The MPCC Cortisol Test

Tuesday, 11 June 2013

Pierre Rolland

La polémique. Yesterday’s news from L’Equipe.fr that Pierre Rolland should not have started the final stage of the Dauphiné has caused an obvious fuss for French cycling featuring a big name, being weeks from the Tour de France and, like it or not, bringing the suspicion of dopage.

The first thing to note is that this is not an anti-doping measure. Instead it is for health reasons and if Rolland is not enjoying the headlines the silver lining is that he’s now able to rest and recover from a potential health scare. But what is this test and what happened with Rolland during the Dauphiné?

Medical Explainer
Cortisol is hormone produced by the adrenal glands which sit on top of your kidneys. When confronted with a shock these glands produce adrenalin but also cortisol in response to the stress. Skimming the medicine it has two effects, one is anti-inflammatory and the other is to help the body access more energy. In both cases there are advantages to an athlete and doping with cortisone has existed for decades. Aching muscles hurt less and instead of a surge of adrenalin, the cortisone provides a more sustained boost. Abuse has a catabolic effort, breaking down muscle tissue. Several ex-riders from the 1970s and 80s have stated they had major problems, for example two time Tour winner Bernard Thévenet, the man who dethroned Eddy Merckx said “I was doped with cortisone for three years, I’m now unable to ride a bike.”

Note the difference, cortisol and cortisone. When someone starts taking big doses of cortisone, perhaps via injection, the body stops producing the natural cortisol.

The Health Check
The MPCC “health check” sees riders on member teams tested for their cortisol levels. Like an anti-doping test this is random, there’s little warning and the tests could occur at any race. Low cortisol levels are indicative of cortisone doping (or approved cortisone use by a Therpeutic Use Exemption) or a health problem, perhaps a disease or a concern with the adrenal glands so it’s good to stop them in any case. If the rider were to, say, crash then the body would respond by producing cortisol for the inflammation but a rider with low levels would not and therefore the body’s natural ability to recover is endangered. This is particularly worrying in the case of a head injury where the body cannot produce its own anti-inflammation response to a cranial injury. This testing is above and beyond anything WADA or the UCI do, the use of cortisone is legal these days. It was banned in the past and WADA is monitoring with a view to banning it again but this is far from certain.

The Delage Case
A year ago FDJ’s Mickaël Delage was stopped from riding the French national championships after a low level was detected. But the matter was cleared up after he showed the team doctor had advised him to take a medicine for bronchitis, a spray to inhale. The team showed the prescription and the matter was cleared. But Delage saw his name in the newspapers for all the wrong reasons. As ever the “rider stopped” headlines create a bigger splash than “rider cleared” news.

The Charteau Case
Before Delage we had Anthony Charteau, the 2010 Tour de France King of the Mountains. He was stopped at the Four Days of Dunkirk for low levels of cortisone after another check by the French Federation. At the time he said he could not explain the result but that he’d been racing a lot and fatigue could be to blame. He underwent tests but the actual explanation or a hypothesis backed by data doesn’t seem to be forthcoming.

The Europcar Case
Just before the Tour de France last year it was announced that the Europcar team was being investigated for cortisone abuse by the police. It made the headlines and TV bulletins right before the Tour. But when the case was dropped because the police found nothing the coverage was predictably disproportionate.

Pierre Rolland
All this brings us to Pierre Rolland. He’s now sucked into a polemic about his cortisol levels. L’Equipe’s print edition sets out the chronology:

  • On Saturday morning 14 teams (MPCC members and French teams) were notified they’d be tested and the team doctors were given the names of the riders to be tested
  • 42 tests were done and by the afternoon the MPCC’s doctor Armand Mégret got the results
  • One rider had insufficient cortisol levels and Dr Mégret approached Europcar
  • The team’s doctor explained that Rolland had been taking a cortisone for medical reasons
  • Regardless of the reason, Rolland’s low levels mean he is not allowed to start Stage 8 on Sunday.
  • But when the race begins, one Europcar has not started and it’s Natnael Berthane
  • Rolland abandons after 20km

