Skeptical Medicine Living longer

Thanks to Allan and U3A for asking me to give a talk on scientific medicine today though I have termed it skeptical medicine. Apart from being a standout headline I wished to draw attention to the fact that scientific medicine has moved beyond  the standard of faith that it enjoyed with most other alternative forms of medicine but has failed in important areas to bring people along with it. Along with providing proof of effect scientific medicine also opens the door to doubt at the same time. I hope to open some of those doors today and correct or clean up the doubt where possible and leave open those doors where science needs to be more rigourous.
I was asked if skepticism was a good word to use in these politically correct times. In fact it is very appropriate because skepticism and  its counterpoint faith are the cornerstones of the progress in medicine.

Medicine is the science of healing concerned with the health of individuals first and then populations. It consists of diagnosis and treatment of medical conditions, originally of the body but also those of the psyche based on reproducible theory. Healing is an innate function of the human body and mind and the body has developed many repair mechanisms to go along with it defensive ones. Medicine is the art of helping the body and mind repair as much as is possible.Hi.

When these fail to work, breakdown or work to slowly As medicine has developed new ideas, treatments and medications replaced older  treatments. [ Osler 11]Feynman , an American scientist has said on science . “It only takes one experiment showing the opposite to disprove a theory”

What is really interesting from a medical perspective is how unskeptical of alternate medicine most people are. To illustrate I will ask hands up those people here who have taken vitamins in their lives? Almost everyone here.

Vitamins  are they good for us to take.

We have a great scientific knowledge of what they are and what they do.
Most people know and use the more common ones.
A through to K,  B 1-B 12  with some gaps there are 13 Vitamins. They are essential to life because they are not normally able to be made in our bodies [exception Vit D].
We have evolved in a world where we interact and depend on our food sources and if we have enough food we get more than enough vitamins.
They are all  available even through a restricted diet or junk food hence there is no need to supplement them as we always get more than we need.
As we get more than we need taking more does not make our bodies any better off.
In some cases e.g. Vitamin A, overdosing can lead to illness and death.
Would I recommend any vitamins to people.
Generally no.**** but some words later.
Perhaps B 12 injections  and vitamin D.
Folic acid in pregnancy as it can reduce Spina Bifida incidence.
There are a few people who do need vitamins due to problems with absorption in the gut, Coeliac disease, Pernicious anaemia, malabsorption syndromes. Surgery removing part of the bowel but they are extremely rare.
Lack of availability, B 12 in vegetarians, Vitamin C if not eating green foods, Vitamin D if not enough fish or sunlight.
Vitamin supplements are expensive and not helpful but still we take them.
The reasoning here appears to be  if a little is good for you, a lot should be better with a dose of I may be low so I will give it a try.

. Vitamins were a discovery of modern science but they are now the best example of alternative medicine. Alternative medicine is the last bastion of faith based medicine, working on faith in a belief even when the belief lacks a logical basis. It also emphasises the triumph of faith over logic. Both a fear of modern medicine and a lack of trust in it.

Junk food is bad for you.    No
Food is food whether it is processed, roasted or pasteurised. It has its own set of protein , fat and carbohydrate usually, with lashings of vitamins and minerals. The two things wrong are that they are very tasty  and eating them fills one up with too many calories.  Secondly they re too easy to get and lead to a lack of discipline in eating sensibly.
It is the overeating that is the problem.
Vary the fast foods and eat in moderation and the dietitians should go away. [Kebabs?]. Personally I feel that cooking is one of the skills that should be taught at school to all children. Domestic science  It used to be called.

In short Vitamins, while a scientific discovery, are mainly just another alternative medicine

Any questions?

Alternative medicine has been around a long time. Alternative medicines are called that to draw a distinction between scientific and non scientific medicine. The distinction is meant to sound harsh. One of the two major factors in healing is the mind. Positive thinking is an essential component of survival. Going forwards against the odds is necessary to survive. And a body with hope or faith doe much better than one. The placebo effect.

