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Chemotherapy doesn’t work? Not so fast… (A lesson from history)

If there’s one medical treatment that proponents of “alternative medicine” love to hate, it’s chemotherapy. Rants against “poisoning” are a regular staple on “alternative health” websites, usually coupled with insinuations or outright accusations that the only reason oncologists administer chemotherapy is because of the “cancer industrial complex” in which big pharma profits massively from selling chemotherapeutic agents and oncologists and hospitals profit massively from administering them. Indeed, I’ve lost track of the number of such rants I’ve deconstructed over the years. Usually, they boil down to two claims: (1) that chemotherapy doesn’t work against cancer (or, as I’ve called it before, the “2% gambit“) and (2) that the only reason it’s given is because doctors are brainwashed in medical school or because of the profit motive or, of course, because of a combination of the two. Of course, the 2% gambit is based on a fallacious cherry picking of data and confusing primary versus adjuvant chemotherapy, and chemotherapy does actually work rather well for many malignancies, but none of this stops the flow of misinformation.

Misinformation and demonization aside, it is also important to realize that the term “chemotherapy,” which was originally coined by German chemist Paul Ehrlich, was originally intended to mean the use of chemicals to treat disease. By this definition, virtually any drug is “chemotherapy,” including antibiotics. Indeed, one could argue that by this expansive definition, even the herbal remedies that some alternative medicine practitioners like to use to treat cancer would be chemotherapy for the simple reason that they contain chemicals and are being used to treat disease. Granted, the expansive definition evolved over the years, and these days the term “chemotherapy” is rarely used to describe anything other than the cytotoxic chemotherapy of cancer that in the popular mind causes so many horrific side effects. But in reality virtually any drug used to treat cancer is chemotherapy, which is why I like to point out to fans of Stanislaw Burzynski that his antineoplastons, if they actually worked against cancer, would be rightly considered chemotherapy, every bit as much as cyclophosphamide, 5-fluorouracil, and other common chemotherapeutics.

Chemotherapy, not surprisingly, is easy to demonize. There are few treatments that cause such odious side effects, and when taken to its fullest extreme, such as complete ablation of a cancer patient’s bone marrow in preparation for a bone marrow transplant, chemotherapy can be brutal. It’s also true that for advanced solid malignancies, it only tends to produce palliation or a prolongation in survival, not a cure, and people with cancer want a cure. Palliation just isn’t that appealing, for obvious reasons. When people think of chemotherapy, they think of hair falling out, nausea and vomiting, fatigue, and death. Since chemotherapy is often given for more advanced malignancies, it’s sometimes hard to tell how many of these symptoms (other than the hair loss) are due to the cancer and how much they are due to side effects of the chemotherapy, and many people incorrectly blame chemotherapy for the deaths of their loved ones with cancer. Also, because, like radiation therapy, chemotherapy is often given in the adjuvant setting (i.e., in addition to curative surgery in order to decrease the risk of recurrence and death), it’s very easy to produce stories in which people with cancer refuse chemotherapy and/or radiation therapy after surgery and attribute their survival not to the conventional therapy (surgery) but to whatever quackery they chose to use. When used in early stage cancer, although its relative efficacy can seem large, for example a 30% decrease in the risk of dying, if the risk of dying of cancer is only 10% to begin with, that’s only a 3% survival benefit on an absolute basis.

I’ve made it a habit of discussing many of these alternative cancer cure anecdotes, such as one about Chris Wark that I did just a couple of weeks ago. It’s a theme of mine that goes back to the very beginning of this blog. Sometimes little or no quackery is involved, but rather patients are pushed away from chemotherapy by major news outlets publishing irresponsible news stories that offer misguided justifications for refusing chemotherapy, making treatment sound as though it will irrevocably destroy lives. In reality, the use of alternative medicine instead of effective treatment for cancer is, where it’s been studied, is always associated much poorer survival, even in pancreatic cancer, for which conventional treatments don’t do so well. Still, among the treatments in the “cut, poison, burn” terminology that believers in alternative medicine like to use to describe conventional cancer therapy, it is the “poison” that causes the most fear and is most viciously demonized in the alt-med “literature.”

It’s for those reasons that I thought that now would be a good time to do a post on the history of chemotherapy by Vincent DeVita (one of the pioneers of chemotherapy) and Edward Chu. It’s also a good time because I came across an article from about five years ago that describes this history quite well. There’s much to be learned there, and this history also explains some of the quotes of scientists often trotted out in an effort to attack chemotherapy.

The early days

For centuries, for solid tumors like breast cancer and colon cancer at least, the only “cure” was surgery. Moreover, because there was no adjuvant therapy, these surgical cures were often radical, because if the tumor recurred after surgery there was close to zero chance of salvaging the patient’s life. In addition, because there were no screening tests, most cancers were not discovered until they were relatively advanced; it was rare back then to find a breast cancer less than 2 cm in diameter. One example that I like to point to is that of William Stewart Halsted, the American surgeon who now stands as almost a god of surgery. In the late 1800s, Halsted developed the radical mastectomy, a procedure that involved taking not only the breast, but the underlying pectoralis major muscle, as well as all the axillary lymph nodes (under the arm). This procedure produced survival rates considerably higher than what were previously achieved at the time, and it relatively rapidly became the standard of care for around 80 years. (Unfortunately, that was probably about 20-30 years longer than it should have.) DeVita describes it thusly:

Surgery and radiotherapy dominated the field of cancer therapy into the 1960s until it became clear that cure rates after ever more radical local treatments had plateaued at about 33% due to the presence of heretofore-unappreciated micrometastases and new data showed that combination chemotherapy could cure patients with various advanced cancers. The latter observation opened up the opportunity to apply drugs in conjunction with surgery and/or radiation treatments to deal with the issue of micrometastases, initially in breast cancer patients, and the field of adjuvant chemotherapy was born. Combined modality treatment, the tailoring of each of the three modalities so their antitumor effect could be maximized with minimal toxicity to normal tissues, then became standard clinical practice.

As the 20th century dawned (and for quite some time thereafter), there really was no effective treatment for cancer except for surgery, which limited cancer treatments to tumors that could be excised and left people with hematological malignancies (leukemias and lymphomas) pretty much out of luck. Leukemias and lymphomas were treated mainly with arsenic, which didn’t actually work very well, if at all; they were thus generally considered to be chronic, incurable diseases.

The first major advance that helped with the development of chemotherapy as we know it today occurred in the 1910s, when George Clowes of the Roswell Park Memorial Institute developed the first transplantable rodent tumor systems. This advance allowed the testing of compounds in animal models before trying them in humans. At the time, tissue culture techniques were in their infancy, having only just been described a few years before, and would not become commonplace in laboratories for another three or four decades. Early systems included sarcomas and Erlich’s ascites tumor. These were all induced by carcinogens in mice and could be transplanted from mouse to mouse.

Decades passed, and the development of chemotherapy didn’t really go anywhere until the 1930s, when, as DeVita describes:

It was Murray Shear, at the Office of Cancer Investigations of the USPHS, a program that was later combined in 1937 with the NIH Laboratory of Pharmacology to become the National Cancer Institute (NCI), who in 1935 set up the most organized program that would became a model for cancer drug screening ( 7). Shear’s program was the first to test a broad array of compounds, including natural products, and had both interinstitutional and international collaborations. He ultimately screened over 3,000 compounds using the murine S37 as his model system. However, because only two drugs ever made it to clinical trials and were eventually dropped because of unacceptable toxicity, the program was dissolved in 1953 just as discussions began about establishing an organized national effort in drug screening. This failure was in part due to the antipathy toward the testing of drugs to treat cancer but also to a lack of information and experience on how to test potentially toxic chemicals in humans.

The failure of this drug screening initiative is part of what contributed to the pessimism with respect to chemotherapy and cancer that developed in the 1950s. Prior, in the 1940s, there had been a great deal of enthusiasm for chemotherapy based on the breakthroughs of Alfred Gilman and Louis Goodman, who tested the effects of nitrogen mustards on lymphoma based on observations that an accidental spill of sulfur mustards on troops from a bombed ship in Bari Harbor, Italy, in WWII had led to the observation that the bone marrow and lymph nodes were markedly depleted in men exposed to the mustard gas. Experiments in mice bearing a transplanted lymphoid tumor with nitrogen mustard resulted in marked regression, which led Goodman and Gilman ask Gustaf Lindskog, a thoracic surgeon, to administer nitrogen mustard to a patient with non–Hodgkin’s lymphoma and severe airway obstruction. The tumor regressed, and the same results were seen in several other patients treated this way. Publication of these results in 1946 led to widespread enthusiasm for the use of drugs related to the chemicals in nitrogen mustard, such as chlorambucil and cyclophosphamide, the latter of which is still commonly used for breast cancer and several other cancers today.

Here’s where the optimism turned sour:

The use of nitrogen mustard for lymphomas spread rapidly throughout the United States after the publication of the Lindskog article in 1946. If one reads the literature of the time, there was a real sense of excitement that perhaps drugs could cure patients with cancer ( 19). Unfortunately, remissions turned out to be brief and incomplete, and this realization then created an air of pessimism that pervaded the subsequent literature of the 1950s. A cadre of academic physicians, led by the famous hematologist William Dameshek, who having seen apparent success turn to failure could never again be persuaded that cancer was curable by drugs (20), became harsh critics of a national drug development program and the effort to prove that drugs could cure advanced cancers.

And it is here where many of the anti-chemotherapy quotes by reputable scientists and physicians originate, albeit often in exaggerated forms. For instance, one of the most famous of these statements is from a man named Hardin Jones, who is quoted as saying, “My studies have proved conclusively that untreated cancer victims actually live up to four times longer than treated individuals.” (Indeed, if you Google Hardin Jones’ name and this statement—or just his name—you will find this quote cited in many different contexts. Frequently articles quoting Jones on these issues will claim that he published these statistics in his article in Transactions, New York Academy of Science, series 2, v. 18, n.3, p.322. As our frequent commenter Peter Moran has pointed out, however, this particular study dates back to 1956 and says no such thing.

There’s no doubt, however, that Jones had a dim view of cancer treatments of his day, but he was not alone. Five or six decades ago, after the hope of the late 1940s that using alkylating agents would cure many cancers had been crushed and improvements in survival from cancer had been shown to be frustratingly elusive, there were a lot of cancer doctors who were despairing that cancer could ever be cured with chemotherapy. Interestingly, Jones used his data to build a statistical model proposing that “…the death rate for all kinds of cancer remains nearly fixed from the moment when cancer is identified…” That sounds a lot like lead time bias. Jones was, however, somewhat prescient in proposing that the biology of the tumor is arguably the prime determinant of survival, even with treatment. In any case, I tend to agree with Dr. Moran that Jones’ pessimistic view was a product of his times.

This pessimism continued into the 1960s. Indeed, one of the more interesting aspects of DeVita’s article is a series of anecdotes about how dimly the medical profession viewed chemotherapy in the 1960s and how skeptical most doctors were that any cancer would ever be cured with chemotherapy. At the time, there was no specialty known as medical oncology, and doctors who administered chemotherapy at hospitals were viewed as “underachievers, at best.” As DeVita describes, very respected physicians and chairs of departments viewed chemotherapists as the “lunatic fringe.” Louis K. Alpert, who had published one of the earliest reports using nitrogen mustards to treat lymphoma was routinely referred to by the house staff and the faculty as “Louis the Hawk and his poisons.” Here is more evidence of the low esteem with which doctors administering chemotherapy for cancer were viewed at the time:

At Yale, the first institution to test chemotherapy in humans in the modern era, the chemotherapist Paul Calabresi, a distinguished professor and founding father in the field, was forced to leave because he was involved in too much early testing of new anticancer drugs, an exercise as unpopular with the faculty and house staff at Yale as it was at Columbia.

