intervention. So instead of perhaps 1 in 30 woman justifying breast imaging, the Breast Disease Industry – including the USA Breast Cancer Association the Industry funds – wants every woman X-ray screened regularly ideally from age 40years for the rest of their lives. But despite rage from the $8billion a year USA breast screening industry, Authorities have steadily cut back the age of starting mass screening XRMGM from age 40 to 50 years and to every 2nd or 3rd years.

No preclinical imaging diagnoses cancer. The only sure diagnosis is lump excision histology – if not multiple biopsies with their risk of needle spread.

Talk about unsubtle seduction. This year – despite massive financial (including stock-market) and marketing pressure- even mammography wine and food parties at USA radiology centers  to persuade women to submit   http://online.wsj.com/article/SB126325763413725559.html  -two books  never mind a flood of scientific journal papers have just  been published questioning routine xray mammography of the well:

Dr Peter Gotzsche and the Danish Cochrane epidemiology team have published the evidence from all over the world – from at least 14 countries- against universal XRMGM for all, against the myth of the benefits and safety of regular xray mammography.. http://www.dailymail.co.uk/health/article-2120750/The-expert-branded-woman-hater-saying-breast-cancer-screening-ruins-lives.html   and 

The Big Squeeze: A Social and Political History of the Controversial (XRAY) Mammogram (Culture and Politics of Health Care Work) by radiologist Dr Handel Reynolds 2012 http://handelreynoldsmd.com/the_big_squeeze_history_mammography.html  


CHRONIC ILLNESS- MANAGED ANTIAGING ANTI AGING ANTI-AGING CLINIC SOUTH AFRICA

 

update 24 May 2011

In Claremont  and Fish Hoek , Cape Town

A Specialist Internist Clinic offers consultations by appointment especially for managing (and ideally preventing)  the major chronic degenerative diseases of aging  and  maintaining physical, mental (and why not sexual?) vigour to a ripe and healthy old age.

The clinic (a specialist physician and a nutritionalist)  offers all-system evaluation and if available, natural  (as well as essential prescription orthrodox) prevention/treatment including metabolic – weight-endocrine-diabetes; heart-lung -kidney; hypertension; neurological-pain; joint & muscle; abdominal, immune system ie infection and cancer and auto-immune  support;  genito-urinary & sexual problems;

and appropriate screening – ECG, non-xray ( no-touch thermography- eg thermomammogram;   SureTouch tactile) mammograms, non-xray (ie  ultrasound) BMD ie  bone fracture risk measurement, body composition, and appropriate hormone profiling/replacement.

Phone during office hours for appointment: for Claremont or Fish Hoek ph 021-6717415  or 6831465 (or 083-6299160) – at Grove Medical Bldg 1st floor no 15 (opp ABSA Bank Parkade c/o Grove Ave Pearce Rd)  , or neil.burman@gmail.com ; or at Fish Hoek  enquire of Coral : 782-2024 or kilbaigie@mweb.co.za   or consultation by telephone/Skype or email .

HOURS: by appt: Claremont:  9am-5pm weekdays, 9am-1pm Saturdays.

                                  Fish Hoek: “Hove To” Specialist Rooms c/o 3rd Ave/Kommetjie Rd – on the 2nd Tuesday after the 2nd Friday each month – 9am -1pm if there are enough bookings to justify a clinic there.

Urgent cases will be dealt with if practical.    But acute emergencies and trauma, bleeding cases  cannot be dealt- these must go to the Emergency Unit at Claremont Clinic 500m away. .

Billing according to means ie specialist professional rates:  eg as a preferred provider for Discovery Health- rate currently R626.70 per  consultation procedure  019; for needy patients, what the medical scheme pays eg R360. Detailed medical report and advice protocol provided at R300. Even Hospital Plans have to pay for outpatient consultation for scores of PMBs ie Prescribed Medical benefit conditions like Menopause.

 Needy patients desiring brief consultation can be seen by arrangement at GP rate.    Bone density scan  (covered by some medical schemes)  procedure 3612  – R250.  Non-xray mammograms are not yet covered by medical schemes codes: R300 for SureTouch, R600 for thermomammogram.

UPDATES: HEALTHY LIVING

This  blog is irregularly updated   with the latest detailed pharmacological information on the ingredients of anti-aging preparations, the powder blend compositions, and mail-order/wholesale prices.

These are all detailed  on the page Product Details and Pricelists. but of course all the ingredients, as food supplements, can be ordered individually to US  or UK  or Japanese pharmacopoea standard anywhere from any reliable importer or manufacturer.

The prices listed are not updated weekly, they are a guide; and  dependent from day to day on imported costs which are mostly rising constantly .

For information email sales@healthspanlife.com (or contact 027836299160).

The public, as well as interested distributors/retailers, are invited to contact Healthspan Life!.

SPECIALIST CHRONIC DISEASES CLINIC OF EXCELLENCE

   a Specialist Internist Physician [MB,ChB(UCT 1966), MRCP (UK 1974),   (fellow of the     Kronos Longevity Research Institute, Phoenix, Arizona 2004)  has opened a   CHRONIC DISEASE CLINIC    

 at Grove Medical Bldg, Grove Ave Claremont Cape Town  bewteen

ABSA Bank Parkade &  Warwick Sq opp. Cavendish Sq (also at Fish Hoek).

MISSION: To address the underlying causes of disease not just the symptoms,  to delay by decades all-cause disability and deaths.    Integrating natural and modern medicine.

managing and if possible delaying all common concurrent diseases of aging

including especially fatigue, frailty, diabetes;

 hypertension, cardiovascular, neurological, respiratory,

 abdominal, pain, headache, neurological -memory, renal, genitourinary,

endocrine , musculoskeletal, sexual and  immune diseases . 

Appropriate physiological Menopause and Aging Male HRT .

No-xray osteoporosis/BMD measurement by quantitative ultrasound.

Distance consulting.

phone/fax  +27216717415  for appointment, or respond below. .

INDEX OF RECENT MAIN TOPICS

MANAGED ANTIAGING CLINIC CONSULTATIONS

PRODUCT DETAILS AND PRICE LISTS;     SUPPLEMENTS AGAINST DISEASE, AGING

UPDATES

SWINE FLU UPDATE; Tamiflu protection?- evidence please? A windfall for USA?

NEGLECTED ESSENTIALS: CoQ10.. VITAMIN D... B12 ; STEVIA; FISH OIL; FAT-SOLUBLE SUPPLEMENTS;

OPIOIDS  NOT NSAIDS IF PANADO  DOESNT  SUFFICE ..ACETAMINOPHEN/ PARACETAMOL RISKS .. WHY USE OTHER THAN PARACETAMOL FOR MILD PAIN?

VESTED INTERESTS IN RISING COSTS

THE MOST IMPORTANT DRUG THERAPY OF HYPERTENSION..  DRUG LISTS .. WHY IGNORE RESERPINE?..

DIABETES, METFORMIN: THE FIRST DIABETES PREVENTION PROGRAM: CHINA… PREVENTION OF OBESITY, DIABETES; PREGNANCY & METFORMIN .. METFORMIN FIRST INSULIN TRIPLES DEATHS ; THE  30 year  UKPDSPREDIABETES TIME BOMB;

DEMENTIA ETANERCEPT;FUTILE MODERN DRUGS;

DANGER, BIAS   OF RANDOMIZED CONTROLLED TRIALS;

THE WOMENS’ HEALTH INITIATIVE WHI:  MISPLANNED, MISREPORTED &  MANIPULATED;

HOMEOPATHY..

SOUTHERN  AFRICAN APOCALYPSE

ESTROGEN+INSULIN vs TESTOSTERONE+METFORMIN ..APPROPRIATE HRT SEX HORMONE REPLACEMENTANDROGENS  GIVE HEART STRENGTH AND HEALTH. NON-ORAL HRTDVT AFTER ORAL HT;

SCAMS & SNARES: STATINS; BISPHOSPHONATES; SCREENING MAMMOGRAPHY; BLACK COHOSH; RIMONABANT; GLITAZONES; FORTEOTIBOLONE;

ARTHRITIS: MULTIPLE EFFECTIVE NATURAL REMEDIES;

CANCER: PROGESTINS; HRT; PROSTATE ; HYPOCHOLESTEROLEMIA ;

SEX: persistent female genital arousal syndrome.

VALUE OF STROKE CLOTBUSTERS QUESTIONED

Thrombolysis review controversy

Sarah Colyer  in the Australian Jnl of Medicine MJA  Monday, 13 October, 2014 reviews the raging argument:   “LEADING neurologists have condemned an Australasian College for Emergency Medicine decision to fund its own analysis of thrombolysis for acute stroke, which the college claims would be free of the conflicts of interest that plague existing guidance on the treatment.The Australasian College for Emergency Medicine (ACEM) is inviting proposals for consultants to analyse the published literature on thrombolysis in acute ischaemic stroke, which it has refused to endorse as a standard of care. (1)

Professor Yusuf Nagree, chair of the ACEM Scientific Committee, said unlike reviews published to date, its analysis would be “uniquely independent”.

“We are trying to find researchers who have no preconceived views or biases”, he told MJA InSight. An expert advisory panel would also be established to support the project, including an emergency physician, neurologist, GP, public health expert and lay person.

