Book Review: The Immortal Life of Henrietta Lacks

Rarely does a book shock me.  This one did multiple times over.

Here’s a quick summary:

Henrietta Lacks was a poor black woman who was raised on a tobacco sharecropping farm.  She was poor, uneducated, abused, and she eventually developed cervical cancer.  She lived in Baltimore about 20 minutes from Johns Hopkins University.  It was the only place that would see blacks with no insurance, so that’s where she went.  Hopkins had a bad reputation for experimenting on their “colored patients” but it was the only place she could go, and they did have brilliant doctors and great facilities.

Also in Baltimore was a man named Dr. George Gey.  He was trying with all his might to keep human tissue samples alive in Petri dishes.  No one had been able to keep human tissues or cells alive for very long.  You could freeze it and preserve it – but all tissue eventually died, the cells would reproduce maybe a few times – then die.  He asked the doctors at the hospitals to collect extra samples of all tissues for him so he could try to keep them alive or even make the cells replicate in a test tube.

Henrietta had a malignant cervical tumor.  Her doctor took a biopsy, and sent part of it to pathology for diagnosis and part of it to Dr. Gey.  He labeled the test tubes with the first two initials of her first and last name: He La

Dr. Gey’s assistant put it the “nutrient bath” like the last few thousand samples and waited and watched.

For the first time ever – a set of human cells didn’t die, they multiplied.  They multiplied so fast it was unbelievable.  Sure they were cancer cells which always grow out of control – in the body.  But Gey had tested tons of cancer cells before, they all died.  These grew and spread like wild fire.  He told a few fellow researchers that he may have found the first “immortal” human cell line ever.  They asked if they could have some, and he freely gave them.  He started giving them to everybody.

Meanwhile Henrietta underwent radiation therapy.  While she was burned from the outside she had the most malignant and vicious cancer destroying her from the inside.  She soon died Oct 4 1951.

1952 was the worst US outbreak ever of Polio and Dr. Jonas Salk was desperately looking for a way to test his vaccine.  He needed human tissue that was susceptible to Polio that he could use his vaccine on and then inject with polio to see if it worked.  He needed to test it thousands and thousands of times and with multiple versions of his vaccine.

Dr. Gey knew he had what Dr. Salk needed.  They tested the HeLa cells, and they were susceptible to Polio.  They set up a massive cell reproduction system and started producing billions of HeLa cells for Polio experimentation.

In 1955 the vaccine was released.  Together with the vaccine developed by Sabin, polio was eradicated.

HeLa cells were then used by everyone for everything.  Bio-Tech companies reproduced HeLa cells on a massive scale and sold them to laboratories around the world.

HeLa cells were the only cells that could be tested forever.  You could test anything on them: diseases, drugs, radiation, zero gravity – if the cells died you just went to the test tube and got more of them.  They never stopped multiplying.  HeLa cells were sent to the moon and were exploded in atomic bombs.  They were fused with animal cells to make hybrid cells with mouse and human genes. 

HeLa cells became the basis of a HUGE portion of biological research.  The cells were a medical revolution and sparked a multi-million dollar industry.

Only one problem - No one told Henrietta or anyone in her family.  They found out 22 years later through a chance encounter.  In 1973 Henrietta’s daughter-in-law, Bobbette, was chatting with her friend and her husband.  She mentioned she was from Baltimore and her married name was Lacks.
The friends husband told her that was amazing because he’d been working for years with these cells in his lab and had just read an article that said they came from a woman named Henrietta Lacks.

Bobbette told him that was her mother in law’s name, but there couldn’t be a relation because her mother in law had died in 1951.

“Did she die of cervical cancer?”  He asked.

-“How’d you know that?”

“Those cells in my lab have to be hers.  They’re from a black woman named Henrietta Lack who died of cervical cancer at Hopkins in the fifties.”

- “WHAT?!” Bobbette yelled, jumping up from her chair.  “What do you mean you’ve got her cells in your lab?”

He held his hand up in the air, like whoa, wait a minute. “I ordered them from a supplier just like everybody else.”

- “What do you mean ‘everybody else’?!”  She snapped “What Supplier?  WHO’S GOT CELLS FROM MY MOTHER IN LAW?!”

And that’s how the nightmare started.  There was a woman whose biopsied cells had been sold for millions or billions of dollars and saved thousands of lives.  Her family was still dirt poor, couldn’t afford health insurance, and they were about to embark on a terrible and heart wrenching journey to find out what had been done to their mother.  Had anyone ever asked for permission to use those cells?  Would they ever see any money from their use?  Over the next 20 years her family would be ignored, followed, tested, lied to, deceived, interviewed and filmed dozens of times over.  

The book tells the story of Henrietta and her family, the story of the HeLa cells and all the good and bad they were used for, and the story of the author, Rebecca Skloot.  It took her 10 years to write the book.  It is fascinating, funny, horrific, shocking and heart-warming all at the same time.

