PREFACE: the conflict between common sense, conventional wisdom and vested commercial interests:
Throughout the ages, innovators and believers in truth and freedom of thought have risked if not attained martyrdom for disputing populist or autocratic wisdom or beliefs, from Socrates to Jesus to objectors against prevailing dogma through the past twenty centuries, Martin Luther, Galileo Galilei and in our time eg Margaret Sanger, Mahatma Ghandi, Linus Pauling, Jack F Kennedy, Nelson Mandela, Steven Biko, now even medical leaders like Dr David Graham at the Federal Drug And Food Administration itself.
But despite the eternal fact that truth will out, even now the USA and South African governments are determined to suppress truth, making it a jail offence for whistleblowers and media reporters to publicise evidence that exposes (eg medical) fact let alone corruption and worse. Jose Saramago the late Nobel-winning Portuguese author of “Blindness” and “Seeing”. will be sadly shaking his heavenly locks. We should heed Saramago’s modern scepticism about official truths if not his atheism and communism.
Eleven years ago the emeritus professors Sirs Stuart Cameron(British) and Bill Hoffenberg (South African) at London University dared to publish jtaboo questions for ethical debate – The ethics of organ transplantation reconsidered: paid organ donation and the use of executed prisoners as donors. This was still hotly debated in 2003- and remains so in South Africa -ironically after 16 years of ‘democratic’ majority rule one of the most violent and corrupt countries in the world – where leading private practice doctors and hospitals are being prosecuted for transplanting kidneys from apparently desperate willing sellers to unrelated paying recipients.
The Case of Disease-Mongering? Screening the well at average (not high) risk for Possible Future Cancer:
The classic Latin phrase Quot Homines, Tot Sententiae- so many people, so many opinions – refers to the dilemma of which opinion to follow, what to vote for. Politics aside, never is this more apposite than about confusing men and women about the grave risks of the overdiagnosis and overtreatment of screening-detected silent cancers.
So perhaps the title should read: Quot Homines Tot Cankeri: not all adults may get crabs, but the screening disease industry posits that all adults may get cancer and thus should be regularly invasively internally screened. .
We are not talking about investigation directed at a possible cancer that has already grown big enough to be causing relevant symptoms eg a lump or pain etc. It is indeed surely negligent if a health professional fails to recommend such diagnostic investigations in the appropriate clinical conditions.
SCREENING FOR BREAST AND PROSTATE CANCER: A review last month of the massive ( New Jersey Cancer Institute) study of prostate cancer bears out the futility- in fact grave risks- of screening for silent dormant prostate cancer in men without symptoms. This is reinforced by a broader recent Medscape review.
Wikipedia usefully sums up the dilemma we face 2500 years after Hippocrates. While Aulus Cornelius Celsus translated the Greek carcinos into the Latin – to many of us the foods of the gods – Galen 150 years later used “oncos” to describe all tumours, the root for the word oncology; but the more thoughtful Hippocrates had long before distinguished benign tumours oncos, Greek for swelling, from malignant tumours carcinos.
We can fast-forward this distinction to 2010 in Hippocratic terms of both ethics and pathology:
1.should tumours that are histologically “malignant” but clinically static over a usual lifetime – as most asymptomatic prostate and breast “cancers” are ie “oncos” (eg screening-detected ductal or cervix carcinoma in situ) if not stirred up by eg hormone therapy or biopsy- be labelled, diagnosed to the patient as clinically malignant “carcinos” ie a spreading crab? Hippocrates , and later Celsus , were indeed talking about cancers as tumours that were clinically and macroscopically malignant. Silent preclinical cancers that are discovered on screening are rarely so. And therefore
2.is it ethical to do cancer screening (by blood, digital, xray, ultrasound, biopsy) of all asymptomatic patients? As Shaughnessy and Slawson (1997) so incisively wrote a decade ago, is such commercially lucrative proactivity Patient-Orientated Evidence that Matters ie POEM to the patient? They continued to publicise this theme relentlessly until their last joint Pubmed-listed essay in 2006, arguing trenchantly for valid evidence-based practice rather than as most doctors seem to do, following ex cathedris views and guidelines by ‘experts’ and committees- who are likely influenced by Big Pharma. They (Shaughnessy and Slawson) individually continue this battle until now.
