Sunday, February 10, 2013

Lung Cancer and the Power of Suggestion

Is it possible that today's high lung cancer rates are in large part due to the power of suggestion? Might the presence of Surgeon General warnings on a pack of cigarets actually cause people to expect to get cancer, and then see their expectation fulfilled?
Will stronger warnings (with ugly pictures) only make the problem worse?

One of the new FDA-approved warning labels.
This idea (that telling smokers they'll get cancer increases their odds of getting cancer) may sound ridiculous. Nevertheless, the epidemiological data tell an interesting tale. Interesting to the point of being spooky.


Placebos and Nocebos
I'll need to take a moment to explain how this idea came about. Bear with me if you can.

I recently happened to stumble onto Michael Specter's December 12, 2011 New Yorker article about placebo-effect research. I told my girlfriend Sally about the article. It sparked an animated discussion about the power of suggestion. We agreed that the power of suggestion is real. (Any doctor knows this to be true.) And it works both ways: negative suggestion can produce negative effects, just as positive suggestion can produce positive effects. This has been verified in placebo research. Nocebos (negative placebos) have been found to produce harm, just as conventional placebos have been found to produce positive results.

Sally and I began to speculate on the role of suggestion in the evolution of epidemic-scale disease. I offered the not-very-original idea that the runaway increase in the prevalence of bipolar illness over the past sixty years might be explained, at least in part, by the power of suggestion. Ever since the introduction of Prozac in 1988, all of us (in the U.S., at least) have been bombarded with pharma ads and popular-media articles telling us that depression is extremely common. And (surprise, surprise) now it is! But it didn't used to be.

In 1955, only 38,200 people in the U.S, were in mental hospitals as a result of disablement due to depression (C. Silverman, 1968, The Epidemiology of Depression, Johns Hopkins Press). Today, depression is the leading cause of disability in the U.S. for people aged 15-44 (according to NIMH stats). Depression now affects 20.5 million American adults: 14.8 million in the form of major depressive disorder and 5.7 million in the form of bipolar disorder. That's a pretty huge jump in numbers: 38,200 to 20 million. Were there millions of depressed people in hiding, in 1955, waiting to come out of the closet in the 1990s? Was 9.3% of the American adult population (the percentage now suffering depression) merely suffering in silence, back in 1955? Or did the drug companies and their media flacks convert a relatively rare psychological condition into a growth industry through massive advertising and media hype (in other words, through the power of suggestion)?


A Weird Suggestion

Sally and I began to speculate about the possible role of the power of suggestion in other epidemic diseases; somatic diseases (not just mental illness). Sally offered an interesting hypothesis involving lung cancer. What if today's high rate of lung cancer among smokers is due in part to the suggestion (planted in every smoker's mind) that smoking will lead inevitably to lung cancer?

I balked at the idea. "That can't be true," I said. "If it were true, today's lung cancer rates should be much higher than can be accounted for by smoking, compared to years past. Also, we should find that lung cancer rates took off after the announcement of the 1964 Surgeon General's Report on smoking. And we should see that lung cancer rates have decoupled from smoking rates entirely, going up when smoking goes down."

It turns out all of those predictions are met.

    (Click to enlarge)

In 1930, the lung cancer death rate for men was 4.9 per 100,000. By 1990, the rate had increased to 75.6 per 100,000 -- a 15-fold increase. We find a similar trend for women. In 1930, the lung cancer death rate for women was 2.5 per 100,000. By 1990, it was just over 30 per 100,000 (again, a 15-fold increase). And yet, per-capita cigaret consumption rose only by a factor of two in the same time period.

The most recent statistics (as reported by the National Cancer Institute) put the 2008 lung cancer rate for U.S. men at 71.85 per year per 100,000 men; for women, it's 53.59 per 100,000. So for men, the rate (since 1990) has leveled off and drifted lower. For women, the rate has continued to soar.

The above illustration shows these data graphically. (Source: www.publichealth.pitt.edu/docs/Perkins.ppt.) We see that the slope of the lung-cancer-rate curve was more-or-less constant from 1930 to 1963. Then the slope increases dramatically in 1964 -- at the time of the first U.S. Surgeon General's Report on lung cancer and cigaret smoking. Following the 1964 Surgeon General's Report, cigaret consumption starts to decline. The rate of cancer, however, continues to skyrocket, even after the especially sharp downturn in cigaret smoking that begins in the early 1970s.


