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.
Archive for Cancer
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:
“Targeted therapy.” It’s the holy grail of cancer research these days. If you listen to its most vocal proponents, it’s the path towards “personalized medicine” that improves survival with much lower toxicity. With the advent of the revolution in genomics that has transformed cancer research over the last decade, including the petabytes of sequence and gene expression data that pour out of universities and research institutes, the promise of one day being able to a patient’s tumor, determining the specific derangements in genome and gene expression that drive its uncontrolled proliferation, and finding drugs to target these abnormalities seems more tantalizingly close than ever. Indeed, it seems so close that even dubious practitioners, such as Stanislaw Burzynski, have jumped on the bandwagon, co-opting the terms used by real oncologists and real cancer researchers to sell “personalized gene-targeted cancer therapy,” which in their hands are really no more than a parody of efforts to synthesize the enormous quantity of genomic data each patient’s tumor possesses and figure out how best to take advantage of it, a “personalized genomic therapy for dummies,” if you will.
That’s not to say that there aren’t roadblocks to realizing this vision. The problems to be overcome are substantial, and I’ve discussed them multiple times before. For example, just a couple of weeks ago I discussed an example of just what it takes to apply these new genomic techniques to an individual patient. The resources required are staggering, and, more problematic, there often aren’t any single “magic bullet” molecular pathways identified that can be targeted with existing drugs. The case I discussed was a fortunate man indeed in that such a pathway was identified, but most tumors are driven by many derangements in growth control, metabolism, migration, and the other hallmarks of malignancy described by Robert Weinberg. Worse, in many cases we don’t even have drugs that can attack many of the abnormalities that drive cancer progression. Then there’s the issue of tumor heterogeneity, which comes about because cancer is as good example of a disease as I can think of in which evolution due to natural selection results in incredible differences in the cancer cells in one part of the tumor compared to other parts of the tumor or in the tumor metastases. A “targeted” therapy that targets the genetic abnormalities in one part of the cancer might well fail to target the genetic abnormalities driving another part of the tumor.
I was contemplating writing a post along the same lines as Harriet’s post about evolutionary medicine last week, but then on Sunday morning I saw an article that piqued my interest. Sorry, Harriet, my response, if I get to it, might have to wait until next week, although we could always discuss the usefulness (versus the lack thereof) of evolutionary medicine over a beer or two at The Amazing Meeting in a few days. In the meantime, this week’s topic will revisit a topic near and dear to my heart, a topic that I tend to view (sort of) in a similar way as Harriet views evolutionary medicine, namely personalized medicine or the “individualization” of treatments. It’s a topic I’ve written about at least twice before and that Brennen McKenzie wrote about just last week. In essence, we both pointed out that when it comes to “complementary and alternative medicine” (CAM) or “integrative medicine” treatments for various conditions and diseases, what CAM practitioners claim to be able to do with respect to “individualized care” is nonsense based on fantasy. Science-based medicine already provides individualized care, but it’s individualized care based on science and clinical trials, not tooth fairy science.
Serendipitously, this point was driven home over the weekend in an article by Gina Kolata in the New York Times entitled In Treatment for Leukemia, Glimpses of the Future. While the story is basically one long anecdote that shows what can be done when new genomic technologies are applied to cancer, it also shows why we are a very long way from the true “individualization” of cancer care. It also turns out that I’ve discussed the same basic story before, but here I’ll try to discuss it in a bit more detail.
A couple of months ago, a reader sent me an article that really disturbed me. In fact, I had originally been planning to write about it not long after I received it. It is, as you might imagine given my specialty and what disturbs me the most wehen I encounter quackery, a story of a cancer patient. Worse, it’s the story of a cancer patient in my neck of the woods. True, it’s not in the same country, but my cancer center is only around two or three miles from the Detroit River and the Canadian border; so it’s plenty close enough. Too close, in fact. Reading the story, in fact, I realized that it features a form of cancer quackery that, as far as my searches have been able to tell me, we haven’t covered before here at SBM, which alone makes it worth taking on, even though the story is two months old. The “cure” is called Cantron, and it is deeply rooted right here in my metropolitan area. Not only that, its siren song and false promises are attracting patients from across the boarder in Canada. Bernie Mulligan is one such patient:
Few awards in anything have the cachet and respect the Nobel Prizes in various disciplines possess. In my specialty, medicine, the Nobel Prize in Physiology or Medicine is quite properly viewed as the height of achievement. In terms of prestige, particularly in the world of science, the Nobel Prize is without peer. To win the Nobel Prize in Medicine or another scientific field, a scientist must have made a discovery considered fundamentally important to the point that it changes the way we think about one aspect of science or medicine. Winning the Nobel Prize in a scientific field instantly elevates a scientist from whatever he or she was before to the upper echelons of world science.