The updated wikipedia review of xray screening for asympotomatic preclinical cancer including breast cancer, soberly reviews the controversy surrounding the benefits – saving possibly one extra life in 2000 healthy women whose breasts are heavily crushed and irradiated for years for no benefit, for the dozens undergoing recalls and biopsies for lesions found, the handful who may have cancer diagnosed and even surgery and radio/chemotherapy, for mostly early cancers that far more often than not would never have presented during lifetime and death from other causes.
Yet screening breast cancer xray mammography of even millions of asymptomatic women not at familial risk cannot be proven to save even one life let alone lives. The increasing doubts about the costs (both financial and emotional) of such screening versus the benefits of such screening of well persons with low risk factors including family, apply to screening for many relatively common feared cancers eg breast, prostate, testicular, ovary, lung.
SCREENING FOR OTHER CANCERS: So the question may well be asked whether there is overall statistically significant benefit (in lower overall mortality and morbidity) of such invasive screening programs even for the other two commonest cancers of older adults- colon cancer and cervix cancer- in those without significant risk factors- relevant symptoms or infections or family history.
This then extends to the longerm questionable overall benefit versus risk of vaccination especially from preteens against human papilloma virus- again, such vaccination is a trillion-dollar industry when it is decreed compulsory for all children. . As screening for breast and prostate cancers has shown no clear benefit to individuals or to the population screened – versus the non-screened- on longterm population followup, it will take comparable careful review of results in thousands of initially low-risk well patients for decades to show whether overall mortality and morbidity was indeed lower in average-risk populations that were invasively screened/ vaccinated for eg cervix or colon cancer versus those that were not.
Only such a study will show whether the public has anything to lose by simply being mandated to report to a healthcare professional for relevant investigation when they develop new symptoms eg change in bowel or gynaecological health. It is damning that on a populist website like Health24, the page on Breast cancer was last updated in 2006, and does not even mention the crucial issue of longterm benefit and risk on those screened. Naturally service providers with vast investments in technology and aggressive management promote screening, as witnessed by national health services, university and private hospitals and high-tech practitioners in all countries. At least the Wikipedia section on breast cancer screening has a lengthy section covering the controversy. .
It is now six years since surgery professors Dent and Panieri published an editorial warning about the lack of convincing evidence for population breast cancer screening. And their editorial did not even consider the added risk factor of repeated crushing and irradiation of presumably health breasts.
And a practicing USA radiologist like Dr Jeff Dach argues realistically against all such screening based on the evidence. . As he says, just switch off the screening imaging machines, stop calling ductal carcinoma in situ of the breast a cancer. The ongoing argument for and against screening is hotly debated by specialists supporting and opposing the vested interest of the Screening Industry.
Without more study, it cannot be assumed, proclaimed, taken for granted that the giant resources- costs, risks, and invasion of everyones’ privacy and time, required for such mass screening and vaccination – are justified. Are they anything more than lucrative disease-mongering? when screening xray mammography alone is already said to gross almost $10 billion a year in USA (300million people) .
Extend that to all countries and the five common adult genetically linked cancers, and the cost of questionable screening (and then managing the discovered cancers) – let alone aging cancer itself) for the whole world of older adults surely rises to above a trillion dollars a year– a nice coveted annual pot of gold for governments in power and the business moguls, big stakeholders they serve.
As with the spurious decade-long unwinnable invasion of Iraq for fictitious nuclear weapons but in reality for the profits of war and oil,
and the USA – European Union -WHO declaration of a swine flu pandemic just a year ago so that the NATO business buddies – governments and their funding private megacorporations – could reap billions in immediate rake-off from unproven screening tests and vaccinations and drugs;
and its trillions a year from uncovering and treating all those sleeping cancers,
so who cares about the benefits and risks decades down the line for those screened and vaccinated and treated now for disease that is unlikely ever to occur?