Vision: A Healthy population in Fiji that is driven by a caring health care delivery system. Mission: To provide a high quality health care delivery services by a caring and committed workforce working with strategic partners through good governance, appropriate technology and appropriate risk management facilitating a focus on patient safety and best health status for the citizens of Fiji.

Medicine, media and accountability

Medicine, media and accountability: What’s the hazard ratio of that?

Here is a copy of an email I received from a friend the other day (all bold emphasis is mine):

Begin forwarded message:

From: Chetan xxxxxxxx
Date: February 9, 2010 11:51:46 PM SST
To: Tej Deol
Subject: 2 cokes a day…

You were saying that there is no issue drinking several cokes a day… the study says you have an 87% chance higher risk…. take a look, made huge news a few days ago in the States.

My friend quoted 3 sources including WebMD, an article in Reuters, and the actual abstract from the Medical Journal, Cancer Epidemiology, Biomarkers & Prevention February 2010 19; 447 . Here is the actual abstract:

Soft Drink and Juice Consumption and Risk of Pancreatic Cancer: The Singapore Chinese Health Study


Background: Sugar-sweetened carbonated beverages (called soft drinks) and juices, which have a high glycemic load relative to other foods and beverages, have been hypothesized as pancreatic cancer risk factors. However, data thus far are scarce, especially from non-European descent populations. We investigated whether higher consumption of soft drinks and juice increases the risk of pancreatic cancer in Chinese men and women.

Methods: A prospective cohort analysis was done to examine the association between soft drink and juice consumption and the risk of pancreatic cancer in 60,524 participants of the Singapore Chinese Health Study with up to 14 years of follow-up. Information on consumption of soft drinks, juice, and other dietary items, as well as lifestyle and environmental exposures, was collected through in-person interviews at recruitment. Pancreatic cancer cases and deaths were ascertained by record linkage of the cohort database with records of population-based Singapore Cancer Registry and the Singapore Registry of Births and Deaths.

Results: The first 14 years for the cohort resulted in cumulative 648,387 person-years and 140 incident pancreatic cancer cases. Individuals consuming ≥2 soft drinks/wk experienced a statistically significant increased risk of pancreatic cancer (hazard ratio, 1.87; 95% confidence interval, 1.10-3.15) compared with individuals who did not consume soft drinks after adjustment for potential confounders. There was no statistically significant association between juice consumption and risk of pancreatic cancer.

Conclusion: Regular consumption of soft drinks may play an independent role in the development of pancreatic cancer. Cancer Epidemiol Biomarkers Prev; 19(2); 447–55

WOW. Look at that conclusion: “soft drinks may play an independent role”. It doesn’t get more definitive than that. Good reason to provoke public anxiety. Eating durians (despite the smell) “may” bring you wealth. “And in a “Look at Me!” article title published by WebMD:

Study Says 2 Sodas Per Week Raises Pancreatic Cancer Risk; Beverage Industry Says Study Is Flawed
By Kathleen Doheny
WebMD Health News
Reviewed by Louise Chang, MD

Feb. 8, 2010 — Drinking as little as two soft drinks a week appears to nearly double the risk of getting pancreatic cancer, according to a new study.

”People who drank two or more soft drinks a week had an 87% increased risk — or nearly twice the risk — of pancreatic cancer compared to individuals consuming no soft drinks,” says study lead author Noel T. Mueller, MPH, a research associate at the Cancer Control Program at Georgetown University Medical Center, Washington, D.C. The study is published in Cancer Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research.

The beverage industry took strong exception to the study, calling it flawed and pointing to other research that has found no association between soda consumption and pancreatic cancer.

etc etc…

Buried in the second page relative to attention-grabber:

The beverage industry protested the results. ”The study has a lot of weaknesses in it,” Richard Adamson, PhD, scientific consultant for the American Beverage Association in Washington, D.C., tells WebMD.

One example, he says, are the small numbers of pancreatic cancer cases. He points out that of the 140 cases, 110 of those people did not drink sodas, while 12 had less than two servings a week, and 18 had two or more servings a week.

