Ian Gawler Blog: Over-medicalisation, mammography and PSA screening

This week, big questions posed by new research concern the over-medicalisation of our health and wellbeing. Key examples cast big doubts over the merits of mammography for 50 yo women and PSA blood tests for prostate cancer in healthy men.

Next come telling comments from the MJA re why they did not publish the controversial article on me, The Age has another go at the Foundation, while another massive review of evidence comes out connecting nutrition with breast cancer.

But first, please do not believe what I say, just because I said it!

Thought for the day: Arrive at your own truth.

At the end of my early workshops I would often say “Everything you may have heard today could be untrue”. Some people were understandably unsettled and required an explanation. Why did I say it? Because I see the truth in the quote that follows, and have always been guided by it. 

"Don't blindly believe what I say. Don't believe me because others convince you of my words. Don't believe anything you see, read, or hear from others, whether of authority, religious teachers or texts. Don't rely on logic alone, nor speculation. Don't infer or be deceived by appearances.

"Do not give up your authority and follow blindly the will of others. This way will only lead to delusion.

"Find out for yourself what is truth, what is real. Discover that there are virtuous things and there are non-virtuous things. Once you have discovered for yourself, give up the bad and embrace the good."

- The Buddha

If someone leaves a program I have presented and says something like “I am eating this way now because Ian said so”, they have really missed the point and I would be very disappointed. 

If they say “I heard what Ian said, have considered it, and have chosen to eat this way”, then I am happy.


Research claims over half breast cancers would amount to nothing if left untreated, and raises questions about breast screening

Writing in the prestigious British Medical Journal, academics from Australia and Canada, claim up to 54% of breast cancers detected in women in their 50s by breast cancer screening would never have manifested clinically.

The article goes on to identify the phenomenon of over-medicalisation, saying healthy people are increasingly harmed by a barrage of unnecessary tests, procedures and drugs. The tendency to over-screen, over-diagnose and over-treat has become rampant in modern medicine, and poses a “significant threat to human health”.

 “Screening programs are detecting early cancers that will never cause symptoms or death, sensitive diagnostic technologies identify ‘abnormalities’ so tiny they will remain benign, while widening disease definitions mean people at ever-lower risks receive permanent medical labels and lifelong treatments that will fail to benefit many of them.”

ADHD, chronic kidney disease, gestational diabetes and prostate cancer were also key areas for concern, they said. Even asthma is over-diagnosed in up to 30% of cases, the authors said.

The article was timed to promote a new international conference called Preventing Overdiagnosis, that will aim to better assess the problem and begin working on solutions.

Click here for the reference: BMJ 2012; online.


Healthy men do not need PSA screens

Controversy has raged for some years about men being routinely screened for prostate cancer using blood PSA tests. I remember cringing while being a part of an SBS TV Insight program where Prof Alan Coates suffered the most vitriolic and personal attack from a prominent and highly emotional politician really suffering from prostate cancer and abusing Coates mercilessly for suggesting the scientific evidence did not support routine PSA testing. Coates was CEO of the Cancer Council of Australia at the time and he endured ongoing professional and personal criticism for his stance.  

However, recently the prestigious US Preventive Services Task Force (USPSTF) has added to this debate, claiming that PSA-based screening could not be widely recommended, due to the “inevitable” risk of over-diagnosis and harms of treatment.

It acknowledged that some men would continue to demand PSA tests, and that some doctors would continue to offer them, but said this should only occur through fully informed, shared decision making. The USPSTF said community and employer-based screening should be stopped altogether. It based its recommendations on an extensive literature review.

“The mortality benefits of PSA-based prostate cancer screening through 11 years are, at best, small and potentially none, and the harms are moderate to substantial,” said the final statement, published in the Annals of Internal Medicine.

The Prostate Cancer Foundation of Australia branded the recommendations “unhelpful”, and not directly applicable to Australia.


