As part of my ongoing effort to make sure that I never run out of blogging material, I subscribe to a number of quack e-mail newsletters. In fact, sometimes I think I’ve probably overdone it. Every day, I get several notices and pleas from various wretched hives of scum and quackery, such as NaturalNews.com, Mercola.com, and various antivaccine websites. I think of it as my way of keeping my finger on the pulse of the antiscience and pseudoscience wing of medicine, but I must admit that I don’t really read them all, but they do allow me to know what the quacks are selling and what new arguments they’re coming up with without actually going to each of their websites. I can then judge by the headlines and the blurbs included in the e-mails whether I think it’s worth it to go to the website itself and, of course, whether the topic might represent fodder for a good blog post. I will admit that not all the sites I monitor are as loony as the Health Ranger’s. In fact, I monitor the blogs and websites of the National Center for Complementary and Alternative Medicine (NCCAM), various naturopath organizations, and the like in order to learn of the “respectable” arguments being used to tout various nostrums.
Sometimes—albeit rarely—I even learn about some interesting new science.
One of the most common themes (besides antivaccine hysteria, claims that diet can prevent 95% of all cancers, etc.) tends to be one of a variety of pitches for various “cures” of serious diseases like cancer and heart disease that “they” don’t want you to know about; i.e., the Kevin Trudeau gambit. Who this “they” is can range from doctors to pharmaceutical companies to universities to the government, but the central message is that someone out there doesn’t want you to know The Truth. A variation of this sort of appeal is the claim that there is a promising new therapy, a cure even, usually natural, that is languishing somewhere because it can’t be patented, because pharmaceutical companies would lose money if it were ever validated and brought into clinical use, or because it goes against current medical dogma. It doesn’t even have to be natural. After all, dichloroacetate (DCA) is not exactly “natural.” After it was shown to have promise in animal models, a pesticide salesman named Jim Tassano sold DCA bought from chemical companies to desperate cancer patients from a website that claimed to be selling it only for pets with cancer, a ruse that fooled no one. Yet the “natural treatment” crowd embraced it whole-heartedly because it looked as though sellers of DCA were sticking it to The Man.
[Editor's note: It's a holiday here in the U.S.; consequently, here is a "rerun" from my other super not-so-secret other blog. It's not a complete rerun. I've tweaked it a bit. If you don't read my other blog, it's new to you. If you do, it's partially new to you. See you all next week with brand spankin' new material. It also (Ih hope) complement's Scott's excellent post from Thursday discussing the same issue and the same paper, but from a different perspective.]
As a cancer surgeon specializing in breast cancer, I have a particularly intense dislike reserved for cancer quacks, which I have a hard time containing at times when I see instances of such quackery applied to women with breast cancer. I make no apologies. These women are, after all, the type of patients I spend all my clinical time taking care of and to whose disease my research has been directed for the last 13 years or so. That’s why I keep revisiting the topic time and time again. Unfortunately, over the years, when it comes to this topic there’s been a depressing amount of blogging material. Indeed, Scott Gavura took a bite out of this particularly rotten apple just a few days ago. Even though he handled the discussion quite well, I thought it would be worthwhile for a breast cancer clinician to take a look. Our perspectives are, after all, different, and this is an issue that, from my perpective, almost can’t be discussed too often.
One question that comes up again and again is, “What’s the harm?” Basically, this question boils down to asking what, specifically, is the downside of choosing quackery over science-based medicine. In the case of breast cancer, the answer is: plenty. The price of foregoing effective therapy can be death; that almost goes without saying. In fact, it can be a horrific and painful death. It is, after all, cancer that we’re talking about. Aside from that, however, the question frequently comes up just how much a woman decreases her odds of survival by avoiding conventional therapy and choosing quackery. It’s actually a pretty hard question to answer. The reason is simple. It’s a very difficult topic to study because we as physicians have ethics. We can’t do a randomized trial assigning women to treatment or no treatment, treatment or quacke treatment, and then see which group lives longer and by how much. If a person can’t see how unethical that would be without my having to explain it, that person is probably beyond explanations. (As an aside, I can’t help but point out that a randomized trial of not vaccinating versus vaccinating is unethical for exactly the same reason; physicians can’t knowingly assign subjects to a group where he knows they will suffer harm. There has to be clinical equipoise.) There’s no doubt that foregoing effective treatment causes great harm.
