As I mentioned recently, as hard as it is to believe, this blog is rapidly approaching the end of its fifth year of existence. Our first post was delivered to the anxiously waiting world on January 1, 2008; so thus upcoming January 1 will represent our fifth anniversary. In the blogging world, that’s almost the equivalent of a fiftieth anniversary, given how fast most blogs turn over. Something that is even more satisfying than mere longevity is that we really have found a niche in the medical blogosphere to the point where we’ve become quite influential. People notice us. Our targets notice it when we discuss them. Sometimes even the press notices us. This is all a very good thing.
Unfortunately, even though we’ve been at this for just shy of five years, there are still topics we haven’t covered, or at least haven’t covered in sufficient depth. The topic of my post today is one of the latter topics. We’ve mentioned it before; we’ve alluded to it before (for instance when discussing the antivaccine website Medical Voices and the Ayn Rand-worshiping Association of American Physicians and Surgeons; but there hasn’t been a post dedicated to this particular topic. I find this particularly odd because it was one a piece of misinformation promoted by elements of the antivaccine movement that truly shocked and disgusted me. Before I learned of this particular myth, I was surprised to learn that there are really people who think that vaccines are dangerous and cause autism, but I viewed it as being of a piece of a lot of other quackery I was discovering at the time.
Way back in the day, when I first encountered antivaccine views in that wretched Usenet swamp of pseudoscience, antiscience, and quackery known as misc.health.alternative (m.h.a.), there was one particular antivaccine lie that disturbed me more than just about any other. As I mentioned, it wasn’t the claim that vaccines cause autism, which is more or less the central dogma of the antivaccine movement. Even ten years ago, before the series of studies that have been released since then that fail to find a hint of a whiff of causation between vaccines and autism, that wasn’t a particularly difficult myth to refute. Indeed, given newer studies, refuting that myth has only gotten easier over the years. Emblematic of how far into the depths that particular myth has been pummeled, I know it’s gotten pretty easy when even the mainstream media start to accept that the claim that vaccines cause autism is a myth and report matter-of-factly on issues such as Andrew Wakefield’s fraud and don’t give nearly as much copious and prominent media time to the likes of Jenny McCarthy. Let’s just put it this way. When the hosts of a “morning zoo”-type radio show in Salt Lake City pummel the latest antivaccine celebrity to make a fool of himself, Rob Schneider, you know that, from an informational standpoint at least, the tide appears to have turned from several years ago, when the media took this myth a lot more seriously. That’s not to say that we don’t still have a problem. After all, “philosophical” exemption rates are going up based on a lot of this sort of misinformation, but at least the media are less insistent on “telling both sides” of a science story that doesn’t really have two sides.
Over the years, I’ve written a lot about “personalized medicine, mainly in the context of how the breakthroughs in genomic medicine and data pouring in from the Cancer Genome Atlas is providing the raw information necessary for developing truly personalized cancer therapy. The problem, of course, is analyzing it and figuring out how to apply it. Another problem, of course, is developing the necessary targeted drugs to attack the pathways that are identified as being dysregulated in cancer cells. Oh, and there’s that pesky evolution of resistance to antitumor therapies. Indeed, most recently, the Cancer Genome Atlas is bearing fruit in breast cancer (a study that I’ve been meaning to blog about).
One problem with modeling the pathways based on next generation sequencing data and expression profiling is testing whether therapies predicted to work from these analyses actually do work without actually testing potentially toxic drugs on patients. Cell culture is notoriously unreliable as a predictor. However, there is another way that’s intriguing. Unfortunately, as intriguing as it is, it has numerous problems, and, unfortunately, it’s being prematurely marketed to patients. Although I had heard of this technique as a research tool before, I learned about its marketing to patients when I came across an article by Andrew Pollack in the New York Times entitled Seeking Cures, Patients Enlist Mice Stand-Ins. Basically, it’s about a trend in science and among patients to use custom, “personalized’ mouse xenograft models in order to do “personalized” therapy:
Countering ideologically motivated bad science, pseudoscience, misinformation, and lies is one of the main purposes of this blog. Specifically, we try to combat such misinformation in medicine; elsewhere Steve and I, as well as some of our other “partners in crime” combat other forms of pseudoscience. During the nearly five year existence of this blog, we’ve covered a lot of topics in medicine that tend to be prone to pseudoscience and quackery. Oddly enough, there’s one topic that we haven’t really written much about at all, and that’s genetically modified organisms (GMOs). GMOs, as you know, are proliferating, and it’s quite worth discussing the potential and risks of this new technology, just as it is worthwhile to discuss the potential benefits versus the risks of any new technology that can impact our health, not to mention the health of the planet. Unfortunately, GMOs have become a huge political issue, and, I would argue, they have become just as prone to pseudoscience, misinformation, and bad science as vaccines, with a radical group of anti-GMO activists who are as anti-science as any antivaccinationist or quack.