I will be hanging a picture of Henrietta Lacks in my office.  I never want to forget her story. 

Is “Prozac” just “Placebo” misspelled?

A few facts:
In 2010 the top 5 antidepressants were prescribed 115 million times in the USA.

Antidepressants have side effects, the most common being weight gain, sexual dysfunction, and upset stomach. The most severe being suicidal thoughts and fatal birth defects.

Conclusion: These are not benign medications.

About me – I did not read just one article about antidepressants and then write a blog post about it. I have researched this topic. I have read many articles, and read the Newsweek article including the drug companies responses. I have read studies sponsored by drug companies as well as those with no “Pharm” funding whatsoever.

I wrote before about the publication bias in antidepressant research.
If we look at EVERY published and unpublished study submitted to the FDA for a set of antidepressants and compare the drug response with placebo response, guess what we find?

I'll give you a hint...it's depressing.

Everyone in the studies took a "depression rating test" before and after the drug trial.
If patients on Prozac said they got got better by 10 points, those on Placebo got by 8 points. Yes, Placebo had 80% of the effect.

You want the exact numbers?
There is a scale for rating depression called HAM-D which has been used since 1960 for pretty much all antidepressant trials. The higher you score, the more depressed you are.

0-7 = No Depression

8-13 = Mild Depression

14-18 = Moderate Depression

19-22 = Severe depression

>23 = Very Severe Depression

So you take the test before the drug trial. Then you get either an antidepressant or placebo and take it for a few weeks. Then you take the test again. How much lower your score is = your improvement.

Average improvement on antidepressants: 9.6 points (that would move you 1-2 levels up on the scale, like from severe to mild, and from moderate to mild or none.)

So that’s some real improvement

Average improvement on Placebo = 7.8

So the medication works better than placebo – but not much. How do we tell if that difference matters? Does a difference of 1.8 points matter?  If you do a statistical analysis – YEP, it’s significant.

If you do a clinical analysis (do the patients notice any real difference?) – NOPE, it's insignificant.

It turns out that to be clinically significant the drug needs to be at least 3 points better than the placebo. (So says the National Institute for Clinical Excellence)

SO WHAT DOES IT ALL MEAN?

Americans are taking drugs for depression and their depression is getting better. If they were getting a sugar pill (but thought it was the drug) they’d do just about as well.

So you tell me - Knowing the side effects and the costs – is it worth it?

Foster Kids: Over-Medicated or Under-Treated?

On December 1st 2011 Diane Sawyer reported on foster children and how many are on psychiatric medications.  She showed them tracking down doctor’s in parking lots as if it were “To Catch a Predator” and asking the doctor about his treatment of a foster child.

The story was very sad, but the spin on the story was even worse.

It speaks of a child and says “Both his father and mother had ended up in Jail.”

It then asks “What would drive a 7 year old to kill himself?”

While no one really knows the answer, they certainly seemed to imply that it had nothing to do with a horrific childhood, rather it was due to medications.

Let’s examine the evidence concerning foster kids and psychiatric treatment.

According to a GAO report in 2011: Foster kids are prescribed psychiatric medications 2.7 to 4.5 times more than non-foster children and often at much higher doses.

That is alarming.  Are we over-medicating these kids?  Are they being given medicines with serious side effects to "calm them down" so they're easier to deal with?

Another study published in 2010 gave us statistics on mental health disorders among adults who were once in foster care.  It turns out that kids in foster care are more likely to have mental illnesses as adults.

PTSD: 3.9 times more likely (30% in foster kids v. 7.6% in the general population)

Major Depression: 1.95 times more likely (41.1% v. 21% in general population)

Panic Disorder: 4.39 times more (21.2% v. 4.8%)

Generalized Anxiety: 2.7 times more (19.1% v. 7%)

Drug Dependence: 4.6 times more  (21% v. 4.5%)

So if we look at these two studies - it looks like kids in foster care are between 1.9 and 4.4 times more likely to have a mental illness, and they are prescribed medications for these conditions 2.7 to 4.5 times more often.

Those seem to correlate pretty well.

But still - isn't it possible that because foster kids automatically have health insurance from the government, that they are seen more and thus prescribed more medication that other kids?

Another 2010 study addressed this:  They found that 96% of all foster kids on psych meds were on them before they entered foster care.  Only 4% were started on psychotropic medications AFTER entering foster care.  And that's the number receiving medications.  The study also showed that 85% of foster kids who saw a psychiatrist ended up with limited or no medication use over time. 
The lesson I learn from this - there is a reason these kids are in Foster care, and it's usually the same reason they end up with a mental illness.  Something about their life before foster care was VERY VERY WRONG.