At the Clinical Center of the NCI, where so many of the early breakthroughs with chemotherapy occurred, the well-known hematologist George Brecher, who read all the bone marrow slides of the leukemic patients, routinely referred to the Leukemia Service as the “butcher shop” at rounds.

And these are only the stories that can be told. It took plain old courage to be a chemotherapist in the 1960s and certainly the courage of the conviction that cancer would eventually succumb to drugs. Clearly, proof was necessary, and that proof would come in the form of the cure of patients with childhood acute leukemia and in adults with advanced Hodgkin’s disease.

It took the success of studies like the ones described in detail by DeVita to start to change the tide. For instance, new protocols for Hodgkin’s lymphoma increased the complete remission rate from near zero to 80%, with 60% of patients with advanced Hodgkin’s disease who attained a complete remission never relapsing. Follow-up is now well-beyond 40 years. By 1970, Hodgkin’s disease went from a death sentence to being viewed as largely curable with drugs, the first adult malignancy cured by chemotherapy. Add to this the amazing progress being made in childhood cancers at the time, and the tide was turning. Successes in hematological malignancies piled on successes, and the principle that some cancers could be cured with drugs became accepted. What amazes me is that this acceptance didn’t really take hold widely until the mid-1970s, which in the scheme of things is really not that long ago. It is also ironic to me that the attitude towards chemotherapy exhibited by believers in alternative medicine is very much akin to the attitude towards chemotherapy exhibited by mainstream science 50-60 years ago. The difference is that science has evolved; chemotherapy critics in the antiscience fringe have not.

Adjuvant chemotherapy

Hematological malignancies (such as leukemias and lymphomas) are much less common in adults than solid malignancies (e.g., breast, colon, lung, and other “solid” organ cancers). Many of these solid malignancies are treated primarily with surgery and have been for many decades. Breast and colon cancer are the most prominent (and among the most common) examples. From the 1970s on, the primary rise in the use of chemotherapy has been as adjuvant therapy; i.e., as therapy added to the curative therapy (surgery) to decrease the rate of recurrence and death. Ironically, using chemotherapy for adjuvant treatment met almost the same level of resistance as the use of chemotherapy to try to cure advanced hematological malignancies. In this, Bernie Fisher at the University of Pittsburgh was a pioneer, and DeVita tells us why:

The main problem was where to test these treatment regimens as adjuvants to surgery. Despite the excitement over the new chemotherapy data, most surgeons in the United States were still reluctant to participate in clinical trials testing its use postoperatively. The courageous Bernard Fisher was the first choice (Fig. 8). He and his group, the National Surgical Adjuvant Breast Project (NSABP), had done an early adjuvant study, sponsored by the CCNSC, testing the use of the alkylating agent thiotepa postoperatively to kill cancer cells dislodged at surgery (81). They were also in the process of challenging the status quo, questioning the need for radical mastectomy and postoperative radiotherapy, and were in position to test chemotherapy. The late Paul Carbone of NCI contacted Bernard Fisher, and he agreed to test L-PAM in a randomized controlled trial. But still no person or institution in the United States was prepared to test combination chemotherapy as an adjunct to surgery in breast cancer. Paul Carbone then contacted Gianni Bonadonna of the Istituto Nazionale Tumori, in Milan, Italy, about doing the study. Under its director, the surgical pioneer Umberto Veronesi, the Istituto was treating a large number of breast cancer patients and, like Fisher, was exploring the use of lesser operations than the radical mastectomy. Bonadonna came to the NIH Clinical Center to review the results of the CMF protocol, which had not yet been published and agreed along with Veronesi to conduct a randomized controlled trial of a slightly dose-reduced version of CMF versus no therapy. The U.S. NCI Chemotherapy program, under Zubrod, paid for the study through a contract with the Istituto Tumori. This contract also provided for costs of a permanent statistical center and was the beginning of long time collaboration between the two National Cancer Centers.

In other words, the National Cancer Institute had to look outside of the U.S. to find an investigator willing to do a trial of adjuvant chemotherapy with a regimen containing more than one drug. Both of these studies were positive and set off a flurry of studies trying to see if the addition of adjuvant chemotherapy could decrease recurrence and prolong survival after curative surgery for cancer. It was also around this time that Lawrence Einhorn developed a chemotherapy regimen that resulted in the cure rate of metastatic testicular cancer going from 10% to 60%. By 1981, Dr. Norman D. Nigro, a colorectal surgeon at my home institution, developed the protocol named after him to treat anal cancer in many cases without having to do an abdominoperineal resection (APR). This was considered a major advance, because an APR basically involves removing the rectum and anus, sewing the hole shut, and leaving the patient with a permanent colostomy.

Chemotherapy and breast cancer

There’s one study that I like to cite to people who claim that chemotherapy doesn’t work, and this post seems as good a place to do it as any. It’s a large meta-analysis from two years ago. Funded by Cancer Research UK, the British Heart Foundation and the UK Medical Research Council, this study was carried out by the Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) at the Clinical Trial Service Unit at the University of Oxford, United Kingdom and entitled “Comparisons between different polychemotherapy regimens for early breast cancer: meta-analyses of long-term outcome among 100,000 women in 123 randomised trials.”

It’s really quite an incredible effort to collate patient-level data for so many women in so many clinical trials. I sometimes say about meta-analyses the prototypical complaint about meta-analyses, namely that the quality of the output is critically dependent on the quality of the input. In other words, “garbage in, garbage out.” However, the inclusion criteria for the EBCTCG are actually pretty stringent. More importantly, the EBCTCG has access to unpublished data and patient-level information, as is explained here. The EBCTCG also goes to great lengths to try to include data from every randomized trial ever published, or an unbiased subset of them, in order to try to minimize selection bias that all-too-often results from too-rigid selection criteria used for meta-analyses. All in all, it’s an enormous effort.

Overall, this meta-analysis involved over 100,000 patients involved in 123 randomized trials over 40 years, and the authors made these comparisons: (1) taxane-based versus non-taxane-based regimens (data for 33 trials, begun in 1994-2003); (2) any anthracycline-based regimen versus standard or near-standard (cyclophosphamide/methotrexate/5-fluorouracil (CMF, 20 trials, begun in 1978-97); (3) higher versus lower anthracycline dosage (six trials, begun in 1985-94); and (4) polychemotherapy versus no adjuvant chemotherapy (64 trials, begun in 1973-96, including 22 of various anthracycline-based regimens and 12 of standard or near-standard CMF). Several meta-analyses were performed, which produced five main findings:

  1. Standard CMF and standard 4AC (ACT without the “T,” which is an older chemotherapy regimen used before taxanes were developed) were roughly equivalent in efficacy. Both of them roughly halved two-year recurrence rates and resulted in a proportional decrease in recurrence over the next eight years by approximately one-third. Overall, breast cancer mortality rates were reduced proportionally by 20-25%.
  2. Regimens with lower chemotherapy doses per cycle were less effective.
  3. Regimens with a lot more chemotherapy than the old standard 4AC (but not so nasty that they required stem-cell rescue) were somewhat more effective. They further decreased breast cancer mortality by 15-20%. The most prominent of these regimens is 4AC plus four cycles of “T” (a taxane), which became the standard of care for node-positive breast cancer after taxanes were developed.
  4. In all chemotherapy comparisons, the ten year overall mortality was reduced because there was not very much excess mortality due to causes other than breast cancer during the first year.
  5. In all meta-analyses looking at taxane-based regimens or anthracycline-based regimens (doxorubicin is an anthracycline), the proportional reductions in early recurrence, any recurrence, and breast cancer mortality were more or less independent of age, nodal status, tumor size, or even estrogen receptor status.

The authors conclude:

While awaiting the results of these new trials, it appears that ER status, differentiation, and the other tumour characteristics available for the present meta-analyses had little effect on the proportional risk reductions with taxane-based or anthracycline-based regimens. The more effective of these regimens offer on average a one-third reduction in 10-year breast cancer mortality, roughly independently of the available characteristics. The absolute gain from a one-third breast cancer mortality reduction depends, however, on the absolute risks without chemotherapy (which, for ER-positive disease, are the risks remaining with appropriate endocrine therapy). Although nodal status and tumour diameter and differentiation are of little relevance to the proportional risk reductions produced by such chemotherapy (and by tamoxifen therapy), they can help in treatment decisions as they are strongly predictive of the absolute risk without chemotherapy, and hence of the absolute benefit that would be obtained by a one-third reduction in that risk.

The bottom line is that, contrary to what you will hear from cranks and alt-med supporters who believe in “alternative” cancer cures, in the case of early stage breast cancer, chemotherapy saves lives. In women with breast cancer, it decreases the risk of their dying from breast cancer by approximately one-third. This is nothing to sneeze at, as it means thousands upon thousands of women who would have died but did not, thanks to chemotherapy. This study simply represents yet another in a long line of studies, another strand in the web of evidence that support the efficacy of chemotherapy in prolonging the lives of women with breast cancer. It’s not perfect, and it has a lot of potential complications, but it works. This is but one example.

Indeed, as DeVita points out, besides its well-demonstrated role in treating hematological malignancies, chemotherapy now has a role in the primary treatment of advanced malignancies such as bladder cancer, breast cancer, cervical cancer, colorectal cancer, esophageal cancer, gastric cancer, head and neck cancer, nasopharyngeal cancer, non-small cell lung cancer, ovarian cancer, pancreatic cancer, and prostate cancer. It’s also used to prolong survival in the adjuvant setting for breast cancer, colorectal cancer, cervical cancer, gastric cancer, head and neck cancer, pancreas cancer, melanoma, non-small cell lung cancer, osteogenic sarcoma, and ovarian cancer. I must admit, though, I’m a bit surprised that other soft tissue sarcomas weren’t included on the list.

Chemotherapy and cancer

I’m no Pollyanna, as I’m sure regular readers realize. You just have to read my posts over the years about screening for cancer or how little better newer drugs seem to be than old drugs used to treat cancer to see that. I realize that chemotherapy is imperfect and doesn’t work well for a lot of cancers. Many of the drugs cause bad side effects, and, as I’ve explained before, in the adjuvant setting you have to treat a lot of patients to benefit relatively few. I also realize that chemotherapy is sometimes oversold. At the same time, I also know that now is the best time there has ever been for treating cancer with drugs. Targeted agents allow us to attack more precisely the molecular derangements driving cancer growth with lower toxicity. Molecular profiling is paving the way for precision medicine, in which someday (or so we hope) we will be able to target treatments to the specific abnormalities in a specific patient’s tumor. Certainly, I have no illusion of how difficult this is to accomplish, but I do believe that over time we will find ways to do it.