So how, one might ask, is it that seemingly so frequently Nobel Laureates embrace crankery or pseudoscience in their later years? They call it the Nobel Disease, and, indeed, it’s a term listed in the Skeptics’ Dictionary (where the term is attributed to me based on this post about Linus Pauling from four years ago, but I can’t claim credit for coining the term; it existed before I wrote that post) and Rational Wiki, complete with examples. What inspired me to take on this topic, dusting off some old knowledge and writings, is that we apparently have a new victim of the Nobel Disease. Well, perhaps “new” is not the right word, but he is the most recent example. I’m referring to Luc Montagnier, who with Françoise Barré-Sinoussi was awarded the Nobel Prize in Medicine for the discovery of HIV in 2008.
Unfortunately, it didn’t take Montagnier very long to devolve into crankery. Until 2009, to be precise. Since then, Montagnier has embraced concepts like DNA teleportation and ideas very much like homeopathy. And then, just last month, his journey to the dark side was complete. Yes, Luc Montagnier presented at the yearly quackfest I discussed last week, the one in which there was much enthusiasm among the attendees for a treatment that involves administering bleach enemas to autistic children. He presented at Autism One, a coup that caused much rejoicing in the antivaccine movement.
I despise cancer quacks.
I know, I know. My saying that is probably akin to saying that the sun rises in the east, water is wet, and Donald Trump’s hair resembles nothing in nature. You know, brain-meltingly obvious statements. It’s true, though. I despise cancer quacks. It doesn’t much matter to me whether the quack is a true believer or a calculating con artist, the end result is the same: People with cancer throwing their one best chance to survive away chasing pixie dust and promises of “natural” cures without the toxicity that is the unfortunate byproduct of the surgery, radiation, and chemotherapy that are the mainstays of our current armamentarium against cancer. I’m a cancer surgeon. This I cannot abide, which is part of the reason I became active promoting science-based medicine, started my other blog, and then was so eager to join up when the opportunity to join this blog presented itself four years ago.
It’s hard to blame patients, too. After all, as I’ve described so many times before, curing cancer is hard. Very hard. Cancer is complicated. Incredibly complicated. Quacks make it sound easy and simple. They postulate One True Cause of Cancer, and, as a result, often what they represent as the One True Cure for All Cancer. Faced with a life-threatening disease and the possibility of chemotherapy, surgery, and/or radiation therapy, patients are understandably frightened and, if they don’t have a scientific background, susceptible to the blandishments of quacks. That’s what happened to a patient I wrote about long ago, and that’s what happened to Kim Tinkham.
It’s also what is happening right now to a woman named Danielle, and, worse, she’s falling victim to the same cancer quack. Worse still, from my point of view, she’s blogging it.
Fear sells, and the media loves it. If it’s scary, no matter how tenuous the link or inconclusive the study, you are going to see it on the news. How many times over the years have you heard that your cell phone might give you brain cancer, even though it never turns out to be true? Once such a claim is made, however, it becomes lodged into the public’s psyche and is accepted as true, even after refutations and retractions are published (see Wakefield, Andrew).
And so it is with x-rays. The latest scare du jour, a recent study out of Yale that claims to show a correlation between dental x-rays and intracranial meningioma — the most common brain tumor and usually benign — has been enjoying widespread attention in newspapers and on the evening news. We don’t know if it will be on Dr. Oz, because we can’t bring ourselves to watch that show, but we feel the chances are good. Other alt-medders will no doubt have collective woogasms over the story and will further incite fear and mistrust into the doctor-patient relationship. In fact, the Mercola website wasted no time in weighing in:
While this study does not necessarily establish causation between dental X-rays and tumors, previous research has also implicated dental X-rays in the development of thyroid cancer, and research clearly shows this type of radiation is not harmless…
Typical alarmist fear-mongering. When has any health care professional claimed that radiation is harmless? This is not cutting edge research; Wilhelm Röntgen, the discoverer of x-rays in 1895 and winner of the Nobel Prize in 1901 for his research in the field, advocated the use of lead aprons for protection from the ionizing radiation way back when. Further, trying to lump one study linking dental x-rays to meningioma to another study linking them to thyroid cancer is taking quite the kitchen sink approach. But if there are multiple alleged possible potential theoretical adverse effects from our dental death rays, it must be true, right?
Well, not so fast. We’re dentists, and unlike many knee-jerkers, we’ve actually read the study and would like to offer a little bit of insight into this before everyone panics. In fact, with respect to Letterman, we’d like to offer our Top Three Reasons Not To Panic: