Inkwell: Authors and Artists

    
#48, Divinea

"I have to admit that I find it a bit confusing that you seem to be
maintaining that pathology is an inexact science, or "art", "

THe last thing I want to do is confuse.  

The art/science thing is not what's important. Here's the part that
matters: 

If you're a wise patient, the slides of any tissue removed from your
body for analysis will go not just to one but to at least two
pathologists in two different areas of the country.    

It is not a good idea to rely on the opinion of the first pathologist
who interprets the cells on your slides, no matter who s/he is, or how
splendidly-educated s/he might be. 

The reason for not relying on one pathologist's report is that the
report is too important for you to let any inaccuracies slip through. 

If you've got breast cancer, for example, 
every single treatment protocol that's laid out for you
by every single specialist you see
is going to be based directly on that pathology report.  

It's worth repeating:  The path report dictates the treatment.  It's
crucial to your treatment because every treatment plan starts with and
flows from the path report.  If the report is inaccurate (and it
HAPPENS), then the patient is the one who suffers for it.  
  
How will you know if the first path report is accurate?  
Well, there's the rub. 

MY way around it is to get a second opinon from a pathologist at a
cancer center in another part of the country.  If you were my sister,
I'd urge you to do the same thing because it's SAFER. 

You also wrote: 
"while you also seem to be advocating thermography over mammograpy,
while thermography is, at least at this point, an unproven technology
with no established clinical standards."

Nolo contendere.  Though it's been in use for at least the last
decade, you're right: the clinical standards are still being worked
out. 

Thermograms differ from mammograms.  The biggest difference for ME is
that the thermogram is SAFE.  It does no harm. Mammograms are xrays of
the most radiation-sensitive tissue in the body.  Over time, the
mammogram can cause the very cancer it's trying to detect. I don't
think it's worth the risk.  
(For further information about the dangers of mammograms, read Sam
Epstein, Burton Goldberg, Gary Null, Ralph Moss, and others.)

If you think thermograms might be for you, I hope you'll look into
them for yourself.  
 
If you don't want additional radiation to your breasts, 
if you have implants or known cysts and you'd rather not have them
compressed and possibly ruptured, 
consider the thermogram for several years.   

If you're working on normalizing fibrocystic breasts or breast tissue
that's received radiation therapy, consider the thermogram because it
cannot aggravate the very tissue you're trying to calm down.  (cf.
<http://iodine4health.com>  and the iodine project at
<http://www.breastcancerchoices.org>).

If you've already had b.c. and want to see if a recurrence is in the
works without dosing your breasts with the radiation that might speed
the recurrence process, consider the thermogram.
 
It IS relatively new technology, but that doesn't mean it's not the
greatest thing since Saran Wrap for many of us. 
 
Both thermograms and mammograms have a place in my life. I'll get
yearly thermograms, but I'll make an appointment for a mammogram the
minute my thermogram shows a change in heat pattern. Unless/until that
change shows up , though,  I see no need to expose my breasts to
radiation.  (Or the compression, come to think of it. Pain hurts, as
Charles Schultz's Lucy pointed out.)
 
 
  

    
>working on normalizing fibrocystic breasts

Age usually fixes this.  Fibrocystic breasts are simply the healthy
breasts of a young woman with very metabolically active tissues ready
to start working on milk production the moment it's needed.  They're
not yet sagging because the fibrous tissues are still holding up well,
and they're dense because the working part of the tissues (the ducts)
are still functional, and they're not so infiltrated by
radiographically less-dense fat.  They're not a disease to be worked
on.

 
  

    
#43, David

I don't see much info re: how often DCIS becomes invasive.

Maybe that's because most women get it removed while it's still in
situ.  What's gone never gets the opportunity to bkm invasive, and so
how can it be counted?

 
  

    
I also have to point out that alkalinizing yourself is a pointless,
fruitless, impossible exercise.  Your tissues function best within a
very tight range of pH, and your kidneys do a heck of a job of
maintaining it, no matter what you throw at them.  

You can change the pH of your urine--since that's where the bulk of
excess acid or base in your diet will end up--but not, significiantly,
your bloodstream, the fluid between your cells, or inside your cells. 

Theories of alkalinization or acidification of bodily tissues  that
ignore these fundamentals of physiology are really, really silly.

