March 27, 2008
Front Row
A Bad Reaction to a Diet
By ERIC WILSON
VOGUE made the proposal, but was it indecent?
Last September, Kate and Laura Mulleavy, the sibling designers of Rodarte, received a phone call from a Vogue editor who suggested that they see a trainer and go on a diet. The sisters, who said they wanted to be healthier and balance their stress levels, agreed, accepted four months of personal training and a meal delivery service paid for by the magazine, lost a combined 50 pounds and kept a journal of their experiences, which appears in the April issue.
“Kate and I have decided we have to do this program in a realistic way,” Laura Mulleavy wrote in an Oct. 22 entry. “We’ll have wine when we feel like it and cheat on holidays.”
Reactions to the issue have been blistering. Dozens of objections were posted to an entry about the diet on the blog Jezebel.
Nonetheless, Cynthia M. Bulik, a professor of eating disorders at the University of North Carolina in Chapel Hill, defended the offer as it was presented in the magazine, noting that the designers had written that a doctor had also told them to get in shape. She said she was surprised by the controversy, given that Anna Wintour, in her editor’s letter, had challenged designers to use healthier looking models.
“I saw more of an emphasis on healthy eating and healthy fitness than an order, ‘You’ve got to lose weight,’ ” Dr. Bulik said.
The magazine has a track record of chronicling the diets of its staff, and in 1998, Oprah Winfrey acknowledged that she had agreed to lose 20 pounds in order to appear on its cover.
On top of this, Vogue has also been accused of racial stereotyping in its April cover choice: a black male athlete posing ferociously with his arm around a skipping-to-my-lou supermodel. Some media critics compared the pose unfavorably to images of King Kong and Fay Wray.
“We thought it was a strong and beautiful photo shoot,” said Abigail Walch, a senior editor at Vogue, who said the pose happened naturally. The Rodarte article, she said, was intended to inspire women who have trouble incorporating fitness into their hectic schedules. On subjects like weight and shape, she added, dissension is to be expected.
“It’s a hot topic that people love to talk about,” Ms. Walch said

March 27, 2008
Personal Best
Yes, Running Can Make You High
By GINA KOLATA
THE runner’s high: Every athlete has heard of it, most seem to believe in it and many say they have experienced it. But for years scientists have reserved judgment because no rigorous test confirmed its existence.
Yes, some people reported that they felt so good when they exercised that it was as if they had taken mood-altering drugs. But was that feeling real or just a delusion? And even if it was real, what was the feeling supposed to be, and what caused it?
Some who said they had experienced a runner’s high said it was uncommon. They might feel relaxed or at peace after exercising, but only occasionally did they feel euphoric. Was the calmness itself a runner’s high?
Often, those who said they experienced an intense euphoria reported that it came after an endurance event.
My friend Marian Westley said her runner’s high came at the end of a marathon, and it was paired with such volatile emotions that the sight of a puppy had the power to make her weep.
Others said they experienced a high when pushing themselves almost to the point of collapse in a short, intense effort, such as running a five-kilometer race.
But then there are those like my friend Annie Hiniker, who says that when she finishes a 5-k race, the last thing she feels is euphoric. “I feel like I want to throw up,” she said.
The runner’s-high hypothesis proposed that there were real biochemical effects of exercise on the brain. Chemicals were released that could change an athlete’s mood, and those chemicals were endorphins, the brain’s naturally occurring opiates. Running was not the only way to get the feeling; it could also occur with most intense or endurance exercise.
The problem with the hypothesis was that it was not feasible to do a spinal tap before and after someone exercised to look for a flood of endorphins in the brain. Researchers could detect endorphins in people’s blood after a run, but those endorphins were part of the body’s stress response and could not travel from the blood to the brain. They were not responsible for elevating one’s mood. So for more than 30 years, the runner’s high remained an unproved hypothesis.
