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Alternative medicine use and breast cancer

Of all the posts I and my cobloggers have written for SBM over the last 15 months, most provoke relatively few comments. However, a few stand out for having provoked hundreds of comments. The very first post that provoked hundreds of comments was Harriet’s excellent discussion of the International Network of Cholesterol Skeptics. In fact, Harriet seems to be quite good at writing posts that provoke a lot of comment, as another of her posts, specifically the one in which she discussed circumcision, also garnered hundreds of comments. However, to my great surprise, the one post that stands out as having received the most comments thus far in the history of SBM is one that I wrote. Specifically, it was a post I called Death by “alternative” medicine: Who’s to blame?, which has collected an astonishing 611 comments thus far. The topic of the post was a case report that I had heard while visiting the tumor board of an affiliate of my former cancer center describing a young woman who had rejected conventional therapy for an eminently treatable breast cancer and then returned two or three years later with a large, nasty tumor that was much more difficult to treat and possibly metastatic to the bone, which would make it no longer even potentially curable. My discussion centered on what the obligation of a physician is to such patients who utterly refuse the science- and evidence-based medicine that we know to be able to cure them of a potentially fatal disease, and I was not only surprised but somewhat taken aback by the vehemence of the discussion.

Since that post, I’ve always been meaning to take a look at what, exactly, the effect of choosing “alternative” medicine over “conventional” medicine is on the odds of survival for breast cancer patients. Even though intuitively one would hypothesize that refusing scientific medicine and relying on placebo medicine instead would have a detrimental effect on survival, it turns out that this question is not as easy to answer as you might think. For example, if you do a search on PubMed using terms like “alternative medicine,” “breast cancer,” and “survival,” the vast majority of the hits will be studies of complementary and alternative medicine (CAM) and breast cancer with little reference to what possible effect these therapies might have on survival. I can envision several reasons for this, the first being that–thankfully–relatively few women actually use alternative medicine exclusively to treat their breast cancer. Also, those that do probably drop off the radar screen of their science-based practitioners, and it is difficult, if not impossible, to capture data regarding their outcomes, given that they all too often stick with their alternative healers until the end. True, they may pop up again in their surgeon’s or primary care doctor’s office with huge, fungating tumors, only to be told that they have to undergo chemotherapy to shrink the tumor before any surgery is possible, after which they will often disappear again. Another important reason is that the natural history of breast cancer is extremely variable, from nasty, aggressive tumors that kill within months to indolent, slow-growing tumors that, even when metastatic, women can survive with for several years. (It is, of course, these women who usually show up in “alternative medicine” testimonials, because they can survive a long time with little or no treatment before their tumors progress.)

Because it’s important to understand the natural history of breast cancer, I’ll reference a classic study examining the natural history of untreated breast cancer. It was published in 1962 by H. J. G. Bloom, W. W. Richardson, and E. J. Harries, and examined data from Middlesex Hospital from 1805 to 1933 where 250 cases of untreated breast cancer were identified and studied. They calculated survival as the period of time from onset of symptoms to death. What they found was that 18% of the 250 patients survived five years; 3.6% survived 10 years; and 0.8% survived 15 years. Of note, it was 19 years before all patients were dead. Overall, the median survival was 2.7 years. A survival graph from this classic paper is below:

Fig1

It should be noted that all of these tumors were detected as (at the very minimum) lumps in the breast, given that there was no other way of detecting them at the time. However, the reason we go back to this study time and time again is because, at least in developed countries, it is the rare woman with breast cancer who does not undergo treatment of some kind for it. These days, most tumors are detected at far less advanced stages; indeed, most are detected by mammography. What that means is that, if such a study could be done today, it is very likely that lead time bias would significantly increase the apparent median survival, because increasingly tiny tumors are being found. It is also possible that a significant number of such small tumors may spontaneously regress, which further complicates the issue today, not to mention making it easier to find women who have rejected some or all of “conventional” medicine to treat their cancers and survived significant lengths of time to produce alternative medicine testimonials.

With this background, I have found a couple of studies that can help answer the question. The first one was published in 2005 in the Annals of Surgery by a group in from Geneva University Hospitals. This study involved a search of Switzerland’s database between 1975 and 2000 and included 5,339 patients diagnosed with nonmetastatic breast cancer. The strength of this study is that the Geneva Cancer Registry includes data from all patients from the Geneva canton who underwent treatment and allowed the investigators to compare the outcomes of the women who refused to undergo surgery with curative intent with those who underwent surgery. In the Registry, there were identified 70 patients (1.3%) who refused surgery and concluded:

These women [those who refused surgery] were older, more frequently single, and had larger tumors. Overall, 37 (53%) women had no treatment, 25 (36%) hormone-therapy alone, and 8 (11%) other adjuvant treatments alone or in combination. Five-year specific breast cancer survival of women who refused surgery was lower than that of those who accepted (72%, 95% confidence interval, 60%–84% versus 87%, 95% confidence interval, 86%–88%, respectively). After accounting for other prognostic factors including tumor characteristics and stage, women who refused surgery had a 2.1-fold (95% confidence interval, 1.5–3.1) increased risk to die of breast cancer compared with operated women.

It is true that this is not a randomized study; rather, it is a retrospective study. Consequently, it’s impossible to rule out selection bias, but, as the authors point out, this is one case where doing a randomized study is completely unethical. Moreover, half the women accepted some form of other standard, effective treatm,ent, such as hormonal therapy alone. In any case, what this study shows is that women with no surgery can still live a long time, but are far more likely to die of their cancer than women who do undergo surgical extirpation.

As far as I can find, there is one study that specifically looked at the question of what happens to women who opt for alternative medicine instead of scientific medicine. This study, like the one I just cited, was published in the surgical literature, namely American Journal of Surgery. Given the nature of the question it was seeking to answer, its design is single-armed and retrospective, using prognosis estimated by Adjuvant! Online, an online tool into which clinicians can enter prognostic factors of a breast cancer at the time of presentation and come up with an estimate of chances of survival and recurrence with and without treatment. This, of course, is a weakness, but, again, randomizing patients to scientific medicine or alternative medicine would be completely unethical. In the case of such questions, we scientists have to make do with whatever methodology we can; i.e., do the best we can with what we have. Unfortunately, the study was also small, only 33 patients. Even so, given the huge difficulties involved in undertaking such a study, the investigators, who, as private practitioners operating a community practice in Eugene, OR, went above and beyond the call by trying to look at their data and answer this question. That their study has a number of shortcomings is not their fault; they appear to haved done the best they could with what they had, which includes patients who underwent a panoply of alternative therapies, including coral calcium, herbal therapy, mushrooms, high dose vitamins, whey, chelation therapy, hemlock, and coenzyme Q10.

So what were their findings?

They’re summed up in the following table:

table

The authors comment:

We found that the overwhelming majority of the patients who initially refused surgical treatment for breast cancer developed disease progression. Five of these patients ultimately underwent surgical resection. Of the other 6 patients, 5 had developed metastatic disease that precluded benefit from surgery. Furthermore, the disease progression caused by the delay in surgery was associated with an increase in the estimated 10-year mortality rate.

Patients who declined chemotherapy or hormone therapy faired slightly better. Optimism for this strategy should be severely tempered by the fact that the length of follow-up evaluation in these patients was relatively short, and these patients had early stage (I or II) disease. By software estimates, the 10-year mortality rate for these patients is still expected to be more than 50% higher than it would have been if the patients had taken their recommended therapy.

A number of patients who expressed their intention to pursue alternative therapies did not return for follow-up evaluation. Attempts were made to contact these patients. Those for whom follow-up evaluation was unavailable were excluded from this study. Although their omission may introduce a selection bias in the results, the effect of this bias is expected to be small because relatively few patients (14 of 47) were in this category.

I find two points important about this study. First, it confirms once again the importance of surgery as a therapeutic modality for breast cancer, especially early stage. Second, and more importantly, it strongly suggests that foregoing or delaying surgery or chemotherapy is at the very least associated with a significantly decreased chance of recurrence-free survival. The authors do note that it is impossible to tell whether this increase in mortality was solely due to delay or refusal of effective therapy or whether the modalities chosen were deleterious. My guess is that it was almost certainly due to the ineffectiveness of the alternative therapies chosen.

