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Archive for Cancer

Mouse “avatars”: New predictors of response to chemotherapy?

Over the years, I’ve written a lot about “personalized medicine, mainly in the context of how the breakthroughs in genomic medicine and data pouring in from the Cancer Genome Atlas is providing the raw information necessary for developing truly personalized cancer therapy. The problem, of course, is analyzing it and figuring out how to apply it. Another problem, of course, is developing the necessary targeted drugs to attack the pathways that are identified as being dysregulated in cancer cells. Oh, and there’s that pesky evolution of resistance to antitumor therapies. Indeed, most recently, the Cancer Genome Atlas is bearing fruit in breast cancer (a study that I’ve been meaning to blog about).

One problem with modeling the pathways based on next generation sequencing data and expression profiling is testing whether therapies predicted to work from these analyses actually do work without actually testing potentially toxic drugs on patients. Cell culture is notoriously unreliable as a predictor. However, there is another way that’s intriguing. Unfortunately, as intriguing as it is, it has numerous problems, and, unfortunately, it’s being prematurely marketed to patients. Although I had heard of this technique as a research tool before, I learned about its marketing to patients when I came across an article by Andrew Pollack in the New York Times entitled Seeking Cures, Patients Enlist Mice Stand-Ins. Basically, it’s about a trend in science and among patients to use custom, “personalized’ mouse xenograft models in order to do “personalized” therapy:
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Posted in: Basic Science, Cancer, Clinical Trials

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Antivaccine versus anti-GMO: Different goals, same methods

Countering ideologically motivated bad science, pseudoscience, misinformation, and lies is one of the main purposes of this blog. Specifically, we try to combat such misinformation in medicine; elsewhere Steve and I, as well as some of our other “partners in crime” combat other forms of pseudoscience. During the nearly five year existence of this blog, we’ve covered a lot of topics in medicine that tend to be prone to pseudoscience and quackery. Oddly enough, there’s one topic that we haven’t really written much about at all, and that’s genetically modified organisms (GMOs). GMOs, as you know, are proliferating, and it’s quite worth discussing the potential and risks of this new technology, just as it is worthwhile to discuss the potential benefits versus the risks of any new technology that can impact our health, not to mention the health of the planet. Unfortunately, GMOs have become a huge political issue, and, I would argue, they have become just as prone to pseudoscience, misinformation, and bad science as vaccines, with a radical group of anti-GMO activists who are as anti-science as any antivaccinationist or quack.

Leave it to that quackery promoter to rule all quackery promoters, Mike Adams, to give me just the opportunity to show you what I mean. Over the last couple of weeks, Mike has been in a fine lather about GMOs, with multiple posts with titles such as The GMO debate is over; GM crops must be immediately outlawed; Monsanto halted from threatening humanity and The evil of Monsanto and GMOs explained: Bad technology, endless greed and the destruction of humanity. In other words, it’s a series of post with Adams’ typical hyperbole. If you were to believe him, GMOs are the product of a plot by Satan, Monsanto, big pharma, and the government, and he’s not sure which one of these is the most evil of the bunch.
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Posted in: Cancer, Genetically modified organisms (GMOs), Politics and Regulation, Public Health

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Frightening Breast Cancer Patients with Bad Science

No Time to Waste: Avoidant Coping Style Scrambles Circadian Rhythms in Breast Cancer Patients, warned the headline of an article in Clinical Psychiatry News. The article went on to claim

Even in the earliest days following a diagnosis of breast cancer, maladaptive coping styles are associated with a disruption in circadian rhythms –which are proven in metastatic disease to be a prognostic indicator of mortality. The surprising finding… holds potentially profound implications for the timing and tailoring of psychosocial interventions in newly diagnosed patients.

And it invoked psychoneuroimmunology for an authoritative sounding warning to breast cancer patients:

The fact that circadian disruption was significant in a subset of patients a mean 19 [sic] days after diagnosis suggests that there may be no time to waste in identifying and treating potentially maladaptive coping responses that could impact not only their adjustment, but also their prognosis.

Women who are diagnosed with breast cancer, enroll yourself immediately in a stress reduction program or support group, if you want to stem the progression of your disease and prolong your life! If you have metastatic disease, maybe you can blame your “maladaptive coping,” your inept handling of the days and weeks immediately after your diagnosis. Such frightening messages to women who are vulnerable because they have just received their diagnosis should require high standards before being released. This article reeks of hype and distortion, starting with its emotional title, No Time to Waste and “Scrambles Circadian Rhythms,” continuing with claims of “profound implications for the timing of psychosocial interventions,” and ending with an exhortation to breast cancer patients that “early breast cancer patients certainly warrant paying closer attention to coping from Day 1.”

The issue is not just skewered science, because  the article contains information that is easily misunderstood without a proper context. Breast cancer patients are urged to take get psychosocial intervention under the threat that if they do not, they are missing an opportunity to control the progression of their disease. This is an example of the irresponsible nonsense that I have been complaining in the past two blogs. There is simply no evidence that psychological interventions can slow progression of cancer or extend life. Claims to the contrary serve to burden cancer patients with an unrealistic responsibility for the outcome of their medical condition. Patients who experience progression to a terminal condition are provided with an irrational sense that they are to blame because they did not take the right steps, namely avail themselves of effective psychological interventions. This article implies that breast cancer patients with an unfavorable course have brought it on themselves by getting too stressed out.

It’s not clear whether journalist Betsy Bates Freed, PsyD. actually interviewed the authors of the study on which the story is based. Media coverage often offers direct quotes that appear to have been obtained directly from authors when they actually come from the scientific article.  In this particular case, Freed provides a highly speculative direct quote that “circadian cycles regulate tumor growth” as if it came directly from the mouth of the lead author of the study. For the record, there is some evidence of an association between circadian rhythms and progression of metastatic breast cancer, but it is not clear that it is causal or  affects”regulation” or in what direction any causal arrows run. Importantly, such findings have not been replicated with early breast cancer patients.

Clinical Psychiatry News is not some dubious CAM website, but an Elsevier published monthly newspaper with an advisory editorial board with recognizable scientist and clinician psychiatrists. It has largely free web access because of pharmaceutical company support. One has to question what editorial control over content is exerted before releasing articles like No Time to Waste.
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Posted in: Cancer, Neuroscience/Mental Health

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Is shameless self-promotion of your science a good idea?

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.
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Posted in: Basic Science, Cancer, Clinical Trials

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Alternative medicine use and breast cancer (2012 update)

[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.
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Posted in: Cancer, Clinical Trials, Health Fraud

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Questioning Whether Psychotherapy and Support Groups Extend the Lives of Cancer Patients

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.

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Posted in: Cancer, Science and Medicine

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Rejecting cancer treatment: What are the consequences?

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…)

Posted in: Cancer, Herbs & Supplements

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The “central dogma” of alternative/complementary/integrative medicine

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).
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Posted in: Cancer, Neuroscience/Mental Health, Science and Medicine

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Prostate Cancer Dilemmas: To Test or Not to Test, To Cut or Not to Cut

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…)

Posted in: Cancer

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Dr. Gorski pontificates about the Gerson Therapy on Uprising Radio

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. :-)

Posted in: Cancer, Nutrition

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