And though you didn't bring this up, it reminds me of the equally
silly theories of food combining--to only eat certain kinds of food
together in one meal, to avoid the precious proteins being expose to
acid foods before they're digested--that ignore the job of the stomach,
which is to acidify your food to help digestion, and that all those
proteins you're eating, unless encapsulated by something to protect
them in transit, are going to be exposed to that pH2 acid and be
inactivated.
  

    
Re #53, I did some research as well and find that indeed there are no
hard numbers.  What we do know is that DCIS is nearly 100% treatable,
while invasive cancer is not.  So it comes down to a decision between
relative risks -- on how much of a risk of death are you willing to
assume before you treat for a condition that might turn out never to
hurt you.

That answer will clearly be different depending on what that treatment
involves, and will differ by individual, and for the same individual
over time.

What is clear to me is that if you make an advance decision that you
do not wish to have DCIS treated, then you may also want to choose not
to perform any tests (e.g. mammograms) that would be likely to find it,
especially where such tests also have a non-zero medical (let alone
emotional) risk to the patient.

I have seen the same thought process go into whether or not to have an
amnio during pregnancy.
  

    
Of course, you do want to detect tumors. That's what mammograms were
invented to detect.

Detecting DCIS is such a conundrum.  As I understood it, DCIS doesn't
literally show up on a mammogram -- it is just often associated with
tiny sparkles of calcium that can be seen.  Calcifications can also
have benign causes, which is one of the reasons for the rate of
unneeded biopsies. But I was told that they are the marker for DCIS on
a mammogram. Subtle points of inflammation that can be detected by
manual examination is another means of DCIS diagnosis, by the way. (At
least, that was what I gleaned as a patient. Other scenarios may exist
and hopefully diagnosis is getting better.)   Actual tumors show up
better on the mammogram (and most likely on the thermogram) and are
more palpable in the form of hard lumps, which is good, because we know
we want to detect them as soon as possible.

So that brings up some questions about thermography compared to
mammography that can't be answered without some form of clinical trials
and comparative data. Is DCIS better identified by using one than the
other?  (Do DCIS-caused calcifications without inflammation throw off
any heat, for example?)  

Then there are the policy and best practices questions that clinical
trials can't address directly.  Does "better identified" mean catch ALL
of them and don't mind the false positives, or just catch most of them
but don't produce a lot of false positives?   With thermagram
screening instead of mammography, is DCIS less detectable, and is that
actually more desirable for screening the general population, or just a
choice for the patient making an informed choice?   

What a lot of conundrums.   
  

    
#50
Thank you for this post, debunix.  It was clear, timely (and
appreciated).  

Re: #52

Yes, fibrocystic breasts are normal for the younger, pre-menopausal
woman.  (The term "fibrocystic breast disease" makes my teeth itch.)

Such breasts, however, present a problem for the pre- and
peri-menopausal woman who has been diagnosed at least once with breast
cancer, gotten a lumpectomy and done radiation, and now finds herself
in the position of having no good way to find out what's in her
breasts.  

Thermography, as has already been pointed out, has its problems (one
of them being that insurance doesn't pay for what has not yet been
standardized and accepted as "standard of care," and that $150 or $200
a pop is not within everyone's reach.)

But (the discomfort of a mammogram on an irradiated breast aside)
mammograms have trouble imaging dense, fibrocystic breasts.

For that reason, the pre-/peri-menopausal woman who has not had time
to age into less lumpy breasts has a problem knowing what might be
growing in there.  Recurrences in the scar line are easy to see, but
what is she to do when a recurrence might be inside the breast?

For a number of women, the solution is to turn to iodine/iodide.  One
of its advantages is that it makes breasts less fibrocystic.  That, in
turn, makes them easier to see on a mammogram, and it has the added
advantage of making Breast Self Exam (BSE) a lot easier (When it's all
lumps, figuring out which, if any, is the new one can be a problem.) 

Whether or not breast tissue SHOULD be made less fibrocystic is a
separate issue.  I'm merely sharing with you the fact that it CAN be
done with either oldfashioned Lugol's solution or Iodoral and that
iodine/iodide are increasingly being studied for their role in the
formation of a number of cancers, breast cancer included.

FYI, the iodine group is a 3,000-member online group using
iodine/iodide as Lugol's solution or as Iodoral for a number of
different health-related issues. 

See <http://www.iodine4health.com>

For iodine/iodide as they relate to cancer-in-general, see
<http://iodine4health.com/disease/cancer/cancer.htm>

For more on how they relate to breast cancer in particular, see
<http://breastcancerchoices.org/iodineindex.html>
  

    <scribbled>
  

    
#38, Mark,
You wrote,

"We badly need a "Biomedical Researchers' Logical Fallacies."

