Finally a Viral Cause of Chronic Fatigue Syndrome? Or Not? – How Results Can Vary and Depend on Multiple Factors

15 02 2010

Last week @F1000 (on Twitter) alerted me to an interesting discussion at F1000 on  a paper in Science, that linked Chronic fatigue syndrome (CFS) to a newly discovered human virus XRMV [1]

This finding was recently disputed by another study in PLOS [2], that couldn’t reproduce the results.  This was highlighted in an excellent post by neuroskeptic “Chronic Fatigue Syndrome in “not caused by single virus” shock!

Here is my take on the discrepancy.

Chronic fatigue syndrome (CFS) is a debilitating disorder with unknown etiology. CFS causes extreme fatigue of the kind that does not go  away after a rest. Symptoms of CFS include fatigue for 6 months or more and experiencing other problems such as muscle pain, memory problems, headaches, pain in multiple joints and  sleep problems. Since other illnesses can cause similar symptoms, CFS is hard to diagnose. (source: Medline Plus).

No one knows what causes CFS, but a viral cause has often been suspected, at least in part of the CFS patients. Because the course of the disease often resembles a post-viral fatigue, CFS has also been referred to as post-viral fatigue syndrome (PVFS).

The article of Lombardi [1], published in October 2009 in Science, was a real breakthrough. The study showed that two thirds of patients with CFS were infected with a novel gamma retrovirus, xenotropic murine leukaemia virus-related virus (XMRV). XMVR was previously linked to prostate cancer.

Lombardi et al  isolated DNA from white blood cells (Peripheral Blood Mononuclear Cells or PBMCs) and assayed the samples for XMRV gag sequences by nested polymerase chain reaction (PCR).

The PCR is a technique that allows the detection of a single or few copies of target DNA by amplifying it across several orders of magnitude, generating thousands to millions of copies of a particular DNA. Nested PCR amplifies the resultant amplicon several orders of magnitude further. In the first round external primers are used (short DNA-sequences that fit the outer end of the piece of DNA to be amplified) and an internal set of primers is used for the second round. Nested PCR is often used if the target DNA is not abundantly present and to avoid the comtamination with products that are amplified as a spin-off due to the amplification of artifacts (sites to which the primers bind as well)

[I used a similar approach 15-20 years ago to identify a lymphoma-characteristic translocation in tonsils and purified B cells of (otherwise) healthy individuals. By direct sequencing I could prove that each sequence was unique in its breakpoint sequence, thereby excluding that the PCR-products arose by contamination of an amplified positive control. All tumor cells had the translocation against one in 100,000 or 1,000,000 normal cells. To be able to detect the oncogene in B cells, B cells had to be purified by FACS. Otherwise the detection limit could not be reached]

Lombardi could detect XMRV gag DNA in 68 of 101 patients (67%) as compared to 8 of 218 (3.7%) healthy controls. Detection of gag as well as env XMRV was confirmed in 7 of 11 CFS samples at the Cleveland Clinic (remarkably these are only shown in Fig 1A of the paper, thus not the original PCR-results).
In contrast, XMRV gag sequences were detected in 8 of 218 (3.7%) PBMC DNA specimens from healthy individuals. Of the 11 healthy control DNA samples analyzed by PCR, only one sample was positive for gag and none for env. The XMRV gag and env sequences were more than 99% similar to those previously reported for prostate tumor–associated strains of XMRV. The authors see this as proof against contamination of samples with prostate cancer associated XMRV-DNA.

Not only PCR experiments were done. Using intracellular flow cytometry and Western blot assays XMRV proteins were found to be expressed in PBMCs from CFS patients. CFS patiens had anti-XMRV antibodies and cell culture experiments revealed that patient-derived XMRV was infectious. These findings are consistent with but do not prove that XMRV may be a contributing factor in the pathogenesis of CFS. XMRV might just be an innocent bystander. However, unlike XMRV-positive prostate cancer cells, XMRV infection status did not not correlate with the RNASEL genotype.

The Erlwein study was published within 3 months after the first article. It is much simpler in design. DNA was extracted from whole blood (not purified white blood cells) and subjected to a nested PCR using another set of primers. The positive control was an end-point dilution of the plasmid. Water served as a negative control. None of the 186 CSF samples was positive.

The question then is: which study is true? (although it should be stressed that the Science paper just shows a link between the virus and CFS, not a causal relationship)

Regional Differences

Both findings could be “real” if there was a regional difference in occurrence of the virus. Indeed XMRV has previously been detected in prostate cancer cells from American patients, but not from German and Irish patients.

Conflict of Interest

Lombardi’s clinic [1] offers $650 diagnostic test to detect XMRV, so it is of real advantage to the authors of the first paper that the CSF-samples are positive for the virus. On the other hand Prof. Simon Wessely of the second paper has built his career on the hypothesis that CFS is a form of psychoneurosis, that should be treated with cognitive behavior therapy. The presence of a viral (biological) cause would not fit in.

Shortcomings of the Lombardi-article [1]

Both studies have used nested PCR to detect XMRV. Because of the enormous amplification potential, PCR can easily lead to contamination (with the positive control) and thus false positive results. Indeed it is very easy to get contamination from an undiluted positive into a weakly positive or negative sample.

