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Archive for April, 2012

Cancer care in the U.S. versus Europe: Is more necessarily better?

The U.S. is widely known to have the highest health care expenditures per capita in the world, and not just by a little, but by a lot. I’m not going to go into the reasons for this so much, other than to point out that how to rein in these costs has long been a flashpoint for debate. Indeed, most of the resistance to the Patient Protection and Affordable Care Act (PPACA), otherwise known in popular parlance as “Obamacare,” has been fueled by two things: (1) resistance to the mandate that everyone has to buy health insurance, and (2) the parts of the law designed to control the rise in health care costs. This later aspect of the PPACA has inspired cries of “Rationing!” and “Death panels!” Whenever science-based recommendations are made that suggest ways to decrease costs by reevaluating screening tests or decreasing various tests and interventions in situations where their use is not supported by scientific and clinical evidence, whether by the government or professional societies, you can count on it not being long before these cries go up, often from doctors themselves.

My perspective on this issue is that we already “ration” care. It’s just that government-controlled single payer plans and hybrid private-public universal health care plans use different criteria to ration care than our current system does. In the case of government-run health care systems, what will and will not be reimbursed is generally chosen based on evidence, politics, and cost, while in a system like the U.S. system what will and will not be reimbursed tends to be decided by insurance companies based on evidence leavened heavily with business considerations that involve appealing to the largest number of employers (who, let’s face it, are the primary customers of health insurance companies, not individuals insured by their health insurance plans). So what the debate is really about is, when boiled down to its essence, how to ration care and by how much, not whether care will be rationed. Ideally, how funding allocations are decided would be based on the best scientific evidence in a transparent fashion.

The study I’m about to discuss is anything but the best scientific evidence.
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Posted in: Cancer, Politics and Regulation, Science and the Media

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Low-Back Pain: Causes, Care, and Consequences

Low-back problems are one of the most common reasons for visits to doctors’ offices and the most common cause of disability among persons under the age of forty five. Most of the time, acute low-back pain is the result of simple strain and is a self-limiting condition that will resolve in four to six weeks, with or without treatment. But since back pain can be a forerunner of disability or a symptom reflecting serious pathology, every effort should be made to seek appropriate care that is based on a definitive diagnosis. Failure of physicians to ease the concerns of back-pain patients by explaining their problem and advising them in the care of back pain often results in dissatisfied patients who may be attracted by the approach of alternative medicine practitioners who tout a spurious quick-cure treatment based on a dubious diagnosis. Misinformation provided by such practitioners may contribute to disability by allowing progression of disease or by exaggerating the seriousness of the problem in the mind of the patient. Thus, while back pain is rarely serious, it should always be carefully evaluated to reach an accurate diagnosis and to determine if specialized care is needed. Care should be taken to inform the patient in a positive manner─to avoid unnecessary surgery as well as inappropriate or unnecessary treatment.

Something to Consider When You have Back Pain

Almost everyone will experience acute low back pain at least once during a lifetime. Much of what must be done to care for a bad back must be done by you. It would certainly help to be well informed about the causes of back pain when seeking appropriate treatment.

It goes without saying that when incapacitating back pain occurs as a result of a serious accident or injury, you should seek emergency medical care. When back pain grows progressively worse, persists unrelieved for longer than a week, or is worsened by rest, you may need the services of a specialist. Back pain that occurs for no apparent reason and does not affect movement may be a symptom referred from an internal organ. Once a diagnosis has ruled out a serious problem and it has been established that you have nonspecific or uncomplicated mechanical-type back pain, self-help measures designed to relieve your symptoms and to protect and strengthen your back may be the only treatment needed. If there is no active pathological process and your back pain lasts three months or longer, you may have a “chronic” back problem that can lead to recurring back pain, requiring ongoing vigilance and self help.

Time is the most important part of treatment for uncomplicated back pain caused by injury. It’simportant, however, to be aware of red flags indicating that back pain might be the result of something more serious that a simple strain. In the absence of red flags, imaging studies or special testing might not be indicated during the first four weeks of low back symptoms. When a red flag is present, you should not delay in reporting your symptoms to your family physician.

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Posted in: Chiropractic, General, Science and Medicine

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Systemic Enzyme Therapy

One of the recurrent themes in alternative medicine is the practice of simplifying complex medical conditions, and then offering up equally simple solutions which are positioned as still being within the realm of science. This approach allows the practitioner to ignore all of the complexity and difficulty of practicing real medicine, yet offer nostrums that, on first glance, can sound legitimate. Science-y, even.

