Another Take on Not Smoking, the Law and Tolerance

The New Yorker published a story this week, on smoking, that caught my attention. It’s by none other than F. Scott Fitzgerald. The author died in 1940 at the age of 44, after a ruinous period of addictions including alcoholism, debts and other problems.

F. Scott Fitzgerald (June, 1937), photo by Carl van Vechten

Thank You for the Light dates to 1936. The main character is a woman: “Mrs. Hanson was a pretty, somewhat faded woman of forty…” She sold girdles and craved cigarettes. Smoking had the power to “rest and relax her psychologically.” He describes her growing frustration at not being able to take a drag in offices where she did business.

The story suggests that although public and workplace smoking wasn’t illegal back then, it was frowned upon in cities like Chicago. The protagonist longs for past years and places where she could chat and share a drink or cigarette with clients after work. Times had changed, she reflects.

In Fitzgerald’s words:

…Not only was she never asked if she would like to smoke but several times her own inquiry as to whether anyone would mind was answered half apologetically with ‘It’s not that I mind, but it has a bad influence on the employees.’

This vignette offers a 1930s perspective on what some call social health – that an individual’s behavior might be influenced by neighbors’ and coworkers’ attitudes. In this story, the woman finds solace in a church. I won’t give away the ending.

The short read lingers. What’s unsettling, still, is whether the socially-driven ban on smoking helped or harmed the woman.

According to the New Yorker’s Page-Turner, the magazine rejected Fitzgerald’s story when he submitted the piece. The writer’s granddaughter recently uncovered it. This time around, it passed muster.


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Reading About Thinking (on D. Kahneman’s Ideas on Perceptions of Knowledge)

An article appeared in yesterday’s NYT Magazine on the hazards of over-confidence. The Israeli-born psychologist (and epistemologist, I’d dare say), Nobel laureate and author Daniel Kahneman considers how people make decisions based on bits of information that don’t provide an adequate representation of the subject at hand. He recounts how poorly, and firmly, army officers evaluate new recruits’ leadership potential and how brash, rash or naive traders maintain investors’ trust while weighing stocks to buy or sell.

The point, as I understand it, is that individuals, including influential and powerful people, routinely make recommendations without having adequate knowledge to support their decisions. And they do so comfortably.

Men are afflicted by overconfidence more than women, he suggests, although I’m not sure he’s right on this point. In the article, he uses reckless investors who rack up stock losses as an example: Guys are more likely to lose lots of money than are women who, in general, are more cautious in their investments and, perhaps, less confident about their predictions.

I’ll have to read Kahneman’s forthcoming book, Thinking Fast and Slow, to learn more about his views on differences between men and women’s cognitive biases.

Nearing the end of the magazine piece, Kahneman alludes to medical decisions. He suggests that some doctors, perhaps through life-and-death sorts of feedback on the outcomes, may be distinguished by their capacity to gauge their own judgment skills.

He writes:

We often interact with professionals who exercise their judgment with evident confidence, sometimes priding themselves on the power of their intuition…

And asks:

How do we distinguish the justified confidence of experts from the sincere overconfidence of professionals who do not know they are out of their depth? We can believe an expert who admits uncertainty but cannot take expressions of high confidence at face value…people come up with coherent stories and confident predictions even when they know little or nothing. Overconfidence arises because people are often blind to their own blindness.

And broaches the topic of doctors’ expertise:

True intuitive expertise is learned from prolonged experience with good feedback on mistakes. You are probably an expert in guessing your spouse’s mood from one word on the telephone…true legends of instant diagnoses are common among physicians….Anesthesiologists have a better chance to develop intuitions than radiologists do….

I read this article on the train last evening and found it fascinating, so much so I hope I can find time to read the full book. Even though Kahneman is just a single human, and necessarily biased like the rest of us, he’s got some interesting and well-articulated ideas. I’m curious, in particular, if he’ll further dissect the critical thinking pathways among different doctor types.

In my experience, we’re a variable bunch. But who knows?


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More on DCIS

More, a magazine “for women of style & substance,” has an unusually thorough, now-available article by Nancy F. Smith in its September issue on A Breast Cancer You May Not Need to Treat.

Ductal Carcinoma in Situ (DCIS) in the breast, histopathology w/ hematoxylin & eosin stain, Wiki-Commons image

The article’s subject is DCIS (Ductal Carcinoma in Situ). This non-invasive, “Stage O” malignancy of the breast has shot up in reported incidence over the past two decades. It’s one of the so-called slow-growing tumors detected by mammography; a woman can have DCIS without a mass or invasive breast cancer.