A Cochrane review published earlier this year found thrombolytic therapy significantly reduced death and dependency rates at 3‒6 months after stroke, and that this overall benefit was apparent despite an increase in symptomatic intracranial haemorrhage and deaths at 7‒10 days.(2)

While we await sight of the full Cochrane  paper, it is noteworthy that the abstract fails to give the absolute numbers.

Cochrane Database Syst Rev. 2014 Jul 29;7:CD000213. doi: 10.1002/14651858.CD000213.pub3.

Thrombolysis for acute ischaemic stroke.  Wardlaw JM1, Murray V, Berge E, del Zoppo GJ.:

“Most strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred and improve recovery after stroke in some people. Thrombolytic drugs, however, can also cause serious bleeding in the brain, which can be fatal. One drug, recombinant tissue plasminogen activator (rt-PA), is licensed for use in selected patients within 4.5 hours of stroke in Europe and within three hours in the USA. There is an upper age limit of 80 years in some countries, and a limitation to mainly non-severe stroke in others. Forty per cent more data are available since this review was last updated in 2009.

OBJECTIVES:

To determine whether, and in what circumstances, thrombolytic therapy might be an effective and safe treatment for acute ischaemicstroke.

SEARCH METHODS:

We searched the Cochrane Stroke Group Trials Register (last searched November 2013), MEDLINE (1966 to November 2013) and EMBASE (1980 to November 2013). We also handsearched conference proceedings and journals, searched reference lists and contacted pharmaceutical companies and trialists.

SELECTION CRITERIA:

Randomised trials of any thrombolytic agent compared with control in people with definite ischaemic stroke.

DATA COLLECTION AND ANALYSIS:

Two review authors applied the inclusion criteria, extracted data and assessed trial quality. We verified the extracted data with investigators of all major trials, obtaining additional unpublished data if available.

MAIN RESULTS:

We included 27 trials, involving 10,187 participants, testing urokinase, streptokinase, rt-PA, recombinant pro-urokinase or desmoteplase. Four trials used intra-arterial administration, while the rest used the intravenous route. Most data come from trials that started treatment up to six hours after stroke. About 44% of the trials (about 70% of the participants) were testing intravenous rt-PA. In earlier studies very few of the participants (0.5%) were aged over 80 years; in this update, 16% of participants are over 80 years of age due to the inclusion of IST-3 (53% of participants in this trial were aged over 80 years). Trials published more recently utilised computerised randomisation, so there are less likely to be baseline imbalances than in previous versions of the review. More than 50% of trials fulfilled criteria for high-grade concealment; there were few losses to follow-up for the main outcomes.Thrombolytic therapy, mostly administered up to six hours after ischaemic stroke, significantly reduced the proportion of participants who were dead or dependent (modified Rankin 3 to 6) at three to six months after stroke (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.78 to 0.93). Thrombolytic therapy increased the risk of symptomatic intracranial haemorrhage (OR 3.75, 95% CI 3.11 to 4.51), early death (OR 1.69, 95% CI 1.44 to 1.98; 13 trials, 7458 participants) and death by three to six months after stroke (OR 1.18, 95% CI 1.06 to 1.30). Early death after thrombolysis was mostly attributable to intracranial haemorrhage. Treatment within three hours of stroke was more effective in reducing death or dependency (OR 0.66, 95% CI 0.56 to 0.79) without any increase in death (OR 0.99, 95% CI 0.82 to 1.21; 11 trials, 2187 participants). There was heterogeneity between the trials. Contemporaneous antithrombotic drugs increased the risk of death. Trials testing rt-PA showed a significant reduction in death or dependency with treatment up to six hours (OR 0.84, 95% CI 0.77 to 0.93, P = 0.0006; 8 trials, 6729 participants) with significant heterogeneity; treatment within three hours was more beneficial (OR 0.65, 95% CI 0.54 to 0.80, P < 0.0001; 6 trials, 1779 participants) without heterogeneity. Participants aged over 80 years benefited equally to those aged under 80 years, particularly if treated within three hours of stroke.

AUTHORS’ CONCLUSIONS:

Thrombolytic therapy given up to six hours after stroke reduces the proportion of dead or dependent people. Those treated within the first three hours derive substantially more benefit than with later treatment. This overall benefit was apparent despite an increase in symptomatic intracranial haemorrhage, deaths at seven to 10 days, and deaths at final follow-up (except for trials testing rt-PA, which had no effect on death at final follow-up). Further trials are needed to identify the latest time window, whether people with mild stroke benefit from thrombolysis, to find ways of reducing symptomatic intracranial haemorrhage and deaths, and to identify the environment in which thrombolysis may best be given in routine practice.”

Post-publication commentary:   Ryan Radecki2014 Aug 04 09:38 a.m.    “The tPA Cochrane Review Takes Us For Fools”   It’s been 5 years since the last Cochrane Review synthesizing the evidence regarding tPA in acute ischemic stroke. Clearly, given such a time span, in an area of active clinical controversy, a great deal of new, important, randomized evidence has been generated!                   Or, sadly, the only new evidence available to inform practice is IST-3 – a study failing to demonstrate benefit, despite its pro-tPA flaws and biases. So, it ought not be a very exciting update, considering the 2009 version included 26 trials, and the 2014 update now includes only 27 trials. Their summary conclusion, with only additional evidence of regression to the mean, ought remain essentially the same, or even less optimistic, right?

Interv Neurol. 2014 May;2(3):97-104. doi: 10.1159/000356087.

Future directions for intra-arterial therapy for acute ischaemic stroke: is there life after three negative randomized controlled studies?

Maingard J1, Yan B2.   Royal Melbourne Hospital, Melbourne, Vic., Australia.

The three randomised controlled trials, Interventional Management of Stroke III (IMS3), Mechanical Retrieval and Revascularization of Stroke Clots Using Embolectomy (MR RESCUE) and Synthesis Expanasion: A Randomized Controlled Trial on Intra-Arterial Versus Intravenous Thrombolysis in Acute Ischaemic Stroke (SYNTHESIS EXP) showed no significant difference in clinical outcomes comparing intra-arterial (IA) therapy with intravenous thrombolysis. This article will explore the reasons for failure to show superiority of IA therapy.:

There are many reasons for the disappointing results of the three randomised controlled trials. Opposing views on IA therapy exist. Critics argue that only a small percentage of patients will be eligible for IA therapy and that it will never be cost-effective. Additionally, current trials have failed to address superior recanalization rates of new generation devices and lack of patient selection by advanced imaging. Time-to-treatment is longer in these randomised controlled trials and stroke outcomes were worse than anticipated. The current randomised controlled trials also took long periods to complete. There is emerging evidence that general anesthetic negatively influences outcome. Next generation trials will attempt to address these issues. Key Messages: There are disparate explanations for the disappointing results from the three IA therapy randomized controlled studies. Poor recanalisation rates with first generation endovascular devices, lack of advanced neuroimaging to aid in patient selection, lack of data surrounding the use of general anaesthesia, and prolonged time-to-treatment are potential contributors to negative results. The new generation of trials has the potential of addressing these pressing issues.

update: COMPLEMENTARY, HOMEOPATHIC MEDICINE APPROVED IN SWITZERLAND, DEBATED IN AUSTRALIA, GERMANY AND SWEDEN

20 Oct 2014  an update Swedish perspective;

Forsch Komplementmed. 2013;20(5):376-81. doi: 10.1159/000355916. Epub 2013 Oct 17.  Homeopathy: meta-analyses of pooled clinical data.
Hahn RG.    Research Unit, Södertälje Hospital, Södertälje, Sweden.

In the first decade of the evidence-based era, which began in the mid-1990s, meta-analyses were used to scrutinize homeopathy for evidence of beneficial effects in medical conditions. In this review, meta-analyses including pooled data from placebo-controlled clinical trials of homeopathy and the aftermath in the form of debate articles were analyzed. In 1997 Klaus Linde and co-workers identified 89 clinical trials that showed an overall odds ratio of 2.45 in favor of homeopathy over placebo. There was a trend toward smaller benefit from studies of the highest quality, but the 10 trials with the highest Jadad score still showed homeopathy had a statistically significant effect. These results challenged academics to perform alternative analyses that, to demonstrate the lack of effect, relied on extensive exclusion of studies, often to the degree that conclusions were based on only 5-10% of the material, or on virtual data. The ultimate argument against homeopathy is the ‘funnel plot’ published by Aijing Shang’s research group in 2005. However, the funnel plot is flawed when applied to a mixture of diseases, because studies with expected strong treatments effects are, for ethical reasons, powered lower than studies with expected weak or unclear treatment effects. To conclude that homeopathy lacks clinical effect, more than 90% of the available clinical trials had to be disregarded. Alternatively, flawed statistical methods had to be applied. Future meta-analyses should focus on the use of homeopathy in specific diseases or groups of diseases instead of pooling data from all clinical trials.