”It has a small number of pancreatic cancer cases compared to the population studied,” he tells WebMD.

Other studies have found no link, he tells WebMD.

In a statement attributed to Adamson, the American Beverage Association points to a 2008 study finding no such link. It also takes exception to the focus on soft drinks rather than overall dietary patterns.

The Reuters article provided this message of caution as well:

But Susan Mayne of the Yale Cancer Center at Yale University in Connecticut was cautious.

“Although this study found a risk, the finding was based on a relatively small number of cases and it remains unclear whether it is a causal association or not,” said Mayne, who serves on the board of the journal, which is published by the American Association for Cancer Research.

“Soft drink consumption in Singapore was associated with several other adverse health behaviors such as smoking and red meat intake, which we can’t accurately control for.”

Other studies have linked pancreatic cancer to red meat, especially burned or charred meat.

As we can see, people pay a lot of attention to titles and sometimes skip the ‘meat and potatoes’. (Mis) Information is easily spread in the digital age and apparently sometimes accountability need not apply. This month, in the NY Times, we got this encouraging, but LONG OVERDUE, action by a highly respected British journal of medicine, the Lancet:

February 3, 2010
Journal Retracts 1998 Paper Linking Autism to Vaccines

A prominent British medical journal on Tuesday retracted a 1998 research paper that set off a sharp decline in vaccinations in Britain after the paper’s lead author suggested that vaccines could cause autism.

The retraction by The Lancet is part of a reassessment that has lasted for years of the scientific methods and financial conflicts of Dr. Andrew Wakefield, who contended that his research showed that the combined measles, mumps and rubella vaccine may be unsafe.

But the retraction may do little to tarnish Dr. Wakefield’s reputation among parents’ groups in the United States. Despite a wealth of scientific studies that have failed to find any link between vaccines and autism, the parents fervently believe that their children’s mental problems resulted from vaccinations.

Tom Skinner, a spokesman for the Centers for Disease Control and Prevention, called the retraction of Dr. Wakefield’s study “significant.”

“It builds on the overwhelming body of research by the world’s leading scientists that concludes there is no link between M.M.R. vaccine and autism,” Mr. Skinner wrote in an e-mail message.

A British medical panel concluded last week that Dr. Wakefield had been dishonest, violated basic research ethics rules and showed a “callous disregard” for the suffering of children involved in his research. Dr. Richard Horton, editor in chief of The Lancet, said that until that decision, he had no proof that Dr. Wakefield’s 1998 paper was deceptive.

“That was a damning indictment of Andrew Wakefield and his research,” Dr. Horton said.

With that decision, Dr. Horton said he could retract the 1998 paper. Dr. Wakefield could not be reached for comment.

Jim Moody, a director of SafeMinds, a parents’ group that advances the notion the vaccines cause autism, said the retraction would strengthen Dr. Wakefield’s credibility with many parents.

“Attacking scientists and attacking doctors is dangerous,” he said. “This is about suppressing research, and it will fuel the controversy by bringing it all up again.”….

….After Dr. Wakefield’s study, vaccination rates plunged in Britain and the number of measles cases soared. etc etc….

I wonder what is the responsibility of The Lancet in evaluating papers for publish. Can any Tom, Dick, or Andrew simply walk up and submit or are reasonable generally accepted principles of scientific research respected especially in news which the media may exploit. Dr. Horton, the editor in chief of The Lancet, claimed that “….until that decision, he had no proof that Dr. Wakefield’s 1998 paper was deceptive”. However, one year ago, this was published:

Times Online

From The Sunday Times
February 8, 2009
MMR doctor Andrew Wakefield fixed data on autism
Brian Deer

THE doctor who sparked the scare over the safety of the MMR vaccine for children changed and misreported results in his research, creating the appearance of a possible link with autism, a Sunday Times investigation has found.

Confidential medical documents and interviews with witnesses have established that Andrew Wakefield manipulated patients’ data, which triggered fears that the MMR triple vaccine to protect against measles, mumps and rubella was linked to the condition.

