Post truth in medicine

Recent political events unfolding in the USA have launched the concept of "post-truth" into many newspaper articles.  It was voted as the Oxford Dictionary "international word of the year".  They defined it as

"adj, Relating to or denoting circumstances in which objective facts are less influential in shaping public opinion than appeals to emotion and personal belief:
‘in this era of post-truth politics, it's easy to cherry-pick data and come to whatever conclusion you desire’"

The adjective is largely used by political commentators.  However, I fear that we are dangerously close to a post -truth era in scientific commentary and debate.   Widespread access to the internet has resulted in many examples of commentators being able to cherry pick "evidence" to support an opinion.

For the purposes of this blog, I asked my ever-patient husband to give me a possible cause of breast cancer to investigate.  "Suntan cream" was the mumbled answer.

My search resulted in nearly 3m results.  On page one (the only one most of us ever take time to read) there were 2 plausible articles.
One was from the Daily Mail suggesting that there may be a link.
The second was from a site called "IFLScience", a site devoted to the lighter side of science, which suggested there was no link between the suntan cream and breast cancer.

Mail online accessed on 12/2/17

IFL Science.com accessed on 12/2/17

I am often asked to talk about breast cancer and inevitably the question of causality is raised. Had this been a topic I wanted to discuss, it would be reasonable for me to have cited either of the articles and come to opposite conclusions.

After doing some considerable research on the subject, I don't think there is a link between suntan creams and breast cancer.  (That is not the purpose of this blog).  We must ensure that as medical practitioners, we guard against  "cherry picking" articles that reinforce our opinion rather than accurately represent the facts.  It takes time and energy.  As an increasing amount of data is published on the internet, working out what is fact and what is fiction will become more difficult and time-consuming. 

However, if we don't do that, medical science will be trumped as well as politics!


New Christiaan Barnard Memorial Hospital

For over 15 years, I have been working as a surgeon at the Christiaan Barnard Memorial Hospital in the heart of Cape Town city centre.  Originally called "City Park Hospital", it was renamed in 2001. On Friday, I discharged my last patient from the old institution.  In the ward at 7 o'clock in the morning just as the hand over from the night staff to the day staff was occurring,  I couldn't help overhearing their conversation.  They were sad.  There was a feeling of the end of an era.

Last night, at a lavish, glittering function, the new hospital was officially opened.  It is in a slightly different, up and coming desirable address (on the foreshore) and promises to be a state of the art institution.  It will boast the first helipad with swift access to emergency services in the heart beat of town. The evening was dedicated to the extraordinary career of Chris Barnard with a documentary about the first heart transplant that was done at Groote Schuur Hospital 49 years ago.  His family, along with some of the original theatre team, received awards and were present together with Dr Friedland and Prof Nomafrench Mbombo MEC for Health who cut the ribbon.  The emphasis of the evening was on the future of cardiac transplantation. There was little time for reflection on what the hospital has achieved and on the many other medical services offered.

Our old hospital is not a beautiful building.  It has seen a lot of wear and tear over the years and is in
need of the upgrade.  What has made me proud to work there, however, is the attitude of the staff. It is a friendly hospital made up of people who care.  I am not just talking about the nurses.  I am talking about the porters, the admin staff, the management, the hostesses and other medical personnel.

The hospital I know is not a cardiac transplant hospital.  It is a multidisciplinary institution. On the surgical side, there are surgeons specialising in orthopaedics, urology (including robotic surgery), vascular procedures, ENT, neurosurgery, plastic and reconstructive surgery, trauma, ophthalmology,  maxillofacial surgery and breast surgery.  There also is a successful renal transplant programme.  There are a number of obstetricians and gynaecologists with a specialised paediatric ICU.  On the non surgical side, there are many physicians each with their own areas of expertise.

The last few months have been very difficult and very busy.  I would like to thank my colleagues and patients for their patience.   Cape Town looks forward to explosive economic growth and welcomes developments that add lustre to the new glittering future.  It would be prudent to take time to reflect on what has been achieved through a multi-faceted team and ensure that the caring attitude is not lost.


Young women discussing their decisions to have a mastectomy

Last Friday, the hospital had their annual breast cancer awareness day.  Each year, we try and focus on different aspect of breast cancer.  This year, the focus was on young women who had decided to have a mastectomy.  Four young women spoke.

Zoe and Helena
Helena was the first to speak.  Just before she was diagnosed with breast cancer, she had started a new relationship.  She felt that her diagnosis was some sort of punishment: some repayment for her sins.  What should her new partner do?  Should he stay or should he go? Her biggest concern however was her daughter.  She is a single parent.  How would her daughter cope?