German perspective:      Homeopathy. 2010;99(1):76-82. Placebo effect sizes in homeopathic compared to conventional drugs – a systematic review of randomised controlled trials.     Nuhn T1, Lüdtke R, Geraedts M.1Klinik Roderbirken, Roderbirken, Leichlingen, Germany.  It has been hypothesised that randomised, placebo-controlled clinical trials (RCTs) of classical (individualised) homeopathy often fail because placebo effects are substantially higher than in conventional medicine.  OBJECTIVES:  To compare placebo effects in clinical trials on homeopathy to placebo effects on trials of conventional medicines.         METHODS: We performed a systematic literature analysis on placebo-controlled double-blind RCTs on classical homeopathy. Each trial was matched to three placebo-controlled double-blind RCTs from conventional medicine (mainly pharmacological interventions) involving the same diagnosis. Matching criteria included severity of complaints, choice of outcome parameter, and treatment duration. Outcome was measured as the percentage change of symptom scores from baseline to end of treatment in the placebo group. 35 RCTs on classical homeopathy were identified. 10 were excluded because no relevant data could be extracted, or less than three matching conventional trials could be located.       RESULTS:  In 13 matched sets the placebo effect in the homeopathic trials was larger than the average placebo effect of the conventional trials, in 12 matched sets it was lower (P=0.39). Additionally, no subgroup analysis yielded any significant difference.     CONCLUSIONS: Placebo effects in RCTs on classical homeopathy did not appear to be larger than placebo effects in conventional medicine

and an Australian perspective from the MJA on a recent Australian ethics review: :

J Bioeth Inq. 2014 Jul 19.    A Gentle Ethical Defence of Homeopathy.
Levy D1, Gadd B, Kerridge I, Komesaroff PA.    1Centre for Values, Ethics and the Law in Medicine, School of Public Health, Faculty of Medicine, University of Sydney, 92-94 Parramatta Rd., Camperdown, NSW, 2006, Australia, David.c.levy@sydney.edu.au.

Recent discourses about the legitimacy of homeopathy have focused on its scientific plausibility, mechanism of action, and evidence base. These, frequently, conclude not only that homeopathy is scientifically baseless, but that it is “unethical.” They have also diminished patients’ perspectives, values, and preferences. We contend that these critics confuse epistemic questions with questions of ethics, misconstrue the moral status of homeopaths, and have an impoverished idea of ethics-one that fails to account either for the moral worth of care and of relationships or for the perspectives, values, and preferences of patients. Utilitarian critics, in particular, endeavour to present an objective evaluation-a type of moral calculus-quantifying the utilities and disutilities of homeopathy as a justification for the exclusion of homeopathy from research and health care. But these critiques are built upon a narrow formulation of evidence and care and a diminished episteme that excludes the values and preferences of researchers, homeopaths, and patients engaged in the practice of homeopathy. We suggest that homeopathy is ethical as it fulfils the needs and expectations of many patients; may be practiced safely and prudentially; values care and the virtues of the therapeutic relationship; and provides important benefits for patients.

Jane McCredie
Monday, 20 October, 2014
Jane McCredie

YOU don’t see the word “gentle” in the title of a scientific paper all that often.

But there it is atop a paper coauthored by two homeopaths and two prominent Australian medical ethicists, Associate Professor Ian Kerridge and Professor Paul Komesaroff: “A gentle ethical defence of homeopathy”.

Homeopathy doesn’t usually keep that kind of company. Medical leaders are generally more likely to lambast the alternative health practice than to defend it.

These authors, however, suggest those who criticise homeopathy as unethical have “an impoverished idea of ethics — one that fails to account for either the moral worth of care and of relationships or for the perspectives, values, and preferences of patients”.

“The choice to seek care from a homeopath can be just as valid and as ethically sound as any other health care choice that a patient or consumer makes, and the notion that consent or agency is untenable in respect to homeopathy is deeply paternalistic and challenges the very idea of moral autonomy”, they write.

I can’t help gently suggesting that perhaps the authors are setting up a bit of a straw man here.

I’m not sure that even the most virulent critics of homeopathy would argue an adult seeking homeopathic care was acting unethically, though they might criticise that choice on other grounds.

But what of the homeopaths? Is it unethical to provide a treatment that comprehensively fails to meet the normal standards of evidence-based medicine (EBM) (see this MJA review)?

The authors of the current paper argue the EBM approach alone is not enough, but that we need “a more sophisticated approach to evidence in medicine” in this and every other field of health care.

“This approach would recognise that what constitutes evidence can be defined and measured in different ways by different people or groups and that judgements about competing epistemes are ultimately statements about the ‘value’ of particular data or outcomes”, they write.

“When looked at in this way, it then seems completely appropriate that congruence with patients’ values, goals and preferences as well as their reported experiences and outcomes from homeopathic interventions should be included in any comprehensive evaluation of the efficacy of homeopathy.”

That’s all getting a bit postmodern for me.

I have no doubt many patients experience benefit from seeing a homeopath, and I support their right to keep doing it. I also don’t doubt the vast majority of homeopaths hold a sincere belief in the value of what they do.

But I don’t believe their medicines “work”, other than by triggering a sometimes powerful placebo effect, and I am disturbed when claims are made for them that go beyond that.

I wrote last year, for example, about homeopathic remedies being sold in pharmacies with claims they were effective against fever and other symptoms in children, claims that were withdrawn after a successful complaint to the Therapeutic Products Advertising Complaints Resolution Panel.

Randomised controlled trials (RCTs) are far from perfect but, as Winston Churchill famously said about democracy, they’re the worst system we have, except for all the others.

I’d certainly rather base my decisions about health care on RCTs than on a bunch of patient anecdotes.

Others have different values and different decision-making processes and that’s fine. I have friends who attest to the mental health benefits of past-life regression and tarot readings and I respect that.

My own ethical concerns about homeopathy arise when attempts are made to place it in contexts where it doesn’t belong, when the public purse subsidises it through private health insurance rebates, for example (something that may come to an end next year).

And I think it’s fundamentally misleading for a practice without a conventional evidence base to be promoted in a scientific context — as happens when pharmacists endorse homeopathic products or universities teach homeopathy as part of a science degree.

The ethics of that, I’d gently suggest, are troubling.

 

Jane McCredie is a Sydney-based science and medicine write

June 2009   editorial comment on `HOMEOPATHIC BASICS (June ’09)   Dr. Ron Beare ND., DHomMed, South Africa below:

On May 17, 2009, in a unique referendum ” the people of Switzerland voted by a two-thirds majority  to force Parliament to pass  a constitutional amendment that supports the use of complementary medicine (CAM), incorporating admission of doctors of anthroposophical medicine, homeopathy, neural therapy, phytotherapy and Traditional Chinese Medicine (TCM) into obligatory health insurance; integration of complementary medicine into teaching and research; and safeguarding of proven remedies.”

This vote by the  notoriously conservative rightwing Swiss  is a stunning precedent for enforcement of the peoples’ sensible rights and wishes irrespective of the machinations of  politicians and Big Business, the inconvenient truth of  oligarchy disaster capitalism especially when it manipulates organized religion as extremist  “right wings” do everywhere from Islam to Baptist America to C of E Britain to Rome to  India, China, Japan and without exception in Africa. Especially in South Africa where the AK47-brandishing State President Rev Jacob Zuma- a habitual serial adulterer  (never mind polygamist) supported by acolytes swearing to kill for him – announces that he will rule until the Christ comes….

Phytotherapy, anthroposophical and TCM deal with foodstuffs, natural plant remedies- the origin and foundation of modern drugs. But what of homeopathy?

In 2005 the University of Berne published a major meta-analysis comparing homeopathy with allopathy (Hahneman’s reference term for conventional modern medicine)  in comparable chronic conditions including respiratory-allergy, musculoskeletal, neurological and gastrointestinal. They concluded that “Biases are present in placebo-controlled trials of both homoeopathy and conventional medicine. Discounting these biases, there was weak evidence for a specific effect of homoeopathic remedies, but strong evidence for specific effects of conventional interventions.”

But “110 homoeopathy trials and 110 matched conventional-medicine trials were analysed. 21 homoeopathy trials (19%) and nine (8%) conventional-medicine trials were of higher quality. When the analysis was restricted to large trials of higher quality, the odds ratio was 0·88 (95% CI 0·65–1·19) for homoeopathy (eight trials) and 0·58 (0·39–0·85) for conventional medicine (six trials).”  This outcome statistically favours alopathic medicines and not homeopathy. .

But such analysis does not address the risk:benefit ie the adverse effects of allopathic drugs; it did note the small number of large trials of high quality.  So what this study largely raises is the power of placebo, belief ie autosuggestion and spontaneous resolution in both homeopathy and alopathy, and the fallacies of randomized controled trials and metanalyses.

It also highlights the paradox that while western medicine aims, claimsto be science-based, for daily minor consultations in the better-off  it is largely in daily practice  the art of  temporizing medicine, symptom-based palliation while the underlying stressor, be it emotional or infection, subsides spontaneously. And apart from trauma, or infection, or the small percent of adults with the most common deadly genetic diseases  eg Huntingdon’s chorea or haemophilia which can only be palliated,  for chronic common  diseases of aging there are no modern drugs which address the rckbasic degenerative pathogenesis.

Metformin the 85year old extract of the age-old medicinal galega officinalis is the only prescription “drug” which does so, in the appropriate dose and patient a true panacea since (like fish oil)  it addresses virtually every pathogenetic mechanism of obesity- lipidemia- diabetes, hypertension- heart-vascular-renal, retinopathy, dementia and hypoimmunity. Quality cannabis the Forbidden Medicine is similarly a powerful multidisease therapy, while vastly safer as a recreational dependency than heavily marketed tobacco smoking, gratuitous sex, alcohol and sugar products-the four horsemen of the apocalypse-  after human bloodlust- mass starvation, violence,  murder and warfare the greatest killers of all ..