The research was published in February 1998 in an article in The Lancet medical journal. It claimed that the families of eight out of 12 children attending a routine clinic at the hospital had blamed MMR for their autism, and said that problems came on within days of the jab. The team also claimed to have discovered a new inflammatory bowel disease underlying the children’s conditions.

However, our investigation, confirmed by evidence presented to the General Medical Council (GMC), reveals that: In most of the 12 cases, the children’s ailments as described in The Lancet were different from their hospital and GP records. Although the research paper claimed that problems came on within days of the jab, in only one case did medical records suggest this was true, and in many of the cases medical concerns had been raised before the children were vaccinated. Hospital pathologists, looking for inflammatory bowel disease, reported in the majority of cases that the gut was normal. This was then reviewed and the Lancet paper showed them as abnormal.

Despite involving just a dozen children, the 1998 paper’s impact was extraordinary. After its publication, rates of inoculation fell from 92% to below 80%. Populations acquire “herd immunity” from measles when more than 95% of people have been vaccinated.

Last week official figures showed that 1,348 confirmed cases of measles in England and Wales were reported last year, compared with 56 in 1998. Two children have died of the disease.

And finally exposed…

The Shame of the Lancet’s Shoddy Autism Study Retraction
By Jim Edwards | Feb 3, 2010

The Lancet has published a retraction of a 1998 study by Andrew Wakefield that purported to show a link between vaccines and autism in children. The retraction is a full-scale reversal and denial of a key study that for years has been used as evidence by parents who believe (wrongly, as it turns out) that vaccines cause autism. But as Matthew Herper of Forbes points out, the wording of the Lancet’s retraction is virtually impossible to understand, and could muddy rather than clarify a debate which many parents of autistic children have tragically misunderstood. Herper:

… the Lancet uses language that is likely to be impenetrable to anyone not versed in the scientific literature. The retraction, as published, reads:

Following the judgment of the UK General Medical Council’s Fitness to Practise Panel on Jan 28, 2010, it has become clear that several elements of the 1998 paper by Wakefield et al* are incorrect, contrary to the findings of an earlier investigation. In particular, the claims in the original paper that children were “consecutively referred” and that investigations were “approved” by the local ethics committee have been proven to be false. Therefore we fully retract this paper from the published record.

(I’m quoting Herper’s version of the retraction because the Lancet has hidden its version in part behind a pay wall!)

That retraction gives you no idea of how bad Wakefield’s study actually was. Among its flaws, the kids were not picked at random. Wakefield (pictured) gathered them from parents who already believed vaccines may have triggered their autism. He also took £55,000 in fees from a legal aid society connected to a lawyer who wanted to sue vaccine makers. And, as The Guardian notes:

He was also found to have unethically arranged for his son’s friends to have blood samples taken from them during his birthday party – for which he paid them £5 each.

Even if you throw out the stuff about paying study participants and gathering data from a self-selecting population, and the financial conflict, the fact that there were only twelve children in the study ought to have indicated that its data was virtually worthless. (Gold-standard studies have hundreds or thousands of patients.)

Yet because it was published in the Lancet and concluded with a “link” between autism and vaccines, parents with autistic children have been searching and advocating a link between the two ever since.

etc etc …

So the media played both angles the way it usually does. First bringing on the panic with initial news release, then subsequently benefiting from exposing the reality. However, Medical Journals have reputations to protect and a responsibility to ensure the highest standards of scientific research are pursued before they publish. It is clear that in this case that was absent. People suffered and even died as a result of contracting measles due to the decline in immunization rates. The only question is will The Lancet be held accountable.

