Metastasis

Last month, when I (and others) noted the ominous ads appearing in NYC subways, urging riders to "demand a CAT scan" -- I looked into the foundation that supported the ads. While the mass-market message was completely irresponsible (the use of CT scans for lung cancer screening has only been tested in smokers over 40, so there's no apparent reason for most riders to 'demand a CAT scan' from their doctors) I was nonetheless impressed by the credentials of their medical advisory board:

I see a medical advisory board full of oncologists, thoracic surgeons, and indeed, the author of the aforementioned 2006 NEJM study touting early detection via CT. Several board members are themselves lung cancer survivors.

I can't doubt this group's dedication or integrity (I originally expected "demandaCATscan.org" would be backed by GE Lightspeed scanners or something similar).

But I must ask, were these board members behind the subway ad campaign? Do they really want the general public demanding a CT scan? Because it's hard to believe such an informed and experienced group could endorse this approach.

Well, it turns out I wasn't cynical enough. The Lung Cancer Foundation is not backed by CT scanner manufacturers -- it's backed by cigarette companies.

Today's NYTimes drops the bomb:

In October 2006, Dr. Claudia Henschke of Weill Cornell Medical College jolted the cancer world with a study saying that 80 percent of lung cancer deaths could be prevented through widespread use of CT scans.

Small print at the end of the study, published in The New England Journal of Medicine, noted that it had been financed in part by a little-known charity called the Foundation for Lung Cancer: Early Detection, Prevention & Treatment. A review of tax records by The New York Times shows that the foundation was underwritten almost entirely by $3.6 million in grants from the parent company of the Liggett Group, maker of Liggett Select, Eve, Grand Prix, Quest and Pyramid cigarette brands.

The foundation got four grants from the Vector Group, Liggett’s parent, from 2000 to 2003.

Dr. Jeffrey M. Drazen, editor in chief of the medical journal, said he was surprised. "In the seven years that I’ve been here, we have never knowingly published anything supported by" a cigarette maker, Dr. Drazen said.

An increasing number of universities do not accept grants from cigarette makers, and a growing awareness of the influence that companies can have over research outcomes, even when donations are at arm’s length, has led nearly all medical journals and associations to demand that researchers accurately disclose financing sources.

Dr. Henschke was the foundation president, and her longtime collaborator, Dr. David Yankelevitz, was its secretary-treasurer. Dr. Antonio Gotto, dean of Weill Cornell, and Arthur J. Mahon, vice chairman of the college board of overseers, were directors.

So, after decades of denying the link between smoking and lung cancer, now a cigarette company has chosen to fund research in cancer detection. That's a good thing, right? It's even charitable, isn't it? Again it's necessary to ratchet up the cynicism:

Dr. Jerome Kassirer, a former editor of The New England Journal of Medicine and the author of a book about conflicts of interest, said he believed that Weill Cornell had created the foundation to hide its receipt of money from a cigarette company. "You have to ask yourself the question, 'Why did the tobacco company want to support her research?' " Dr. Kassirer said. "They want to show that lung cancer is not so bad as everybody thinks because screening can save people; and that’s outrageous."

Dr. Henschke’s work, while controversial among cancer researchers, has been embraced by many lung-cancer advocacy organizations, which have pushed for legislation in California, New York and Massachusetts to create trust funds to pay for lung cancer screening — often with language tailored to benefit Dr. Henschke’s group.

From this perspective, a mass-market campaign for lung cancer screening, instead ads targetted to smokers over 40, makes much more sense. What better way to build the association, in the public mind, that lung cancer is detectable and treatable if caught early? You could even imagine tobacco companies trying to limit future medical liability by pointing to the research they funded. "Everybody knows smoking causes cancer," they'd say -- "but everybody also knows a screening CT would have caught this early, while it was treatable."

So, the millions Liggett gave to Dr. Henschke wasn't motivated by charity or guilt, but rather, looks like a wise investment. Similarly, the misleading subway ads were never designed to protect the public -- the exist to protect cigarette company interests.

Blood Makes Noise

I recently heard US Army Major (and emergency medicine physician) report on his research, conducted in a major trauma center in Iraq. To give some context to his investigations on Factor VII and clotting, he mentioned a number of incredible statistics about the volume his hospital sees, the throughput his ER achieves, and even the turnaround time for lab results.

But one thing he said really stayed with me: all the hospital personnel have their blood typed and crossmatched. When a wounded soldier or Iraqi civilian requires a massive transfusion in the OR, they'll summon someone with the right blood and just hook them up to the patient, in the OR. He said, "There's nothing like transfusing warm, fresh whole blood to a patient -- it's like a magic bullet. Too bad we could never do that in the States."

(Another Iraqi hospital, one not run by the US Army, has apparently adopted different techniques).

But more data is accumulating on the inadequacy of current blood products practices. We already knew banked blood has poorer oxygen carrying capacity and is immunosuppressive (at best). Now, the NEJM just published a paper from Koch et al that demonstrated more post-operative complications from older blood transfusions. Cardiac surgery patients were significantly more likely to stay intubated, to have their kidneys fail, to develop sepsis, and to die -- when they were transfused packed red cells that had been stored more than two weeks.

Blood transfusion has come a long way and the practice of whole-blood transfusion has fallen out of favor, at least among US civilian institutions. But military studies have shown, at least, non-inferiority of the practice fresh whole blood transfusions, compared to frozen blood products (and patients requiring FWB required more blood, which is typically associated with worse outcomes). And others are looking at ways to mitigate the risk of infection.

It will be interesting to see this military practice finds some applicability in stateside trauma centers, and if the pendulum swings back towards whole blood transfusion in certain cases. If reviews bear out the benefit of fresh whole blood, hospitals should set up some kind of system where volunteer employees can be summoned to the OR to donate. It somehow seems more immediate and personal than current blood donation and banking. And when you consider all the expensive, marginal interventions we use in emergency medicine, it's nice to think we're sitting on something that could make a dramatic difference for a critically ill patient.

More, Now, Again

If, for some reason, you haven't read enough about me in the past few months, you can read my profile (html, pdf), by Dr. Tiago Villanueva, in this month's Student BMJ.