While some people with this diagnosis choose to have surgery, radiation or hormonal treatments, others opt for a watchful waiting strategy. The article quotes several physicians, including oncologists, who consider the surveillance approach favorably and otherwise.

In 2009 the NCI sponsored a conference on diagnosis and management of DCIS. The participants issued a helpful, albeit technical, consensus statement.

The bottom line is that optimal treatment for DCIS remains uncertain because doctors don’t yet know the natural course of this early-stage breast malignancy. The website lists active and ongoing studies.


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Notes on Kris Carr and Crazy Sexy Cancer

I’m half-tempted to put down yesterday’s new NYT Magazine feature on crazy sexy cancer goddess Kris Carr. Her blog was one of the first I found when I started ML, and it was the most popular link on my fledgling site until I pulled it, fearful of somehow sponsoring a too-alternative oncology perspective.

But I give Carr credit, sincerely: Crazy Sexy Cancer is a lot more appealing a title than, say, Medical Lessons. I’d read CSC, for sure, if I had a new diagnosis or, maybe, if I were alone and bored or suffering from a condition like chronic fatigue syndrome or insomnia and hadn’t gone to med school. Even for people who really have cancer, letting loose and being attractive sounds, well, like a lot of fun.

Kris Carr has played her C-card like a Queen of Diamonds. You go, girl!

So this morning I pulled a hard-cover edition of Cancer: Principles and Practice of Oncology, 7th Edition (2005; Lippincott, Williams & Wilkins; edited by DeVita, Hellman and Rosenberg) off my shelf and looked up Carr’s stated disease, epithelioid hemangioendothelioma. Being the old-fashioned woman that I am, I read about EH* in print. Only then did I discover a handy, unopened CD housed inside the cover of the “oncology bible,” as we used to call this text.

the editors, 'Cancer: Principles and Practice of Oncology,' Lippincott

DeVita and his colleagues classified this condition as a vascular tumor in a chapter on sarcomas, in a section on tumors that develop in smooth muscle. Now, at risk of boring my readers with the medical “scoop” on this strange and sometimes benign-behaving sarcoma variant:

As its name implies, epithelioid hemangioendothelioma is an angiocentric vascular tumor with metastatic potential…These lesions may appear as a solitary, slightly painful mass in either superficial or deep soft tissue. Metastases to lung, regional lymph nodes, liver, and bone are reported. Another pattern is that of a diffuse bronchoalveolar infiltrate or multiple small pulmonary nodules. This entity has also been called IBVAT…can also arise in the liver, often presenting as an incidental finding or as part of a workup for mild elevation of liver enzymes or vague abdominal pain. Multiple liver nodules are the rule. Although these lesions can metastasize, they usually run an indolent course. Liver transplantation has been performed…

This sounds scary, sure, but the bottom line is that this tumor falls into unchartered oncology territory because they’re so rare. As reported in the Times piece there are only 40-80 cases per year in the U.S. A reference in the textbook, above, leads to a 1989 report in the American Journal of Surgical Pathology. In that study of 10 cases, the authors describe an unpredictable course for the disease.

As told by Mireille Silcoff in the magazine, EHE comes roughly in two forms: one’s aggressive and one’s not. So what the oncologist at Dana Farber suggested – that she go about her life, and “let the cancer make the first move” – was a reasonable strategy, one that allowed them (patient and doctor) to find out, over time, what would be the nature of her particular EHE.

Carr lucked out: She has the “good EH” as Larry David might say. So far, at least, she’s enjoyed a  productive, enterprising  life with cancer. From the Times:

She was given the diagnosis in 2003 and rose to prominence with a 2007 documentary called “Crazy Sexy Cancer.” She subsequently wrote two successful books— “Crazy Sexy Cancer Tips” and “Crazy Sexy Cancer Survivor” — about her peppy, pop-spiritual approach to her disease, and she soon became what she sometimes describes as a “cancerlebrity” or, at other times, a “cancer cowgirl.”

Now she has a blossoming business. At the cafe, she laid it all out while sipping a coconut-vanilla chai with soy. Her blog postings are being syndicated, she has pending sponsorship contracts, her weekend workshops are thriving and she has provided one-on-one coaching sessions on Skype ($250 for 90 minutes). She also just bought a farm — 16 acres complete with two houses, a barn, a meadow and a forest…

Am I jealous? Sure, maybe, some…But I’d be hopeless on a farm.

