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RESEARCH ETHICS AND RESEARCH PRIORITIES.
PART 2: ENVIRONMENTAL RESEARCH
Jim Till, Ph.D.
Joint Centre for Bioethics, University of Toronto
c/o The Ontario Cancer Institute
610 University Avenue, Room 9-416
Toronto, Ontario, Canada M5G 2M9
ABSTRACT
The current debate about possible environmental causes of breast cancer is
used as an example of a dilemma about priorities for future research on
breast cancer. Those that strongly support the 'hormone disrupter'
hypothesis for the causation of breast cancer believe that there is
justification for immediate actions designed to reduce the level of
suspected 'hormone disrupters' in the environment. There is a genuine
scientific controversy about the adequacy of this justification,
especially from those who strongly believe that actions which may have
substantial harms as well as benefits for society should always be
evidence-based. Important aspects of the dilemma are that the 'society'
in question is a global one, that the expected harms and benefits are not
well understood, and that they seem likely to be unequally distributed
among the poorer and richer members of the global society. Advocacy for
environmental causes of breast cancer was highlighted during the First
World Breast Cancer Conference, held in Kingston, Ontario, Canada on July
13-17, 1997. The Kingston conference could be regarded as a noteworthy
'case study' in breast-cancer advocacy. The intent of these notes is to
provide an illustration of some ways in which ethical considerations may
be relevant to debates about advocacy issues and research priorities.
INTRODUCTION
What is research ethics and what might it be able to contribute to debates
about research priorities? I've argued elsewhere that research ethics has
an important role to play in such debates, in that research ethics
includes the systematic analysis of ways in which research serves the
needs of society as a whole.[1] In particular, concepts and principles
derived from research ethics can help to illuminate dilemmas about
research priorities.
AN EXAMPLE OF A DILEMMA
An illustrative example of a dilemma about research priorities can be
found in a message sent by the author to the Breast-Cancer mailing list on
July 12, 1997.[2] It was in response to a message posted by Joyce Maltz on
July 11.[3] The subject of her message was: "Ruminating on Pesticides".
An excerpt from the message from Joyce Maltz was:
"What a quandry. Due to fertilizers and pesticides, it is now possible
to produce a great amount of food relatively cheaply. With the
population explosion in the world, this is probably necessary. When we
read about countries such as Zaire whose population is starving, it is
something that we, on the North American continent can barely fathom.
We are able to produce an abundance of crops due to natural and man
made amenities".[3]
She continued:
"This also introduces problems, which had not been seen in prior ages
or populations. In the U.S., it is found that women menstruate earlier
than in some other populations. This is considered partly due to the
diet which is consumed. Early menstruation is considered one of the
factors looked at in onset of breast cancer. It is thought by some
experts that this exposes women to a larger dose of estrogen than they
would have received if menstruation started later".[3]
In my response,[2] I commented on a hypothesis (and some evidence) about
the dietary basis for early menstruation (a link to a commentary about
this hypothesis is currently available).[4] An excerpt:
"Breast cancer: Women who eat diets rich in animal foods reach
menarche earlier, thereby producing more estrogen over their
lifetimes and developing breast cancer at a significantly higher
rate".[4]
WHAT'S THE DILEMMA?
In my opinion, this example illustrates one situation (of many!) where
there is no clear consensus about research priorities. Some believe very
strongly that pesticides and other man-made chemicals in the external
physical environment are a major cause of cancers in general, and of
breast cancer in particular (perhaps, for breast cancer, because of
disruptive effects on hormone metabolism). They advocate immediate action
to reduce levels of man-made chemicals in the physical environment, and a
major research emphasis on environmental studies.
Others disagree, and regard determinants of health other than those
associated with the external physical environment as meriting a higher
priority for further research, especially in relation to breast cancer.
Sandra Steingraber has characterized a crucial aspect of this controversy
as a conflict between two forms of conservatism:[5]
"...cancer activists embrace a form of conservatism that advocates
prudence in the face of exposure to estrogenic and other endocrine-
disrupting chemicals. This perspective stands in contrast to scientific
conservatism, which directs its caution toward the issue of
proof".[5]
The "issue of proof" poses a major dilemma. There is a genuine scientific
controversy, which may indeed provoke some scientific conservatism,
especially from those who strongly believe that actions which may have
substantial harms as well as benefits for society should always be
evidence-based. Important aspects of the dilemma are that the 'society'
in question is a global one, that the expected harms and benefits are not
well understood, and that they seem unlikely to be equally distributed
among the poorer and richer members of the global society.
This particular "issue of proof" is a specific example of the kind of
public-policy decisions that Wade Robison has called "decisions in
doubt".[6] He has proposed a model for making decisions about public
policy when the evidence about expected harms and benefits is still in
doubt. He suggests (pp. 149-150) that some questions to ask include:
a) How much current harm is likely be mitigated by the policy?; b) How
expensive will it be to act now?; c) How much will current interests be
impacted by what we propose to do to mitigate both present harm and
potential future harm?[6]
For all decision-analysis models, the most crucial question of all is
likely to be: Have we been able to identify all of the relevant harms and
benefits (current and potential), and have we included them all in the
decision-making model (and, in a way that is explicit, and easy to
identify and understand)?
My own personal opinion is that decision-analysis models (such as
cost-effectiveness analysis models) are often incomplete, difficult for
anyone but specialists to understand, and incorporate hidden assumptions,
biases and values. A major challenge for policy makers (and policy
analysts) is to bring to light, and take into account, these implicit
assumptions, biases, and values.
PESTICIDES AND CANCER
For an example of the information about the current status of scientific
evidence (or lack of it!) about pesticides and cancer, see reference [7].
An excerpt:
"Because of the absence of studies on women with known exposures to
DDT, and the inconsistent results in the studies examining levels of
DDT/ DDE in breast cancer patients and women without the disease,
there is currently not enough evidence to say that DDT or DDE does or
does not cause breast cancer in humans. There is some, limited
evidence that certain forms of DDT may affect breast cancer risk by
"promoting" the growth of breast tumors that might be started by other
carcinogens, or by affecting the levels of hormones circulating in the
blood that may affect breast cancer risk".[7]
For an example of a view about pesticides and diets rich in fruits and
vegetables, see reference [8] (warning - controversial!):
An excerpt:
"The great bulk of chemicals ingested by humans is natural, by both
weight and number. For example, 99.99% of the pesticides in the diet
are naturally present in plants to ward off insects and other
predators (151). Half of the natural pesticides tested (29/57) are
rodent carcinogens (81). Reducing exposure to the 0.01% that are
synthetic, either to individual chemicals or to mixtures, will not
appreciably reduce cancer rates. On the contrary, fruits and
vegetables are important for reducing cancer; making them more
expensive by reducing use of synthetic pesticides is likely to
increase cancer. People with low incomes eat fewer fruits and
vegetables (152) and spend a higher percentage of their income on
food".[8]
There is some scientific evidence about the carcinogenicity of pesticide
chemicals. A brief summary (dated 1995) is available from reference [9].
An excerpt:
"Persistent pesticides. Certainly, great benefits have been derived
from agrochemicals and pesticides, not the least of which is the
ability to produce large amounts of food crops at a savings of
millions of dollars a year. At the same time, scientific literature is
replete with evidence of the carcinogenic properties of various
pesticide chemicals. For example, organophosphate insecticides have
been linked with a risk for non-Hodkgin's lymphoma, and
organochlorines, including DDT, have been associated with leukemia.