Charles Chiu who belongs to the group detecting XMRV in a specific kind of hereditary prostate cancer, puts it like this [5]:

In their Dissenting Opinion of this article, Moore and Shuda raise valid concerns regarding the potential for PCR contamination in this study. Some concerns include 1) the criteria for defining CFS/ME in the patients and in controls were not explicitly defined, 2) nested PCR was used and neither in a blinded nor randomized fashion, 3) the remarkable lack of diversity in the six fully sequenced XMRV genomes (<6 nucleotide average difference across genome) — with Fig. S1 even showing that for one fully sequenced isolate two of the single nucleotide differences were “N’s” — clearly the result of a sequencing error, 4) failure to use Southern blotting to confirm PCR results, and 5) primary nested PCR screening done in one lab as opposed to independent screening from start to finish in two different laboratories. Concerns have also been brought up with respect to the antigen testing

Shortcomings of the Erlwein-article [2]

Many people have objected that the population of CSF patients is not the same in both studies. Sure it is difficult enough to diagnose CSF (which is only done by exclusion), but according to many commenters of the PLOS study there was a clear bias towards more depressed patients. Therefore, a biological agent is less likely the cause of the disease in these patients. In contrast the US patients had all kinds of physical constraints and immunological problems.

The review process was also far less stringent: 3 days versus several months.

The PLOS study might have suffered from the opposite of contamination: failure to amplify the rare CSF-DNA. This is not improbable. The Erlwein group did not purify the blood cells, used other primers, amplified another sequences and did not test DNA of normal individuals. The positive control was diluted in water not in human DNA. The negative control was water.

Omitting cell purification can lead to a lower relative amount of the XMRV-DNA or to inhibition (often seen this with unpurified samples). Furthermore the gel results seem of poor quality (see Fig 2). The second round of the positive PCR sample results in an overloaded lane with too many aspecific bands (lane 9), whereas the first round leads to a very vague low molecular band (lane 10). True that the CSF-samples also run two rounds, but why aren’t the aspecific bands seen here? It would have been better to use a tenfold titration of the positive control in human DNA (this might be a more real imitation of the CSF samples: (possibly) a rare piece of XMRV DNA mixed with genomic DNA) and to use normal DNA as control, not water.Another point is that the normal XMRV-incidence of 1-3,7% in healthy controls is not reached in the PLOS study, although this could be a matter of chance (1 out of 100).

Further Studies

Anyway, we can philosophize, but the answer must await further studies. There are several ongoing efforts.


  1. Lombardi VC, Ruscetti FW, Das Gupta J, Pfost MA, Hagen KS, Peterson DL, Ruscetti SK, Bagni RK, Petrow-Sadowski C, Gold B, Dean M, Silverman RH, & Mikovits JA (2009). Detection of an infectious retrovirus, XMRV, in blood cells of patients with chronic fatigue syndrome. Science (New York, N.Y.), 326 (5952), 585-9 PMID: 19815723
  2. Erlwein, O., Kaye, S., McClure, M., Weber, J., Wills, G., Collier, D., Wessely, S., & Cleare, A. (2010). Failure to Detect the Novel Retrovirus XMRV in Chronic Fatigue Syndrome PLoS ONE, 5 (1) DOI: 10.1371/journal.pone.0008519
  5. Charles Chiu: Faculty of 1000 Biology, 19 Jan 2010

Photo Credits

Nested PCR

Still Confusion about the Usefulness of PSA-screening.

13 04 2009

Prostate cancer is the most commonly diagnosed cancer affecting older men and second-biggest cancer killer. pc_epid_fig11a

Prostate Specific Antigen (PSA), a protein mainly produced by the prostate gland, is often elevated in prostate cancer – and often proportional to the prostate cancer volume. Since more men are diagnosed with prostate cancer by using PSA screening, middle-aged men have been advised to undergo a simple blood test to determine their blood PSA levels.

Indeed in the 20 years that the PSA test has been used there has been a significant drop in prostate cancer deaths.

However, this may have also resulted from better treatment modalities.

Furthermore, PSA tests are prone to false negative results (prostate cancer present in the complete absence of an elevated PSA level ), or vice versa, false positive results: elevated PSA occurring in non-cancerous prostate diseases, like prostate infection and benign prostatic hyperplasia (BPH). Some detected prostate cancers may also be indolent, never giving any trouble on the long term. Since the further diagnosis methods (biopsy) and treatment methods (irradiation, surgery, hormonal treatment) often have serious side effects (erectile dysfunction, urinary incontinence and bowel problems), there is a clear need to demonstrate whether PSA screening is worth the high risks of overdiagnosis and overtreatment:

Thus, does PSA screening really saves lives?
And what is the trade off between benefits and harms?

A Cochrane Systematic Review from 2006 [5] (also reviewed in EBM-online) concluded that there was no proof of benefit of PSA-screening. Yet absence of proof is not proof of absence. Moreover, both trials on which the review was based had methodological weaknesses.
Therefore, the main conclusion was to wait for the results from two large scale ongoing randomized controlled trials (RCTs).