But now medical technology has caught up with exercise lore. Researchers in Germany, using advances in neuroscience, report in the current issue of the journal Cerebral Cortex that the folk belief is true: Running does elicit a flood of endorphins in the brain. The endorphins are associated with mood changes, and the more endorphins a runner’s body pumps out, the greater the effect.
Leading endorphin researchers not associated with the study said they accepted its findings.
“Impressive,” said Dr. Solomon Snyder, a neuroscience professor at Johns Hopkins and a discoverer of endorphins in the 1970’s.
“I like it,” said Huda Akil, a professor of neurosciences at the University of Michigan. “This is the first time someone took this head on. It wasn’t that the idea was not the right idea. It was that the evidence was not there.”
For athletes, the study offers a sort of vindication that runner’s high is not just a New Agey excuse for their claims of feeling good after a hard workout.
For athletes and nonathletes alike, the results are opening a new chapter in exercise science. They show that it is possible to define and measure the runner’s high and that it should be possible to figure out what brings it on. They even offer hope for those who do not enjoy exercise but do it anyway. These exercisers might learn techniques to elicit a feeling that makes working out positively addictive.
The lead researcher for the new study, Dr. Henning Boecker of the University of Bonn, said he got the idea of testing the endorphin hypothesis when he realized that methods he and others were using to study pain were directly applicable.
The idea was to use PET scans combined with recently available chemicals that reveal endorphins in the brain, to compare runners’ brains before and after a long run. If the scans showed that endorphins were being produced and were attaching themselves to areas of the brain involved with mood, that would be direct evidence for the endorphin hypothesis. And if the runners, who were not told what the study was looking for, also reported mood changes whose intensity correlated with the amount of endorphins produced, that would be another clincher for the argument.
Dr. Boecker and colleagues recruited 10 distance runners and told them they were studying opioid receptors in the brain. But the runners did not realize that the investigators were studying the release of endorphins and the runner’s high. The athletes had a PET scan before and after a two-hour run. They also took a standard psychological test that indicated their mood before and after running.
The data showed that, indeed, endorphins were produced during running and were attaching themselves to areas of the brain associated with emotions, in particular the limbic and prefrontal areas.
The limbic and prefrontal areas, Dr. Boecker said, are activated when people are involved in romantic love affairs or, he said, “when you hear music that gives you a chill of euphoria, like Rachmaninoff’s Piano Concerto No. 3.” The greater the euphoria the runners reported, the more endorphins in their brain.
“Some people have these really extreme experiences with very long or intensive training,” said Dr. Boecker, a casual runner and cyclist, who said he feels completely relaxed and his head is clearer after a run.
That was also what happened to the study subjects, he said: “You could really see the difference after two hours of running. You could see it in their faces.”
In a follow-up study, Dr. Boecker is investigating if running affects pain perception. “There are studies that showed enhanced pain tolerance in runners,” he said. “You have to give higher pain stimuli before they say, ‘O.K., this hurts.’ ”
And, he said, there are stories of runners who had stress fractures, even heart attacks, and kept on running.
Dr. Boecker and his colleagues have recruited 20 marathon runners and a similar number of nonathletes and are studying the perception of pain after a run, and whether there are related changes in brain scans. He is also having the subjects walk to see whether the effects, if any, are because of the intensity of the exercise.
The nonathletes can help investigators assess whether untrained people experience the same effects. Maybe one reason some people love intense exercise and others do not is that some respond with a runner’s high or changed pain perception.
Annie might question that. She loves to run, but wonders why. But her husband tells her that the look on her face when she is running is just blissful. So maybe even she gets a runner’s high.

March 27, 2008
Pressured, Motorola Splits in Two
By LAURA M. HOLSON
After a two-month strategic review of its businesses, Motorola said on Wednesday that it would split itself into two separate publicly traded companies, spinning off its unprofitable mobile phone unit to investors.
The activist investor Carl C. Icahn, who has pressured Motorola to make such a move, said in a letter to its board that the announcement was “clearly a step in the right direction.” But he questioned Motorola’s commitment to moving quickly to solve its problems.