It’s helpful to look at the scope of advances over the last 100 years or so, as provided in these helpful diagrams in DeVita’s article:

ChemotherapyHistory1

ChemotherapyHistory2

As slow as it seems to those of us living it, cancer research has produced a lot of breakthroughs. Those who wonder why we haven’t cured “cancer” yet should read earlier posts I’ve written on the topic. Cancer is hard. Real hard. It is also hundreds of diseases, not some monolithic disease, just as chemotherapy is dozens of drugs and hundreds of drug combinations, not some monolithic mythical “chemotherapy.” It is not reasonable to expect that a span of a mere few decades or even a century is enough to cure all cancer. We have, however, brought the cure of several cancers within reach and do actually cure many cancers. Also, contrary to popular belief, the death rate from cancer is decreasing. In the US, it’s been decreasing for nearly the last 25 years, as shown in this graph from the most recent American Cancer Society statistics:

Cancer statistics, 2013

Note that this is happening even as the age-adjusted incidence of cancer is remaining steady or slightly increasing. Fewer and fewer people with cancer die of their disease. I realize that this is no consolation to anyone who has lost loved ones to the disease (as I have), but it does give hope for the future.

And, yes, promoters of alternative cancer cures can deny it all they like, but chemotherapy is indeed a major part of the reason for better outcomes and more hope in cancer. “Cut, poison, burn”? Well, yes. Unfortunately, that’s what works, including the “poison” part. Until we find something that works without as much morbidity, “cut, poison, burn” will have to do.

That reminds me. I really need to review the movie of the same title.

Posted in: Basic Science, Cancer, Clinical Trials, History

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76 thoughts on “Chemotherapy doesn’t work? Not so fast… (A lesson from history)

  1. I dont like using the word cancer, its misleading and groups many unrelated diseases in one lump.
    Carcinoma of the lung for example, the most common type of deadly tumor, has a worse death rate now than 40 years ago. So what did 40 years of cutting poisoning and burning do exactly?

    1. WilliamLawrenceUtridge says:

      Do you know what’s misleading? Not calling “cancer” “cancer”. Patients see doctors to get context and guidance, since very few patients are actually doctors and even fewer have the necessary expertise to understand the literature or even what cancer truly is.

      Carcinoma of the lung for example, the most common type of deadly tumor, has a worse death rate now than 40 years ago.

      …never mind that it’s been dropping for what, two decades? Down from a peak in the early 90s? Never mind that this is basically what we would expect given the rates of smoking over the past century?

      So what did 40 years of cutting poisoning and burning do exactly?

      So…because chemotherapy, surgery and radiation therapy can’t treat one of the most deadly cancers that exist, that means all chemotherapy is irrelevant? It’s funny, on one hand you say “you can’t treat all cancers as a single lump”, but then treat them all as a single lump, as if lung cancer were characteristic of all cancers. It’s almost if your motivation wasn’t an honest discussion of the topic, but rather an effort to be dishonestly critical at all costs. But then again, you are a CAM proponent, so you don’t really care about reality. It seems like you just want to be the troll who gets there first.

    2. David Gorski says:

      Incidence and mortality for lung cancer are almost entirely driven by smoking tobacco. In actuality, the mortality of due to lung cancer is actually decreasing among men—and quite rapidly at that. This decline began after mortality peaked in the late 1980s. All of this is very much due to smoking more than anything else. Lung cancer mortality in men peaked in the late 1980s because cigarette smoking peaked in the early 1960s, and the lag period between smoking and the development of lung cancer is generally between 20-25 years. Indeed, if you look at graphs of incidence and mortality from lung cancer, they closely parallel graphs of cigarette consumption, with a delay of a little over 20 years.

      http://teachercenter.insidecancer.org/view/Causes%20and%20Prevention/956/Causes,%20Smoking:%20Lung%20cancer%20epidemic.html

      http://onlinelibrary.wiley.com/doi/10.3322/caac.21166/abstract

      The case in women is different. Lung cancer mortality leveled off about ten years ago after having climbed steadily for 40 years. This is due to (1) not as many women smoking as men and (2) women’s taking up the habit in big numbers a couple of decades later than men. So the mortality curve for lung cancer in women is shifted to the right compared to men.

      Now, it is true that lung cancer is one of the cancers where progress has been disappointing, but, make no mistake, it’s cigarette smoking that drives incidence (and therefore mortality) from lung cancer.

      1. Absolutely, the overall number of deaths from lung cancer is going down with the ciggie puffing and better awareness of asbestos-caused mesothelioma.

        What is not improving are the survival chances for those diagnosed with lung cancer. Today its about 16% over 5 years, and 40 years ago it was 20%.

        4 decades of cutting, burning and poisoning with no results to show for it. Why are these patients milked for tens of thousands of dollars to go through horrible chemical torture, is it any different from what Dr Burzynski is doing?

        The ironic thing is, medical professionals are the most likely to refuse aggressive treatment for lung cancer when they find one in their own body — “Cutting, poisoning and burning FOR YOU, as for ME, just a cheap painkiller please”

        1. WilliamLawrenceUtridge says:

          4 decades of cutting, burning and poisoning with no results to show for it.

          That’s deceptive. We now know that there are a large variety of treatments that don’t work.

          Why are these patients milked for tens of thousands of dollars to go through horrible chemical torture, is it any different from what Dr Burzynski is doing?

          Are patients actually charged tens of thousands of dollars to go through horrible chemical torture? Generally, since there is not really any particular effective treatment for many lung cancers, most are probably involved in clinical trials.

          As for how this is different from Dr. Burzynski, well duh. These treatments are explicitly given as part of tests to see if they work or not. And when the tests come back as “ineffective”, they stop being offered. Burzynski is using the clinical trial process as a loophole to charge patients a mint for the privilege of being a guinea pig for a clinical trial that never reports out, that is poorly done in the first place, and that contributes nothing to the greater medical knowledge. Burzynski is charging patients for slapshod guesswork treatment and slapping a label of “clinical trial” on it afterwards to avoid the FDA shutting him down.

          The ironic thing is, medical professionals are the most likely to refuse aggressive treatment for lung cancer when they find one in their own body — “Cutting, poisoning and burning FOR YOU, as for ME, just a cheap painkiller please”

          First, [citation needed].

          Second, doctors have seen death, lots of it, presumably of cancer. So they appreciate the pain and suffering patients to through, and their frame of reference would be different. They would understand, in a visceral way, what a 5% chance of survival means in comparison to the adverse effects of chemotherapy.

          Third, do you mean this as an opening to a discussion about physician-assisted suicide? That would be a brave and laudable thing for you to do, it’s a conversation that the US needs to have.

          1. Are patients actually charged tens of thousands of dollars to go through horrible chemical torture?

            Absolutely, cancer treatment is huge business. Big money.

            Why do I keep harping about lung cancer? Its the most important one, 30% of cancer deaths are from lung cancer. It’s also the disease where the costs of treatment rose the most for the least benefit.

            Citation from Harvard study that investigated this:

            The authors used Surveillance, Epidemiology, and End Results (SEER) data to calculate life expectancy after diagnosis [of lung cancer] over the period 1983 to 1997. Life expectancy improved minimally, with an average increase of approximately 0.60 months. Total lifetime lung cancer spending rose by approximately $20,157 per patient in real, ie, adjusted for inflation, 2000 dollars from the early 1980s to the mid-1990s. Cost effectiveness, as measured by the cost of an additional year of life gained, was poor, with a high average cost of $403,142.

            So essentially they found that gazillions of dollars spent on lung cancer chemo drug development bought miserable 20 days of life for the average patient, basically nothing, at an exorbitant cost to the state sickcare system and the patients family.

          2. weing says:

            “Why do I keep harping about lung cancer? Its the most important one, 30% of cancer deaths are from lung cancer. It’s also the disease where the costs of treatment rose the most for the least benefit. ”

            Wow. Has it changed since that report? Has there been progress? Have you looked? You probably would complain about the casualties on D-Day and recommend not bothering to fight.

          3. WilliamLawrenceUtridge says:

            Absolutely, cancer treatment is huge business. Big money.

            Yeah, so is the $34 billion spent out of pocket on CAM in the US alone. However, chemotherapy is proven to work, on a statistical basis, for many conditions. Pity the same can’t be said for CAM.

            But now you have to justify the “torture” part of your first comment. Is emergency surgery without analgesic or anaesthetic, or childbirth without pain relief torture? Or is it simply a medical procedure that, of necessity, has unpleasant side effects? If you can’t have effective medical treatment without side effects, it’s hardly torture.

            Why do I keep harping about lung cancer?

            I’m guessing it’s because you want to pick the worst possible example of untreatable cancer because you want to make medicine look bad – without ever examining more promising treatments or the effects of leaving cancer untreated. Becuase you’re dishonest.

            Its the most important one, 30% of cancer deaths are from lung cancer. It’s also the disease where the costs of treatment rose the most for the least benefit.

            And why is it 30%? Because it’s among the least treatable cancers. So initially that nubmer would have been a lower percentage, because the effects of smoking hadn’t hit yet, and because there were no treatments for any type of cancer. Gosh, it sounds like we should do something to prevent lung cancer, like reducing smoking rates or treating asbestos as a potent carcinogen that requires special handling procedures. But we don’t do that, do we? My doctor hands out free cigarettes with every appointment!

            So essentially they found that gazillions of dollars spent on lung cancer chemo drug development bought miserable 20 days of life for the average patient, basically nothing, at an exorbitant cost to the state sickcare system and the patients family.

            Wow, it’s like treating lung cancer is somehow…difficult. It’s like we need some way of discovering new treatments. If only we could get clinicians to run some sort of test, a way of trialing different compounds, to see if somehow they increase survival rates. A…trial…of clinicians? A trial…in clinics? Something like that.

            Or, maybe we just save all that money and shoot people with lung cancer in the head. Because that’s the essence of your argument – because we haven’t found a reliable cure for lung cancer, we should give up. Because we can’t treat lung cancer, we should just let them die.

            If you’ve got any better solutions, either for the evidence-based treatment of lung cancer or a cheaper, more efficient means of testing cancer treatments, let’s hear it. Because otherwise you’re just pointing out something we already know and pretending it’s new.

            Cancer treatment is hard. You go to school to arrive at that conclusion?

          4. CHotel says:

            The next sentence of the abstract that FBA nicely left out was that “The cost-effectiveness ratio was $143,614 for localized cancer, $145,861 for regional cancer, and $1,190,322 for metastatic cancer.” Still not good, but clearly the poor monetary measures are driven by the worst form of the disease. As such, the authors do make one of their conclusions in the paper that “almost all gains in survival have been in localized-cancer cases”, due to surgical advances (technique, imaging, pretreatment planning) and perioperative care, and they do reference that some studies use up to $200,000/QALY as a cutoff (though most do cap at $100,000) so perhaps the treatments are cost-effective where those gains are made.

            Let’s also keep in mind that the survival data for this ENDED in 1997, and was compared to data from as EARLY as 1983. So in addition to the (albeit minimal) gains we made in those 14 years, the paper does not address the additional gains made in the 16 years since then. Again, from the authors’ conclusion: “Several promising new therapies have been developed since 1997 that could affect future cost-effectiveness criteria, but uncertainties remain about these treatments.” So no concrete improvements to speak of, but if we consider timeline once again: THAT statement was published in 2007 (and possibly written even before then, with how long the peer-review process can take in some cases).