Animal and epidemiological studies have shown an association between
non-Hodgkin's lymphoma and brain and kidney cancer and exposure to
pesticides or solvents such as gasoline".[9]
So, there is scientific evidence that is relevant to this issue. And,
more is being sought:[10]
"NCI, in collaboration with the National Institute of Environmental
Health Sciences, has undertaken two large initiatives to investigate
reasons for elevated breast cancer death rates in the Northeast/Mid-
Atlantic regions".
"Six studies, which comprise the Northeast/Mid-Atlantic Study, are
focusing on organochlorine compounds, which are commonly used as
pesticides. The Long Island Breast Cancer Study Project is
investigating whether environmental factors are responsible for breast
cancer risk in Nassau and Suffolk counties. This research includes
assessments of exposure to organochlorines and other chemicals,
magnetic fields, contaminated drinking water, air pollution, and
hazardous and municipal waste".[10]
An important research question continues to be: to what extent are
elevated breast cancer incidence or death rates in a particular geographic
area attributable to: a) changes in known risk factors (see, for example,
references [10,11]); b) changes in diagnosis and/or treatment; c) chance;
and, d) as-yet-unidentified risk factors?
An example is provided by an article about breast-cancer rates in
Hawaii.[12] An excerpt:
"Rising breast cancer rates in Hawaii may be partially attributable to
intensive pesticide use in the state, according to a recent study in
Environmental Health Perspectives. Breast cancer rates have increased for
all racial groups in Hawaii since 1970, but only 30% to 40% of these
cancers can be explained by known risk factors .... The researchers
said that breast cancer screening is slightly more common in Hawaii
than in other areas of the U.S., but not enough to explain the higher
breast cancer rates".[12]
Long Island and the Bay Area of California,[10,11] Hawaii [12] and perhaps
Israel (see note, reference [12]) are places where the 'pesticide
hypothesis' are likely to continue to receive attention from environmental
researchers. The 'pesticide hypothesis' can be regarded as one aspect of
the 'endocrine disrupter', or 'hormone disrupter' hypothesis.[13]
THE SEARCH FOR UNRECOGNIZED RISK FACTORS
There may be as-yet unrecognized risk factors for breast cancer, and there
seems little reason to doubt that the search for such risk factors merits
a high priority, as pointed out in an article about the 'endocrine
disrupter' hypothesis, by Devra Lee Davis and Susan M. Sieber.[14]
An excerpt:
"While the importance of hormones for breast cancer has been understood
for some time, only recently has attention focused on the need to
develop and validate standardized methods for measuring hormones
directly and for assessing the mechanisms by which they affect breast
cancer and other aspects of women's health. In addition, several
investigators have proposed that environmental factors, such as
xenoestrogens and other xenohormones, may alter hormonal metabolism
and thereby contribute to the development of breast cancer. As most
cases of breast cancer occur in women with few of the established risk
factors, efforts to identify new risk factors and new protective
factors must continue to rank as high priority".[14]
It should be noted that studies based on the 'endocrine disrupter'
hypothesis may reveal new protective factors (that act by altering
hormonal metabolism) as well as new risk factors. For example, studies of
'phytoestrogens' found in some foods (such as soy products) may merit
attention from this point of view.[15]
PERCEPTIONS OF RISKS
Scientists concerned about decision making in situations of uncertainty
have emphasized the extent to which public perceptions of risks, and thus
of priorities for public policy, may be distorted. An example is provided
in an article entitled: "The Dangerous Sandbox ... and Other
Absurdities".[16] An excerpt:
"In an age of accelerating information overload, trivial carcinogen
warnings must surely dull our ability to recognize and avoid real
dangers. This Chicken Little approach to health promotion, which
conveys an impression that everything in the environment causes cancer,
must be particularly welcomed by the tobacco industry as an aid to
their campaign promoting the addiction of our youth to
smoking".[16]
There is ample evidence that cigarette smoking is a major risk factor for
many cancers, and particularly cancers of the respiratory system. Whether
or not cigarette smoking is associated with any increased breast cancer
risk is still being investigated.[17,18]
It's well-established that perceptions of risk, and of risk-taking
behavior, can vary a great deal across individuals and groups, and
research on risk perception and communication of risk is highly relevant
to debates about environmental risks. For example, see the research on
risk perception and risk communication of Paul Slovic and his colleagues,
such as references [19] and [20].
However, the dilemma remains: what priority should be given to research
on factors in the external (and internal) environment that might be
associated with an increased risk of breast cancer, and, which such
factors should receive the most attention?
RELEVANCE TO BREAST-CANCER ADVOCACY
The dilemma outlined above was highlighted during the First World Breast
Cancer Conference, held in Kingston, Ontario, Canada on July 13-17, 1997.
Reports of the conference in the popular press left an impression that,
because of their presence at the same conference, activists concerned with
environmental risks had been linked with advocates for unconventional
therapies, who in turn, had been linked with the international
breast-cancer advocacy movement. The Kingston conference could be regarded
as a noteworthy 'case study' in breast-cancer advocacy.
A concise summary of the proceedings of this conference was posted to the
Breast-Cancer mailing list by Musa Mayer.[21]
She commented on the apparent linkage, at this conference, of two groups
both concerned about man-made chemicals. One group is concerned about the
presence of toxic man-made chemicals in the environment. The other is
concerned about the aggressive use of very toxic man-made chemicals in
conventional cancer medicine:
"It was Sharon Batt, of Breast Cancer Action of Montreal and author of
"Patient No More: The Politics of Breast Cancer," (Gynergy Books/Ragweed
Press, 1994) who helped me place this in context with the history of
breast cancer advocacy. She spoke of "minimalists" and "go getters"
when it comes to breast cancer treatment. Clearly, the great
preponderance of people at the conference represented the "minimalist"
point of view, casting a suspicious eye, for example, on such issues as
screening mammography, genetic testing, widespread tamoxifen use,
mastectomy vs. lumpectomy, etc.".[21]
Joyce Maltz, in a response to Musa Mayer's summary, commented:[22]
"I would hope that the next conference would attract some of the more
cutting edge researchers and physicians. It seems that this conference
was not subsidized by pharmaceutical companies, but the presentation of
alternative cures, was no more valid than some of the wishful thinking
of the chemo manufacturers".[22]
Karen Gray, in another response to Musa Mayer's summary, pointed out:[23]
"But it is a valid question to ask: For the dollars spent, where can
you get the most benefit? I profoundly believe in spending money on the
environment. But I have to admit, I suspect we'll save more lives by
learning the biology of cancer first and thus having a clearer picture
both of what in the environment to change and how to treat the cancer
than by rather blindly putting money into environmental changes that may
or may not be playing a key role in cancer and that may or may not be
correctable without, as I said, returning to agrarianism. (Are we
really so naive as to believe that technology and industry are possible
without paying an environmental cost?)".[23]
As Karen Gray points out, one important dimension of any debate about
cancer research priorites is the priority that should be given to
"learning about the biology of cancer first". So, what priority should be
given to research on possible environmental causes of cancer (versus
research on other potential risk factors [8], on the biology of cancer
[23], or on any of the many other kinds of cancer-related issues)?
