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Rapid Responses: Rapid Responses published:
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Safe sunlight "doses"
- Phillip J. Colquitt (13 June 2008)
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Sunshine
- Hugh Mann (13 June 2008)
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Missing the tree for the forest
- John J Cannell (15 June 2008)
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Opportunity
- John J Cannell (16 June 2008)
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English, not American, quotations
- John J Cannell (17 June 2008)
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Misleading 25-hydroxyvitamin D Laboratory Reference Ranges
- Gregory A Plotnikoff (17 June 2008)
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Phillip J. Colquitt, Technician/RN Independent Comment
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Realizing that doctors can't "prescribe" sunlight, I still think it would be interesting to have seen some classical exposures of sunlight which might produce a preventative "dose" of Vitamin D. For example, ten minutes with the torso exposed, one hour with only the head exposed, and so on. Competing interests: None declared |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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The sun is as miraculous as life itself. In fact, the miracle of life depends on the miracle of the sun. But the sun is so powerful that we only need a little sunshine. Too much sunshine causes blindness, skin cancer, and even death. This is particularly true for pale-skinned people who don't tan easily. It is important to protect ourselves from excess sunshine by avoiding the midday sun and by wearing a hat, sunglasses, and appropriate clothing. We must regulate the amount of sunshine in our lives, so that we get enough, but not too much. Competing interests: None declared |
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John J Cannell, pyschiatrist Atascadero State Hospital, USA, 93423
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Sievenpipper et al, and Holick’s editorial their work generated, missed a potentially crucial possibility. In case report #1, her physicians diagnosed the patient with metastatic breast cancer, gave her a poor prognosis, but were unable to begin standard therapy. However, without any treatment, her symptoms completely resolved after a six-week summer trip to Pakistan. On return to cloudy England, her symptoms of bony metastasis returned and they gave her an aromatase inhibiter and single injection of aminobisphosphonate, to which she promptly developed hypocalcemia. They diagnosed severe vitamin D deficiency and began treatment with 300,000 IU of cholecalciferol monthly. Four years later, she remains in complete remission, apparently cancer free, and her bone scan is completely normal.
Unless one ascribes her apparent miraculous cure to aromatase inhibiters and a single injection of bisphosphonate, one wonders if first, the sun in Pakistan, and second, the pharmacological doses of vitamin D, cured her breast cancer.
Hollis and I recently predicted such robust cancer treatment effects were theoretically possible.
(Cannell JJ, Hollis BW. Use of vitamin D in clinical practice. Altern Med Rev. 2008 Mar;13(1):6-20.)
Competing interests: Dr. Cannell heads the non-profit educational organization, the Vitamin D Council |
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John J Cannell, psychiatrist Atascadero State Hospital
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I wonder if the authors could give us further details on case report #1, the Pakistani women with invasive ductal carcinoma of the breast apparently “cured” with vitamin D. She had a mastectomy; what were further details of the pathology? Was a biopsy of any of her rib lesions done or was the etiology of the lesions to obvious to warrant further work -up? Where any tumor markers, such as CA 15-3 and CEA, assessed and followed over time? Was a CT scan of her abdomen done before she went to Pakistan or only after? When exactly was the first serum 25(OH)D done? The authors report she been taking 300,000 IU of cholecalciferol every month for the last 4 years. (I congratulate on their dose. It is the dose I’d take if I had a life threatening cancer.) What is her current 25(OH)D level? If the rib lesions were not due to her breast cancer, and due to osteomalacia unrelated to her primary diagnosis, how often does osteomalacia cause such localized lesions on bone scan without more widespread bone scan reactivity? Both epidemiological evidence and vitamin D’s mechanism of action suggest that vitamin D may have a treatment effect in cancer. For example, a study of recurrence-free survival in early-stage non-small-cell lung cancer patients found those with the highest vitamin D input had double the 5-year recurrence-free survival and much better overall survival than those with the lowest. (Zhou W, Suk R, Liu G, et al.: Vitamin D is associated with improved survival in early-stage non-small cell lung cancer patients. Cancer Epidemiol. Biomarkers and Prev. (2005) 14:2303-2309.) This strongly implies a vitamin D treatment effect, that is, untreated vitamin D deficiency in non-small-cell lung cancer patients is a risk factor for early death. Furthermore, season of diagnosis has a survival effect on numerous cancers. Cancer patients live longer if the diagnosis is made in the summer rather than the winter, that is, summer has a treatment effect on cancer. (Porojnicu A, Robsahm TE, Berg JP, Moan J. Season of diagnosis is a predictor of cancer survival. Sun-induced vitamin D may be involved: a possible role of sun-induced Vitamin D. J Steroid Biochem Mol Biol. 2007 Mar;103(3-5):675-8.) and (Lim HS, Roychoudhuri R, Peto J, Schwartz G, Baade P, Møller H. Cancer survival is dependent on season of diagnosis and sunlight exposure. Int J Cancer. 