            Now I am personally not up to date on the latest NSCLC literature, maybe those new therapies still haven’t improved survival to a cost-effective standpoint. Considering that we seem to be making more significant progress in shorter time periods in many areas over the last few decades, it wouldn’t be a stretch to believe the opposite could be true as well. As WLU said, cancer is hard, and if you have any ideas the medical world is all ears. However, if all you have to contribute to the conversation is pessimism and dated data (although “dated data” is kinda fun to say) then maybe it’s best to keep your opinions to yourself.

          5. @weing

            Wow. Has it changed since that report? Has there been progress? Have you looked?

            I am looking at prices of chemo, they only got more expensive. Avastin $1800 per 16ml vial, Pemetrexed $2700 a flask, Dont see much evidence any of this expensive toxic waste is improving the therapeutic outcomes.

            Where I see progress is on the diagnostic side, in new tests to detect these tumors while they are small, and on the genetic testing side to identify the high risk people.

            Not impressed with new ways of chemically poisoning the patient, as usual the allopathic sickcare system focuses on disease management not prevention. But it boosts the pharma indutry bottom line. Healthy people dont buy Pemetrexed and dead people dont buy it, the profit is in the middle – not quite healthy not quite dead!

        2. mousthatroared says:

          You act as if surgery is universally recommended for lung cancer. It’s not. I know it wasn’t in my father’s case and chemo was only offered as pallative care. Also, something you seemed to have forgotten, painkillers have side effects too. The most serious side effects that my father experienced were related to those “cheap painkillers”.

          When I look for a healthcare provider, I look for someone who can balance risk and benefit, consider individual diagnoses and analyze the details of current research. Your judgement appears to be crippled by a tendency to form opinions based on sweeping generalizations of a bias selection of research (at best).

          I feel sorry for the folks who make the unfortunate mistake of trusting you.

          1. mousthatroared says:

            ^^^My above comment was addressed to FBA’s above comment.

        3. qetzal says:

          Today its about 16% over 5 years, and 40 years ago it was 20%.

          Where do you get those numbers? According to Seer, 5-year survival rates have been going up steadily since 1975 for lung & bronchial cancer:

          1975: 11.4%
          1980: 12.5%
          1985: 13.1%
          1989: 13.4%
          1993: 14.2%
          1997: 14.7%
          2001: 14.9%
          2005: 17.3%

          1. Today its about 16% over 5 years, and 40 years ago it was 20%.

            Sorry, typo, that should read 12% not 20%

          2. MadisonMD says:

            FBA:

            What is not improving are the survival chances for those diagnosed with lung cancer.

            I guess you need to retract this too. Care to retract anything else or do require someone to source every incorrect statement you make? (If so, please limit yourself to one statement per day so there is a chance to keep up.)

          3. qetzal says:

            A typo?! You claim, in two separate posts, that lung cancer survival is worse now than it was 40 years ago, and when I cite data that shows the opposite, you claim it was a typo?

            No. A typo is when you accidentally hit a wrong key. You didn’t accidentally hit the wrong keys to say ‘worse’ when you meant ‘better.’

            Are you lying? Or trolling? Because I can’t think of any other reasonable explanation.

    3. Pareidolius says:

      Well, in my sister’s case, radiation and chemo gave her another 17 years of cancer-free life. Her lung tumor was too close to her heart and was deemed inoperable. You’re as idiotic here as you are over at RI..

  2. catwhoorg says:

    Whats the cause of the spike around 1991 in males ?

    Something different about prostate diagnoses ?

    1. David Gorski says:

      PSA screening programs began in the 1980s and resulted in that spike. Unfortunately, most of that spike was overdiagnosis of indolent prostate cancer.

  3. catwhoorg says:

    Thank you Dr Gorski

  4. mousethatroared says:

    DG “Fewer and fewer people with cancer die of their disease. I realize that this is no consolation to anyone who has lost loved ones to the disease (as I have), but it does give hope for the future.”

    Actually I’ve had loved ones die from cancer and every time I hear about an increase in survival rates for any particular kind of cancer I feel a big sense of consolation. For example, when I was in middle school (1970′s) a friend died from leukemia. When I heard about the increases survivial (remission) of children with leukemia, I felt a huge sense of Yeah! FU leukemia.

    I probably personify cancer too much, but I don’t think that’s unusual.

    1. AnObservingParty says:

      I feel a huge sense of gratitude for those cancer patients who succumbed whilst in the midst of a clinical trial. Even if that new treatment didn’t work, I take comfort knowing that they got at least standard of care, and helped produce data that will help others, including possible me.

  5. The Midwesterner says:

    My experience with chemo is through my brother, who went the cut, burn, poison route. after being diagnosed with pancreatic cancer All it got him was the chance to see his son graduate from high school and four years later from college, more time to spend with his wife and family, to work, travel, live his life to the fullest knowing what the eventual outcome was going to be. During the last year or so of his life, whenever he went in for chemo, he would be asked if he had had enough yet. It was his choice to say no, as I assume it would be for anyone in his position. It certainly wasn’t pretty at the end but I never for a moment thought he didn’t feel it was worth it. Certainly the rest of his family was grateful for the time. By the way, he never did lose his hair but, while it was about 50% gray at the start of his illness, he died with all brown hair. I always thought that was quite bizarre and assume, because I can’t imagine any other reason fir it, that one of the chemo drugs caused it.

  6. DG says:

    Fabulous overview, Dr Gorski. There’s no doubt in my mind that, God forbid, I ever developed a malignancy, I would consult widely within the mainstream to select the best possible regimen of drugs, surgery and/or radiotherapy (as appropriate to the disease, stage, grade, biology, etc).

    But I have become more and more interested in the prevention of cancer outright (admittedly beyond the scope of your review).

    Obviously smokers have to stop smoking, but they also need to lose weight and become more physically active every day; as well, they need to drink less alcholol and not engage in unprotected sex. Those are the standard recommendations.

    Finally, there is sufficient evidence in my view to recommend a plant-based diet to anyone who wishes to reduce their risk of cancer (and who doesn’t?). The epidemiological evidence, coupled with clinical trials on remission and basic science data, are now as resounding as they are ever going to be. Interestingly, we would need a lot less chemotherapy (as well as the other tools) if everyone went vegetarian (but I’m not holding my breath). While I don’t think chemotherapy will ever become “history” (ie a tool of the past) with this approach (there’s still environmental pollutants and nocturnal light exposure to deal with), we’d do well to view ca. as a largely preventable disease through effective and sustained lifestyle modification. Having lost two in-laws in the past year to cancer in their 50′s, I wish I had had a chance to transmit this approach to them ten or twenty years ago, before it was too late.

    1. mousethatroared says:

      DG “Obviously smokers have to stop smoking, but they also need to lose weight and become more physically active every day; as well, they need to drink less alcholol and not engage in unprotected sex. Those are the standard recommendations.”

      They do? I’m always confused by general recommendations to lose weight (what, even if you are under weight?) drink less – less than what…or maybe you should drink more, depending upon what you are tryin to avoid and don’t have unprotected sex? What if you are trying to reproduce….giving birth to children reduces the risk of some cancers.

      So tell me the report that shows I should cut down on my 4 to 6 alchoholic beverages a weeks and what I’m going to achieve from that. Because, the thing is, whenever I actually see a report that breaks down these risks (except for some high risk activities like smoking) the results seem to come down to possibly living a few months to a couple of year longer, 20 or 30 years from now. So if that’s what we are talking about, I don’t think I see an adequate benefit to that trade-off…particularily if the alchohol may have other health benefits.

      1. CHotel says:

        I’ve always disliked the vague “standard” recommendations for lifestyle changes as well.

        For losing weight (if needed at all, as you point out), what target becomes ideal? How should one reach it, and in what time frame? Taking up swimming and losing 20 pounds in a year for someone with a BMI of 28 is a lot different than someone with a BMI of 40 losing 60 lbs in 4 months by radical diet and exercise changes that border on malnutrition.

        How physically active should one be? What type of activity should they do? What if they already are mildly active, do we know an increase will have a net benefit? Over-exertion can lead to muscle and joint problems (which can, in some cases, lead to lifelong pain and disability), and in very extreme cases you can even have instances of rhabdo, cardiac hypertrophy, or strokes, to name a few.

        What is the ideal number of drinks one should have? Alcohol is hard on your liver in high amounts, but in moderate amounts is beneficial for certain cardiac factors, and may also be beneficial in diabetes risk. From what I have read in the literature Mouse, you seem to be right on the money at 4-6/wk, but depending on your personal risks of various things it could go either way. What is the ideal beverage? When the Mediterranean Diet was hot it was thought by some that red wine was best (and some still think that), but is it really better than a beer after work or the scotch I have while watching The Daily Show before bed?

        As we learn more about what goals will produce the most benefit for what outcomes in which people, hopefully sweeping blanket statements will fall by the wayside

  7. Joe says:

    What most of the alternative cancer therapies I’ve read about have in common is a calorie restricted (CR), mostly raw vegetable/fruit/legume diet.

    Chris Wark, referred to in this article, used this “treatment” exclusively after colon surgery. The lady pushing for the mistletoe trials is also in remission after having used a similar diet plus mistletoe after colon and liver surgery to remove tumors (the colon cancer metastasized to her liver and she had 20% of it removed after the colon surgery). There is also a video on Chris’ website of a young gal who refused a 3rd brain surgery to remove cancer, and is in remission after dietary changes only. And there’s a fourth testimonial of a lady who made dietary changes as well as admittedly quack remedies after refusing pancreas surgery. She is in remission 13 years later.

    I also came upon the following quote from an article on cancer vaccines,
    “As soon as it [cancer] starts metastasising it pours out immunosuppressive cytokines so the immune system can’t get locked on to attack. We’ve documented that for colorectal cancer.”

    So in light of these statements, my questions are:
    1) What makes you so sure dietary changes as described above can’t increase your odds, if only slightly, in overcoming cancer? Or another way of asking the question would be that instead of saying Chris was cured by surgery, he was probably cured by surgery. Is there something about the biochemistry of all cancers that eliminates the possibility that these dietary changes can help?
    2) I read the article on this site entitled “Boost Your Immune System?”, but if cancer can suppress your immune system, if even only locally, isn’t it possible a CR, nutrient rich diet could reverse that effect?
    3) Is it possible a CR diet could slow the growth rate of cancer (I’m aware that Roy Walford, MD, a pioneer of CR, claimed a CR diet can help prevent cancer, but he also states “… there is no evidence that CR will help cure cancer once that cancer has occurred …”.) ?

    TIA

    1. WilliamLawrenceUtridge says:

      1) What makes you so sure dietary changes as described above can’t increase your odds, if only slightly, in overcoming cancer? Or another way of asking the question would be that instead of saying Chris was cured by surgery, he was probably cured by surgery. Is there something about the biochemistry of all cancers that eliminates the possibility that these dietary changes can help?

      Cancers are casued by mutations of the DNA within cells that govern division, removing the “rate limiters” and augmenting the effects of the “growth promoters”. It’s like disabling the brakes on a car while nailing down the gas pedal. Certainly having an adequate diet would help your body resist the cancer (though theoretically, starving yourself might work too as the cancers themselves have high metabolic demands I believe). It could also help prevent cancers (and there is evidence this is the case, but primarily when you’re a kid; diet during youth seems to have a significant impact on presence of cancer during adulthood) by interfering with strongly oxidizing intracellular constituents (but won’t do a damned thing for cancers due to nonoxidating damage to DNA such as ionizing radiation). But once those DNA changes have occurred, diet doesn’t magically have the ability to reprogram DNA, to reduce gene duplication and scrambling, and to eliminate promoters and enhance the activity of growth-limiting genes.