Gregory Q. Brown, Motorola’s chief executive, conceded that the main problem facing the company was its inability to come up with new products to replace the highly successful Razr, which was once a must-have phone but has faded from the scene.
He said he hoped that by turning the mobile devices business into its own unit, the company would have better luck attracting a new chief executive to run it and revive Motorola’s reputation.
“I think the challenges around Motorola have been about consistent execution,” Mr. Brown said. “That is why it is so important for us to expand and improve our product portfolio.”
Motorola’s influence and stock price have declined as rivals have taken the lead in creating interesting devices. Apple and its popular iPhone, for example, have captured the attention of buyers in the high-end market.
Executives of Motorola, which is based in Schaumburg, Ill., declined to talk about what new handsets it planned to offer consumers in the coming months.
Next week is a big one for the mobile business, as all of the top handset makers and wireless companies are gathering in Las Vegas for the industry’s largest American trade show, CTIA Wireless 2008. Many will take the opportunity to unveil flashy new phones that consumers will be snapping up over the next year.
But when it comes to Motorola, expectations are low.
“It will be interesting to see if they announce anything at CTIA,” said Roger Entner, a senior vice president at IAG Research.
Rivals aside, Motorola is also facing pressure from investors — in particular Mr. Icahn — who are dissatisfied with Motorola’s weak stock performance; the shares have dropped 44 percent in the last year. Cellphone production is the largest division of the company, with $18.99 billion in net sales in 2007, a 33 percent decline from a year earlier. Last year, the division lost $1.2 billion. Motorola’s other two units are smaller but profitable.
Analysts have questioned what effect a split would have on operations and on attracting solid executives to the troubled company. Already there has been an exodus of executives from Motorola, among them Stu Reed, the former chief of the mobile devices division.
“The danger is they are getting rid of the underperforming part of the business just to get rid of it,” Mr. Entner of IAG said. “The fear is in a year or two the operations will cease to exist.”
The profitable side of Motorola is decidedly less well known than the mobile devices division. It makes set-top boxes and products used by businesses and law enforcement officials for scanning and fingerprinting, as well as data and video communications systems for public agencies like fire departments.
Motorola expects to have the spinoff, which will be a tax-free distribution to shareholders, completed by 2009.
The move to split the company has long been advocated by Mr. Icahn, who led a fight last year for a seat on Motorola’s board. That effort failed, but it helped lead to the departure of the chief executive, Edward J. Zander, who was succeeded by Mr. Brown.
This week, Mr. Icahn sued Motorola, demanding internal board documents that he believed would show that it was lax in its oversight of management. Mr. Icahn is now leading a proxy fight for four Motorola board seats ahead of the company’s annual meeting in May.
In his letter to the board, Mr. Icahn also questioned why it would take so long to complete the split, and why it took “the threat of a proxy fight for you to make promises we all want to hear.” He did not return calls seeking comment.
There is still the chance that Mr. Brown and his board could decide to sell the mobile phone division if they do not find a suitable chief executive to run it. Selling it to a competitor was one option that Motorola pursued, according to a person involved in those discussions, but there were no takers.
Mr. Brown declined to discuss whether the division could be sold. “We’ve never had a ‘For Sale’ sign on it,” he said. “After our review, we believe this is the appropriate action.”

March 5, 2008
Yes, MSG, the Secret Behind the Savor
By JULIA MOSKIN
IN 1968 a Chinese-American physician wrote a rather lighthearted letter to The New England Journal of Medicine. He had experienced numbness, palpitations and weakness after eating in Chinese restaurants in the United States, and wondered whether the monosodium glutamate used by cooks here (and then rarely used by cooks in China) might be to blame.
The consequences for the restaurant business, the food industry and American consumers were immediate and enormous. MSG, a common flavor enhancer and preservative used since the 1950s, was tagged as a toxin, removed from commercial baby food and generally driven underground by a new movement toward natural, whole foods.
