Ian Gawler Blog: Research, daily life and cancer

Groups, mushrooms, CD47, surgeons, PSA tests, mistletoe and coconut oil.
What do they have in common? They all feature in important research that throws light on what might make for a good choice if you or someone you love has cancer – or wants to avoid it. So this week, some compelling reading that just might help to save a life.

Plus Ruth and I start our tour of New Zealand next week, so more details of the talks and retreats, but first

Thought for the day
If I die
I want to be the healthiest person ever to die of this disease
                           One of the women in my Friday cancer group

Yes, that dot in the middle is me speaking at the Happiness and its Causes Conference in Perth last week; some highlights next week.

1. Attending a therapeutic group halves the risk of recurrence and the risk of dying from breast cancer
This study is a few years old now, but very significant all the same.

After a median of 11 years of follow-up, this study involving 227 women showed that those women provided with a psychological intervention via small groups that included strategies to reduce stress, improve mood and alter health behaviours, were found to have around halved the risk of both breast cancer recurrence (hazards ratio [HR] of 0.55; P=.034) and death from breast cancer (HR of 0.44; P=.016).

Follow-up analyses also demonstrated that women in the groups had a 50% reduced risk of death from all causes (HR of 0.51; P=.028) during the time of the study.
The authors concluded that psychological interventions can improve breast cancer survival.

Reference: Andersen BL et al, Psychologic Intervention Improves Survival for Breast Cancer Patients - A Randomized Clinical Trial.  Cancer. 2008; 113:3450-3458

2. Psychological and behavioural variables can have profound effects on cancer. 
In a related study, a meta-analysis (analysis of a large number of studies) revealed stress-related psychosocial factors to be associated with a higher cancer incidence in initially healthy people, poorer survival in patients diagnosed with cancer, and higher cancer mortality.1

Reference: Chida Y, Hamer M, Wardle J, Steptoe A. Do stress-related psychological factors contribute to cancer incidence and survival? Nat Clin Pract Oncol. 2008;5:466–475. [PubMed]

3. CD47: The cancer breakthrough I believe may really happen
Many of those who attend my workshops may remember I have been speaking hopefully of CD47 for some time. Here is an update.

CD47 is a kind of protein that is found on the surface of many cells in the body. It tells circulating immune cells called macrophages not to eat these cells. The body uses the CD47 protein to protect cells that should be protected and to help dispose of cells that are aged or diseased.

Unfortunately, some cells that should be destroyed are not. Researchers at Stanford discovered that nearly every kind of cancer cell has a large amount of CD47 on the cell surface. This protein signal protects the cancer against attack by the body's immune system.

Stanford investigators have discovered if they block the CD47 "don't-eat-me" signal through the use of anti-CD47 antibodies, macrophages will consume and destroy cancer cells. Deadly human cancers have been diminished or eliminated in animal models through the use of anti-CD47 antibody.

For the last year, many people have been working to make clinical trials in humans possible. Stanford is hopeful that the first human clinical trials of anti-CD47 antibody will take place in mid-2014, and clinical trials may also be done in the United Kingdom. Stay tuned; this one just might work!

4. Mushrooms – cook them and reap the rewards!
Some will know that mushrooms have been under something of a cloud (OK – bad pun ) and even on the Gerson banned list. I have never been able to find a satisfying rationale for this avoidance and more recent research indicates that maybe the problem was eating them raw, while cooking them seems quite beneficial.

In 2009 a study of 2,018 women correlated a large decrease of breast cancer in women who consumed common white button mushrooms (Agaricus bisporus). Women in the study who consumed fresh mushrooms daily were 64% less likely to develop breast cancer, while those that combined a mushroom diet with regular green tea consumption reduced their risk of breast cancer by nearly 90%.

Some studies have revealed that raw A. bisporus - along with some other edible mushrooms - contain small amounts of carcinogens. However, this research also noted that when cooked, these compounds were reduced significantly.

Reference: Zhang, M et al;  "Dietary intakes of mushrooms and green tea combine to reduce the risk of breast cancer in Chinese women". International Journal of Cancer 124 (6): 1404–1408.