Presumably phone calls were made to stop Rolland. It’s here the case takes a twist. The team claimed a slight problem with his Achilles tendon as the reason why he pulled out… but 24 hours later L’Equipe reported that he was instructed not to start but his team ignored this. If Rolland or Europcar were clearly told they could not start but they ignored it then they risk trouble for ignoring the MPCC rules. There’s a now dispute between the team and the French Federation’s doctor Armand Mégret over whether Rolland could start. Europcar manager Jean-René Bernaudeau sayed tests were done too early, too soon after breakfast and that Dr Mégret said it was ok to start. Mégret was contacted by L’Equipe and said Bernaudeau’s claims were “scandalous and inadmissible.” It means the case is growing from one about a rider’s health to the systemic issue of teams and the MPCC.

There’s also the health issue: if the team knew Rolland’s levels were low, what was he doing in the race? The answer is that if Rolland’s levels were low, they were not zero. Of the 42 riders tested the average reading was 600 nmol/L but Rolland was on 107 nmol/L and the team contested the way the way the tests were done early in the morning. The Europcar doctor Hubert Long decided that it was ok for Rolland to start because the levels were not so low and suspected the results were distorted by an early test.

What next for Rolland?
The case will rumble on but for now Rolland still needs to explain what happened. He’s taken to Facebook to explain that his levels were “low” but not “collapsed” as reported. He wrote “today my image is affected. Note that I race to win races and to be known for my values and not have fingers pointed at me” and if it’s good to see him comment, this is no firm denial. But note Rolland is one of the peloton’s few riders without an agent and if he puts something on Facebook, it’s his words and we can’t expect him to master crisis management. I’m not in the business of advising Europcar but public relations 101 says they need to get all the facts out to the media as quick as possible especially as they’re trying to sign a deal with a sponsor and this coverage is so toxic.

Conclusion
Chapeau to the MPCC for testing and the French Federation too. These tests are limited to MPCC members and the French licence holders meaning the likes of Team Sky, BMC and Radioshack are not checked. There are good reasons for cycling as a whole, under the UCI, to test for cortisone abuse. Until then let’s hope these big budget teams can afford to join the MPCC if only to have equal testing.

The problem with being rested is the suspicion of dopage. Other sports don’t even look at cortisol levels so they don’t get the negative headlines and once again the D-word is linked to cycling. Then again the sport has long had a problem with cortisone abuse and if this can be traced back for decades it remains a concern today with riders abusing prescriptions as cover for muscular injections of cortisone, itself a break of the “no-needles” policy used by the UCI.

Away from the scandal the only certainty is the tests revealed one rider who should not have been racing for health reasons. That’s a good thing. Yet many will join the dots and if this is unfair, that’s the way the game is played. A health test generates the most unhealthy suspicions and headlines. If there’s nothing to hide it’s up to Rolland and his team to explain. If he was using cortisone for medical reasons what did he take? How much? Who’s got the prescription? Can another doctor diagnose and testify the illness that required medical treatment? And so on.

Remember, if the police file was empty the newspapers and TV bulletins were not. It’s the kind of publicity that scares sponsors. Europcar need to shout if they want to be heard.

Photo: with thanks to Flickr’s jomenager.

christine June 11, 2013 at 10:55 am

Sadly, i dont believe Rolland nor his team doc. cortisol levels are highest in the morning so no real natural reason to be low if blood was drawn “early in the day”, also what about the other 41 riders tested presumably at the same time (with levels averaging 600).
His doc knew Pierre would be fit to ride (on the Sun) cause he would have known that the reason for the low endogenous cortisol was due to Pierre having taken cortisone tablets or injections- either doping or TUEs. i did wonder why no english news site reported this as it hit l’Equippe 48 hours ago but now we have more details so thank you inrng- fantastic work! shocking work europcar.