Comments (2,721)

Said this on 21/09/2010 At 10:38 am

good approach

Dr Anand shukla



Said this on 27/09/2010 At 09:42 am

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Said this on 17/11/2010 At 03:31 am

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dr anand shukla

Said this on 25/12/2011 At 09:38 pm
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Said this on 25/12/2011 At 09:38 pm
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Said this on 29/01/2012 At 06:07 am
This shows real exeprtsie. Thanks for the answer.
Said this on 04/03/2012 At 09:00 pm
I think another ctueribntor to the largeness of NBCAM, in addition to hard work, is something pretty simple. Breasts are on the outside of the body and are an immediately recognized and highly visible symbol of femininity. Due to the high visibility and natural awareness of the breasts, this particular cause receives a lot of attention. Fortunately, advances in Breast cancer research will ultimately help advance research in other cancers as well. Not to trivialize Breast cancer or to make a direct comparison of the level of impact the two can have on an individual's life, but in terms of awareness campaigns, it's sort of like campaigns to save different endangered animals. The cutest ones who do the most interesting things, such as the giant panda and whales, end up getting a lot more attention than say the dwarf wedge mussel. However, all is not lost for efforts to save other lesser known endangered species because the campaigns for the panda act as a sort of gateway (for many people) to a broader awareness of conservation efforts and activism. Sign up to help save one, and the World Conservation Union will be sure to let you know about others that you weren't aware of. Not to mention, many people will seek the info out on their own as they begin to wonder what other species are endangered. After all, if we can let something as cute as the panda get on the endangered list, what other things are we neglecting. NBCAM similarly becomes a gateway to awareness of cancer in general, which is a positive thing. If something as visible as Breasts can be affected, what about everything else we can't see? (And come to think of it, the two are related. Keys to fighting cancer may be held in species of plants and animals that are dying off that most people don't know about.)Ultimately, I think the high profile of NBCAM is beneficial. On the one hand, some frustration over not having as much attention given to other cancers is understandable, but we also have to be careful about not diluting the beneficial impact of NBCAM on all cancer efforts by running too many derivative campaigns. If we end up with a major colored ribbon month for every cancer, even NBCAM could lose its voice as the audience becomes fatigued. All cancer efforts would then begin to suffer. I also understand the distaste for a lot of the marketing surrounding NBCAM, but the fact of the matter is, marketing has a huge impact on awareness and thus involvement. There will be people who make money off of it by not directly contributing to efforts, but as unappealing as that may be to those not familiar with marketing and business, the harsh reality is that if some form of market cannot form around something, you simply will not yield the same results. It's taking the good with the bad, unfortunately. Capitalism is a double-edged sword, that's for sure. As someone else pointed out though, individuals can (and should) make choices to purchase pink-ribbon items through vendors who are known to maximize contributions to research and education efforts, or those who work in conjunction with the actual nonprofit organizations. Someone mentioned think before you pink . Individuals and facilities can also seek out vendors through (NBCAM=National Breast Cancer Awareness Month).
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Said this on 09/04/2012 At 09:39 am
Family History as a Risk Factor for Breast CancerIn cross-sectional studies of adult potluapions, 5% to 10% of women have a mother or sister with Breast cancer, and about twice as many have either a first-degree relative or a second-degree relative with Breast cancer.[3-6] The risk conferred by a family history of Breast cancer has been assessed in both case-control and cohort studies, using volunteer and population-based samples, with generally consistent results.[7] In a pooled analysis of 38 studies, the relative risk (RR) of Breast cancer conferred by a first-degree relative with Breast cancer was 2.1 (95% confidence interval [CI], 2.0-2.2).[7] Risk increases with the number of affected relatives and age at diagnosis.