      Of course, this is a very high-level suggestion, each cancer is different. There’s no such thing as “cancer”, each tissue can become a “cancer” (an undifferentiated mass of dividing cells) but does so in a different way, and there can be mutliple paths for each tissue – so even an osteosarcoma, a cancer starting in the bone, can become completely different types with different prognoses and treatments.

      Further, the origins of the dietary interventions are often based on “toxins”, the idea that regular food is somehow dangerously polluted (an idea with more in common with ritual purity than science). There are certainly carcinogenic compounds that exist. Food is actually a sizeable source of them – most flavour molecules are actually toxic and chemogenic in large enough doses – but we’ve got livers, kidneys and other mechanisms to deal with them. Assuming these “toxins” are the cause of cancer, which they generally aren’t, even if you stopped eating them and removed them from your body – the DNA damage is still there. It’s like buckling a corpse ejected from a crashed car back into its seat and expecting it to come back to life. Treating cancer requires a totally separate intervention from preventing it.

      2) I read the article on this site entitled “Boost Your Immune System?”, but if cancer can suppress your immune system, if even only locally, isn’t it possible a CR, nutrient rich diet could reverse that effect?

      Only if your depressed immune system is depressed because of nutrient deficiency. Vanishingly rare in North America. I’m not positive, but my guess would be that the immune-depressing effects of cancers are not due to nutrietn deficiency, they’re likely due to the cancer mass itself producing immune-supressing chemicals. Cancer masses are evolutionary, nasty little buggers that will evolve resistance to chemotherapy much like bacteria evolve resistance to antibiotics. But they will also evolve to better-survive in their environment. That means any mass that prevents the immune system from recognizing and destroying cancer cells (i.e. by supressing it) will be more likely to survive. The immune-suppressing nature of cancer is almost certainly a factor of the cancer itself, not the body around it.

      3) Is it possible a CR diet could slow the growth rate of cancer (I’m aware that Roy Walford, MD, a pioneer of CR, claimed a CR diet can help prevent cancer, but he also states “… there is no evidence that CR will help cure cancer once that cancer has occurred …”.) ?

      The cancer cells might simply see the rest of your body as a large, ambulatory meal that can be cannibalized for resources to promote further development. I would bet that this is where the “invasive” part of “invasive cancers” comes in. Not to mention, a calorie-restricted person will still produce nutrient-rich blood the cancer will happily neovascularize a rich supply of, then siphon off to promote further growth. You might just kill the patient quicker, and I’m guessing thin cancer patients die a lot quicker than chubby ones.

      TIA

      Transient ischemic attack?

      Anyway, one must always remember with anecdotes – it’s much easier to find people with dramatic stories of survival. They get advertised on the news, and you can actually talk to/about them. The press rarely reports “wo/man dies of cancer after usual care” because it’s not dramatic. Dead people can’t become spokespersons and start websites. That’s why you need careful record keeping and follow-up, for cancer and really all health research, because otherwise you lose people who are doing well. You can even, and often in fact, have people who proclaim loudly how well they are doing, and these stories are recirculated throughout the internet. Rarely do you hear the long-term follow-up of “and then they died”. A similar problem exists with AIDS denialists.

      Think of it another way – how often do you remember a license plate that for some reason catches your eye? How often do you remember one that says “B0OB I3S”? How often does the story get told in the bar of the time you saw the “boobies” car?

      Now, how often do you hear “Man, did I ever tell you the story of the time I saw a car with the license plate 3B9 4CW?”

      Rare stories get repeated, it’s a cognitive failing (availability heuristic) of humans that the dramatic ones stick in our minds and we are oblivious to the banal ones.

      1. DG says:

        There’s a fairly large body of observational studies suggesting that vegans and vegetarians have a lower incidence of many types of malignancies than non-vegans/non-vegetarians. There are also weaker ecological studies suggesting that predominantly plant-based cultures have lower rates of cancer than non-plant-based western cultures (and their rates go up after they immigrate to the west and adopt our diets).

        This alone is not proof of causality, but if you also look at clinical trials such as Ornish’s study of a plant-based diet to remit prostate cancer, the use of flaxseed as therapy in patients with treated breast cancer, as well as an astonishing array of animal and in vitro studies — it’s about a good a case as you’re ever going to see. In other words, I wouldn’t wait for a large randomized trial, since no one is going to do it or fund it.

        If you don’t feel this is sufficient, stay within your comfort zone. Don’t let’s all suddenly become appalled by the high rates of cancer in our society, since apparently we’ve become quite used to it (few people ever talk about preventing cancer through lifestyle change – other than for a couple of prominent examples such as tobacco cessation). There’s certainly very little effort going on in terms of designing large randomized trials of dietary approaches to prevent cancer (although the Lyon Heart Trial did document a large and statistically significant reduction in cancer about 15 years ago).

        1. David Gorski says:

          This alone is not proof of causality, but if you also look at clinical trials such as Ornish’s study of a plant-based diet to remit prostate cancer,

          I’ve looked at Ornish’s study in detail, including his most recent publication. It is highly underwhelming. Perhaps I’ll blog why sometime.

          1. DG says:

            “I’ve looked at Ornish’s study in detail, including his most recent publication. It is highly underwhelming. Perhaps I’ll blog why sometime.”

            Prof. Gorski,

            Each little piece of the puzzle is incomplete and imperfect on its own. When the entire accumulated evidence base is looked at with the so-called “bird’s eye view”, the pieces fall into place and interconnect quite well. Unfortunately, only a large randomized trial with hard endpoints will be sufficient proof for the skeptics. The problem is that the designers of such studies – such as the Harvard School of Public Health (Manson et al) – are still doing enormous trials of isolated micronutrient supplements (VITAL), rather than fashioning whole new patterns of healthy eating for the general population. These trials will continue to be a failure, as they have been in the past. So don’t hold your breath waiting for such a large trial – the stakeholders are entirely disinterested. I, for one, will continue to consume a whole foods plant-based diet to reduce my risk of chronic (and acute) degenerative conditions that afflict our post-industrial society. Whether others make the same decision or not, let each consult their conscience and the evidence.

            Of course, what is considered avant garde or outside the mainstream today often becomes de rigeur tomorrow. Vegetarianism as a popular trend outside Asian countries is only about 50 years old (British vegans post-World War II in essence started, or restarted, the modern movement). Today about 2% of the population call themselves vegetarian and fewer than that call themselves vegan (in Ontario, 6.5% of females self-classify as vegetarian, versus only 1% of males, which is very interesting, since women often take better care of their health). What is truly remarkable is how many nutritionists/dieticians are becoming vegan – is this inside knowledge? Who knows!

          2. WilliamLawrenceUtridge says:

            I, for one, will continue to consume a whole foods plant-based diet to reduce my risk of chronic (and acute) degenerative conditions that afflict our post-industrial society. Whether others make the same decision or not, let each consult their conscience and the evidence.

            That’s great, but don’t pretend you’re doing anything drastic, remarkable, or out of keeping with the mainstream nutritional recommendations. If you’re only eating plants, I hope you’re keeping an eye on your iron, B12 and protein levels. Vegetarianism is definitely a valid nutritional choice, and an ethical one in many ways (I was an economic vegetarian, my objections were to the amount of water, calories and land mass required to grow meat), but it’s not a panacea and it’s not the only healthy way to eat. Humans did not evolve to be vegetarians, they are omnivores, as evidence by coprolites, dentition, gut arrangement, taste preferences, vitamin requirements and more.

        2. WilliamLawrenceUtridge says:

          Realistically, once you quit smoking and follow the conventional mainstream advice (exercise regularly, get enough sleep and eat according to the USDA recommendations), nearly anything else you do probably won’t do much to lower your risk of cancer dramatically. It’s all diminishing returns, and the belief that there is some magical ingredient, or food, or drug, that prevents cancer is probably more marketing from POM than anything else. I think tamoxifen is supposed to be the latest drug shown to reduce your risk of cancer, and it’s something negligible.

          1. DG says:

            USDA guidelines are written in consultation with industry. Furthermore, a branch of the USDA called the American Egg Board, which is entirely funded by American tax dollars, serves to promote the consumption of eggs amongst the public. Following these guidelines will only take you so far, unfortunately. I am glad you have so much faith in government bureaucrats to draft and promote dietary guidelines for the general public. I do not. Be well.

          2. DG says:

            I was wrong.

            The American Egg Board (AEB) is the U.S. egg producer’s link to consumers in communicating the value of the incredible egg. Our mission is to increase demand for egg and egg products on behalf of U.S. egg producers.

            AEB is funded by a national legislative checkoff on all egg production from companies with greater than 75,000 layers. Its board is appointed by the U.S. Secretary of Agriculture and consists of 18 members and 18 alternates from all regions of the country all are egg producers nominated by certified state and regional organizations representing egg producers.

          3. WilliamLawrenceUtridge says:

            The evidence suggests that cooked eggs are a source of low-fat, high-quality protein and micronutrients. They’re flexible, delicious, cheap, have a lower environmental impact than eating the chicken itself, and not associated with any health harms that I am aware of. Too many people seem to think that merely because an industry exists, whatever the industry is promoting is automatically evil. This is not the case, any more than the existence of soy milk and tofu producers means soy beans are unhealthy. Frankly, the existence of an entity promoting egg consumption over that of chickens, cows, pigs and other animals is a pretty good thing in my mind, for health and environmental reasons. If more people spent money on eggs rather than on chocolate, candy and fast food, chances are America would be a healthier place.

        3. Chris says:

          It didn’t help my neighbor. He was a vegetarian, and yet died in 50s/60s from pancreatic cancer.

      2. Joe says:

        TIA = thanks in advance. Appreciate everyone’s response.

    2. Young CC Prof says:

      A calorie-restricted diet does NOT improve cancer survival rates, it only takes away the energy that cancer patients need to beat the disease and get through the day. Juice fasts heavy on the Vitamin A have been shown to actually hasten deaths from lung cancer.

      If you don’t have cancer, eating vegetables slightly reduces your risk, especially of colon cancer. Vitamin supplements do not.

      For someone who already has cancer, a generally good diet, with protein, veggies, etc can’t hurt and might help. At the very least, it’ll provide your body with the energy to endure treatment and keep going. But there aren’t any dietary cures.

      1. James says:

        It is all about dosage.

        I would agree that a calorie restricted diet only takes away the energy that cancer patients need to beat the disease.
        However there is some good evidence showing that fasting before chemo enhances the effect of the chemo.

        http://www.cancer.gov/ncicancerbulletin/071012/page5

        So maybe intermediate fasting might help cancer patients?
        Of course I am just postulating.

  8. AnObservingParty says:

    Excellent post. The complexity of cancer and its therapies is enormous and it should be insulting to everyone (doctor, caretaker, survivor, someone who didn’t beat it) to hear something so heavy described as “cut, poison, burn,” as some people are wont to do. The Emperor of Maladies should be required reading for core bio courses in undergraduate, in my opinion, so everyone’s eyes could be opened just a little bit as to the complexity of the disease (or rather diseases under the umbrella of “cancer”) and the complexity of treatment development and how doctors have continuously developed ways to cut LESS, poison LESS, and burn LESS while still increasing long-term survival and quality of life.