More evidence of the uselessness of “alternative” medicine in breast cancer was published two years ago by Edzard Ernst, author of Healing, Hype or Harm? A Critical Analysis of Complementary or Alternative Medicine, which Harriet reviewed about a month ago. In 2006, he wrote a review for the Breast Journal along with Katja Schmidt, MSc, C Psychol, and Michael Baum, MD, ChM, a review entitled Complementary/Alternative Therapies for the Treatment of Breast Cancer. A Systematic Review of Randomized Clinical Trials and a Critique of Current Terminology. The objective of the study was to examine all studies randomized clinical trials (RCTs) for “alternative cancer cures” (ACCs). Treatments examined included various methods of psychosocial support such as group support therapy, cognitive behavioral therapy cognitive existential group therapy, a combination of muscle relaxation training and guided imagery, the Chinese herbal remedy Shi Quan Da Bu Tang, thymus extract, transfer factor, melatonin, and factor AF2.

The first finding was that the methodological quality of the studies was, by and large, pretty low. The most common deficiencies included: lack of power sample calculation; small sample size; lack of adequate randomization and/or (patient and assessor or only assessor) blinding; and insufficient follow-up periods. It was noted that only one trial applied an intention to treat analysis. From the 15 studies Ernst examined, this is what was concluded:

The totality of the data fails to show a single intervention that would be demonstrably effective as an ACC. The paucity and the often-low methodological quality of the RCTs are as unexpected to us as they are disappointing. Most trails had small sample sizes; thus a type II error is conceivable. But even if this were true, one would be correct in stating that to date, no effective ACC has been identified.

A lot of this is, of course, true based on discussions of prior plausibility alone. One could argue that, given the poor quality of the studies examined by Ernst, there might be an effect that was missed. However, if an effect were missed, it would have to be small or, at most, moderate. That is not what is claimed for many of these ACCs. What is often claimed is a near-miraculous “cure” for cancer, which, if it were true, would be relatively easy to detect. As I’ve often argued about, for example, the Gonzalez regimen for pancreatic cancer, if such ACCs really were cures, it would actually be fairly easy to show. In the case of pancreatic cancer, for instance, just producing well documented case reports of a few five year survivors among patients with documented metastatic adenocarcinoma of the pancreas would, I daresay, make even Wally Sampson and Kimball Atwood sit up and take notice. Somehow, we never see this. Of course, what makes the question in breast cancer more difficult to answer is its highly variable natural history. In contrast, the vast majority of patients with pancreatic cancer die within the first year (more than half die within six months); fewer still live beyond two years; and very close to none live beyond three years. In contrast, lots of women with metastatic breast cancer live longer than two or three years; a few.

Finally, about five years ago, there was a study out of Norway that looked at the effect of alternative medicine on cancer survival. This study did not limit itself to breast cancer, but it is interesting and useful nonetheless. The hypothesis of the study was that the use of alternative medicine does not have any effect on the survival of cancer patients, and to test the hypothesis investigators studied data from surveys done by the Norwegian Board of Health, which asked patients standard demographic information, but then asked them about their use of alternative medicine as follows:

In the questionnaire presented to the patients, AM was defined as any treatment outside of mainstream therapy that had been used to treat their cancer. A multiple-choice list consisting of the best known and frequently used non-proven methods in Norway was presented. Patients also had the opportunity to add other types of alternative therapy in response to an open question.

The following alternative methods were described in the multiple choice questionnaire: Use of biological treatments, herbs, faith healing or healing by hand, homeopathy, reflexology (zone therapy), megadoses of vitamins, diet treatments, injection therapies such as iscador (a mistletoe preparation) and a Norwegian injection therapy called “Nitter therapy”. Nitter therapy consists of vitamin B12, gammaglobulins, tranexamic acid, multivitamins and nutritional supplements.

Modalities such as relaxation, psychotherapy, participation in a self-help group or changes in lifestyle activities that were used to reduce distress and to improve the patient’s subjective well being were not coded as AM.

I actually very much approve of the fact that the investigators did not define relaxation, psychotherapy, lifestyle changes, etc., as “alternative.”

A total of 515 patients were analyzed, and results were as follows:

In January 2001, survival data were obtained with a follow-up of 8 years for 515 cancer patients. A total of 112 (22%) assessable patients used AM. During the follow-up period, 350 patients died. Death rates were higher in AM users (79%) than in those who did not use AM (65%). In a Cox regression model adjusted for demographic, disease and treatment factors, the hazard ratio of death for any use of AM compared with no use was 1.30, (95% Confidence Interval (CI) 0.99, 1.70; P=0.056), suggesting that AM use may predict a shorter survival. Sensitivity analyses strengthened the negative association between AM use and survival. AM use had the most detrimental effect in patients with an ECOG (Eastern Cooperative Oncology Group) performance status (PS) of 0 (hazard ratio for USE=2.32, 95% CI, 1.44, 3.74, P=0.001), when compared with an ECOG PS of 1 or higher. The use of AM seems to predict a shorter survival from cancer. The effect appears predominantly in patients with a good PS.

In other words, not surprisingly, use of alternative medicine is correlated with poorer surival in the patients with a good performance status and thus who are likely to have a more favorable prognosis. Patients with a poor performance status are more likely to undergo less aggressive therapy because they are less able to tolerate, for example, radical surgery or heavy-duty chemotherapy regimens.

The authors speculated about a number of reasons why use of alternative medicine might be associated with poorer survival. Obviously, it may not be causative. (Remember again that correlation does not necessarily equal causation. One possible explanation is that users of alternative medicine are less likely to undergo optimal medical therapy. One interesting possibility is that users of alternative medicine were more likely to be having severe symptoms, which led them to turn to “alternative medicine” to try to relieve their symptoms. In any case, this study had a number of problems, including a high attrition rate that could have resulted in significant selection bias.

Putting it all together, I conclude that there is no compelling evidence for a significant survival benefit due to any “alternative” therapy, nor is there good evidence for significant treatment effects. The studies that do purport to show an effect are virtually all plagued with methodological difficulties and tend to show effects that are barely above background noise. Even the much touted psychosocial support of late has failed to demonstrate any improvement in the survival of cancer patients. Moreover, although there is a relative paucity of studies, and they, too, are generally retrospective and difficult to interpret, what evidence is out there is that alternative medicine use among cancer patients is associated with an increased risk of dying from cancer, particularly when conventional therapy is eschewed. Taken together, these data make it very hard not to conclude that at best the vast majority of alternative therapies are either useless, no more than placebos, or might even be harmful. That is why they have no role in science-based medicine at present.

As Edzard Ernst put it:

The idea of an “alternative cancer cure” assumes that conventional oncology would not adopt a cancer treatment simply because it originates from an area outside of mainstream medicine. We feel that, should such a cure one day emerge, it would be investigated without delay by oncologists and adopted into routine care as soon as the data supporting it are convincing. Plant-based cancer medications such as Vincristin and Vinblastin (both extracted from the plant Vinca rosea) or Taxol (Taxus baccata) could be employed to back up this theory. It follows that the term ACC is and most likely will always be a contradiction in terms.

Or, as I frequently put it: There is no such thing as “alternative” medicine. There is medicine that is effective, medicine that is not, and medicine that has not been tested yet. Nearly all of so-called “alternative” medicine falls into one of the latter two categories, and those that have not been tested yet nearly all fall into the category of being so wildly improbable that testing them without more positive evidence makes no sense. In any case, as a cancer surgeon, I don’t care where a therapy came from. I really don’t. If someone could show me that reiki or homeopathy cures cancer, I’d use either. In the meantime, I will continue to argue that the very concept of “alternative” medicine is a potentially deadly false dichotomy for cancer patients.

REFERENCES:

  1. H. J. G. Bloom,, W. W. Richardson, & E. J. Harries (1962). Natural History of Untreated Breast Cancer (1805-1933) British Medical Journal, 2, 213-221 DOI: PMC1925646
  2. Chang, E., Glissmeyer, M., Tonnes, S., Hudson, T., & Johnson, N. (2006). Outcomes of breast cancer in patients who use alternative therapies as primary treatment The American Journal of Surgery, 192 (4), 471-473 DOI: 10.1016/j.amjsurg.2006.05.013
  3. T Risberg, A Vickers, R.M Bremnes, E.A Wist, S Kaasa, & B.R Cassileth (2003). Does use of alternative medicine predict survival from cancer? European Journal of Cancer, 39 (3), 372-377
  4. Verkooijen, H., Fioretta, G., Rapiti, E., Bonnefoi, H., Vlastos, G., Kurtz, J., Schaefer, P., Sappino, A., Schubert, H., & Bouchardy, C. (2005). Patients’ Refusal of Surgery Strongly Impairs Breast Cancer Survival Annals of Surgery, 242 (2), 276-280 DOI: 10.1097/01.sla.0000171305.31703.84

Posted in: Cancer, Herbs & Supplements, Science and Medicine, Surgical Procedures

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70 thoughts on “Alternative medicine use and breast cancer

  1. ImperfectlyInformed says:

    In Cassileth and Deng’s 2004 review (http://www.theoncologist.com/cgi/content/full/9/1/80), a few treatments come off as promising. For example, shark cartilage extract Neovastat (now disproven), polysaccharide K (approved in Japan, so arguably not CAM), and perhaps antineoplastons. The latest Cochrane review of laetrile actually stated that clinical trials are necessary, and there’s allegations that Moertel used the relatively inactive isoamgydalin at far too low of doses, and gave up on intravenous (nontoxic) for oral (possibly toxic) far too quickly.