Leave it to that quackery promoter to rule all quackery promoters, Mike Adams, to give me just the opportunity to show you what I mean. Over the last couple of weeks, Mike has been in a fine lather about GMOs, with multiple posts with titles such as The GMO debate is over; GM crops must be immediately outlawed; Monsanto halted from threatening humanity and The evil of Monsanto and GMOs explained: Bad technology, endless greed and the destruction of humanity. In other words, it’s a series of post with Adams’ typical hyperbole. If you were to believe him, GMOs are the product of a plot by Satan, Monsanto, big pharma, and the government, and he’s not sure which one of these is the most evil of the bunch.
There’s an oft-quoted saying that’s become a bit of a cliché among skeptics that goes something like this: There are two kinds of medicine: medicine that’s been proven scientifically to work, and medicine that hasn’t. This is then often followed up with a rhetorical question and its answer: What do call “alternative medicine” that’s been proven to work? Medicine. Of course, being the kind of guy that I am, I have to make it a bit more complicated than that while driving home in essence the same message. In my hands, the way this argument goes is that the whole concept of “alternative” medicine is a false dichotomy. There is no such thing. In reality, there are three kinds of medicine: Medicine that has been shown to efficacious and safe (i.e., shown to work); medicine that has not yet been shown to work (i.e., that is unproven); and medicine that has been shown not to work (i.e., that is disproven). So-called “complementary and alternative medicine” (CAM or, its newer, shinier name, “integrative medicine”) consists almost completely of the latter two categories.
Part of the reason why this saying and its variants have become so commonplace among those of us who support science-based medicine is that they strike at a common truth about medicine, both science-based and “alternative.” That common truth is what we here at SBM have been arguing since the very inception of this blog, namely that there must be one science-based standard of evidence for all treatments, be they “alternative” or the latest creation of big pharma. That point informs everything I write here and everything my blogging parters in crime write about too. What that means is a single, clear set of standards for evaluating medical evidence, in which clinical evidence is coupled to basic science and scientific plausibility. Indeed, one of our main complaints against CAM and its supporters has been how they invoke a double standard, in which they expect their therapies to be accepted as “working” on the basis of a much lower standard of evidence. Indeed, when they see high quality clinical trials demonstrating that, for example, acupuncture doesn’t work, they will frequently advocate the use of “pragmatic” trials, lower quality trials of “real world effectiveness” that do not adequately control for placebo effects. It’s putting the cart before the horse.
It’s that time of year again, namely flu vaccine time. My very own cancer institute will be offering the flu vaccine for its staff beginning October 1, and I plan on getting mine just as soon as I get back from the American College of Surgeons Clinical Congress in Chicago early next week. In the meantime, it’s always great to read Mark Crislip’s take on the yearly flu vaccine kerfuffle, particularly this part:
I have little (actually none) respect for HCW’s [health care workers] who do not get vaccinated. We have a professional and moral obligation to place our patients first. I think those who do not get vaccinated, except for a minority with a valid allergy, are dumb asses.
Preach it, Dr. Crislip!
However, this time of year is also a vaccine time of year for another reason (well, actually it was about a month ago). That’s because in late August or early September, depending on your state, the little kiddies (and not-so-little kiddies) return to school and therefore have to be up to date on their required vaccines or face not being able to go to school. No wonder the antivaccine movement goes nuts this time of the year, given the double whammy of antivaccine parents trying to avoid vaccinating their children before going to school by hook or by crook and the yearly promotion of flu vaccines and mandates that health care workers get them. (For the record, my cancer center requires it, and if there’s one thing the administration of my hospital has done that I fully support it’s the yearly vaccine requirement. We’re a cancer hospital, fer cryin’ out loud, and we have lots of immunosuppressed patients that we take care of!) The only other time of year when antivaccinationists are even close to this actively ridiculous is every April, which is Autism Awareness Month, when they start trying to tar attempts to highlight autism and autism research with demands that antivaccine pseudoscience be thrown into the mix like the proverbial cow pie added to the apple pie.