    1. AnObservingParty says:

      The Emperor of all Maladies. Me fail book titles. Sorry, Dr. Mukherjee, wherever you are.

      1. WilliamLawrenceUtridge says:

        I consistently call that book Cancer: A Biography, which is at best the subtitle :)

        Man, that was an excellent book. One part I remember is how the idea of chemotherapy being brutal and unlivable was based on the clinical trials of the 80s, where the doses and combinations were incredibly high with the belief that you had to almost kill the patient to kill the tumor(s). Apparently current doses are more reasonable, depending on the cancer and the chemo, and equally effective. My unsteady recall from TEOAM.

        1. AnObservingParty says:

          Yes, and more targeted. It’s amazing. Even the treatments that are designed to essentially kill the patient–a conditioning regimen for a bone marrow transplant was originally described to me by our doc as like the walking-ghost-period of radiation poisoning–are becoming so fine tuned that they’re starting to do autologous transplants as OUTPATIENTS. It blows my mind.

  9. Angora Rabbit says:

    I am thankful every day for chemotherapy. Without chemo, my nephew (who was diagnosed with leukemia at 2yrs old) would not have lived to graduate from college – an engineer, no less! – and next July we will celebrate his wedding.

    No amount of woo can beat that record.

  10. Flower says:

    The overall contribution of cytotoxic chemotherapy to survival in the 22 cancers reviewed in the study below is less than 3%.

    Morgan G, Ward R, Barton M. The contribution of cytotoxic chemotherapy to 5-year survival in adult malignancies. Clin Oncol 2004;16:549-60

    Abstract available at – http://www.ncbi.nlm.nih.gov/pubmed/15630849

    1. David Gorski says:

      You obviously didn’t click on the links in the very first paragraph. There’s a name I’ve given the distortion you’re using based on a not-so-good study: the 2% gambit. Go back and click on the links in the first paragraph, and learn.

      1. Sawyer says:

        I always appreciate the irony of CAMsters that insist they are the only ones qualified to evaluate incredibly complex medical evidence, while they are simultaneously struggling with middle-school reading comprehension. As a lay person with minimal education in medicine, it makes it MUCH easier for me to figure out who is right.

  11. Flower says:

    Chemo-so-called-therapy is carcinogenic in and of itself, as classified by the World Health Organisation. It is cynical to be wanting to treat cancer with cancer-causing agents!

    Chemo (and radiation – another carcinogen) certainly doesn’t address the causes of cancer development. Doctors do not understand or do want to advise their patients as to why cancer develops in the first place and the public is misled into equating the tumour with the cancerous state and, hence, are happy when the tunour shrinks.

    Chemo causes chemo-resistance and leads to iatrogenic metastasis and death in later years. It’s the treatment that leads to premature death, not the initial state of having cancer, which in many cases would simply regress without any treatment at all and which would certainly be positively influenced by non-toxic therapies, such as dietary modification, nutritional and herbal medicines.

    “Most cancer patients in this country die of chemotherapy… Chemotherapy does not eliminate breast, colon or lung cancers. This fact has been documented for over a decade. Yet doctors still use chemotherapy for these tumors… Women with breast cancer are likely to die faster with chemo than without it.” – Alan Levin, M.D

    In 1990, German epidemiologist, Dr. Ulrich Abel from the Tumor Clinic of the University of Heidelberg, conducted the most comprehensive investigation of every major clinical study on chemotherapy drugs ever done. Abel contacted 350 medical centers and asked them to send him anything they had ever published on chemotherapy. He also reviewed and analyzed thousands of scientific articles published in the most prestigious medical journals. It took Abel several years to collect and evaluate the data.

    Abel’s epidemiological study, which was published on August 10, 1991 in The Lancet, should have alerted every doctor and cancer patient about the risks of one of the most common treatments used for cancer and other diseases. In his paper, Abel came to the conclusion that the overall success rate of chemotherapy was “appalling.” According to this report, there was no scientific evidence available in any existing study to show that chemotherapy can “extend in any appreciable way the lives of patients suffering from the most common organic cancers.”

    The evidence against chemo is mounting. Besides Ulrich Abel, Ralph Moss questions chemotherapy in Questioning Chemotherapy; Kurt G Bluchel writes about organised crime in the cancer industry, and still the medi-ocracy that is drugs-based medicine continues unabated, holding sway over desperate and ignorant people like religion.

    Though a bit dated, a 1986 report in the New England Journal of Medicine assessed progress against cancer in the United States during the years 1950 to 1982. Despite progress against some rare forms of cancer, which account for 1 to 2 per cent of total deaths caused by the disease, the report found that the overall death rate had increased substantially since 1950: “The main conclusion we draw is that some 35 years of intense effort focussed largely on improving treatment must be judged a qualified failure.” The report further concluded that “. . . we are losing the war against cancer” and argued for a shift in emphasis towards prevention if there is to be substantial progress.

    And therein lies the sticking point: Cancer is only of interest to the cancer industry so long as it is neither prevented nor cured!

    1. David Gorski says:

      And we see that Flower really didn’t bother to click on the links in the very first paragraph, where I discuss why Dr. Abel’s study doesn’t show what you think it shows. Oh, and it also wasn’t published in The Lancet, either. If she had examined those links, she wouldn’t have bothered citing Dr. Abel here, because I’ve already discussed it.

      As for Ralph Moss and Kurt Bluchel, don’t make me laugh.

    2. Sawyer says:

      “Cancer is only of interest to the cancer industry so long as it is neither prevented nor cured!”

      Then why are hospitals not advising patients to start smoking? How is it that pulmonologists are the only cancer docs that have resisted Big Pharma’s evil influence?

    3. David poo-poos the 2% study because it did not include blood and lymph cancers, where the success of chemo treatment is most evident.

      He’s also a big fan of adjuvant chemo, often dragging patients who chose not to take it onto this blog, referring to Adjuvant! Online and flashing improved survival chances of 10% of more.

      While there is some evidence chemo improves survival of breast cancer patients, the benefit is greatly exaggerated by Adjuvant!. For example, patients who took chemotherapy without radiotherapy for breast cancer suffered an 8% increase in mortality, suggesting the adjuvant benefit was mostly from the radio treatment, while chemo got an undeserved “adjuvant” reputation from it..

      I already mentioned the exorbitant financial costs of the drugs, there is also the physical cost of long term damage to patients health, including cardiac toxicity, neurotoxicity, reduced cognitive function, and of course, cancer.

      But hey, Adjuvant Online says there is a single digit bump in survival rates, so its open laughing season on patients like Chris Wark who chose not to poison themselves.

      1. Harriet Hall says:

        “For example, patients who took chemotherapy without radiotherapy for breast cancer suffered an 8% increase in mortality, suggesting the adjuvant benefit was mostly from the radio treatment, while chemo got an undeserved “adjuvant” reputation from it..”

        That’s not at all what that study showed. Apparently you can’t even read.

      2. WilliamLawrenceUtridge says:

        Yep, sounds like cancer treatment is not optimal and causes problems. What was your solution again? My interpretation was you thought we should simply shoot cancer patients in the head.

        But really, who are you to say that because cancer treatment is not perfect, it is worthless? It is up to patients to decide whether they want treatment at all, and whether they want adjuvant chemotherapy with its attendant risks and benefits. Some patients want those extra 4 percentage points of increased survival. Some want the tumor shrunk for quality of life. Some want the extra six months survival to take a trip, spend time with family, finish their favourite book series, or whatever. Yes, cancer treatment is not perfect. That doesn’t make it worthless, and it doesn’t make CAM treatments any more effective. And it doesn’t make patients who reject chemotherapy after surgical resection any more honest in their discussion of what cured them.

      3. MadisonMD says:

        While there is some evidence chemo improves survival of breast cancer patients, the benefit is greatly exaggerated by Adjuvant!. For example, patients who took chemotherapy without radiotherapy for breast cancer suffered an 8% increase in mortality, suggesting the adjuvant benefit was mostly from the radio treatment, while chemo got an undeserved “adjuvant” reputation from it..

        OK, FBA. I suppose this is your false fact du jour. Lets have a look at your reference:

        (1) Your citation says “Because adjuvant chemotherapy has been shown to improve survival,20 the great majority of node-positive patients would currently be treated with adjuvant chemotherapy. ”

        (2) Only one trial (B-16) included in the analysis by the article you cite compared chemo versus no chemo with the conclusion that chemo (older type circa 1990) reduced the rate of recurrence from 84% to 67% at 3 years(ref).

        (3) Your statement “For example, patients who took chemotherapy without radiotherapy for breast cancer suffered an 8% increase in mortality” is unsupported by your citation which actually cites another study which suggests that radiation reduces mortaility to a lesser dergree.

        (4) Your logic is absurd. If radiation did reduce mortality by 8%, this certainly does not preclude the fact that chemotherapy also reduces mortality.

        Either you are profoundly ignorant or eternally blowing trollish smoke.

      4. FUCancer says:

        As a current, stage III, 36-year-old breast cancer patient, I know that chemo works. I was offered neo-adjuvant chemotherapy. On diagnosis my tumour was slightly larger than 3 cm and had spread to my lymph nodes. After chemotherapy my tumour was so small that they couldn’t find it during a pre-operative ultrasound. After lumpectomy, the tumour that they removed was less than 2mm in size. And while chemo sucked, it was bearable.
        The worst part about having cancer? Having “woo” touting idiots telling me how to cure my cancer.

    4. WilliamLawrenceUtridge says:

      Chemo-so-called-therapy is carcinogenic in and of itself, as classified by the World Health Organisation. It is cynical to be wanting to treat cancer with cancer-causing agents!

      And therein lies the complications of cancer treatment. Yep, chemotherapy can cause a different type of cancer, years down the road. I believe this is mostly a factor for leukemias, but I could be wrong. Are you saying we’re better off letting children die of untreated lukemia because a decade or more later the treatment itself causes a different type of cancer? This seems to be the myth of the perfect solution – if the cure isn’t perfect, it is worthless. I would venture you might have a hard time explaining this to a child dying of leukemia – “I’m sorry Billy, but because you might die of cancer in your 20s, you’ll have to die of untreated cancer now”.

      Chemo (and radiation – another carcinogen) certainly doesn’t address the causes of cancer development.

      Of course not. Why would you expect them to? When someone has a disease, including cancer, you stop trying to prevent it; the cancer already exists. Using an analogy I’ve used before, would you buckle someone back into their crashed car, or would you treat the injuries they received after being ejected?

      Doctors do not understand or do want to advise their patients as to why cancer develops in the first place and the public is misled into equating the tumour with the cancerous state and, hence, are happy when the tunour shrinks.

      That’s a bit of a blatant lie. Citizens are urged to quit smoking, x-rays and similar ionizing radiation is carefully controlled (except by chiropractors) so the risks of use are more than offset by the benefits. Asbestos is a restricted substance and removing it from buildings is very, very carefully undertaken because of its association with lung cancer. Nutrition, the basic preventive cancer strategy, has a host of recommendations primary of which are “eat lots of fruits and vegetables”. Not the doctors’ fault if patients don’t follow this advice. Plus, there’s a fair bit of research on carcinogenic herbs and other natural products.

