Monthly Archives: November 2011

THE GROWING RISKS OF CHEMO-FOG; THE ETHICAL DILEMMA OF INFORMED CONSENT. WHAT SHOULD BE OBLIGATORY SCREENING?

neil.burman@gmail.com.      for debate.

ETHICAL CONSIDERATIONS: given the increasing evidence of cognitive and mood effects of cancer and fear on patients with extracranial cancer, let alone after chemo-and radio-therapy, it becomes a major ethical issue as to whether the patient alone should be the decision-maker in the fearmongering-driven decision about whether  to have xray-screening mammography  or prostate  or colon cancer screening in the absence of symptoms and familial high risk.

Similarly, given the epidemic nature of HIV-AIDs and  overweight-prediabetes-Hypertension in Africa, and the giant public cost of illness and deaths  from these diseases, should screening and treatment  for these be voluntary or compulsory?

Equally, are patients diagnosed with cancer, hypertension or HIV-AIDs  competent to make decisions alone for themselves about cancer or other  therapy? Can the patient alone decide about active interventions, versus withdrawal from all therapy – giving up and accepting death – when there are so many options that may help and even cure despite advanced cancer, AIDs and diabetes-hypertension. Surely the patient’s most responsible relative needs to be involved.

  We frequently see such patients plunge into therapy, or withdraw from therapy to die. Current cancer reviews from America, Italy and Portugal  explore this need for truly informed consent. and adequate support for cancer, AIDs and hypertension. 

The need is as great in  AIDs- HIV infection- in our local state AIDs  clinics,   patients have to bring along a buddy, someone – partner, family or friend – from their neighbourhood- who can be relied upon to support the patient through thick and thin, ensure compliance with both complicated drug therapy and all aspects of nutrition and function in consultation with the medical and social backup team.

BACKGROUND:

The analogy of Cancer  with AIDs and overweight-prediabetes-hypertension  is strong. With HIV-AIDs there is oftem  inital  anxiety and depression in anticipation of the screening test, especially in someone who has symptoms; and then if the test is positive. more guilt, anger, fear and despair needing support till the patient adjusts to living with HIV and the necessary prevention and precautions;  until the cycle repeats itself when deterioration necessitates active therapy for active AIDs ARVs (antiretroviral therapy) and if necessary antituberculous therapy. . Both AIDs and ARVs can seriously affect both mood, cognition and thus behaviour. The latest Pubmed  reviews are  from Spain and USA.

 In survivors of brain cancer as well as cancer outside the nervous system, the effects of radiotherapy on the brain’s longterm mental, sensory, cognitive  and motor  function and hormone output, are well known, even in the absence of nervous system malignancies or direct nervous system therapeutic irradiation. The same applies to the deadly longterm consequences of untreated overweeight-prediabetes-hypertension and HIV-AIDs.

Cramond 1968 is the earliest reference found on Pubmed search  (for cognitive impairment and cancer),  an omnibus pair of articles that reviewed all of organic psychosis – cognitive, mood and behaviour effects on the brain of organic disease;  but in the second article   he  quoted only a case of intracranial cancer.  He did not refer to brain effects of extracranial cancer or chemo-radiotherapy.

The first report of brain impairment after combined radio-chemotherapy appears on Pubmed in 1978.  

” Affective and cognitive effects of chemotherapy in cancer patients”   was  first linked in 1980  by  Silberfarb PM, Philibert D, and Levine PM         

 and Chemo brain in  a 2005 review  of  cognitive impairment in patients before any treatment. 

 By 2007 chemo fog was no longer regarded as an illusion in a major New York Times review

There are increasing numbers of long-lived survivors of cancer treatment -especially in middle-aged ie prime-time women after breast cancer. .

Now teams from Amsterdam and Oxford universities 2011,  and Harvard 2010,   show cognitive impairment is common long term in survivors treated even only with cancer chemotherapy for non- nervous system cancers. . This is associated with predictable white and grey matter damage from cytotoxic drugs- such poisons naturally damage healthy as well as killer cells.

 This was and is  the deadly fallacy of the profiteering screening xray mammography industry marketeering that “xray mammography saves lives” highlighted previously in this column, that lowdose irradiation and chemotherapy would not damage healthy tissues. .

Obviously this  cognitive impairment long term with cancer, and iatrogenic after chemo/radiotherapy,  must also be weighed up by the patient who faces multiple choices of therapies for cancer – especially as conventional allopathic cancer therapy does not cure even 10% of all cancers.

Most patients who die old – with or without a history of cancer- have some usually undiagnosed ie dormant cancer somewhere in their body.