The first study results of these two large RCT’s,  that many observers hoped would settle the controversy, have appeared in the March issue of the New England Journal of Medicine (NEJM). [1,2] The results are discussed in an accompanying editorial [3] and in a Perspective Roundtable [4] (with a video).

It should be stressed, however, that these are just interim results.

One of these two studies [1], the prostate component of the U.S. National Cancer Institute’s Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) showed no prostate specific mortality reduction over 11 yrs follow-up in 76,705 men by annual PSA screening and DRE (digital rectal exam). However:

  • The cut off is relatively high (4.0 ng per milliliter), which means that some prostate cancers could have been missed (on the other hand lowering the screening criteria might also have led to a higher false negative response)
  • The control group is “highly contaminated”, meaning that many men in the so called nonscreened arm had a PSA-test anyway ((52% in the nonscreened versus 85% in the screened arm).
  • The 11 yr follow up may be too short to show any significant effect. “Only” 0,1% of the men died of prostate cancer. On the long term the differences might become larger.
  • Since there were only 122 prostate cancer deaths in the screening group versus 135 in the control group, the power of the study to find any differences is mortality seems to be rather low.

The European ERSPC study [2] is larger than the PLCO trial (190,000 men), the cut off rate was lower (3.0 µg/L), and there was less contamination of the nonscreened arm. A shortcoming of the trial is that the diagnosis methods varied widely among centers participating in the trial. The follow-up time is 9 years.

The ESPRC trial noticed a difference in mortality between the screened and non-screened arms. Surprisingly the same outcome led to widely different conclusions, especially in the media (see Ben Goldacre on his blog Bad Science [6])

English newspapers concluded that the ERPSC study showed a clear advantage: Prostate cancer screening could cut deaths by 20% said the Guardian. Better cancer screening is every man’s right was the editorial in the Scotsman (see 6). These newspapers didn’t mention the lack of effect in the US study.

But most US newspapers, and scientists, concluded that the benefits didn’t outweigh the risks.

Why this different interpretation?

It is because 20% is the relative risk reduction. This means that the risk of getting prostate cancer is reduced by 20%. This sounds more impressive than it is, because it depends on your baseline risk. It is the absolute reduction that counts.
Suppose you would have a baseline chance of 10% of getting prostate cancer. Reducing this risk by 20% means that the risk is reduced from 10% to 8%. This sounds a lot less impressive.
But in reality your chance of getting prostate cancer comes closer to 0,1%. Then, a risk reduction of 20% becomes even less significant: it means your risk has decreased to 0,08%.

Absolute numbers are more meaningful. In the ESPRC trial[2], the estimated absolute reduction in prostate-cancer mortality was about 7 deaths per 10,000 men after 9 years of follow-up. This is not a tremendous effect. However the costs are high: to prevent one death from prostate cancer 1410 men would need to be screened and 48 additional cases of prostate cancer would need to be treated.

Overdiagnosis and overtreatment are probably the most important adverse effects of prostate-cancer screening and are vastly more common than in screening for breast, colorectal, or cervical cancer.

It is difficult to realize the impact of a false negative diagnosis. People tend to think that saving any live is worth any cost. But that isn’t the case.

This quote says a lot (from Ray Sahelian)

A few years ago my dad was found to have a high PSA test. He was 74 at the time. He underwent multiple visits to the doctor over the next few months with repeated PSA tests and exams, and eventually a biopsy indicated he had a small prostate cancer. I remember my dad calling me several times a month during that period constantly asking my thoughts on how he should proceed with radiation or other treatments for his cancer. My dad had a preexisting heart condition known as atrial fibrillation. I suggested he not undergo any treatment for the small cancer but just to follow the PSA levels. His doctor had agreed with my opinion. His PSA test stayed relatively the same over the next few years and the prostate cancer did not grow larger. My dad died at 78 from a heart rhythm problem. Ever since the discovery of the high PSA level, he was constantly worried about this prostate gland. What good did it do to have this PSA test at his age? It only led to more doctor visits, a painful prostate gland biopsy, and constant worry. Maybe the constant worry even made his heart weaker.

Indeed more men die with prostate cancer than of it.It’s estimated that appr 30% of American men over age 60 have small, harmless prostate cancers.

Although still hypothetical, non-invasive tests that would discriminate between low- and high risk prostate cancer could be a real solution to the problem. One such candidate might be the recently discovered urine test for sarcosine [7]

In conclusion
PSA-screening is associated with an earlier diagnosis of prostate cancer, but the present evidence shows at the most a slight reduction in prostate related mortality. Since screening and subsequent testing do have serious side effects, there seems a trade off between uncertain benefits and known harms. However, definite conclusions can only be drawn after complete follow-up and analyses of these and other studies [1,2,3]


