…Steve Novella, who will be featured as the guest on a live chat with Trine Tsouderos discussing alternative treatments for Alzheimer’s, ALS and other neurological conditions at noon CST. Be there, aloha.
Naturopathy has been a recurrent topic on this blog. The reasons should be obvious. Although homeopathy is the one woo to rule them all in the U.K. and much of Europe, here in the U.S. homeopathy is not nearly as big a deal. Arguably, some flavor of naturopathy is the second most prevalent “alternative medical system” here, after chiropractic of course, and perhaps duking it out with traditional Chinese medicine, although naturopathy does embrace TCM as part of the armamentarium of dubious medical systems that it uses. In any case, some sixteen states and five Canadian provinces license naturopaths in some form, and in some states naturopaths are fighting for–and in some cases winning–the power to prescribe certain real pharmaceutical medications and order real medical tests. For instance, in California, naturopaths can order laboratory tests and X-rays, which reminds me of a conversation I had with a mammographer from California at TAM last summer. He told me a tale of the dilemma he had when naturopaths and other “alt-med” practitioners ordered tests at his facilities. Specifically, the dilemma came about because he doubted that the naturopath knew what to do with the results. Meanwhile, in Oregon, naturopaths can prescribe certain types of pharmaceutical drugs (as opposed to the usual supplements, herbs, or homeopathic remedies they normally prescribe). Meanwhile, moves are under way to expand the prescribing privileges of naturopaths in Canada, as Ontario (which is, remember, just across the Detroit River, less than two and a half miles as the crow flies from my cancer center—a truly frightening thought to me).
Unfortunately, naturopathy is a hodge-podge of mostly unscientific treatment modalities based on vitalism and other prescientific notions of disease. As a result, typical naturopaths are more than happy in essence to “pick one from column A and one from column B” when it comes to pseudoscience, mixing and matching treatments including traditional Chinese medicine, homeopathy, herbalism, Ayurvedic medicine, applied kinesiology, anthroposophical medicine, reflexology, craniosacral therapy, Bowen Technique, and pretty much any other form of unscientific or prescientific medicine that you can imagine. Despite their affinity for non-science-based medical systems, naturopaths crave the imprimatur of science. As a result, they desperately try to represent what they do as being science-based, and they’ve even set up research institutes, much like the departments, divisions, and institutes devoted to “complementary and alternative medicine” (CAM) that have cropped up on the campuses of legitimate medical schools and academic medical centers like so many weeds poking through the cracks in the edifice of science-based medicine. Naturopaths also really, really don’t like it when they encounter criticism that their “discipline” is not science-based. Indeed, the president of the American Association of Naturopathic Physicians, Carl Hangee-Bauer, ND, LAc (he’s an acupuncturist, too!), wrote a revealing post on the official AANP blog entitled Science and Naturopathic Medicine.
Science. You keep using that word. I do not think it means what you think it means.
Why haven’t we cured cancer yet?
If we can put a man on the moon, why can’t we cure cancer?
If we can harness the atom, why can’t we cure cancer?
How many times have you heard these questions, or variants thereof? How many times have you asked this question yourself? Sometimes, I even ask this question myself. Saturday was the two year anniversary of the death of my mother-in-law from a particularly nasty form of breast cancer, and, even though I am a breast cancer surgeon, I still wonder why there was nothing in the armamentarium of science-based medicine that could save her from a several month decline followed by an unpleasant death. That’s why, to me at least, the timing of the publication of a study examining the genome of prostate cancer that was published in Nature and summarized in this Science Daily news story was particularly apt. Performed as part of the National Cancer Institute’s Cancer Genome Project, the study undertook complete genome sequencing of seven advanced and aggressive prostate cancers. The results, as ERV put it, revealed what can be describe as a “train wreck.”
Personally, I’d describe it as looking as though someone threw a miniature grenade into the nucleus of a prostate epithelial cell. You’ll see what I mean shortly.