I’ve discussed this before in non-science-based approaches to food intolerances, whether it’s using clinically useless IgG blood tests, or declaring the universal dietary enemy to be gluten. David Gorski elaborated on the same theme just a few days ago in the context of cancer treatment, contrasting the simplistic views of alternative medicine purveyors with the facts of cancer research. Cancer is stunningly complex – each of the hundreds of different variants of the disease. I’m always amazed when I speak with oncologists about how treatment regimens have been established. They describe how the results of dozens of clinical trials, led by different trial groups around the world have each contributed to establishing the current “best” regimens for each cancer: the appropriate drugs, doses, intervals and treatment intensities. Good evidence speaks all languages, and as new data emerges, practices change quickly to build upon whatever new evidence has emerged. The complexity of treatments continue to increase. Overlay the genetic and genomic complexity David described, and you get a sense of the challenges (and opportunities) cancer researchers face in order for science continue to improve outcomes for patients with cancer.

So it’s a bit of a shock when you shift your attention to the alternative medicine “literature”, where simple solutions abound. One that’s popular among patients I speak with, particularly those with European backgrounds, is the use of what are called systemic enzymes – enzymes, consumed orally, with the intent of whole-body effects. These products are not used as part of “conventional” medicine but are popular supplements recommended by alternative practitioners. I was recently asked about a product called Wobenzym N, a product with German roots which is advertised with the following claims [PDF]: (more…)

Posted in: Herbs & Supplements

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Herbal Medicine and Aristolochic Acid Nephropathy

It has been a stunning triumph of marketing and propaganda that many people believe that treatments that are “natural” are somehow magically safe and effective (an error in logic known as the naturalistic fallacy). There is now widespread belief that herbal remedies are not drugs or chemicals because they are natural. The allies in Congress of those who sell such products have even passed laws that embody this fallacy – taking herbal remedies away from FDA oversight and regulating them more like food than drugs.

The other major fallacy spread by the “natural remedy” industry is that if a product has been used for a long time (hundreds or thousands of years), then it must also be safe and effective because it has stood the test of time (this fallacy is referred to as the argument from antiquity).  This fallacy even has a specific regulatory term to invoke it – GRAS or “generally recognized as safe.” With food and food ingredients the FDA does not require evidence of safety if the ingredient is generally recognized as safe. This might make sense when referring to foods that have be eaten by humans for a long time. Although the logic is still dubious, it’s just practical – the FDA could not take upon itself the task of proving that every food eaten by humans has no significant negative health consequences. It is more a recognition of practicality than reality.

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Posted in: Herbs & Supplements

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Update: Homeopathy in Brazilian Scientific American

Last week I wrote about a regrettable piece on homeopathy that was published in Scientific American Brasil.  There have been gratifying developments. Within hours, the editor in chief of Scientific American, Mariette DiChristina, appeared in the Comments. She said that Scientific American does not condone the pseudoscience of homeopathy, that the piece clearly should not have been published, that it would never have been published if Scientific American had been consulted beforehand, and that she had complained to the responsible parties. I was very grateful for her response to my article, for her intervention, and for her willingness to speak out in support of good science.

An Apology

Lo and behold, two days later Ms. DiChristina reported that the editor of Scientific American Brasil had written a letter of apology and had published it on the website. Here is a full translation:

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Posted in: Homeopathy, Science and the Media

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Why haven’t we cured cancer yet? (Revisited): Personalized medicine versus evolution

About a year ago, I addressed what might seem to the average reader to be a very simple question: Why haven’t we cured cancer yet? As I pointed out at the time, it’s a question that I sometimes even ask myself, particularly given that cancer has touched my life. Three years ago, my mother-in-law died of a particularly nasty form of breast cancer. Even though I am a breast cancer surgeon, I still wonder why there was nothing that could save her (and there still is nothing that could have saved her, if it existed then) from a decline over several months followed by an unpleasant death. Yet, as a cancer researcher, I do understand somewhat. A couple of years ago, I wrote in depth about the complexity of cancer from a science-based viewpoint, as compared, of course, to the incredibly simplistic view that many purveyors of alternative medicine quackery promote as being The One True Cause of Cancer. As I put it at the time, shamelessly stealing from Douglas Adams: Cancer is complicated. You just won’t believe how vastly, hugely, mind-bogglingly complicated it is. I mean, you may think algebra is complicated, but that’s just peanuts to cancer.