  1. ResearchBlogging.orgAndriole, G., Grubb, R., Buys, S., Chia, D., Church, T., Fouad, M., Gelmann, E., Kvale, P., Reding, D., Weissfeld, J., Yokochi, L., Crawford, E., O’Brien, B., Clapp, J., Rathmell, J., Riley, T., Hayes, R., Kramer, B., Izmirlian, G., Miller, A., Pinsky, P., Prorok, P., Gohagan, J., Berg, C., & , . (2009). Mortality Results from a Randomized Prostate-Cancer Screening Trial New England Journal of Medicine DOI: 10.1056/NEJMoa0810696
  2. Schroder, F., Hugosson, J., Roobol, M., Tammela, T., Ciatto, S., Nelen, V., Kwiatkowski, M., Lujan, M., Lilja, H., Zappa, M., Denis, L., Recker, F., Berenguer, A., Maattanen, L., Bangma, C., Aus, G., Villers, A., Rebillard, X., van der Kwast, T., Blijenberg, B., Moss, S., de Koning, H., Auvinen, A., & , . (2009). Screening and Prostate-Cancer Mortality in a Randomized European Study New England Journal of Medicine DOI: 10.1056/NEJMoa0810084
  3. Barry, M. (2009). Screening for Prostate Cancer — The Controversy That Refuses to Die New England Journal of Medicine, 360 (13), 1351-1354 DOI: 10.1056/NEJMe0901166
  4. Lee, T., Kantoff, P., & McNaughton-Collins, M. (2009). Screening for Prostate Cancer New England Journal of Medicine, 360 (13) DOI: 10.1056/NEJMp0901825
  5. Ilic D, O’Connor D, Green S, Wilt T. Screening for prostate cancer. Cochrane Database Syst Rev. 2006;3:CD004720.[Medline]
  6. Goldacre, Ben (2009) Bad Science: (2009/03/), also Published in The Guardian, 21 March 2009
  7. Sreekumar A et al. (2009) Metabolomic profiles delineate potential role for sarcosine in prostate cancer progression Nature 457 (7231): 910-914 DOI: 10.1038/nature07762

MnSOD, Carotenoids & Prostate Cancer – “You are what you eat” depends on who you are.

22 02 2009

ResearchBlogging.orgWhen you type Cancer Food Prevention in Google you get about 9 million hits, many of them dotcom sites telling you which nutrients, pills or extracts you should take to prevent cancer. Much of this information is unreliable at least.

Although it is true that numerous observational studies (cohort and case-control) do indicate a relationship between diet and cancer incidence, it is difficult to pinpoint the exact nutrients that may be responsible for a beneficial effect. Furthermore, as explained in “The Best Study Design for Dummies” observational studies provide weaker empirical evidence than RCT’s (randomized controlled trials).

For prostate cancer observational (and preclinical) data indicate that diets high in cruciferous vegetables, soy lecithins and other phytoestrogens, vitamins E and C, lycopene, Selenium, green tea (to name a few) are associated with a lower risk of prostate cancer [1].

However, recent randomized trials did not confirm positive effects of vitamin E and C and Selenium (see previous post on the negative SELECT and the PHS II-trial) and data from the PLCO (Prostate, Lung, Colorectal, Ovarian) Trial [2] suggest that the benefit of lycopene (a powerful anti-oxidant that gives tomatoes their red color) is small and that beta-carotene, an antioxidant related to lycopene, even increases the risk for aggressive prostate cancer.


There may be many reasons why these results discords with the many observational studies performed (3)

  • Earlier positive observational studies have less methodological rigor than (large) RCT’s. In controlled trials, the random assignment of subjects to the intervention eliminates the problems of dietary recall and controls the effects of confounding factors.
  • RCT’s test one or two nutrients in isolation and sometimes in high doses assuming that a single compound may reproduce the beneficial effects of the whole foods.
  • RCT’s are often not stratisfied, differences between individuals are often not taken into account.

That this may be important is shown in a recent study on the manganese superoxide dismutase (MnSOD) polymorfism, prostate cancer and lycopene (4)

The manganese superoxide dismutase (MnSOD) gene encodes an antioxidant enzyme (SOD2) that may protect cells from oxidative damage (which may play an important role in prostatic carcinogenesis). A polymorphism [valine (V) -> alanine (A)] of MnSOD has been recently associated with a higher risk of prostate cancer.

The present study performed by Mikhak et al was a nested case-control study in the Health Professionals Follow-up Study (HPFS) with 612 incident prostate cancer cases and 612 matched controls.

The study not only investigates the role of the MnSOD gene Ala16Val polymorphism in prostate cancer risk, but also measures its interactions with baseline plasma carotenoid concentrations.

In line with several other studies (5), no overall association between MnSOD polymorphism and prostate cancer risk was found. However, a 3-fold [95% confidence interval: 1.37-7.02] increased risk of aggressive prostate cancer was observed among men with the Ala/Ala genotype in the presence of low long-term lycopene status (P-value, test for interaction = 0.02) as compared with men with the Ala/Val+Val/Val genotypes with low long-term lycopene status. In other words when the lycopene blood level is low, the Ala/Ala genotype confers a higher risk of aggressive prostate cancer compared with individuals with the other genotypes.

These results are consistent with findings from an earlier study (6) that reported when total antioxidant status is low, the MnSOD Ala/Ala genotype may be associated with an increased risk of aggressive prostate cancer. In contrast, men with the Val allele were much less sensitive for prediagnostic plasma levels of the anti-oxidants selenium, lycopene and {alpha}-tocopherol.

