Medical scan scam

DRUG BUST Alan Cassels

Seek and ye shall find. We can find disease wherever we look; the question is do we need to be looking? One of the longest-running debates in health care circles involves the dichotomy of “prevention” versus “treatment.” Some people complain that our “health” system has nothing to do with health and basically exists to patch you up once you’re broken. It’s a system that, by design, ignores many of the factors that make us sick in the first place. Many people praise the need for prevention using very compelling arguments, stressing that the bucks need to go towards health promotion and disease prevention in order to save further billions on medical services down the road. This would avoid much needless suffering and engender a healthier, happier society at a fraction of the cost we currently incur.

There’s no doubt that, as a society, we need to do a better job of following the classic triumvirate of health promotion advice: Eat well. Exercise often. Don’t smoke. However, that which passes for prevention is often an exercise in consumerism to get us to part with even more of our dollars. All in the name of health, of course.

We’ve seen many examples of how “prevention” consumerism drives the use of pharmaceutical drugs prescribed to “prevent” all kinds of chronic disease, even when the evidence underlying those treatments really applies to only a small subset of “high risk” people who may benefit. The incessant drumbeat of preventative pharmacology persistently fails to remind us that many of those treatments provide infinitesimally small benefits for relatively healthy people at great costs with unknown risks.

The pharmaceutical industry is not alone in discovering that prevention sells. Others, particularly those that market organ screening with some of the highest tech tools on the planet, such as the CT (computed tomography) or PET (positron emission tomography) scanning machines, have discovered that screening for disease is a cash cow capable of providing a much more lucrative revenue stream than that yielded by simply providing treatments for the sick.

In fact, one way to sell “prevention” is to establish a market for screening for the deadliest diseases lurking in your body – seeking out markers of disease, such as heart disease or cancer, before the disease can get you.

This new generation of scanning devices wouldn’t look out of place in Dr. McCoy’s sickbay on the Starship Enterprise. These space-age devices generate three-dimensional images of your body’s insides and, in terms of diagnosing what is wrong with you, a CT or PET scan might be the best medicine for you. But, at the same time, because these machines are so good at detecting tumours and arterial plaque, entrepreneurs would naturally reason that we should grow that market by expanding the machines’ uses to more and more healthy people. In fact, why not send the whole population to get “screened,” under the guise that it would (like most arguments for prevention) ultimately save the health system money?

It’s not that simple. Population-wide screening of healthy people seems intuitively sound until you look a little closer and realize the costs and potential for harm are considerable, including, in this case, the massive doses of radiation that some of the tests themselves deliver.

What do we really know about the overall screening of the population using these devices? The answer is not much. And it provides no solace that even the screening paradigm about which we know the most – screening mammography for breast cancer – is no slam-dunk. Maryann Napoli, associate director of the Centre for Medical Consumers in Manhattan (, has an in-depth consumer’s view of the controversies around mammography. In a recent interview, she shared some of the statistics with me: “For every 2,000 women who have mammography over the course of 10 years, one woman will have her life extended because she was saved from having or dying from breast cancer. Meanwhile, 10 more women will be diagnosed and treated for a cancer that they didn’t need to know about.”

The fact is the more mammography screening you do, the more things you’ll find. And the more stuff you find, the more you will be driven to determine if the lumps are lethal, beginning a cascade of biopsies, surgery, radiation, hormone therapy and so on. Any screening, if pursued too aggressively in well people, will deliver high rates of false positives – the equivalent of crying wolf. One of the surprising findings of mammography screening research, despite our profound belief in its usefulness, is that breast cancer death rates don’t vary, regardless of whether or not you religiously have mammograms or avoid them. The equation tilts in favour of older women being more rigorous about mammography, but then why do we still recommend screening so aggressively for younger women?

Cancers don’t just show up in the breast, and around the world, private entrepreneurs with scanning machines are promoting their high-tech search and destroy missions in hearts, lungs and other organs. In Canada, these scans seem to be currently limited to those who can plunk down the fee of several thousand dollars, unless you’re a CEO and you get the screen as a perk of “executive health” coverage. The promotion of these types of screenings tend to use a predictable technique designed to grab your attention: 1) the hook –sell the size of the problem. 2) the set-up – sell the wonders of the technology. 3) the pitch – and then close the deal by asking the customer to commit to some action.