“It was a nightmare for my family,” said Jennifer Hsu, a graphic designer whose parents owned several Chinese restaurants in New York City in the 1970s. “Not because we used that much MSG — although of course we used some — but because it meant that Americans came into the restaurant with these suspicious, hostile feelings.”
Even now, after “Chinese restaurant syndrome” has been thoroughly debunked (virtually all studies since then confirm that monosodium glutamate in normal concentrations has no effect on the overwhelming majority of people), the ingredient has a stigma that will not go away.
But then, neither will MSG.
Cooks around the world have remained dedicated to MSG, even though they may not know it by that name. As hydrolyzed soy protein or autolyzed yeast, it adds flavor to the canned chicken broth and to the packs of onion soup mix used by American home cooks, and to the cheese Goldfish crackers and the low-fat yogurts in many lunchboxes.
It is the taste of Marmite in the United Kingdom, of Golden Mountain sauce in Thailand, of Goya Sazón on the Latin islands of the Caribbean, of Salsa Lizano in Costa Rica and of Kewpie mayonnaise in Japan.
“It’s all the same thing: glutamate,” said Dr. Nuripa Chaudhari of the University of Miami, who was part of the first research team to identify human glutamate receptors.
In September Dr. Chaudhari will take part in the University of Tokyo’s centenary celebrations honoring Prof. Kikunae Ikeda’s 1908 discovery of glutamate flavor. The Japanese company Ajinomoto turned that discovery into crystalline powder form, MSG, and patented it in 1909.
“Just like salt and sugar, it exists in nature, it tastes good at normal levels, but large amounts at high concentrations taste strange and aren’t that good for you,” Dr. Chaudhari said.
If you live in the United States and like spicy tuna rolls, Puerto Rican roast pork or Thai noodles, there is a good chance you are eating, and enjoying, MSG. And if you are the kind of cook who likes to keep a globe-trotting kitchen, well, then, some of these MSG-laden ingredients may deserve a place in your cupboard.
“I don’t cook with MSG because that’s not my training, but it definitely has its place,” said Zak Pelaccio, a New York chef whose ride to fame has been greased with Kewpie mayonnaise. One of the dishes that put him on the map was a sandwich of roasted salmon on pumpernickel bread slathered with wasabi aioli: wasabi from a tube and the mayonnaise.
In regions where meat and meaty flavors have been out of reach for most cooks, MSG has long filled the gap.
“My father called Maggi sauce la segunda venida, the second coming, because he was not a very good cook and it saved him,” said Irma Cecilia Sanchez, a home health aide from Puebla, Mexico, who was waiting in line at a taco truck on the Upper West Side. Maggi sauce is a 19th-century Swiss creation, a general flavor enhancer now made with MSG, sweeteners and extracts.
Her mother died when she was young, she said, and her father was a reluctant cook, making scrambled eggs most nights. “Huevos revueltos with Maggi sauce is still one of my favorite things, with tortillas and pico de gallo,” she added.
Maggi sauce (there are various other Maggi products, not all of which contain MSG) is extremely popular in regions as far-flung as India, Mexico, the Philippines and the Ivory Coast. One of Thailand’s favorite late-night street foods, pad kee mao, or drunkard’s noodles, relies on its sweet-salty-meaty taste; the Malaysian version is called Maggi goreng.
“It’s the kind of thing people crave late at night,” said Bee Yinn Low, who is from Penang but lives in Irvine, Calif., and writes a blog about Malaysian food at rasamalaysia.com. Maggi has a faintly similar flavor to Indonesian kecap manis, a salty-sweet-savory condiment that is one ancestor of modern tomato ketchup.
“Asia wouldn’t survive without MSG,” said Mike Crewe-Brown, a cooking teacher who recently spent three months producing a food documentary in Southeast Asia.
Even after “No MSG” signs began appearing across the United States, “most Chinese restaurants, honestly, kept right on using it,” Ms. Hsu said. “And at home most Chinese cooks will sprinkle in a little bit at the end, especially if the ingredients they had to cook with were not that great.”