HERE IS THE INVITATION

Pause,  focus on the scene below,  take a deeper breath or two,  bring yourself into this present moment     :-) 

then read on

Photo taken near the river at the Gawler Foundation's Yarra Valley Living Centre where we conducted the training /retreat with Dr Nimrod Sheinman recently and where Ruth and I will lead next year's pre-Easter retreat Meditation in the Forest

5. Would you travel to save your life? Surgeons and survival
A fairly well kept secret is that when it comes to cancer surgery, particularly the more complex, complicated surgery, your surgeon’s experience levels can drastically affect your chances of long-term survival. This is an excellent thing to know BEFORE you might ever need it. Tell anyone you care for about it!

This proposition has been further validated recently by a well-funded Swedish prospective cohort study in which all patients who underwent eosophagectomy between 1987 and 2005 were followed until 2011.

Results demonstrated that surgeons who performed above the Swedish median number of operations per year had a 20% reduction in mortality. The median number was about 10 operations per year. What that means is that if you had been operated on by a surgeon who was doing more than 10 esophagectomies per year, you would have had a 20% reduction in mortality.

What should we make of this? Seek an experienced surgeon if you need a tricky operation.

Reference: Derogar M et al. Hospital and surgeon volume in relation to survival after esophageal cancer surgery in a population-based study. J Clin Oncol. 2013;31:551-557.

6. Are PSA tests more trouble than they are worth?
Here we go! This is really going Out on a Limb! PSA testing for prostate cancer seems to ignite untold passions in many of those involved, but speaking in The Age recently, health reporter Julia Medew pointed out

“PSA tests are controversial because they can cause "overdiagnosis" of prostate cancer that is so slow-growing it was never going to cause men harm. It is now estimated that for every man thought to be saved by the test, another 12 to 47 will be diagnosed with cancer that will not kill them. Many will have surgery and other interventions that can lead to sexual impotence and incontinence.”

A recent Australian review has called into question one of the major studies that is used to support PSA screening and in doing so, adds more caution to taking that test.

Here is the Abstract of the paper so that if you are interested you have some facts.

Major clinical trials using prostate-specific antigen (PSA) as the screening test to detect localized early-stage prostate cancer and to attempt to change its natural history with early intervention have yielded conflicting interpretations.

The US Prostate, Lung, Colorectal, and Ovarian (US PLCO) cancer screening trial concluded that PSA-based screening conferred no meaningful survival benefit, whereas the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the GOTEBORG clinical trial (GOTEBORG) trials claimed statistically significant life-saving benefits.

These divergent outcomes have not provided physicians with clarity on the best evidence-based treatment. To determine the extent to which these divergent outcomes are clinically meaningful, we evaluated these data and those of a long-term prospective cohort study in the context of the clinically documented harms of androgen deprivation therapy (ADT) (hormone treatment).

We noted the unheralded fact that in both European trials far more patients received hormonal treatment in the control than the prostatectomy arm, whereas hormonal therapy in the US trial was balanced between arms. We examined this imbalance in ADT treatment and prostate cancer–related deaths in the contexts of contamination, stage migration, and attribution of cause of death, all of which impinge on data interpretation.

The ERSPC and GOTEBORG data are compatible with the hypothesis that ADT treatment contributes differentially to an increase in prostate cancer deaths in control patients. If so, the claim of a reduction in prostate cancer deaths in the screened cohort requires reappraisal.

The conventional interpretation that PSA screening and radical treatment intervention are the major contributors to the results of these two studies needs more rigorous scientific scrutiny, as does the role of ADT treatment of nonmetastatic disease.

Reference: Haines I, Miklos G et al; Prostate-Specific Antigen Screening Trials and Prostate Cancer Deaths: The Androgen Deprivation Connection JNCI J Natl Cancer Inst, Vol 105; 20, 1534-1539.


To read The Age report: CLICK HERE: 

7. Mistletoe doubles survival in advanced pancreatic cancer
Advanced pancreatic cancer is a tough disease and while over the years I have seen a number of people actually survive for long periods following our approach, often the side-effects of any medical treatments are outweighed by any benefits. This then is an interesting study as although the times were still disappointingly short, the mistletoe injections almost doubled survival. Also, mistletoe has been one of those controversial treatments often labelled as "alternative", so it is good to see it being evaluates scientifically and that it does seem to have some efficacy.