The following two examples derive from a centre in a large, western Canadian city pitching its screens for lung cancer, heart disease, and other conditions.

Lung cancer screening

1. The hook: “The Lung Scan – The Best Defence is a Good Offence”

2. The setup: The most preventable of all cancers, lung cancer remains the leading cause of cancer death for both men and women.

3. The pitch: After quitting smoking, early detection may be your best defence against lung cancer. Researchers have recently demonstrated that routine CT screening reveals most lung cancers while they are potentially curable.

4. The close: The lung scan is very accurate in detecting small lung cancers before they become symptomatic or before they become visible on standard chest X-rays. Early detection of lung cancers can mean a longer life and, in many cases, a cure.

Heart Disease

1. The hook: “The Heart Scan – Know the Score”

2. The setup: Cardiovascular disease is the single greatest health problem in Canada and the rest of the developed world. Health Canada suggests 37 percent of Canadian men and 41 percent of women will eventually die of some form of cardiovascular disease.

3. The pitch: A heart scan is an “effective, non-invasive way to measure the amount of calcified plaque in blood vessels – your ‘cardiac calcium score.’ Once identified, at-risk patients can be treated for problems such as high blood pressure, cholesterol pathology and borderline diabetes, significantly improving their chances of survival.”

4. The close: “Starting at age 45 for men and 55 for women, individuals should consider a heart scan to determine their calcified plaque levels.”

So there you have it – all the reasons why you should be proactive. There is this disease – lung cancer or heart disease – that is a huge killer. You could be at risk. The technology could save you. And luckily for you, you can act now (and pay the thousands of dollars your scan will cost you). And the narrative flows to the point where you are willing to part with your money.

By now, you would probably like to ask me, “So what’s wrong with paying a few thousand dollars to find out if your body is harbouring any latent disease?” One way to answer this question is by asking yourself what matters to you.

Does it matter that a single CT scan could expose you to as much radiation as 300 chest x-rays, which, statistically, will cause cancer in a small number of patients thus exposed?

Does it matter to you if the World Health Organization, as well as almost every federal agency in Canada and the US and many radiology societies and associations around the world, gives the thumbs down to population screening of asymptomatic (healthy people) for coronary artery disease or lung cancer using CT scans? In other words, for a variety of reasons, the experts don’t recommend it.

Does it matter that the language used to sell many types of population screening is prone to many forms of bias? Three types of bias – lead-time, length time and overdiagnosis bias – collectively conspire to make the screening appear to improve your chances of survival when it actually doesn’t? (Check Wikipedia for a good explanation of the types of possible bias.)

Does it matter that many of us who are healthy are harbouring slow-growing tumours and other moles, lumps and bits inside our bodies that we don’t know about and which may never bother us, yet, if those things were to be discovered, the medical cascade of investigations, biopsies and surgeries (as well as complications arising from hospitalization and surgery) would tend to follow?

Let me conclude by saying that while we all hope that high tech, such as CT or PET screening, saves lives, it’s worth waiting for the evidence to back up that hope. In the meantime, it’s buyer beware; watch for the hook and beware of those ready to “close” the deal.

Alan Cassels is a pharmaceutical policy researcher at the University of Victoria and is the author of The ABCs of Disease Mongering. He is currently studying the marketing and regulation of private scanning in Canada. Have you been scanned? Do you have a story to tell? Contact

Health Canada takes baby steps toward drug safety

DRUG BUST Alan Cassels

If you thought we could get through these lazy days of summer without another major drug warning from Health Canada for a class of drugs taken by thousands of Canadians, think again.

The most recent advisory is among the more mystifying of the “adverse drug reactions” warnings I’ve seen lately; it warns of tendonitis and even tendon rupture linked to a commonly prescribed, relatively new class of antibiotics. And while the warning threatens to make me riff, for the umpteenth time, on the variety of ways in which drug regulators around the world – Health Canada not excepted – seem to go through the motions of monitoring and ensuring drug safety, there was also some good news. In a separate announcement, Health Canada advised it would provide some new seed money to help establish a drug safety research network in Canada.

This is very good news, but first, about the warning. The fluoroquinolone antibiotics, which include ciprofloxacin (Cipro) and other drugs whose generic names end in floxacin, have been under a dark cloud for a while now. More than two years ago, the drug watchdog group Public Citizen petitioned the US FDA to strengthen the warnings, stating, “…tendon ruptures associated with these drugs continue to occur at a disturbing rate, but could be prevented if doctors and patients were more aware of early warning signals.”

Last month, Health Canada was seemingly spurred into action by the US FDA’s ruling that makers of fluoroquinolone drugs had to issue a “black box” warning – the FDA’s strongest safety warning – on these drugs. Black box warnings don’t come along all that frequently and they usually emerge after much negotiation between the manufacturers and the regulator. A “black box” often precedes the removal of a drug from the market and it is a serious signal that the regulators are concerned about the drug’s toxicity.

For all you active individuals out enjoying the summer sunshine, the phrase “tendon rupture” is likely to strike fear in your heart. Tendon damage and perhaps a torn Achilles tendon could wreck anyone’s day. And this due to a drug you took for a simple infection? While the potential effects on your tendons from these drugs have been known for some time, what isn’t entirely clear is why any physician would prescribe the drug, being fully aware of the risk it carries when other antibiotics carry no such risk. As far as I can tell, there is no valid evidence that the fluoroquinolones are any better at treating most infections compared to the alternatives, such as older penicillin-type antibiotics.

My knee-jerk reaction is to suspect that the fluoroquinolone antibiotics have been widely prescribed – both mis-prescribed and over-prescribed – and only a little research confirms those suspicions. There is that perennial, but misapplied, axiom “newer equals better,” which has likely driven much of the marketing and subsequent prescribing of these drugs, and as with any newer treatment, the drug roars onto the scene with bells and whistles while the vital safety signals are spoken in whispers years later.

It is obvious to me that these drugs are marketed as being useful for indications for which they would, at best, be someone’s second choice. At least one manufacturer of this type of antibiotic has been slapped on the wrist by the US FDA for “…making false and misleading statements regarding the safety and efficacy” of the treatment in its advertising.

In terms of how well the drugs are being prescribed, one study involving 100 patients in two academic medical centres in the US found that 81 percent of the patients taking fluoroquinolone antibiotics had been given them for an inappropriate indication. In that same study, 43 percent of the patients received these antibiotics as a first-line treatment and 27 percent of recipients had no evidence of an infection. If this study, which was small and perhaps not applicable to the wider population, comes even close to representing the actual use of these drugs in the “real world,” it is a damning indictment of a serious failure in prescribing, made all the more serious because the drugs have the inconvenient capacity to cause “tendon rupture.”

Should we not expect Health Canada, as our drug regulator, to ensure that proper and timely prescribing information, especially safety information, is made available to guide our physicians? Sadly “too little and too late” seems to characterize the safety signals reaching physicians. After a new drug is approved, the marketers jump into action putting the new drug front and centre of our doctors, our hospitals and health clinics, plying them with free samples and glowing literature.

So what can we do to ensure that new drugs are used properly, rather than inadvertently inflicting tendon damage on the population?

Essentially, we need better “real world” data. It is slowly being recognized that Canada lacks the capacity to properly ensure that “real world” data is generated for new drugs, and that vital safety information about how drugs work in the world in which you and I live must be delivered to physicians in a timely manner. We hope that our physicians are acting in the most prudent manner possible when it comes to treating our infections. We also hope they will reserve newer drugs for patients for whom the older, more established classes of drugs clearly don’t work. Although hope is a pretty frail framework upon which to build a drug safety system.

The demand for “Real World Safety and Effectiveness” research around pharmaceuticals is a topic I’ve written about in the past (Common Ground, August, 2007). This need was initially enshrined in the National Pharmaceutical Strategy (NPS), a federal-provincial initiative boldly launched in September 2004, with the goal of providing Canadians with more equitable, sustainable and safer access to new drugs.

Almost four years later, I’m not the only one to notice that the NPS is largely a dud. Some have said that the “new” Conservative government’s mighty tendency to jettison those Liberal initiatives sounded the death knell for the NPS. Others have noted that provincial-federal wrangling over drug issues – the provinces want help to stanch the bleeding of red ink on the provincial drug file while the feds want to please the drug industry – means the NPS is going nowhere fast.

One of the things buried in the NPS’s objectives was a desire to “strengthen evaluation of real-world drug safety and effectiveness” and this recent announcement seems like it’s about to happen, albeit with baby steps.