Meat and MSG work beautifully together. Throughout Latin America and the Caribbean, the fallback rub for pork shoulder or flank steak is Goya Sazón: MSG and salt, cut with garlic, cumin and annatto. Accent, which is mostly MSG, was introduced in 1947 and quickly became a staple for American home cooks.
But it is in Japan that MSG has been most thoroughly integrated into popular food, through two main delivery systems: instant ramen noodle soup and mayonnaise, now popular on pizza, omelets and sushi. (Mayonnaise Kitchen, a food stall in Tokyo, serves only mayonnaise-friendly foods and lets patrons store their own bottles of Kewpie, the most popular brand.)
Japanese mayonnaise is flavored with MSG and rice vinegar, giving it an addictive roundness and tang. It is the main ingredient in dynamite sauce, a mix of mayonnaise and chili sauce that has become a staple of sushi bars here and in Japan. At Ginza in Boston, a dish called hotate hokkaiyaki — baked shellfish with dynamite sauce — has had a passionate following for more than 10 years.
If you have ever wondered what makes spicy tuna rolls so much tastier than plain tekka maki, dynamite sauce, or perhaps the MSG in it, is the answer.
In upscale restaurants, whether by tradition or by inclination, chefs are unlikely to use monosodium glutamate. “We don’t need to use Ajinomoto because we can get the ingredients that have natural umami: shiitake mushrooms, egg yolks, shellfish, masago,” said Sotohiro Kosugi, the chef of Soto in New York.
Although umami is only a bit player in Japanese cuisine, reams of breathless prose have been produced here on this elusive fifth taste, which is supposedly linked to the profoundly pure, deep-sea flavors of kelp and dried tuna.
Umami “is delicious,” Katsuhiro Utada told The New York Times in 1983, and a food-lovers’ swoon began. Mr. Utada, not coincidentally, was the president of the Ajinomoto Company — then, and now, the world’s largest producer of monosodium glutamate.
Whether umami is the fifth taste or the 50th — there is little agreement among neuroscientists — it has been positively identified as the flavor of glutamic acid, an amino acid naturally present in many savory foods, from seaweed to soppressata. Food writers lost no time adding umami to their mental glossaries. But this same crowd rarely mentions MSG, a cheap, synthetic route to the flavor of glutamate.
I keep kecap and (umami-rich) ketchup on hand, but MSG is not normally present in my kitchen. The spice drawer has never seen Accent, the canned chicken broth has a big “No MSG” stamp on the label and the hoisin, soy and fish sauces on hand are the food-writer-approved brands. Again, no MSG.
So the food I produced at home using Maggi sauce, MSG-laden bouillon cubes and Japanese mayonnaise tasted ... different.
I made two versions of pad kee mao, with and without Maggi, and while both were good, the one with MSG had the kind of round flavor I’d normally associate with homemade chicken stock or some form of professional expertise.
Tasted straight, though, the sauces had the chemical, tangy aftertaste common to many processed foods.
“Too much MSG and you get that harsh, acrid taste,” said Mr. Pelaccio, who uses an empty barrel of Ajinomoto-brand MSG he found on the street as a plant stand in his Chinatown apartment. “But get it just right and that dish will sing.”
The role of MSG in food, and its effects on health, remain controversial. Linda Bartoshuk, a director of the University of Florida’s Center for Smell and Taste, who has studied the sensory effects of MSG for years, believes not only that MSG is harmful to health, but also that it has virtually no effect on the taste of food. “All this umami stuff is just marketing,” she said.
In 1995 the Food and Drug Administration issued a large-scale review by the Federation of American Societies for Experimental Biology, clearing glutamates as a health risk for the vast majority of consumers.
An international research review in 1987 by the World Health Organization and the Food and Agriculture Organization of the United Nations had come to the same conclusion.
“There was simply no clinical evidence for any of it,” said Marion Nestle, a professor of nutrition at New York University.
She did not even mention MSG in her recent book “What to Eat,” much of which is devoted to health concerns over food additives. “I thought the issue was settled, though I know a lot of people will never believe that,” she said.