Abstract: The unfavourable side-effects of late-stage pancreatic cancer treatments call for non-toxic and effective therapeutic approaches. Over 12 months, we compared the overall survival (OS) of patients receiving an extract of Viscum album Mistletoe (VaL) or no antineoplastic therapy.

Findings: We present the first interim analysis, including data from 220 patients. Patients in both groups received best supportive care. Median OS was 4.8 for VaL and 2.7 months for control patients (prognosis-adjusted hazard ratio, HR = 0.49; p < 0.0001). Within the ‘good’ prognosis subgroup, median OS was 6.6 versus 3.2 months (HR = 0.43; p < 0.0001), within the ‘poor’ prognosis subgroup, it was 3.4 versus 2.0 months respectively (HR = 0.55; p = 0.0031). No VaL-related adverse events were observed.

Conclusion: VaL therapy showed a significant and clinically relevant prolongation of OS. The study findings suggest VaL to be a non-toxic and effective second-line therapy that offers a prolongation of OS as well as less disease-related symptoms for patients with locally advanced or metastatic pancreatic cancer.

Reference: Tro ̈ger W. et al., Viscum album [L.] extract therapy in patients with locally advanced or metastatic pancreatic cancer: A randomised clinical trial on overall survival, Eur J Cancer (2013), http://dx.doi.org/10.1016/j.ejca.2013.06.043
 

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NEWS UPDATE
I am being asked in workshops why coconut oil melts at room temperature, around 22 -24C, yet Prof George Jelinek in his guest blog on coconut oil (Coconut oil- are you nuts?) says the simple, obvious reason not to use coconut oil is that it contains saturated fats that are solid at body temperature - 37C.

At first glance this may seem confusing, but here is the detail, and again, I quote George:

The explanation for this melting point of the oil is pretty simple. Coconut oil is a complex mixture of fats; while 88.7% is saturated fat, there are also mono- and poly-unsaturated fats in the oil, as with other oils.

So the melting point of the oil depends on the relative proportions of the various fats making up the oil, and is lower than the individual melting points of the saturated fats referred to in the blog because of the lower melting points of some of the other shorter chain saturated fats, mono-unsaturated fats, and poly-unsaturated fats.

However, coconut oil does not get absorbed whole, but rather as the individual fatty acids, and it is the melting point of each of those individual fatty acids that is the important factor when they are incorporated into cell membranes.

By way of example, butter melts at 32-35C despite being composed of 63% saturated fats, most of them with melting points higher than body temperature, yet no-one would recommend it for good health.

NOTICEBOARD
Ruth and I will be presenting a range of public talks, workshops and retreats around New Zealand
in November/December.

There are a range of events in Auckland, Rotorua, Christchurch and Nelson.

We are delighted to be including our first meditation retreat in New Zealand (which quite a few Aussies have also booked for already!) - December 2 -8.

Please do let anyone you may know in NZ about the visit -  all the details are on my new public Facebook page: Dr Ian Gawler,    or the website.

Ian Gawler Blog: Who needs prostate surgery?

This week, let us go “Out on a Limb” and examine crucial new research that adds another piece to the compelling conclusion that many men with early prostate cancer are not being well served by surgery. In fact, there is a high probability they would be better advised not to have surgery and instead to change their lifestyle. This is crucial information for everyone, as at diagnosis, fear often drives people to make poor choices that ignore the evidence. But first:

Thought for the day

“The great danger for most of us is not that our aim is too high and we miss it, 
but that it is too low and we reach it.” 

                                                                    – Michelangelo (1475-1564)

A long-running study has found radical prostatectomy (removal of the prostate) fails to save lives in most men with localised prostate cancer. 

In a randomised trial of over 700 men who were aged 67 years on average, and had a median PSA of 7.8 ng/mL at the time of enrolment, 47% of those who underwent prostatectomy died from all causes during follow-up of up to 12 years, compared to 50% of those assigned to observant management.

Specifically, there was no significant difference in deaths directly related to prostate cancer: 5.8% of men in the prostatectomy group died from prostate cancer or treatment, compared to 8.4% in the observation group.

On top of this, the side effects of the surgery were highly significant. Two years after treatment, urinary incontinence was almost three times as common in the prostatectomy group as in the observation group, and erectile dysfunction was almost twice as common.