      Chemo causes chemo-resistance and leads to iatrogenic metastasis and death in later years.

      Again, this is known, what’s your point? Should we just let people die of untreated cancer?

      It’s the treatment that leads to premature death, not the initial state of having cancer, which in many cases would simply regress without any treatment at all and which would certainly be positively influenced by non-toxic therapies, such as dietary modification, nutritional and herbal medicines.

      And your evidence for this is…what? Not to mention, there are studies of the rare patient who declines cancer care. And what happens is, they die.

      If cancer simply naturally regressed – nobody would ever have died of cancer before chemotherapy was invented. And this is not the case. Cancers were known in Ancient Egyptian times. The Ebers papyrus notes the treatment of cancer – don’t bother doing anything, your patient is going to die.

      I’m assuming you learned all these claims in herbal or naturopathy school, and just accepted them uncritically? And seriously, what’s with the citation of 20-year-old research? Is it because you can’t find anything more recent that portrays chemotherapy badly? Because it’s pretty clear you didn’t really read or understand Dr. Gorski’s article, or the deep links that refute these claims from two decades ago. Questioning Chemotherapy is from 1996, and is written by an advocate of cyanide poisoning (also known as laetrile). Why do you describe evidence as “mounting” when your sources are so old? At best they “mounted” 20 years ago, did it decline since then? See, since 1990, there’s been this series of tubes called “the internet”, and it has kinda changed things; it’s linked to this other thing called ‘computers”, which had a bit of an impact on research. We use both, in conjunction with something called “genomics” to try to understand cancer, and it’s had a bit of an impact.

      And therein lies the sticking point: Cancer is only of interest to the cancer industry so long as it is neither prevented nor cured!

      You seriously think, given the notorious reputation of Big Pharma for prioritizing short-term gains over long-term feasibility, that they wouldn’t cash in on a genuine cure for cancer? Such a drug would redefine the term “blockbuster”, it would make billions for whatever company patented it, and much like aspirin or acetominophen, would continue to make billions even when off-patent. At this point I think you’re just stupid.

      Also, there’s no such thing as “cancer”, it’s a hundred different diseases spawning from dozens of different tissues. Each is specific and has a different course and treatment – there’s a reason lung cancer is more deadly than skin or bone. Read a book.

      1. Flower says:

        Your comment, just eat lots of fruit & veg shows how ignorant you are when it comes to nutritional medicine

        1. WilliamLawrenceUtridge says:

          Your comment, just eat lots of fruit & veg shows how ignorant you are when it comes to nutritional medicine

          That’s true, since “nutritional medicine” isn’t a real discipline. I mean, nutrition is real, medicine is real, medicine discusses nutrition, but the idea that food is naught but fuel and preventive maintenance is, for lack of another word, wrong. You may believe it, but that doesn’t mean it’s true. Humans are obligate omnivores, we can survive on nearly anything, bar certains specific diseases (favism and PKU are my favourites) and allergies, if you eat enough fresh food, but not too much, you’ll be fine.

          And really, you’re not talking about “nutrition” in terms of the foods you should eat. You’re talking supplements and vitamins. And fear. Lots of fear.

  12. DG says:

    “I’ve looked at Ornish’s study in detail, including his most recent publication. It is highly underwhelming. Perhaps I’ll blog why sometime.”

    Prof. Gorski,

    Each little piece of the puzzle is incomplete and imperfect on its own. When the entire accumulated evidence base is looked at with the so-called “bird’s eye view”, the pieces fall into place and interconnect quite well. Unfortunately, only a large randomized trial with hard endpoints will be sufficient proof for the skeptics. The problem is that the designers of such studies – such as the Harvard School of Public Health (Manson et al) – are still doing enormous trials of isolated micronutrient supplements (VITAL), rather than fashioning whole new patterns of healthy eating for the general population. These trials will continue to be a failure, as they have been in the past. So don’t hold your breath waiting for such a large trial – the stakeholders are entirely disinterested. I, for one, will continue to consume a whole foods plant-based diet to reduce my risk of chronic (and acute) degenerative conditions that afflict our post-industrial society. Whether others make the same decision or not, let each consult their conscience and the evidence.

    Of course, what is considered avant garde or outside the mainstream today often becomes de rigeur tomorrow. Vegetarianism as a popular trend outside Asian countries is only about 50 years old (British vegans post-World War II in essence started, or restarted, the modern movement). Today about 2% of the population call themselves vegetarian and fewer than that call themselves vegan (in Ontario, 6.5% of females self-classify as vegetarian, versus only 1% of males, which is very interesting, since women often take better care of their health). What is truly remarkable is how many nutritionists/dieticians are becoming vegan – is this inside knowledge? Who knows!

  13. Self Skeptic says:

    Well, of course chemotherapy works, at least sometimes. The question to ask is, how good are current recommendations at assessing and conveying the true state of knowledge and uncertainty in the field.

    When evaluating how science-based a subfield of medicine is, the first thing to examine, is whether the field has a culture of safeguarding against power players gaming the recommendatons. Guidelines can be improperly biased, for financial or non-financial reasons, just as in any human endeavor. Social status, money, and influence are just as motivating in medicine, as they are in politics, or for that matter, the hen yard.

    I noticed some funny business of this type, when examining the guidelines mentioned in Dr. Gorski’s article on chemotherapy under-dosing in the obese. Two of the guideline-makers in that sub-field have a slew of industry COIs, and at least one of them has been caught being untruthful about it, by the Sunshine Act. That doesn’t tell us whether those particular guidelines are right, or not. To me, it just means that these men are spending a lot of their time working on business arrangements instead of on science and medicine, and I doubt that’s the kind of people we want, making recommendations on patient care. I guess the naive idea is that these extensive business deals are evidence that they have intelligence to spare, but it seems just as likely to me, that they are simply shrewd at leveraging their assets. We don’t need to argue about this; my point is that there is an appearance of conflict of interest, and that doesn’t inspire a patient’s confidence in the field. .

    I didn’t collect the primary literature and evaluate the data (or what parts of it have been published) to see if it has been misrepresented in some obvious ways in that set of guidelines. There are other fields ahead of oncology, on my list. (But if I were going to endorse any guidelines in public, I would certainly do such an analysis, first.) However, it did cause me to realize that if guidelines are to be scientifically credible, there had better be a lot of safeguards in the process, to try to keep both financial and non-financial biases from invalidating them, in the eyes of honest observers.

    Other people, within medicine, have picked up on this issue, too. Not enough to effect wholesale reform; but at least a few MDs, including the IOM, are calling attention to the problem.

    http://www.ncbi.nlm.nih.gov/m/pubmed/23752105/
    J Clin Oncol. 2013 Jul 10;31(20):2563-8. doi: 10.1200/JCO.2012.46.8371. Epub 2013 Jun 10.
    Critical evaluation of oncology clinical practice guidelines.
    Reames BN, Krell RW, Ponto SN, Wong SL.
    Source
    Division of Surgical Oncology, Department of Surgery, University of Michigan, Ann Arbor, MI 48109-5932, USA.
    Abstract
    PURPOSE:
    Significant concerns exist regarding the content and reliability of oncology clinical practice guidelines (CPGs). The Institute of Medicine (IOM) report “Clinical Practice Guidelines We Can Trust” established standards for developing trustworthy CPGs. By using these standards as a benchmark, we sought to evaluate recent oncology guidelines.
    METHODS:
    CPGs and consensus statements addressing the screening, evaluation, or management of the four leading causes of cancer-related mortality in the United States (lung, breast, prostate, and colorectal cancers) published between January 2005 and December 2010 were identified. A standardized scoring system based on the eight IOM standards was used to critically evaluate the methodology, content, and disclosure policies of CPGs. All CPGs were given two scores; points were awarded for eight standards and 20 subcriteria.
    RESULTS:
    No CPG fully met all the IOM standards. The average overall scores were 2.75 of 8 possible standards and 8.24 of 20 possible subcriteria. Less than half the CPGs were based on a systematic review. Only half the CPG panels addressed conflicts of interest. Most did not comply with standards for inclusion of patient and public involvement in the development or review process, nor did they specify their process for updating. CPGs were most consistent with IOM standards for transparency, articulation of recommendations, and use of external review.
    CONCLUSION:
    The vast majority of oncology CPGs fail to meet the IOM standards for trustworthy guidelines. On the basis of these results, there is still much to be done to make guidelines as methodologically sound and evidence-based as possible.
    Comment in
    Guidelines for guidelines: measuring trustworthiness. [J Clin Oncol. 2013]
    PMID: 23752105 [PubMed - indexed for MEDLINE]

    1. WilliamLawrenceUtridge says:

      Two of the guideline-makers in that sub-field have a slew of industry COIs

      What kind of COIs? Owning stocks? Funding for their labs and research? Outright bribes? For anything except an outright bribe, I think the concerns are fairly overblown, or borderline-unavoidable under current conditions. Without a massive infusion of cash from the government, the costs of drug development must of necessity be borne by Big Pharma either internally or by giving grants to university-based researchers. How much of a COI is it if you are a researcher whose lab is funded by Pfizer to conduct research? Restrictions on spending by university research offices means you can’t use the money to buy yourself a new car, costs are restricted to grant funds only, and there is a limited pool of experts to draw upon. You want someone to give expert advice on monoclonal antibodies in cancer care? Chances are it’s going to be someone who has successfully competed for industry funding to conduct research on their new line of chemotherapy-focused monoclonal antibodies.

      The exception is when there are muzzling agreements, where researches are prevented from publishing or commenting. That’s an area where the feds could do a lot of good, basically enforce the opposite – drug companies should be prevented from having any control over the data or researcher. If you fund a lab or a research project, it’s completely hands-off. I would love to see it go one step further. You develop a new drug? You give the cost of the controlled trial to the NIH and researchers compete for the grant to test it.

      The blanket use of the term “COI” irritates me, it treats any involvement, any link whatsoever, as if it were a reason for an unreserved condemnation of any and all work every done by the researcher. Too often it’s used as a reason to close the conversation, as if it were some sort of trump card that was unanswerable, and as if there were no publications or data upon which to base conclusions and no other experts to debate and challenge, no peer-reviewed literature and commentary to draw upon. Yes, COIs are an issue, but they aren’t everything.

      To me, it just means that these men are spending a lot of their time working on business arrangements instead of on science and medicine, and I doubt that’s the kind of people we want, making recommendations on patient care.

      Doesn’t that seem a little excessive? What were the specific links? Were they consultants? Did they give CME talks? Are they stockholders? Are they an adjunct scientific director? Or do they just hold a grant from a company, a grant that supports research and patient care? All are COIs, not all are crippling to credibility, and the last one is still a COI but also a powerful indication that the researcher holds a large amount of expertise, the exact kind of expertise you would need to have an informed opinion on patient care due to having done a lot of work on cancer treatment.

      I wonder if they’ve ever studied the question of “do our IOM standards actually produce superior clinical practice guidelines”? Or are they over-focused on appearances for the sake of appearances?

      Ugh, I hate the way CAM-promoters are forcing me to defend Big Pharma. Not you specifically SS, this is a pattern I’m noticing in my comments over the years. Bleah.