Jon Church, as part of a commentary on the Kingston conference, has argued
that the priority now given to research on the biology of cancer is too
high, and that research related to prevention in general (and to
environmental research in particular) is too low.[24] An excerpt:
"It is time to move breast cancer from a purely medical/health model to
a new paradigm involving politics, sociology and the environment. Let's
redirect research efforts and dollars to prevention, not a failed
'magic bullet' approach. Let's look to good data from wildlife studies
and from work in laboratory animals, and put the billions of dollars we
now spend on basic research in cell biology into an expanded attack on
environmental contamination. Let's learn from our errors and not wait
30 years to act like we did with tobacco".[24]
WHAT CAN RESEARCH ETHICS CONTRIBUTE?
I've outlined some of the basic principles of research ethics elsewhere
[1]. They are summarized in the Belmont Report (1979).[25]
From a societal perspective, an issue highlighted by the first of these
principles (respect for persons) is: what degree of respect should be
given to the perspectives of different advocacy groups (especially, ones
that may meet a reasonable definition of a 'collectivity').[26]
I'll argue that the more that these perspectives involve "considered
opinions and choices", and are not "clearly detrimental to others", the
more respect they should receive.
My own view (I'm a researcher!) is that opinions are not "considered"
unless they have taken into account the quality and quantity of scientific
evidence that is currently available. In the absence of definitive
evidence, further research is clearly needed before truly evidence-based
actions can be taken.
However, quite often, actions must be taken, even in the absence of
definitive evidence. In such situations, ethical considerations of the
kind being discussed here can also serve as helpful guides to action.
A very important broad issue highlighted by the second and third of the
Belmont ethical principles (beneficence and justice) are: what are the
anticipated benefits and harms of proceeding immediately to reduce the
numbers of man-made chemicals in the environment (without waiting for
further research to be done)? And, benefits to whom? Harms to whom?
For example, as has been pointed out above,[3,8,9] if the use of
fertilizers and pesticides reduces the cost of food, then those most in
need of cheap food may have a different perspective from those with a
lesser need (fairness based on relative need is one formulation of the
principle of justice).[1,25]
If fruits and vegetables in the diet are very important for reducing
cancer, then making them more expensive by reducing the use of synthetic
pesticides is likely to "be detrimental to others", and perhaps may even
increase cancer rates. People in North America with low incomes eat fewer
fruits and vegetables and spend a higher percentage of their income on
food.[8]
From this (justice-oriented) perspective, a very high priority should be
given to the identification and promotion of ways to produce and
distribute fruits and vegetables at reduced cost, but without the use of
synthetic herbicides and pesticides. Then, a very high priority should be
given to obtaining evidence that such ways of producing and distributing
fruits and vegetables result in greater net overall benefits, rather than
harms, to society as a whole. Challenging tasks, and ones not usually
considered to be within the domain of current cancer research!
Perhaps advocacy efforts focused on enhanced consumption of plant-based
foods might be justified from both a scientific and an ethical
perspective (see, for example, reference [4])?
SOME CONCLUDING COMMENTS
1. Current uncertainties about environmentally-based risk factors for
breast cancer do not imply that no useful actions can be undertaken now in
relation to environmental protection. They only mean that current
scientific research has not yet provided conclusive evidence about the
extent to which actions designed to protect the physical environment might
be expected also to reduce the incidence of breast cancer.
This interpretation of current state of the evidence should not be
regarded as an argument in favor of pollution of the environment.
Instead, it only raises questions about the extent to which policies
designed to enhance environmental protection may be expected to reduce the
incidence of breast cancer. I agree with Robert Proctor's argument that
cancer is as much a political problem as it is a health problem.[27]
2. We can expect to see a continuing series of new research results that
are relevant to environmental carcinogenesis. The controversy is not
about whether or not such research should be done. It is mainly about
what public policy actions should be taken immediately, on the basis of
existing knowledge.
Arguments that 'lifestyle-oriented' environmental factors should have a
high priority are susceptible to the 'you want to blame the victim'
counter-arguments. (Here I use the word 'environmental' to mean
'non-hereditary', and 'lifestyle-oriented' to mean factors such as smoking
[17,18] or diet [4,8,28] ... but, should your house be regarded as a
'lifestyle-oriented' factor, or a 'physical-environment' factor [29])?
3. If up to 80-90% of breast cancers are indeed (in the words of Erik
Parens):[30]
"triggered by chance and/or environmental assaults"
(where the term "environmental" should encompass all external factors that
influence the way we live, including our diet) then:
"We ought to be deeply worried about the prospect of elegant and simple
genetic explanations diverting our attention and resources from the
messy and complex business of managing environmental triggers".[30]
As Parens points out, cigarette companies' attempts to attribute lung
cancer to genetic susceptibility is one very good example of the use of
genetic explanations, instead of an environmental one (carcinogens in
cigarette smoke), as a way to let "genes become the scapegoat".[30]
4. My own opinion is that we need to learn much more about the complex and
often subtle interactions between genes and the environment that lead to
the onset of cancer, and that research on genetic/environmental
interactions merits an increasingly high priority. I agree with what
Wolff and colleagues have said in a recent review article:[31]
"Research on etiology of breast cancer should measure environmental
exposures and take into account the time of life at which these occur.
Complex interactions between exogenous and endogenous carcinogenic
agents need further focus, as modulated by varying genetically
determined individual susceptibilities".[31]
5. Interactions between combinations of environmental chemicals and
between such chemicals and different human genotypes may be a fruitful
area for further research. Unfortunately, a very interesting and
influential report of the synergistic activation of estrogen receptor with
combinations of environmental chemicals has been retracted.[32]
REFERENCES AND NOTES
1. https://members.tripod.com/~ca916/index-5.html
Notes of mine entitled: "Research Ethics and Research Priorities, Part 1:
Role of Advocacy Groups". Some background material about basic principles
of research ethics is included in these notes.
2. http://cure.acor.org/lists/cancer/bc/97/07/2/0498.html
A link, via Gilles Frydman's ACOR archives, to the (copyrighted) message
that I sent to the Breast-Cancer Discussion Group on July 12, 1997
(Subject: Re: Ruminating on Pesticides). For more information about
copyright and messages sent to mailing lists, see:
https://members.tripod.com/~ca916/index-4.html.
3. http://cure.acor.org/lists/cancer/bc/97/07/2/0438.html
A link to a (copyrighted) message posted by Joyce Maltz to the
Breast-Cancer Discussion Group on July 11, 1997 (included here with her
permission). The subject was, again, Re: Ruminating on Pesticides. This
link is also via the ACOR archives.
4. http://www.envirolink.org/arrs/essays/veg_diet.html
A link, via the envirolink.org website, to a (copyrighted) article by
Susan Lang, entitled: "China Study Shows Need for Eating Plant-Based
Diet".
The envirolink.org website provides access to other advocacy-oriented
information, such as an article by Lori Sklar, entitled "Environmental
Consequences of Corporate Farming":
http://www.envirolink.org/arrs/AnimaLife/spring97/farming.html
An excerpt:
"Plants that could feed twelve people
will only feed one person if first given to an animal and then eaten
by the human (Achor, 64). Land is therefore much more productive when
used to cultivate plants rather than animals".