But  homeopathy is like religion: ineffable, unprovable. As  the great Dane Søren Kierkegard the founder of modern psychology and  fierce critic of the Church wrote almost two centuries ago,  personal religion (as opposed to tribal membership) can only be by a leap of faith, a suspension of reason. The theologian Karen Armstrong, the scientist Steven Jay Gould, the London philosophers AC Greyling and John Gray, and many top novelists – George Elliott,   Hermann Wouk, Margaret Attwood and John Fowles – have written perceptive books dissecting  true religion- which is at worst a harmless fulfilling moral code – and caring calling-  for many, except when (like religion and medicine through the ages) abused for political domination and greed in the pursuit of power by the ruthless. Homeopathic physicians surely  cannot be thus accused, unlike the Disease Industry and Big Pharma ..  Homeopathy did not, like mainstream medicine in Hahneman’s time, incarcerate and even neuter  like animals the feeble and the  sad with the bad irrespective.

It is commonly said that one in three admissions to USA hospitals, and thousands of premature deaths there  each year, are iatrogenic, contributed to by modern medicines and rash surgery. Except in nondiagnosis of serious treatable illness which progresses by neglect, this cannot happen with homeopathy.

But if these beliefs and organized practices- homeopathy, reflexology, craniosacral medicine, faith healing, personal (not dictated) religion, nutritional supplements in moderation by experience –   are harmless, are they better or worse than most modern marketed chronic drugs, which mostly prove for common chronic conditions eventually  to be inferior to old and proven remedies, if they do not collapse or fall into neglect within years of their launch from adverse effects or disillusion. Examples are non-steroidal anti-inflammatory analgesics including coxibs (compare to the enduring paracetamol, and analgesic herbs); bisphosphonates (compare to appropriate ancient anabolic supplements including enduring appropriate HRT), or statins and glitazones (compare to ancient metformin and other natural antioxidants); or the troublesome angiotensin blockers for common hypertension (compare to gold standard old  low dose reserpine plus low dose coamilozide) .

In that context of inquiry one can read this exposition by a naturo-/homeopathic physician with well over 50 years of practice experience on the observations and teachings of Hahnemann, a profoundly observant and ethical medical practitioner, linguist and scientist for his times. . . he was certainly the first and most famous medical doctor of modern times. Although Edward Jenner was four years his senior and William Harvey two centuries earlier, they made their mark each in only one field, whereas Hahnemann applied his mind to all disease – both chronic, infectious, poisoning and the humane care of the insane. He was eerily prophetic of our modern Disease Industry- sell at any cost: he  claimed that the medicine of his time did as much harm as good: ‘My sense of duty would not easily allow me to treat the unknown pathological state of my suffering brethren with these unknown medicines. The thought of becoming in this way a murderer or malefactor towards the life of my fellow human beings was most terrible to me’ .” If only the FDA and it’s devotees would follow this principle before applying relatively untested new drugs where well-proven old have long existed.

It is not inconceivable that molecular biology may yet, paradoxically,  explain by quantum mechanics a theoretical basis for homeopathy, setting it aside from pseudoscience and quackery, since modern critical reviews still leave room for doubt. .

ndb

`HOMEOPATHIC BASICS (June  ’09)   Dr. Ron Beare ND., DHomMed, South Africa.

“It is amazing to think that Dr. Samuel Hahnemann MD  (1755-1843), a German physician and the Founder of homeopathy, http://en.wikipedia.org/wiki/Samuel_Hahnemann lived at a time when medicine recognized bloodletting and purging, mixtures made from vipers, opium, mercury; and other physically degrading poisons.

He was always mindful of the teachings of that other genius Hippocrates, Father of herbal medicine.

Hippocrates, the Father of Natural/Herbal Medicine, died about 400 years before the Christian era.

It is he whose Hippocratic Oath defines the Code of medical ethics even to-day.

Hippocrates denied the then superstitious causes of disease.

He stated in lectures and books that feelings and thought came from the brain, not the heart or liver (as it was thought for centuries before and after Hippocrates).

He was the first dr. to describe epilepsy and pneumonia.

He also said that physicians should do no harm.

Because health is our greatest blessing, we must always improve our lifestyles, by walking, diet and hygiene.

Some 2000 years after Hippocrates’ entreaties about Natures’ healing without perpetrating invasive harm;  Dr. Samuel Hahnemann (1755-1843) established a vibrant energy type of medicine, based on the totality of each patient’s individual symptoms.

“The Removal of the Totality of Symptoms means the Removal of the Cause” (Kent, “Lectures on Homeopathic Philosophy”).

Continue reading

update Oct 2014: TIME TO COMPEL LOWDOSE RESERPINE+ LOWDOSE AMILOZIDE+- DIHYDRALAZINE/AMLODIPINE AS FIRST LINE THERAPY OF AVERAGE HYPERTENSION.

dedicated to: YK Seedat; Roy Keeton; Allan Taylor; Norman Kaplan; Colin Dollery; 

neil.burman@gmail.com    for previous reviews see  http://healthspanlife.wordpress.com/?s=reserpine+

update 12 Oct 2014     For the past decade we have advocated  for uncomplicated patients the gold-standard evidence-based combination of reserpine  0.0625 to 0.125 mg with  1/4  Amilozide (ie hydrochlorothiazide  HCTZ 12,5mg and amiloride 2.5mg) ie HAR daily as the most cost-efficient baseline treatment of hypertension.    Sometimes patients require the lower doses 1/4 tab each reserpine and Amiloretic 55mg) only 3 times a week for good control once on some cod liver oil, coconut oil and multivite-multimineral  to reverse arteriosclerosis, insulin resistance, reactive oxygen species,  and promote nitric oxide.

For more resistant cases we add  dihydralazine 25 mg/d or amlodipine 5 to 10mg as add-ons if required  – if necessary both-  occasionally for optimal HBP control around 120  to 130 systolic (the new international  Guideline target). With this regime of up to five drugs all more than 40 years in use, for hypertension we rarely find need to add the more costly / troublesome old eg methyldopa, or betablockers, spironolactone,   or new eg ACEI or ARBs ,  with   their  cardio-respiratory risks that are so rare with the  multi-low dose reserpine- amilozide- amlodipine- dihydralizane  combination.

There are now 250 000 antihypertensive drug studies on Pubmed since 1947.

 The latest  and definitive study  published on reserpine for HBP in Clin Drug Investig. 2011;31:769-77 is   Long-term efficacy and tolerability of a fixed-dose combination of antihypertensive agents: an open-label surveillance study in China a  massive  3 year (4500 patient-years) study  by  Wu Y, Li L. ea of   Peking University Health Science Center, Beijing, China   .  A fixed-dose combination (FDC) of four compounds, hydrochlorothiazide  HCTZ 12.5 mg, triamterene 12.5 mg, dihydralazine 12.5 mg and  reserpine 0.1 mg (HTDR), is widely used as an antihypertensive treatment in China. Although used in China for more than 30 years, there have been few comprehensive evaluations of this treatment.          METHODS:This was a 36-month, community-based, open-label surveillance study, conducted in Shanghai in local primary healthcare settings. Subjects were recruited with  essential hypertension, aged ≥35 years at the time of enrolment. Patients with secondary hypertension, myocardial infarction or stroke within 6 months of screening, impaired renal or hepatic function, history of cardiomyopathy or chronic heart failure, or were pregnant or lactating were excluded. HTDR was administered as one or two tablets per day in the morning. If necessary, additional hydrochlorothiazide was added. Blood pressure (BP) was measured at baseline and throughout the 36-month surveillance period every 3 months.    RESULTS: A total of 1529 patients (65%  female; mean age 65.7 years) entered the study. After the 36-month treatment period, 93.1% of patients had achieved the SBP target, 97.9% had achieved the DBP target, and 92.1% had achieved both. The mean decreases in SBP and DBP were 15.3 mmHg and 9.9 mmHg, respectively. Overall, 127 adverse events in 119 patients (7.8%) occurred during the follow-up period, most of which were mild to moderate. Plasma lipids, uric acid and potassium improved.                                                               CONCLUSION: HTDR was found to have good long-term efficacy and tolerability in Chinese patients with essential hypertension.

The mean  15/10  BP lowering  from a mean baseline BP of 149/89 after 3 years of the four-drug Chinese combination  in China   compares  starkly with the mean ~51/30 mm Hg lowering (from untreated HBP of 200/120 down to ~149/90)  over 4 months reported  below  by Alan Taylor in his 1989 thesis study in local rural Africans with similar doses of reserpine, HCTZ and dihydralazine- Taylor’as study achieving in Blacks  in 4 months the starting BP of the Chinese some 25 years later.  But  the long Chinese study speaks to to the tolerance of the HTDR combination.

The China reserpine study  of 1500 pts, 4500 pt years, strongly complements the ~13 trials  of reserpine   between 1977 (the Veterans’ Admin trial) and 1997(the German reserpine research group trials)  in 7500 patients for 1 to 3 years;   showing that low dose reserpine (and lowdose  thiazide ) together are  as good as or better than all more modern drugs- especially when augmented by amiloride.