Of course, although that image does give you an idea of the chromosomal chaos in the heart of prostate cancer cells, it is inaccurate in that it implies a sudden explosion, after which the damage is done, and if there’s one thing we know about cancer it’s that in most cases it takes many years for a normal cell to progress to a cancer cell fully capable of metastasizing and killing its host. I’ve written in detail about the complexity of cancer before, of course, and have even pointed out before that when President Nixon launched the “war on cancer” 40 years ago scientists had no idea how difficult it would be. Indeed, before I discuss the current study, it’s probably useful to reiterate a bit why, in order to put the study in context.
As hard as it is to believe, it’s been nearly a year since Steve Novella, Kimball Atwood, and I were invited to meet with the director of the National Center for Complementary and Alternative Medicine (NCCAM), Dr. Josephine Briggs. Depending upon the day, sometimes it seems like just yesterday; sometimes it seems like ancient history. For more details, read Steve’s account of our visit, but the CliffsNotes version is that we had a pleasant conversation in which we discussed our objections to how NCCAM funds dubious science and advocacy of complementary and alternative medicine (CAM). When we left the NIH campus, our impression was that Dr. Briggs is well-meaning and dedicated to increasing the scientific rigor of NCCAM studies but doesn’t understand the depths of pseudoscience that constitute much of what passes for CAM. We were also somewhat optimistic that we had at least managed to communicate some of our most pressing practical concerns, chief among which is the anti-vaccine bent of so much of CAM and how we hoped that NCCAM would at least combat some of that on its website.
Looking at the NCCAM website, I see no evidence that there has been any move to combat the anti-vaccine tendencies of CAM by posting pro-vaccination pieces or articles refuting common anti-vaccine misinformation. Of all the topics we discussed, it was clearest that everyone, including Dr. Briggs, agreed that the NCCAM can’t be perceived as supporting anti-vaccine viewpoints, and although it doesn’t explicitly do so, neither does it do much to combat the anti-vaccine viewpoints so ingrained in CAM. As far as I’m concerned, I’m with Kimball in asserting that NCCAM’s silence on the matter is in effect tacit approval of anti-vaccine viewpoints. Be that as it may, not long afterward, Dr. Briggs revealed that she had met with homeopaths around the same time she had met with us, suggesting that we were simply brought in so that she could say she had met with “both sides.” Later, she gave a talk to the 25th Anniversary Convention of the American Association of Naturopathic Physicians (AANP), which is truly a bastion of pseudoscience.
In other words, I couldn’t help but get the sinking feeling that we had been played. Not that we weren’t mildly suspicious when we traveled to Bethesda, but from our perspective we really didn’t have a choice: if we were serious about our mission to promote science-based medicine, Dr. Briggs’ was truly an offer we could not refuse. We had to go. Period. I can’t speak for Steve or Kimball, but I was excited to go as well. Never in my wildest dreams had it occurred to me that the director of NCCAM would even notice what we were writing, much less take it seriously enough to invite us out for a visit. I bring all this up because last week NCCAM did something that might provide an indication of whether it’s changed, whether Dr. Briggs has truly embraced the idea that rigorous science should infuse NCCAM and all that it does, let the chips fall where they may. Last week, NCCAM released its five year strategic plan for 2011 to 2015.
Truly, it’s a case of The Good, The Bad, and The Ugly.
Lest I be left out of the fun, I can’t help but point out that yesterday the Amazing One himself, James Randi, issued a challenge to manufacturers of homeopathic remedies and retail pharmacies that sell such remedies, in particular large national chains like Walgreens and CVS and large national chains that include pharmacies in their stores, such as Walmart and Target. This was done in conjunction with the 10:23 Challenge, which is designed to demonstrate that homeopathy is nonsense. All over the world, skeptics and supporters of science-based medicine gathered to engage in overdoses of homeopathic medicines in order to demonstrate that there is nothing in them.