With prescription drug spending now in excess of $22 billion per year, and a strong public appetite for more rigorous drug safety in Canada, Health Canada announced in mid-July it would provide the seed money needed to set up an independent research network to study the real world safety and effectiveness of prescription drugs in Canada. The business plan behind this network called for about $20 million per year, but Health Canada announced an immediate five percent of that ($1 million dollars) to get things up and running.

The hope is that the provinces will jump in with their own money and make the network a reality, a network that will likely link researchers in Canada, who are already doing “post-market” surveillance work, and allow them to cooperate in tracking real world drug use issues across the country.

No one can argue that Canadians must be protected from the unanticipated, adverse effects of prescription drugs, as the recent drug safety warning related to the fluoroquinolones has highlighted. Some, however, are insulted with the measly five percent Health Canada is kicking in, as it barely represents a down payment on the initiative.

Some have said that regardless of what form Bill C-51 ultimately takes, if it even survives, any promise of a “cradle-to-grave” surveillance of drugs in Canada will have to be bankrolled by “real world” drug data, and this money will ensure that Canadian researchers are organized and funded to use those data.

I say we give credit where credit is due. Health Canada has anted up so let’s wait and see if the provinces will come on board. Only time will tell if they will do their part to make this network fly. Or perhaps this initiative, like so many other important initiatives in the past, is destined to die from the lack of political will.

My strategy? I’m going to say a little prayer for those who are suffering needless Achilles damage this summer and I’ll feel a little guilty as I continue to enjoy running, jumping, hiking and walking. Because of our collective ignorance about a particular class of drugs, many Canadians won’t be enjoying the summer as I will.

It doesn’t have to be this way. Let’s make drug safety a priority this year and put the money behind that decision.

Alan Cassels is a pharmaceutical policy researcher at the University of Victoria and can be reached at;

If you think you have been injured by a prescription drug, you should call the Canada Vigilance Program at 1-866-234-2345. You can also submit an adverse reaction report on the Med Effect Canada website (

Higher education just got higher

by Naseem Salila Gulamhusein

As human beings, our greatness lies not so much in being able to remake the world, as in being able to remake ourselves.

– Mohandas Gandhi

While finishing a degree at UBC, I dreamed of a curriculum that included yoga and wellness. I had already completed a degree at Langara College and I was well aware of the stress and pressure placed on students to succeed. I also questioned the logic of having to take some of the classes deemed “mandatory” to obtain a degree and I thought colleges and universities would be wise to include a six-credit course in yoga and holistic health. This way, when students got into the “real world,” they would have some valuable tools to deal with the changes and challenges of life.

In 1999, I was heading down the path to depression; life was taking its toll on me and sadness consumed my heart. I remember leaving campus one day after seeing a psychologist who had recommended I go on Prozac. I knew this was not an answer to my problems. Walking away from the institution, I was aware that I needed to make a choice between a path of suffering (where I was getting great marks) or embracing a path towards peace. In that moment, I remembered a quote my uncle had written in a yoga book: “When you surrender to emptiness, you will find happiness.”

The Centre for Holistic Health Studies at Langara College states its purpose as follows: “…to re-evaluate how health is created in the mind, body and spirit by expanding a client centred healthcare model that awakens the body’s innate healing potential and opens the path of the Heart.” After selecting the centre from a long list of potential workplaces that would be a good fit for my skills and passions, I was called in for an interview for the position of program coordinator.

During the interview, we talked about a number of things in relation to the programs. I spoke about wanting to share my passion for teaching yoga, and the interview changed into a larger discussion about creating a yoga teacher-training program at Langara. It would be vital to create a balance between the art and science of yoga and program development; and conversations with the Dean and others helped clarify how we could accomplish this in a college setting.

Spirituality and religion have always been a part of my life. Growing up, I was exposed to a diverse cultural and religious background. My father is Ismaili Muslim, born is East Africa, and my mother is Catholic, born in Northern Ireland. As a little girl, on Friday nights I would accompany my father when he went to the mosque. On Sundays, I attended church with my mother. Hearing the words of God, Allah, Jesus and Mohamed, I would think to myself how similar they all sounded; the meaning and message were about living by one’s virtues and helping those in need.