Ah, THERE's an idea whose time has come.
So have you started on it yet?
  
  

    
Well, I'm not a biomedical researcher, so I'd have to find one to
collaborate with who wanted to be persona non grata for the rest of his
life.  I've got someone in mind, but time, money, energy, and lack of
promotional skill... need to find an agent, etc.

Actually it is a great idea, and with some help, I'm pretty sure I
could do a good job of explaining it so that civilians could
understand.  There's some really ridiculous stuff out there.

I think two things drive it: 1) a lot of people, yes, even scientists,
fail to understand either logic or statistics or both. 2) a lot of
people just do research which they feel will advance their careers,
just as you see in a lot of liberal arts research.

"The big boss is very into x, so I'll do a study on x."
  

    
#60:

Mark, you wrote,

"I think two things drive it: 1) a lot of people, yes, even
scientists,fail to understand either logic or statistics or both. 2) a
lot of people just  do research which they feel will advance their
careers, just as you see in a lot of liberal arts research.

"The big boss is very into x, so I'll do a study on x." "

You are my HERO. I'm glad you're here.

I don't want to blow this post away yet again, so I'm going to send
this part now, and finish the rest in a minute.
  

    
The rest of the post. 


It's unfortunate that scientists aren't as good at statistics as we'd
like them to be.  

The problem gets compounded when their published information gets
disseminated to physicians who may themselves  have trouble
understanding the data as it’s presented.  

And then the patient, the one at bottom of this info-chain, the one
with the most to lose, is the one who has to make the treatment
decision based on his/her ‘informed consent.'

I see some room for improvement there.   

* * *
 
When I was seeking information on radiation, I asked two questions of
each physician on my team.  I naively thought they'd have the answers
on the tips  of their tongues.   
Q1:  If I DON'T do radiation, what are the chances of my recurring in
that breast?
Q2:  If I DO do radiation, how much will that cut down on my risk of
recurrence in that breast? 

I thought the sum of those two answers would be 100%.  DIdn't happen.
 
* * *
Until Mark's book is written, here are two patient strategies that can
help the newly-diagnosed slog through the information  deluge:

•Ask physicians to explain the figures in terms of 100 or 1000 women,
not in terms of percents.   

•See <http://annieappleseedproject.stores.yahoo.net/reriveabri.html> 
for a helpful ‘primer’ on  absolute vs, relative risk. 

 
  

    
(Any off-WELL readers can send their questions/comments to
inkwell@well.com and the comments will be posted here.
  

    
> Q1:  If I DON'T do radiation, what are the chances of my recurring
in
> that breast?
> Q2:  If I DO do radiation, how much will that cut down on my risk of
> recurrence in that breast? 

> I thought the sum of those two answers would be 100%.  DIdn't
happen.

But there's no special reason for them to add to 100% -- in fact, it
is very unlikely for that to be the answer.  For example, suppose the
chance of recurrence without radiation is 20%.  Then with radiation,
the chances will be lower, but the amount that it will cut down your
risk is perhaps 15 percentage points (which is not really "additive" in
any meaningful way to the 20% -- it is subtractive).

If you want to think of it as a percentage reduction rather than a
percentage-point reduction, then from 20% down to 5% (a 15 percentage
point reduction) you've lowered the risk by 75% (of the risk).  But
again, there is no reason to add 75% to the original 20% -- that is not
a meaningful mathematical exercise, and just happens at random to be a
sum that gets anywhere close to 100%.
  

    
[I just made up those numbers for mathematical illustration.  I have
no idea what the actual risk numbers are.]
  

    
From Off well reader Gould01@aol.com:

A study for the Mammogram discussion:

Patients with clinical/radiological hyperplasia of mammary glands show
pathological persistence of temperature of skin points.
Li H, Shen X, Ying J, Zhao L, Jin M, Thu S, Sun C, Voorhorst F,
Soiland H, Lende T, Baak JP.

Acupuncture and Tuina College, Shanghai University of Traditional
Chinese Medicine, 1200 Cailun Road, Shanghai 201203, People's Republic
of China.

Abstract
BACKGROUND: Hyperplasia of mammary glands (HMG) is a frequent disease,
with increased cancer risk for women aged 20-55 years. The aim of this
study was to explore a non-invasive method to identify which patients
with breast complaints need additional mammography for HMG diagnosis.