This applies also to those considering having invasive screening tests for clinically asymptomatic cancers of eg the breast and prostate, for which the wished-for longterm benefits of preclinical diagnosis and treatment have been disproven, indeed discredited by the risks.. As a result, even the value of colon screening for all is being increasingly questioned in the asymptomatic without family history of colon disease.

This doubt about screening obviously falls away in patients who have strong risk (from previous cancer or family history) of the Big Five sexhormone-linked cancers – breast, prostate, colon, endometrium and ovary.

 Obviously accumulating life stresses, familial anxiety-depression and dementia,  aging-related vascular disease, smoking, alcohol, virus infection, multiple hormone and other imbalances (dietary and minerals; vitamin- and other biologicals) will compound the problem of cancer-therapy-associated mood, cognitive and behavioural  impairment. These need anticipation ie simple holistic prevention with safe natural supplements from as young as possible, to prevent both cancer and the other common comorbid degenerative diseases of aging.

The authoritative Life Extension Foundation lists many useful and often evidence-based brain-protective supplements.

www.cancer-prevention.net  is a comprehensive review of different strategies, although it strangely discredits itself because it is incomprehensibly undated, anonymous and unreferenced. .

 But each putative individual supplement can be simply referenced for it’s evdence base  on Google and Pubmed.

CONCLUSION: Like untreated asymptomatic hypertension, diabetes,  menopause and AIDs, cancer screening let alone cancer itself is often associated with  organic brain problems-  depression, cognitive and perhaps behavioural.  These require  evaluation and consideration at all time, especially in regards to invasive screening and management- or avoidance of these. Is eager consent to invasive screening or invasive therapy- or refusal thereof – truly informed ethical consent, understanding of benefits and risks?

 The similarity  between hypertension, HIV-AIDs and cancer is that both avoidance of risk factors, lifestyle and supplements can make a major difference.

The difference is that many cancers can be left well alone, the immune system optimized by optimal diet-lifestyle and supplements, with permanent remission or progression often unaffected by conventional allopathic cancer therapy. In asymptomatic eg lung, prostate and breast cancer, and eg asymptomatic chronic leukemia,  screening of those not  symptomatic, not at high risk is thus fultile. Treatment can wait till cancer if ever presents clinically, while all practice sensible prevention.

 In HIV carriers and asymptomatic overweight-prediabetes-hypertension in  Africa at least,  only a tiny proporttion will not progress to terminal AIDs or malignant diabetes-hypertension, so regular monitoring is necessary to decide when to start ARVs and metformin plus antihypertensives to prolong life and health for decades. It can be strongly arguesd that compulsory periodic HIV and waistgirth and bloodpressure screening are both lifesaving and in the public interest since early diagnosis and mandatory intervention can be life-and health-saving.

Helen Zille, the Leader of the Opposition here, has the last word this morning, on the paradigm shift in thinking needed  in ‘Tackling the new AIDs denialism’.

Is recklessly spreading AIDs by unprotected sex- as African male culture apparently still promotes despite the outrage the promiscuous  then deputy-president Jacob Zuma himself provoked a decade ago in his rape trial- any different from reckless promotion of harmful screening xray mammography, or the legislative ignoral of the need for regular mandatory screening for hypertension and HIV?

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NEGLIGENT PROMOTION OF SCREENING XRAY MAMMOGRAPHY AS SAVING LIVES.

neil.burman@gmail.com

Two weeks ago, in response to mounting international concern for the welfare of older women, the UK government announced that it is setting up an independent review of the risks and benefits of xray mammography screening. 

 It has been publicised since the 1970s that low-dose mammographic irradiation may increase risk of breast cancer 4 (to 6) fold, and more so in women with a genetic risk. (Heyes ea 2006 Dept Medical Physics Birmingham Hospital UK; publicised studies -including from survivors of atomic bomb exposure).

A new French study published this month confirms in human breast cancer cells that a significant dose-effect of lowdose irradiation was observed, “with an exacerbation in high-risk compared to low-risk patients (p = 0.01). The dose repetition (2 + 2 mGy) provided more induced and more unrepaired DSB than 2 mGy and 4 mGy, and was exacerbated in HR (p = 0.006). ”

 Just three weeks after the last review in this column of the mounting evidence against xray breast screening, at least 4 more major studies (three from USA) have been published the past month refuting the marketing spiel that “Xray screening Mammography Saves Lives” :

1. A trenchant debunking appeared in the New York Times a fortnight ago based on the latest USA Dartmouth University study of USA 20 year national Breast cancer statistics published in a leadng medical journal that day It concluded: “Most (87% to 97% of) women found to have breast cancer by xray screening are not helped by the test. Only some 4% to 8% of women with breast cancer so detected are helped by such screening. Most are instead either diagnosed early (with no effect on their mortality) or overdiagnosed. Thus of millions of average-risk asymptomatic women having breast irradiation screening each year, only 1 in 10 000 really benefit.”  They put the risk of having breast cancer found on xray screening at 2% over 10years ie 0.2% per year in a 50year old women, and her 20 year risk of dying of breast cancer at 1% . Most women with screen-detected breast cancer have not had their life saved by screening.  