(As Prof YK Seedat reported  here  in 2000), the China   paper reports zero noteworthy dihydralazine  risks at 12.5mg/d :     J Hum Hypertens. 2000 ;14:739-47. Hypertension in developing nations in sub-Saharan Africa. Seedat YK. University of Natal, Durban, South Africa.  There is a rapid development of the ‘second wave epidemic’ of cardiovascular disease that is now flowing through developing countries and the former socialist republics. It is now evident from WHO data that coronary heart disease and cerebrovascular disease are increasing so rapidly that they will rank No. 1 and No. 5 respectively as causes of global burden by the year 2020. In spite of the current low prevalence of hypertensive subjects in some countries, the total number of hypertensive subjects in the developing world is high, and a cost-analysis of possible antihypertensive drug treatment indicates that developing countries cannot afford the same treatment as developed countries. Control of hypertension in the USA is only 20% (blood pressure <140/90 mm Hg). In Africa only 5-10% have a blood pressure control of hypertension of <140/90 mm Hg. There are varying responses to antihypertensive therapy in black hypertensive patients. Black patients respond well to thiazide diuretics, calcium channel blockers vasodilators like alpha-blockers, hydralazine, reserpine and poorly to beta-blockers, angiotensin-converting enzyme inhibitors and All receptor antagonists unless they are combined with a diuretic.  There are social, economic, cultural factors which impair control of hypertension in developing countries. Hypertension control is ideally suited to the initial component on an integrated CVD control programme which has to be implemented.  The existing health care infrastructure needs to be orientated to meet the emerging challenge of CVD, while empowering the community through health education.

Interestingly, a new  metaanalysis of HCTZ trials  by Musini ea Cochrane Database Syst Rev. 2014 May   Blood pressure-lowering efficacy of monotherapy with thiazide diuretics for primary hypertension. shows that BP lowering  over the dose range 6.25 mg, 12.5 mg, 25 mg and 50 mg/day is 4/2 mmHg, 6/3 mmHg, 8/3 mmHg and 11/5 mmHg, respectively. For other thiazide drugs, the lowest doses studied lowered blood pressure maximally and higher doses did not lower it more. Due to the greater effect on systolic than on diastolic blood pressure, thiazides lower pulse pressure by 4 mmHg to 6 mmHg. This exceeds the mean 3 mmHg pulse pressure reduction achieved by ACE inhibitors, ARBs and renin inhibitors, and the 2 mmHg pulse pressure reduction with non-selective beta-blockers as shown in other Cochrane reviews. 

2009:     ABSTRACT: When modern antihypertensive drugs cost far more than the old and tried, and have around 40% risk of adverse effects (Girerd 2002 Paris),  and give inferior risk reduction, it is unethical for routine hypertension patients initially to  be  prescribed modern drugs singly or in combination in uncomplicated cases before trying the gold standard old risk-free lowdose reserpine-amilozide combination.

2009 has been a landmark year of published studies on first-line  hypertension treatment.

IT IS COMMON CAUSE THAT:

i. hypertension  (with or without overweight- excessive waist girth) is today the commonest presenting, simply detectable, monitorable and controllable chronic lifestyle degenerative disease;

ii. the bedrock prevention and therapy  of essential hypertension is  public- patient  education – exercise, stopping smoking,  and minimizing salt (since 1904) , sugar, alcohol and cooked fat intake so as to reduce overweight;

iii. genetics and the above risk factors aside, three  of the primary “endogenous”  and easily correctable causes of essential hypertension are water deficiency; marine omega3 (EPA eicosapentanoic and DHA docosahexanoic acid) deficiency; and insulin resistance if not frank adiposity/overweight and diabetes.

So adequate water intake, and fish oil, and metformin/galega to tolerance, (in appropriate adipose/overweight  cases) are cornerstones of antihypertensive therapy along with diet and lifestyle changes before any antihypertensive drugs are added.

Recently there have been contentious suggestion  (eg Law and Ward UK 2009)  that target bloodpressure should be that of youth- 120/70 down to 100/60 – as long as it does not fall so low that the patient gets dizzy on standing up. But the non-contentious gold standard remains  that no one should be left with bloodpressure above at most 140/90 sitting.

ANTIHYPERTENSIVE DRUGS: There are over 34 000 RCTs, reviews and metaanalyses  (since 1965) on Pubmed on these drugs.

Controlling   hypertension asymptomatically  before it causes damage and symptoms is the heart of successful prevention.

It is now claimed  that hypertension risk starts as low as >120/70, that we should be targeting this level if tolerated.

This can only be done gently and slowly, if possible by optimising diet , lifestyle and natural supplements.

But prevention in asymptomatic patients must especially be at most a once-a-day regime, and avoid causing symptoms, and still give stable cover even if taken erratically. Only reserpine provides gentle cover lasting weeks, thus avoiding wide BP variation due to erratic dosing.

Apart from the notorious adverse effects of the older antihypertensives like guanethidine, methyldopa and atenolol, search of Pubmed under  ‘ARBs, ACEI Cough;’ and under metaanalysis ‘antihypertensive cough’  with the established drugs, reveals 10 abstracts since the mid 1990s.

The nub of the matter is, the lowest-cost multiple-combination therapy (lowdose reserpine -amiloride – hydrochlorothiazide) gives the best bloodpressure and risk reduction with zero adverse effects – especially when combined with probably the best pluripotential drug of all,  fish oil..   A new Cochrane metaanalysis from Univ Brit Columbia confirms that lowdose thiazide gives the best reduction of all antihypertensives in both all-morbidity and mortality outcomes -RR 0.89 (CI 0.82-0.97, p=0.0067 = highly significant) . And that metaanalysis didn’t deign to mention reserpine in the abstract.

There are at least a dozen trials each of reserpine and thiazide  showing that they are the best,  ideally in lowdose combination .   As always, one fixed-dose combination pill (eg Brinerdin, Rautrax Imp) may work for many. But it is both cheaper, more efficient and scientific to prescribe the components separately so that reserpine and amilozide can  each be titrated individually to tolerance, starting with eg reserpine (0.25mg tab ) 1/4/day and amilozide (55mg tab) 1/4 a day (costing locally retail  perhaps US$0.5/month, $6/year) …

In some patients eventually this dose 3 days a week is all that is needed. With sensible advice about omitting sugar and smoking, and minimal alcohol, salt and cooked fats, and adding a multinutrient including magnesium, vitamins and the many favourable biologicals (including appropriate physiological sexhormone replacement), few patients need more than 1/2 a tab each of reserpine and amilozide for optimal BP and metabolic-vascular risk control. In the rare still- resistant cases, amlodipine is the next safest effective antihypertensive  drug to add, starting with 2.5mg/d. But of course in those with insulin resistance (ie most cases), metformin is the most appropriate pluripotential drug.

Yet no trial has shown  lower cost, and better superiority and safety  of any modern-drug  or combination over the triple-combination  lowdose amilothiazide (thiazide since 1956, amiloride since 1967)  with  lowdose reserpine (from the ages-old rauwolfia – extracted  as reserpine since 1949). Since the German Reserpine trials, and results of ALLHAT and SHEP showing that reserpine as add-on gave  by far the best clinical outcomes, no head-on trials against modern drugs dare be done by drug companies or the clinicians they employ.

Over a year ago this column   reviewed that fifty year old treatments of overweight -hypertension – diabetes are still best, echoing an SAMJ analysis 24 years ago of New antihypertensive drugs–blessing or costly nemesis? .

In 1989 pharmacist Alan Taylor published his MPharm thesis (Rhodes University)  on Cost Effective Antihypertensive Therapy at A Day Hospital. – showing in a prospective randomized controlled trial for 4 months that stepped outpatient care (starting with a mean untreated BP of about 200/120) achieved the target BP ( then <165/95) in 73% compared to 11.5% on individualized treatment, and with a cost saving of 36%, with somewhat lower incidence of side effects. Hydrochlorothiazide HCT 12.5 to 25mg/d was the first step;  methyldopa 250-500mg/d or reserpine  0.1mg/d  as the 2nd; hydralazine 10-50mg/d  low dose as the 3rd, alternatively atenolol  100mg as the 3rd or 4th step. Individualized treatment reduced bloodpressure by a mean  32.6/19 whereas stepped-care did so by 51.6/29.5mm Hg.. The HCT-Reserpine- Hydralazine-atenolol regime was the most frequently prescribed (in 61.6%),

Obviously today methyldopa, hydralazine  and atenolol have become last-ditch add-ons, with amlodipine being the 1st- choice 4th drug to add to reserpine and amilozide. ,

and  in 2007 Rayner, Blockman ea from the Hypertension Clinic    at Groote Schuur Hospital found that at two community  health clinics  in Cape Town, only 40% of patients achieved a bloodpressure below 140/90, on a mean of 2.4 drugs per patient   – clinics where reserpine and amilozide were unwisely  removed from the available drug list years ago, for no plausible reason, leaving hydrochlorothiazide, atenolol, hydralazine and amlodipine as the choices- with invariably poor results in poor patients attending such free clinics.