[4,5,7] Refer to the Penetrance of Mutations section for a discussion of familial risk for women from families with BRCA1/2 mutations who themselves test negative for the family mutation. Autosomal Dominant Inheritance of Breast/Ovarian Cancer PredispositionAutosomal dominant inheritance of breast/ovarian cancer is characterized by transmission of cancer predisposition from generation to generation, through either the mother’s or the father’s side of the family, with the following characteristics: Inheritance risk of 50%. When a parent carries an autosomal dominant genetic predisposition, each child has a 50:50 chance of inheriting the predisposition. Although the risk of inheriting the predisposition is 50%, not everyone with the predisposition will develop cancer because of incomplete penetrance and/or gender-restricted or gender-related expression.Both males and females can inherit and transmit an autosomal dominant cancer predisposition. A male who inherits a cancer predisposition and shows no evidence of it can still pass the altered gene on to his sons and daughters. Breast and ovarian cancer are components of several autosomal dominant cancer syndromes. The syndromes most strongly associated with both cancers are BRCA1 or BRCA2 mutation syndromes. Breast cancer is also a common feature of Li-Fraumeni syndrome due to TP53 mutations; of Cowden syndrome due to PTEN mutations; and with mutations in CHEK2 .[9] Other genetic syndromes that may include Breast cancer as an associated feature include heterozygous carriers of the ataxia telangiectasia (AT) gene and Peutz-Jeghers syndrome. Ovarian cancer has also been associated with Lynch syndrome, basal cell nevus (Gorlin) syndrome (OMIM), and multiple endocrine neoplasia type 1 (MEN1) (OMIM).[9] Mutations in each of these genes produce different clinical phenotypes of characteristic malignancies and, in some instances, associated nonmalignant abnormalities.The family characteristics that suggest hereditary Breast and ovarian cancer predisposition include the following: Cancers typically occur at an earlier age than in sporadic cases (defined as cases not associated with genetic risk). Two or more primary cancers in a single individual. These could be multiple primary cancers of the same type (e.g., bilateral Breast cancer) or primary cancer of different types (e.g., Breast and ovarian cancer in the same individual). Cases of male Breast cancer.Possible increased risk of other selected cancers and benign features for males and females. (Refer to the Major Genes section of this summary for more information.)There are no pathognomonic features distinguishing Breast and ovarian cancers occurring in BRCA1 or BRCA2 mutation carriers with those occurring in noncarriers. Breast cancers occurring in BRCA1 mutation carriers are more likely to be estrogen receptor (ER)-negative, progesterone receptor (PR)-negative, and HER2/neu receptor-negative and have a basal phenotype. BRCA1-associated ovarian cancers are unlikely to be of mucinous or borderline histopathology. [Refer to the Pathology/Prognosis of Breast Cancer and Pathology/Prognosis of Ovarian Cancer sections for more information.]Difficulties in Identifying a Family History of Breast and Ovarian Cancer RiskWhen using family history to assess risk, the accuracy and completeness of family history data must be taken into account. A reported family history may be erroneous, or a person may be unaware of relatives affected with cancer. In addition, small family sizes and premature deaths may limit the information obtained from a family history. Breast or ovarian cancer on the paternal side of the family usually involves more distant relatives than on the maternal side and thus may be more difficult to obtain. When comparing self-reported information with independently verified cases, the sensitivity of a history of Breast cancer is relatively high, at 83% to 97%, but lower for ovarian cancer, at 60%.[10,11]Other Risk Factors for Breast CancerOther risk factors for Breast cancer include age, reproductive and menstrual history, hormone therapy, radiation exposure, mammographic Breast density, alcohol intake, physical activity, anthropometric variables, and a history of benign Breast disease. (Refer to the PDQ summary on Prevention of Breast Cancer for more information.) These factors are considered in more detail in numerous reviews,[12,13] including among BRCA1/BRCA2 mutation carriers.[14] Brief summaries are given below, highlighting, where possible, the effect of these risk factors in women who are genetically susceptible to Breast cancer. (More information about their effects in BRCA1/BRCA2 mutation carriers can be found in the section on Interventions later in this document.) AgeCumulative risk of Breast cancer increases with age, with most Breast cancers occurring after age 50 years.