As much as I like Randi, unfortunately, I doubt that the prospect of winning $1 million will make much difference to huge companies like Boiron (a French company that manufactures popular homeopathic remedies), Walmart, or Walgreens, but I do like the spirit of the protest, in particular how it drives home a very simply message about homeopathy: There’s nothing in it.
A couple of weeks ago, both Steve Novella and I criticized Dr. Mehmet Oz (a.k.a. “America’s doctor”) for not only hosting a man I consider to be a major supporter of quackery, but going far beyond that to defend and promote him. After that, I considered Dr. Oz to be a lost cause, with nothing to excuse him for his having embraced a man whose website is a wretched hive of scum and quackery almost as wretched as NaturalNews.com (in my opinion, of course). Unfortunately, apparently Dr. Oz’s defense of Dr. Mercola was only the beginning of the end of whatever minimal credibility Dr. Oz had left as a practitioner of evidence-based medicine.
This week, Dr. Oz put the final nails in the coffin of his credibility as a practitioner of science-based medicine. I realize that some would argue that he did that long ago. Fair enough. However, I always held out some hope that he might stop mixing pseudoscience like reiki with science. Then he embraced Dr. Joseph Mercola. Strike one! Unfortunately, strikes two and three followed over the last week or so.
|The Colbert Report||Mon – Thurs 11:30pm / 10:30c|
Looks like a win to me. I particularly like how Dr. Offit says that the question of whether vaccines cause autism has been “asked and, fortunately, answered.” Heh. That’s a shot across the bow to J.B. Handley, who, as Steve Novella has pointed out (as have I) is utterly clueless about science and how to interpret the medical literature, as he has demonstrated time and time again with his “14 Studies” nonsense. Of course, anyone who calls Handley out on his ignorance is subject to personal attack. Reporters have felt it. Steve Novella has felt his wrath. So have I. Meanwhile Handley gloats over the decline in confidence in vaccines that his organization Generation Rescue has helped foster.
Fortunately, Colbert appears to get it. I like how Colbert does a faux rejection of one of Dr. Offit’s points by pointing out that he is “ruled by fear.” I particularly like how he mentions Andrew Wakefield, but not by name (rather like Lord Voldemort), and how he asks Dr. Offit a bunch of questions based on talking points the anti-vaccine movement likes to use to frighten parents. No wonder the anti-vaccine collective at Age of Autism is going crazy, having posted (and reposted) numerous attacks old and new on Paul Offit ever since it was announced that he was going to be on The Colbert Report last night, all topped off with one by J.B. Handley himself in which he calls Dr. Offit a “blowhard liar.”
Stay classy, J.B. Stay classy.
I must admit that I have a bit of a love-hate relationship with breast implants. On the one hand, as a breast cancer surgeon, I see them as a major benefit to my patients who are unfortunate enough to require mastectomy in order to control their disease. The armamentarium of techniques for reconstructing breasts after mastectomy generally falls into one of two categories, either various form of muscle flaps or breast implants. However, some women are, for various reasons, not eligible for various muscle flap reconstructions. That leaves either breast implants–or nothing. Certainly, some women are perfectly fine with no reconstruction after mastectomy, but many, if not most, women are not. For these women, it would be difficult to overstate how much of a boon to body image and self-esteem reconstruction can be, particularly given how much better at it plastic surgeons have become over the last couple of decades.
On the other hand, breast implants make my life as a breast cancer surgeon more difficult for a variety of reasons. First, they tend to make mammography more difficult by obscuring part of the breast, thus decreasing the sensitivity of mammography. Good mammography facilities can get around this to some extent by using various displacement techniques, but it takes some effort, and it doesn’t completely correct the problems that implants cause for mammographic screening. Moreover, when a woman who has had implants placed for cosmetic reasons comes to see me for a breast mass or an abnormal mammogram, the presence of the implants can complicate treatment decisions. If the abnormality or mass is close to the implant, we worry about rupturing it in the process, particularly if the implant is not below the pectoralis major muscle. Even when the implant is subpectoral, the muscle overlying it frequently ends up being so stretched out that the muscle in essence forms part of the capsule around the implant and ends up being a lot thinner than you might expect. Let me tell you, my anal sphincter tone is always much tighter when operating near an implant, particularly a silicone implant. True, I’m perfectly capable of removing an implant if it’s accidentally ruptured, but such an outcome is not desirable, particularly with silicone implants, where cleaning up the leaking silicone can be difficult.