The Inner Ring June 11, 2013 at 11:11 am

Like you say the levels are highest in the morning when the body is stimulated after sleep. L’Equipe reports this too and the levels recorded show something is up.

Velonation reported it English yesterday.

sam June 11, 2013 at 11:28 am

When I looked late yday afternoon, the only English language cycling site to have reported it was Cycling Weekly – there was nothing on Velonation, Velonews or Cyclingnews

Shane June 11, 2013 at 12:47 pm

Hi Sam, the piece is here – it was up since yesterday morning. http://www.velonation.com/News/ID/14747/MPCC-doctor-Megret-denies-giving-green-light-to-Pierre-Rolland-after-irregular-cortisol-levels-detected.aspx However due to a glitch on the site, a couple of articles on the front page are ‘lost’ between the transition between the central column of newest stories and the left column of slightly older ones. It’s something that I am hoping will be fixed at some point, as it means a couple of stories are not visible on the home page. In the meantime, to see the full list of stories, people can click on the ‘news’ tab at the top (or go here http://www.velonation.com/News.aspx).

Inrng, nice analysis of the situation. Is cortisone allowed across the board by WADA, or only if it is applied topically and not injected?

Kjetil June 11, 2013 at 11:02 am

Thanks. Another fine entry.

Typo here?
“Mégret was contacted by L’Equipe and said Bernaudeau’s claimed were “scandalous and inadmissible.””
claims, I presume?

Europcar does seem to push the boundaries of the MPCC rules now and again. Professional disagreement between doctors?

The Inner Ring June 11, 2013 at 11:13 am

Fixed the typo. As for the doctor, the team manager Bernaudeau makes the point that he lets the doctor do his thing, presumably just as the doctor doesn’t advise on recruitment or race tactics. If this is the case then the doctor probably needs to be the source of the explanations.

Kjetil June 11, 2013 at 11:49 am

Seems like Bernaudeau has a loose cannon to tie down if the wants to avoid more damage to his soon without contract ship.

James Vaughan June 11, 2013 at 11:14 am

I think the MPCC doing additional tests is a good thing and should be encouraged. Sport is hard and particularly in cycling where the potential for accidents and injury are common place. Ensuring the athletes are not doing long term harm by continuing to race is a positive thing.

However, as I’ve commented here before, the MPCC (as well as WADA, the UCI etc) should be open about the testing that they do. They should publish the method by which riders are selected (saying random is one thing, but it should be a transparent process), name the riders, say which tests are being performed and publish the results (or the anomalies). A clean team, a clean rider and a clean doctor have nothing to fear from being open.

The TUC is a valid thing, athletes like anyone need medication for conditions and those should be made available. Of course riders, teams and doctors are abusing the TUC process. It’s a subtle backdoor to the use/abuse of products which would otherwise bring sanctions. However, like most of the anti-doping processes there are flaws which permit trivial abuse. How about, ensuring that all riders pre-declare TUCs at the start of an event? In event TUCs needing a second opinion by an independent physician? The TUC process is being abused, therefore the UCI and WADA need to vigorously examine the system, look for vulnerabilities in the process and implement controls to prevent exploitation.

There will always be loopholes, but working hard to test, challenge and then close them is a key anti-doping process. Ask the question ‘If I’m an athlete and I want to cheat, how would I do it?’ defeat or mitigate the answer and then ask the question again.

BC June 11, 2013 at 11:24 am

The correct course of action for both Rolland and his team would have been to withdraw him from the race – why did they nor follow the rules and their own common sense. The implications of why the low levels of cortisol could have been addressed and dealt with later.
The guy claims to have knee problems, my cynical mind would expect that to be an excuse for the use of cortisone and thus suppress natural cortisol !