What a wonderful world it would be if cancer patients could extend their survival time by mobilizing their immune systems by eating the right foods, practicing yoga, and venting their emotions in a support group. The idea that patients can enlist their immune systems to fight the progression of cancer is deeply entrenched in psychosomatic medicine and the imagination of the lay public, and evidence to the contrary has been sometimes bitterly resisted. Of course, cancer patients can use psychological techniques to relieve stress or find emotional relief in support groups and thereby improve the quality of their lives. But the prospect of being able to improve the quality of life pales in comparison to the promise of being able actually to extend life.
The hope that psychosocial intervention extends lives attracts philanthropic contributions to cancer centers and justifies research programs to determine just how psychological processes affect cancer. It is a lot easier to obtain funding if we promise to slow progression of cancer than if we merely claim to offer patients solace and support or to be study ways to reduce stress and improve emotional well-being.
No mechanism by which the mind can alter the course of cancer has been convincingly demonstrated. But the jury was still out until the late 2000s, when well-resourced, carefully designed trials — with survival as the primary endpoint — repeatedly failed to show that psychological interventions were effective. My colleagues and I asked at the 2006 European Health Psychology Conference whether we could “Bury the Idea…” that psychotherapy could extend lives of cancer patients, and this was followed by our systematic review of the available data, “The Conflict Between Hope and Evidence.” Investigators who had undertaken ambitious, well-designed trials to test the efficacy of psychosocial interventions echoed with “Letting Go of Hope” and “Time to Move on.” For some of us, to make claims in earshot of cancer patients that we could extend their lives with psychotherapy was perpetuating a cruel hoax.
One of the points I’ve tried to emphasize through my contributions to Science-Based Medicine is that every treatment decision requires an evaluation of risks and benefits. No treatment is without some sort of risk. And a decision to decline treatment has its own risks. One of the challenges that I confront regularly as a pharmacist is helping patients understand a medication’s expected long-term benefits against the risks and side effects of treatment. This dialogue is most challenging with symptomless conditions like high blood pressure, where patients face the prospect of immediate side effects against the potential for long-term benefit. One’s willingness to accept side effects is influenced, in part, by and understanding of, and belief in, the overall goals of therapy. Side effects from blood-pressure medications can be unpleasant. But weighed against the reduced risk of catastrophic events like strokes, drug therapy may be more acceptable. Willingness to accept these tradeoffs varies dramatically by disease, and are strongly influenced by patient-specific factors. In general, the more serious the illness, the greater the willingness to accept the risks of treatment.
As I’ve described before, consumers may have completely different risk perspectives when it comes to drug therapies and (so-called) complementary and alternative medicine (CAM). For some, there is a clear delineation between the two: drugs are artificial, harsh, and dangerous. Supplements, herbs and anything deemed “alternative”, however, are natural, safe, and effective. When we talk about drugs, we use scientific terms – discussing the probability of effectiveness or harm, and describing both. With CAM, no tentativeness or balance may be used. Specific treatment claims may not be backed up by any supporting evidence at all. On several occasions patients with serious medical conditions have told me that they are refusing all drug treatments, describing them as ineffective or too toxic. Many are attracted to the the simple promises of CAM, instead. Now I’m not arguing that drug treatment is always necessary for ever illness. For some conditions where lifestyle changes can obviate the need for drug treatments, declining treatment this may be a reasonable approach – it’s a kick in the pants to improve one’s lifestyle. Saying “no” may also be reasonable where the benefits from treatment are expected to be modest, yet the adverse effects from treatments are substantial. These scenarios are not uncommon in the palliative care setting. But in some circumstances, there’s a clear medical requirement for drug treatment – yet treatment is declined. This approach is particularly frustrating in situations where patients face very serious illnesses that are potentially curable. This week is the World Cancer Congress in Montreal and on Monday there were calls for patients to beware of fake cancer cures, ranging from laetrile, to coffee enemas, to juicing, and mistletoe. What are the consequences of using alternative treatments, instead of science-based care, for cancer? There are several studies and a recent publication that can help answer that question. (more…)
There is something in molecular biology and genetics known as the “central dogma.” I must admit, I’ve always hated the use of the word “dogma” associated with science, but no less a luminary than Francis Crick first stated it in 1958, and it has been restated over the years in various ways. Perhaps my favorite version of the central dogma was succinctly stated by Marshall Nirenberg, who said, “DNA makes RNA makes protein,” which about sums up all of molecular biology in five words. Or at least it did until the last ten or twenty years, when we’ve been finding exceptions to this dogma.