Early medical practice worked  on faith and herbs. Witch doctors became herbalists, herbalists became doctors and witches and a little science crept into the mix.
Chiropracty, Acupuncture, Herbalism, Cupping , Faith healing, Homeopathy,  Diet pills, Anti aging pills and creams developed. Some forms like Acupuncture and Herbalism predate Western Medicine, Others like Chiropracty grew up together with it and  modern inventions. A few I would not touch with a barge pole, think Colonic irrigation. They are all treatments intended to improve health. They generally lack scientific [provable] links between the treatment and the disease but have had many years of use and experience. Quote 4

Does it work? Yes but not in most cases. People who are prepared to try have a higher success rate.
There are two golden rules to enjoying life which also apply to Alternative and normal Medicine use.
-Try it and see.            Give it a few weeks and if it helps you, go for it.
–   Never be first .

Is there Quackery involved? Yes. Selling snake oil in the old days is the modern day anti wrinkle cream. An easy way to spot a scam is to look for these traits in the marketing. New, Improved, Expensive, Rare, Unusual and impossible.  Like rhinoceros horn, or the latest juice from an unknown, exotic sounding South American plant to lose 10 kilos in 2 weeks.

In summary Alternative Medicine is the last bastion of faith based medicine which is one of the two major was that we heal. Particularly when we have become skeptical of modern medicine

 

You have a choice.  Let someone else try it first. This works extremely well in conventional medicine as well [Vioxx, Lipobay etc]
Quotes 12, 10, 2,

Myth A placebo effect  exists   Yes

The placebo effect is one of the major reasons why any therapy works. Believing that something is having an effect seems to encourage the patient to feel better and in some case for problems to actually resolve. Mind over matter? It seems that health and illness can be matters of perception in many cases. It seems to have a higher strike rate with symptoms that are non physical and hence not testable as in depression.  his in turn makes it much harder medically to assign values to drugs used in these conditions.
The effect is patient variable and effected by belief. If one knows a placebo is being used there may still be some effect but it is nowhere near as strong. Hence the ability or ease with which people can be hypnotised, or not. In strictly assessable conditions, like infection or trauma, placebos have little value.
What is it. I like to think of it as the antithesis or opposite of skepticism, belief or faith, and yes in some cases it does move mountains

Anecdotes, if needed. I had a patient who had had Talipes and club feet as a child. At 60 I had occasion to check his feet and balance. To my surprise the whirled arthritic stumps of tissue he moved on gave him no pain or problems. He had adapted perfectly to what he had been gifted with and did not seem be aware that he had any limitations or pain. Another patient had a severe carpal tunnel syndrome in both wrists proven on USS.  He also had a morbid fear of surgery. He went to see a Chiropractor in a neighbouring town and pronounced himself cured, which he was. Did the disease go or spontaneously remit or was he believing he was not in pain.

Vaccination mentioned only to be discarded.

Vaccination is good for most people, and for the population as a whole.
It needs to be encouraged.
There are side effects to vaccination just as there are to all medical and alternative medical treatments.
Some people have too much faith in the few bad effects to see the large number of good effects.
People who experience bad effects will always look for a cause and proximity appears to be proof.
Demonizing people for their fears is wrong and does not help. It makes them stubborn and suspicious.
Remember if our immunisation is up to date there is very little risk for us.

Flu vaccines are for the H1N1  Influenza A , formerly known as the swine flu. It is the same variety that caused the Spanish Flu in 1920

Screening tests and treatment

Cholesterol testing and treatment
This is where Skepticism should come into play.

We can all have a cholesterol test but what should we do with it?
There are Government guidelines giving some advice.
There are two competing views out there.
One is that the statins are so good we should all be on them as soon as we are old enough  and stay on them forever. There are studies to show that even in people with normal cholesterol lowering it will increase your life expectancy.
So, we all take vitamins that are useless and expensive, in handfuls,why not take something which is useful and expensive and works?

This is the nub of the distrust in medicine we have talked about.
Sometimes the selling of the product gets a little bit too close to snake oil.

A statement again. Statins do have a place and a target. Cholesterol should be dropped.
But not on the basis of cholesterol levels.

