Sunday, November 22, 2009

Tonal Dissonance

There creeps in, at a steady pace, a comical antagonism that on its outstretched arms reveals little of its banality but the disarming smile of congeniality. It is within its substrate of slow disarmament and constant ridicule that the manner of its conspired gains are brazenly achieved. Sometimes these ridicules are innocent and sometimes they have far reaching quills that prick the essence of a firmament established in society. Humans will forgo the truth but become so involved with the political will that musters and eggs them on that they in their own benign innocence will yield to the temptation of self-righteousness. One such story is that of the age To Be!

We as a society having achieved of things once thought impossible like viewing the Titanic wreck on the dark depths of the Atlantic Ocean floor or stepping on the moon to hit a golf ball with a 9-iron club to the images of the rugged Martian surface, now consider no task unreachable and rightly so. It is manifest in our destiny that realizing one’s dream is the gateway to success. It is also manifest in our present the successes of the past that make the future so bold and yet easy. We have succumbed many times and will many more to the riches of varying degrees of truth that sometimes we have fallen victims to the very lies we try to avoid. Sometimes this is for expediency of our political desires and other times to the material desires of our self.

It is always in the rewards of truth that life unfolds its most beauteous of flowers. There is no controversy of thought or action. No blame or victimization and no lies to be told. It is the essence of reality. Of what it is and what it will become. No revisions of history to speak for the present and no obscuration of the peaks and valleys of the lessons learned from the past, just the truth.

The quiet pandemonium of muffled voices, clanking of silverware on the ceramic plates and murmur of hurried movements lays the scene in an enclosed space with some 80 people seated or in the process of sitting in an auditorium.  Some happily munching on the green salad while others sampling the large brownies with chocolate icing on top encrusted with colorful sprinkles right of the bat. There is a sense of urgency amongst all to get seated before the speaker begins. Most of the seats are taken in the rear of the room while the first row is virtually empty.  Between quick glances and mouthfuls the crowd assembles into a uniform audience. The lights are dimmed and the speaker who has been checking his computer screen for the presentation slides, shifts his weight on his right leg, clears his throat and welcomes the crowd.

He is an authority in his field of medicine. He is well traveled and distinguished in his field of expertise. He knows his subject. His sharp focused eyes, an aquiline nose and chiseled features define him.

“Ladies and gentlemen, I am going to discuss the ramification of the screening processes that we as humans have to endure for the single defined purpose of living healthy lives. I encourage any questions during this discourse. We will start with knowing about the types of Risks encountered in medicine.” He turns to the projector and presses the navigation button and the screen fills in.

“The Absolute Risk is defined on the bases of real numbers such as 1 in 10. Or for instance as in Breast cancer 1 in 7 during the lifetime of a woman. But it is as low as 1 in 25,000 in a 25 year old and as high as 1 in 3 for a woman aged 85 years.” He waits for the impact on the crowd and witnessing a few nodding heads he moves on, "The relative Risk issue is based on percentages and does not reflect true value. This is strictly based on a relationship with some other findings. I will digress to make a point between the two risks and use a slide on Pravastatin a Cholesterol lowering medication versus placebo in 1000 patients.”

Now compare that to the fact that the Relative Risk reduction which was computed as 32/(32+41) = 43%. In other words the promotional discourse is the calculated relative risk reduction but the truth is different and a little unsettling like the dust particles in this room.” There were a few coughs around the auditorium followed by muffled laughter.

“Now lets turn our attention to the value of mammograms in women.”

“The answer to the question is in the following slides and will become apparent to you shortly. But in the meantime keep thinking the answer to the posed question about the probability of a woman with a positive mammogram to have breast cancer on your own.”

The answer is 8 out of 1000 women screened with a 0.07% probability of disease in the population.” He waits again for a question but none is uttered.

“Lets deal with the risks of radiation from the screening process. It is established that the older machines before 1970s exposed the breasts to higher Rems then the current ones. The current exposure is well within the annually expected exposure.”

A hand shoots up from the audience, “ And who determines the annualized risks?”
“Good question. The linear hypothesis of radiation exposure and death is 2500 Rem. A value of 100 Rem is considered safe with less than 2% probability of disease. With mammography we are talking of millirems only.”
“But how do you know the breast tissue will sustain that amount of radiation without changing to cancer?”
“Here is a slide that answers to that question and I will expound on that.”