PATIENTS AND METHODS: Skin digital infrared thermal imaging (DITI) in
74 patients with HMG and 63 controls was carried out.

RESULTS: In the controls, the temperature of points close to the
breasts and ovaries decreased with age. In women older than 39 years,
HMG patients showed persistently high temperatures but in the lower
extremities there were no differences. With a threshold for thoracic
skin point KI21 of 33.2 degrees C, sensitivity and specificity in
distinguishing controls from HMGs were 96% and 52% (p=0.0001)
respectively, as validated in a test set, similar to recent DITI
results for breast cancer detection.

CONCLUSION: Infrared temperature imaging of specific skin points is a
rapid, non-invasive method to identify patients requiring mammography
to confirm HMG.
  

    
#66, Julie / Gould021@aol.com,

Interesting article.  Thanks for sending it in!  

It certainly highlights thermography's value for the woman with 
breast hyperplasia.   

The obvious question is "What's the connection between bc and
hyperplasia?"
 
The answer's elusive.  All sources agree that hyperplasia refers to
too many cells in a given organ, but they don't all agree on whether
the cells themselves are normal or abnormal. 

Several sources point out that there's no problem with hyperplasia in
itself; the problem, as always, is that nobody knows when or if those
cells will become cancerous.

THanks for sending it in.
 
  

    
#64, David

Yes, well, but I wanted simple answers to simple questions.

They said “If you don't do rads, there's a 30-40 % that you WILL
recur." (or somesuch)

And I  thought, "So that also means I have a 60-70% chance of NOT
recurring."

That's the 100% I was trying to get at earlier.  
  

    
MAMMOGRAMS AGAIN: 

Check out this VERY interesting article by Samuel Epstein, MD, cancer
prevention expert and prof.emeritus at U. of IL School of Public
Health, Chicago.

Entitled    "Breast Cancer UNawareness Month,"

it's in the 10/15/2010 issue of the Huff.Post, at 

<http://www.huffingtonpost.com/samuel-s-epstein/the-breast-cancer-unaware_b_754
641.html>

                
  

    
Interesting.  That led me to another Huffpo article,
<http://www.huffingtonpost.com/christiane-northrup/the-best-breast-test-the-_b_
752503.html>

and this one addresses a few of my musings and questions about
Thermography.  Yes, it detects DCIS and from what the author says,
perhaps much better than a mammogram. However, it allows watch and wait
without excessive doses of cancer-causing radiation.

The article also includes a list of questions about thermography, how
the equipment is used and how it is interpreted.  Very interesting
considerations indeed.  
  

    
Terrific article, Gail; thanks. Wish I'd found it myself!  It's got
the double bonus of having been written by Christiane Northrup, whose
work I much admire.

You wrote, "... it allows watch and wait without excessive doses of
cancer-causing radiation"

For me (and perhaps for you, too?), that "watch and wait" time is one
of the best things about thermography.  It's a gift, that chance to
head breast cancer off at the pass, to undo a process early enough in
its infancy that it's actually feasible.  

I wonder if some folks' reluctance to consider thermography is that
they don't know what to DO during that watch-and-wait time.  For them,
perhaps a thermogram carries with it the weight of anxiety without
relief 

And yet there is MUCH that can be done to head breast cancer off at
the pass.  And if they didn't ask...maybe they didn't know there was
anything TO ask.

To those reading this, plz rest assured: there are multiple strategies
for helping our own breast tissue stay or return to normal.   

Is this interim period, this time of using various strategies,
something you've looked into for yourself, Gail?  Do you have, for
example, a list of things you might do if a thermogram showed something
was brewing and you wanted to stop it in its tracks? or even if you
just thought your breast tissue were becoming abnormal?
 
  

    
More from off WELL reader Gould018@aol.com:

Cited below is a memorable study finding that angiogenesis is
associated with the ONSET of hyperplasis in human ductal breast
disease.  Already, when there is hyperplasia, the angiogenic switch is
turned on.  If I had a breast cancer website, this study, as a warning,
would be on the front page.  .... THANK YOU for your engaging
intellectual discussion. ..... Sally

 

Br J Cancer. 2009 Aug 18;101(4):666-72. Epub 2009 Jul 21.

Angiogenesis is associated with the onset of hyperplasia in human
ductal breast disease.
Bluff JE, Menakuru SR, Cross SS, Higham SE, Balasubramanian SP, Brown
NJ, Reed MW, Staton CA.

Microcirculation Research Group, Academic Unit of Surgical Oncology,
University of Sheffield Medical School, Sheffield, South Yorkshire, UK.