I don’t want to dwell on the central dogma. As I’ve said, I loathe the use of the term “dogma” to describe anything in science, although a discussion of the central dogma and its exceptions might make for a decent post one day. What brought the central dogma to mind is a series of articles I saw recently in ONCOLOGY: Perspectives on Best Practices that let me to ponder the question: What is the “central dogma” of “alternative medicine”? I realize that alt-med is an unwieldy gmish of ideas that range from the semi-plausible but unproven to the completely ridiculous (i.e., homeopathy or reiki), but after reading these articles and thinking about it, I do believe that there is in actuality a “central dogma” of alternative medicine. I also believe that it is entirely appropriate to call it a “dogma” in this situation, because it is far more a matter of faith than it is of science. Moreover, the more that quackademic medicine infiltrates academic medicine, the more this “central dogma” has infiltrated academic medicine with it. Indeed, as you will see, when this central dogma is questioned, even by someone sympathetic to “complementary and alternative medicine” (CAM; i.e., “complementing” medicine with quackery) or “integrative medicine” (i.e., the “integration” of pseudoscientific medicine with medicine).
The issue of PSA screening has been in the news lately. For instance, an article in USA Today reported the latest recommendations of the US Preventive Services Task Force (USPSTF): doctors should no longer offer the PSA screening test to healthy men, because the associated risks are greater than the benefits. The story was accurate and explained the reasons for that recommendation. The comments on the article were almost uniformly negative. Readers rejected the scientific evidence and recounted stories of how PSA screening saved their lives.
It’s not surprising that the public fails to understand the issue. It’s complicated and it’s counterintuitive. We know screening detects cancers in an early stage when they are more amenable to treatment. Common sense tells us if there is a cancer present, it’s good to know about it and treat it. Unfortunately, common sense is wrong. Large numbers of men are being harmed by over-diagnosis and unnecessary treatment, and surgery may not offer any advantage over watchful waiting. (more…)
Every so often I get requests to be interviewed on the radio about skeptical topics. Now, why anyone would ever want to interview me, who knows? But they do, and when I can manage to accommodate reporters or interviewers, I do. Last week, I was interviewed on Uprising Radio, in which I discussed alternative medicine (particularly the Gerson therapy for cancer). My segment is around 10 or 15 minutes, and I invite SBM readers to take a listen. I’m afraid I might have been a bit “strident” in my dismissal of various bits of quackery for some. Whether I was too “strident” or not, the interview request came about in response to another radio personality on the same radio station shilling for the Gerson therapy, which reminds me. Perhaps I should revisit Max Gerson; for some reason there appears to be a flurry of promotion of that hoary old quackery. Stay tuned on Monday to see if that’s what I decide to blog about.
One issue that keeps coming up time and time again for me is the issue of screening for cancer. Because I’m primarily a breast cancer surgeon in my clinical life, that means mammography, although many of the same issues come up time and time again in discussions of using prostate-specific antigen (PSA) screening for prostate cancer. Over time, my position regarding how to screen and when to screen has vacillated—er, um, evolved, yeah, that’s it—in response to new evidence, although the core, including my conclusion that women should definitely be screened beginning at age 50 and that it’s probably also a good idea to begin at age 40 but less frequently during that decade, has never changed. What does change is how strongly I feel about screening before 50.