Zoe, her daughter, was with us for the morning.  It was her 10th Birthday.  What an amazing and engaging child.  Once her mother had stopped speaking, she came to the front.  I asked her what advice she would give a child going through the same thing and she said "It will be alright in the end".  Helena told us how important her friends had been in getting her through.

There wasn't a dry eye in the room when Helena and Zoe had finished speaking.

Clare took over. She was in her early 30s when she was faced with the decision as to whether she should have a mastectomy.  She took an analytical approach to the whole process.  She researched the topic as much as possible. What were her chances of recurrence with her different treatment options? What were the effects of reconstruction.  She summarised her experience by saying it made her a better feminist: she became less judgmental of decisions taken by other women.

At the time that Elizabeth was diagnosed, she had a 3 year old boy.  She was planning to have another child and was ready to move to a family sized house.  The diagnosis of breast cancer catapulted her into a different life trajectory.  She became closer to her religion and learnt to ask for and accept help.  She described the disease as being levelling and humbling.  She described despair as the antithesis of hope.  Steve, her husband then recounted his experience of having been a cancer survivor.  We asked him to give other partners some words of wisdom:
"Don't underestimate Forries" "Express your fear and get it out""Book a holiday" "Focus on the other side"

Last but not least was Danilla.  Although she hasn't had cancer, she has inherited the BRCA mutation. She has seen her relatives get breast cancer and knows she has an 80% chance of developing the disease.  She had an enormous fight with the medical funders.  Her medical aid seemed to think it was fine for a 30 year old (who needed a bilateral mastectomy) to have the surgery with no reconstruction... After a 3 year fight, she eventually got a reconstruction.  She said that many of her friends felt the step was too drastic.  However, she feels an enormous burden has been lifted from her and that her decision has been validated.

It was such a privilege to listen to their stories: to hear about the experience from the other side. Please share yours.

Thank you.

Lancet, LAOSA, Morton and Partners, Pathcare, the Breast Course for Nurses and others attended the event


The Hummingbird Centre, Cape Town

The newest addition for the provision of Complementary and Alternative medicine for people with cancer living in Cape Town with is the Hummingbird centre. It is opening up in Century City.    I have serious reservations about the validity of the therapy being offered as a core therapy so last week, I went to the launch to find out more.
The Hummingbird will be a cancer centre offering holistic and alternative management for cancer. The core therapy at the unit is NGPDT: New Generation PhotoDynamic Therapy.  What is that?  A person is given a photosensitizer that is derived from chlorophyll.  In theory, over the next few hours, normal cells release the agent and cancer cells retain it.  The light therapy then causes lysis of the cells containing the pigment and are destroyed.

Topical Photodynamic Therapy has been around for decades and has been successfully used to manage superficial lesions.  The European guidelines have recommended it's use for Actinic Keratosis, Bowen's disease, Basal cell carcinoma  What the new generation therapy is supposed to do is treat other cancers as well.  Before I went, I understood that the centre was primarily offering treatment to people with metastatic cancer but during the evening, reference was made to treating people with early cancer as well.

Light only penetrates a few millimetres.  In order to treat non superficial tumours, the light source has to be introduced by means of a probe to the cancer site.  There are 4 ways of administering the therapy:
1. Superficially
2. Focus laser beams onto the tumour directly
3. Apply the beam interstitially
4. Use XRay guidance to apply the therapy into deep tumours

This is interventional treatment.  Complications can occur when needles/probes are inserted into the body.  It is not clear to me how people with metastatic cancer with many deposits of cancer will be adequately treated.

The invitation promised a summation of the evidence based research using NGPDT.  Dr Donald Murphy presented the results of a phase 1 clinical trial in the management of men with prostate cancer.  A Phase 1 clinical trial has to show that the therapy does no harm: it doesn't show that it works.  There were a few case studies presenting showing its effectiveness but there was no scientific evidence presented showing that NGPDT cures cancer.

Gary Scallan, the CEO, gave a talk outlining the vision of the new centre.  He said that they wished to bring affordable cancer care to millions of Southern Africans.  He noted that conventional cancer medicine is very expensive and that that NGPDT is cheaper.  Dr Comyn (medical director) said that he believes NGPDT can be used to treat Karposi's Sarcoma.  However, there have been no studies looking at it's usefulness in the management of these patients.

Several cancer NPOs have joined with the Hummingbird centre.  The largest of these, PLWC, was rumoured to be receiving some form of commission for referring patients to the centre for treatment.  I was concerned about the rumour as PLWC is an excellent NPO providing cancer care for many cancer survivors and I was worried that they were loosing their autonomy.  I was therefore delighted to hear Mr Scallon confirm that the rumour is not true and PLWC will not be receiving financial incentives from them.

