[Part one- of many – probably]
The last few decades have seen medicine move inexorably towards the idea that its primary function is to prevent diseases from happening in the first place. Rather than trying to cure them after they have started. Which is a nice simple thought. It also seems an inarguably good thing. So presenting any case against preventative medicine can seem wilfully contrarian, and is often met with extreme anger….’do you want people to die!’
In truth, I do not want people to die – although I would have to add that we are all going to die anyway, whatever we do, so what would be your point exactly? No, what I want is for more people to understand that prevention is not a panacea. It can do more harm than good. Indeed, in certain cases, it can cause significant damage to health and general wellbeing.
It almost goes without saying that many preventative activities are a good thing. Clean water supply, surgeons washing their hands before operations, stopping smoking, taking exercise, and suchlike. But once you have got past such obviously useful activities, the benefit to harm ratio can rapidly become far less straightforward.
I spent some time recently reading a book by Peter Gotzsche called ‘Mammography Screening, Truth Lies and Controversy’. It helped to highlight many issues about cancer screening that have disturbed me for some time.
The first, and most important, is this. Many women have cancerous cells in their breasts. Around 40% of women in their forties, on autopsy, have detectable breast cancer(s). To balance this out, most men after forty, if you took out their prostate and sliced them open, would have detectable cancer cells present as well.
Although 40% of women have potentially detectable cancers, around 4% of women die of breast cancer.
This means that, the vast majority of breast cancers do not actually do anything very much. They sit there, and they sit there and…..presumably, many of them regress (shrink) back down to nothing at all. They cause no health problems, and a large proportion of women will die with, rather than of, breast cancer.
Increasingly, however, someone calls you in for mammography, and you have your scan, and they find a small suspicious lump. In an instant you turn from a happy healthy person, into someone with cancer – the deadly killer. At which point all hell breaks loose.
Now, if that cancer happened to be one that was going to grow and kill you, then all the crushing fear and despair, and biopsies, and operations, would be a small price to pay. But if that cancer was one of the 90% that was going to sit there doing nothing for the rest of your life, then you have paid an exceedingly heavy price indeed.
In addition to this downside, in many cases, the suspicious lump was not even cancerous at all. The mammography identified a possible cancer – and it wasn’t. In screening terms this is known as the false positive. In human terms it is known as, the most terrifying thing that has ever happened to me….. and you’re telling me it was a mistake!
There are those who take an absolutist position on this and say that ‘If even one life is saved, it is all worth it.’ Perhaps, but mammography exposes a women to a radiation dose that is around five hundred times that of a simple chest x-ray. Some estimates suggest that each mammography carries a one in two thousand risk of causing cancer.
If, over a lifetime of screening, you have ten mammograms, that represents a one in two hundred chance that a procedure designed to pick up cancer, may actually cause it. Or maybe the risk is greater than is. Is the potential to cause cancer additive, or multiplicative? I can find no-one able to answer this particular question.
Then, of course, there is the risk that the mammogram is negative. You are reassured that you do not have cancer – but you do. So when you feel a lump you think. It’s OK, I’ve had a mammogram and I am clear. But you are not. You could have been treated, but you waited too long. This is known as the false negative.
I could go on into further downsides, but I hope to have made the general issue clear. Breast cancer screening sounds wonderful, it is presented as an absolute good, but it is not. There are significant. and not uncommon. harms. Yet such is the zealotry (I hesitated to use the word zealotry, but I can’t think of a better one) of those involved in breast cancer screening that no downsides at all are ever presented.
Screening is good, breast cancer screening is perfect….or not. Here is what Professor Michael Baum has to say on the matter:
‘After a systematic review of all websites on this subject, a recent paper in the British Medical Journal concluded that women are being coerced into screening by those organisations connected to the government or the screening industry. I am neither for nor against screening, but I am a passionate champion of informed choice for women. For an informed choice women should be treated as adults and provided with balanced information, not with propaganda.’ http://www.spiked-online.com/articles/0000000CA382.htm
Preventative medicine, and screening and scanning, has almost become a religion for those involved. Only the positives are ever mentioned, and those who dare criticise are subjected to ruthless attacks. As I will be for writing this.