Cardiovascular disease is the most important  cause of death  in people over 70 accounting for 50 percent of all deaths, half due to heart attacks, slightly less to strokes then other vessels.  Basically we start off with good arteries but half of us are genetically primed to wear out  after 70. The arteries build up atheroma which is a combination of calcification and plaque in the vessel walls. We can hasten the process. Bad dental hygiene causing infection in the blood vessels, smoking, Excessive alcohol, Lack of exercise and obesity. Illnesses like diabetes and blood pressure.

Cardiac CT for calcium scoring  shows this progression with age nicely, less than 15% of patients under 56 years had significant coronary stenosis, but this was increased to 29% and 38% in the age groups of 56–65 years and over 66 years. In one study, 44% of individuals had a coronary score of zero. This cohort has  a low long-term risk (99.4% 12-year survival).  In contrast cholesterol levels are ineffective at predicting heart attacks.

What this means is that  up to 44% of people are at little to no risk of heart attack whatever their cholesterol level. But over half of us are.
Early studies showed a relationship of cholesterol levels with heart disease but some more recent studies dispute this, What is indisputable is that if you have proven blood vessel disease a statin has some chance of helping reduce your risk.
Cholesterol levels not being  a help one needs to be guided by family history, diabetes, hypertension and smoking  and by your risk averse nature.
If at high risk a CT scan being clear could suggest medication is not needed.
There are drawbacks with the risk of radiation exposure the younger one is  and medication might be a safer option.
For an older person the CT risk is less and the benefits of a clear study need to be weighed up against the possibility of a score causing needless anxiety or the need to go further and do an angiogram.

 

Infection and Kidney and lung disease a large amount of the rest along with infections often secondary to these preexisting conditions.
A cholesterol test and treatment with statins is often advised by doctors.This brings up the second problem of screening  for cancer.
The problem with screening is when to start, who to start with and how often
Cancer is a disease of aging and most cancer occurs over 50. Cancer cells can start from one cell or sometimes as a field change in susceptible cells. Cells can double at different rates, every 12 hours or every week Cancers appear to be growing rapidly when in fact they are slowing down and are mostly undetectable in the early most rapid divisive phase which can be as little as 6 months or as long as 8 years to get to a detectable size.
The problem is if the cells are capable of metastasizing by blood or lymph spread. The more vascular the organ or the more aggressive the tumour the higher the chances that it will have already spread before being found.

Treatment consists of two modalities. Removal or destruction once identified. Waiting to assess for recurrence when hopefully a chemotherapy regime or the newer MIB ad MAB treatments may be possible.

Breast Cancer screening

Breast cancer is the most common female cancer over 50. It comes on earlier than the male equivalent, prostate cancer by 10 years. Younger patients are in middle age with families just grown up, a husband to look after and still active in a career, perhaps paying off a house. Enjoying life in other words. The outcome was distressing on every level, a high risk of death, usually  disfigurement and scarring with a mastectomy and radiotherapy and emotional distress. Genetics showed a small group of at risk people with a history  of breast cancer in the family, about 10% so no other good guideline for investigation. Diagnosis was by mammography if available or operation with a biopsy and re operation.

Breast cancer screening as a project started 25 years ago with mammogram guidelines.
People at risk with a family history are strongly recommended to have them , usually from 40 onwards or earlier if the family history includes a relative who developed it at an early age. Routine screening is recommended and free  for women from 50-74  in Australia.

Facts.
More than 75% of breast cancers occur in women over 50.
90% of women who get breast cancer have no family history.
An estimated 3,046 Australian women died from breast cancer in 2016.
In 2012, 14 680 people (14 560 women and 120 men) were diagnosed.

Positive reports and statistics. A bit of mathematics. Not all positive reports from screening programs mean you are at high risk. When a condition is relatively rare, like cancer, and increases with age, it is good to be at the shallow end [younger].

Breast cancer is uncommon in younger women so a woman of 40 with a positive result has a much higher result of a false positive. The news should not be treated with doom and gloom but a positive attitude of hope  and investigation started. On the other hand a positive result at 75 should set the alarm bells ringing. This is much more likely to be the real deal. The outlook must still be positive but firm.

