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Archive for 2014

Selling “integrative oncology” as a monograph in JNCI

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Sometimes, it’s hard not to get the feeling that my fellow bloggers at Science-Based Medicine and I are trying to hold back the tide in terms the infiltration of pseudoscience and quackery into conventional medicine, a term I like to refer to as quackademic medicine. In most cases, this infiltration occurs under the rubric of “complementary and alternative medicine” (CAM), which these days is increasingly referred to as “integrative medicine,” the better to banish any impression of inferior status implied by the name “CAM” and replace it with the implication of a happy, harmonious “integration” of the “best of both worlds.” (As I like to point out, analogies to another “best of both worlds” are hard to resist.) Of course, as my good buddy Mark Crislip has put it, the passionate protestations of CAM advocates otherwise notwithstanding, integrating cow pie with apple pie doesn’t make the cow pie better. Rather, it makes the apple pie worse.

In any case, over the last three months, Steve Novella and I published a solid commentary in Trends in Molecular Medicine decrying the testing in randomized clinical trials of, in essence, magic, while I managed to score a commentary in Nature Reviews Cancer criticizing “integrative oncology.” Pretty good, right? What do I see this month in the Journal of the National Cancer Institute (or JNCI, as we like to call it)? An entire monograph devoted to a the topic, “The Role of Integrative Oncology for Cancer Survivorship”, touting integrative oncology, of course. And where did I find out about this monograph? I found out about it from Josephine Briggs, the director of the National Center for Complementary and Alternative Medicine (NCCAM) herself, on the NCCAM blog in a post entitled “The Evidence Base for Integrative Approaches to Cancer Care“, in which she touts her perspective piece in the JNCI issue entitled “Building the Evidence Base for Integrative Approaches to Care of Cancer Survivors.” In an introductory article, Jun J. Mao and Lorenzo Cohen of the Department of Family Medicine and Community Health, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania and the University of Texas M.D. Anderson Cancer Center, respectively, line up this monograph thusly:
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Posted in: Cancer, Clinical Trials, Medical Academia

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In the Spirit of Choosing Wisely

Oh, loneliness and cheeseburgers are a dangerous mix.
- Comic Book Guy

Same can be said of viral syndromes and Thanksgiving. My brain has been in an interferon-induced haze for the last week that is not lifting anytime soon. Tell me about the rabbits, George. But no excuses. I have been reading the works of Chuck Wendig over at Terrible Minds. (Really, really like the Miriam Black books). Writers write and finish what they start and only posers use excuses for not completing their work.

Recently I attended an excellent Grand Rounds on some of the reasons doctors do what they do. Partly it is habit. We learn to a certain way of practice early in our training and it carries on into practice and it is not always best practice. Patients also learn from us and have expectations on what diagnostics or treatments they should receive, and that too it is not always the best practice.

So to educate physicians and patients, the American Board of Internal Medicine (ABIM) started the Choosing Wisely initiative. (more…)

Posted in: Acupuncture, Chiropractic, Critical Thinking, Energy Medicine, Homeopathy, Science and Medicine

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Announcement: The Society for Science-Based Medicine is co-sponsoring NECSS

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Steve is off today, so I thought it would be a good idea to use this slot for a little shameless self-promotion (of Science-Based Medicine and the Society for Science-Based Medicine, of course).

The Northeast Conference on Science & Skepticism (April 9-12, 2015 in New York City) will be bigger than ever in 2015 with fabulous presenters, exciting panels, and engaging workshops.

We’re thrilled to announce that NECSS 2015 will be co-sponsored by the Society for Science-Based Medicine and will expand to include a third full day of programming! Friday’s schedule will be curated by the team at SfSBM and features content available exclusively at NECSS 2015. Saturday and Sunday schedules will once again feature the best of science and skepticism.

NECSS weekend also includes a special evening performance on Friday, two workshop tracks on Thursday for the early-birds, our popular “Drinking Skeptically” socializers, and more!