Prevention is better than cure?
Sometimes. Maybe.
Dr. Malcolm Kendrick 
Would you same the same thing about the relentless encouragement to have a colonoscopy every few years, given the very small but very real risk of complications (perforation, reaction to anesthesia)? I think I would.
So pleased to discover that you have started a blog Dr Kendrick – I just read “The Great Cholesterol Con” and found it impossible to put down until I had reached its compelling conclusion. Truly incisive analysis combined with humour worthy of Douglas Adams – a terrific and life-changing read!
Dear Dr Kendrick, a great fan of your work, how do I go about getting in contact with you regarding hiring you to do an academic talk for some students? – my email is: jamesdsallen@live.co.uk – I look forward to hearing from you, James Allen
As a doctor, I am appalled by your practice. If you are so convinced about the lack of an association between cholesterol and heart disease, why have you never published such work in peer reviewed journals? The fact is you have manipulated the facts to reach the conclusion you wish in order to reach an incorrect, controversial opinion. Your only motive is quite clearly making money from your book. I hope that the GMC pick up on your practice and take you down for miseducating the public. As an educated doctor, I assume that you are fully aware of the nonsense of your argument, and hence I fail to understand how you can practice as a doctor knowing full well that you may be shortening the life expectancy of thousands of people.
Thank you for your comment. It may interest you to know that I was invited to write a paper on this topic for the BMJ – which I did, outlining why women should not take statins (you can look it up on the internet). I am also a peer-reviewer for the BMJ. I also helped set up the original website for NICE, and spent three years developing the on-line educational website for the European Society of Cardiology. I have also been invited to give lectures on this topic to the BMA, the Medical Research Trials Unit, the Society of Chemical Industry and more recently the International Society of Cardiology. I do not say this for self-aggrandizement, mainly to point out that my views, whilst controversial, are taken seriously by mainstream researchers and doctors around the world. Also – although I use humour, do not doubt that I am a serious man, with an extremely serious agenda.
I would also be more than happy if the GMC (General Medical Council) picked up on my practice, for then I would have the opportunity to explain why my views are, indeed, evidence based. However, it is unlikely to happen, I speak regularly to many doctors who are in positions of authority within the GMC, as I meet them through my work with the BMA for the General Practitioners Committee which, as you may know, is the body that negotiates with the Government on the GP contract. In short, please do not threaten me with the GMC – they still allow people to hold different views. Equally, please refrain from accusing me of ‘shortening the life expectancy of thousands of people.’ If you disagree with what I say, then I am happy to engage in a scientific debate with you. Accusing people of killing patients is an old and wearisome game, designed to shut people up.
Here is an interesting article on the matter from a Dutch journalist Melchior Maijer, on the matter.
‘My name is Melchior Meijer. I’m medical reporter for several magazines and newspapers in The Netherlands. Reporting about the many obvious flaws in the cholesterol hypothesis, shedding light on the biologically plausible adverse consequences of statin therapy, is as close to 21st century blasphemy as a medical journalist can come.
I experienced this in 2004, when I wrote an article about statins in a national newspaper. In the article, several doctors and scientists expressed well founded doubts about the safety of statin therapy in the general population. I also presented a few `anecdotal’ cases of statin induced harm, which were extremely easy to find.
The medical establishment reacted in fury and started an aggressive media offensive. Carefully avoiding the arguments in my article, they used their authority to hang me out on TV as a liar, a potential mass murderer. They called for `official measures’ to prevent naive journalists from making similar `tragic mistakes’ in the future.
They also took me to the Press Court, but they didn’t reckon with the fact that the Press Court checks facts and figures. The Court did an investigation and decided that I had just done my job, observing and questioning. [As an aside: the chief of my newspaper, born into a family of influential physicians, was not happy with the Court’s decision. He had already apologized on television for `this tragic mistake’.]
After this statin users started calling and mailing to the media, always reporting the same symptoms: various degrees of (muscle pain) and loss of muscle mass, exhaustion, personality changes and amnesia. But my colleagues didn’t like to take up this serious issue. That is, until last March when the TV-colleagues of TROS Radar, a consumer programme with an average of 2 million watchers (we have 16 million inhabitants), took up the subject.