Issues  Anxiety that may last for years even when  biopsies  have been done .
Cumulative radiation exposure. at a 2 yearly rate. which may lead to an increase in 30 years time of thyroid and other cancers.
Missing  a tumour that may be there but missed and present in the next 2 years, advise to keep doing BSE .  >50% of tumours are found by the patient or doctor, not screening.
Over diagnosis. In the older age group the chance of dying before a cancer grows enough to cause death means one should not have done the scan in that person [which person?].

While screening has been pushed strongly in Australia and the death rate has dropped it is not clear cut that screening is needed or cost effective. BSE is widely practiced in China and Canada and result outcomes are not that much different. One recent analysis interpreted breast cancer mortality trends by age to indicate that these reductions were mostly a result of treatment rather than screening.44

The problem as always is that the patients who do not screen but develop breast cancer  will always have someone saying you should have had a mammogram. Women seem to have addressed this issue themselves breaking into 56% having mammograms and 44% not. It is voluntary, If one is risk averse it is a wise move. It is always a wise move if you get cancer and never a wise move if you don’t. By refusing to call up women over 74, the highest risk group , the Breast screening  self acknowledge that there are age and cost constraints and actually helping diagnose everyone is not their goal.  The same with not calling up 40 year olds shows the perceived risk for this group is low.

If one does regular checking and finds a lump then one can at least say that a mammogram done more than 4 months previously would have missed it. and since it has already been there in excess of 2 years in most cases the 4 months does not make much difference to the question of spread and outcome. Especially as the reduction in mortality is heavily weighted towards the newer drugs available for some of the responsive cancers.

Prostate cancer and screening

PSA tests. The jury was out. Top specialists like Tony Costello at RMH actively push for early detection for early treatment. Other  groups like the USANZ preferred that screening not be done as the rewards of detection and the downside of the treatment outweigh, they felt,  any active management. How times change. Now the guidelines are to

  1. Offer evidence-based decisional support to men considering whether or not to have a PSA test, including the opportunity to discuss the benefits and harms of PSA testing before making the decision.
  2. For men at average risk of prostate cancer who have been informed of the benefits and harms of testing and who decide to undergo regular testing for prostate cancer, offer PSA testing every 2 years from age 50 to age 69, and offer further investigation if total PSA is greater than 3.0 ng/mL.

 

Compare and contrast the attitude here to that for women. Several factors weigh in the men are older, The cancer is internal rather than external so harder to get at. The operation has functional rather than cosmetic consequences..

I am an interventionist, I believe that the test itself is easy to do, compared to a mammogram and the results are easier to interpret. The follow up for a positive result is just as traumatic with the biopsy and examination being more difficult. I find it hard to square the idea of watching known cancer if presumed low risk and would prefer the idea of some treatment earlier rather than later.  Of great interest are 3 concepts. One that with a low PSA < 1.0 at 40 and at 60 YO ones risk of cancer is almost negligible [less tests one good outcome. Secondly that if the blood test is going up but there is no lump felt an MRI of the prostate can be done to give complete visualization of it and guide management better.

Choice of procedure Robotic surgery or radiation or both. With apologies to the surgeon who has done all the work Radiation would be a preferred option, just. The upside is that any local spread should get knocked off. secondly the side effects are broadly similar. Prostate cancer is particularly prevalent in the Shepparton area and perhaps a study should be done by our local hospital on the actual incidence.

Screening for skin cancer. Absolutely essential in fair skinned people in Shepparton. Most of us have a good knowledge of our own skin through touch if not through sight. Any skin lesion that does not heal after 6 weeks is skin cancer, get it checked. Any lump that should not be there and is growing might be skin cancer, get lumps checked. Any black or brown discoloured spot is probably a seborrhoeic keratosis, but you cannot exclude  melanoma. vital to get any flat lesions like freckles that appear or are growing checked.

Non Melanomas are either basal cell or squamous cell cancers. SCC are flat ulcers, BCC’s have raised edges. A BCC can be excised, curetted  or sometimes if small treated with a cream that reverses it’s growth. The earlier one gets to it the easie to treat. Field of change means you can get new lesions near he old lesion de novo, not as a recurrence so keep an extra watch on that area and the corresponding area on the other side of th body.

Finally for Alan who so kindly issued an invitation to talk. I want to thank him for the opportunity and all those of you who have come along today and asked such interesting questions.

  • Estimates of over diagnosis vary widely. Based on UK and European reviews, it is estimated that for every 1000 women in Australia who are screened every two years from age 40 onwards , notified 50 to age 74, around 8 (between 2 and 21) breast cancers may be found and treated that would not have been found in a woman’s lifetime.
  • There has been international debate and differing conclusions about the contributions of screening and improvements in treatment to reductions over time in breast cancer mortality. One recent analysis interpreted breast cancer mortality trends by age to indicate that these reductions were mostly a result of treatment rather than screening.44 However, statistical modelling analyses of national US data, using seven independent statistical models, gave a combined estimate that around half the mortality reduction was attributable to screening and half to treatment.4
  • In Australia, even with a fully implemented mammographic screening program, more than half of breast cancers are diagnosed after investigation of a breast change found by the woman or by her doctor.7

We start as a single cell and live on average 70 years after being born.
Our death rate after the first year is quite low and usually due to bad luck.
Say 2 deaths per thousand per year.  At that rate we should live on average 250 years.
But little things get in the way as we age. Fourteen and the mind starts working and some people decide to leave of their own volition. This stays steady at 1 per thousand increasing the rate to  3. Car accidents and activity related problems kick in by 20, Things increase slowly till 55  at a rate of 7 with the consequences of lifestyle choices due to alcohol tobacco, drugs, sex, diabetes, diet, Blood pressure , atheroma and cancer. From then to 70 the rate increases to 20 a year at the turning point. 500 people have gone. But now the rate kicks up steeply until the majority of people  die in the next 14 years. the rate going up to 40 people a  year at 80.

Cardiovascular disease is the most important  cause of death  in people over 70 accounting for 50 percent of all deaths, half due to heart attacks, slightly less to strokes then other vessels. Cancer accounts for 30 percent. Infection and Kidney and lung disease a large amount of the rest along with infections often secondary to these preexisting conditions.

Basically we start off with good arteries and we are genetically primed to wear out  after 70. The arteries build up atheroma which is a combination of calcification and plaque in the vessel walls. We can hasten the process. Bad dental hygiene causing infection in the blood vessels, smoking, Excessive alcohol, Lack of exercise and obesity. Illness like diabetes and blood pressure.

We can actually measure the development of the atheroma with a High quality CCTA (64-slice and higher) is not only able to provide reliable information on coronary luminal changes, but also has the potential to visualize morphological changes of the coronary artery wall, characterize atherosclerotic plaques and identify non-stenotic plaques which may not be detected by invasive coronary angiography. This showed a significant age related increase in calcification
Of these patients with abnormal changes to the coronary arteries, the number of significant coronary stenosis was directly related to the age group, as less than 15% of patients under 56 years had significant coronary stenosis, but this was increased to 29% and 38% in the age groups of 56–65 years and over 66 years,

Cardiac CT for calcium scoring It has been assumed that measurement of risk factors causal for CAD (e.g. dyslipidaemia or hypertension) would be predictive of coronary events, but the relative hazard ratios of these risk factors are inadequate to accurately predict outcome. Seventy-five per cent of previously asymptomatic patients (men < 55 years, women < 65 years) developing their first MI, would have been ineligible for lipid-lowering therapy prior to the event if assessed with a global risk score.
In four major studies, more than 75% of all hard coronary events occurred in persons classified as low or intermediate risk, and the majority of persons classed as high risk had no coronary events. Risk score assessment alone is inadequate in predicting individual coronary risk.

In contrast, a measure of flow limiting obstruction (with ischaemia testing or CT coronary angiography) is not likely to predict risk.
Sixty-eight per cent of MIs occur in vessels with less than 50% obstruction prior to plaque rupture and thrombosis; and 86% occur in vessels with a less than 70% obstructive lesion (the degree of obstruction required to provoke a positive ischaemia test).Similarly, recurrent MIs are usually caused by a second ‘angiographically minor lesion’ commonly found in patients with a large plaque burden.

44% of individuals had a coronary score of zero. This cohort has such a low long-term risk (99.4% 12-year survival), that any further coronary testing is not required, and interventions like lipidlowering therapy are not likely to alter outcome.

 

A study of asymptomatic persons with a CAC score of greater than 1000 demonstrated they had a 25% risk of death or MI at one year,

I did not ask who had tried these other modalities as some of us who did might feel ashamed at being skeptical.  It is funny how the skepticism that produced medicine is sometimes turned back on it.

[So what is it that drives us to seek health treatments and to take treatments  in the manner that we do. One is our vanity, one is our mortality, one is health, one part is our wives. Fear of our looks and performance, fear of death, fear of illness and fear of our spouse. What tempts us to try the paths less trodden? The ones without  trials and proof. The ones that demand experiment and belief at the same time? The truth is that people wish to feel in control and not have other people tell them what to do.  [To be an individual, just like everybody else. Yet at the same time they want to follow the crowd and conform. It is the nature of human beings to be contradictory in their choices  and decisions.]

Why do we get sick and how do we restore  or keep better health?Life brings trauma There is a saying he who is his own doctor has a fool for a patient.
Usually said by doctors when a patient goes against their own sage advice.
Health is an individual responsibility but one can always seek external advice.
Health is having a sound  mind and body. An old Latin proverb, Mens sana in corpore sano.
So onto understandingMedicine deals with healing, [Doctors are teachers] but one does not have to be a doctor to understand the concept of healing

ABC Catalyst statins program ‘could contribute to deaths’www.theaustralian.com.au/…statins…deaths/…/6da032cef8cc643075c46713f8c95272

 Jun 15, 2015 – The ABC may have contributed to the death of thousands of … “If patients continue to avoid statins over the next five years, this could result in …

British government figures released last week show that 92 deaths have been linked to the statin drugs developed to lower cholesterol. It is believed that the …In July 1999, Bayer ’ s clinical trial of Baycol 1.6 mg revealed a ‘ high incidence (about 12 per cent) of severe CK elevation …partly connected with symptoms ’ , leading to a decision to discontinue the project without publishing the results of the trial. 13 . The safety margin for our compound from the noeffect level to non-tolerable dose is less than three-fold, whereas for (Mevacor) it is at least 12-fold ’ .

Vitamins  are they good for us to take.

We have a great scientific knowledge of what they are and what they do.
Most people know and use the more common ones.
A through to K,  B 1-B 12  with some gaps there are 13 Vitamins. They are essential to life because they are not normally able to be made in our bodies [exception Vit D].
We have evolved in a world where we interact and depend on our food sources and if we have enough food we get more than enough vitamins.
They are all  available even through a restricted diet or junk food hence there is no need to supplement them as we always get more than we need.
As we get more than we need taking more does not make our bodies any better off.
In some cases e.g. Vitamin A, overdosing can lead to illness and death.
Would I recommend any vitamins to people.
Generally no.**** but some words later.
Perhaps B 12 injections  and vitamin D.
Folic acid in pregnancy as it can reduce Spina Bifida incidence.
There are a few people who do need vitamins due to problems with absorption in the gut, Coeliac disease, Pernicious anaemia, malabsorption syndromes. Surgery removing part of the bowel but they are extremely rare.
Lack of availability, B 12 in vegetarians, Vitamin C if not eating green foods, Vitamin D if not enough fish or sunlight.
Vitamin supplements are expensive and not helpful but still we take them.
The reasoning here appears to be  if a little is good for you, a lot should be better with a dose of I may be low so I will give it a try.

Myth 2 Junk food is bad for you.    No
Food is food whether it is processed, roasted or pasteurised. It has its own set of protein , fat and carbohydrate usually, with lashings of vitamins and minerals. The two things wrong are that they are very tasty  and eating them fills one up with too many calories.  Secondly they re too easy to get and lead to a lack of discipline in eating sensibly.
It is the overeating that is the problem.
Vary the fast foods and eat in moderation and the dietitians should go away. [Kebabs?]. Personally I feel that cooking is one of the skills that should be taught at school to all children. Domestic science  It used to be called.

In short Vitamins, while a scientific discovery, are mainly just another alternative medicine

Any questions?

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