I saw more evidence of that at the American Association for Cancer Research meeting last week. In fact, if there’s anything I’ve learned, it’s that developing personalized therapy for cancer is going to be a hell of a lot more difficult than we had ever suspected. Actually, it wasn’t just the AACR meeting that taught me this, but it’s as good a pretext as any to discuss some cool new science. I only wish it was science that pointed an obvious path forward to the development of personalized therapy. On the other hand, if it were easy then anyone could do the “personalized therapy for dummies” approach that, for example, Stanislaw Burzynski takes. Then there’s the even more ridiculously simplistic approach that certain practitioners of “complementary and alternative medicine” (CAM) take.

So why haven’t we cured cancer yet? Again? One reason that I discussed last time I covered this topic concerns a study that used the latest next generation sequencing (NGS) techniques to sequence seven aggressive and advanced prostate cancers. I described the results as these genomes looking like someone threw a miniature grenade into the nucleus of a prostate epithelial cell. In other words, these are some really messed up genomes. (I wanted to use another word to describe it, but this is a family blog—sort of, anyway.) I used this example to explain once again that cancer is not a single disease. It’s hundreds of diseases. Although there are common themes in how cells become cancerous, such as loss of responsiveness to growth signals with a resultant ability to grow unchecked, evasion of programmed cell death (apoptosis), inducing the surrounding tissue to provide a blood supply (angiogenesis), evading the immune system, and invading the blood or lymphatic systems to travel elsewhere in the body and take up shop in other organs, such as liver, lung, or bone, individual cancers acquire these necessary (to the cancer) abilities through many different mechanisms. For this reason, it’s completely ridiculous to speak of a “cure for cancer.”

It’s also the reason I expressed skepticism when Steve Novella discussed a potential universal anti-cancer drug. Ditto when the press breathlessly reports studies suggesting a “universal cancer vaccine.” While these sorts of research findings are promising, they need to be put into perspective. We’ve seen their like many times before, and various cancers are still deadly diseases. In fact, my career intersected with this sort of hype back in the 1990s, when I studied combining angiogenesis inhibitors with radiation therapy in experimental models of cancer in mice. For a period of time in the late 1990s, I lived the hype. Then reality, as it always does, brought us all down to earth. Now, 15 years later, we know that angiogenesis inhibitors, although useful, are not any sort of “magic bullet” cure for all solid tumors. Like many advances before, they have now taken their place in the armamentarium of anticancer drugs, more important than some but not as important as others.

It’s even more complicated than that.

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Posted in: Basic Science, Cancer, Evolution

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Drinking from the Fire Hose: Odds and Ends on the Gasping Oppression

I spend most of my time taking care of hospitalized patients with acute infections and issues of public health are, outside of infection control, not a high priority. Vaccinations in training were always like clean water and fresh food: their benefit was a given and I never needed to consider the benefits and subtleties of  vaccination. There is just so much time in a day and I was more concerned with AIDS, endocarditis and meningitis to worry about the ins and outs of vaccination.

One of the many benefits of writing for SBM, and being the Chair of Infection Control, is it is a stimulus to keep up on aspects of medicine that I might not otherwise pay close attention to, like vaccines. I have been far more interested in vaccines, especially influenza vaccines, since starting practice in 1990 than I ever was in the decade I spend in training.

Vaccination and the efficacy of vaccines is not as straightforward as I would have thought 30 years ago. It was give a vaccine, generate an antibody, and, viola, the patient is protected. The vagaries of the flu vaccine are even more pronounced, since response to the vaccine is variable and the population has never been vaccinated at levels, more than 90%, where herd immunity would likely kick in.

My ideal flu vaccine study, which would be both impossible and unethical, would be to vaccinate everyone West of the Mississippi and no one to the East (no coincidence that me and mine live in the West) and study the short and long term effects. Until that day, I am stuck with the hodgepodge of medical studies that look at the results of influenza vaccination and add insights into the disease.