    Bizarrely, Cassileth and Deng don’t mention perhaps the most promising CAM cancer treatment: melatonin. A recent meta-analysis found that melatonin “reduced the risk of death at 1 yr (relative risk: 0.66, 95% confidence interval: 0.59-0.73, I2=0%, heterogeneity P<or=0.56). Effects were consistent across melatonin dose, and type of cancer”. This involved 643 patients. No blinding, no placebo, 2/10 RCTs used intent to treat; most trials tested melatonin + treatment against only treatment. Admittedly, same research group for all the trials, which is suspicious. Still, it’s a remarkable effect which should have brought major attention when the first trial was published in 1992. Incidentally, one of the coauthors, Seely, is a naturopath who published a very critical review of chelation therapy. He’s the research director at the Canadian College of Naturopathic Medicine, and is now conducting a dbRCT on melatonin and cancer due to be completed in 2012. Have you never heard about the melatonin-cancer research?

    The shallow reading of alternative cancer treatments displayed in this post (and even, strangely, in Cassileth’s review), confirms an earlier statement I made in a comment that this blog has strong ideological rather than (or in addition to) scientific elements. There’s little interest in sifting the wheat from the chaff and providing a balanced overview of medical science, including major problems in mainstream medicine. Ultimately this website preaches to the choir, and it’s articles are typically obviously biased.

  2. @II:

    Sorry, but you are, well, imperfectly informed. Seely’s chelation review is neither “very critical” nor competent. You probably don’t know this because you haven’t read the primary literature that it reviews. Nor, apparently, did Seely. I have: Kitchell’s 1963 report did not find ‘chelation therapy’ to be beneficial, as Seely et al reported, nor was it even a controlled trial. Olszewer’s 1990 report, the other RCT that Seely et al called “positive,” was not credible. For a comprehensive discussion of these and other pertinent chelation articles, including highly touted case reports, look here:

    http://www.ncbi.nlm.nih.gov/pubmed/18596934?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

    For a discussion of the “allegations” about Moertel’s Laetrile study, look at the report itself, the LTEs, and his response to them. What you’ll find is advocates changing the rules midstream–typical for implausible claims. The Cochrane review calls for RCTs of Laetrile (bizarrely!) for a reason that I’ve discussed several times here, but that I apparently need to do again: it conflates RCTs and the much broader realm of science. Look here:

    http://www.sciencebasedmedicine.org/?p=83

    There you’ll also find links to evidence against Laetrile that was compelling enough so that it should have “closed the books” even before Moertel’s study. Look especially at the long report by FDA commissioner Donald Kennedy:

    http://www.cancertreatmentwatch.org/q/laetrile/commissioner.pdf

  3. David Gorski says:

    My first response to II, who does, as Kim so astutely put it, seem to be “imperfectly informed,” would be to ask why he/she considers melatonin to be in any way “alternative.” It’s yet another example of how CAM coopts certain aspects of “conventional” medicine.

    In any case, it raises red flags that virtually all of the positive studies of melatonin as a breast cancer chemotherapeutic agent come from a single group, Lissoni et al. Here is how a rather good, very recent (2009) review on the subject described them:

    Human trials of melatonin as a cancer chemotherapy agent, particularly those of Lissoni et al., have been reviewed in detail (Ref. 19). It is significant that when attempting a comprehensive review and meta-analysis of studies examining melatonin as a chemotherapeutic agent, Mills et al. (Ref. 103) were able to find only ten reports, all from the Lissoni group, that analysed melatonin definitively alone or in combination with standard therapies. All studies were performed on advanced cancer patients, were unblinded and did not include placebos. These reports included: three studies on lung cancer (one alone and two in conjunction with genotoxic chemotherapy, including cisplatin); one study each on breast cancer, renal cell cancer, glioblastoma and malignant melanoma; two studies of mixed populations of patients with either advanced or metastatic solid tumours; and one study specifically of brain metastases from assorted solid tumours. The average number of subjects in these studies was 75. The meta-analysis concludes that melatonin significantly reduced the risk of death of these patients at one year.

    In a systematic review of randomised controlled trials of melatonin in solid-tumour cancer patients and on one-year survival, Mills et al. (Ref. 103) have shown that there is a positive benefit from the use of melatonin. These trials were all performed by the same group in the same hospital and are thus without independent confirmation from any other group; the results, although intriguing, are therefore difficult to assess. In addition, one year survival is very short term in the context of many cancers such as breast (with a mean recurrence time of seven years) and a much longer trial would need to be conducted. The most significant finding is that no adverse outcomes were reported from the use of melatonin. There seems to be very limited toxicity of this chemical in the context of what can be very toxic exposures during chemotherapy. This characteristic would make larger clinical trials of melatonin feasible.

    All of which are very reasonable conclusions. Independent verification is incredibly important. As an extreme example, I would point out that there are lots of antivaccine “scientists” out there who all claim to find an association between vaccines and autism that no other investigator who’s looked at the question has been able to find. Could this be the case with melatonin and cancer therapy? I don’t know, but I do know that I’m always very skeptical about results that come from only one group of investigators. I will also note that I tend to cast an especially skeptical eye on any clinical trial done by the Cancer Treatment Centers of America, given how much CTCA promotes and supports woo in addition to standard therapy; i.e., “integrative medicine.”

    From the very meta-analysis that II cites, the authors cautioned:

    There are several limitations to be considered in the interpretation of our meta-analysis. Perhaps the most significant is that the same network of investigators in Italy and Poland conducted all 10 trials. While this will not necessarily bias the results, the lack of independent verification, particularly in the presence of an effect that is perhaps surprisingly large, warrants skepticism.

    So, as far as melatonin goes, my retort to II would be that (1) melatonin as an anticancer therapy is not in any way “alternative” and (2) that the evidence for its efficacy is rather weak. Hopefully, future studies will answer the question.

    Now, regarding an “ideological bias,” we at SBM have one bias and one bias alone: We assert that medicine based on science is the best medicine for patients. We make this assertion based on what we consider strong and sound evidence. If any “alternative” medicine can make the cut when subjected to scientific scrutiny, both in terms of evidence supporting its efficacy against disease and of a scientifically remotely plausible mechanism that can be studied, we will then consider it to be part of SBM. We do not apologize for this; differentiating science-based from non-science-based medicine is the raison d’être of this blog.

    In brief, II’s entire response strikes me as the CAM equivalent of The Courtier’s Reply to criticisms of the excesses of religion.

  4. ImperfectlyInformed says:

    @Atwood:

    Indeed I didn’t know about Kitchell, and I’m chastened. However, that wouldn’t have changed the negative conclusions of Seely’s review, and somehow I find it hard to believe that both Lamas and Seely outright didn’t read Kitchell, rather than simply interpreting it differently than you did. Nevertheless, if that is true, then it’s a fairly heavy blow against them, and your description of it is fairly specific so I’m inclined to believe you. I read the article previously, by the way, and added it as a reference in Wikipedia. Your article is so incriminating of Lamas that I’m surprised you haven’t filed some sort of case with the Office of Research Integrity. Considering that it is a BMC article, you should consider adding a comment.

    As far as laetrile, I don’t have convenient NEJM access that far back, although I’d love to see those issues. One obvious problem with your article is that it doesn’t clarify that oral and not intravenous laetrile is generally (as far as I’ve heard) considered toxic. The 1970s from the FDA commissioner is not compelling either, and similarly doesn’t seem to make the toxicity clarification. That’s evidence of bias, which you should try to avoid. Admittedly much of the altmed use may be oral.