A Time-Delay Effect?
Of course, it takes years of smoking to get lung cancer. So you might expect the high 1990 cancer rate to reflect the high 1960 cigaret consumption rate. But the numbers are still out of whack. Cigaret smoking doubled in the 20 years leading up to 1960. Lung cancer, on the other hand, tripled in the 20 years leading up to 1990.

One could explain this as some kind of dose-response relationship in which cancer rates just naturally happen to increase at 1.5 times the rate of increase of "cigaret dose." But according to the scientific literature, that isn't true at all. A large Danish study found that a 100% increase in cigaret consumption (going from 9 sticks a day to 19) causes lung cancer rates to increase by only 50%. A "saturation effect" has been noted many times in the literature. After a certain number of cigarets per day, cancer rate no longer increases linearly with cigaret dose.

There's another possible explanation for the recent runaway increase in lung cancer. Perhaps people in 1930 simply didn't live long enough to come down with lung cancer. And there's some truth to that. The life expectancy in the U.S. in 1930 was only 58.1 years for men and 61.6 for women. In 1990 it was 71.8 for men and 78.8 for women. Statistics show that the odds of lung cancer go up by a factor of 1.73 between age 60 and age 70. But this falls far short of explaining the 15-fold increase in lung cancer from 1930 to 1990.

So we're left with a dilemma. Either cigaret smoking is mysteriously becoming deadlier (much deadlier), or something other than smoke is contributing to the runaway lung cancer rate in smokers.


What We Know from the Latest Research
This mystery was the subject of a 2011 paper by David M. Burns and colleagues, titled "Has the lung cancer risk from smoking increased over the last fifty years?", in Cancer Causes & Control, 2011 March; 22(3): 389–397. The authors of the paper note that "U.S. lung cancer mortality rates are [now] substantially higher than those expected from changes in smoking behaviors."

In their analysis of epidemiological data, Burns et al. used a risk model that took into account, among other things, rates of smoking initiation; prevalence of current and former smoking; distributions of duration of smoking; duration of abstinence and number of cigarettes smoked per day for current and former smokers; and the duration of abstinence for former smokers. It was a fairly detailed model, in other words.

What did they find? The Burns paper concluded, first of all, that the apparent rise in lung cancer risk for smoking is real, not an artifact of some kind. The authors cite not only their own work but work by others:
Swartz [20] used birth-cohort-specific smoking prevalence data and a multi-stage carcinogenesis model similar to that developed by Whittemore [21] to predict overall age-adjusted trends in lung cancer mortality for white males from 1970 to 1985. He estimated that there should have been a 12% decline in rates over the interval based on the assumption of a constant effect over time in the risk model. This estimated decline contrasts sharply with the 26% increase in the observed lung cancer mortality rates over that interval. Tolley and colleagues [22] used an updated set of birth cohort smoking prevalence estimates, and a risk model developed by Peto [23], to predict lung cancer death rates over time by birth cohort. They estimated that overall lung cancer mortality should have begun to decline in the early 1980s for white males and in the mid-1990s for white females. Observed lung cancer mortality continued to rise throughout the 1980s peaking in the early 1990s for white males [24] and may have only recently peaked for white females [25]. A similar approach using risk models developed from the CPS I data and birth-cohort-specific smoking prevalence data from the National Health Interview Survey (NHIS) demonstrated a systematic trend of increasing underestimation of observed lung cancer mortality rates across all birth cohorts with advancing calendar year [6].

Secondly: When Burns et al. tried to adjust their model's smoking-duration assumptions to account for the epidemiological data, they failed to get a good fit with the data. (They fiddled with duration parameters rather than cigarets-per-day parameters because "the contribution of cigarettes smoked per day to lung cancer risk is much smaller than the contribution of duration.") As the authors put it: "Adjustments of the duration effect in the CPS I risk equations do not provide reasonable estimates of the U.S. lung cancer mortality experience." Elsewhere they restate it this way: "Adjustments for healthy population effects and for potential underestimates of the contribution of duration to risk are not able to eliminate either the differences in estimation accuracy across birth cohorts or the progressive underestimate of observed lung cancer mortality as calendar year advances." (By "healthy population effects," they mean effects due to overall increasing health in the U.S. population over the past 50 years. Better baseline health might make cancer rates appear worse depending how they're expressed.)