Abstract
BACKGROUND: The precise timing of the angiogenic switch and the role
of angiogenesis in the development of breast malignancy is currently
unknown.

METHODS: Therefore, the expression of CD31 (pan endothelial cells
(ECs)), endoglin (actively proliferating ECs), hypoxia-inducible
factor-1 (HIF-1alpha), vascular endothelial growth factor-A (VEGF) and
tissue factor (TF) were quantified in 140 surgical specimens comprising
normal human breast, benign and pre-malignant hyperplastic tissue, in
situ and invasive breast cancer specimens.

RESULTS: Significant increases in angiogenesis (microvessel density)
were observed between normal and benign hyperplastic breast tissue
(P<0.005), and between in situ and invasive carcinomas (P<0.0005). In
addition, significant increases in proliferating ECs were observed in
benign hyperplastic breast compared with normal breast (P<0.05) cancers
and in invasive compared with in situ cancers (P<0.005).
Hypoxia-inducible factor-1alpha, VEGF and TF expression were
significantly associated with increases in both angiogenesis and
proliferating ECs (P<0.05). Moreover, HIF-1alpha was expressed by
60-75% of the hyperplastic lesions, and a significant association was
observed between VEGF and TF in ECs (P<0.005) and invasive tumour cells
(P<0.01).

CONCLUSIONS: These findings are the first to suggest that the
angiogenic switch, associated with increases in HIF-1alpha, VEGF and TF
expression, occurs at the onset of hyperplasia in the mammary duct,
although the greatest increase in angiogenesis occurs with the
development of invasion.
  

    
Angiogenesis is required for the tissue to develop to abnormal
density, because the normal blood vessels can't keep up with the tumor
tissue.  This is a limiting factor that probably prevents a lot of
'precancerous' lesions from becoming cancerous:  there is a limit to
how large they can become unless they can trigger the formation of new
blood vessels.
  

    
Here's what Science Based Medicine had to say about Dr. Northrup's
article, and thermography in its current state:

<http://www.sciencebasedmedicine.org/?p=7454>
  

    
Re <71> - Carole, I considered watch and wait (with the support of my
oncologist) of 15 years ago, and was only up for it emotionally and
intellectually for a year, during which time my oncologist was able to
do some experimental MRI imaging that eventually convinced me that I
was not a good candidate for that strategy.   I would have had interest
in the idea of a way to do screening that does not involve radiation,
but thermography was not much discussed at that time.

It was in the early 1990s, and the phenomenon of e-patient support
groups had not taken off.  However, the integrative medicine movement
was gaining momentum.  I like the idea of pulling from multiple healing
traditions and looking at science as well as placebo effect or
whatever we want to call belief-based or holistic healing contexts.  

Here's a quote from that article, by David Gorski MD, managing editor
of the Science Based Medicine blog, about the medical establishment and
thermography:

> "Despite various studies that suggest positive results for
thermography, there has never been a major randomized controlled trial
to determine baseline measurements of sensitivity and specificity. It
is hard to imagine thermography being accepted by the conventional
medical establishment without such data or evidence of
cost-effectiveness. In addition to questions about the effectiveness of
thermography, research needs to be conducted to determine the cost of
using it for widespread cancer screening."

That sounds accurate.  Widespread screening is in question with
mammograhy, too.  Gorski also appears to brand the entire alternative
medicine and integrative medicine movement with the dismissive term
"woo-woo" in this and in other posts, but he is very interesting and
worth reading when he steps out of the quackery rants, and deals with
tough choices, such as in his discussion of the Norwegian data and
screening recomendations:  http://www.sciencebasedmedicine.org/?p=6940

In summing that up, he says something that is important for any kind
of screening. Policy choices do not have to be binary:

>  "It’s not a black-and-white question, but advocates and physicians
who become invested in the status quo sell it as such. Evidence and the
science change, but policy recommendations become fossilized because
certainty is perceived as being better than nuance. I will admit that
three or four years ago I probably would have been one of the docs
circling the wagons in the face of these new studies. No longer. I also
detest the “other side,” who represent mammographic screening as
useless because the benefits appear to be more modest than we
originally believed. I believe that patients are far more capable than
we give them credit for of understanding and acknowledging that there
are gray areas in medicine. We should not be selling certainty when
there is none."

Better clinical data on modern thermography would be good for
everybody, no doubt about it. After the better data, the policy debate
will no doubt continue.