There was another scary part to this story - the real concern and what Diane Sawyer saw.  The problem is not necessarily how many foster kids are being prescribed medications, but rather how these medications are prescribed.  Some studies showed infants under the age of one receiving medication - in my opinion this should NEVER happen.  There were also small number of kids taking 4 or 5 medications at once.  This should be the RARE exception, and even when needed should still cause the prescribing doctor to worry.

In my estimation - that is where our focus should lie.  There should be more standardized guidelines for the diagnosis and treatment of foster kids.  They are a high risk group, we need to at least be aware that they are more likely to need help than other kids, and it should be available.  But we should also be aware of possible polypharmacy - over medicating of our foster kids.

One last parting thought:  Texas has more foster kids on more medications than any other state.  Minnesota has the least.  Which state do you think is scarier for foster kids? 

Right to Die V. Right to Prevent Suicide

There is a difficult and cumbersome conundrum in mental health.  There are two opposing forces which are strongly supported and have many laws and policies to support them, and once in a while – they collide.

WE HAVE THE RIGHT TO DIE

We cannot be kept alive against our will.  In 1990 the supreme court ruled in Cruzan v. Director: "A competent person has a liberty interest under the Due Process Clause in refusing unwanted medical treatment.”

In other words – any “competent” person can refuse medical treatment.  If you’re dying of cancer, or kidney failure, or anything else – you can refuse medical treatment because you have a right to die.

The Supreme Court clarified further in 1997 in Washington v. Glucksberg that we have a “constitutionally protected right to refuse life-saving hydration and nutrition”

This is why Advance Directives have become so prevalent.  If we don’t want to be kept alive on a ventilator and a feeding tube – we can refuse it ahead of time.  We can specify if we ever want to be intubated, if we want CPR, etc…

WE DO NOT HAVE THE RIGHT TO KILL OURSELVES

There is another law - the one that says we don’t have the right to kill ourselves.  In most every state there is law that states that anyone who threatens or attempts to kill themselves may be held against their will.  Yes.  If a police officer, nurse, doctor, social worker, therapist, or psychologist hears you say you are suicidal or you've attempted – they can fill out a form that binds you legally.  If a psychiatrist or any other physician agrees, you can be transferred to a psychiatric facility to be assessed and treated until you are “no longer a danger to yourself .”

Call it a "381", a "5150", a "Legal 2000" or whatever you want.  Most states will commit you to a psych hospital if you try to kill yourself.  You don't have the right.

So – You can’t kill yourself – or you can’t get caught planning it or attempting it.  It is considered a public safety issue.

NOW THE CONUNDRUM

What if someone has an advance directive saying they don’t want life saving treatment?  They don’t want to be intubated, they don’t want CPR.  It's in writing.  That person is found after a suicide attempt and taken to the hospital.  Their health is deteriorating and they go into respiratory failure.  A frantic family begs the doctors to save them.   The person is dying, which they have a right to do.  It’s because of suicide – which they do not have the right to do.

What does the doctor do?  There is a legal document from the patient that says they DO NOT want to be saved.  To intubate them or do CPR could be considered battery in this case.  Doctor’s are not to mess with individual rights and liberty – you do not ignore a DNR order. 

You also don’t let people commit suicide.  You save them, you treat them.   

  

QUESTIONS:   

Can a person obtain an advance directive stating their wish NOT to be treated, then make a suicide attempt and have that order honored?

Is a suicidal person a "competent" person?  Can they make a Do-Not-Resuscitate decision?

Antidepressants - Publication Bias

In 2008 the FDA decided to look at all the published data about antidepressants.  They found that 51 studies had been published.  They looked back at their own records about how many studies had been done on antidepressants, and found the number to be much higher - 74.

Where were the missing 23 studies?  (Those 23 studies had 3,449 patients who went through full drug trials, and their results were never published)

Why weren't they published?

The FDA looked at the 51 studies that were published and the looked at the publication itself to see how the drugs were represented.  The graph below shows the result of that analysis:

(White Boxes above the red line are studies that showed that the drug worked.  Black Boxes below the red line are studies that had negative or mixed results)

Basically this says that out of the 51 studies, 48 showed that the drug had a positive effect.  That's 94% of all studies showing a positive result!

There were only 3 studies that showed that the drug had negative or mixed results. 

THEN, the FDA looked all 74 the trials that had been done, without looking at the publications.  They analyzed the data themselves to see what they would find.  Were the unpublished studies mostly positive, or negative?  Were all the published studies portrayed accurately?

The graph below is their result when they FDA analyzed the data from all 74 trials themselves:

Yep.  It turns out that 36 studies showed mixed or negative results.  Only 38 studies were positive.  The positive results dropped from 94% to 51%
All 23 missing studies showed negative or mixed results.  13 of the published studies were misrepresented in the publication to make them look like they had a positive result.