Dutch cardiologist Dr Paul de Groot expressed his doubts about cholesterol as a causal factor, and postulated that statins sometimes do more harm than good, especially in primary prevention. Dr Uffe Ravnskov, who by the way was honoured yesterday with the prestigious Leo Prize for independent science, pointed out the many flaws in the cholesterol hypothesis.
The programme also interviewed people who had experienced devastating side effects from statins, which quickly disappeared upon discontinuation – although sometimes they did not. I was on the programme to explain how Unilever had succeeded in keeping an unfavourable article about its cholesterol lowering spread Flora out of the press.
When the shit hits the fan…
My time is limited, so I will make it short. Radar was vigorously attacked from all directions. Professors Martijn Katan and John Kastelein used various media outlets to shamelessly fire irrelevant, slanderous attacks on Dr Ravnskov. As usual, they did not address any of the scientific arguments. Radar invited Katan and Kastelijn for a public debate with Drs Ravsnkov and Kendrick, but they declined.
The Dutch Cardiologists Association, together with the Healthcare Inspectorate – and this is critical – announced official guidelines for medical journalists who plan to cover `delicate medical matters.’
I trust you will now recognise that threats have absolutely not the slightest impact on what I have said, and will continue to say. I recognise them for what they are, and in fact welcome them. As a wise man once said. ‘When the flak is at its greatest, you know you are close to the target.’
Thanks for the reply. I read your article on statins for females – it contained none of the controversial views you write about in your book. You have gone to such great lengths to make up theories and put them in a book, why not publish them in a journal? Clearly it would be rejected and ridiculed for a lack of scientific rigour. If we take ANY scientific theory and manipulate the data, we can skew the image (as you have done) to the uninformed reader (the general public). I also direct you to a recent study published in the lancet, which using data from over 130,000 patients clearly demonstrates an increase in life expectancy, irrespective of sex (thereby rendering your earlier article in the BMJ moot):
http://www.lancet.com/journals/lancet/article/PIIS0140-6736(12)60367-5/fulltext
Forming theories and challenging the prevailing view is welcomed in science – but if done in the right way. You have bypassed scientific publication and gone straight to the general public, and this is VERY dangerous, and I hope that in the future all scientifically related articles and books which could have such a profound impact on patient life will be monitored by medical bodies such that books such as yours are unable to make it to publication – as would be the case if you tried to submit any aspect of your book to a medical journal.
Dr.Kendrick’s critic came up with a Jeremiad about his alleged manipulation of the data and the “thousands” of lives he allegedly put at risk by this. Why doesn’t he point out where this “manipulation” is to be found? If there is such an obvious lack of “scientific rigour” there as he claims there is this should be easy. But no he prefers to threaten him with the GMC.
He also castigates him for not publishing his heretical views in “peer reviewed” journals. Is he joking? Knowledge is not produced in a social vacuum. There is in every field of research a network of social interests – careers, established reputations, subsidy streams. There is an established “paradigm” of “acceptable” and “non acceptable” theory. Established reputations and the “established paradigm” are closely interwoven.
This is all the more the case when big financial interests are at stake – as there undoubtedly are in the whole statin business. As the Financial Post wrote recently in a far less relevant context:
“money has a corrupting influence, not least on the peer-review process.
Many scientific journals, including prestigious internationally acclaimed ones, have now become captured by insider groups of leading researchers in particular fields. Researchers who act as editors of journals then select referees from within a closed circle of scientists who work in the same field and share similar views.”
The Alliance for Human Research Protection said under the heading “Medical Journals complicit in the corruption of medicine”:
“The Truth About Drug Companies” (2004) an influential book by Marcia Angell, MD, who had been the editor of The New England Journal for two decades, laid bare the ubiquitous influence industry has on medicine.
Doctors “on the take” [to borrow the title of a book (2005) by another former editor of the NEJM, Jerome Kassirer, MD] are encouraged to promote and widely prescribe clinically worthless drugs for untested uses, without regard for the serious harm caused patients.