5. PubMed abstract
A link to a (copyrighted) PubMed abstract of a paper by Sandra
Steingraber, published in Environmental Health Perspectives 105,
Supplement 3: 685, April 1997. To see the policy of the National Library
of Medicine about downloading such abstracts, Click here
Sandra Steingraber is also the author of a controversial book, "Living
Downstream". A review of this book in the New England Journal of
Medicine, at: http://www.nejm.org/public/1997/0337/0021/1562a/1.htm
has also generated controversy about the reviewer's impartiality,
according to an article by Larry Tye on page A01 of the Dec. 27, 1997
issue of the Boston Globe. Boston Globe website
6. Robison, Wade L. "Decisions in Doubt: The Environment and Public
Policy", Dartmouth College, University Press of New England, Hanover and
London, 1994.
7. http://www.cfe.cornell.edu/bcerf/fctsht.DDT.html
A link, via the www.cfe.cornell.org website, to (copyrighted) material on
"DDT, DDE and the Risk of Breast Cancer", prepared in late 1996 by Suzanne
M. Snedeker, for the Program on Breast Cancer and Environmental Risk
Factors in New York State.
8. http://socrates.berkeley.edu/mutagen//ames.pnas3.html
A link to a (copyrighted) article by Bruce Ames, Lois Gold and Walter
Willett, entitled: "The causes and prevention of cancer". It was
published in the Proceedings of the National Academy of Sciences of the
U.S.A. 92(12), 5258-5265 (1995). PubMed abstract
9. Click here
for a link, via the website of the Environmental Health Information
Service, to a (copyrighted) article by Kate Cahow, entitled: "The Cancer
Conundrum" (from the EHP monthly journal, volume 103(11) November, 1995).
This article includes a review of evidence relevant to the scientific
controversy about the basis for observed increases in breast cancer
incidence.
10. http://www.pslgroup.com/dg/2f8a2.htm
A link to a (copyrighted) article entitled "Metropolitan Northeast Has
Highest Breast Cancer Mortality in U.S.", via the "Doctor's Guide to the
Internet" website.
11. Bay Area
A link, via the ACOR archives, to a message about breast cancer
rates in the Bay Area of California that I sent to the Breast-Cancer
mailing list on July 2, 1997. The subject was: 'Interesting article in
JNCI'.
Click Here for a subsequent (copyrighted) article in the San
Francisco Chronicle, in which it is suggested that breast cancer rates in the
Bay Area may no longer be exceptional in relation to elsewhere in the
U.S. (but that noteworthy differences across groups with different ethnic
origins are still apparent).
12. Allen, RH and colleagues, "Breast Cancer and Pesticides in Hawaii:
The Need for Further Study". Environmental Health Perspectives, Volume
105, Supplement 3: 679, April 1997. PubMed abstract
Changes in pesticide levels in Israeli milk have also been suggested to
show an association with changes in breast cancer risks. See: Westin JB
"Carcinogens in Israeli milk: a study in regulatory failure". The article
does not mention the possibility that changes in breast cancer risks in
Israel might also be associated with changes in the population of Israel
as a result of recent immigration from areas of low breast-cancer risk.
13. An excellent source of information about various perspectives on the
endocrine disrupter hypothesis, both for and against, is available at:
http://www.pbs.org/frontline/shows/nature/
For those interested in more information about hormone disrupters from
the perspective of the World Wildlife Fund (Canada), a webpage is
available at the WWF Canada site
14. http://ehpnet1.niehs.nih.gov/docs/1997/Suppl105-3/davis.html
A link to a (copyrighted) article about hormones and breast cancer,
authored by Devra Lee Davis and Susan Sieber, and published in
Environmental Health Perspectives 105, Supplement 3: 557, March 1997.
15. Davis DL, et al.
A link to a PubMed abstract that describes a hypothesis about
'xenoestrogens' and breast cancer, and includes comments about
'phytoestrogens'.
16. http://www.ahfmr.ab.ca/March/sandbox.html
A link to a (copyrighted) article entitled: "The Dangerous Sandbox ... and
Other Absurdities", about the scientific field of "risk management".
17. PubMed abstract
of a report by K.T. Kelsey and colleagues, 1997. They found no
significant increase in risk of incident breast cancer associated with a
particular genotype (the "GSTM1 null" genotype), and no significant
interaction with cigarette smoking.
18. Morabia A, et al.
A PubMed abstract of an article by A. Morabia & colleagues, about passive
smoking and risk of breast cancer.
19. PubMed abstract of an article by Slovic P, Malmfors T, Mertz CK, Neil
N, Purchase IF, "Evaluating chemical risks: results of a survey of the
British Toxicology Society", Hum. Exp. Toxicol, 1997;16(6):289-304.
20. PubMed abstract of an article by Flynn J, Slovic P, Mertz CK,
"Gender, race, and perception of environmental health risks", Risk. Anal.
1994;14(6):1101-1108.
21. Click here
for a link to Musa Mayer's comments about the Kingston conference (link
provided with her permission). These comments were entitled: "A
perspective on the First World Conference on Breast Cancer" and were
posted on July 19, 1997.
22. Click here
for a link to Joyce Maltz's comments about the Kingston conference,
posted on July 20, 1997 (link provided with her permission).
23. Click here
for a link to Karen Gray's comments about the Kingston conference, posted
on July 20, 1997 (link provided with her permission).
24. Click here
for a link, via the ACOR archives, to a perspective on the Kingston
conference provided by Jon Church, on August 14, 1997. He is the
listowner for the Breast-Cancer mailing list, based at Memorial
University, Newfoundland. (This link provided with his permission, and
with the permission of the publisher of the Canadian Breast Cancer Network
newsletter).
25. http://www.nih.gov/grants/oprr/belmont.htm#xbasic
Some basic ethical principles, which form a very influential part of the
Belmont Report.
26. https://members.tripod.com/~ca916/index-3.html
A link to some more notes of mine, in which I review some definitions of a
'collectivity'.
27. Proctor, Robert N, "Cancer Wars: How Politics Shapes What We Know and
Don't Know About Cancer", Basic Books, New York, 1995. For a review of
Robert Proctor's book, by Steve Farnsworth, in the Multinational Monitor,
vol. 17, no. 3, March 1996, Click here.
An excerpt:
"This well-researched book is the latest effort to draw more attention
to the ways in which the modus operandi between corporations and the
government is steadily increasing the toxic load on the planet and its
inhabitants".
28. Reference to work of Alicja Wolk & colleagues
Link to a (coprighted) article "A prospective study of monounsaturated
fat and other types of fat with the risk of breast cancer". It is about
a study by Alicja Wolk and colleagues, published in Arch. Intern. Med.
1998;158(1):41-45. A PubMed abstract is available.
29. Ott WR, Roberts JW, 1998
A link to a (copyrighted) article by Wayne R. Ott & John W. Roberts,
"Everyday exposure to toxic pollutants", in the February 1998 issue of
Scientific American.
30. Parens, Erik. Glad and terrified: on the ethics of BRCA1 and 2 testing.
Cancer Investigation 14(4): 405-411, 1996. PubMed citation
(no abstract is provided for this article). Click here
for a link to the (copyrighted) article itself, via Oncology Online.
31. Wolff MS et al, 1996
A PubMed abstract of a review article by M.S. Wolff, G.W. Collman, J.C.
Barrett & J. Huff, entitled: "Breast cancer and environmental risk
factors: epidemiological and experimental findings", published in the
Annual Review of Pharmacology and Toxicology, 36: 573-596, 1996.
32. McLachlan JA: Science 1997 Jul 25;277(5325):462-3)
Retraction of an influential report of the synergistic activation of
estrogen receptor with combinations of environmental chemicals.
Copyright 1998 by Jim Till
Last modified on June 8, 1998
-----------------------------------------------------------
To see the first part of this set of notes on Research Ethics and
Research Priorities, please go to: PART 1: ROLE OF ADVOCACY GROUPSReturn to top of pageGo to my home pageDisclaimer
RESEARCH ETHICS AND RESEARCH PRIORITIES. PART 2: ENVIRONMENTAL RESEARCH Jim Till, Ph.D. Joint Centre for Bioethics, University of Toronto c/o The Ontario Cancer Institute 610 University Avenue, Room 9-416 Toronto, Ontario, Canada M5G 2M9 ABSTRACT The current debate about possible environmental causes of breast cancer is used as an example of a dilemma about priorities for future research on breast cancer. Those that strongly support the 'hormone disrupter' hypothesis for the causation of breast cancer believe that there is justification for immediate actions designed to reduce the level of suspected 'hormone disrupters' in the environment. There is a genuine scientific controversy about the adequacy of this justification, especially from those who strongly believe that actions which may have substantial harms as well as benefits for society should always be evidence-based. Important aspects of the dilemma are that the 'society' in question is a global one, that the expected harms and benefits are not well understood, and that they seem likely to be unequally distributed among the poorer and richer members of the global society. Advocacy for environmental causes of breast cancer was highlighted during the First World Breast Cancer Conference, held in Kingston, Ontario, Canada on July 13-17, 1997. The Kingston conference could be regarded as a noteworthy 'case study' in breast-cancer advocacy. The intent of these notes is to provide an illustration of some ways in which ethical considerations may be relevant to debates about advocacy issues and research priorities. INTRODUCTION What is research ethics and what might it be able to contribute to debates about research priorities? I've argued elsewhere that research ethics has an important role to play in such debates, in that research ethics includes the systematic analysis of ways in which research serves the needs of society as a whole.[1] In particular, concepts and principles derived from research ethics can help to illuminate dilemmas about research priorities. AN EXAMPLE OF A DILEMMA An illustrative example of a dilemma about research priorities can be found in a message sent by the author to the Breast-Cancer mailing list on July 12, 1997.[2] It was in response to a message posted by Joyce Maltz on July 11.[3] The subject of her message was: "Ruminating on Pesticides". An excerpt from the message from Joyce Maltz was: "What a quandry. Due to fertilizers and pesticides, it is now possible to produce a great amount of food relatively cheaply. With the population explosion in the world, this is probably necessary. When we read about countries such as Zaire whose population is starving, it is something that we, on the North American continent can barely fathom. We are able to produce an abundance of crops due to natural and man made amenities".[3] She continued: "This also introduces problems, which had not been seen in prior ages or populations. In the U.S., it is found that women menstruate earlier than in some other populations. This is considered partly due to the diet which is consumed. Early menstruation is considered one of the factors looked at in onset of breast cancer. It is thought by some experts that this exposes women to a larger dose of estrogen than they would have received if menstruation started later".[3] In my response,[2] I commented on a hypothesis (and some evidence) about the dietary basis for early menstruation (a link to a commentary about this hypothesis is currently available).[4] An excerpt: "Breast cancer: Women who eat diets rich in animal foods reach menarche earlier, thereby producing more estrogen over their lifetimes and developing breast cancer at a significantly higher rate".[4] WHAT'S THE DILEMMA? In my opinion, this example illustrates one situation (of many!) where there is no clear consensus about research priorities. Some believe very strongly that pesticides and other man-made chemicals in the external physical environment are a major cause of cancers in general, and of breast cancer in particular (perhaps, for breast cancer, because of disruptive effects on hormone metabolism). They advocate immediate action to reduce levels of man-made chemicals in the physical environment, and a major research emphasis on environmental studies. Others disagree, and regard determinants of health other than those associated with the external physical environment as meriting a higher priority for further research, especially in relation to breast cancer. Sandra Steingraber has characterized a crucial aspect of this controversy as a conflict between two forms of conservatism:[5] "...cancer activists embrace a form of conservatism that advocates prudence in the face of exposure to estrogenic and other endocrine- disrupting chemicals. This perspective stands in contrast to scientific conservatism, which directs its caution toward the issue of proof".[5] The "issue of proof" poses a major dilemma. There is a genuine scientific controversy, which may indeed provoke some scientific conservatism, especially from those who strongly believe that actions which may have substantial harms as well as benefits for society should always be evidence-based. Important aspects of the dilemma are that the 'society' in question is a global one, that the expected harms and benefits are not well understood, and that they seem unlikely to be equally distributed among the poorer and richer members of the global society. This particular "issue of proof" is a specific example of the kind of public-policy decisions that Wade Robison has called "decisions in doubt".[6] He has proposed a model for making decisions about public policy when the evidence about expected harms and benefits is still in doubt. He suggests (pp. 149-150) that some questions to ask include: a) How much current harm is likely be mitigated by the policy?; b) How expensive will it be to act now?; c) How much will current interests be impacted by what we propose to do to mitigate both present harm and potential future harm?[6] For all decision-analysis models, the most crucial question of all is likely to be: Have we been able to identify all of the relevant harms and benefits (current and potential), and have we included them all in the decision-making model (and, in a way that is explicit, and easy to identify and understand)? My own personal opinion is that decision-analysis models (such as cost-effectiveness analysis models) are often incomplete, difficult for anyone but specialists to understand, and incorporate hidden assumptions, biases and values. A major challenge for policy makers (and policy analysts) is to bring to light, and take into account, these implicit assumptions, biases, and values. PESTICIDES AND CANCER For an example of the information about the current status of scientific evidence (or lack of it!) about pesticides and cancer, see reference [7]. An excerpt: "Because of the absence of studies on women with known exposures to DDT, and the inconsistent results in the studies examining levels of DDT/ DDE in breast cancer patients and women without the disease, there is currently not enough evidence to say that DDT or DDE does or does not cause breast cancer in humans. There is some, limited evidence that certain forms of DDT may affect breast cancer risk by "promoting" the growth of breast tumors that might be started by other carcinogens, or by affecting the levels of hormones circulating in the blood that may affect breast cancer risk".[7] For an example of a view about pesticides and diets rich in fruits and vegetables, see reference [8] (warning - controversial!): An excerpt: "The great bulk of chemicals ingested by humans is natural, by both weight and number. For example, 99.99% of the pesticides in the diet are naturally present in plants to ward off insects and other predators (151). Half of the natural pesticides tested (29/57) are rodent carcinogens (81). Reducing exposure to the 0.01% that are synthetic, either to individual chemicals or to mixtures, will not appreciably reduce cancer rates. On the contrary, fruits and vegetables are important for reducing cancer; making them more expensive by reducing use of synthetic pesticides is likely to increase cancer. People with low incomes eat fewer fruits and vegetables (152) and spend a higher percentage of their income on food".