It doesn’t help that silicone breast implants have been the subject of controversy since the late 1980s and early 1990s, when thousands of women with silicone implants reported a variety of ailments, including autoimmune disease and a variety of other systemic illnesses. These reports led to a rash of lawsuits and, ultimately, the banning of silicone breast implants for general use in 1992. After that, silicone breast implants were only permitted in women requiring breast reconstruction or women enrolled in clinical trials studying breast implants. This ban was partially lifted in 2006, as evidence accumulated that the claims of autoimmune diseases and increased cancer risk due to silicone breast implants were not supported by clinical and scientific evidence and two products made by Allergan Corp. (formerly Inamed Corp.) and Mentor Corp. Not surprisingly, given that the furor over silicone breast implants as a cause of autoimmune and other systemic diseases is based on about as much solid scientific evidence as the antivaccine furor over vaccines as a cause of the “autism epidemic,” there was widespread criticism of this decision. Even now, it is not difficult to find articles about breast implants with titles like Breast Implants: America’s Silent Epidemic and websites like the Humantics Foundation and Toxic Breast Implants . I do note, however, that the number of such sites and articles does appear to be declining and, at least to my impression, seems to have decreased markedly over the last 10 years or so.
Having reviewed the literature and found evidence for a link between silicone breast implants and the systemic diseases attributed to them to be incredibly weak at best, I had little problem with the FDA’s decision. Actually, the only thing I had a problem with at the time, my opinions of how breast implants interfere with breast cancer detection and treatment notwithstanding, is that the FDA was probably being more cautious than the evidence warranted after 14 years.
Was I wrong?
Occasionally, there are topics that our readers want — nay, demand — that I cover. This next topic, it turns out, is one of them. It’s a link to a TED Talk. I’m guessing that most of our readers have either viewed (or at least heard of) TED talks. Typically, they are 20-minute talks, with few or no slides, by various experts and thought leaders. Many of them are quite good, although as the TED phenomenon has grown I’ve noticed that, not unexpectedly, the quality of TED Talks has become much more uneven than it once was. Be that as it may, beginning shortly after it was posted, readers of both this blog and my other super-not-so-secret other blog started peppering me with links to a recent TED Talk by Dr. Deborah Rhodes at the Mayo Clinic entitled A tool that finds 3x more breast tumors, and why it’s not available to you.
At first, I resisted.
After all, I’ve written about the issues of screening mammography, the USPSTF guideline changes (here, too), the early detection of cancer (including lead time and length time bias, as well as the Will Rogers effect), and a variety of other topics related to the early detection of breast cancer, such as overdiagnosis and overtreatment. Moreover, to put it bluntly, there really isn’t anything radically new in Dr. Rhodes’ talk, at least not to anyone who’s been in the field of breast cancer for a while. Certainly, there’s no new conceptual breakthrough in breast imaging and screening described. As I will discuss in more depth later in this post, there’s an interesting application of newer, smaller, and more sensitive detectors with a much better spatial resolution. It’s cool technology applied to an old problem in breast cancer, but something radical, new, or ground-breaking? Not so much. What Dr. Rhodes describes in her talk is the sort of device that, when I read about it in a medical journal, produces a reaction along the lines of, “Nice technology. Not ready for prime time. I hope it works out for them, though. Could be good.” So it was with molecular breast imaging (MBI), which is the topic of Dr. Rhodes’ talk. So I continued to resist for about two or three weeks.