MODERN DRUGS?  But why should patients be subjected to the multiple and indisputable major risks of modern antihypertensive drugs compared to the gold standard lowdose reserpine and low dose amilozide?

eg

ABs angiontensin blockers - ACEI agiotensin converting enyme inhibitors and ARBs angiotensin receptor blockers like enalapril, candesarten  – pervasive cough, rashes, but far worse, lifethreatening angiodema, asphyxiation, skin sloughing; and now well-recognized acute or slowly progressive loss of kidney function- which doesnt always reverse on stopping the drug (Onuigbu ea  2008, 2009); Suissa ea  2006 at McGill University published the first major longterm – > 10year- followup (1982-1997)  of hypertensive diabetes patients, showing that compared to thiazide, only  ACEI increased the risk of endstage kidney failure 4.2 fold.

betablockers like atenolol, metoprolol – too slow heart rate, cold extremities, more depression, impotence,  asthma, glucose intolerance/ diabetes, heart failure, deaths;

and even calcium channel blockers -the gold standard of which is amlodiopine- have a formidable list of potential adverse effects (that lowdose reserpine and amilozide lack), of which some may be major nuisance if not dangerous eg (from the Sandoz product sheet): “Often: dizziness; palpitations; muscle-, stomach- or headache; dyspepsia; nausea – in 1 in 100 users; Sometimes: blood disorders, gynecomastia, impotence, depression, insomnia, tachycardia – in 1 in 1,000 users;  erratic behavior, hepatitis, jaundice – in 1 in 10,000 users; Very rarely: hyperglycemia, tremor, Stevens-Johnson syndrome – in 1 in 100,000 users. ”

From the trials and experience, lowdose amlodipine is certainly the modern drug of choice to add if counselling plus ceiling doses of reserpine and amilozide, plus fish oil plus  metformin for underlying adiposity/insulin resistance,  do not adequately control hypertension and other risk factors.

Why use modern drugs with their major potential hazards  except for special circumstances last ditch?; when lowdose reserpine plus lowdose amilozide titrated to best effect rarely need a 4th drug added for good BP control;  and practically – unlike methyldopa, guanethidine and more modern drugs-  never causes persisting symptoms.

THIAZIDE ADVERSE EFFECT possible in even very low dose: anaphylaxis: Goetschalckx ea in 2007 could find exactly 49 case reports of allergic thiazide-induced pulmonary oedema in the literature after 50 years of use ie millions of patient-years. Thiazides are obviously sulphonamides, but fortunately serious- anaphylactic- reactions like lupus vascullitis and shock – are extremely rare. Wikipedia does not even mention these under thiazides, and no abstracts on Pubmed even guess at their rare  incidence. 50 cases in at least 10million patient years is an incidence of below 5 per million.

RESERPINE:   In 2007 Jos Barzilay ea documented Getting to goal blood pressure: why reserpine deserves a second look.

We last year examined closely the trials on thiazides and reserpine 1, 23.

and we published on line the only ever tabulation of all accessible trials  of thiazides and reserpine, showing in the ~12 thiazide trials between 1985 (the UK MRC trial)  and 2003 (the CONVINCE trial) that  in 115000 patients for a mean of 4 years,  thiazide is as good as or better than all more modern drugs;

and that reserpine in ~13 trials between 1977 (the Veterans’ Admin trial) and 1997(the German reserpine research group trials)  in 7500 patients for 1 to 3 years is as good as or better than all more modern drugs. Of course  the 2003 ALLHAT  and CONVINCE papers were by far the biggest trials validating thiazide as the gold standard in 50 000 patients for  3 and 5 years respectively;

and the VA trials of 1977, 1982 and  and 1990 in 1479 patients showing reserpine as equal or superior to betablockers,  and the German trials of 1997  in 400 patients validating reserpine as equivalent to thiazide or a CCB, and the combination of thiazide and reserpine superior to an ACEI.

Now in 2009:

Shamon ea’s Cochrane review last month confirms that reserpine  alone is at least equivalent  in antihypertensive effect to any  modern first line antihypertensive alone ;

Wald and Law’s metanalysis of single or combination antihypertensives confirms that  “The extra blood pressure reduction from combining drugs from 2 different classes is approximately 5 times greater than doubling the dose of 1 drug.”

Wright ea’s Cochrane review confirms that

“thiazides reduce all-cause mortality by 11%;   Low-dose thiazides (8 RCTs) reduced CHD  by 28%;

Beta-blockers and CCB reduced stroke by 17% and 42%, but not CHD  or mortality .        ACE inhibitors reduced mortality 17%; stroke  35%.

No RCTs were found for ARBs or alpha-blockers.”

However, that abstract does not enumerate the major adverse effects of betablockers and ABs.

Wright ea’s   ALLHAT reanalysis confirms that thiazide was superior to the ACEI, CCB, betablocker and especially the alphablocker doxazocin. neither alpha-blockers, ACEI nor CCBs  surpass thiazide-type diuretics (at appropriate dosage) as initial therapy for reduction of cardiovascular or renal risk. Thiazides are superior in preventing HF. new-onset DM associated with thiazides does not increase CVD outcomes.”

Costanzo ea’s Italian study confirms that CCBs reduce the risk of stroke by 14% compared to ACEI; reduce allcause mortality by a trivial 4%; increase heart failure by 17% compared with ‘active’ treatment;

Hoffman ea’s review from New York confirms that, in autopsies of Alzheimer cases, those on antihypertensives had far less plaques that those without hypertension.

Sozen ea confirms that “ABs- Drugs with blocking effects on the renin-angiotensin-aldosterone system –  do not improve endothelial dysfunction long-term in hypertensive patients”.

Mackenzie ea’s Comparison of the effects of antihypertensive agents on central blood pressure and arterial stiffness in isolated systolic hypertension shows that central Pulse Pressure was only reduced significantly by perindopril, lercanidipine, and bendrofluazide, whereas atenolol had no effect. Lercanidipine reduced the augmentation index, whereas atenolol increased it. Aortic pulse wave velocity was not changed by any of the drugs. In summary, despite similar reductions in peripheral systolic and PPs with the 4 classes of drug, changes in central pressure and augmentation index varied. Because central PP and increased wave reflections are considered important risk factors in patients with isolated systolic hypertension, the choice of therapy may be influenced by these findings in the future.”

Landmark’s Norwegian abstract confirms that thiazides (and betablockers)  increase insulin resistance and blood glucose risk (let alone lipidemia), but simply – selectively- as usual ignores that neither lowdose amilozide nor reserpine do this.

Nothing illustrates better why the triple combination of amilozide and reserpine is the best.

It has previously been pointed out that in the long term Cache County study, potassium-sparing diuretic was the only antihypertensive that lowered- in fact by 75% – the incidence of new Alzheimers disease;  and amilozide-like combinations are more effective than either component alone in safely and effectively lowering hypertension. – Patterson Dollery & Haslam in 1965; Rosenfeld in 1980; and the Multicenter Diuretic Cooperative Study Group in 1981.

CONCLUSION:  Reserpine has indisputable central and peripheral benefits in lowering central pressure via peripheral vasodilation, and via mild lowering of anxiety, cardiac rate and cardiac output; while thiazide and amiloride both lower both excessive body salt and water, while thiazide vasodilates and conserves calcium,  and amiloride  reverses the  potassium -magnesium depletion  seen in hypertension and with thiazide. .

Since the lowdose combination of reserpine and amilozide is superior to all other first-line drugs alone or in combination, and retail costs about   US$1 a month in South Africa, (with negligible adverse effects compared to all other antihypertensive drugs), this combination is the mandatory  firstline therapy for all  hypertensive patients, with rare exceptions. This regime  starts with amilozide 13.75mg (1/4 tab) and reserpine 0.0625mg (1/4tab) /d- and many patients can eventually be controlled with these doses just 3 days a week; with other antihypertensives added only if hypertension is not controlled with these increased to the ceiling tolerated eg of amilozide 27.5mg/d and reserpine 0.125 mg/d (maximum reserpine 0.25 mg 5/week ie 0.18mg/d if tolerated).

Since roleplayers are there to serve patients, not the Drug and Disease Industry, all roleplayers ( National Hypertension societies, provincial and national health and medical school authorities, medical schemes and all health practitioners)  have no choice but to obey the gold-evidence-based medicine set out herein, and reinstate reserpine and amilozide as mandatory 1st-line therapy of essential hypertension, with motivation  for alternatives to be provided in the  exceptional cases.

Unlike the USA and the East  where reserpine is still in national recommendations,  Authorities, regulators, suppliers and prescribers  in South Africa, Australia, the UK and Europe can no longer continue to defraud the public and deny patients this best treatment, since the two tablets (cheap amilozide and reserpine) are freely and universally available for  at most the retail South African prices quoted (less in bulk buy).

There is no shortage of reserpine, HCT or amiloride;  and the evidence for them over all modern antihypertensives  is binding under  rules of evidence and therefore medical ethics. The current evidence discussed shows that this  old lowdose combination is superior to all modern drugs and modern marketted combinations in both reduction of all-cause endpoints, adverse effects, and cost.

As Henry Black said recently, triple antihypertensive therapy is simply Back to the Past – and it can be both very low cost and risk-free..

And if proof is wanted, we must agree on a simple long term multicentre trial of the lowdose reserpine-amiloretic regime versus modern marketed combinations.- as in  ALLHAT but comparing combinations..But who is to pay for yet another trial to prove what is already so well proven?

35 years after Illich’s Medical Nemesis, it is very sad to have to be fighting overwhelming profiteering vested interests for what is now by far the commonest and most easily correctable major common degenerative disease – mild to moderate hypertension.

29 SEPT 2014 OVARIAN CANCER UPDATE: PROGESTERONE REPLACEMENT IS IDEAL; WHY USE ORAL HT? WHEN ESPECIALLY LONG TERM PROGESTINS GREATLY INCREASE RISK OF OVARIAN AS WELL AS BREAST CANCER.