This graph shows that increased lung cancer rates don't match the predictions of existing models.
Taken from http://www.cbsnews.com/htdocs/pdf/SRNTPoster.pdf

Desperate to explain their results, Burns et al. end up suggesting that unspecified changes in cigaret design, occurring over a period of 50 or more years, are to blame for the otherwise-inexplicable increase in lung cancer rates. But they fail to cite evidence connecting any particular design change with a worsening of cigaret toxicity. Their sole "evidence" for the supposed greater toxicity of modern-day cigarets comes simply from the fact that fudging their model's toxicity assumptions gives a perfect fit with the data:

We support that hypothesis by showing that even a simple adjustment of the CPS I risk equations for an increase in risk due to changes in cigarettes adequately predicts the observed mortality data. 

This is, of course, tantamount to saying that if you change your risk model to assume a more dangerous cigaret design, it supports the idea that cigarets are more dangerous. It's circular logic.


Are Cigarets Really More Toxic Now?
So where does that leave us? It leaves us with a mystery. Lung cancer rates have simply outraced any ability of smoking rates to explain them.

One possibility is that the Burns group is actually right: Cigaret design features have made cigarets more dangerous. But this is not supported by the literature. Quite the contrary, in fact.

The single largest (and toxicologically most significant) change in cigaret design of the last 100 years was the addition of filters to cigarets. Prior to 1959, over half of cigarets sold were non-filtered. Sales of filtered cigarets skyrocketed following their introduction. The difference in toxicity between filtered and non-filtered cigarets, it turns out, is huge.

According to "Risks Associated With Smoking Cigarettes With Low Machine-Measured Yields of Tar and Nicotine" (National Cancer Institute; 2001. Smoking and Tobacco Control Monograph 13):
A large U.S. case-control study demonstrated significantly lower lung cancer odds ratios among filter cigarette smokers who had shifted to filtered cigarettes 10 or more years prior to diagnosis (Kabat, 1996) as well as for lifetime filter use (Stellman et al., 1997). [And] Two reports from a large multicountry case-control study in Europe also reported reductions in lung cancer risk associated with lifetime filtered cigarette use (Lubin et al., 1984; Lubin, 1984a & b)

The magnitude of the effect is large: almost 50%. (See Bross, I.D., and Gibson, R. "Risks of lung cancer in smokers who switch to filter cigarettes." American Journal of Public Health and the Nations Health 58(8):1396-1403,1968.)

The same National Cancer Institute monograph cites studies showing a significantly decreased (not increased) cancer risk with low-tar cigarets. Ironically, the chapter of the monograph that discusses these results (Chapter 4) was coauthored by David M. Burns, lead author of the 2011 increasing-cancer-risk study discussed above.

Bottom line: Design changes have almost certainly made cigarets less toxic, not more toxic.

The literature around greater toxicity of "light" cigarets has centered on the recent shift of lung cancer cytology from squamous-cell carcinoma to the more fatal adenocarcinoma. But evidence connecting light cigarets to this shift has been notoriously indirect and anecdotal. Much more work is needed before a causal connection can definitively be said to exist between light cigarets and deadlier cancers.


Other Factors?
Maybe other factors are at work in making cigaret smoking more hazardous. But what could these "other factors" be?

Bear in mind that because the rate of lung cancer in non-smokers has not gone up, environmental factors affecting all populations equally (smokers and non-smokers) cannot account for any increase in lung cancer rates among smokers. In other words, if increased exposure to air-borne carcinogens via urbanization (to take one example) could explain the increase in lung cancer over the past 80 years (a time when America did in fact become more urbanized), you'd still be left trying to explain why lung cancer hasn't gone up in non-smokers. The same can be said for arguments involving radon, asbestos, contaminants in drinking water, etc. All of these would affect smokers and non-smokers equally. And yet lung cancer rates have not gone up for non-smokers.

