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

Abstract

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
By GARDINER HARRIS

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.