: ABSTRACT:  since last review in  this column 5 years ago, what progress has there been with ovarian cancer OvCa? On Pubmed there are 81000 references,  45500 reviews on OvCa

5 Oct 2014:  Ovarian Cancer Often Arises from Precursor Endometriosis    Frontline Medical News, 2014 Sep 29, B Jancin

   29 Sept 2014  The good news is that if ovariectomy is not done at hysterectomy, then at least salpingectomy should be done- it does not cause earlier menopause.  And the modern fashion for progesterone cream as baseline hormone balancing in this age of estrogen dominance, the feminization of nature,  also adds major protection for heart, bone, memory, mood,  and against cancer, without the risks of estrogen.

Before this month’s update,  the latest, an Australian cancer review  Mette ea 2013, shows that cigarette smoking increases the risk of OvCa by 30% to 60%.

The latest   review 2013 Modugno ea at Univ Pittsburgh/Mayo Clinic  Hormone response in ovarian cancer: time to reconsider as a clinical target?   said “Ovarian cancer is the sixth most common cancer worldwide among women in developed countries and the most lethal of all gynecologic malignancies. There is a critical need for the introduction of targeted therapies to improve outcome. Epidemiological evidence suggests a critical role for steroid hormones in ovarian tumorigenesis. There is also increasing evidence from in vitro studies that estrogen, progestin, and androgen regulate proliferation and invasion of epithelial ovarian cancer cells. Limited clinical trials have shown modest response rates; however, they have consistently identified a small subset of patients that respond very well to endocrine therapy with few side effects. We propose that it is timely to perform additional well-designed trials that should include biomarkers of response.The most consistently reported reproductive and hormonally related factors found to protect against EOC are use of oral contraceptives (OCs), increasing parity, and having a tubal ligation. In contrast, increasing age and nulliparity have been consistently shown to increase EOC risk. 

    Recent studies, including the prospective Women’s Health Initiative (WHI) (Anderson et al. 2003) and the Million Women Study (Beral et al. 2007), report an increase in risk for both estrogen-only (ET) and estrogen–progestin (EPT) formulations, although the risk associated with EPT was lower than that of ET. A recent meta-analysis of 14 published studies found risk increases 22% per 5 years of ET use compared with only 10% per 5 years of EPT use, suggesting that risk differs by regimen (Pearce et al. 2009).               Exogenous androgens may be associated with EOC. One case–control study found that use of Danazol, a synthetic androgen commonly used in the treatment of endometriosis, significantly increased EOC risk (Cottreau et al. 2003), although this finding has not been replicated (Olsen et al. 2008). Ever use of testosterone (tablets, patches, troches, or cream) has been associated with a threefold increase in EOC (Olsen et al. 2008).             

     Reproductive disorders and other reproductive factors :  Factors affecting childbearing have also been shown to be associated with EOC. In most studies, infertility has been associated with an increased risk, which may be greatest among women who fail to conceive (Vlahos et al. 2010). In general, infertility treatment does not appear to increase EOC risk, although the subset of treated women who remain nulliparous may be at an increased risk (Vlahos et al. 2010).

         Endometriosis, defined as the presence and growth of endometrial tissue outside the uterine cavity, has also been associated with EOC. A recent pooled analysis of 13 case–control studies showed a threefold increase in the incidence of clear cell EOC and a twofold increase in endometrioid EOC among women with a self-reported history of endometriosis (Pearce et al. 2012).

    An increased risk of EOC was reported by one case–control study (Schildkraut et al. 1996) among women with polycystic ovary syndrome (PCOS), a condition associated with menstrual dysfunction, infertility, obesity, the metabolic syndrome, hyperandrogenism, and insulin resistance. However, the finding was based on a small number of cases (n=7) and the association was limited to nonusers of OCs and thin women. Further case–control and prospective studies have failed to confirm this relationship (Pierpoint et al. 1998, Olsen et al. 2008, Brinton et al. 2010).

   Tubal ligation has been consistently shown to be associated with reduction in EOC risk (Cibula et al. 2011). This protection appears similar in magnitude to OC use and child bearing (about 30%) and is protective in high-risk women (i.e. BRCA1/2 carriers) as well. Hysterectomy has also been shown to reduce EOC risk, although the magnitude of the association is not as great nor as consistent as that reported for tubal ligation (Riman et al. 2004). Finally, reproductive factors associated with other hormonally linked cancers, such as age at first menarche, age at menopause, and length of reproductive years, have not been consistently associated with EOC (Riman et al. 2004).

    Estrogens and androgens –  The evidence linking these  to EOC are mixed. The majority of women who develop ovarian cancer are postmenopausal at the time of diagnosis. In postmenopausal women, the major source of circulating estrogen is from the peripheral conversion (in skin and adipose tissue) of androstenedione by the enzyme aromatase.

    Progesterone and progestins- Epidemiological data suggest that progestins and progesterone may have a protective role against EOC. Importantly, there is some evidence that progesterone might synergize with chemotherapeutic drugs to induce apoptosis.

Now this month  comes exciting news about  a  Paradigm Shift: Prophylactic Salpingectomy for Ovarian Cancer Risk Reduction   Frontline Medical News, 2014 Sep 24, B Jancin     :   Removing the fallopian tubes at the time of pelvic surgeries as a potential means of reducing ovarian cancer risk appears to be a movement that’s picking up steam in clinical practice.
       A recent survey of 234 U.S. gynecologists showed prophylactic bilateral salpingectomy is catching on when performed in conjunction with hysterectomy, but far less so for tubal sterilization, Dr. Austin Findley observed at the annual Minimally Invasive Surgery Week.                                                                       A total of 54% of respondents indicated they routinely perform salpingectomy at the time of hysterectomy in an effort to reduce the risk of ovarian cancer as well as to avoid the need for reoperations. However, only 7% of the gynecologic surgeons said they perform salpingectomy for tubal sterilization, even though 58% of respondents stated they believe the procedure is the most effective form of tubal sterilization (J. Minim. Invasive Gynecol. 2013;20:517-21).
  “In my experience at various hospitals, I think these numbers are a pretty accurate reflection of what folks are doing,” commented Dr. Findley of Wright State University in Dayton, Ohio.
     The prophylactic salpingectomy movement is an outgrowth of the tubal hypothesis of ovarian cancer.
    “There is now increasing and dramatic evidence to suggest that most ovarian cancers actually originate in the distal fallopian tubes. I think this is a concept most people are unaware of or are just becoming accustomed to. The tubal hypothesis represents a major paradigm shift in the way we think about ovarian cancers. The previous belief that excessive ovulation is a cause of ovarian cancer is no longer regarded as accurate,” he explained at the meeting presented by the Society of Laparoscopic Surgeons and affiliated societies.
      Ovarian cancer is the No. 1 cause of mortality from gynecologic malignancy, accounting for more than 14,000 deaths per year, according to National Cancer Institute data. The lifetime risk of the malignancy is 1.3%, with the average age at diagnosis being 63 years.
       Only 10%-15% of ovarian cancers occur in women at high risk for the malignancy because they carry a BRCA mutation or other predisposing gene. The vast majority of ovarian cancer deaths are caused by high-grade serous tumors that have been shown to be strongly associated with precursor lesions in the distal fallopian tubes of women at low risk for the malignancy.
            There is no proven-effective screening program or risk-reduction method for these low-risk women. However, with 600,000 hysterectomies and 700,000 tubal sterilizations being performed annually in the United States, prophylactic salpingectomy has been advocated as an attractive opportunity to potentially reduce ovarian cancer risk. Other common pelvic surgeries in which it might be used for this purpose include excision of endometriosis and laparoscopy for pelvic pain. It also has recently been shown to be feasible and safe post partum at cesarean or vaginal delivery (Obstet. Gynecol. 2014 [doi: 10.1097/01.AOG.0000447427.80479.ae]).
   But the key word here is “potentially.” It must be emphasized that at present the ovarian cancer prevention benefit of prophylactic salpingectomy remains hypothetical; in theory, the procedure should reduce ovarian cancer risk, but there is not yet persuasive evidence that it actually does, Dr. Findley emphasized at the meeting, presented by the Society of Laparoendoscopic Surgeons and affiliated societies.
            In contrast, one well-established ancillary benefit of prophylactic salpingectomy is that it eliminates the need for future reoperation for salpingectomy. This was demonstrated in a large Danish cohort study including close to 10,000 women undergoing hysterectomy and a similar number undergoing sterilization procedures. Among the nearly two-thirds of hysterectomy patients who had both fallopian tubes retained, there was a 2.13-fold increased likelihood of subsequent salpingectomy, compared with nonhysterectomized women.
        Similarly, Danish women who underwent a sterilization procedure with retention of the fallopian tubes – typically tubal ligation with clips – were 2.42 times more likely to undergo subsequent salpingectomy, most often because of the development of hydrosalpinx, infection, ectopic pregnancy, or other complications (BMJ Open 2013;3 [doi:10.1136/bmjopen-2013-002845]).
     The most commonly cited potential risk of prophylactic salpingectomy – decreased ovarian function – now appears to be a nonissue. This was demonstrated in a recent retrospective Italian study (Gynecol. Oncol. 2013;129:448-51) as well as in a pilot randomized controlled trial conducted by Dr. Findley and his coworkers (Fertil. Steril. 2013;100:1704-8), which appears to have answered many skeptics’ concerns. Indeed, Dr. Findley’s coinvestigator Dr. Matthew Siedhoff said he has recently been approached by researchers interested in collaborating in a larger confirmatory randomized trial, but all parties eventually agreed it was a no-go.
    “It’s a little hard to demonstrate equipoise for a larger randomized controlled trial. We’re beyond that now, given that prophylactic salpingectomy really doesn’t seem to make a difference as far as ovarian function,” according to Dr. Siedhoff, director of the division of advanced laparoscopy and pelvic pain at the University of North Carolina, Chapel Hill.
         Another oft-expressed reservation about salpingectomy as a means of reducing ovarian cancer risk in women seeking sterilization is that salpingectomy’s irreversibility may lead to “tubal regret” on the part of patients who later change their mind about further pregnancies. However, Dr. Findley cited a recent editorial whose authors criticized colleagues who made that claim. The editorialists argued that the tubal regret concern indicates surgeons weren’t really listening to their patients’ true desires during the informed consent conversation.
     “We should not have started thinking about salpingectomy for female sterilization only once a decrease in ovarian cancer risk became part of the equation,” they declared (Obstet. Gynecol. 2014;124:596-9).
           Dr. Findley noted that Canadian gynecologists are leading the way forward regarding prophylactic salpingectomy as a potential method of ovarian cancer prevention. The Society of Gynecologic Oncology of Canada in a 2011 policy statement recommended patient/physician discussion of the risks and benefits of bilateral salpingectomy for patients undergoing hysterectomy or requesting permanent sterilization. The Society of Gynecologic Oncology followed suit with a similar clinical practice statement in late 2013.
        Additionally, the Canadian group declared that a national ovarian cancer prevention study focused on fallopian tube removal should be a top priority.
    Gynecologic oncologists in British Columbia recently reported the eye-catching results of a province-wide educational initiative targeting gynecologists and their patients. In 2010, all British Columbia gynecologists had to attend a course on the role of the fallopian tubes in the development of ovarian cancer, during which they were advised to consider performing bilateral salpingectomy for ovarian cancer risk reduction.
              Surgical practice changed dramatically in British Columbia in response. In 2009 – the year prior to the physician education initiative – salpingectomy was utilized in just 0.3% of permanent sterilization procedures. In 2010, it was 11.4%. By 2011, it was 33.3%.
           Similarly, only 7% of hysterectomies performed in British Columbia in 2009 were accompanied by bilateral salpingectomy. This figure climbed to 23% in 2010 and jumped further to 35% in 2011. Meanwhile the rate of hysterectomy with bilateral salpingo-oophorectomy remained steady over time at 44% (Am. J. Obstet. Gynecol. 2014;210:471.e1-11).
     This project was conducted in collaboration with the B.C. Cancer Agency, which maintains comprehensive province-wide registries. Over time, it will be possible to demonstrate whether prophylactic salpingectomy is indeed associated with a reduction in the incidence of ovarian cancer. “I think this study demonstrated that there’s a lack of awareness on this issue, but also [that there’s] potential effectiveness of introducing an educational initiative like this in changing our practice patterns. As we start talking more about this issue amongst our colleagues and our patients, we’re more likely to see a practice pattern shift in the United States as well,” Dr. Findley commented.