    In Wade’s 1977 article covering the early part of the controversy (http://www.ncbi.nlm.nih.gov/pubmed/17741690), it’s clear that laetrile was assumed prior to testing to be ineffective. Mysteriously, their veteran researcher Kanematsu Sugiura found it effective in several animal experiments. If I recall correctly Wade says he wasn’t able to distinguish when blinded, but it’s still suspicious. Dean Burk’s continued support of the therapy is similarly suspicious, and altogether it’s enough to leave room for doubt that the therapy was properly tested.

    @Gorski:

    I consider melatonin “CAM” because, well, for one thing it would be at best “complementary”. For another, OTC dietary supplements and herbs, even ones with real pharmacological effects, are typically considered CAM, and receive greater attention from CAM people. I’m not saying that’s a good thing, but it is a fact. It’s partly the fault of mainstream medicine for dismissing these chemicals prematurely and preferentially using other more complicated, expensive chemicals. Really, though, the argument that melatonin is not CAM is fairly weak, especially since it was mentioned in your above post.

    As far as the single group, I mentioned that fact as suspicious in my comment, which apparently Gorski didn’t notice. Still, I find it equally suspicious that nobody else has bothered to try to replicate the findings in all these years.

  5. ImperfectlyInformed says:

    Clarification on the above: I read Atwood’s article previously, and Atwood should consider submitting a comment on Seely’s work.

  6. pec says:

    “We assert that medicine based on science is the best medicine for patients. We make this assertion based on what we consider strong and sound evidence. If any “alternative” medicine can make the cut when subjected to scientific scrutiny, both in terms of evidence supporting its efficacy against disease and of a scientifically remotely plausible mechanism that can be studied, we will then consider it to be part of SBM.”

    But you want to prevent CAM researchers from getting funding.

    It’s interesting that as soon as a CAM therapy is shown to be effective, you say it isn’t CAM. Even if it its origin was obviously alternative and it had been rejected by mainstream medicine for decades.

    So if a CAM researcher manages to get some funding in spite of your all-out ideological war, and if they demonstrate effectiveness, you will say well maybe it works but, since it has now been scientifically verified, it isn’t CAM.

    So no matter what happens, you win. CAM treatments cannot possibly be scientific because you define CAM as treatments that have not been scientifically verified.

    And in this way you can always claim that no CAM treatments work, and CAM research should never be funded.

    Your definition of CAM is deceptive and incorrect. CAM is not anti-scientific and they are as interested as you are in testing their ideas scientifically (but you want to prevent them). The difference between mainstream and CAM is not scientific vs. unscientific. The difference is that current mainstream medicine is materialist, mechanistic and reductionist, while CAM does not share these limitations.

  7. David Gorski says:

    CAM is not anti-scientific and they are as interested as you are in testing their ideas scientifically (but you want to prevent them).

    I’m sorry, pec, but you owe me a new keyboard. I just spit up my iced tea all over it when I read that sentence.

    Actually, you have it all wrong with the “no-lose” proposition. It’s CAM advocates who use the “alternative” label as a marketing term and an excuse not to have to test their woo scientifically before using it on actual people. When science suggests that the chances of something like, say, homeopathy working are so infinitesimally small as to be in essence zero, they can then cry “persecuted!” and “close-minded!”

    A no-lose situation for the CAMsters.

  8. shadowmouse says:

    le sigh,

    pec’s tiresome patterings, with a heaping helping of snarkiness

    “But you want to prevent CAM researchers from getting funding”

    No, CAMmers refuse to legtimatly set up proper testing studies, and blame everyone else.

    “It’s interesting that as soon as a CAM therapy is shown to be effective, you say it isn’t CAM.”

    Duh, cause it now has proven scientific legitimacy, and is no longer CAM, it’s mainstream!

    “Even if it its origin was obviously alternative and it had been rejected by mainstream medicine for decades.”

    If it’s legitimatly tested and found effective…

    So if a CAM researcher manages to get some funding in spite of your all-out ideological war, and if they demonstrate effectiveness, you will say well maybe it works but, since it has now been scientifically verified, it isn’t CAM.

    See above.

    So no matter what happens, you win. CAM treatments cannot possibly be scientific because you define CAM as treatments that have not been scientifically verified.

    Whiiine….

    And in this way you can always claim that no CAM treatments work, and CAM research should never be funded.

    “Your definition of CAM is deceptive and incorrect. CAM is not anti-scientific and they are as interested as you are in testing their ideas scientifically (but you want to prevent them). The difference between mainstream and CAM is not scientific vs. unscientific. The difference is that current mainstream medicine is materialist, mechanistic and reductionist, while CAM does not share these limitations.”

    Yep, no limit to the outrageous claims, false hope, misrepresentation, and continuous health fraud from the CAM crowd.

    Same babble, different day.

  9. Dr Benway says:

    pec,

    Surely you believe that some therapies are not worthy of our precious resources.

    For example: cow urine for migraine.

    Or: bear bile for rejuvenating brain cells.

  10. pec says:

    The blog authors here and at Neurologica are fighting a political war (that is how they describe it) against CAM funding. They do not want CAM treatments and ideas to be tested scientifically. You can search for their comments on this subject and you will see that they are fighting hard against funding for scientific testing of anything currently considered to be alternative.

    This is in spite of the fact that they know very well an alternative idea today could become mainstream tomorrow.

  11. David Gorski says:

    One notes that pec didn’t answer Dr. Benway’s question, so I’ll throw out another one:

    Should we study urine injections for treating autism?

    After all, there are physicians who advocates such “therapy.” I’ve even written about one on this very blog.

  12. Diane Henry says:

    I wasn’t aware that CAM had contributed anything to mainstream medicine–what modalities has CAM proven that then became incorporated into the standard of care? I would love to know.

  13. Calli Arcale says:

    pec, why would it not be a good thing if CAM modalities were tested, proven, and then integrated into the mainstream? Would you rather they remain constantly on the fringe? If they are all as great as is claimed, wouldn’t that mean that the majority would be deprived of the benefits of such therapies?

    ImperfectlyInformed:

    It’s partly the fault of mainstream medicine for dismissing these chemicals prematurely and preferentially using other more complicated, expensive chemicals.

    This isn’t really reflective of the reality. The more complicated and expensive a drug is to manufacture, the narrower the profit margin will be. After all, there is an upper limit to what people are able to pay (with the exception of the very wealthy). This is part of why generics are so common (once patent protection expires). Part of the cost of a drug is its manufacturing costs, part is its material costs, and part is its development costs. A generic drug doesn’t have to pay very much for development; they just have to apply with the FDA to get their version approved, which is much less onerous than proving that the stuff works as advertised in the first place. Basically, they just have to prove that it’s functionally identical to the original drug and that their manufacturing methods pass muster.

    So, if a drug is cheaper to make, this is actually to the drug company’s benefit. Just look at Gardasil. People hold it up as an example of drug companies only wanting to sell expensive things, but its high price is a barrier to purchase which significantly limits their market share. Compare that with Airborne, a “dietary supplement” sold as a cold remedy (despite a lack of evidence), which is extremely cheap to make. Airborne is marked up considerably, but still people buy a lot of it. Certainly more than will buy Gardasil, and lots more doses per person. The profit margin for the overhyped multivitamin is much higher than for the elective vaccine, and the manufacturer could still lose their shirt over it if they can’t recoup their research and development costs due to the high price.

    Complicated, expensive chemicals are not preferred by drug companies, because the higher costs make them riskier to market. But since most of the cheap ones have already been taken, they are usually forced to either compete in an existing market for a simple, cheap chemical (eg ibuprofen, where Advil and Motrin are engaged in all-out advertising war) or try to come up with something new where they won’t have so much competition. So this drives them towards complicated, expensive chemicals anyway, which can give the impression that they somehow prefer selling things that are very expensive despite the lower profit margin that comes with that.

  14. Citizen Deux says:

    And then there is the UK. Despite a strong set of laws protecting the public from cancer cure quackery (CCQ), there still exist a number of practicioners who insist on alternate treaments for their very ill patients, depsite no evidence of efficacy and the possible interference or delay of legitimate treatment.

    Patients certainly benefit from placebo treatments, in concert with viable methodologies, however, to the exclusion of effective treatment they are a measure of criminal negligence.

    David Colquhuon has a great post on homeopathy and cancer cures in the UK.

    http://dcscience.net/?p=1196

  15. Karl Withakay says:

    Can you guys set it up so that any post where pec comments automatically gets tagged as “humor”?