Besides, she hasn’t received chemo, had limb-removing cancer surgery, undergone early menopause…She looks fabulous! And with that kind of cancer, maybe so would you.

The issue is that Karr runs a well-connected wellness enterprise. She sells a way of life, David Servan-Schreiber style, with the message that you can beat cancer and be well if you nourish your body and mind with the likes of 21-day cleansing diets, juiced Whole Foods and meditation-enhancing mala bead jewelry.

The danger is that readers and customers/followers may believe that her current well-being is due to her lifestyle choices. And that some people with the malignant form of EHE, whose emails she may not read, struggle with feelings of inadequacy and defeat.

So I’ve learned from Kris Carr: For one thing, I don’t think I ever saw a case of EH and she, through her story, persuaded me to look it up. Second, she’s a smart business woman, who’s turned her life around upon a cancer diagnosis. Third, (am undecided, ideas?)

And I’m taking careful notes. Let’s leave it with that, for now.

*This author prefers to call epithelioid hemangioendothelioma EH, but most sources use EHE, so I’ll abbreviate as do the sources or use my own style, accordingly.

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Human Milk For Sale, Where’s the FDA?

The June issue of Wired carries a feature on the Booming Market for Human Breast Milk. You can read about the under-the-counter and over-the-Internet sale of “liquid gold” with a typical asking price in the range of $1 to $2.50 an ounce.
Here’s a taste, from the article:

…“rich, creamy breast milk!” “fresh and fatty!”… Some ship coolers of frozen milk packed in dry ice. Others deal locally, meeting in cafés to exchange cash for commodity…

Late last year, the FDA issued a warning about feeding your child human milk from strangers. Still, the stuff’s barely regulated.

milk containers, Wired Magazine, June 2011

As much as I think it’s a good idea for women to breast feed their babies as best they can, I was pretty shocked to learn about this unregulated industry.  Mainly because if a woman who donates milk is infected with a virus, like HIV or HTLV-1, the milk often contains the virus. The infant can absorb the virus and become infected. Feeding human breast milk from an unknown donor is kind of like giving a child a blood transfusion from a stranger, unchecked by any blood bank.

I’m not sure why Wired ran this story, which is admittedly interesting. Maybe it’ll push the FDA to take a more aggressive stance on this matter, as it should.

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Art, Science and Radiation Imagery on a Magazine Cover

This week’s New Yorker cover pretty well sums up my thoughts lately. It’s a bleak, semi-natural image that blends art and science, offers brightness amidst darkness, and reminds us of how little most of us know about physics, nuclear energy and radioactivity.

And it’s a strange, unsettling start for the Spring.

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A New Twist on Peanut Allergies and Other Allergic Reactions

The current New Yorker unfolds an engaging story on childhood food allergies. As related by Dr. Jerome Groopman, there’s a shift in how some doctors think about how these conditions  are best managed and, even better – might be prevented. The article feeds into the recent discussion that medical science, and even dogma, too-often turns out to be incorrect.

Groopman interviews Dr. Hugh Sampson, director of the Jae Food Allergy Institute at Mount Sinai Medical Center in New York:

…”This increase in the incidence of food allergy is real,” Sampson said when we spoke recently. He cannot say what is causing the increase, but he now thinks the conventional approach to preventing food allergies is misconceived. For most of his career, he believed, like most allergists, that children are far less likely to become allergic to problematic foods if they are not exposed to them as infants. But now Sampson and other specialists believe that early exposure may actually help prevent food allergies.”

I recommend the full read if you can get it: Groopman probes potential causes of discordant food allergy rates in children of different geographic regions. I learned a number of details on how some doctors in the U.S. use protein-breakdown methods desensitize children to food allergies, how in Israel newly-speaking infants are said to ask eagerly for Bamba, a manufactured, peanut-containing snack (which, for the record, I don’t particularly endorse), and how in some cultures parents chew their young children’s food in a manner that might that might facilitate breakdown of complex proteins by enzymes in saliva.

All interesting –

Of course it’s hard to know exactly what’s true in this, and the causes of allergies are likely to vary among children. There’s a randomized LEAP study (Learning Early About Peanut Allergy) in the U.K. that may provide some hard evidence on this one way, or another.