[8] There is some scientific evidence about the carcinogenicity of pesticide chemicals. A brief summary (dated 1995) is available from reference [9]. An excerpt: "Persistent pesticides. Certainly, great benefits have been derived from agrochemicals and pesticides, not the least of which is the ability to produce large amounts of food crops at a savings of millions of dollars a year. At the same time, scientific literature is replete with evidence of the carcinogenic properties of various pesticide chemicals. For example, organophosphate insecticides have been linked with a risk for non-Hodkgin's lymphoma, and organochlorines, including DDT, have been associated with leukemia. Animal and epidemiological studies have shown an association between non-Hodgkin's lymphoma and brain and kidney cancer and exposure to pesticides or solvents such as gasoline".[9] So, there is scientific evidence that is relevant to this issue. And, more is being sought:[10] "NCI, in collaboration with the National Institute of Environmental Health Sciences, has undertaken two large initiatives to investigate reasons for elevated breast cancer death rates in the Northeast/Mid- Atlantic regions". "Six studies, which comprise the Northeast/Mid-Atlantic Study, are focusing on organochlorine compounds, which are commonly used as pesticides. The Long Island Breast Cancer Study Project is investigating whether environmental factors are responsible for breast cancer risk in Nassau and Suffolk counties. This research includes assessments of exposure to organochlorines and other chemicals, magnetic fields, contaminated drinking water, air pollution, and hazardous and municipal waste".[10] An important research question continues to be: to what extent are elevated breast cancer incidence or death rates in a particular geographic area attributable to: a) changes in known risk factors (see, for example, references [10,11]); b) changes in diagnosis and/or treatment; c) chance; and, d) as-yet-unidentified risk factors? An example is provided by an article about breast-cancer rates in Hawaii.[12] An excerpt: "Rising breast cancer rates in Hawaii may be partially attributable to intensive pesticide use in the state, according to a recent study in Environmental Health Perspectives. Breast cancer rates have increased for all racial groups in Hawaii since 1970, but only 30% to 40% of these cancers can be explained by known risk factors .... The researchers said that breast cancer screening is slightly more common in Hawaii than in other areas of the U.S., but not enough to explain the higher breast cancer rates".[12] Long Island and the Bay Area of California,[10,11] Hawaii [12] and perhaps Israel (see note, reference [12]) are places where the 'pesticide hypothesis' are likely to continue to receive attention from environmental researchers. The 'pesticide hypothesis' can be regarded as one aspect of the 'endocrine disrupter', or 'hormone disrupter' hypothesis.[13] THE SEARCH FOR UNRECOGNIZED RISK FACTORS There may be as-yet unrecognized risk factors for breast cancer, and there seems little reason to doubt that the search for such risk factors merits a high priority, as pointed out in an article about the 'endocrine disrupter' hypothesis, by Devra Lee Davis and Susan M. Sieber.[14] An excerpt: "While the importance of hormones for breast cancer has been understood for some time, only recently has attention focused on the need to develop and validate standardized methods for measuring hormones directly and for assessing the mechanisms by which they affect breast cancer and other aspects of women's health. In addition, several investigators have proposed that environmental factors, such as xenoestrogens and other xenohormones, may alter hormonal metabolism and thereby contribute to the development of breast cancer. As most cases of breast cancer occur in women with few of the established risk factors, efforts to identify new risk factors and new protective factors must continue to rank as high priority".[14] It should be noted that studies based on the 'endocrine disrupter' hypothesis may reveal new protective factors (that act by altering hormonal metabolism) as well as new risk factors. For example, studies of 'phytoestrogens' found in some foods (such as soy products) may merit attention from this point of view.[15] PERCEPTIONS OF RISKS Scientists concerned about decision making in situations of uncertainty have emphasized the extent to which public perceptions of risks, and thus of priorities for public policy, may be distorted. An example is provided in an article entitled: "The Dangerous Sandbox ... and Other Absurdities".[16] An excerpt: "In an age of accelerating information overload, trivial carcinogen warnings must surely dull our ability to recognize and avoid real dangers. This Chicken Little approach to health promotion, which conveys an impression that everything in the environment causes cancer, must be particularly welcomed by the tobacco industry as an aid to their campaign promoting the addiction of our youth to smoking".[16] There is ample evidence that cigarette smoking is a major risk factor for many cancers, and particularly cancers of the respiratory system. Whether or not cigarette smoking is associated with any increased breast cancer risk is still being investigated.[17,18] It's well-established that perceptions of risk, and of risk-taking behavior, can vary a great deal across individuals and groups, and research on risk perception and communication of risk is highly relevant to debates about environmental risks. For example, see the research on risk perception and risk communication of Paul Slovic and his colleagues, such as references [19] and [20]. However, the dilemma remains: what priority should be given to research on factors in the external (and internal) environment that might be associated with an increased risk of breast cancer, and, which such factors should receive the most attention? RELEVANCE TO BREAST-CANCER ADVOCACY The dilemma outlined above was highlighted during the First World Breast Cancer Conference, held in Kingston, Ontario, Canada on July 13-17, 1997. Reports of the conference in the popular press left an impression that, because of their presence at the same conference, activists concerned with environmental risks had been linked with advocates for unconventional therapies, who in turn, had been linked with the international breast-cancer advocacy movement. The Kingston conference could be regarded as a noteworthy 'case study' in breast-cancer advocacy. A concise summary of the proceedings of this conference was posted to the Breast-Cancer mailing list by Musa Mayer.[21] She commented on the apparent linkage, at this conference, of two groups both concerned about man-made chemicals. One group is concerned about the presence of toxic man-made chemicals in the environment. The other is concerned about the aggressive use of very toxic man-made chemicals in conventional cancer medicine: "It was Sharon Batt, of Breast Cancer Action of Montreal and author of "Patient No More: The Politics of Breast Cancer," (Gynergy Books/Ragweed Press, 1994) who helped me place this in context with the history of breast cancer advocacy. She spoke of "minimalists" and "go getters" when it comes to breast cancer treatment. Clearly, the great preponderance of people at the conference represented the "minimalist" point of view, casting a suspicious eye, for example, on such issues as screening mammography, genetic testing, widespread tamoxifen use, mastectomy vs. lumpectomy, etc.".[21] Joyce Maltz, in a response to Musa Mayer's summary, commented:[22] "I would hope that the next conference would attract some of the more cutting edge researchers and physicians. It seems that this conference was not subsidized by pharmaceutical companies, but the presentation of alternative cures, was no more valid than some of the wishful thinking of the chemo manufacturers".[22] Karen Gray, in another response to Musa Mayer's summary, pointed out:[23] "But it is a valid question to ask: For the dollars spent, where can you get the most benefit? I profoundly believe in spending money on the environment. But I have to admit, I suspect we'll save more lives by learning the biology of cancer first and thus having a clearer picture both of what in the environment to change and how to treat the cancer than by rather blindly putting money into environmental changes that may or may not be playing a key role in cancer and that may or may not be correctable without, as I said, returning to agrarianism. (Are we really so naive as to believe that technology and industry are possible without paying an environmental cost?)".