2006 Oct 1;119(7):1530-6). Finally, Dr. Pamela Goodwin of the University of Toronto just announced that in her cohort of 500 breast cancer patients, women deficient in vitamin D were 94 per cent more likely to have their cancer spread and were 73 per cent more likely to die than women with higher levels. This is not prevention, this is evidence of a treatment effect. (Judd, T. Breast cancer survival linked to vitamin D. The Independent, May 19. (http://www.independent.co.uk/life-style/health-and-wellbeing/health- news/breast-cancer-survival-linked-to-vitamin-d-830576.html) Obviously, we do not want to jump on the latest Laetrile bandwagon. Just as obvious, we do not want to miss an opportunity. As Thomas Edison once said, “Opportunity is missed by most people because it is dressed in overalls and looks like work.” Competing interests: Dr. Cannell heads the non-profit educational organization, the Vitamin D Council |
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John J Cannell, psychiatrist Atascadero State Hospital, USA, 93423
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For those who do not care for American pundits like Thomas Edison, I have the words of two English immortals, words relevant to the vitamin D facts published every day, words relevant to the change necessary to deal with the epidemic of vitamin D deficiency. How do we change the pathetic fact that most cancer patients currently battle for their lives in a vitamin D deficient state? (Tangpricha V, et al. Prevalence of vitamin D deficiency in patients attending an outpatient cancer care clinic in Boston. Endocr Pract. 2004 May-Jun;10(3):292-3.) (Plant AS, Tisman G. Frequency of combined deficiencies of vitamin D and holotranscobalamin in cancer patients. Nutr Cancer. 2006;56(2):143-8.) Thomas Huxley once said, “Sit down before fact as a little child, be prepared to give up every preconceived notion, follow humbly wherever and to whatever abyss nature leads, or you will learn nothing.” George Bernard Shaw was blunter: “Progress is impossible with out change; those who cannot change their minds cannot change anything.” Competing interests: Dr. Cannell heads the non-profit educational organization, the Vitamin D Council |
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Gregory A Plotnikoff, medical director, Institute for Health and Healing Abbott Northwestern Hospital Minneapolis, MN 55407-3799
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The authors have emphasized for us two crucial lessons. The first is clear: insufficient vitamin D places patients at great risk for misdiagnosis and inappropriate treatment. This includes common oncologic, rheumatologic, cardiovascular, nocioceptive, neuromuscular and mental health disorders. Yes, clinicians must remain vigilant to vitamin D deficiency's heterogeneous and potentially sinister presentations. (1,2,3) And, yes, widespread deficiency certainly mandates more frequent testing of serum 25-hydroxyvitamin D. The second lesson is more indirect. In both cases cited by the authors, the local laboratory reference range for 25-hydroxyvitamin D was 25-75 nmol/l. Readers should recognize that reference ranges for vitamin D are based upon statistical, not physiological, parameters. Use of current local laboratory reference ranges can blind both physicians and patients to vitamin D deficiency. According to leading authorities in the physiology of vitamin D in vivo, the optimal serum concentration is greater than 75 nmol/l (4) which can exceed the upper range of normal for many laboratories. Regrettably, physicians looking at "normal" reference ranges might mistake optimal vitamin D levels with a risk of vitamin D toxicity. Hence the authors' second crucial lesson for us: optimal treatment requires supplementation to greater than 75 nmol/l. Gregory A. Plotnikoff, MD, MTS, FACP (1) Sievenpiper JL, McIntyre EA, Verrill M, Quinton R, Pearce SHS. Lesson of the Week: Unrecognised severe vitamin D deficiency. BMJ 2008; 336:1371-4. (2) Nellen J, Smulders YM, Frissen PHJ, Slaats EH, Silberbusch J. Lesson of the Week¡ªHypovitaminosis D in immigrant women: Slow to be diagnosed. BMJ 1996; 312: 570-2. (3) Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc 2003; 78: 1463-70. (4)Bischoff-Ferrari HA, Giovannucci E, Willet WC, Dietrich T, Dawson- Hughes B. Estimation of optimal serum concentrations of 25-hydroxyvitamin D for multiple health outcomes. Am J Clin Nutr 2006; 84:18-28. Competing interests: None declared |
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