So at present, the Hummingbird Centre is a space offering alternative cancer treatment and support.  The medical team doesn't include any oncologists/surgeons.  The core therapy being offered is NGPDT.  There are no clear guidelines as to who will receive the treatment.  Many organizations have expressed their reservations about this treatment.  The NHS, has said "It is not supported by any scientific evidence".

I hope that proper trials will be carried out to define exactly what cancers can be treated with this modality and that the Hummingbird centre will be clear as to who can be treated.  Personally, I still have reservations about the validity of NGPDT as a systemic cancer treatment.


Cancercare cancer survivors day

Well done Linda Greef for organising a excellent survivors summit at His Peoples Church in Goodwood.  It was well attended and everyone I spoke to was very impressed.

The summit was opened by Hanif Hamdulay from Cancercare.  (GVI have become Cancercare). They are a national network of oncology centres with 9 centres in the Western and Eastern Cape.

The MC for the morning was the charming Dr Michael Mol who trained as a medical doctor years
ago but has spent most of his working life in other areas including being a presenter on Top Billing.  The first speaker that he introduced was Conn Bertish, a cancer survivor and creator of Cancer Dojo.  What an incredible speaker.  What an incredible story.  He was diagnosed with a brain tumour and was teated with surgery and radiotherapy.  He has made an excellent recovery and is now a member of "the world's scariest club".  He has used his background in branding and advertising to set up Cancer Dojo.  The concept is fascinating and he encourages people to "take themselves out of helplessness".

The next speaker was the oncologist Dr Jill Harris, who Michael likened to the actress Sigourney Weaver.  She talked about the guidelines for follow up for cancer survivors.  The debate for many is about how many investigation should survivors have? Should they have regular expensive scans exposing them them to the risks of radiotherapy or should they be followed up symptomatically?  The point she made that really resonated with me was that seeing a well, longtime survivor for for a follow up is a privilege for all of us who work in the cancer field.

I spoke afterwards about some of the aspects of the the Na/utroceutical industry.  I will blog about my talk separately.

Rod Warner is a resilience consultant and author of the book "The Building Resilience Handbook".  His talk can be summed up with a phrase he used.  "Life is 10% what happens and 90% how you react to it".

DrAaron Motsoaledi (Minister of Health) was unable to join us and was ably represented by Prof Melvyn Freeman, the chief director of NCD from the Dept of Health.  He expanded the idea of a survivor being the individual with cancer to the notion of the family being survivors of the
experience.  However, the most poignant part of his speech, for me, was when he quoted from Mike Marqusee's book, The Price of Experience.

I was unable to stay for the parallel workshops which I heard were excellent.  To all of you who attended and helped organise the event: thank you


Isolates, Herbs and Formulations in Breast Cancer Care

Yesterday, I spent 3 hours at Cape Town's Mount Nelson Hotel listening to Dr Weber on the subject of isolates, herbs and formulations in breast cancer care.  I am not a homeopath and have never attended a lecture on the subject before.  I found it fascinating.

Dr Weber, the CEO of Panaxea, a company which "provides our practitioners with the most efficacious natural remedies available"  He is based in Australia and is a visiting professor at Tianjin
University.  His talk was based on the content of his book "Botanical Oncology:isolates" which was published in 2014.  He went through 220 slides and it would be an impossible task to even begin to summarise all the information presented. Nearly all the slides had a least one reference cited.

His talk was a mixture of traditional Chinese medicine, evidence based medicine and translational research. The different approaches were applied variously to different subtypes and stages of breast cancer.   I found it difficult to follow.  It is perhaps because I am not au fait with many of the concepts (eg phlegm which in traditional Chinese medicine apparently refers to interstitial fluid).  What bothered me was the lack of clinical outcome data.

When a drug is being developed, it has to go through at least 3 phases:
When a drug is being considered for use for cancer treatment, the oncologist wants to know whether or not the administration of the drug will lead to improved outcome (There has been a lot of criticism about the pharmaceutical companies.  Amongst other issues, they often do not publish the results when a drug is shown not to work and do not always take account of patient side effects).  Herbal products fall outside the current legislation omitting the need for outcome based studies, and controlled trials do not have to be conducted before they are marketed.

In a short three hours, an amazing number of products were discussed (I think, over 100) but survival data was given on only 90 patients: half of whom had received "herbs" or JLBSHJ formula.  All of the rest of the data was anecdotal.

Western medicine does not always get it right and there is an increasing demand from patients for Complementary and Alternative Medicine.  Dr Weber urged oncologists to engage in more dialogue with integrative oncologists.  I am encouraged by his commitment to "research and evidence based medicine" and am sure as the evidence for the usage of isolates, herbs and formulations in the management is produced, a more integrated approach will result.