If we rule out changes in cigaret design and environmental factors as explanations for the enormous increase in lung cancer, what are we left with? Burns and others have put forth the absurdly desperate suggestion that today's smokers draw more heavily (and inhale more deeply) on cigarets, pulling smaller smoke particles deeper into their lungs. In other words, smokers are getting more cancer than ever before simply because they're sucking harder.

Making Ourselves Sick
I'm starting to like Sally's Hypothesis: The power of suggestion, acting over a long period of time, may be predisposing smokers toward cancer. Every pack of cigarets sold in the U.S. contains increasingly grave-sounding (and grave-looking) warnings about the power of cigarets to cause cancer. We're bombarded with that message now: Smoking leads to cancer. It inevitably leads to cancer. You will get cancer; get used to it.

For whatever reason, that has, in fact, become a self-fulfilling prophecy.

42 comments:

  1. I don't know if I agree with your article. Mainly, because I might be to mind blowing. But, I loved it. Really great read, with a lot of thought provoking content.

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    1. Anonymous12:26 PM

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  2. Anonymous10:49 AM

    I wonder if suing the government for causing cancer is winnable.

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  3. You're trying to claim that many (most/majority?) cases of depression are made up and hyped. They are trying to claim that it's impossible for there to be that many actual depressed people now.

    But turn it around. How many (openly) gay people/couples are there today? Millions! But there weren't that many in 1955! So what happened? Was it all media hype? Or are we expected to believe that all those gay people were suffering in silence in the 1950s?!.
    Of course all the gay people were suffering in silence in the 50s. People don't doubt that. So why the doubt about mental illness?

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    1. Anonymous11:13 AM

      """"But turn it around. How many (openly) gay people/couples are there today? Millions! But there weren't that many in 1955! So what happened? Was it all media hype? Or are we expected to believe that all those gay people were suffering in silence in the 1950s?!."""

      Mainly that most of them didn't exist at all. There are studies that suggest homosexuality is a social construction. People in the past had same-sex sex occasionally, but not a homosexual identity.

      Foucault, homosexual himself, gay activist and a scholar in sexuality wrote: "homosexuality appeared as one of the forms of sexuality when it was transposed from the practice of sodomy into a kind of interior androgyny, a hermaphrodism of the soul. The sodomite had been a temporary aberration; the homosexual was now a species."

      Or:

      "The very word "homosexual" came into English only in 1892, formed after a German neologism coined about twenty years earlier.[7] Homosexuality, then, is a social construct of our own culture, and virtually even of our own century. What we mean by "homosexuality" did not exist in [Ancient] Greece; there is no such thing as Greek homosexuality"
      http://www.amazon.com/One-Hundred-Years-Homosexuality-Ancient/dp/0415900972

      That means no stable same-sex orientation, no cross dressing, no mimesis of the feminine or masculine by the opposite sex, etc. They were rather "bi-curious" and that did not characterise their orientation, in the way "homosexuality" does. Mind you, in lots of societies it wasn't even something to hide, it was out in the open. So it wasn't the naive case one assumes that they suppressed their "true homosexual instincts". It is rather those that are "manufactured" socially.

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    2. What's even worse is that in the next DSM (Ed. V, coming in May), gender-identity confusion will be pathologized into a new disorder.

      I think LGBTs who are now out of the closet and in some cases depressed can account for some of the nearly 1000-fold increase in depression since 1955, but not the majority of it. The rest aren't faking it -- I didn't say that. Depression is real. Just as placebo effects are also real (but again, I'm not equating the two, just using an analogy). Somewhere along the line 20 million of us became convinced that we're depressed (me among them; I've been on 12 different meds over the years, none of which helped except Remeron). It's real. But how do you account for the 1000-fold increase in depression since 1955? How much of it would have happened without the billions of dollars of drug ads and brainwashing of the public AND of doctors?

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  4. Anonymous10:52 AM

    Very interesting. Is it possible that screaming "man made global warming" is making natural global warming worse? (Joking)
    I do agree with your idea.

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    1. Anonymous11:12 AM

      Why on earth would you agree with his idea? It's poorly argued and unsupported by any evidence.