Since Mark’s already covered the flu vaccine so well, let’s talk about the topic of nonmedical exemptions to school vaccine mandates. This topic came up when I noticed that the bloggers and denizens of that most wretched hive of antivaccine scum and quackery, Age of Autism, have swarmed over to a news story about how Washington State has made it harder for parents to obtain nonmedical exemptions to school vaccine requirements:
There’s been a lot of discussion, both in the scientific literature and online, about recent pertussis outbreaks, which are the worst outbreaks in the US in the last 50 years. How could this possibly be, it is asked, when vaccine uptake for the pertussis vaccine remains high? True, there are pockets of vaccine resistance, where uptake of the vaccine is low, but it’s becoming increasingly clear that, unlike the case of measles outbreaks, low uptake of the pertussis vaccine does not appear to be nearly enough to explain the frequency and magnitude of the outbreaks. Given that it’s been a while since any of us has discussed the recent pertussis outbreak here on SBM, I thought that it would be a good time for me to do so, particularly because there have been some new studies and new developments since April, including a paper hot off the presses last Thursday in the New England Journal of Medicine. As a result, those of you who read me at my not-so-super-secret other blogging location might find some of the material in this post familiar, but given the new NEJM paper, I thought that now would be a good time to synthesize and update what I’ve discussed before in different forums in a more comprehensive way, even at the risk of some repetition of previous material I’ve published elsewhere. Hopefully, it will also provide materials for skeptics and supporters of SBM to counter the antivaccine movement, which has pounced on the recent pertussis outbreaks as evidence that the “vaccine doesn’t work.”
Without a doubt (to me, at least), the biggest difference between science-based doctors and quacks is a very simple one. When a treatment or preventative measure isn’t working as well as it should, we science-based physicians ask why. We try to find out what is not working optimally and why. Then we try to figure out how to make things better. So it is with the acellular pertussis vaccine. This vaccine protects against whooping cough, which is caused by Bordetella pertussis, and is administered to children in the form of a combination vaccine, the DTaP (diptheria/tetanus/acellular pertussis). Five doses are recommended for children, the first at age 2 months, and then at ages 4 months, 6 months, 15-18 months, and 4-6 years. There is also the newer formulation, the Tdap (tetanus, diptheria, and acellular pertussis), which is recommended for people between the ages of 11 and 64. The Tdap is now usually administered first at age 11-12, with additional recommendations for a Tdap booster in adolescents and adults summarized here, here, and here. Unfortunately, although the vaccine works, recent outbreaks have suggested that we need to change our approach to pertussis vaccination. Let’s see why.
As part of my ongoing effort to make sure that I never run out of blogging material, I subscribe to a number of quack e-mail newsletters. In fact, sometimes I think I’ve probably overdone it. Every day, I get several notices and pleas from various wretched hives of scum and quackery, such as NaturalNews.com, Mercola.com, and various antivaccine websites. I think of it as my way of keeping my finger on the pulse of the antiscience and pseudoscience wing of medicine, but I must admit that I don’t really read them all, but they do allow me to know what the quacks are selling and what new arguments they’re coming up with without actually going to each of their websites. I can then judge by the headlines and the blurbs included in the e-mails whether I think it’s worth it to go to the website itself and, of course, whether the topic might represent fodder for a good blog post. I will admit that not all the sites I monitor are as loony as the Health Ranger’s. In fact, I monitor the blogs and websites of the National Center for Complementary and Alternative Medicine (NCCAM), various naturopath organizations, and the like in order to learn of the “respectable” arguments being used to tout various nostrums.
Sometimes—albeit rarely—I even learn about some interesting new science.
One of the most common themes (besides antivaccine hysteria, claims that diet can prevent 95% of all cancers, etc.) tends to be one of a variety of pitches for various “cures” of serious diseases like cancer and heart disease that “they” don’t want you to know about; i.e., the Kevin Trudeau gambit. Who this “they” is can range from doctors to pharmaceutical companies to universities to the government, but the central message is that someone out there doesn’t want you to know The Truth. A variation of this sort of appeal is the claim that there is a promising new therapy, a cure even, usually natural, that is languishing somewhere because it can’t be patented, because pharmaceutical companies would lose money if it were ever validated and brought into clinical use, or because it goes against current medical dogma. It doesn’t even have to be natural. After all, dichloroacetate (DCA) is not exactly “natural.” After it was shown to have promise in animal models, a pesticide salesman named Jim Tassano sold DCA bought from chemical companies to desperate cancer patients from a website that claimed to be selling it only for pets with cancer, a ruse that fooled no one. Yet the “natural treatment” crowd embraced it whole-heartedly because it looked as though sellers of DCA were sticking it to The Man.