Thus reasoned the other way around: the anticancer effects of supplemented lycopene and other anti-oxidants may depend on the the MnSOD genotype and the levels of both endogenous and exogenous antioxidants. Similarly, a positive effect of {alpha}-tocopherol (vitamin E) observed in earlier trials appeared to be limited to smokers and/or people with low basal levels of vitamin E (see previous post).


  1. E-medicine/Medscape: prostate cancer and nutrition (2008) (free e-txt)
  2. Peters U, Leitzmann MF, Chatterjee N, Wang Y, Albanes D, Gelmann EP, Friesen MD, Riboli E, Hayes RB. Serum lycopene, other carotenoids, and prostate cancer risk: a nested case-control study in the prostate, lung, colorectal, and ovarian cancer screening trial. Cancer Epidemiol Biomarkers Prev. 2007 May;16(5):962-8. (free PDF)
  3. Byers T. What can randomized controlled trials tell us about nutrition and cancer prevention? CA Cancer J Clin. 1999 Nov-Dec;49(6):353-61. Review (free PDF)
  4. B. Mikhak, D. J. Hunter, D. Spiegelman, E. A. Platz, K. Wu, J. W. Erdman, E. Giovannucci (2008). Manganese superoxide dismutase (MnSOD) gene polymorphism, interactions with carotenoid levels and prostate cancer risk Carcinogenesis, 29 (12), 2335-2340 DOI: 10.1093/carcin/bgn212
  5. Bag A, Bag N. Target sequence polymorphism of human manganese superoxide dismutase gene and its association with cancer risk: a review.
    Cancer Epidemiol Biomarkers Prev. 2008 Dec;17(12):3298-305. Review. (Abstract)
  6. Li H, Kantoff PW, Giovannucci E, Leitzmann MF, Gaziano JM, Stampfer MJ, Ma J. Manganese superoxide dismutase polymorphism, prediagnostic antioxidant status, and risk of clinical significant prostate cancer.Cancer Res. 2005 Mar 15;65(6):2498-504.

You may also want to read:

Photo Credits

Yet Another Negative Trial with Vitamins in Prostate Cancer: Vitamins C and E.

15 12 2008

Within a week after the large SELECT (Selenium and Vitamin E Cancer Prevention) Trial was halted due to disappointing results (see previous posts: [1] and [2]), the negative results of yet another large vitamin trial were announced [7].
Again, no benefits were found from either vitamin C or E when it came to preventing prostate ànd other cancers.
Both trials are now prepublished in JAMA. The full text articles and the accompanying editorial are freely available [3, 4, 5].

In The Physicians’ Health Study II Randomized Controlled Trial (PHS II), researchers tested the impact of regular vitamin E and C supplements on cancer rates among 14,641 male physicians over 50: 7641 men from the PHS I study and 7000 new physicians.

The man were randomly assigned to receive vitamin E, vitamin C, or a placebo. Besides vitamin C or E, beta carotene and/or multivitamins were also tested, but beta carotene was terminated on schedule in 2003 and the multivitamin component is continuing at the recommendation of the data and safety monitoring committee.

Similar to the SELECT trial this RCT had a factorial (2×2) design with respect to the vitamins E and C [1]: randomization yielded 4 nearly equal-sized groups receiving:

  • 400-IU synthetic {alpha}-tocopherol (vitamin E), every other day and placebo (similar to the SELECT trial)
  • 500-mg synthetic ascorbic acid (vitamin C), daily and placebo
  • both active agents
  • both placebos.

Over 8 years, taking vitamin E had no impact at all on rates of either prostate cancer (the primary outcome for vitamin E), or cancer in general. Vitamin C had no significant effect on total cancer (primary outcome for vitamin C) and prostate cancer. Neither was there an effect of vitamin E and/or C on other site-specific cancers.

How can the negative results be explained in the light of the positive results of earlier trials?

  • The conditions may differ from the positive trials:
    • The earlier positive trials had less methodological rigor. These were either observational studies or prostate cancer was not their primary outcome (and may therefore be due to chance). (See previous post The best study design for dummies).
    • Clinical data suggest that the positive effect of vitamin E observed in earlier trials was limited to smokers and/or people with low basal levels of vitamin E, whereas animal models suggest that vitamin E is efficacious against high fat-promoted prostate cancer growth (20), but lacks chemopreventive effects (i.e. see [1,4] and references in [5], a preclinical study we published in 2006).
      Indeed, there were very low levels of smoking in the PHS II study and the effect of the vitamins was mainly assessed on induction not on progression of prostate cancer.
    • Eight times higher vitamin E doses (400IE) have been used than in the ATCB study showing a benefit for vitamin E in decreasing prostate cancer risk! [1,4]
  • Other forms of vitamin E and selenium have been proposed to be more effective.
  • As Gann noted in the JAMA-editorial, the men in both recent studies were highly motivated and had good access to care. In SELECT, the majority of men were tested for PSA each year. Probably because of this intense surveillance, the mean PSA at diagnosis was low and prostate cancers were detected in an early, curable stage. Strikingly, there was only 1 death from prostate cancer in SELECT, whereas appr. 75-100 deaths were expected. There also were indications of a deficit in advanced prostate cancer in PHS II, although a much smaller one.
    In other words (Gann):
    “how can an agent be shown to prevent serious, clinically significant prostate cancers when PSA testing may be rapidly removing those cancers from the population at risk before they progress?”
  • Similarly, in the SELECT trial there was no constraint on the use of other multivitamins and both studies put no restriction on the diet. Indeed the group of physicians who participated in the PHS II trial were healthier overall and ate a more nutritious diet. Therefore Dr Shao wondered
    “Do we really have a placebo group – people with zero exposure? None of these physicians had zero vitamin C and E” [7]. In the Netherlands we were not even able to perform a small phase II trial with certain nutrients for the simple reason that most people already took them.