[23] As Karen Gray points out, one important dimension of any debate about cancer research priorites is the priority that should be given to "learning about the biology of cancer first". So, what priority should be given to research on possible environmental causes of cancer (versus research on other potential risk factors [8], on the biology of cancer [23], or on any of the many other kinds of cancer-related issues)? Jon Church, as part of a commentary on the Kingston conference, has argued that the priority now given to research on the biology of cancer is too high, and that research related to prevention in general (and to environmental research in particular) is too low.[24] An excerpt: "It is time to move breast cancer from a purely medical/health model to a new paradigm involving politics, sociology and the environment. Let's redirect research efforts and dollars to prevention, not a failed 'magic bullet' approach. Let's look to good data from wildlife studies and from work in laboratory animals, and put the billions of dollars we now spend on basic research in cell biology into an expanded attack on environmental contamination. Let's learn from our errors and not wait 30 years to act like we did with tobacco".[24] WHAT CAN RESEARCH ETHICS CONTRIBUTE? I've outlined some of the basic principles of research ethics elsewhere [1]. They are summarized in the Belmont Report (1979).[25] From a societal perspective, an issue highlighted by the first of these principles (respect for persons) is: what degree of respect should be given to the perspectives of different advocacy groups (especially, ones that may meet a reasonable definition of a 'collectivity').[26] I'll argue that the more that these perspectives involve "considered opinions and choices", and are not "clearly detrimental to others", the more respect they should receive. My own view (I'm a researcher!) is that opinions are not "considered" unless they have taken into account the quality and quantity of scientific evidence that is currently available. In the absence of definitive evidence, further research is clearly needed before truly evidence-based actions can be taken. However, quite often, actions must be taken, even in the absence of definitive evidence. In such situations, ethical considerations of the kind being discussed here can also serve as helpful guides to action. A very important broad issue highlighted by the second and third of the Belmont ethical principles (beneficence and justice) are: what are the anticipated benefits and harms of proceeding immediately to reduce the numbers of man-made chemicals in the environment (without waiting for further research to be done)? And, benefits to whom? Harms to whom? For example, as has been pointed out above,[3,8,9] if the use of fertilizers and pesticides reduces the cost of food, then those most in need of cheap food may have a different perspective from those with a lesser need (fairness based on relative need is one formulation of the principle of justice).[1,25] If fruits and vegetables in the diet are very important for reducing cancer, then making them more expensive by reducing the use of synthetic pesticides is likely to "be detrimental to others", and perhaps may even increase cancer rates. People in North America with low incomes eat fewer fruits and vegetables and spend a higher percentage of their income on food.[8] From this (justice-oriented) perspective, a very high priority should be given to the identification and promotion of ways to produce and distribute fruits and vegetables at reduced cost, but without the use of synthetic herbicides and pesticides. Then, a very high priority should be given to obtaining evidence that such ways of producing and distributing fruits and vegetables result in greater net overall benefits, rather than harms, to society as a whole. Challenging tasks, and ones not usually considered to be within the domain of current cancer research! Perhaps advocacy efforts focused on enhanced consumption of plant-based foods might be justified from both a scientific and an ethical perspective (see, for example, reference [4])? SOME CONCLUDING COMMENTS 1. Current uncertainties about environmentally-based risk factors for breast cancer do not imply that no useful actions can be undertaken now in relation to environmental protection. They only mean that current scientific research has not yet provided conclusive evidence about the extent to which actions designed to protect the physical environment might be expected also to reduce the incidence of breast cancer. This interpretation of current state of the evidence should not be regarded as an argument in favor of pollution of the environment. Instead, it only raises questions about the extent to which policies designed to enhance environmental protection may be expected to reduce the incidence of breast cancer. I agree with Robert Proctor's argument that cancer is as much a political problem as it is a health problem.[27] 2. We can expect to see a continuing series of new research results that are relevant to environmental carcinogenesis. The controversy is not about whether or not such research should be done. It is mainly about what public policy actions should be taken immediately, on the basis of existing knowledge. Arguments that 'lifestyle-oriented' environmental factors should have a high priority are susceptible to the 'you want to blame the victim' counter-arguments. (Here I use the word 'environmental' to mean 'non-hereditary', and 'lifestyle-oriented' to mean factors such as smoking [17,18] or diet [4,8,28] ... but, should your house be regarded as a 'lifestyle-oriented' factor, or a 'physical-environment' factor [29])? 3. If up to 80-90% of breast cancers are indeed (in the words of Erik Parens):[30] "triggered by chance and/or environmental assaults" (where the term "environmental" should encompass all external factors that influence the way we live, including our diet) then: "We ought to be deeply worried about the prospect of elegant and simple genetic explanations diverting our attention and resources from the messy and complex business of managing environmental triggers".[30] As Parens points out, cigarette companies' attempts to attribute lung cancer to genetic susceptibility is one very good example of the use of genetic explanations, instead of an environmental one (carcinogens in cigarette smoke), as a way to let "genes become the scapegoat".[30] 4. My own opinion is that we need to learn much more about the complex and often subtle interactions between genes and the environment that lead to the onset of cancer, and that research on genetic/environmental interactions merits an increasingly high priority. I agree with what Wolff and colleagues have said in a recent review article:[31] "Research on etiology of breast cancer should measure environmental exposures and take into account the time of life at which these occur. Complex interactions between exogenous and endogenous carcinogenic agents need further focus, as modulated by varying genetically determined individual susceptibilities".[31] 5. Interactions between combinations of environmental chemicals and between such chemicals and different human genotypes may be a fruitful area for further research. Unfortunately, a very interesting and influential report of the synergistic activation of estrogen receptor with combinations of environmental chemicals has been retracted.[32] REFERENCES AND NOTES 1. https://members.tripod.com/~ca916/index-5.html Notes of mine entitled: "Research Ethics and Research Priorities, Part 1: Role of Advocacy Groups". Some background material about basic principles of research ethics is included in these notes. 2. http://cure.acor.org/lists/cancer/bc/97/07/2/0498.html A link, via Gilles Frydman's ACOR archives, to the (copyrighted) message that I sent to the Breast-Cancer Discussion Group on July 12, 1997 (Subject: Re: Ruminating on Pesticides). For more information about copyright and messages sent to mailing lists, see: https://members.tripod.com/~ca916/index-4.html. 3. http://cure.acor.org/lists/cancer/bc/97/07/2/0438.html A link to a (copyrighted) message posted by Joyce Maltz to the Breast-Cancer Discussion Group on July 11, 1997 (included here with her permission). The subject was, again, Re: Ruminating on Pesticides. This link is also via the ACOR archives. 