I thought this week it would be fun to mention some interesting studies about influenza, the vaccine and flu immunity that have come out in the last 2 years. This is not meant to be anything more than a compilation of articles I thought were interesting, and the only purpose is to give a hint as to the complexities of influenza and  vaccination. (more…)

Posted in: Basic Science, Science and Medicine, Vaccines

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The “CAM” Consumer: Misled and Abused

There is a disturbing lack of protection for the consumer of “complementary and alternative” products and services. I can think of no other area of commerce where misleading, as well as out and out false, information is so regularly employed, without consequence, to entice the consumer into forking over his hard-earned cash. Nor do I know of any other manner of goods or services where giving consumers patently false information is protected by law.

Consider first the fact that nonsensical gibberish is enshrined in state law in the form of “CAM” practice acts, which give practitioners of implausible, if not wholly discredited, diagnostic methods and treatments carte blanche to ply their trades. For example, as has been discussed before on SBM, state law defines chiropractic as the detection and correction of subluxations, which, as many chiropractors themselves admit, do not exist. State practice acts define acupuncture in such pseudoscientific terms as “modulation and restoration of normal function in and between the body’s energetic and organ systems and biomechanical, metabolic and circulation functions using stimulation of selected points.”

As well, naturopathy practice acts allow “mixing and matching treatments including traditional Chinese medicine, homeopathy, herbalism, Ayurvedic medicine, applied kinesiology, anthroposophical medicine, reflexology, craniosacral therapy, Bowen Technique, and pretty much any other form of unscientific or prescientific medicine that you can imagine.” State practice acts also permit the indiscriminate use of the term “doctor” and “physician.” Scope of practice is broadly defined as “primary care.” (more…)

Posted in: Acupuncture, Chiropractic, Energy Medicine, Herbs & Supplements, Homeopathy, Legal, Naturopathy, Politics and Regulation

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Whooping Cough Epidemic

The Washington State Department of Health has released a statement stating that they are in the midst of a whooping cough epidemic, which will likely reach its highest levels in decades. So far this year there have been 640 cases, compared to 94 cases over the same time period last year. This is a dramatic increase. Whooping cough is a vaccine preventable disease, and so the resurgence of this infection raises questions about the efficacy of the vaccine program – specifically, to what extent is this increase due to vaccine refusal vs waning efficacy of the vaccine itself?

Background

Whooping cough is caused by the Bordetella pertussis bacterium (a Gram-negative, aerobic coccobacillus, for those who are interested), which produce a toxin that paralyzes respiratory cells and causes inflammation. The result begins like an ordinary upper respiratory infection (a common cold) but then develops into a severe cough which can last for weeks. The name of the disease, whooping cough, comes from the sound made by the sudden inhalation after a sustained cough. The disease can be severe at any age, but is especially pernicious in infants, in whom it can cause apnea, or brief pauses in breathing. In infants less than 1 year of age half will need to be hospitalized and 1 in 100 will die.

The pertussis bacterium was first isolated in 1906 by Belgian scientists Jules Bordet and Octave Gengou. In 1939 researchers at the Michigan Department of Public Health demonstrated the efficacy of a vaccine against Bodetella pertussis. The vaccine reduced the incidence of whooping cough from 15.1 to 2.3% and reduced the severity of the illness in those who contracted it. In 1948 the whole cell pertussis vaccine was combined with vaccines for diptheria and tetanus to make the DTP vaccine.

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Posted in: Vaccines

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Scientific American Declares Homeopathy Indispensable to Planet and Human Health

I recently received an e-mail from one of SBM’s readers in Brazil, Felipe Nogueira Barbara de Oliveira, a PhD candidate in Medical Science who holds an MS in Computer Science and is who is trying to promote critical thinking and scientific medicine in his country. He sent me a jpeg copy of a short piece that was published (in Portuguese) in the April, 2012 issue of Scientific American Brasil. He was appalled that this appeared under the aegis of Scientific American, and so was I.  He provided the translation which follows.

Warning: this is painful.

The Questioned Effectiveness of Homeopathy

Application of this technique in agriculture shows recuperation of plants and environment.

Homeopathy is known as an alternative treatment for human beings, but few people know about its utilization on animals, plants, soils, and water. This technique is the target of critiques regarding results and efficacy.  One of them is about the “placebo effect” of its remedies, which do not contain any trace of the raw material used in its preparation. To answer this criticism, a clarification is necessary: homeopathy is not related to chemistry, but to quantum physics, because it works with energy, not with chemical compounds that can be qualified and quantified. (more…)

Posted in: Homeopathy, Science and the Media

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