MSG is blamed by some groups for a range of serious neurological and physiological disorders. Some studies have identified both MSG and aspartame (another Ajinomoto product) as excitotoxins, substances that overstimulate the neurotransmitters to the point of cell damage. But no large-scale clinical research has been done since the F.D.A.’s 1995 review.
Since the 1970s, MSG has sidled back onto American supermarket shelves, under assumed names: hydrolyzed proteins, yeast extracts, protein concentrates and other additives that are not labeled as MSG but, according to nutritionists and the United States Department of Agriculture, are essentially the same thing: synthetically produced glutamates.
The whey protein concentrate and liquid aminos that many Americans buy at health food stores are also, essentially, pure glutamate, Dr. Chaudhari said.
According to U.S.D.A. guidelines, “labeling is required when MSG is added as a direct ingredient.” But other glutamates — the hydrolyzed proteins, the autolyzed yeasts and the protein concentrates, which the U.S.D.A. acknowledges are related to MSG — must be identified under their own names.
Alternatively, they may also be included under certain terms, like vegetable broth or chicken broth. Thus, these ingredients are now routinely found in products like canned tuna (vegetable broth is listed as an ingredient; it contains hydrolyzed soy protein), canned soup, low-fat yogurts and ice creams, chips and virtually everything ranch-flavored or cheese-flavored.
Thus, the richest source of umami remains your local convenience store. Grab a tube of Pringles or a bologna sandwich, and glutamic acid is most likely lurking there somewhere.
Nacho-cheese-flavor Doritos, which contain five separate forms of glutamate, may be even richer in umami than the finest kombu dashi (kelp stock) in Japan.
No wonder they taste so good.

March 5, 2008
Easily Overlooked Lesions Tied to Colon Cancer, Study Finds
By DENISE GRADY
An easily overlooked type of abnormality in the colon is the most likely type to turn cancerous, and is more common in this country than previously thought, researchers are reporting.
The findings come from a study of colonoscopy, in which a camera-tipped tube is used to examine the lining of the intestine. Generally, doctors search for polyps, abnormal growths that stick out from the lining and can turn into cancer. But another type of growth is much more dangerous, and harder to see because it is flat or depressed and similar in color to healthy tissue.
Japanese researchers became concerned about these flat lesions in the 1980s and ’90s, but studies here had mixed results and American doctors tended to think that flat growths were less common and less dangerous in the United States.
The new study, to be published Wednesday in the Journal of the American Medical Association, suggests otherwise.
Some doctors in this country were already alert to flat lesions, but the findings will pose a challenge to others, because it takes a trained and vigilant eye to see the growths and special techniques to remove them. The results also mean it is especially important that patients take the harsh laxatives that many dread in advance of the test. The flat lesions, hard to find even under the best conditions, will be impossible to see if any waste is left in the bowel.
Colon cancer is the second-leading cause of cancer death in the United States, after lung cancer, with about 154,000 new cases detected and 52,000 deaths a year. It is one of the few cancers that is totally preventable if precancerous growths are found and removed; it can also be cured with surgery alone if found early enough.
People who have just had a colonoscopy should not rush to schedule another one just to look for the flat growths, doctors said.
“I don’t think people have to panic that they’ve somehow been neglected and had poor care,” said Dr. David A. Rothenberger, deputy chairman of surgery at the University of Minnesota.
But he and other experts emphasized that people should see a doctor any time they have persisting symptoms that could indicate colon cancer, like rectal bleeding or a change in bowel habits — no matter how recently they had a colonoscopy. The test is highly reliable, but not perfect, doctors say.
Some doctors who perform colonoscopy just are not good at seeing flat lesions, but may improve with training and practice, said Dr. Douglas K. Rex, a gastroenterologist and professor of medicine at Indiana University.
“I think there are people who expect everything in there to be shaped like a golf ball,” he said. “It’s not.”