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    2. Anonymous12:48 PM

      Placebo effect is proven. Maybe not everyone got cancer just because it is advertized to give you cancer, but it's obvious that some people got affected by advertising of free cancer. Hell I saw homeopathic medicine heal people, I saw people drinking only tap water for 10 years and get "cured" from eye sight problem (she is like 80 years old now and read somewhere that drinking tap water will cure her eye sight. If advertisement like that can heal eye sight of old person wearing glasses that works like 10x magnifying glass I am sure some advertisement can give people cancer. For example - your post gave me cancer.)

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    3. Anonymous1:51 PM

      No, you saw statistically irrelevant levels of coincidence.

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    4. Anonymous2:10 PM

      Quick at dismissing ideas you don't like, aren't you?
      My point is - if water and homeopathic medicine can heal people then there must be people that got cancer after reading "you will get cancer if you smoke this".

      But I am sure you have scientific evidence and relevant statistics proving that bad-placebo doesn't work if it's in form of warning or advertisement.

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    5. Anonymous2:14 PM

      Anecdotes are not evidence. And really, you have no idea what caused her eyesight to improve - you're just taking a guess that somehow it was ten years of drinking tap water.

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  5. Bear in mind that because the rate of lung cancer in non-smokers has not gone up, environmental factors affecting all populations equally (smokers and non-smokers) cannot account for any increase in lung cancer rates among smokers.

    Hmm, how about the mix of two, though? I mean the case of environmental factors making it worse, but ONLY for those that in addition smoke.

    Assume substance X is poisonous when consumed along with substance Y, or that it intensified the effects of the already harmful Y.

    Let's now say the environment gets ever higher doses of X particles.

    People that consume stuff that has Y would get sick in larger numbers that before the X, whereas those that don't consume Y won't be affected.

    Makes sense as I put it?

    That said, I really like the idea behind your article.

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    1. I had similar thoughts while reading:

      Why hasn't the rate of lung cancer in nonsmokers gone down?

      If cigarette smoking decreases, so should second-hand smoking!

      So other factors should have played a role.

      That does not mean that nocebos play no role but that they might play a smaller role than the author suggests.

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  6. What about the use of additives in cigarettes that started around the 1960s? From wikipedia on 'cigarette': "According to data from the World Health Organization,[40] the amount of tobacco per 1000 cigarettes fell from 2.28 pounds in 1960 to 0.91 pounds in 1999, largely as a result of reconstituting tobacco, fluffing and additives."

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    1. That's an interesting stat. Thank you for providing it.

      I guess the question is, is that enough to account for the 15-fold increase in lung cancer rate with only a 2-fold increase in per capita consumption?

      The jury is still out. That's about all we can say.

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  7. Anonymous11:07 AM

    You have entirely failed to prove your hypothesis. All you've shown is that there has been rise in lung cancer risk for smoking, not any underlying reason. Your speculation about the power of suggestion is very much unfounded, and has no research to support it.

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    1. Bug Powered11:18 AM

      You have entirely failed to prove your hypothesis.

      So what? Did it seem to you that he even TRIED to prove it? Do this blog look like a scientific paper to you?

      He just wrote his findings and some statistics on the matter.

      All you've shown is that there has been rise in lung cancer risk for smoking, not any underlying reason. Your speculation about the power of suggestion is very much unfounded, and has no research to support it.

      No, but it has no research to deny it either. And he provided several examples of research that deny alternative theories (e.g the delay effect, more toxicity, etc).

      Not everything has to be spoon fed to you.

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    2. Anonymous12:25 PM

      Don't be silly now. Making wild unsupported claims and expecting someone to do the research to deny your nonsense is not how science works.

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    4. Anonymous1:54 PM

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  8. Very interesting idea. However I think that your analysis doesn't account for the fact that impact on health of all negative influences is not continuos. It has a certain threshold, because human body is capable of defending itself up to the some point. When you take that into the consideration there is a possibility that while each of the factors is not statistically such an important factor, some specially risky combinations will have extremely high impact on health. Also different combinations of factors will cause a completely different symptoms, so it's very hard to say that there is no impact on the general population, maybe it's just not always causing the cancer? As an illustration, we all know that environmental pollution has been rising for years. Also the level of the everyday-life stress has risen in the past years. Since both the pollution and the stress have negative impact on ones health (while not that significant on their own), we might speculate that those risk factors combined with the heavy smoking will make smokers far more prone to lung cancer (while the rest of the population is affected in a completely different way, depending on their habits and genetics). Just my 2 cents...