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Another Brooklyn (and how I feel when I look in the mirror)

The image of Brooklyn Decker, a real woman and model from Middletown OH, streamed through my Google news feed this morning. I have to admire any person named Brooklyn, the place where I was born.

From a post on my BlogHer health RSS:

Brooklyn Decker on the cover of Sports Illustrated, in 2010

The BlogHer subject is Decker’s diet and exercise secrets: “…no matter how wealthy or famous you are, Decker says the only thing that really works is exercise, eating healthy and accepting your body for what it is that will make you succeed.”

Got it.

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The U-Shaped Curve of Happiness

This evening, when I finished cleaning up the kitchen after our family dinner, I glanced at the current issue of the Economist. The cover features this headline: the Joy of Growing Old (or why life begins at 46). It’s a light read, as this so-influential magazine goes, but nice to contemplate if you’re, say, 50 years old and wondering about the future.

The article’s thesis is this: Although as people move towards old age they lose things they treasure—vitality, mental sharpness and looks – they also gain what people spend their lives pursuing: happiness.

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Science Takes a Double Hit in the Press, Maybe

In his latest New Yorker piece The Truth Wears Off, Jonah Lehrer directs our attention to the lack of reproducibility of results in scientific research. The problem is pervasive, he says:

…now all sorts of well-established, multiply confirmed finding have started to look increasingly uncertain. It’s as if our facts were losing their truth: claims that have been enshrined in textbooks are suddenly unprovable. This phenomenon  doesn’t yet have an official name, but it’s occurring across a wide range of fields, from psychology to ecology. In the field of medicine, the phenomenon seems extremely widespread…

The Decline Effect, as Lehrer calls it, refers to scientists’ inability to reproduce reported results. The problem isn’t simple: it’s not just that different investigators or teams come up with conflicting information, or interpret the same raw data in disparate ways; over time, a single scientist may not be able to reproduce his or her own observations.

Lehrer begin his story with a target loaded with potential bias and conflicts of interest – a 2007 meeting in Brussels of scientists, shrinks and pharma executives contemplating the disappointing results in recent large clinical trials of blockbuster antipsychotic drugs like Abilify, Seroquel and Zyprexa. Initial reports, mainly from the early 1990s, which supported these drugs’ FDA approval and widespread use, turned out to present a too-positive story. Later studies indicate these agents are not as terrific as was advertised; new data call into question the drugs’ effectiveness and safety.

This is probably true, but it’s hardly surprising. It happens in oncology all the time – when drug companies support initial studies of new drugs with an intention to sell those, it’s sometimes the case (and unfortunately frequent) that initial reports are more promising than what really happens after a decades’ worth of less careful (i.e. more open) selection of patients who take an FDA-approved medication. Once you include a broader group of patients in the analysis, whose doctors aren’t researchers whose salaries are supported by the drug makers, the likelihood of getting truthful reports of side effects and effectiveness shoots up.

So I don’t think Lehrer’s big-pharma example is a reasonable shot at the scientific method, per se. Rather, it’s a valid perspective on problems that arise when drug companies sponsor what’s supposed to be objective, scientific research.

Lehrer moves on to what might be purer example of the decline effect. He tells the story of Professor Jonathan Schooler, a now-tenured professor who discovered in the 1980s that humans’ memories are strengthened by the act of describing them. The work is cited often, Lehrer says.

…But while Schooler was publishing these results in highly reputable journals, a secret worry gnawed at him: it was proving difficult to replicate his earlier findings. ‘I’d often still see an effect, but the effect just wouldn’t be as strong.’

Next, Lehrer steps back in history. He relates the story of Joseph Banks Rhine, a psychologist at Duke who in the early 1930s developed an interest in the possibility of extrasensory perception. (Yes, that would be ESP.) Rhine devised experiments to evaluate individuals’ capacity to guess which symbol-bearing cards might be drawn from a deck, before they’re drawn. The initial findings were uncanny: “Rhine documented these stunning results in his notebook and prepared several papers for publication. But then, just as he began to believe in the possibility of extrasensory perception, the student lost his spooky talent…”

Schooler, plagued with self-doubt about his published findings on human memory, as Lehrer tells it, embarked on an “ironic” attempt to replicate Rhine’s work on ESP. In 2004, he set up experiments in which he flashed images and asked a subject to identify those; next he randomly selected some of those images for a second showing, to see if those were more likely to have been identified in the first round.