    “They do not want CAM treatments and ideas to be tested scientifically. ”

    Yes, they are opposed to wasting precious, limited funds on highly implausible treatments, especially those that have already been tested scientifically and failed to show any difference from placebo. Should we test any treatment anybody invents? How about any treatment that anybody invents that enough people swear by? If I can invent a treatment and can convince half the members of the church of Scientology to use it, should the NCCAM spent millions of dollars to study it?

    (see http://www.theness.com/neurologicablog/?p=502 far a parallel outside medicine)

    They are also opposed to repeatedly running low quality pilot quality studies over and over again instead of following up with higher quality double blinded RCT’s that can separate a signal form the noise.

    I feel comfortable in saying that if there was an “alternative” treatment with a plausible basis in science, or it the underlying basis for an apparently implausible treatment could be plausibly supported, and it had not already been properly tested, you wouldn’t find any of the authors on this site opposing high quality testing of that treatment, and if those high quality trials showed it to be effective, the treatment would become part of scientific medicine, perhaps requiring a rewrite of our knowledge of science and medicine.

    The NCCAM has thrown a lot of money at “CAM” over the years, and it has yet to validate any of those implausible treatments, much to the dismay of Sen Tom Harkin.

  16. pec says:

    “Should we study urine injections for treating autism?”

    One extreme would be to formally study any ridiculous idea proposed by anyone and promoted as CAM. Another extreme would be refusing to study anything not in accord with mainstream preconceptions.

    The obvious common sense approach is somewhere between those extremes.

  17. pec says:

    “why would it not be a good thing if CAM modalities were tested, proven, and then integrated into the mainstream?”

    I never said or implied there would be anything wrong with that. That is obviously the goal.

    My complaint was that Gorski is able to claim that there are no effective CAM treatments, because any that have been shown to be effective are now mainstream.

  18. Zetetic says:

    Pec sez: “…refusing to study anything not in accord with mainstream preconceptions.”

    Approaching the feasibility of research focused on CAM modalities based on scientific plausibility (which is what SBM does) IS NOT equal to “mainstream preconceptions.”

  19. Harriet Hall says:

    pec,

    I will repeat Diane Henry’s request. Please give us an example of something that was classified as alternative that was shown to be effective and has now become mainstream. I can’t think of one.

  20. The Blind Watchmaker says:

    I think this discussion hinges on the definition of “alternative”. If a good RCT shows that a treatment has utility, then it is medicine. If not, then it is “not medicine”. Untested things still have to be considered “not medicine” until utility is proven or at least highly suggested.

    Unconventional treatments are tested. Studies go from anecdotal reports, to preliminary studies, to stage one clinical trials and then on up to formal RCTs. If the ‘treatment’ does not pass the early phases, plausibility is unlikely and it never makes it to formal RCTs. This is what the so-called “Drug Pipelines” are all about.

    A big problem with the SCAM world is that anecdotal reports and small preliminary-like studies are presented as actual, hard evidence. These studies are quoted to unsuspecting consumers.

    When organizations like NCAM perform real RCTs and find no value in whatever “snake oil”, the SCAM community condemns the findings (see all of the Sen Harkin related posts). 2+2 can’t equal 5 even if a lot of people want it too.

  21. David Gorski says:

    Quoth pec regarding a question about whether we should study urine injections for autism:

    One extreme would be to formally study any ridiculous idea proposed by anyone and promoted as CAM. Another extreme would be refusing to study anything not in accord with mainstream preconceptions.

    The obvious common sense approach is somewhere between those extremes.

    You didn’t answer the question: Should we study urine injections for autism or not? And if not, why not? Please justify your answer.

    We’ll get to your other points if you answer that question with a simple yes or no and a brief justification.

  22. weing says:

    There is medicine on the one hand and quackery on the other. The sCAM business is all about reintroducing quackery into the marketplace. The main goal of sCAM studies is marketing. It’s the exact opposite of genuine medicine where the studies showing safety and efficacy are done before it ever comes to market. In sCAM the quack cures are sold all over and the corporations selling them are laughing all the way to the bank. They don’t need to do any studies of safety and efficacy. That would be a waste of time and then you have to spend money denouncing the studies when they inevitably find that the treatments don’t work.

  23. wertys says:

    What about the Amezcua Bio Disc, pec ?

    See it here
    http://www.marystaggsdetox.com.au/index.php?cPath=112&osCsid=b84286145e08fe903403a15ce902cc89

    It has a sciencey-looking graphic showing it works, and the website says it works so it must be OK mustn’t it?

    I’m interested to hear what your criteria for investigating a treatment scientifically would actually be…..

  24. David Gorski says:

    Yes, I’d like to see if pec thinks that we need to do a randomized, double-blinded placebo-controlled study for intravenous urine therapy for autism or for the Amezcua Bio Disc.

    We can then move on in the discussion, but I want a simple yes or no question from pec on two questions:

    1. Should we do an RCT of urine injection therapy for autism to see if it’s effective? If not, please explain briefly why not.

    2. Should we do an RCT for the Amezcua Bio Disc to see if it works? If not, please explain briefly why not.

  25. Calli Arcale says:

    I think pec’s response makes it fairly clear he/she considers urine injections to be absurd, since he/she responded with a statement about the absurdity of extremes. There was a good underlying point to the question, though — trying to show pec that it is worthwhile to pick and choose what to study based on prior plausibility. I’m not sure pec’s answer to the stated question would be all that useful; the point is simply that we can judge some things as being too absurd to waste resources on, and I think pec agrees.

    pec:

    “why would it not be a good thing if CAM modalities were tested, proven, and then integrated into the mainstream?”

    I never said or implied there would be anything wrong with that. That is obviously the goal.

    My complaint was that Gorski is able to claim that there are no effective CAM treatments, because any that have been shown to be effective are now mainstream.

    The point that Gorski (and others) has been trying to make is not that there are no effective CAM treatments but that the term “CAM” is useless, in part because it’s so vague but mostly because “alternative” versus “conventional” is a false dichotomy. There should only be “proven” and “unproven”. The trend of late to divide medical therapies into “conventional” and “alternative” really doesn’t help the community. If something works, it should become mainstream so that everybody can benefit. If it doesn’t work, or is surpassed by something else, it should be set aside so that people are not harmed by it.

    Are there no effective CAM treatments? Well, since they are all in the “unproven” category, we cannot say that there are any effective ones. This is not the same thing as saying that there are no effective ones, but it’s really not much better. As long as this false dichotomy exists, I don’t hold out much hope of “CAM” modalities ever being proven effective — or proven ineffective, for that matter.

  26. pec says:

    “Should we do an RCT of urine injection therapy for autism to see if it’s effective? If not, please explain briefly why not.”

    I can’t give you a simple yes or no answer, because it depends on what people have experienced with this therapy so far. When very large numbers of seemingly normal people swear by something, it warrants at least a casual investigation. If I were a medical researcher faced with this decision I would read up on it, and then decide if it deserved any further consideration.

    Unlike most “skeptics,” I do not believe that most people are self-deceiving fools. On the other hand, anecdotes and testimonials are not scientific evidence. So, I would take it one step at a time. I would not plunge into elaborate and expensive formal research until I had seen some very good evidence in favor of the therapy.

    I would give a similar answer regarding any CAM proposal. I would not rule out treatments just because they depend on the idea that water can store information, for example, or that there are as-yet unrecognized forms of energy.

  27. Harriet Hall says:

    pec,

    Once again, please give us an example of something that was classified as alternative that was shown to be effective and has now become mainstream. I can’t think of one.

  28. David Gorski says:

    I can’t give you a simple yes or no answer, because it depends on what people have experienced with this therapy so far. When very large numbers of seemingly normal people swear by something, it warrants at least a casual investigation. If I were a medical researcher faced with this decision I would read up on it, and then decide if it deserved any further consideration.

    I’m not going to let you dodge the question that easily. You already have all the information you need to answer the question. So please answer the question: “Should we do an RCT of urine injection therapy for autism to see if it’s effective? If not, please explain briefly why not.”

    Oh, and Harriet’s question is a good one, too.

  29. Peter Lipson says:

    “Should we do an RCT of urine injection therapy for autism to see if it’s effective? If not, please explain briefly why not.”

    I can’t give you a simple yes or no answer, because it depends on what people have experienced with this therapy so far.

    Well, that pretty much clinches it for me.

    How about an RCT to see if slapping someone upside the head reduces kidney stone pain?

  30. pec says:

    Obviously, I would have to take time to read up on urine for autism. Who the heck knows? I wouldn’t reject it just because it sounds odd. I think we should become informed before making decisions. Well, does that even need to be said?

    And as I mentioned, verifying a treatment goes in stages. Anecdotal evidence may come first, then a series of small pilot studies, and eventually, if the treatment looks promising, carefully controlled experiments.

    One trick you “skeptics” use in your war against CAM is to ridicule and dismiss successful pilot studies, because they are small. In this way, you can block CAM treatments from getting through the initial stages of careful scientific investigation.

    Clever of you.

  31. pec says:

    “Once again, please give us an example of something that was classified as alternative that was shown to be effective and has now become mainstream”

    Just for a start, because I have to get to work:

    Chiropractic and many other forms of physical therapy are now pretty mainstream. You “skeptics” still reject chiropractic but you accept other forms of physical therapy (you just hate chiropractors).

    Anything related to lifestyle and disease prevention — nutrition, exercise, relaxation — was very much on the alternative side and is now very much mainstream.

    And please don’t tell me relaxation was always mainstream! It’s just another name for meditation.

  32. David Gorski says:

    Obviously, I would have to take time to read up on urine for autism. Who the heck knows? I wouldn’t reject it just because it sounds odd. I think we should become informed before making decisions. Well, does that even need to be said?

    And as I mentioned, verifying a treatment goes in stages. Anecdotal evidence may come first, then a series of small pilot studies, and eventually, if the treatment looks promising, carefully controlled experiments.

    You are continuing to dodge the question, and, once again, you already have all the information you need to answer the question. So please answer the question: “Should we do an RCT of urine injection therapy for autism to see if it’s effective? Yes or no. If not, please explain briefly why not.”

    Methinks you realize the obvious trap you have fallen into and are trying to wriggle your way out of it with lame justifications.

  33. Dr Benway says:

    pec, I hope you’re not a pedicatrician. Or a busy person, as you seem to have no means for quickly dismissing the idea of giving autistic kids urine shots.

    How about adding a tablespoon of urine to your gas tank in order to improve fuel efficiency? Is it necessary to “read up” on the idea before rejecting it?

    I will hand you two cognitive tools that will improve your decision-making efficiency and perhaps your bank account:

    1. A new hypothesis that contradicts established scientific understanding is always rejected with rare exception: the new hypothesis must explain something previously unexplained AND have more predictive power than the theory it contradicts.

    2. The onus or responsibility for providing evidence in support of any claim rests squarely on the shoulders of the person making that claim.

  34. pec says:

    “Methinks you realize the obvious trap you have fallen into”

    I don’t see any trap. I spent a little time with Google and found out that urine therapy is, and has been, widely practiced in many traditional cultures. That alone makes me curious about it — why do so many people feel that it does some kind of good? I also found that one woman in South America died from a urine injection. That alone would not make me dismiss it as dangerous, without knowing all the details of that particular case.

    Maybe there is a substance in urine that benefits the immune system in some way. I simply don’t know, and if I were a medical researcher I might try to find out. I would see if any animal testing had been done, for one thing. I would read what I could find, and I might speak to some patients and practitioners who use it.

    As I said before, I would not jump to any uninformed conclusions.

    “Should we do an RCT of urine injection therapy for autism”

    No, I would definitely not start with an RCT, and most definitely not with human subjects. I think that was clear from my earlier answer.

  35. tmac57 says:

    Dr Gorski: “which has collected an astonishing 611 comments thus far. ”
    Were 305.5 of those from PEC?

  36. Harriet Hall says:

    “why do so many people feel that it does some kind of good?”

    Read Barry Beyerstein’s essay “Why Bogus Therapies Often Seen to Work” at http://www.quackwatch.org/01QuackeryRelatedTopics/altbelief.html
    Remember all the doctors and patients throughout the centuries who believed bloodletting cured patients by balancing their humours.

    Learn some human psychology.

  37. pec says:

    “Learn some human psychology”

    I have. I know that we all deceive ourselves about many things. But we do not, if we are sane, deceive ourselves in the face of clear and obvious evidence. Sometimes health fads catch on for a while, but if they are truly useless they will die out pretty soon. I am suspect of your bloodletting example — either the evidence was variable and ambiguous, or it wasn’t as widely believed as you claim (I’ll look it up).

    And yes I know you always fall back on the placebo effect. But it is weak and people get tired of bothering with things that only make them feel slightly better. I know I don’t like to waste time and money on things that have no obvious benefit.

    The “skeptic” movement depends entirely on the idea that people are fools (except, of course, the “skeptics” themselves). I know that we are all very limited and fallible, but I also believe in the essential reasonableness of human nature. And that is one of the major differences between us Harriet. You have no respect for people in general.

  38. David Gorski says:

    And yes I know you always fall back on the placebo effect. But it is weak and people get tired of bothering with things that only make them feel slightly better. I know I don’t like to waste time and money on things that have no obvious benefit.

    The placebo effect is only operative in mostly subjective outcomes, such as reduction of pain, etc. To my knowledge, no one has ever shown an improvement in survival from cancer or even the shrinkage of a tumor due to placebo effect.

    Regarding alt-med and cancer, I highly recommend the website of one of our regular commenters, Peter Moran:

    http://www.cancerwatcher.com

    He’s done yeoman’s work in describing the issues of figuring out whether a cancer therapy works or not and in describing why cancer cure testimonials are almost never good evidence for the efficacy of an “alternative cancer cure.”

  39. Karl Withakay says:

    pec

    “I know that we all deceive ourselves about many things. But we do not, if we are sane, deceive ourselves in the face of clear and obvious evidence.”

    I think that delusion is a core part of the problem. Perfectly sane people do ignore, disregard, and discount clear and obvious evidence that contradicts positions they “know” to be true all the time.

    Which parts of the concepts of cognitive dissonance and compartmentalization do you not understand?

    While I don’t think they’re being rational in regards to their belief that the earth is 6000 years old, I don’t consider most young earth creationists to be not sane.

    “Sometimes health fads catch on for a while, but if they are truly useless they will die out pretty soon.”

    It’s not a health fad, but that fact that astrology hasn’t died out yet kind of shoots a hole in that position.

  40. Harriet Hall says:

    pec said,

    “You have no respect for people in general.”

    I love it when pec tells me what I think, especially when it is not what I think I think.

    Jerry Andrus was an inventor of optical illusions. He showed that our assumptions are often wrong. For instance, he would take off his glasses and show that there was no glass in them; everyone had assumed they were real glasses but they were empty frames. People are easy to fool in many ways. But Jerry always said the reason he could fool people is not that they are fools but is because they have wonderful brains. Our brains have learned to take shortcuts and jump to conclusions because of the survival value. It is better to misinterpret shadows in the bushes as a lion than to miss a real lion. It would be a silly waste of our time to not assume that frames contain glass and to try to verify every instance. We can be more efficient by using such mental shortcuts, but occasionally they mislead us.

    I have the highest respect for people and their wonderful brains; I just recognize that because of the way our wonderful brains are constructed, we tend to make mistakes that can only be countered by science.

    Oh, and skeptics do not exempt themselves from human foolishness. We recognize that we can be fooled as easily as anyone else. Richard Feynman said, “The first principle is that you must not fool yourself–and you are the easiest person to fool.”

  41. pec says:

    “Our brains have learned to take shortcuts and jump to conclusions because of the survival value.”

    That’s true. And there is no survival value in repeating a stupid medical mistake for thousands of years. People notice when something doesn’t work. Of course certain treatments have been overused and sometimes dangerous. But the same is true of modern chemotherapy for cancer, for example.

    Medicine has always been and still is difficult and fallible. People use whatever they happen to have, and it’s always very limited. The way you see it, there was nothing but superstitious nonsense before modern science.

    “I just recognize that because of the way our wonderful brains are constructed, we tend to make mistakes that can only be countered by science.”

    You just feel you have to pretend to have respect for non-Western people.

    Science is just a formalization of the way people naturally think; it is not different from the normal logic and common sense that all people in all times have possessed.

    How do you think primitive hunter/gatherers learned what is ok to eat? They experimented. No the experiments aren’t blinded and controlled, but they’re still experiments and they still give valid results in the long run.

    You “skeptics” think the reason people make stupid mistakes is because they have not been educated into the scientific elite. You are wrong — people make stupid mistakes because the world is complicated and our data is limited.