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  9. Hmmmm... what about skyrocketing rates of diabetes and obesity? What "suggestions" caused those?

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    1. Eating like a pig, the way McDonald, BK, and all the rest have brainwashed us to do, using billions of dollars of ads, is what made us diabetic. It's pretty clear.

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    2. It's very far from clear. There are many possible causes for the obesity/diabetes epidemic. A breakdown of discipline around eating and industrial production of crappy food are only two of them. Among other possibilities are changes in bacterial flora due to overuse of antibiotics.

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    3. I should point out there is some experimental evidence for the last point.

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  10. The title of the article suggests a rather dubious explanation, but covers the major bases pretty well as one reads through it, including environmental, cigarette design and lifespan issues.

    One thing I'd like to comment on: "Burns and others have put forth the absurdly desperate suggestion that today's smokers draw more heavily (and inhale more deeply) on cigarets, pulling smaller smoke particles deeper into their lungs. In other words, smokers are getting more cancer than ever before simply because they're sucking harder."

    This is not an unreasonable suggestion. I would expect that with all the anti-smoking campaigns, negative social pressures and tax penalties associated with smoking, the only smokers left are probably the most addicted (and therefore perhaps the most likely to inhale more deeply/hold longer etc.). In this hypothesis, anti-smoking campaigns have effectively removed social and casual smokers from the pool (many of whom didn't actually inhale at all, which is why they were "casual" I guess) and left us with a pool of hardcore deep inhalers. It's something to consider, rather than dismiss without further thought.

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    1. I don't find it totally unreasonable either, but I don't think it can account for a 15-fold increase in lung cancer rate.

      Look at it this way. There's only so much toxic crap in a single 1.2-gram cigaret. A max of 1.2 grams. Right? So no matter how fast or how slow you smoke those 1.2 grams, you're never going to get more than yea-much poison into your body. True, you might draw it deeper into your lungs if you suck like hell. But even then, there's a limit to how much damage you can do. The question is whether extreme sucking can make cancer rates go up 15 times. I don't think it can. I'm open to it, but I want to see strong repeatable scientific evidence based on some kind of testing.

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  11. Anonymous comments are for cowards. So don't be a jerky little coward. Put your name on things, like an adult, unless you're too ashamed of your opinions to do that.

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    1. Anonymous1:55 PM

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    2. Anonymous3:13 PM

      Cry more, bitch.

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  12. I don't know why this thing hasn't been touched. Neither in the post nor in the comments. Its the fact that with the recent advancements in technology and medical research, our diagnostic abilities have grown by leaps and bound. We have cutting age technology with which we are very easily diagnosing diseases which were just like a dream 50-70yrs ago!!
    Besides, the people are more and more conscious about health. Regular health check ups is one of the key factors in screening of a disease nowadays. With more money being spent by the government and insurance companies coming to our rescue to cover up costly tests, we are more able to track the health or the progression of the disease process. Of course Nocebos might have some role but untill and unless it is persistent and continuous and the person is ardently made to believe in it beyond all means, it wont make such an impact at all..leave apart the 15times increase altogether. But what I said can surely justify the increased number of diagnosed cases. I hope tbis will suffice. :)

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    1. "Better diagnosis" does certainly explain part of it (especially for mental illness) but I don't think it's the whole answer. Even over-diagnosis doesn't explain the 1000-fold rise in depressive illness.

      The "better diagnosis" hypothesis doesn't hold up for lung cancer, because very few cases of lung cancer are "missed" in doctor visits. It is neither under- nor over-diagnosed.

      Overall, I don't discount anything you are saying. The only question is how to quantify it, to see the degree to which it explains the epidemiological data.

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    2. Please note that better diagnosis was just one of the points that I mentioned. Plus the increase in education and awareness. Heavy research funding along with insurance covers also contribute. Plz read my above coment for details. Thank you for your response. :)

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  13. A big Thank You to all the thoughtful and constructive Commenters. I truly appreciate the discussion. We can all benefit from this kind of back-and-forth.