What can we learn from these negative trials (the SELECT trial and this PHS II-trial)?

  • Previous positive results were probably due to chance. In the future a better preselection of compounds and doses in Phase 2 trials should determine which few interventions make it through the pipeline (Gann, Schroder).
  • Many other trials disprove the health benefits of high dose vitamins and some single vitamins may even increase risks for specific cancers, heart disease or mortality [9]. In addition vitamin C has recently been shown to interfere with cancer treatment [10].
  • The trials make it highly unlikely that vitamins prevent the development of prostate cancer (or other cancers) when given as a single nutrient intervention. Instead, as Dr Sasso puts it “At the end of the day this serves as a reminder that we should get back to basics: keeping your body weight in check, being physically active, not smoking and following a good diet.”
  • Single vitamins or high dose vitamins/antioxidants should not be advised to prevent prostate cancer (or any other cancer). Still it is very difficult to convince people not taking supplements.
  • Another issue is that all kind of pharmaceutical companies keep on pushing the sales of these “natural products”, selectively referring to positive results only. It is about time to regulate this.


Sources & other reading (click on grey)

  1. Huge disappointment: Selenium and Vitamin E fail to Prevent Prostate Cancer.(post on this blog about the SELECT trial)
  2. Podcasts: Cochrane Library and MedlinePlus: (post on this blog)
  3. Vitamins E and C in the Prevention of Prostate and Total Cancer in Men: The Physicians’ Health Study II Randomized Controlled Trial. J. Michael Gaziano et al JAMA. 2008;0(2008):2008862-11.[free full text]
  4. Effect of Selenium and Vitamin E on Risk of Prostate Cancer and Other Cancers: The Selenium and Vitamin E Cancer Prevention Trial. Scott M. Lippman, Eric A. Klein et al (SELECT)JAMA. 2008;0(2008):2008864-13 [free full text].
  5. Randomized Trials of Antioxidant Supplementation for Cancer Prevention: First Bias, Now Chance-Next, Cause. Peter H. Gann JAMA. 2008;0(2008):2008863-2 [free full text].
  6. Combined lycopene and vitamin E treatment suppresses the growth of PC-346C human prostate cancer cells in nude mice. Limpens J, Schröder FH, et al. J Nutr. 2006 May;136(5):1287-93 [free full text].

  7. The New York Times (2008/11/19) Study: Vitamins E and C Fail to Prevent Cancer in Men.
  8. BBC news: (2008/12/10) Vitamins ‘do not cut cancer risk’.
  9. The New York Times (2008/11/20) News keeps getting worse for vitamins.
  10. The New York Times (2008/10/01) Vitamin C may interfere with cancer treatment.

Podcasts: Cochrane Library and MedlinePlus

13 12 2008

podcastI added two podcasts to the Google-speadsheet wiki: Best Medical podcasts, made by Ves Dimov (see my previous post here): Cochrane reviews and Medline Plus.

Ves Dimov has described his top 5 podcasts in another post [1]. For other medical podcasts see [2,3,4].

A podcast is nothing more than a digital audio or video file, just like any other song or MP3 file on your computer. They can be listened to, saved and shared on the internet. Although podcasts were initially meant for i-pods (hence podcast), you can also subscribe to podcasts by other Podcast-readers, Web browsers or RSS-Readers.

I would like to shortly review the two podcasts.

1. Cochrane Reviews (Click here for Feed)

The Cochrane Library, published by John Wiley for The Cochrane Collaboration, is updated and expanded every three months.
The Cochrane podcasts are freely available audio summaries of:

  • highlights of each quarterly issue. This is just a summary of main topics. Example below (with bad handling of the microphone):
  • a selection of systematic reviews from The Cochrane Library. I found the ones below very interesting and may blog about them later.
    It is often said that Cochrane Reviews are difficult to understand and that even physicians find them hard to read. The podcasts I’ve heard are very informative and understandable for doctors, journalists, librarians and patients. The essentials of the conclusions are very clear. I think it would be a good thing if all Cochrane Reviews were podcasted this way.

Adverse events of formoterol (and salmeterol) in asthma

St John’s wort for major depression


Cochrane Podcasts of issue 4 2008: you can listen or subscibe to and/or download/embed the podcasts

2. MedlinePlus (click here for feed)

The MedlinePlus podcasts is a weekly series of highlights of health news and accompanying information from MedlinePlus.The update is generally given by Donald A.B. Lindberg, M.D., Director of the National Library of Medicine.
It is very clearly indicated how you can listen or subscribe to these podcasts. There is also a transcript.