My mother and father struggled to find a balance and I soon came to understand why people fight over religion. Because of their interracial marriage, my parents were on the fringe of their own religions, providing me with a rich, cultural experience. In my teenage years, my father took me to my first yoga class, where I met my first teacher, a woman named Joy who suggested that one day I teach yoga. In saying that, she sealed my destiny.

My yoga-training journey brought me many blessings and the honour of studying with four great teachers: the first of which are my parents, who have taught me patience; the second, Yogi Bhajan (Kundalini yoga), taught me courage; the third, Gurumayi (Siddha yoga), taught me to follow my heart, and, to this day, Baba Hari Dass (classical Ashtanga and Raja Yoga) teaches me selfless service and devotion.

In 2001, I ended up in New Mexico with a backpack and a small tent, which would be my only possessions for the next six months. I couldn’t help but ask myself, “What am I doing?” but I knew there was no turning back. I had a strong desire to burn off the karma of sadness and suffering and my days consisted of chanting every morning at 4 AM, yoga, meditation and working in the gardens and the office. On the first day of our yoga teacher-training, Yogi Bhajan advised, “You are going to work through your stuff now!” and he made us hold our arms in the air for what seems like hours. After I completed my stay there, he admonished me to go and teach the world.

After travelling and teaching yoga full time for several years, my life took a dramatic turn. Having just spent more than a year in service at the Mount Madonna Center in Northern California and the Salt Spring Centre of Yoga in BC, I received news that my beloved mother in Ottawa had breast cancer. The prognosis was not good – she had three to six months to live. My reality crashed around me as I fell to the ground in deep sadness. Only a few days before, I had talked with a close friend about what it would be like to lose a parent. I was not prepared, but bolstered with the support of community, I headed home to do my duty. Initially, my duty to my family took me to Ottawa, but it was my love for my mother that kept me there. Hospitals, chemotherapy, painkillers, nausea, cooking, laughter, forgiveness and tears became our day-to-day reality. Having lived independently for so many years, I was once again a daughter, living at home.

I have heard that the greatest test of anyone’s practice is to move back home with parents and continue to remain in a state of shanti (peace). Three to six months turned into 18 months and I was honoured to be by my mother’s side during the process. In the summer of 2006, the cancer consumed my mother’s body, the battle was over and all that remained was to surrender. In the face of death, all I knew to do was chant. Both the Catholic priest and the Mukhi Kamadia from the mosque gave the Last Rights and I chanted the shanti mantra so that peace would prevail.

I was graced by watching my mother live and die without fear. She offered all of her suffering to God and forgave those who had trespassed against her. In her final hours, I watched the true meaning of life unfold. We come into this world on an inhale and we literally leave on an exhale. Everything in between is an experience that brings us closer to our inner truth and divine consciousness. Life is pairs of opposites seeking balance and union (yoga). Balance arises when we give up suffering, negativity and fear.

In the face of fear, there is always love and this is what guides me to live in the world. I choose to live and love through the path of devotion and action. After my mother’s death, I travelled with my beloved teacher Baba Hari Dass to India. For two months, I lived at Sri Ram Ashram, an orphanage for 68 destitute and orphaned children and school for 500 children. It is also a charitable medical clinic. It was there that my feelings of gratitude for having the love of a mother became more than I can ever express.

All these experiences brought me back to Vancouver in the fall of 2007, where I was led to Langara College to follow my dream at the Centre for Holistic Health Studies. Langara College is the first college in Canada to offer a 250-hour, experiential yoga teacher-training certificate program, which offers students the opportunity to study and practice these ancient teachings, which can bring about personal transformation, as well as allowing them to develop a daily at-home yoga and meditation practice.

One of the foundations of yoga is a regular daily practice (sadhana). Through meditation, self-affirming thinking and developing a positive approach to life, students learn how to solve personal challenges and promote peaceful change in society. They also gain the knowledge and skills to effectively teach mindful yoga classes and deliver workshops to diverse groups.

It is our life experiences that make us great teachers. We can only teach people from where we have gone before. Teaching yoga is a life journey, which begins with cultivating awareness of one’s mind, body and soul and a strong desire to free oneself from the bondage of suffering. When we are free, life becomes a joyous dance with the divine. The heart opens and blossoms, providing beauty and light to all.

Naseem Salila Gulamhusein is the Yoga Teacher Training Program Coordinator and Teacher Trainer at Langara College. She has taught all levels of students internationally and has instructed for yoga teacher training programs in Canada and the US.,