Dr. David Lieberman, chief of gastroenterology at Oregon Health and Science University, who wrote an editorial accompanying the study, said: “I think there will be some surprise. There has been in general some skepticism in the United States about how common flat and depressed lesions are and how important they are. So I think this study, coming from the United States and from a good group of investigators, will be a wake-up call to a lot of physicians and will prompt people to be looking for these lesions.”
The study, of 1,819 military veterans, mostly men, found that 9.35 percent had flat lesions, and those lesions were five times as likely as polyps to contain cancerous or precancerous tissue. Depressed or indented lesions were the least common but the most risky. Together, the flat or depressed lesions accounted for only 15 percent of the potentially cancerous growths found in the study, but were involved in half of the cancers. Once the doctors spotted the flat lesions, they sprayed a bluish dye on them to see their outlines better and remove them completely.
The first author of the study, Dr. Roy M. Soetikno of the Veterans Affairs Palo Alto Health Care System said, “The message for doctors is, Here is a large amount of data showing that these precursors of cancer, always believed to be a Japanese disease, are actually a disease here, and are important, because they are much more likely to be cancerous, and doctors need to spend the time to provide quality colonoscopy.”
The message to patients, Dr. Soetikno said, is that when preparing for colonoscopy, they must follow instructions to the letter and take the hated laxatives to make sure their bowels are empty so that doctors can see the lining.
If any waste remains, flat lesions will be buried by it. Studies have shown that in about a quarter of all colonoscopies, the bowel preparation is inadequate.
Dr. Rex said that male veterans tended to have more precancerous colon growths than other groups, so the rate of flat lesions in women or the general population might not be quite as high as those in the study.
Dr. Soetikno and his colleagues started an exchange program with doctors in Japan to learn their techniques for recognizing and removing the flat lesions.
American doctors should learn from overseas colleagues more often, Dr. Rothenberger said, adding, “We tend to get very smug about our abilities.”
The quality of colonoscopy has become a delicate issue, because an article in The New England Journal of Medicine in December 2006 found that some doctors were 10 times better than others at finding precancerous polyps. A major factor in their success was taking enough time to examine the colon thoroughly, as opposed to rushing through the procedure. Doctors who miss polyps would almost certainly miss flat lesions as well because they are harder to see. The new study underscores the need for careful examinations, because the flat lesions are more dangerous.
The study also raises doubts about whether “virtual colonoscopy,” performed by a CT scanner, will ever be able to take the place of the colonoscope inserted into the rectum, as many patients had hoped. The problem is that CT scans use X-rays to reveal shapes, and find polyps because they stick out. Flat lesions are unlikely to show up in such scans.
Studies show that from 0.3 percent to 0.9 percent of patients develop colon cancers within just a few years of having a colonoscopy and polyp removal — exactly what the procedure is supposed to prevent. Some doctors think that flat lesions, missed entirely during the colonoscopy or not fully removed, may account for some of these apparent failures.
Dr. Robert Smith, the director of screening for the American Cancer Society, said flat lesions were “a vexing issue” that had provoked a lot of arguments among doctors.
“This paper shows they’re more prevalent than we believed, and also quite serious with regard to the presence of features associated with an elevated risk of cancer,” Dr. Smith said.
The difficulty facing patients is how to be sure their doctors are doing a good job. Professional groups have issued guidelines about the best way to perform a colonoscopy, but they are recommendations, not rules. The groups also urge doctors to track their own success rates at finding precancerous growths to see how they measure up to standards, but even if they do keep track, the doctors do not have to share the data with anyone. And many people are loath to ask about it. The doctor wielding the scope is the last person most patients would want to offend.
“The patient really has no way to act as an informed consumer,” Dr. Smith said. “You can’t call up a facility and say, ‘By the way, is my doctor any good?’ or, ‘Tell me who the best one is.’ ”
He added: “For some physicians there is an expectation of trust, and it is offputting to have a patient request documentation of competence. However, some physicians know patients are hearing about these issues and are not offended by questions about performance and errors.”