4. http://www.envirolink.org/arrs/essays/veg_diet.html A link, via the envirolink.org website, to a (copyrighted) article by Susan Lang, entitled: "China Study Shows Need for Eating Plant-Based Diet". The envirolink.org website provides access to other advocacy-oriented information, such as an article by Lori Sklar, entitled "Environmental Consequences of Corporate Farming": http://www.envirolink.org/arrs/AnimaLife/spring97/farming.html An excerpt: "Plants that could feed twelve people will only feed one person if first given to an animal and then eaten by the human (Achor, 64). Land is therefore much more productive when used to cultivate plants rather than animals". 5. PubMed abstract A link to a (copyrighted) PubMed abstract of a paper by Sandra Steingraber, published in Environmental Health Perspectives 105, Supplement 3: 685, April 1997. To see the policy of the National Library of Medicine about downloading such abstracts, Click here Sandra Steingraber is also the author of a controversial book, "Living Downstream". A review of this book in the New England Journal of Medicine, at: http://www.nejm.org/public/1997/0337/0021/1562a/1.htm has also generated controversy about the reviewer's impartiality, according to an article by Larry Tye on page A01 of the Dec. 27, 1997 issue of the Boston Globe. Boston Globe website 6. Robison, Wade L. "Decisions in Doubt: The Environment and Public Policy", Dartmouth College, University Press of New England, Hanover and London, 1994. 7. http://www.cfe.cornell.edu/bcerf/fctsht.DDT.html A link, via the www.cfe.cornell.org website, to (copyrighted) material on "DDT, DDE and the Risk of Breast Cancer", prepared in late 1996 by Suzanne M. Snedeker, for the Program on Breast Cancer and Environmental Risk Factors in New York State. 8. http://socrates.berkeley.edu/mutagen//ames.pnas3.html A link to a (copyrighted) article by Bruce Ames, Lois Gold and Walter Willett, entitled: "The causes and prevention of cancer". It was published in the Proceedings of the National Academy of Sciences of the U.S.A. 92(12), 5258-5265 (1995). PubMed abstract 9. Click here for a link, via the website of the Environmental Health Information Service, to a (copyrighted) article by Kate Cahow, entitled: "The Cancer Conundrum" (from the EHP monthly journal, volume 103(11) November, 1995). This article includes a review of evidence relevant to the scientific controversy about the basis for observed increases in breast cancer incidence. 10. http://www.pslgroup.com/dg/2f8a2.htm A link to a (copyrighted) article entitled "Metropolitan Northeast Has Highest Breast Cancer Mortality in U.S.", via the "Doctor's Guide to the Internet" website. 11. Bay Area A link, via the ACOR archives, to a message about breast cancer rates in the Bay Area of California that I sent to the Breast-Cancer mailing list on July 2, 1997. The subject was: 'Interesting article in JNCI'. Click Here for a subsequent (copyrighted) article in the San Francisco Chronicle, in which it is suggested that breast cancer rates in the Bay Area may no longer be exceptional in relation to elsewhere in the U.S. (but that noteworthy differences across groups with different ethnic origins are still apparent). 12. Allen, RH and colleagues, "Breast Cancer and Pesticides in Hawaii: The Need for Further Study". Environmental Health Perspectives, Volume 105, Supplement 3: 679, April 1997. PubMed abstract Changes in pesticide levels in Israeli milk have also been suggested to show an association with changes in breast cancer risks. See: Westin JB "Carcinogens in Israeli milk: a study in regulatory failure". The article does not mention the possibility that changes in breast cancer risks in Israel might also be associated with changes in the population of Israel as a result of recent immigration from areas of low breast-cancer risk. 13. An excellent source of information about various perspectives on the endocrine disrupter hypothesis, both for and against, is available at: http://www.pbs.org/frontline/shows/nature/ For those interested in more information about hormone disrupters from the perspective of the World Wildlife Fund (Canada), a webpage is available at the WWF Canada site 14. http://ehpnet1.niehs.nih.gov/docs/1997/Suppl105-3/davis.html A link to a (copyrighted) article about hormones and breast cancer, authored by Devra Lee Davis and Susan Sieber, and published in Environmental Health Perspectives 105, Supplement 3: 557, March 1997. 15. Davis DL, et al. A link to a PubMed abstract that describes a hypothesis about 'xenoestrogens' and breast cancer, and includes comments about 'phytoestrogens'. 16. http://www.ahfmr.ab.ca/March/sandbox.html A link to a (copyrighted) article entitled: "The Dangerous Sandbox ... and Other Absurdities", about the scientific field of "risk management". 17. PubMed abstract of a report by K.T. Kelsey and colleagues, 1997. They found no significant increase in risk of incident breast cancer associated with a particular genotype (the "GSTM1 null" genotype), and no significant interaction with cigarette smoking. 18. Morabia A, et al. A PubMed abstract of an article by A. Morabia & colleagues, about passive smoking and risk of breast cancer. 19. PubMed abstract of an article by Slovic P, Malmfors T, Mertz CK, Neil N, Purchase IF, "Evaluating chemical risks: results of a survey of the British Toxicology Society", Hum. Exp. Toxicol, 1997;16(6):289-304. 20. PubMed abstract of an article by Flynn J, Slovic P, Mertz CK, "Gender, race, and perception of environmental health risks", Risk. Anal. 1994;14(6):1101-1108. 21. Click here for a link to Musa Mayer's comments about the Kingston conference (link provided with her permission). These comments were entitled: "A perspective on the First World Conference on Breast Cancer" and were posted on July 19, 1997. 22. Click here for a link to Joyce Maltz's comments about the Kingston conference, posted on July 20, 1997 (link provided with her permission). 23. Click here for a link to Karen Gray's comments about the Kingston conference, posted on July 20, 1997 (link provided with her permission). 24. Click here for a link, via the ACOR archives, to a perspective on the Kingston conference provided by Jon Church, on August 14, 1997. He is the listowner for the Breast-Cancer mailing list, based at Memorial University, Newfoundland. (This link provided with his permission, and with the permission of the publisher of the Canadian Breast Cancer Network newsletter). 25. http://www.nih.gov/grants/oprr/belmont.htm#xbasic Some basic ethical principles, which form a very influential part of the Belmont Report. 26. https://members.tripod.com/~ca916/index-3.html A link to some more notes of mine, in which I review some definitions of a 'collectivity'. 27. Proctor, Robert N, "Cancer Wars: How Politics Shapes What We Know and Don't Know About Cancer", Basic Books, New York, 1995. For a review of Robert Proctor's book, by Steve Farnsworth, in the Multinational Monitor, vol. 17, no. 3, March 1996, Click here. An excerpt: "This well-researched book is the latest effort to draw more attention to the ways in which the modus operandi between corporations and the government is steadily increasing the toxic load on the planet and its inhabitants". 28. Reference to work of Alicja Wolk & colleagues Link to a (coprighted) article "A prospective study of monounsaturated fat and other types of fat with the risk of breast cancer". It is about a study by Alicja Wolk and colleagues, published in Arch. Intern. Med. 1998;158(1):41-45. A PubMed abstract is available. 29. Ott WR, Roberts JW, 1998 A link to a (copyrighted) article by Wayne R. Ott & John W. Roberts, "Everyday exposure to toxic pollutants", in the February 1998 issue of Scientific American. 30. Parens, Erik. Glad and terrified: on the ethics of BRCA1 and 2 testing. Cancer Investigation 14(4): 405-411, 1996. PubMed citation (no abstract is provided for this article). Click here for a link to the (copyrighted) article itself, via Oncology Online. 31. Wolff MS et al, 1996 A PubMed abstract of a review article by M.S. Wolff, G.W. Collman, J.C. Barrett & J. Huff, entitled: "Breast cancer and environmental risk factors: epidemiological and experimental findings", published in the Annual Review of Pharmacology and Toxicology, 36: 573-596, 1996. 32. McLachlan JA: Science 1997 Jul 25;277(5325):462-3) Retraction of an influential report of the synergistic activation of estrogen receptor with combinations of environmental chemicals. Copyright 1998 by Jim Till Last modified on June 8, 1998 ----------------------------------------------------------- To see the first part of this set of notes on Research Ethics and Research Priorities, please go to: PART 1: ROLE OF ADVOCACY GROUPS Return to top of page Go to my home page Disclaimer