Tom Gakes June 11, 2013 at 11:36 am

The team’s doctor explains than Rolland got a cortisone injection for medical reasons, an inflammation of the Achilles tendon to be specific. Although this is a valid reason to get a cortisone injection, new UCI rules say that he was not allowed to start the race as a rider who received a cortisone injection is not allowed to race for 8 days independently of cortisol levels. His team doctor should also inform the UCI about the injection. See this link for the UCI declaration of this rule: http://bit.ly/1brg00J

So even while this may not be a case of doping to enhance performance, it seems that Rolland should not have been allowed to start the race and Europcar did not only break MPCC rules, but also UCI rules. It is not up to me to decide whether this should have consequences for the rider and the team, but the team has obviously made a pretty big mistake in the way they handled this case.

DorianSalome June 11, 2013 at 12:15 pm

Well, the cortisol test is not only a health check. The basic idea behind this is of course to tackle the problem of cortisone doping.

I believe I have read the L’Equipe articles, so I’m a bit confused. I thought the test was conducted on Sunday or am I mistaken? Also I don’t remember that Rolland had been given cortisone by the team doctor and that a prescription has been produced.

Which would make the whole debate kind of obsolete, because if Rolland had been given cortisone, he wouldn’t have been allowed to ride according to MPCC rules in the first place. What’s a prescription worth that wasn’t presented to officials BEFORE any tests could be conducted?

So either Rolland’s cortisol levels were too low, or he was using cortisone (bronchitis!!), or both – in all of these cases the rider should have been withdrawn from the race.

Citing tendonitis doesn’t really help because it might have been used as an excuse for using cortisone.

And according to the MPCC the test was done at a time according to the rules (6.30-7.00 / 8.30-9.00).

Either way, Europcar have messed this up and it seems they got caught red-handed.

I’m pleased to see that these cortisol tests are indeed done and were not merely a lip-service.

What makes you so sure that Rolland wrote that message on fb himself? The way it sounded it might as well have been ghost-written.

The Inner Ring June 11, 2013 at 12:25 pm

The test was done on Saturday and the results came back from the lab in the afternoon so riders could be stopped only on Saturday.

With Rolland he’s one of the few riders not to have an agent and he prefers to handle these things himself. But that’s no guarantee. Either way he and the doctors have some explaining to do as you suggest.

Klaus June 11, 2013 at 12:52 pm

Why don’t they make a rule to the effect that if a rider is to be prescribed with a regulated substance for therapeutic reasons, the diagnosis and treatment needs to be approved by an independent doctor, for example the race doctor?

The Inner Ring June 11, 2013 at 1:26 pm

Good idea. David Millar mentioned something similar on Twitter too.

The whole of the team doctor is something I mean to write about. Are they coaches, nutritonists, nurses etc?

Robbo June 11, 2013 at 5:26 pm

Understanding that the use of cortisone is not currently banned: Is any organization made aware of a rider being prescribed a substance subject to a TUE either before or during treatment, or is the treatment only revealed if questions are raised via a test? Are the UCI or WADA kept informed of each rider’s or team’s use of medicines that would be subject to a TUE? 1) it would seem to keep people more ‘honest’, and 2) it would be interesting to know which teams and riders are perhaps chronically sick or seeking medical intervention.

“for health reasons” conjurs images of the late ’90s and hematocrit…

Alpen June 11, 2013 at 12:57 pm

It sounds like the implementation and communication pathways of the MPCC and its rules are still in their infancy and need some time to be ironed out which is completely understandable.

Thanks again to Inrng for wading through the mess and making some sense for the rest!

Klaus June 11, 2013 at 1:59 pm

Much of the focus in doping is on detection (and the ensuing controversy), whereas pre-approval of therapeutic use exemptions is a simple preventative measure that can readily be implemented, while at the same time providing objective evidence to quell any speculation that might otherwise arise.

J June 11, 2013 at 4:55 pm

I thought you had written a few weeks ago that as part of the MPCC a rider holding a TUE for cortisone was expected to not race while undergoing treatment. Is this correct or am I just misremembering?

channel_zero June 11, 2013 at 5:25 pm

Were the error rates on the test published? In other words, what are the chances the tests produced results that were not true? Most biological tests have them and the error rates vary.

I’m not defending the athlete, not at all. For me, this story speaks to the anti-doping theater of the ‘no needles’ rule. What good is it if it isn’t used to sanction riders?