 Dr Susan Love a leading USA professor of surgery would like to see “less emphasis on screening and more focus on cancer prevention and treatment for the most aggressive cancers, particularly those that affect younger women. Roughly 15 percent to 20 percent of breast cancers are deadly. And even with screening, bad cancers are still bad. ” 

Dr Cornelia Baines an emeritus professor at the University Toronto affirms that “the benefit (of breast xray screening) is much smaller in terms of avoiding death than is the harm arising from over-diagnosis and unnecessary treatment for breast cancer, to say nothing of increased rate of mastectomy associated with screening.These issues are not widely known to the general public. ”

 2. Similarly, a massive study from  Georgetown University Washington DC, concluded that  “Biennial screening from 50-74 reduces the probability of breast cancer death from 3% to 2.3%. Screening annually from 40 to 84 only lowers mortality an additional one-half of one percent to 1.8% but requires substantially more mammograms and yields more false-positives and over-diagnosed cases. Decisions about screening strategy depend on preferences for benefits vs. potential harms and resource considerations”.

 3. A pan-USA consortium found that in 170 000 USA women followed with xray screening annually for 10 years, more than half of women received at least 1 false-positive recall, and 7% to 9% a false-positive biopsy recommendation.

 And finally a survey of the Swedish screening mammography program since 1986 found similar outcome as in the Norwegian program: “the 4-year cumulative incidence of invasive breast cancer was -significantly higher in the screened group by 49% (982 per 100 000) than it was in the control group (658 per 100 000). Because the cumulative incidence among controls did not reach that of the screened group, we believe that many invasive breast cancers detected by repeated xray screening do not persist to be detected by screening at the end of 6 years, suggesting that the natural course of many of the screen-detected invasive breast cancers is to spontaneously regress”.

It is obvious to most when the light is switched off; and that lengthy exposure to intense sunshine damages- no randomized cotrolled trials are needed. Conversely it took millennia before most educated people recognized that neither our Earth nor Sun are the centre of the universe- and many people still do not believe in human rights..

 In contrast to eternal human need for mysticism /spiritualism promoting blind faith in deities and prayer and an afterlife, rationalists like Steven Jay Gould argue irrefutably that science and religion are incompatible non-overlapping magisteria. Even Kierkegaard had to admit this in conceding that its tough going against mainstream belief however strong and wrong the mainstream may be, even though religious belief is simply that- irrational blind faith. From the heart, not from rational reasoning.

 Search of Pubmed for “randomized controlled trials screening xray mammography” yields not a single trial. In fact the only truly randomized long trial ever conducted with modern xray mammography – the Canadian Breast Screening trial between 1980 and 1990 and comparing manual self-examination alone versus combined with xray mammography (Miller & Baines 1997) – showed that adding screening xray mammography had no impact on the rate of death from breast cancer at up to 13 years’ follow-up from entry.

This outcome has never been disproven except in the minds of those who zealously promote the $8billion a year xray mammography industry, whatever their vested interests from fundraising organizations to service providers and screening machine manufacturing countries.

There are thus at least 20 studies already published showing that screening xray mammography has no benefits compared to its many risks, for reduction in future breast cancer and breast procedures or mortality.

  So it is ethically, morally and scientifically negligent to continue to promote fearmongering  xray screening mammography without explaining to women that xray screening has no benefit for survival from breast cancer, and may in fact not just promote fruitles pain, anxiety, mastectomy and radiochemotherapy but also hasten death.

Should screening xray mammography even still be offered as a diease-mongering  choice for women ? when it is now so well proven by independent studies and expert reviewers that it offers no benefit over regular manual breast examination, but indeed offers many cumulative risks to women, at great cost to individual women and society.

The analogy is the sale of tobacco smoking and alcohol. Unlike the safe use of moderate social alcohol in private, should aggressive promotion, marketing of xray breast mammography, smoking,  alcohol and other addictive drug (like designer antidepressants and other psychotropics) consumption be allowed at all?