Then our very own Harriet Hall sent me the link. I cannot resist Harriet. When she suggests that perhaps I should blog about a topic, it’s rare that my response would be anything other than, “Yes, ma’am. How soon would you like that post and how many words?” I keed, of course, but only just. The best I could come up with was a wishy-washy “But this isn’t really anything all that new,” which is true enough, but the way Dr. Rhodes tried to sell the audience on the idea of her technology brings up a lot of issues important to our audience. I also thought it was important to put this technology in perspective. So here I go. First, I’ll start by describing what really set my teeth on edge about Dr. Rhodes’ talk. Then I’ll go to the primary literature (namely her brand, spankin’ new article in Radiology describing the technology) and discuss the technique itself.
I’ve been highly critical of Dr. Mehmet Oz, Vice Chair of the Department of Surgery at Columbia University and medical director of the Integrative Medicine Program (i.e., Columbia’s quackademic medicine) program at New York-Presbyterian Hospital. Those are his academic titles. More important, in terms of his promotion of pseudoscience, is his role as daytime medical show host. Dr. Oz’s television show, called, appropriately enough, The Dr. Oz Show, is a direct result of his having been featured on Oprah Winfrey’s show on numerous occasions as one of her regular medical experts. Because of his popularity, Dr. Oz became Oprah’s protégé and ultimately scored his very own daytime TV show, which has been quite successful since its debut in September 2009.
So what has led me to conclude that I’ve finally completely had it with Dr. Oz? Or, as Popeye would say, “I’ve had all I can stands, I can’t stands no more!”
The final straw occurred yesterday, but this has been building up for a while. Of course, I’ve known for a long time that Dr. Oz has a weak spot for “alternative medicine.” A decade ago, he was known for bringing reiki masters into the operating room do their mystical magical gestures during cardiac surgery, the better to channel the healing energy of the “universal source” into his patients before they went onto the cardiopulmonary bypass machine. His wife is also a reiki master, which might explain his particular fondness for this form of faith healing. Even so, even though I always knew Dr. Oz was into some woo, most of the times I ever saw him on Oprah’s show and the rare occasion that I’ve seen his show, the worst I could say about him was that he is at best a shruggie and at worst too prone to mixing perfectly valid, science-based information with the “softer” forms of “complementary and alternative” medicine (CAM) modalities, such as acupuncture and reiki. Even so, CAM didn’t seem to be a major part of his show. That seems to have changed in 2010.
As 2010 dawned, I became aware of a show in which Dr. Oz promoted reiki completely uncritically, beginning the year with a show entitled Dr. Oz’s Ultimate Alternative Medicine Secrets. It wasn’t too long before Dr. Oz did it again, delivering a two-fer of “quantum” quackery coupled with just plain quackery, when he invited Deepak Chopra and Joe Mercola on his show. Around the same time, Dr. Oz also revealed in an interview also hadn’t had his children vaccinated against H1N1. In all fairness, he seemed embarrassed to admit this and uncomfortable about the situation (Dr. Oz has never, to my knowledge, expressed anti-vaccine views), but, even so, he did seem to be more sympathetic than the evidence warrants to the concept that vaccines might somehow cause autism. None of these occurrences was good, but, as disturbing as they were, none of them quite crossed a line. Quite.
As 2011 dawns, there is no doubt in my mind that Dr. Oz has now irrevocably crossed his Woo-bicon (link there to make my pun painfully obvious), gone over to the Dark Side, betrayed the cause, gone woo, or whatever you want to call it. He’s done, as far as science-based medicine goes. That’s because yesterday he featured one of the biggest promoters of highly dubious medical remedies on the Internet on his show in one fawning segment after another. I’m referring, of course, to Dr. Joe Mercola, who was the main guest on The Dr. Oz Show yesterday in segments entitled The Alternative Health Controversy (part 1, part 2, part 3), coupled with another segment entitled The Surprising Supplement You Need. Let’s just say that Dr. Oz’s journey to the Dark Side is now complete. He has controlled his fear but released his woo, and it is strong woo indeed.