“Medical literature can be compared to a jungle. It is fast growing, full of dead wood, sprinkled with hidden treasure, and infested with spiders and snakes.” – Peter Morgan, Scientific Editor, Canadian Medical Association.(1.)
In this age of information, how do we clinicians guide our patients towards making informed decisions about their health and medical care? Negotiating this avalanche of data and highlighting the solid facts, decoding confusing messages, exposing bogus claims and protecting them from charlatans peddling treatments backed by quasi-science or even fraudulent promises is a daunting task. It is one thing to have evidenced-based Protocols and Guidelines as we do in ICON but what about all the other noise around health and cancer?
There have been two stories that have dominated the press in South Africa in recent weeks: 1. the WHO report on red and processed meats and their link to cancer; 2. the story of Professor Tim Noakes who faces a professional conduct hearing over his alleged advice to a mother to place her baby on a low-carb high-fat diet.(2.) For some of us the statistics and claims of these two unrelated cases would be variously described as confusing, self-serving or even hokum depending on how precious and unbending your stance on accepting the scientific process as well as the hippocratic principle of primum non nocere (first do no harm) was.
For an international organisation and a seasoned academic not to expect their pronouncements to the general public to make waves, or go unchallenged, demonstrates an arrogance and hubris that reflects badly on them both and is not helpful to the medical fraternity in general. Grand medical claims not couched in the careful tones of the academic research article is in nobody’s best interests, and especially not those of the uninitiated lay person nor the vulnerable sick. These claims play to the audiences’ basest fears and do nothing to advance those causes we all value as doctors and carers – good science and the appropriate care of our patients.
The central scientific principle always bears repeating: formulation of a hypothesis; careful design of a testing of this hypothesis; collection and interpretation of test data and then either confirming or denying the hypothesis. That this hypothesis remains a hypothesis only until disproved and can never be considered a law (unless repeatedly confirmed and never subsequently disproved) is central to the scientific principle. This is so often forgotten. Without these rigorous processes being followed, a theory remains just that, a theory. To make claims (and money) based on an unproven theory, no matter how much you ‘believe’ it, is nonsense and needs to be treated as such.
The other less commonly remembered, but certainly no less important, principles of scientific research include the integrity of knowledge, collegiality, honesty, objectivity and openness. I would argue that in the modern world this collegiality and openness is now spread wider than ever before and needs to include all who would be affected by this research, not just fellow researchers or academics. In the case of the WHO saga, potentially inflammatory and un-decoded statements were revealed to the world with little or no clarification. This was then sensationalised by the lay press without filter or thought, causing alarm and confusion. Badly done all round.
To state blandly, as did the International Agency on Research in Cancer (IARC) Press release monograph No. 240 that their group of 22 experts from 10 countries “classified the consumption of red meat probably carcinogenic to humans (Group 2A) based on limited evidence… and strong mechanistic evidence supporting a carcinogenic effect.” while that of processed meat ‘’carcinogenic to humans (Group 1), based on sufficient evidence in humans” (their italics) and that “the experts concluded that each 50 gram portion of processed meat eaten daily increases the risk of colorectal cancer by 18%”.(3.) Each portion eaten increases risk by 18%? This is quoted directly from the release as written for the press on the 26 October 2015 and to me is not at all clear. Does that mean eating 100g a day increase the risk by 36%? Or is this, as I suspect, an increase in the current baseline risk of 5% for colorectal per lifetime; i.e. eating 50g processed meat per day raises this risk from 5% to about 5.8% over one’s lifetime? More likely, but I am still not totally sure.
This confusion was only compounded by the Q&A session release to the press that stated that “…processed meat has been classified in the same category as causes of cancer such as tobacco smoking and asbestos (IARC Group1, carcinogenic to humans) but this does NOT mean that they are all equally dangerous.” It then fails to clarify if meat is more, equal or less dangerous than smoking or asbestos? On questioning they reiterate the statement that “every 50 gram portion eaten daily increases the risk of cancer by 18%”.(4.) How can we criticise the press here as these statistics in their undigested form become meaningless nonsense that could be interpreted in any way? To expect the press to then delve into this and extract the true meaning is a very unlikely unless a highly trained medical journalist is available to do this. Once the news was out it was taken at face value and believed as the truth as it came from a respected authority figure (WHO). I have not seen or heard too much in the way of clarification of this statement subsequently. And so this is accepted as gospel and we all move on to the next juicy titbit.
How do patients cope with this barrage of (mis)information? In this time of information overload, it is not just patients who are faced with these challenges but also us clinicians. With medical and scientific knowledge increasing exponentially it can be a challenge to stay at the forefront of new developments and ahead of the information curve.
It also means that patients now more than ever wish to become part of the decision making process in their treatment plan and we clinicians need to be able to manage this. Oncologist James Salwitz writes in his blog on KevinMD.com: “Once-upon-a-time, the doctor decided for patients, as he would decide for his own children. The movement toward individual patient empowerment has changed the tone and balance of the conversation. The doctor is no longer the final decision maker. The doctor is advisor, educator and guide.” (5.) It is our role to help our patient separate fact from fiction as well as decode some of the more obscure information out there. Otherwise our patients will rely on unvetted opinion, quasi-science and anecdotal evidence to guide their decisions.
The controversial low-carb high-fat diet alluded to above has many advocates, but a number of critics argue that due scientific process has not been followed in determining its efficacy. The challenge in such a situation is that, while advocates speak of its success, there seems to be very little, if any, robust scientific evidence to back it up. Studies have been conducted, but very few have been published and this means, ultimately, that it does not meet the requirements of scientific evidence as stated above. A popular recipe book cannot be held up as anything more than opinion and needs to be treated as such by professionals, even its author.
Patients are particularly vulnerable to “lies, damn lies, statistics and clinical opinion” but, unfortunately, so are we if we are not critical at every turn. Our patients deserve to know what their options truly are. We as clinician have the duty to explain the available proven treatment options appropriate to their diagnosis, as well as the possible outcomes of each option. This means that we need to be alert to the dangers of misinformation, be critical of information provided no matter the source and be particularly wary of so-called wonder cures, diets and scaremongering. We owe this to ourselves as scientists and to our patients. If we do not guide them through this jungle of information and towards the real treasure of scientifically proven treatment, then we are not living up to our duty as doctors.
David Eedes November 2015