The full NECSS speaker line up will be announced shortly, but, as always, Rationally Speaking and the Skeptics’ Guide to the Universe will record live podcasts during the conference.

We have secured discounted room rates at the Hilton Fashion District, located one block from the main conference hall. These rates are available exclusively to NECSS attendees and we will be available shortly.

Conference registration will open in December, but you can like the NECSS Facebook page or follow us on Twitter for updates.

See you in April!

Posted in: Announcements, Science and Medicine

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Product B: Here We Go Again

“Telomeres shorten each time a cell divides. In most cells, the telomeres eventually reach a critical length when the cells stop proliferating and become senescent. But, in certain cells, like sperm and egg cells, the enzyme telomerase restores telomeres to the ends of chromosomes. This telomere lengthening insures that the cells can continue to safely divide and multiply. Investigators have shown that telomerase is activated in most immortal cancer cells, since telomeres do not shorten when cancer cells divide.” — National Institute of Aging

“Telomeres shorten each time a cell divides. In most cells, the telomeres eventually reach a critical length when the cells stop proliferating and become senescent. But, in certain cells, like sperm and egg cells, the enzyme telomerase restores telomeres to the ends of chromosomes. This telomere lengthening insures that the cells can continue to safely divide and multiply. Investigators have shown that telomerase is activated in most immortal cancer cells, since telomeres do not shorten when cancer cells divide.” — National Institute of Aging

New health products are constantly appearing on the market in such numbers that I can’t hope to keep up. Product B was new to me. I was introduced to it by a doctor who said a family member was “quite enthusiastic” about its potential to “lengthen telomeres and thereby address a myriad of health issues.” Of course, I immediately asked “What exactly are they claiming Product B does?” and “Do they have evidence that it actually does what they claim?” Their website didn’t provide satisfactory answers.

Product B is described as “a powerful blend of complex botanicals and vitamins uniquely designed to offer superior telomere support for youthful aging.” It is sold as part of a multilevel marketing (MLM) scheme. Because it is classified as a dietary supplement, FDA regulations only allow them to make “structure and function” claims, so the claims are deliberately nebulous. Basically, they seem to be saying that short telomeres are bad (they cause aging and disease), telomerase is good because it makes telomeres longer, and Product B is an effective way to increase telomerase; therefore Product B prevents disease and retards aging. But these assertions are questionable, and the website doesn’t offer any credible evidence of clinical efficacy for any single health issue, much less a myriad of them. Or any evidence of safety, for that matter.

Oh, good grief! It’s sold by the Isagenix company. Talk about déjà vu! Isagenix keeps coming back to haunt me; it even generated my favorite insult ever: “Dr. Harriet Hall is a refrigerator with a head.” You can read the three articles I wrote about Isagenix here, here, and here.

If I am a refrigerator, at least I try to be a fair one. I wasn’t going to reject the claims out of hand just because Isagenix made them. I spent quite a bit of time searching the Internet for information, and I even wrote the company to ask directly for their evidence. They didn’t bother to reply.

One thing puzzled me right off the bat. Was there a Product A that I had somehow missed? Why did they name this “Product B”? That doesn’t impress me as a savvy marketing choice. Couldn’t they have thought up something catchier like “Telomiracle”? I couldn’t help wondering what the B might stand for and my mind quickly associated the words bogus, blarney, business, baloney, bunk, bullshit, blunder, basura (Spanish for garbage), barbaridad (Spanish for stupid thing), and blague (French for joke). It made me think of second choice, as in “plan B.” What does it make you think of?

Pardon the digression. It makes no difference what they call it. “A rose by any other name…” All that matters is what it is and whether it works. (more…)

Posted in: Herbs & Supplements

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Selective pressures on alternative medicine

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(Editor’s note: I was away at Skepticon over the weekend, where I gave a talk entitled “The Central Dogma of Alternative Medicine”. (When the talk’s up on YouTube, I’ll provide a link, of course.) Because of all the fun and travel delays I didn’t get a chance to turn my slides and notes into a blog post yet. Also, I’m on vacation this week. However, this gives me the opportunity to resurrect a blog post from 2007 on my not-so-super-secret other blog, because I think the concept is interesting. I even use it in a slide that shows up in many of my talks (above). I’ve updated dead links and added some text to include relevant links to posts written since. Enjoy, and I’ll definitely be back next week with original material, if not sooner, given that there are others here who might have the temerity to take part or all of this week off.)