  14. THE TRUTH LIES NEVER IN THE EXTREMES.

    As a research fellow for more than an half century I can confirm that the alternative medical science contempts a lot of nonsense. I’m anti non-guided alternative implications by patients.

    On the other hand we cannot consider food and nutrients as alternative.
    Make the calculation about what’s your daily consumption from food and drinks is multiply that figure by 365 days/year and multiply again by your age.
    That amount passed your intestines. Tell me again that nutrition is alternative.

    So let’s be clear. The medical profession is not a monopoly from the medical world but a cohabitational science from Medical doctors – Pharmacologists – Nutritionists and last but not least from scientists as myself.

    The main problem is that the whole is not enough coordinated and infiltrated by people who give prevalence to their commercial interests. This goes for the classical and alternative world.

    Last remark: I like people who think – I prefer people who know but I have a hell of a problem with people who “think they know”
    I like the way how your articles are brought forward

    Prof.Dr.Sc. Guy Van Elsacker -BIOMED Expert
    Specialization – Cell membranes & Crosstalk of cells
    Founder MEDITALK (www.meditalk.cz)
    Chair Scientific Trade Mission 2014 to the UK

  15. Trevor Roberts says:

    We may be happy to be convinced by your argument that “cut, burn and poison will have to do” for people diagnosed with cancers, but part of the reason that proponents of alternatives tend to reject mainstream convention is the lack of strong encouragement for people to improve their lifestyle/eating habits and thereby enhance their bodies’ immune systems. It has been repeatedly demonstrated that enhanced immune systems can best resist diseases, including many (most?) cancers. This is where the feeling that cancer is a business comes from: as much as the medical profession defends its approaches to disease, it should also (but doesn’t) promote prevention. Just as we see “Don’t Speed” billboards on the highways, and “Drink in moderation” warnings on wine bottles, and “Smoking kills” warnings on cigarette packets, we need to see more of such similar warnings prominently displayed wherever people are damaging products (e.g. added sugars). It is my understanding that alternative treatments attempt to avoid/defer invasive treatments such as surgery: most people I know who assert that chemotherapy is useless or dangerous do so out of their belief in their immune systems, and they note that immune system support seldom accompanies other mainstream treatments.

    1. Harriet Hall says:

      People with good immune function also develop cancers. Since cancer cells arise from mutations in normal human cells, they often don’t have enough different antigens for the body to recognize them as “foreign” and try to fight them off. And there is no evidence that enhancing immune function improves patient outcomes, except when specific tumor antigens are targeted.

    2. WilliamLawrenceUtridge says:

      It has been repeatedly demonstrated that enhanced immune systems can best resist diseases, including many (most?) cancers.

      1) Repeatedly demonstrated? Surely you have a citation for this.

      2) Well, it’s a good thing the mainstream nutritional information emphasizes the importance of fresh fruits and vegetables, whole grains and minimal consumption of processed foods. But while the antioxidants in foods may help prevent the development of certain cancers (there are some genetically inevitable cancers that food won’t do a damned thing for), they are useless for things like smoking (where antioxidants might make things worse, at least in pill form) or ionizing radiation, or really anything that causes transcription errors through non-oxidative means. But is there any evidence that nutrition is beneficial for the treatment of cancers, once the genetic damage has already occurred, and the cells are undergoing undifferentiated division?

      Further, what other sort of encouragement do you think we should have to make sure people eat more fresh fruits and veggies? Subsidies for the purchase of fresh produce and canned goods? That’d be great, making the food cheaper might make people more likely to buy it. School meal programs? Good idea, politically it’s not really supported much these days. Unfortunately, it’s difficult to get people to change their eating habits, and even I think it’s too much nanny-state intervention to coerce people into downing a serving of brocolli once a week.

      I wish SCAM proponents would stop pretending doctors had their patients a candy bar, prescription and pack of cigarettes with every appointment. The information you are asking for does exist – food is labelled, and has a list of ingredients. Where I shop, it is explicitly labelled, with healthier options given a higher rating on the in-store nutritional guide that is displayed next to the prices.

      This is where the feeling that cancer is a business comes from: as much as the medical profession defends its approaches to disease, it should also (but doesn’t) promote prevention.

      What should doctors do, refuse to treat patients and instead focus solely on prevention? How would you feel if your oncologist said “oh, sorry, I’m closing shop to focus on prevention so you’ll just have to die”. Also, do you realize how complicated cancer is? It’s not one disease, each tissue type can develop multiple cancers, with mutliple genetic deviations, each requiring different treatment. Tumors evolve over time, evading both the body’s defences and medical interventions as it does so. Researching these topics is devilisly expensive, at least in humans. Cancer is pretty rare in the young, you have to screen millions to figure out who has cancer (before it is symptomatic), and even then – you rarely know what causes it. There are few reliable preventive interventions beyond diet, exercise, maintaining a proper weight, smoking prevention and ceassation and avoiding known carcinogens. Often those carcinogens are not ones readily-available to the public anyways, or are externalities produced by industry or individual activity (like driving) whose results can not be reliably linked to source.

      The single biggest cause of cancer is smoking. You may have noticed that the only people who smoke in movies these days are the villains. Doctors and society do take prevention seriously – it’s just hard to do and extremely difuse.

      It is my understanding that alternative treatments attempt to avoid/defer invasive treatments such as surgery:

      Yeah, most doctors will also present this as an option.

      most people I know who assert that chemotherapy is useless or dangerous do so out of their belief in their immune systems, and they note that immune system support seldom accompanies other mainstream treatments.

      Generally by the time a tumor is causing symptoms, it is usually pretty dangerous. For solid tumors, surgical excision is often the best, and safest bet. The body has already lost the fight to contain it, and the bigger the tumor gets, the less likely it will be to disappear into spontaneous remission. You might want to tell the people who claim this that they are wrong.

  16. Trevor Roberts says:

    need to amend: wherever people are served damaging products

  17. Hangon says:

    ” Unfortunately, it’s difficult to get people to change their eating habits, and even I think it’s too much nanny-state intervention to coerce people into downing a serving of brocolli once a week.”

    Yes it is when doctors are not educated in these matters, when government allows fast food joints to label their products as food.

    1. WilliamLawrenceUtridge says:

      Fast food products are food. They aren’t perfectly nutritious food guaranteed to be healthful in large quantities, but what is? Food is food, it doesn’t all need to be antioxidant-rich blueberries or protein-packed quinoa or nothing-but-fiber spinach. In fact, it shoudln’t, because each of those foods, in isolation, will eventually kill you. Even that pariah of food, McDonalds, can be a valuable source of nutrients if you are a protein- and caloire-starved kid who has trouble meeting their basic energy needs.

      You seriously think it’s a good idea for the government to tell you what you can and can’t eat? What you can and can’t feed your children? What did you think of Bloomberg’s decision to make large-volume sugary drinks illegal in New York?

      Don’t blame the doctors. Doctors know what a good diet looks like, what a malnourished child looks like, what an obese adult looks like, and what a nutrient deficiency looks like. I would even venture to not believe the problem is necessarily patient ignorance. It’s simply too easy to over-eat. The larger food problem in first-world nations is not that of nutrient deficiency, it is caloric excess. There has been no epidemic of rickets, or scurvy, or beriberi. There has been an epidemic of obesity, which has nothing to do with micronutrients and everything to do with macronutrients.

      What solution do you propose instead of “banning fast food” or labelling it as (what exactly – garbage? Inedible? Hazardous? It is none of these things)? Do you really think that will make people suddenly realize their bucket of chicken is what is making them fat? They already know.

      I would suggest increasing federally-funded programs to support food stamps and welfare payments, subsidies for fresh fruits and vegetables, school lunch programs that provide edible and nutritious food at low or no cost, and other incentives to decrease the cost of eating well. I would also support a consumption tax on fast foods. But what about somewhere like Subway, where you can get a whole wheat sandwich laden with vegetables? The devil is in the details. Do you tax a sub? Or only the meat-based subs? Or only those with mayo?

      And of course, if you are claiming doctors are no educated because they don’t know about the miraculous benefits of blueberries, or raspberry ketones, or green coffee beans, or the other nonsense shilled by Dr. Oz, may I point out that these products have no well-conducted human trials demonstrating they have either a chronic or acute benefit to human health? So learning about them is less about health than it is about marketing for Big Fruit (or Big Ketone, or Big…Coffee I guess). And while fruit is definitely good and valuable, it’s not a panacea and it’s not magic.

  18. Dave says:

    Hangon, please tell us what dietary advice you would give that differs from the established advice which WLU desribed – ” the mainstream nutritional information emphasizes the importance of fresh fruits and vegetables, whole grains and minimal consumption of processed foods.” And, can you reference the data that supports further advice?

    Are you suggesting that the government pass a law requiring fast food restaurants to call their products something different than food? They do post nutritional data already in their stores but I suspect that people going in to a fast food joint know the stuff is unhealthy, and just dont care. This is fault of the government?

    I can’t speak for other doctors, but I routinely tell my patients who smoke that quitting smoking will extend their lives much more than any medication they can take.
    I can also state that smoking cessation counselling is monitored in my system. Each provider is monitored on whether they meet this quality measure. The patients of course already heard this from their mothers when they were 4 years old and see multiple antismoking ads on TV. How can anyone not know the risks?
    Other measures that are monitored are counselling about exercise, ordering flu shots and pneumonia shots, and several other things.

    I attended a talk once at a conference put on by Harvard Medical School by Deepak Chopra, not highly regarded on this website, but he’s a very good speaker and he made one comment that I remember – “One problem you as physicians face is that many of your patients do not really want to get better”. When we sat in stunned silence, he elaborated further – “What they want is symptom relief. To get better means they have to change their diet, lose weight, exercise, stop unhealthy behaviors, and that takes work, and they dont want to do that. What they want is a pill to relieve their symptoms.” There was a lot of truth in that statement.

  19. Dave says:

    We’re talking preventative care in the above post. Once you’ve got a disease it should be treated.

  20. Isabel says:

    I’m well aware this is anecdotal, but here goes: Two years ago, at 57, I was diagnosed with invasive lobular breast carcinoma, Grade 3, Stage III. I did neoadjuvant chemo, modified mastectomy (1 “hot” lymph node), and 6 wks. radiation. Now it’s back. The kicker is, I’ve been pretty-much a vegetarian since birth (always weighed #120), always exercised, never smoked, occasional alcohol, no family history, early menarche/late menopause, no children. NO supplements or woo. I’ve controlled the variables I could(except having children—-considered that a worse fate!), but here I am.
    As a schoolteacher, my immune system has always been under attack, but I hardly ever succumb. I live in a rural area (no industrial pollutants). So I’d like to know what I did wrong. All the preventative measures suggested, I’ve always done. It appears to me we can’t prevent this thing.

  21. Sarah says:

    Hello.

    I enjoyed your article very much and am heartened to learn of the efficacy of chemotherapy in the early stages of breast cancer. It is wonderful news. I am curious if you could refer me to a study that assesses the efficacy of chemotherapy in general (i.e it’s therapeutic value overall, not just in the breast). The chart is very helpful and also makes me happy that less people are dying. I showed it to my friend and he said that part of the reason might be because of the improvement in early detection techniques. So I guess I am wondering, what might the chart look like if we are talking about say, stage 2 and 3 cancer. Thanks so much and I look forward to your response.

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