[15] In women with a genetic susceptibility, Breast cancer, and to a lesser degree, ovarian cancer, tends to occur at an earlier age than in sporadic cases. Reproductive and menstrual historyBreast cancer risk increases with early menarche and late menopause, and is reduced by early first full-term pregnancy. Although results have been complex and may be gene dependent, several studies have suggested that the influence of these factors on risk in BRCA1/BRCA2 mutation carriers appear to be similar to noncarriers.[14,16]Oral contraceptivesOral contraceptives may produce a slight increase in Breast cancer risk among long-term users, but this appears to be a short-term effect. In a meta-analysis of data from 54 studies, the risk of Breast cancer associated with oral contraceptive use did not vary according to a family history of Breast cancer.[17] Oral contraceptives are sometimes recommended for ovarian cancer prevention in BRCA1 and BRCA2 mutation carriers, but studies of their effect on Breast cancer risk have been inconsistent.[18-20] Hormone Replacement TherapyData exist from both observational and randomized clinical trials regarding the association between postmenopausal hormone replacement therapy (HRT) and Breast cancer. A meta-analysis of data from 51 observational studies indicated a RR of Breast cancer of 1.35 (95% CI, 1.21–1.49) for women who had used HRT for 5 or more years after menopause.[21] The Women's Health Initiative (WHI), a randomized controlled trial of about 160,000 postmenopausal women, investigated the risks and benefits of HRT. The estrogen-plus-progestin arm of the study, which randomized more than 16,000 women to receive combined HRT or placebo, was halted early because health risks exceeded benefits.[22,23] Adverse outcomes prompting closure included significant increase in both total (245 vs. 185 cases) and invasive (199 vs. 150 cases) Breast cancers (RR = 1.24; 95% CI, 1.02–1.5, P
Said this on 24/05/2012 At 11:27 pm
Yes, it is. With stage IV breast caecnr the choice of chemotherapy treatment depends on the patient's goal of treatment. If the goal of treatment is to reduce symptoms and improve quality of life, it may be more desirable to select a chemotherapy treatment with minimal side effects. On the other hand, if the goal of treatment is to attempt to cure the caecnr, treatment with more aggressive chemotherapy regimens is opted. Either way, all the new advanced drug therapies have recorded average survival rates of fewer than 24 months—so your mom sure had a passion for life! Here are some recent trial findings:ET (Ellenceae (epirubicin) and Taxotereae (docetaxel)): In a randomized clinical trial comparing ET to FEC (fluorouracil, epirubicin, and cyclophosphamide) as first-line therapy for stage IV breast caecnr, the response rate to ET was 63%, compared to 31% for FEC. The average time to caecnr progression was 8.6 months for patients treated with ET, compared to 6.1 months for patients treated with FEC.TAC (docetaxel, doxorubicin, and cyclophosphamide): In an attempt to further improve treatment, a third drug has been added to the combination of doxorubicin and docetaxel and evaluated as initial treatment for patients with stage IV breast caecnr. Two years following treatment, nearly 60% of patients were still alive. The average survival had not yet been established past two years following treatment.AT (doxorubicin and paclitaxel): A recent clinical trial evaluated the use of AT in patients with stage IV breast caecnr. Patients received AT or a common chemotherapy combination consisting of fluorouracil, doxorubicin and cyclophosphamide (FAC). The results of the two groups were then directly compared. The average survival time was 23.3 months for patients receiving AT versus 18.3 months for patients receiving FAC.Taxotereae (docetaxel) and Xelodaae (capecitabine): Researchers conducted a clinical trial to directly compare docetaxel plus capecitabine to docetaxel alone in the treatment of patients with stage IV breast caecnr. Patients who received treatment with docetaxel/capecitabine were more likely to experience anti-cancer responses, have a longer time to caecnr progression and survive longer when compared to patients treated with docetaxel alone. One year following therapy, 57% of patients treated with docetaxel/capecitabine had survived, compared to only 47% of patients treated with docetaxel alone.Gemzarae (gemcitabine): Recently, clinical trials indicated that gemcitabine and paclitaxel is an effective treatment option for initial therapy of stage IV breast caecnr. In one trial, researchers from France treated 36 patients with stage IV breast caecnr or locally advanced breast caecnr with gemcitabine and paclitaxel. Following therapy, approximately 42% of patients had an anti-cancer response. The average time to caecnr progression was approximately 7.5 months.
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