I wish I had thought of this one, but I didn’t. However, I never let a little thing like not having thought of an idea first to stop me from discussing it (even if Steve Novella’s also discussed it), and this particular idea is definitely worth expanding upon because (1) it’s interesting and (2) it combines two of my interests, alternative medicine and evolution. I agree with parts of the idea, but it’s not without its shortcomings. Indeed, I’d very much welcome any of the evolutionary biologists who read this blog to chime in with their own ideas.

A colleague of mine, Martin Rundkvist over at Aardvarchaeology, has proposed a rather fascinating idea regarding the evolution of alternative medicine in which he argues that alternative medicine evolves according to certain selective pressures. As you may or may not know, evolution is not just for biology, but has been proposed as a mechanism in cultural memes, for example. Since alternative medicine is a cultural phenomenon, it is not unreasonable to look at such non-evidence-based medicine and hypothesize what might be the selective pressures that shape its popularity and evolution. After all, if we’re going to discourage the use of non-evidence-based medicine or even quackery, it’s helpful to understand it. We already know that alt-med terminology has evolved considerably into the current preferred term, “integrative medicine.” (See also the image above and my blog posts on this evolution here and here.)
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Posted in: Basic Science, Evolution, Science and Medicine

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Energy Drinks are Risky, Especially for Kids

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This is not for kids?

Last month I wrote a post on the causes of poor sleep in adolescents, as well as the myriad problems that can result in this high-risk population. Fortunately there is a system-wide public health measure proven to work, and now groups like the American Academy of Pediatrics are fully endorsing it. In that post, I briefly mentioned the increasing popularity of energy drinks and shots as caffeine delivery devices, and their role as both a potential cause of sleep deprivation and a means of temporarily ameliorating the effects.

I have been planning on addressing in greater detail the intentional, and unfortunately often accidental, ingestion of energy drinks in the pediatric population and the various associated risks for quite a while. What finally motivated me to get to work on this topic was the recent spate of media coverage regarding the results of a study presented this week at the American Heart Association’s Scientific Sessions 2014. The research, which involved the analysis of data obtained from the National Poison Data System for October 2010 through September 2013, supports concerns that pediatricians and other pediatric healthcare professionals have had for a very long time. Energy drinks are dangerous, particularly in young children, and a large part of the blame falls on the shoulders of manufacturers as well as the 1994 Dietary Supplement Health and Education Act (DSHEA) so frequently discussed on SBM.

Before I break down the scary numbers from the study, first a little background on energy drinks. (more…)

Posted in: Science and Medicine

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Naturopathy vs. Science: Autism

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Just when I thought I was out, they pull me back in. My blogging plan was to take a break from my series of naturopathy versus science posts, where I’ve been contrasting the advice from naturopaths against the scientific evidence. From a blogging perspective, naturopathy is a fascinating subject to scrutinize as there is seemingly no end of conditions for which naturopaths offer advice that is at odds with the scientific evidence. From a health care perspective, however, reading the advice of naturopaths is troubling. Naturopaths promote themselves as health professionals capable of providing primary care, just like medical doctors. And they’re increasingly seeking (and obtaining) physician-like privileges from governments. Naturopathy seems to be getting an easy ride from regulators, despite a lack of evidence that shows naturopathy offers anything distinctly useful or incrementally superior to science-based medicine.

Defining the scope of “naturopathic” treatment is difficult. Naturopaths offer an array of disparate health practices like homeopathy, acupuncture and herbalism that are only linked by the (now discarded) belief in vitalism – the idea we have a “life force”. From this philosophy can sometimes emerge reasonable health advice, but that has little to do with the science or the evidence. As long as it’s congruent with the naturopathic belief system, it’s acceptably “naturopathic”. In past posts I’ve looked at the naturopathic perspectives on fake diseases, infertility, prenatal vitamins, vaccinations, allergies and even scientific facts themselves. An advertisement passed to me this week promoted a naturopath who claims to treat pediatric conditions like ADHD and learning disabilities: (more…)

Posted in: Herbs & Supplements, Naturopathy, Vaccines

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Low Dose Aspirin for Primary Prevention

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From the Wikimedia Commons.

A new study published in JAMA sheds further light on a controversial question – whether or not to prescribe low-dose aspirin (81-100mg) for the primary prevention of vascular disease (strokes and heart attacks).

Primary prevention means preventing a negative medical outcome prior to the onset of disease, in this case preventing the first heart attack or stroke. Secondary prevention refers to treatments given to patients who have already had their first heart attack or stroke in order to reduce the risk of subsequent events.

The evidence strongly supports the efficacy of aspirin for the secondary prevention of both heart attacks and strokes. Aspirin has two effects which likely contribute to this protective effect. First, aspirin is an anti-platelet agent – it reduces the stickiness of platelets, which are cell fragments in the blood that clump together to stop bleeding. They can also clump together around an ulcerated cholesterol plaque on an artery, forming a thrombus, resulting in blockage or embolus (the clot traveling downstream) and causing either a heart attack or stroke.

Other anti-platelet agents, such as clopidogrel, are also effective in preventing stroke and heart attack.

Of course, platelets exist for a reason, and blocking their action increases the risk of bleeding or can make bleeding worse when it occurs. Therefore determining the optimal dose and target population are important to maximize the benefit of aspirin or other anti-platelet agent while minimizing the bleeding risk. (more…)

Posted in: Neuroscience/Mental Health, Public Health

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Recent Developments and Recurring Dilemmas in Cancer Screening: Colon, Lung, Thyroid

Cancer screening - lead time bias small

Screen detection and tumor growth rates. Cancers have different growth rates, which determine their potential to be detected by screening. Tumor A remains microscopic and undetectable by current technology (although more sensitive tests in the future might render it detectable). Tumor B eventually becomes detectable by screening (*), but its growth rate is so slow that it will not cause symptoms during the life of the individual; its detection will result in overdiagnosis. Tumor C is capable of metastasizing, but it grows slowly enough that it can be detected by screening (*); for some, this early detection will result in survival. Tumor D grows very quickly and therefore is usually not detected by screening. This will present as an interval cancer (i.e. detected clinically in the interval between screening examinations) and has a particularly poor prognosis. Note that of the four tumor types, only Tumor C has the potential to benefit from screening. Red dashed lines represent the natural history of a tumor in the absence of detection by screening. (Figure 1 from Gates, 2014).

A new stool DNA test was recently approved by the FDA for colon cancer screening. My first reaction was “Yay! I hope it’s good enough to replace all those unpleasant, expensive screening colonoscopies.” But of course, things are never that simple. I wanted to explain the new test for our readers; but before I could start writing, some other issues in cancer screening barged in and demanded to be included. They exemplify the dilemmas we face with every screening test. We have covered these issues before, but mainly in reference to mammography and prostate (PSA) screening. My article morphed into a CLT sandwich: colon, lung, and thyroid cancer screening.

The current issue of American Family Physician has a great article on cancer screening. It uses lucid graphics to illustrate lead time bias, length time bias, and overdiagnosis bias, as well the effect of varying tumor growth rates on screening success rates, all concepts that have been covered by Dr. Gorski here. Briefly, screening may do more harm than good if:

  1. It detects cancerous cells that never would have developed into invasive cancers or harmed the patient in any way;
  2. Early diagnosis and treatment decrease quality of life without reducing death rates; or
  3. The test falsely indicates cancer in patients who don’t have it or fails to indicate cancer in some who do. (more…)

Posted in: Cancer, Diagnostic tests & procedures

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