The US researchers reported that “our findings support observation for men with localized prostate cancer, especially those who have a low PSA value and those who have low-risk disease.”

Remarkably, they said that currently, nearly 90% of men diagnosed with localised cancer received early intervention with surgery or radiotherapy, despite up to two thirds having a relatively low PSA value or low-risk disease.

It is important to note that the study found radical prostatectomy did reduce all-cause mortality in men whose PSA value at diagnosis was greater than 10ng per mL.

However, overall the authors could not conclude whether prostatectomy improved or worsened the risk of death: statistical analysis found the surgery could reduce all-cause mortality by up to 10%, or increase it by up to 4%.

An accompanying editorial said the challenge remained identifying which men had aggressive, high-grade cancers and would most benefit from surgery.

“Prostate cancer is not a monolithic cancer, but a spectrum of disease. The screening, detection and treatment we provide must focus on cancers that matter, and future clinical trials must do so as well,” the editorial said.

REF: Witt, TJ et al, New England Journal of Medicine 2012; 367:203-13

COMMENT: This study is very important for men diagnosed with early prostate cancer. It compliment’s Dean Ornish’s randomized trial with early prostate cancer that demonstrated a lifestyle program very similar to that set out in You Can Conquer Cancer and taught at the Gawler Foundation, was able to lead to significant decreases in PSA with a dose related effect – meaning that those men who followed the program diligently got the best results.

The challenge is to manage the fear associated with the diagnosis and the need to be confident in one’s own healing potential. In my observation many people diagnosed with cancer become so fearful they will do things that do not always have logic or evidence on their side, such as accepting being pressured into having radical surgery by medical staff as well as family and friends who believe that radical medical intervention is in their best interests.

This research provides good evidence. It would seem very reasonable that for early, localized prostate cancer, the treatment of choice may well be not to have surgery, not to sit idly by and hope for the best while you are being “observed”, but to actively pursue a lifestyle based treatment regime.

This is the sort of medical information one is wise to think of when well. In my experience, when people face a cancer diagnosis it is often hard to think clearly for a while, and as a consequence, sometimes decisions are made that lead to later regret.

WHAT DO YOU THINK? Have you say in the comment section below.

NEWS
1. Friends, control and power.

Friends of Science in Medicine have refuted claims in two Medical Journal of Australia (MJA) articles that the group is trying to get rid of all complementary and alternative medicine courses from universities.

FSM president Professor John Dwyer, said his organisation “clearly” supports CAM research where there is evidence for potential benefit.

“It will be a great pity if parallel health care still exists in 10 years, for science has the ability to see a convergence of CAM and orthodox medicine”, he said.

Two articles have been published in the MJA in response to an editorial written by members of FSM published earlier this year in the Journal.(1)

This current controversy was sparked earlier in the year by a letter sent from the FSM to vice-chancellors of universities offering CAM courses. It asked that the universities review their teaching of health sciences “to ensure that primacy is given to scientific principles based on experimental evidence”.

In an editorial this week in the MJA, (2) the authors, led by Professor Stephen Myers, professor of complementary medicine at Southern Cross University in NSW, wrote:

“The debate on whether complementary medicine should be a university discipline, when seen from a sociological perspective, says much less about good science and much more about control and power.

“This controversy is simply the latest episode in a long-contested battle between orthodox and divergent views.

“CAM courses clearly develop critical thinking and fulfill the criteria for legitimate university disciplines”.

In the second article, the authors, led by Professor Paul Komesaroff, of Monash University, called on members of FSM to “revise their tactics and instead support open, respectful dialogue in the great spirit and tradition of science itself”. (3)

The authors said that they believed the views promoted by FSM in the earlier MJA editorial, “exceed the boundaries of reasoned debate and risk compromising the values that FSM claims to support”.

REFERENCES
1. MJA 2012; 196: 225-226 

2. MJA 2012; 197:69-70 

3. MJA 2012: 197: 82-83

To read an example of how the popular press is reporting this issue, link here to The Age

2. The travels.
Is Israel leading the way in integrating Integrative Medicine into the mainstream? Many think so and it was a delight to present last week to over 200 enthusiastic doctors, psychologists and other health professionals at a day Masterclass arranged by Tel Aviv’s Beilinson Hospital’s Integrative Medicine unit.