Although industry’s cash inducements have corrupted both individual doctors, universities, professional associations, and industry front groups that masquerade as “patient advocates,” those most responsible for the corruption of medicine are medicine’s academic leaders, prestigious medical institutions, journal editors, experts charged with formulating practice guidelines, and federal oversight agencies–in particular, the FDA, the National Institutes of Health, and the Center for Disease Control.
When academia and government agencies became stakeholders in the business of medicine, promoting the commercial interests of manufacturers, rather than the public interest, they betrayed the public trust and their professional integrity.
Richard Smith, MD, the former editor of the BMJ (for 25 years) has been an outspoken critic focusing in particular on the role journal editors have played in the corruption of medicine. His book, The Trouble With Medical Journals, 2004, describes journal editors’ unacknowledged significant conflicts of interest.”
From this point of view the most important information in the Lancet article that so excited Dr.Kendrick’s critic comes at the very end when it states:
“Most of the trials in this report were supported by research grants from the pharmaceutical industry. Some members of the writing committee have received reimbursement of costs to participate in scientific meetings from the pharmaceutical industry. AK and JS have also received honoraria from Solvay for lectures related to these studies.”
The following interview with Professor Beatrice Golomb by Dr.Mercola is rather enlightening. She mentions inter alia that an FDA inquiry uncovered that in a certain drug trial 37 of 38 of the favorable reports (favorable to the drug company’s interest) were published. However of the 36 unfavorable reports 22 were not published at all and 11 of the remaining ones were published in such a fashion that the outcome appeared to be favorable. See http://www.youtube.com/watch?v=O6Z1vo-psWc
So how do we know how many articles not favorable to the use of statins got conveniently overlooked, or were buried or misleadingly presented right from the start, as compared to the 22 picked out by the authors of the Lancet article for their “meta analysis”? Perhaps Dr.Kendrick’s anonymous critic has some ideas on this.
Thank you for your thoughtful and supportive post
Your diatribe is befitting of those who are “sheeple.” Not a single logical thought about the postulates of Dr Kendrick; rather, an emotional attack against his clearly thought out and scientifically reasoned arguments based on evidence. Trying to coerce authorities to silence dissenters is exactly waht the Nazis and all authoritarian thugs do- well done- you are in great infamous company!
I’ve just finished reading The Great Cholesterol Con. I’m not a doctor but have been involved in the NHS over the years (originally a diagnostic radiographer) and have always been a little suspicious of the things that are ‘taken for granted’ (more so since my NHS experiences) – especially when there is an ulterior motive (usually a financial incentive of some kind). Dr Kendrick’s work is fully referenced and his view is not just some fancy idea he might have dreamed up – there are plenty of others medics out there fighting against the ‘established view’.
How does Dr Saxena explain the many paradoxes where the cholesterol theory doesn’t stand up? For example the Swiss, the French, the Australian aborigines etc? I am now training as a homeopathic practitioner (Dr Saxena, please don’t comment on this – I can almost hear you laughing as I write and I’m not interested in negative views about this so-far ‘unscientifically proven’ way of dealing with health issues) and am well aware that many, if not all, of my patients developed physical ailments as a result of a significant emotional event in their personal history – so Dr Kendrick’s explanation for how heart disease can come about due to ‘stress’, social dislocation etc seems pretty accurate to me.
I can hardly believe that Dr Saxena would like to censor such publications as Dr Kendrick’s – it’s already happening though. I recently read that ‘What Doctors don’t tell You’ were asked to change their advertising for various publications (eg ‘The Cancer Handbook’ now has to be called ‘The Cancer Book’ – because they aren’t allowed to publicise alternative ways of treating the disease, even those that have been shown to be highly effective!). Soon the whole of western medical practice will be controlled by the people who stand to gain the most – ie the pharmaceutical companies and all those who own shares in them and we, the public, will be at their mercy.
In my time working in the NHS (which I still am) I have concluded that doctors are often chosen for their ability to swallow unquestioningly that which they are taught and regurgitate it when required. They are clever enough to learn and pass exams but very few of them actually think for themselves or question orthodoxy. Thankfully there are some of the latter out there – Dr Kendrick and his supporters are just some of them.
Very interested in your opinion on modern drugs and the latest application of nhs strategies,and
the false assertions of the general public that the medication given is really necessary or effective. I have read with interest your article in Nexus magazine,