[Editor’s note: It’s a holiday here in the U.S.; consequently, here is a “rerun” from my other super not-so-secret other blog. It’s not a complete rerun. I’ve tweaked it a bit. If you don’t read my other blog, it’s new to you. If you do, it’s partially new to you. See you all next week with brand spankin’ new material. It also (Ih hope) complement’s Scott’s excellent post from Thursday discussing the same issue and the same paper, but from a different perspective.]
As a cancer surgeon specializing in breast cancer, I have a particularly intense dislike reserved for cancer quacks, which I have a hard time containing at times when I see instances of such quackery applied to women with breast cancer. I make no apologies. These women are, after all, the type of patients I spend all my clinical time taking care of and to whose disease my research has been directed for the last 13 years or so. That’s why I keep revisiting the topic time and time again. Unfortunately, over the years, when it comes to this topic there’s been a depressing amount of blogging material. Indeed, Scott Gavura took a bite out of this particularly rotten apple just a few days ago. Even though he handled the discussion quite well, I thought it would be worthwhile for a breast cancer clinician to take a look. Our perspectives are, after all, different, and this is an issue that, from my perpective, almost can’t be discussed too often.
One question that comes up again and again is, “What’s the harm?” Basically, this question boils down to asking what, specifically, is the downside of choosing quackery over science-based medicine. In the case of breast cancer, the answer is: plenty. The price of foregoing effective therapy can be death; that almost goes without saying. In fact, it can be a horrific and painful death. It is, after all, cancer that we’re talking about. Aside from that, however, the question frequently comes up just how much a woman decreases her odds of survival by avoiding conventional therapy and choosing quackery. It’s actually a pretty hard question to answer. The reason is simple. It’s a very difficult topic to study because we as physicians have ethics. We can’t do a randomized trial assigning women to treatment or no treatment, treatment or quacke treatment, and then see which group lives longer and by how much. If a person can’t see how unethical that would be without my having to explain it, that person is probably beyond explanations. (As an aside, I can’t help but point out that a randomized trial of not vaccinating versus vaccinating is unethical for exactly the same reason; physicians can’t knowingly assign subjects to a group where he knows they will suffer harm. There has to be clinical equipoise.) There’s no doubt that foregoing effective treatment causes great harm.
There is something in molecular biology and genetics known as the “central dogma.” I must admit, I’ve always hated the use of the word “dogma” associated with science, but no less a luminary than Francis Crick first stated it in 1958, and it has been restated over the years in various ways. Perhaps my favorite version of the central dogma was succinctly stated by Marshall Nirenberg, who said, “DNA makes RNA makes protein,” which about sums up all of molecular biology in five words. Or at least it did until the last ten or twenty years, when we’ve been finding exceptions to this dogma.
I don’t want to dwell on the central dogma. As I’ve said, I loathe the use of the term “dogma” to describe anything in science, although a discussion of the central dogma and its exceptions might make for a decent post one day. What brought the central dogma to mind is a series of articles I saw recently in ONCOLOGY: Perspectives on Best Practices that let me to ponder the question: What is the “central dogma” of “alternative medicine”? I realize that alt-med is an unwieldy gmish of ideas that range from the semi-plausible but unproven to the completely ridiculous (i.e., homeopathy or reiki), but after reading these articles and thinking about it, I do believe that there is in actuality a “central dogma” of alternative medicine. I also believe that it is entirely appropriate to call it a “dogma” in this situation, because it is far more a matter of faith than it is of science. Moreover, the more that quackademic medicine infiltrates academic medicine, the more this “central dogma” has infiltrated academic medicine with it. Indeed, as you will see, when this central dogma is questioned, even by someone sympathetic to “complementary and alternative medicine” (CAM; i.e., “complementing” medicine with quackery) or “integrative medicine” (i.e., the “integration” of pseudoscientific medicine with medicine).