A delight to have such interest in meditation and its capacity to build resilience and satisfaction levels in health professionals, while enhancing empathy, decision making and clinical outcomes.

Over three quarters of the audience had done some meditation before and many indicated they were regular meditators. How the world has changed.

It has been another source of delight to be a part of Ruth reconnecting with aunts and uncles and cousins not seen for many years. And now we head for Jerusalem!!!

RESOURCES
You Can Conquer Cancer

Mindbody Mastery – downloadable meditation program

Gawler Foundation programs

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Ian Gawler Blog: Over-medicalisation, mammography and PSA screening

This week, big questions posed by new research concern the over-medicalisation of our health and wellbeing. Key examples cast big doubts over the merits of mammography for 50 yo women and PSA blood tests for prostate cancer in healthy men.

Next come telling comments from the MJA re why they did not publish the controversial article on me, The Age has another go at the Foundation, while another massive review of evidence comes out connecting nutrition with breast cancer.

But first, please do not believe what I say, just because I said it!

Thought for the day: Arrive at your own truth.

At the end of my early workshops I would often say “Everything you may have heard today could be untrue”. Some people were understandably unsettled and required an explanation. Why did I say it? Because I see the truth in the quote that follows, and have always been guided by it. 

"Don't blindly believe what I say. Don't believe me because others convince you of my words. Don't believe anything you see, read, or hear from others, whether of authority, religious teachers or texts. Don't rely on logic alone, nor speculation. Don't infer or be deceived by appearances.

"Do not give up your authority and follow blindly the will of others. This way will only lead to delusion.

"Find out for yourself what is truth, what is real. Discover that there are virtuous things and there are non-virtuous things. Once you have discovered for yourself, give up the bad and embrace the good."

- The Buddha

If someone leaves a program I have presented and says something like “I am eating this way now because Ian said so”, they have really missed the point and I would be very disappointed. 

If they say “I heard what Ian said, have considered it, and have chosen to eat this way”, then I am happy.


Research claims over half breast cancers would amount to nothing if left untreated, and raises questions about breast screening

Writing in the prestigious British Medical Journal, academics from Australia and Canada, claim up to 54% of breast cancers detected in women in their 50s by breast cancer screening would never have manifested clinically.

The article goes on to identify the phenomenon of over-medicalisation, saying healthy people are increasingly harmed by a barrage of unnecessary tests, procedures and drugs. The tendency to over-screen, over-diagnose and over-treat has become rampant in modern medicine, and poses a “significant threat to human health”.

 “Screening programs are detecting early cancers that will never cause symptoms or death, sensitive diagnostic technologies identify ‘abnormalities’ so tiny they will remain benign, while widening disease definitions mean people at ever-lower risks receive permanent medical labels and lifelong treatments that will fail to benefit many of them.”

ADHD, chronic kidney disease, gestational diabetes and prostate cancer were also key areas for concern, they said. Even asthma is over-diagnosed in up to 30% of cases, the authors said.

The article was timed to promote a new international conference called Preventing Overdiagnosis, that will aim to better assess the problem and begin working on solutions.

Click here for the reference: BMJ 2012; online.


Healthy men do not need PSA screens

Controversy has raged for some years about men being routinely screened for prostate cancer using blood PSA tests. I remember cringing while being a part of an SBS TV Insight program where Prof Alan Coates suffered the most vitriolic and personal attack from a prominent and highly emotional politician really suffering from prostate cancer and abusing Coates mercilessly for suggesting the scientific evidence did not support routine PSA testing. Coates was CEO of the Cancer Council of Australia at the time and he endured ongoing professional and personal criticism for his stance.  

However, recently the prestigious US Preventive Services Task Force (USPSTF) has added to this debate, claiming that PSA-based screening could not be widely recommended, due to the “inevitable” risk of over-diagnosis and harms of treatment.

It acknowledged that some men would continue to demand PSA tests, and that some doctors would continue to offer them, but said this should only occur through fully informed, shared decision making. The USPSTF said community and employer-based screening should be stopped altogether. It based its recommendations on an extensive literature review.