I’d rather see more stories like this than more of Pat and Hein reselling the ‘cleanest peloton ever.’ It means somebody, somewhere is more serious about anti-doping and rider health than the UCI.

James June 11, 2013 at 8:31 pm

I noticed several commenters saying the UCI should require TUEs before events or should vet them in some way for validity. Well, theoretically at least, that is what they do: http://www.uci.ch/templates/UCI/UCI2/layout.asp?MenuId=MTU2ODY&LangId=1 . I assume this page is up to date (except for the now lengthened 48 hour rest period after injections).

According to this, anyone seeking a TUE must apply for it through the ADAMS system, include full documentation (presumably the prescription itself along with any tests and other info from the doctor) and then “after the UCI Therapeutic Use Exemption Committee has reviewed the application, you may be given authorization to take the needed medicine.” Now is this only a formality? Do they actually review and possibly deny anyone in practice (assuming riders are not trying to get EPO exemptions)? I don’t know.

Also, there is good information on that page about corticosteroids; things change depending on the way they are administered. If you do any kind of local injection, you are required to sit out of competition, as others mention here. Further, there is a whole list of ways of administering corticosteroids that do not require at TUE at all; the only methods that do require one are: oral, rectal and intravenous and intramuscular injection (note that these two injections do not include injections around joints or tendons).

One final somewhat unrelated note- there was a suggestion or two above that all test results and TUEs should be made public. While I appreciate the motive behind this, shouldn’t riders have some expectation of privacy? I don’t know what it is like in other countries, but at least in the US, medical information is very heavily protected by law and disclosing anything (as a doctor, healthcare company, etc) without a person’s consent can bring big fines. I’m not saying this would apply to TUEs and other things, but it does at least speak to a certain expectation of privacy.

The Inner Ring June 11, 2013 at 8:38 pm

Very informative, thanks.

On the privacy point, it’s a real issue and tactical too. Riders might have an injury but don’t want to tell the world because of the pressure. Imagine if Rolland said he had a problem, suddenly the media would be asking questions?

Nick Evans June 11, 2013 at 8:56 pm

re: privacy, sensitive personal information – including medical details – is generally more strictly protected in EU countries and Switzerland than it is in the US, which is generally a more open place than most European countries other than Scandinavia. So similar expectations should be in place. Except, of course, that the riders here will also have the explicit expectation that a positive result should not be kept private.

Doubter June 12, 2013 at 12:43 am

Forget cortisol, I want to know what the heck team skybot is on. That’s the good stuff.

Anonymous June 12, 2013 at 6:27 am

Cash. Lots of lovely cash.

Raymond Ledy June 12, 2013 at 11:10 am

There’s a whole plethora of enhancements, shall we say, that cyclists can take that are not on the banned list. This saga sits in that grey area twixt one and the other, where the media is the final arbitrator on innocence. I pray uselessly daily that other sports have the same light of inquisition shone upon them.

Will June 12, 2013 at 11:37 pm

Great post, makes clear a complex and potentially hyperbolic issue

Bikelink June 13, 2013 at 9:39 pm

The sport has a history of team doctors…doctoring things by doping. In addition, if anyones livelihood was dependent on doing ‘what was needed’ then they are often going to do just that. I’m a doctor. I like to think I’m a moral, trustworthy person (really)! However, being a doctor means you graduated from medical school, not that you are morally completely impervious. A truly “independent” doctor to validate TUEs makes sense. That means how individual riders or even teams do in the race couldn’t affect them. That pulling the plug on half the riders in a race for doping couldn’t affect them. Therefore it couldn’t be a doctor hired by the rider, the team, the race, or even the UCI. Perhaps a doctor from a list of WADA certified/approved doctors? It would help if such doctors did not do this for a majority of their income either (e.g., they are real practicing doctors who do this on the side). This is always a problem for doctors providing legal testimony…if you keep saying things people don’t like you don’t get rehired.

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