    If every single person became a scientist and lived according to the scientific method, there would be just as many stupid mistakes, and just as many irrational beliefs.

  42. qetzal says:

    Science is just a formalization of the way people naturally think….

    More than anything else you’ve ever written here pec, that statement demonstrates the depth of your willful ignorance.

  43. David Gorski says:

    Indeed. pec gets it entirely wrong with that statement. In reality, the scientific method is a barrier against the way people naturally think that prevents how humans naturally think from leading them to confuse correlation with causation and jump to the wrong conclusions. Pec’s ignorance of what science is and its very purpose are revealed by that comment more than anything else. Truly depressing.

  44. pec says:

    I understand the scientific method and the reasons for controlled experiments. I have a PhD in an experimental science. I am always noticing how most people — including scientists in non-experimental disciplines — confuse correlation and causation.

    But we do not see ordinary people going around doing ridiculous things because they have confused correlation with causation. Not in practical everyday life.

    Non-Western traditional people do not use harmful or useless medical treatments repeatedly over thousands of years because they have confused correlation with causation.

    Most of the time most things are unknown and we do our best. This is also true in science, certainly in modern medicine.

  45. David Gorski says:

    But we do not see ordinary people going around doing ridiculous things because they have confused correlation with causation. Not in practical everyday life.

    Are you living on the same planet as we are? Of course we do!

    That’s exactly how people do think in everyday life! Astrology wouldn’t exist if that weren’t the case. Neither would the myth that things go crazy around the time of a full moon (it’s been studied; there are, for example, no more ER visits on average around the time of a full moon than any other time). Athletes wouldn’t refuse to shave or wear their “lucky shirts” when they’re on a winning streak if that weren’t the case. Selective memory, confirmation bias, and confusing correlation with causation is how people think. Such rapid “jumping to conclusions” probably had an evolutionary advantage because waiting for more information could be fatal, but it is a method of thinking that is very ill-suited for answering scientific questions regarding medicine.

    People confuse correlation with causation all the time, especially with questions of causation in medicine. Science is the answer. At best, anecdotal evidence can be hypothesis generating. At most. For correctly inferring causation, it’s very, very unreliable.

  46. qetzal says:

    pec,

    You should sue your PhD program and advisor, because they clearly failed to train you properly. You may well have a PhD in an experimental science, but you definitely lack a PhD understanding of experimental science.

  47. tmac57 says:

    pec, “Non-Western traditional people do not use harmful or useless medical treatments repeatedly over thousands of years because they have confused correlation with causation.”
    Congratulations, you have successfully combined the argument from antiquity, with the argument from incredulity, topped off with blatant cultural chauvinism . Good job!!!

  48. pec says:

    “That’s exactly how people do think in everyday life! Astrology wouldn’t exist if that weren’t the case. Neither would the myth that things go crazy around the time of a full moon … ”

    Yes because you are absolutely certain that every ancient “superstition” is complete nonsense you would say that. But you have, of course, missed the point. People do not make serious errors in practical matters because they lack conscious knowledge of the scientific method.

    If a member of a primitive tribe eats a mushroom and dies the other members might jump to the conclusion that the mushroom was poisonous. But someone might note that they have eaten the same mushroom and it was ok, so the death may have been a coincidence.

    You do not need any scientific training to do this kind of analysis — everyone does it every day. We could not survive otherwise.

    Confusions about causation also happen all the time, but they are in areas where we do not know the cause. The world is complex and very often, as the AI pioneers Simon and Newell described it, we have to “satisfice.”

    Whenever evidence is clear and unambiguous people go along with it. When, as is often the case, there is no clear evidence, we do our best.

    Controlled scientific experiments have their place, but most of the time are not practical. Yet we are able to sort out cause and effect well enough to navigate complex everyday life.

    Our “wonderful brains” are very good at navigating this world. It is not the case that our brains constantly deceive us and lead us into grave errors.

    Yes we deceive ourselves all the time, but they are seldom self-destructive deceptions. We deceive ourselves in things we do know know and cannot know, accepting whichever answers we find most pleasant. But we do not, in general, fool ourselves into eating poisonous mushrooms.

    We are all scientists. All normal humans, including those who lack a Western education, are able to reason.

    The “skeptic” movement believes they can improve the world and eliminate irrationality and superstition by educating everyone into the “correct” way of thinking. It makes you feel good to believe that.

  49. David Gorski says:

    Yes we deceive ourselves all the time, but they are seldom self-destructive deceptions.

    Wrong, wrong, wrong, wrong.

    Counterexamples:

    1. Cancer quackery.
    2. The entire antivaccine movement, which leads to autism quackery.
    3. Several patients I’ve seen who through denial of their condition had deluded themselves that they did not have cancer, even after the tumor was growing through the skin.

    Really, pec, you’re descending into some risibly bad arguments.

  50. HCN says:

    pec said “I have a PhD in an experimental science.”

    What!!! Earlier you said you were a computer scientist! See:
    http://www.sciencebasedmedicine.org/?p=87#comment-2869 … “I am a woman in computer science and we are very very scarce.”

    I am sorry but testing software does not make you a real scientist.

  51. pec says:

    “What!!! Earlier you said you were a computer scientist!”

    I have studied more than one thing in my life. You seem so amazed. Did you think there was a law that restricts us each to one and only one field?

  52. daedalus2u says:

    I actually have looked at the literature on urine therapy (such as I could find it, there wasn’t that much when I looked). Books I have on it are:

    Urine Therapy Nature’s elixir for good health by Peschek-Bohmer and Scheiber
    The Water of Life A Treatise on Urine Therapy by J. W. Armstrong
    The Golden Fountain The complete guide to urine therapy by Coen van der Kroon
    Ancient secret of the Fountain of Youth by Peter Kelder

    There is considerable woo in the idea of urine therapy (to be charitable ;). I got it because of my interest in nitric oxide physiology, and because urine is a good source of urea, which I hypothesized that indigenous peoples in regions where other NO sources were unavailable might turn to.

    My fundamental NO hypothesis is that ammonia oxidizing bacteria on the skin oxidize ammonia in sweat into nitrite and NO, and this is important in setting the basal level of NO/NOx. NO/NOx physiology is pretty complicated and there is cross-talk with dietary nitrate which is most abundant in leafy green vegetables and which some have hypothesized is the reason that a diet rich in green leafy vegetables is associated with good health.

    When humans migrated out of Africa, they left the tropics and entered regions where it was not hot year round, where sweating was virtually absent for parts of the year. Many cultures developed the customs of wearing clothing so as to cause sweating (i.e. sweaters), or adopted the custom of sweat baths (i.e. sauna). In Tibet at high altitude, fuel was scarce, and also green leafy vegetables were not available year round. The terminal metabolite of NO is nitrate, and that is excreted in the urine, so urine is a source of nitrate as well as a source of urea (which becomes ammonia on hydrolysis).

    Topically applied urine might be able to substitute for exercise or thermal sweating provided one had the right biofilm of the bacteria I am studying. Ingesting urine might be able to substitute for ingesting nitrate in green leafy vegetables. The ancient practice of urine therapy did use both of these treatment modalities. I could find no mention of injection of urine (which I think would be a death wish).

    There are some folk practices that suggest that topical urine may cause increased NO/NOx. There is a folk remedy for impotence, the golden shower, which might have a mechanism via NO/NOx (erections are mediated through NO physiology).

    It has been suggested that UTIs can be treated by ingesting nitrate (as in 100 g of lettuce), allowing the nitrate to be excreted in the urine, allowing the bacteria causing the UTI to reduce that nitrate to nitrite (E. coli does this), and then acidifying the urine and ingesting vitamin C which facilitates reduction of nitrite to NO, producing acidified nitrite which is a broad spectrum antimicrobial.

    http://aac.asm.org/cgi/content/full/47/12/3713

    When this author presented this work at a conference, I asked for his comment on how his NO/NOx results in urine might reflect on the effectiveness of a golden shower regarding UTI status. He was not prepared to speculate on that.

    Nitrite and NO also disrupts the biofilm phenotype of many bacteria, causing biofilms to disperse. This occurs at levels well below that necessary for bactericidal effects.

    In no way do I suggest that anyone use urine therapy for anything. There are far better ways of stimulating the growth of the bacteria I am working with to supply NO/NOx. The correct way to supply more NO is topically where it feeds into the natural physiological pathways that regulate it.