    Please note that I wasn't trying to "prove a hypothesis" with this post, only trying to provide a starting point for discussion. I would never, by any means, say that Sally's hypothesis is the only hypothesis that could possibly fit the evidence. It's just one hypothesis. I would like to see others. So far, the hypotheses forwarded by the official scientific community have not stood up well.

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  14. An interesting post, Kas. Some light years from now it may not be as far-fetched by then to make a correlation between we become what we bring to manifest from what we think.

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    1. Anonymous10:56 AM

      Quantum theory shows its head again. You can easily prove in a lab that what you know effects (not affects) what exists; that what you observe causes it to be observable, etc. If I were to preach either religion or quackery, I would begin with a discussion of quantum physics. That would dismiss the concept of logic from any further discussion.

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  15. One way of testing this hypothesis would be to do a cross-national study correlating cancer rates with anti-smoking campaigns in different countries. Countries taking a less fear-mongering approach to public-health education should show lower rates of lung cancer relative to their levels of smoking.

    I have to say that I'm skeptical, since I thought it was pretty well established that meditation, positive imagery, and similar psychological techniques don't improve outcomes for cancer patients. Your hypothesis seems somewhat similar.

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    1. I do like your cross-national study idea.

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  16. All I'm doing is offering one of many possible hypotheses. (It's not really mine, it's Sally's.) I don't necessarily expect it to hold up. I'm actual hoping it doesn't; I hope there's a "real" scientific explanation for what's going on.

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  17. Here is the answer to your quandry: Many specific and strong associations between lung cancers and environmental factors are known, probably more than for any other type of cancer. Lead, asbestos, diesel fumes, arsenic and radon gas (found in many basements) are all extremely strong factors. Indeed, asbestos and cigarette smoke are muplicative in their causative effect, not merely additive. Dr. Irving Selikoff of Mt. Sinai estimated that workers who smoked and breathed asbestos heavily on the job were 100x more likely to have lung cancer. As millions of construction and auto workers were exposed as late as the 1970s to large doses of asbestos daily, and as the latency for these cancers can be 20 or 30 years, that explains a great deal of your math.

    Probably WHY you are confused is that you don't realize that there have been two warring schools of thought backed by two different types of big business in the 20th Century. One is cigarettes are the main cause of lung cancer and one is that environmental factors are the main cause. Professor Sir Richard Doll of Oxford and the ACS championed the first view. They were supported heavily by corporate America which donated to the ACS. But the other half, including Dr. Wilhelm Heuper of the U.S. Public Health Service and his protege, Rachel Carson, urged government to look at environmental factors.

    Famously, Dr. Heuper discovered an extremely strong relationship between analine dye used to make the color blue in cloth and bladder cancer. Unfortunately for his career, he discovered this when he was a company doctor for DuPont where those workers were employed. He refused to cover up his data and was fired. DuPont scientists and doctors worked tirelessly to ruin his career ever afterward. He eventually became the first head of the "Environmental Section" of the National Cancer Institute, but constant corporate criticism kept his work from gaining the popular support it deserved. However, Rachel Carson was a student of Dr. Heuper's and gained her understanding of cancer causation from him. Some of the pesticides she vocally opposed were made by... DuPont.

    You would probably very much enjoy the following reading: (1) "Smoking Kills" The Revolutionary Life of Richard Doll", by Conrad Keating, (2) "The Secret History of the War on Cancer" by Devra Davis, MD, (3) "The Nazi War on Cancer", by Richard Dalton (it sounds scandalous, but it is actually a serious book) and (4) David Michaels, "When Science Isn't Enough: Wilhelm Hueper, Robert A.M. Case and the Limits of Scientific Evidence in Preventing Occupational Bladder Cancer,"Int'l. J. of Occup. and Environ. Health, 1 (1995) pp. 278-288.

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  18. p.s it is also true that diagnosis of lung cancers (there are many types, non-small cell lung cancer, small cell lung cancer, adenocarcinomas, etc.) only started to be seriously documented en masse in the 1950s. One of the troubles with studies from the 30s, 40s and 50s is that they lacked pathological confirmation of cancer type in the study. And many doctors did not bother with biopsies of older patients at all. Since the creation of the NCI SEER data collection effort in 1973, we now almost have reliable results.

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