The last audio is about the negative results of the huge Vitamine E-Selenium (SELECT) Prostate Cancer, I described almost a month ago in this post.
It is rather long (with disclaimers and links like “go to double u double u double u …dot com etcetera”), but understandable and about interesting topics.


More Reading, viewing or listening (click on grey):

  1. MD Ves Dimov has described his top 5 podcasts, including JAMA Audio Commentary and NEJM This Week podcast at his blog. He also gives a short description how you can subscribe to the podcasts/videocasts.
  2. Very good and complete medical podcasts-directory at Not only podcast-series, but also individual podcasts, such as class lessons of statistics (which are difficult to follow without seeing figures) or psychology.
  3. Dean Giustini: [pdf] “Podcasting” howto + select list of medical podcasts
  4. new2.gif See also:Dean Giustini, UBC Health and Library Wiki: Podcasts and Videocasts (very comprehensive!)
  5. And if you want to know more why podcasts are useful than view this short commoncraft you-tube video.


nl vlag NL flagEen podcast is gewoon en digitaal audio of video bestand, net als elk ander MP3 bestand op je computer. Je kunt ze beluisteren, downloaden en delen. Hoewel podcasts oorspronkelijk voor i-pods bedoeld waren (vandaar podcast), kun je je ook op podcasts abonneren via andere Podcast-readers, Web browsers of RSS-Readers.

Hier bespreek ik twee podcasts die ik aan de Google-speadsheet wiki Best Medical podcasts heb toegevoegd (zie eerder bericht): Cochrane reviews en Medline Plus.

Ves Dimov heeft zijn top 5 podcasts op zijn blog beschreven [1]. Voor andere medische podcasts, zie [2,3].

1. Cochrane Reviews (Klik hier voor feed)

The Cochrane podcasts zijn gratis audio samenvattingen van:

  • De belangrijkste onderwerpen van elke 3-maandelijkse update van de Cochrane Library.

2. MedlinePlus (klik hier voor feed)

Medline Plus podcasts zijn een wekelijkse serie van hoogtepunten uit het gezondheidsnieuws van de MedlinePlus. De update wordt meestal verzorgd door Donald A.B. Lindberg, M.D., baas van de National Library of Medicine.
Het wordt duidelijk aangegeven hoe je de podcasts kunt beluisteren en hoe je een abonnement (feed) kunt nemen. Er is ook een transcript. Dit heb je er wel een beetje bij nodig. De tekst is verder duidelijk, maar erg droog en lang (incl disclaimers en links. “go to double u double u double u …dot com etcetera”).

Hier is een audio van de laatste week over de negatieve resultaten van de grootschalige Vitamine E-Selenium (SELECT) prostaat kanker trial, Idie ik een maand geleden reeds op dit blog beschreef.

Meer lezen: zie links in engelstalig gedeelte.

Huge disappointment: Selenium and Vitamin E fail to Prevent Prostate Cancer.

16 11 2008


October 27th the news was released that ([see here for entire announcement from]

“an initial, independent review of study data from the Selenium and Vitamin E Cancer Prevention Trial (SELECT), funded by the National Cancer Institute (NCI) and other institutes that comprise the National Institutes of Health shows that selenium and vitamin E supplements, taken either alone or together, did not prevent prostate cancer. The data also showed two concerning trends: a small but not statistically significant increase in the number of prostate cancer cases among the over 35,000 men age 50 and older in the trial taking only vitamin E and a small, but not statistically significant increase in the number of cases of adult onset diabetes in men taking only selenium. Because this is an early analysis of the data from the study, neither of these findings proves an increased risk from the supplements and both may be due to chance.”

SELECT is the second large-scale study of chemoprevention for prostate cancer. Chemoprevention or chemoprophylaxis refers to the administration of a medication to prevent disease. The SELECT trial aimed to determine whether dietary supplementation with selenium and/or vitamin E could reduce the risk of prostate cancer among healthy men. It is a randomized, prospective, double-blind study with a 2×2 factorial design, which means that the volunteering men received either one of the supplements, b2x2-select-vierkantoth supplements or no supplements (but placebo instead), without knowing which treatment they would receive.
The trial volunteers were randomly assigned to one the following treatments:

  1. 200 µg of selenium and 400 IU of vitamin E per day. (both supplements)
  2. 200 µg of selenium per day and placebo
  3. 400 IU of vitamin E per day and placebo
  4. two different placebo’s (neither supplement)
    (µg = micrograms, IU = International Units)

Enrollment for the trial began in 2001 and ended in 2004. Supplements were to be taken for a minimum of 7 years and a maximum of 12 years. Therefore the final results were anticipated in 2013. However, but due to the negative preliminary results, SELECT participants still in the trial are now being told to stop taking the pills. The participants will continue to have their health monitored by study staff for about three more years, continue to respond to the study questionnaires, and will provide a blood sample at their five-year anniversary of joining the trial, to ensure their health and to allow a complete analysis of the study. (see SELECT Q & A).

In an interview with CBS, one of the investigators Dr Katz, said he was highly disappointed and concerned, because he had high hopes for the trial. “I”m disappointed with the study. I’m very concerned about the results of the trial.

Vodpod videos no longer available.

more about “Vitamin E A Flop In Prostate Cancer T…“, (with 15 sec advertisement first) posted with vodpod. This video is derived from CBS news.

Dr. Klein, one of the principal investigators, has published as many as 14 publications on the SELECT trial (see PubMed). He has always been a strong advocate of this huge trial.

The question now is:
Was there enough evidence to support such a large trial? Could this result have been foreseen? Would the trial have had different outcomes if other conditions had been chosen?

The SELECT trial seems to add to the ever growing list of disappointing “preventive” vitamin trials. See for instance this blogpost of sandnsurf on “a systematic review of all the published randomized controlled trials (RCTs) on multivitamins and antioxidant supplements in various diseases, and their effect on overall mortality” concluding:

“Taking the antioxidant vitamins A (and its precursor beta-carotene) and E singly or in multivitamins is dangerous and should be avoided by people eating a healthy diet. On a diet like that recommended here, the intake of these and other important vitamins should be high, with no need for supplementation.”

Quite coincidentally I commented to Sandsnurf blogpost referring to the SELECT trial, 1 week before the bad outcome was announced):

Indeed, in many RCT’s vitamin supplements didn’t have the beneficial effects that they were supposed to have. Already in the early nineties, adverse effects of beta-carotene (higher mortality in smokers) have been shown in several RCT’s. Still, because vitamin E had an expected positive effect on prostate cancer in one such trial, vitamin E is now being tested together with selenium (2X2) in a very large prostate cancer trial. Quite disturbingly, 8 times higher doses vitamin E are being used (400IE) compared to the original study. If the Lawson study is right, the outcome might be harmful. Worrying.

It might be argued that it is easy to criticize a study once the outcome is known. However, this critique is not new.

Already in 2002 a very good critique was written by MA Moyad in Urology entitled: Selenium and vitamin E supplements for prostate cancer: evidence or embellishment?

Here I will summarize the most important arguments against this particular trial (largely based on the Moyad paper)

  • SELECT was based on numerous laboratory and observational studies supporting the use of these supplements. As discussed previously such study designs don’t provide the best evidence.
  • The incidence, or rate of occurrence, of prostate cancer was not the primary focus or endpoint of the few randomized controlled trials studies on which the SELECT study was based.
  • A 2×2 design is inadequate for dose-response evaluations, in other words: before you start the trial, you have to be pretty sure about the optimal dose of each supplement and of the interactive effect of vitamin E and selenium in the particular doses used. The interaction between two agents might be synergistic or additive, also with respect to any negative (i.e. pro-oxidant) effect.
  • Eight times higher vitamin E doses (400IE) have been used than in the ATCB study showing a benefit for vitamin E in decreasing prostate cancer risk! This is remarkable, given the fact that high doses of anti-oxidants can be harmful. Indeed, a prospective study has shown, that vitamin E supplements in higher doses (> or =100 IU) are associated with a higher risk of aggressive or fatal prostate cancer in nonsmokers.
  • Other forms of vitamin E and selenium have been proposed to be more effective. For instance dietary vitamin E (gamma tocopherol and/or gamma tocotrienols) might be more effective in lowering prostate cancer risk than the chemically-derived vitamin E (dl-alpha tocopherol acetate) used in SELECT. Also the used selenomethionine might be less effective than organically-bound selenium.
  • Selenium and vitamin E supplements seem to provide a benefit only for those individuals who have lower baseline plasma levels of selenium or vitamin E.
  • There may be other compounds that may be more effective, like finasteride, lycopene, statins (or with respect to food: a healthy lifestyle)

Katz said. “I would have hoped this would have been the way to prevent cancer in this country.”

Isn’t it a little bit naive to expect such huge effects (25% less prostate cancers) just by taking 2 supplements, given the thoughts summarized above?

In the interview, shown in the CBS-interview LaPook concludes “This is a major disappointment, but it is also progress. Because it’s also important to know what does not prevent cancer.”

Well I wonder whether it is ethical ànd scientifically valid, to do such a costly experiment with 35.000 healthy volunteers, based on such little evidence. Do we have to test each single possibly effective food ingredient as a single intervention?

Official publications and information

– EA Klein:
– Lippman SM, J Natl Cancer Inst. 2005 Jan 19;97(2):94-102. Designing the Selenium and Vitamin E Cancer Prevention Trial (SELECT). (PubMed record)
new2.gif The results of the SELECT trial are published in JAMA: Effect of Selenium and Vitamin E on Risk of Prostate Cancer and Other Cancers: The Selenium and Vitamin E Cancer Prevention Trial. Scott M. Lippman, Eric A. Klein et al SELECT)JAMA. 2008;0(2008):2008864-13, published online December 9th 2008.

– General information on SELECT
– Information on Study design (from Cancer Gov.clinical trialsSWOG s0000) and from

– More information on study designs and the ATCB trial (on which this study was based) in a previous post: the best study design for dummies

– CBS Evening News Exclusive: Vitamin E And Selenium Fail To Prevent The Disease In Large Clinical Trial, NEW YORK, Oct. 27, 2008
– Los Angelos Times; Vitamin E, selenium fail to prevent prostate
– Emaxhealth: NCI stops prostate cancer prevention trial. With many good links to further information