  53. pec says:

    daedalus2u,

    Your post seems to confirm the idea that non-Western people are capable of reasoning and of making scientific observations. Their “wonderful brains” are not always leading them into moronic mistakes.

  54. pec says:

    “2. The entire antivaccine movement, which leads to autism quackery.
    3. Several patients I’ve seen who through denial of their condition had deluded themselves that they did not have cancer, even after the tumor was growing through the skin.”

    I can understand why parents might be afraid to have their children vaccinated, and that they don’t always have blind faith in the all-knowing medical priesthood and those fabulous drug companies.

    I can understand why a patient with advanced cancer might feel they have no good options and might be afraid to accept the reality. How is that evidence of the idiocy of non-scientists?

  55. David Gorski says:

    The antivaccine movement is based on confusing correlation with causation in blaming autism on vaccines, for one.

    It’s also a straw man to say that this is evidence of the “idiocy” of nonscientists. What it is is evidence that human beings, contrary to your claims, do frequently confuse correlation with causation and demonstrate all those other cognitive shortcomings we’ve been discussing. Smart human beings do it too. Indeed, I sometimes think that the more intelligent among us are more prone to such thinking, at least with respect to medicine, simply because they believe that their intelligence is such that they would never be so easily misled by such cognitive shortcomings that appear to be hard-wired into the human brain. Indeed, when a person refuses to admit that he or she can be prone to such cognitive shortcomings, it’s more a case of hubris than anything else.

    In fact, your labeling such shortcomings as “idiocy” says a lot about you. You seem completely unable to believe that all humans are prone to these sorts of cognitive shortcomings in every day life. Everyone is. You, me, Steve, everyone. And, yes, all those ancient peoples who thought bloodletting was a great cure for what ails you or that it’s not possible for so many people to be so wrong for so many hundreds (or thousands) of years about something. (Astrology and ghosts come to mind as counterexamples.) Science is the way to prevent such cognitive quirks from leading to the wrong conclusion.

  56. Diane Henry says:

    I must say, I am not a fan of the false dichotomy of “western” and “non-western”. As someone who I suppose straddles the line, having an asian parent, and who lived in asia for a while, I can tell you that “non-western” folk are just like us. They are us. We are them. They have no particular viewpoints that render them either superior or inferior. You can find as much silliness and intelligence in “non-westerns” as you can here. Just saying.

  57. daedalus2u says:

    pec, you don’t understand. The topical use of urine might have therapeutic effects in “the wild” provided the proper biofilm is present. The modern use of urine therapy stresses sterility and prevention of any and all bacteria. Modern urine therapy likely has no beneficial effects and the current practitioners of it don’t realize it.

    Modern urine therapy users adopted practices with no understanding of the physiology behind them, and then modified those practices to suit their aesthetic sensibilities with no understanding of the underlying physiology. They lost any physiological effects by changing what they did. All that remains is the placebo effect.

    This is what happens (in the words of the song) When you believe in things that you don’t understand you will suffer, Superstition ain’t the way! Very superstitious, wash your face and hands

    The point that Dr Hall was trying to make, and which you agreed with, was that there needed to be some sort of a priori plausible physiology behind a treatment before going into clinical trials. You suggested you would try it in animals first (we shall ignore that there are no animal models of autism).

    In the case of blood letting, your approach was to find out if ancient people really did use blood letting, rather than try and figure out what physiology blood letting might influence. Try and rely on “ancient wisdom”, rather than modern understanding of the physiology involved.

    People have all sorts of biases. Ancient people had the bias that they didn’t know about physiology, bacteria, metabolism, and a zillion other things. Modern people have the bias that they don’t know those things either and would rather listen to an ignorant charismatic fraud than a non-charismatic knowledgeable nerd. Ancient people are no different than modern people. They listened to ignorant charismatic frauds too because there was no one knowledgeable to listen too.

    Faith in drug companies or faith in charismatic frauds is still faith. The belief that the majority of MDs (i.e. the standard of care) are always wrong is faith too.

  58. pec says:

    “I sometimes think that the more intelligent among us are more prone to such thinking, at least with respect to medicine, simply because they believe that their intelligence is such that they would never be so easily misled by such cognitive shortcomings that appear to be hard-wired into the human brain.”

    Yes, I sometimes think the most educated high-IQ types tend to make the most serious errors, because they have so much confidence in their own thinking. Consider the the complex mathematical models that helped cause the financial crisis, for example.

    But you are very steadfast in missing my point. I keep saying we are ALL limited and fallible. But it’s NOT because of a lack of scientific eduction. It’s because we just do not know, and cannot know, very much.

    Yes I know we deceive ourselves, as I already said, but not because we aren’t scientific enough. If it were possible to be perfectly scientific, it would still not be possible to know the “truth” because we never have enough data. We have to “satisfice.”

  59. pec says:

    [I can tell you that “non-western” folk are just like us. They are us. We are them.]

    In the context of the discussion it should have been obvious what I meant by non-Western. I had been talking about traditional cultures and the practice of folk medicine, as opposed to modern Western medicine. I was saying that traditional people who do not have a Western scientific education are nevertheless capable of being reasonable and making scientific observations.

  60. pec says:

    ” possible for so many people to be so wrong for so many hundreds (or thousands) of years about something. (Astrology and ghosts come to mind as counterexamples.)”

    Yes that is always your ultimate “proof” that traditional people are capable of fooling themselves endlessly. Ghosts can’t possibly exist, but all kinds of people have been seeing them everywhere. I don’t want to veer off into an argument about astrology or ghosts. But I wonder if you could try to imagine that maybe your certainty might contain a trace of self-deception?

  61. pec says:

    “You suggested you would try it in animals first (we shall ignore that there are no animal models of autism).”

    I DID NOT suggest that. I said that IF I found good reasons to suspect it might have some benefit, I would FIRST try it on animals to find out if it’s safe. I KNOW there are no autistic animals! Jeez.

  62. David Gorski says:

    I must say, I am not a fan of the false dichotomy of “western” and “non-western”. As someone who I suppose straddles the line, having an asian parent, and who lived in asia for a while, I can tell you that “non-western” folk are just like us. They are us. We are them. They have no particular viewpoints that render them either superior or inferior. You can find as much silliness and intelligence in “non-westerns” as you can here. Just saying.

    Agree 100%. In fact, I view it as condescending to Asians to hold remedies that originate from the “East” to a lower standard of evidence than those that originated from the “West.”

  63. weing says:

    “I DID NOT suggest that. I said that IF I found good reasons to suspect it might have some benefit, I would FIRST try it on animals to find out if it’s safe. I KNOW there are no autistic animals! Jeez.”

    What would you consider to be good reasons to suspect urine might have some benefit in this situation?

  64. weing says:

    I’ve heard of using urine for wound irrigation in the wilderness. In the middle ages urine was used as a mouth wash. I’ve also read about the Chichimeca indians drinking the urine of their chief after he consumed a hallucinogenic mushroom in order to experience hallucinations.

  65. tmac57 says:

    pec:”I keep saying we are ALL limited and fallible. But it’s NOT because of a lack of scientific eduction. It’s because we just do not know, and cannot know, very much.”
    The point that you seem to be missing here is that the scientific method came about to compensate for those recognized human vulnerabilities.
    And though we may not know very much in comparison to all that the universe is, we still know a hell of a lot ! Just take a look around you. Take, for example the computer that you use, it represents tremendous amounts of known science. How about the entire space program, a modern automobile, and yes, modern medicine.
    I suggest that you take off your postmodern blinders, and join the real world. Come on in, the reality is fine.

  66. Chris says:

    pec said “I have studied more than one thing in my life. ”

    Fail.

    studying != learning

    You seem to be of either the open mind where too much has fallen out, or too closed minded to actually learn about the subject under discussion.

    And to repeat what tmac57 said: “I suggest that you take off your postmodern blinders, and join the real world. Come on in, the reality is fine.”

  67. pec says:

    “I suggest that you take off your postmodern blinders, and join the real world. ”

    I have stated many times at this blog that I am not against modern science, not at all. I am interested in science and technology and that’s why I studied them. What I am against is pseudo-skepticism and dogmatic materialism, which are not scientific.

    I am a skeptic and I do not make up my mind about things just because I follow a certain ideology. I think science is great and that the dogmatic pseudo-skeptics only block its progress.

  68. weing says:

    “I am a skeptic and I do not make up my mind about things just because I follow a certain ideology. I think science is great and that the dogmatic pseudo-skeptics only block its progress.”

    I find all that hard to believe.

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