NEWS

1. The Medical Journal of Australia explains why it did not publish 

- with direct quotes

First: I did not give my permission and they value patient rights

Second: The article "presented supposition, nothing new in the way of facts".

Finally:  The Editor, Annette Katelaris summarised, and again I quote "patient consent, accountable editorial processes and an articles validity, significance and potential to advance medical practice are primary considerations in the MJA's editorial decisions...  These principles were applied in the MJA's final decision not to publish the article".

Conclusion: The Journal of Internal Medicine Journal obviously has different standards that allowed them to publish.

The letter that provoked the response, along with the editorial, will be linked to on my website soon.


2. Good nutrition may reduce the progression or recurrence of breast cancer.

Following on from last week’s blog on nutrition and cancer, comes news of a major work citing 353 references put together by Natalie Ledesma from the University of California, San Francisco.

Link here for the full work which makes for compelling reading:

Here is Natalie’s summary:

Good nutrition may reduce the incidence of breast cancer and the risk of breast cancer progression or recurrence. There are many studies in progress to help further understand how diet and cancer are related. We do know, however, that improved nutrition reduces risk of chronic diseases, such as diabetes, obesity, hypertension and heart disease, and also enhances overall quality of life. It is estimated that one third of cancer deaths in the U.S. can be attributed to diet in adulthood.


3. The Age is at it again!

A personal account has been published in the Medical Journal of Australia by a Melbourne psychiatrist who attended the Gawler Foundation’s 12 week non-residential cancer program. Writing under the strident headline “Doctor denounces Gawler program's 'harsh' healing”, health editor Julia Medew quotes and comments on the patient’s concerns regarding the rigours of the dietary approach, perceived guilt around the cancer prone personality, and the suggestion her group leader said there was no evidence chemotherapy works.

Join the link, read and decide for yourself.

I wish the psychiatrist good health and a long and happy life. Discussion, feedback and constructive criticism is always welcome, even when it turns up for the first time in a medical journal.

Comments from the Foundation’s CEO, Karin Knoester and the oncologist from Peter Mac seem worth quoting directly.

“Ms Knoester said although no independent evaluations had shown the Gawler programs were an effective cancer treatment, there was evidence that nutrition, exercise, meditation and positive thinking could all on their own help people overcome illness.

Deputy Head of Oncology at Peter MacCallum Cancer Centre, Associate Professor Michael Jefford, said he got the impression from patients that the Gawler Foundation's staff were ''overvaluing'' their therapies while telling people conventional treatments were less effective and more toxic than they really are.

''There is very good evidence for the efficacy of chemotherapy … so to say it doesn't work is blatantly wrong,'' he said. “There is also good evidence that chemotherapy improves quality of life … so to say it's toxic is incorrect.''

My comment. 

1. The Morgan study of 2004 reviewed the 5 year increased survival benefits of chemotherapy for the major 22 cancers at an average of 2.3%. Modest efficacy overall, although chemotherapy does have major benefits for a number of the less common cancers, including some of those that affect children. (I know of no more recent comprehensive review since that of Morgan in 2004. It was not very popular in oncology or the popular press at the time, but not refuted, apart from Prof Boyer who claimed on ABC radio he could “massage” the figures up to 5 - 6%!).

2. There is good evidence that chemotherapy impacts adversely on some people’s quality of life and that most chemotherapy is given with palliation in mind, not cure. Therefore the equation of pluses and minuses has to be considered carefully when making decisions regarding this form of treatment. No doubt good oncologists inform their patients of the risks and benefits, encourage open dialogue and assist in the making of good clinical choices.

3. If chemotherapy is not toxic, why is it called cytotoxic therapy? I wonder if Professor Jefford was quoted accurately.

People who do choose to have chemotherapy will benefit from a healthy, therapeutic lifestyle that is highly likely to reduce the risk of side-effects, improve survival and improve quality of life. The two, chemotherapy and a therapeutic lifestyle, work well together. This should be a co-operative venture.

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