“The mortality benefits of PSA-based prostate cancer screening through 11 years are, at best, small and potentially none, and the harms are moderate to substantial,” said the final statement, published in the Annals of Internal Medicine.

The Prostate Cancer Foundation of Australia branded the recommendations “unhelpful”, and not directly applicable to Australia.


NEWS

1. The Medical Journal of Australia explains why it did not publish 

- with direct quotes

First: I did not give my permission and they value patient rights

Second: The article "presented supposition, nothing new in the way of facts".

Finally:  The Editor, Annette Katelaris summarised, and again I quote "patient consent, accountable editorial processes and an articles validity, significance and potential to advance medical practice are primary considerations in the MJA's editorial decisions...  These principles were applied in the MJA's final decision not to publish the article".

Conclusion: The Journal of Internal Medicine Journal obviously has different standards that allowed them to publish.

The letter that provoked the response, along with the editorial, will be linked to on my website soon.


2. Good nutrition may reduce the progression or recurrence of breast cancer.

Following on from last week’s blog on nutrition and cancer, comes news of a major work citing 353 references put together by Natalie Ledesma from the University of California, San Francisco.

Link here for the full work which makes for compelling reading:

Here is Natalie’s summary:

Good nutrition may reduce the incidence of breast cancer and the risk of breast cancer progression or recurrence. There are many studies in progress to help further understand how diet and cancer are related. We do know, however, that improved nutrition reduces risk of chronic diseases, such as diabetes, obesity, hypertension and heart disease, and also enhances overall quality of life. It is estimated that one third of cancer deaths in the U.S. can be attributed to diet in adulthood.


3. The Age is at it again!

A personal account has been published in the Medical Journal of Australia by a Melbourne psychiatrist who attended the Gawler Foundation’s 12 week non-residential cancer program. Writing under the strident headline “Doctor denounces Gawler program's 'harsh' healing”, health editor Julia Medew quotes and comments on the patient’s concerns regarding the rigours of the dietary approach, perceived guilt around the cancer prone personality, and the suggestion her group leader said there was no evidence chemotherapy works.

Join the link, read and decide for yourself.

I wish the psychiatrist good health and a long and happy life. Discussion, feedback and constructive criticism is always welcome, even when it turns up for the first time in a medical journal.

Comments from the Foundation’s CEO, Karin Knoester and the oncologist from Peter Mac seem worth quoting directly.

“Ms Knoester said although no independent evaluations had shown the Gawler programs were an effective cancer treatment, there was evidence that nutrition, exercise, meditation and positive thinking could all on their own help people overcome illness.

Deputy Head of Oncology at Peter MacCallum Cancer Centre, Associate Professor Michael Jefford, said he got the impression from patients that the Gawler Foundation's staff were ''overvaluing'' their therapies while telling people conventional treatments were less effective and more toxic than they really are.

''There is very good evidence for the efficacy of chemotherapy … so to say it doesn't work is blatantly wrong,'' he said. “There is also good evidence that chemotherapy improves quality of life … so to say it's toxic is incorrect.''

My comment. 

1. The Morgan study of 2004 reviewed the 5 year increased survival benefits of chemotherapy for the major 22 cancers at an average of 2.3%. Modest efficacy overall, although chemotherapy does have major benefits for a number of the less common cancers, including some of those that affect children. (I know of no more recent comprehensive review since that of Morgan in 2004. It was not very popular in oncology or the popular press at the time, but not refuted, apart from Prof Boyer who claimed on ABC radio he could “massage” the figures up to 5 - 6%!).

2. There is good evidence that chemotherapy impacts adversely on some people’s quality of life and that most chemotherapy is given with palliation in mind, not cure. Therefore the equation of pluses and minuses has to be considered carefully when making decisions regarding this form of treatment. No doubt good oncologists inform their patients of the risks and benefits, encourage open dialogue and assist in the making of good clinical choices.

3. If chemotherapy is not toxic, why is it called cytotoxic therapy? I wonder if Professor Jefford was quoted accurately.

People who do choose to have chemotherapy will benefit from a healthy, therapeutic lifestyle that is highly likely to reduce the risk of side-effects, improve survival and improve quality of life. The two, chemotherapy and a therapeutic lifestyle, work well together. This should be a co-operative venture.

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