What does this say about "double-blinded, placebo controlled, randomized control trials?"  What does is it matter that the studies are done correctly if they are misrepresented or selectively published?

This is only part of the depressing news about anti-depressants.  More to come...

Source: New England Journal of Medicine Article

Reducing Salt Intake Could Kill You Faster

Everyone knows you should eat less salt...right?  Salt makes you retain water, it increases your blood pressure, it makes you more likely to have a heart attack or stroke...right?

The Mayo Clinic says the average American eats 3.4 grams per day, and should eat <2.3 grams (and <1.5 grams if you have high blood pressure)

Livestrong reiterates this same information, as does the CDC.  The CDC goes on to states that lowering sodium could save thousands of lives annually because there are 400,000 deaths per year attributed to high blood pressure.

They can't all be wrong...right?

The problem is - they are all assuming they understand cause and effect.  They assume that lower sodium decreases blood pressure, and that lowering blood pressure in that way decreases deaths.

Sadly the ACTUAL RESEARCH does not verify their claims or assumptions.

The latest research, published in July 2011 shows something quite interesting.  It shows that as expected, decreasing salt intake can help the healthy American decrease their risk (a little) of dying by a cardiovascular accident.

That's not the interesting part.  Guess what the data show when you look at patients who have high blood pressure or already have heart failure?

If you already have high blood pressure - decreasing salt intake will have no effect whatsoever on your chances of dying by stroke or heart attack.

If you already have heart failure - lowering salt intake will kill you faster.

SO......if this article and research are accurate that means the CDC, Mayo Clinic, Livestrong, and all cardiologists and family docs should be telling you:

Everyone out there reading this who is healthy - decrease your salt.  (yeah, because that's gonna happen)

Everyone who has high blood pressure - don't change your salt intake at all.

Everyone who has heart failure - Don't you dare decrease your salt intake or you're even MORE likely to die of a heart attack or stroke!

I am getting to enjoy reviewing medical research literature more and more.  Each time I go to research conferences I learn more and more about how the conventional wisdom and even medical advice is completely wrong.
If anyone is curious - the source for this information is pretty much the best source there is.  It's almost universally agreed that the Cochrane Database is THE database for information.

Medications Likely Do You No Good

You might freak out when you realize how likely it is that your medication will do you no good.
There’s a very important term in medicine that is often ignored, it is “Number Needed to Treat.”
It means, how many people have to take the medication for one of them to avoid the bad outcome.

For example – why do people take Lipitor?
 - So they don’t have a heart attack or stroke and then die or become seriously impaired.
What does Lipitor do?
 - It lowers cholesterol
Why lower Cholesterol?
 - To avoid clogging arteries.
Why avoid clogged arteries?
 - To prevent a heart attack or stroke
Why prevent a heart attack or stroke?
 - to prevent death or serious impairment.
How many people have to take Lipitor to prevent one of them from dying or becoming seriously impaired?
 - 500. 

Okay – forget death or impairment, let’s just talk about a heart attack
How many people have to take Lipitor to prevent one of them from having a heart attack?
- 100.  Yeah.  One hundred people have to take Lipitor for 3 years in order to prevent one heart attack.

And Lipitor isn’t the worst drug, not by far.

Zetia is also taken to lower cholesterol – but it’s NNT is so high it isn’t shown to prevent any heart attacks at all.  Over 1000 people have to take it just to avoid heart disease.
How about aspirin?  Its NNT is 350.

Well what about exercise?  What is exercise’s NNT for preventing a heart attack? 
 - 3.  For every three people who exercise regularly, one of them will be saved from having a heart attack.

All of these number are speaking about healthy people, but it’s still poor even for those who already have disease.
Take people who already have heart disease or have had a heart attack.  How many of them have to take Lipitor to prevent one heart attack?  20.

You’ve had a heart attack, is it worth the 1 in 20 chance to pay for and take a pill every single day?
You just have high blood pressure, is it worth the 1 in 250 chance then?  Is it worth $500-$1000 per year to take a pill that has a 1/250 chance of helping you?
Okay  - forget the money.  What about the side effects?  Lipitor can cause diarrhea, muscle pain, nausea, headache, etc…  Is it worth it to take a pill knowing that the only effect it will most likely have is negative?
Remember, Lipitor is one of the BEST drugs that way.  It's side effects are fairly mild and what it prevents is fatal.  Even so, with such a small chance of benefit, is it worth it?

My point is this.  Medications cost money and they have side effects.  They work, but not nearly as well as most people think.  They bring peace of mind, they correct lab values, and for a small number of people, they prevent a bad outcome.
I am not callous or disinterested.  I prescribe medications every day with this knowledge.  I know my own family history and I’m going to be watching my cholesterol levels like a hawk the rest of my life.  Nevertheless, it is disheartening to know that for the HUGE majority of people taking medication, it will have no positive effect in their life whatsoever.