“The craziness of the hypothesis was the point,” Lehrer says. “But he wasn’t testing extrasensory powers; he was testing the decline effect.” He continues:

‘At first, the data looked amazing, just as we’d expected,’ Schooler says. ‘I couldn’t believe the amount of precognition we were finding. But then, as we kept on running subjects, the effect size’ – a standard statistical measure – ‘kept on getting smaller and smaller.’ The scientists eventually tested more than two thousand undergraduates …’We found this strong paranormal effect, but it disappeared on us.’

OK, are we talking science, or X-Files? I find this particular episode – both in its original, depression-era version and in Schooler’s 1990s remake – fascinating, even thought-provoking. But these don’t change my confidence in the scientific method one iota.

He moves on to consider a zoologist in Uppsala, Sweden, who published on symmetry and barn swallows’ mating preferences, aesthetics and genetics whose Nature-published theories on “fluctuating asymmetry” haven’t stood the test of time. After an initial blitz of confirmatory reports and curious, related findings, the observed results diminished. Another scientist, said to have been very enthusiastic about the subject and who tried to reproduce them with studies of symmetry in male horned beetles, couldn’t find an effect. The researcher laments:

‘But the worst part was that when I submitted these null results I had difficulty getting them published. The journals only wanted confirming data. It was too exciting an idea to disprove…’

Next, Lehrer advances toward a more general discussion on bias in scientific publishing. This can only partly explain the decline effect, he says. Intellectual fads and journal editors’ preferences for new and positive results lead to imbalance in reporting. Publication bias distorts the reporting of positive clinical trials over negative or inconclusive results. No argument here –

Still, the problem goes deeper. Lehrer interviews Richard Palmer, a biologist in Alberta who’s used a statistical method called a funnel plot to evaluate trends in published research findings. What happens, Palmer says, is that researchers are disposed (or vulnerable?, ES) to selective reporting based on their unconscious perceptions of truth and uneven enthusiasm for particular concepts. He gives an example:

…While acupuncture is widely accepted as a medical treatment in various Asian countries, its use is much more contested in the west. These cultural differences have profoundly influenced the results of clinical trials. Between 1966 and 1995, there were forty-seven studies of acupuncture in China, Taiwan, and Japan, and ever single trial concluded that acupuncture was an effective treatment. During the same period, there were ninety-four clinical trials of acupuncture in the United States, Sweden, and the U.K., and only fifty-six percent of these studies found any therapeutic benefits.

These discrepant reports support that scientists see data in ways that confirm their preconceived ideas. “Our beliefs are a form of blindness,” Lehrer writes. In Wired he quotes Paul Simon: “A man sees what he wants to see and disregards the rest.” The point is clear.

Nearing the end, Lehrer draws on and extends upon David Freedman’s November Atlantic feature, Lies, Damned Lies, and Medical Science, on the critical, outstanding oeuvre of John Ioannidis, a Stanford epidemiologist who elucidates falsehoods in published research.

Re-reading these two articles together, as I did this morning, can be disheartening. “Trust no one,” I recalled. Seems like many – and possibly most – published research papers are untrue or at least exaggerated and/or misleading. But on further and closer review, maybe the evidence for pervasive untruths is not so solid.

In sum, the Truth Wears Off, in last week’s Annals of Science, offers valuable ideas – the decline effect (new), the statistician’s funnel plot (not new, but needing attention) and publication bias (tiresome, but definitely relevant). The ESP story is an obvious weak link in the author’s argument, as is the article’s emphasis and reliance, to some degree, on psychological models and findings in relatively soft fields of research. Physics, genetics, molecular biology and ultimately most aspects of cancer medicine, I know and hope – can be measured, tested and reported objectively.

My approach to new information is always to keep in mind who are my sources, whether those are authors of an article I’m reading or a doctor who’s making a recommendation about a procedure for someone in my family, and the limitations of my own experiences. I’m skeptical about new drugs and medical tools, but determinately open-minded.

The problem is this: if we close our minds to all new findings, we’ll never learn anything. Nor will we ever get better. Sometimes scientific reports are accurate, life-saving or even paradigm-shifting; if only we could know which those are –

“When the experiments are done, we still have to choose what to believe,” Lehrer concludes.

He’s right; I agree. Our choices, though, should be informed – through literacy, multiple sources of information, and common sense.


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