“We know what happens to people who stay in the middle of the road, they get run over.” – Aneurin Bevin
Breast cancer is usually big news. Heart-rending tales of heartache and heroism in this area are classic media fodder, as are scare stories about links between lifestyle factors and causation or genetics and risk. Yet, in these days of bloggers and twitterers, the public and media response to the insulin glargine “is it or isn’t it associated with breast cancer” story is surprisingly underwhelming. Typing “Lantus and breast cancer” into Google today (7 July) generated less than 50000 articles, of which a significant number were from US lawyers touting for medico-legal business on a basis of a possible link. Where were the newspaper headline scare stories, the switch-boards jammed with anxious users, or the collapsing stock price of the manufacturer? In our unit we have had only a handful of enquiries from people with diabetes.
The initial output from the European Association for the Study of Diabetes was unprecedented, with direct notification to members, including a webcast from the president of the organisation and the editor of the journal publishing the studies (http://tinyurl.com/ll5u9x). Perhaps the thoughtful and balanced presentation of the information allowed the media to see that we still do not really know if the risk is real or not. Or perhaps the data are so full of assumptions and caveats that the story simply does not have the legs or is too complicated to synthesise into a Daily Mail article for the coffee table?
Similarly the response from high-profile organisations has also been somewhat muted. For example, advice from Diabetes UK has been that the “evidence in these studies is not conclusive and that there are limitations with the research”, and for people using glargine that “if you are concerned about these findings then you should speak to your healthcare team about your anxieties before discontinuing any treatment” (Diabetes UK, 2009). This is similar to other organisations, who were worried that people’s first reaction would be to simply stop taking the stuff because of a fear of inducing cancer at a later stage. Fortunately, people with diabetes seem to be much more intelligent than this advice suggests, which must be a good result for the diabetes educators who started insulin in the first place. Or is it because they are unaware of what is going on?
Learned organisations, such as Diabetes UK, are uniformly advising that the solution to the problem at the moment should be left to individual clinicians in discussion with each person with diabetes to decide what is best. Even an update from the European Medicines Agency (2009) concluded that “the data do not provide a cause for concern and that changes to the prescribing advice are therefore not necessary”. This is a breath of fresh air in these days of national guidelines, protocols and targets, and is somewhat old-fashioned and goes against the recent tendencies for central control.
Locally, we have published pragmatic guidance to hopefully help individual doctors and nurses have useful discussions with people with diabetes (www.b-dec.co.uk – latest news). The advice is likely to change, but to us it makes sense to have something available, at least for the time being. Another option is to do nothing and await further guidance from on high. However, the fact that there are US lawyers already on the case does suggest that an ostrich-like “head-in-sand” approach is not going to be the most useful. One needs to have an opinion rather than no opinion at all.