17 July 2009     A new cancer study of  over 7 million women years is another major coffin for unopposed estrogen ET, for progestin Pg, and for oral  sex hormone therapy SHT.

Danish  Universities prospectively document  the incidence of ovarian cancer OvCa in a million postmenopausal women PMW  from 1995 through 2005.  Compared to non-users, use of HT increased OvCa (mean age 62yrs) by about 40%   for up to 2 years after stopping Ht, ie increased the absolute incidence  of clinically diagnosed OvCa from ~ 0.04 to ~0.052% ie per 100 patient yrs.

Transdermal TD ET alone  increased risk by 13%; vaginal ET by 23%;                                            Oral ET alone increased  risk by  34%; oral E+ progestin Pg by  48%;          TDE+Pg by 67%.

Thus the relative incidence of OvCa rose about 33% by 7 years on HT, to 48% if HT continued beyond 7years.

In 2004 Glud ea reported an increase risk of 31% for OvCa in Danish women on OHT use – total ET dose of ~5gm ie for about  for 15yrs – at a time when the standard premarin  dose was 0.625mg/d (equivalent to l mg E2)  if not double that .

For perspective,  the relative incidence of cancers in similar mostly 1st world European women from the  the USA SEER data for 2006 age over 50  years  are: BrCa 0.33%,  uterus 0.07%, ovary o.03%(ie very similar to the baseline Danish figure of 0.04% above), colon 0.15%,and cervix 0.01%. The new (Norwegian)  analysis in the latest BMJ suggests that screening mammography may result in overdiagnosis of BrCa by up to 50% (the other 50% may arguably never have been clinically significant-diagnosed- during life) , so the provocative could argue that the relative incidence of clinically significant BrCa to OvCa is more like eg BrCa 0.2 to ovary 0.03 ie just below 10:1. But OvCa is notoriously about 70% fatal within a few years, so  the absolute  mortality rate – at age 60-64yrs-  from  the same SEER  source and period are as relevant: BrCa 0.063%, uterus 0.011%, ovary 0.033%, colon 0.03% & cervix 0.005%. ie new OvCa may be only 1/10th as common as newBrCa, but BrCa  kills only twice  as many PMW as OvCa.

And finally the 2007  survey by  Rossing ea of  Menopausal Hormone Therapy and Risk of Epithelial Ovarian Cancer in women in Washington State 2002-2005 showed that  ET -mostly premarin (but not ET + progestin- MPA medroxyprogesterone provera) – especially in  low-parity  younger slim women increased OvCa compared to non-users, and that this risk  was highest- up to 90%-  in  users of OET  for more than 6 years.

By comparison – BREAST CANCER BrCa and HT: Hoover ea  1976  are the first on Pubmed to report doubling in  risk of breast cancer  BrCA after 15yrs on premarin in USA ie at least 5gm cumulative dose.

In Denmark by 1994 Ravn ea reported that if there was a risk of BrCa from OHT, it was small, and only after prolonged use of estrogen (15-20 years).  But by 2004 -2005 Tjønneland ea , Stahlberg ea  and Ewertz ea  found increased risk for BrCa  of 61 to 112%  associated with current use of HT.  Stahlberg ea already in 2003 concluded from recent studies from both the USA and Europe that the combined treatment regimens with estrogen and progestin increase the risk of BrCa  beyond the risk of unopposed estrogen.

In Norway, a recent Tromso study suggested that the dominant HT therapy used in Norway was oral estradiol E2 plus the progestin norethisterone acetate. . An earlier Tromso study in only 35000 PMW was too small- it showed that use of such OHT for >5yrs trebled the incidence of breast cancer BRCa, but did not influence that of OvCa.

Apart from smokers’ lung cancer, the commonest cancer in older women- BrCa- clinically affects perhaps 5% of PMW  lifelong – but  with prompt therapy after clinical presentation kills as few as 5% of sufferers- and with appropriate OHT (premarin +- provera)  for up to 8years in the Women’s Health Initiative both the incidence of and mortality from BrCa, and all-cause mortality,  were reduced by about one-third. Hence appropriate HT saves many from both BrCa and from premature death and disability from the commonest degenerative diseases- vascular, dementing and fracturing. 75% of women who develop BrCa  die with it –  not from it but from far more prevalent degenerative diseases after an  otherwise normal lifespan. But the Danish evidence is that combined OHT will increase OvCa by >50%.

Ovarian Ca kills 70% of victims, and is it so rare compared to BrCa? .

Hence with the perhaps 2/3  lower incidence of OvCa, it is a relatively trivial problem for women overall- except for the 4  in  10 000 women  who develop it, who have <50% 5year survival, ie 3 out of 4  of whom it will kill within a few years- compared to <25% of breast cancer victims who will be killed by the BrCa.

However, it becomes clear that these hormone-dependent cancers are both  duration-  and total-dose HT related; but even more important, that unopposed OET is a risk if persisted more than about 12 yrs; and even if used in far lower dose parenterally, the risk of OvCa is far higher if combined with the European fashion of androgenic synthetic progestins Pg – even parenterally; whereas the American MPA for up to 8years at least apparently if anything mitigates the OvCa risk of ET..

By contrast this column has repeatedly reviewed evidence that balancing physiological ERT with physiological testosterone replacement TRT eliminates the risk  for BRCA and endometrial cancer of unopposed ERT +- PRT in PMW.  Intuitively this should also apply to ovarian cancer.

Hence the message strengthens that PMW should not be exposed for  any length of time at any stage to the much higher oro-hepatic HT doses (needed for symptom control) or OET+- Pg; but as in all other endocrine replacement for permanent  multisystem prevention – let alone sexual function-  patients with gonadal deficiency should have physiological sexhormone balance restored  ie with balanced parenteral  human androgen, estrogen and progesterone replacement.

It is common cause that (reproductive cycles and pregnancy aside) all the physiological  prime sex hormones-DHEAdehydroepiandrosterone, P4, T, E2, E3 – are as important as all other human hormones, essential life long  for optimal health; and that estrogen dominance (due to inadequate  androgen and progesterone levels) is deleterious. Hence most PMW require both physiological progesterone and androgen replacement- sometimes to balance excessively high endogenous estrogens, usually to accompany necessary ERT for full balance.

ndb