“You notice that there is a peak and fall out as a result of radiation exposure. So the cumulative effects are important and one has to balance out the benefits to the population in terms of early detection. Here is information from the JNCI about the suspected risks. You may have to squint to see the material clearly but it is worth it. I will give you ample time to review this slide.”

(Click on this slide to enlarge for full review)

“But if we are inducing cancers in the screening then isn’t that a self-fulfilling prophecy of ultimately finding the cancer after many years of testing?”
“Tough question and true in its premise. The real answer is the number of lives saved to the number of lives at risk from the procedure. Refining the breast imaging procedure and limiting exposure are tow important methodologies. Mind you and this is important to know; that we are all sustaining carbon 14 nuclear decays at a rate of 120,000 per second. Each decay yields gamma rays that disrupt cells and mutate their DNA. We are also exposed to the solar flares with trillions of neutrinos cascading through our bodies and of course the Radon decay in the soil that permeates through the soil and moves upwards into the atmosphere all yield radiation exposure to us. Our bodies have this mechanism called Mismatch Repair Gene. This governs the DNA replication process so that any error in recording of information to the dividing cell results in apoptosis or cell death. So the body rids itself of all these bad genetics. However if the mechanism is overwhelmed with the onslaught of bad genetic cells it can be over powered and the body can lose the battle. Another important factor is in women with dense breasts the mammogram yield is 62.2% while the norm in a non-dense breast is 88.2% and the detection rate of cancer in women with dense breasts is 9.7% compared to 4.7% in the normal breast. The denser the breast the more radiation is required for optimal viewing.”  He looks around the auditorium with his sharp focused eyes for any further questions. There is quiet and a few people shifting in their seats. The dark auditorium is under his spell.

“Now let me talk about the costs of screening.”

“Look at the facts. For 10 abnormal mammograms only one is truly positive for cancer or a10% probability. Repeat mammograms causes an enormous resource depletion and early detection if DCIS is really of no benefit since almost 99% of these will sit there and can be detected later without spread. It is the false positives that create anxiety and the false negatives that lead to potential problems. Here is one of the proposed algorithm for screening and interpretation and the potential complications that ensue from it." He waits a moment and then in a clearer and more forceful voice says, "every false positive has a potential for extra testing and intervention and every false negative has the risk of potential delayed diagnosis!"

“Now let us talk about real and perceived costs.” He flips the slide with a certain amount of flair. Almost maestro-like performance and immediately regrets it when a few snickers and suppressed laughter breaks out into a muted chorus.

“Interesting how our perceptions dictate our lives. We are fearful for the wrong reasons and fearless when caution should be the order of the day. Initially the advocacy was to use screening in women at age 40 every other year. But that is counter-intuitive since breast cancer in the young is more aggressive then in the old, so you would want to screen them more frequently. Now the issue is to screen women over the age of 50 years and once every two years. I think governmental interference over physician based intellectually designed scientifically considered options are a recipe for disaster. The politicians have no business in the profession of life saving. It is heretical in a communist society to question where the government knows best but in a society where diverse opinions and logical understanding based on verifiable scientific data exist, the decision must be evidence based and left to the physician. There are some women who need closer monitoring with higher risk factors and they have to know the risks of screening and then there are others that do not. A clinical examination performed by a competent practitioner and any findings can be confirmed by diagnostic testing may yield better results. To date the reduction in breast cancer has been attributed to cessation of Hormone Replacement Therapy and early detection to screening and therefore by implication more cures although the latter confirmation still remains elusive. The time for Medicine which is Tailor Based to the individual as other methodologies become available will yield better outcomes, limit risks and diminish fiscal pressures.” He stopped and took a quick swallow of water from the glass on the podium.

“I am going to leave you with these thoughtful questions?”

The thunderous applause drowns out silence. Many people walk up to shake his hands and words like “iconoclast” are heard and repeated around the room. The disbanded group walks out with a new understanding of the facts. The culture has to be refined one individual at a time and he is changing them by the scores.

“Omni Verum Vero Consonat.” (All truth accords with truth)

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