My changes in emphasis and conclusions regarding screening mammography derive from my reading of the latest scientific and clinical evidence, but it’s more than just evidence that is in play here. Mammography, perhaps more than screening for any disease, is affected by more than just science. Policies regarding mammographic screening are also based on value judgments, politics, and awareness and advocacy campaigns going back decades. To some extent, this is true of many common diseases (i.e., that whether and how to screen for them are about more than just science), but in breast cancer arguably these issues are more intense. Add to that the seemingly eternal conflict between science and medicine communication, in which a simple message, repeated over and over, is required to get through, versus the messy science that tells us that the benefits of mammography are confounded by issues such as lead time and length bias that make it difficult indeed to tell if mammography—or any screening test for cancer, for that matter—saves lives and, if it does, how many. Part of the problem is that mammography tends to detect preferentially the very tumors that are less likely to be deadly, and it’s not surprising that periodically what I like to call the “mammography wars” heat up. This is not a new issue, but rather a controversy that flares up periodically. Usually this is a good thing.
And these wars just just heated up a little bit again late last week.
My science writing covers diverse topics but increasingly concerns two intertwined themes in cancer and psychology. First, I bring evidence to bear against an exaggerated role for psychological factors in cancer, as well as against claims that the cancer experience is a mental health issue for which many patients require specialty mental health interventions. Second, I explore unnoticed social and organizational influences and publishing practices, which limit evaluation of the best evidence for theories and practices claiming to be evidence based, especially those recommended (and even mandated) by professional organizations and accrediting bodies.
I benefit from a great set of international collaborators, and my colleagues and I have repeatedly debunked claims that psychological interventions increase the survival time of cancer patients by improving their immune systems. Wally Sampson and Bernie Fox provided important inspiration for these efforts. A key source of such claims is the classic Lancet study by David Spiegel, which I will dissect in a later post for ScienceBasedMedicine.org (for now, see our published critique of Spiegel).
Dying of cancer can be a horrible way to go, but as a cancer specialist I sometimes forget that there are diseases that are equally, if not more, horrible. One that always comes to mind is amyotropic lateral sclerosis (ALS), more commonly known as Lou Gehrig’s disease. It is a motor neuron disease whose clinical course is characterized by progressive weakness, muscle atrophy and spasticity, with ultimate progression to respiratory muscles leading to difficulty breathing and speaking (dysarthria) and to the muscles controlling swallowing. The rate of clinical course is variable, often beginning with muscle twitching in an arm or a leg or slurring of speech. Ultimately, however, ALS progresses to the loss of ability to move, speak, eat, or breathe. The most common cause of death is from respiratory failure, usually within three to five years after diagnosis, although there is the occasional outlier with a less malignant form of the disease with a slower course of progression who can live a long time, such as Steven Hawking.
In other words, ALS is a lot like cancer in some ways. It is a progressive, fatal disease that usually kills within a few years at most. On the other hand, it is different from cancer in that, at least for many cancers we actually do have effective treatments that prolong life, in some cases indefinitely. In contrast the most effective treatment we currently have for ALS is a drug (riluzole) that is not particularly effective—it prolongs life by months—and can be best described as better than nothing, but not by a whole lot. So it is not surprising that ALS patients, like cancer patients, become desperate and willing to try anything. This is completely understandable, but sometimes this desperation leads to activities that are far more likely to do harm than good. I was reminded of this when I came across a post in the antivaccine propaganda blog, Age of Autism, referring to an article in The Scientist entitled Medical Mavericks. The fortuitous posting of this story, which was apparently designed to try to show that it’s not as crazy as critics have said to be treating autistic children with “Miracle Mineral Solution” (MMS) (which is a bleach) given that the introduction explicitly mentioned Kerri Rivera and the patient described in the article used sodium chlorite to treat his ALS, provided me the opening to discuss a group whose existence and advocacy brings up a complex tangle of issues that boil down to questions of how far patient autonomy should be allowed to go. I’m referring to a company, PatientsLikeMe, which describes itself thusly: