Respectful Insolence

I’ve had this story sent to me by a few readers over the weekend, and I think it’s worth a brief comment.

I’m basically a child of the 1970s. Although I didn’t watch it much, if ever, I remember Charlie’s Angels when I was in junior high and high school. Like any adolescent who came of age in the late 1970s, I remember the famous and hot-selling poster of Farrah Fawcett, which graced the bedroom of more than one of my friends, although I never actually owned a copy. A while back, I heard that Fawcett had been successfully treated for anal cancer. Now, I hear from my readers that her anal cancer is back and that she is seeking out alternative medical treatments:

Actress Farrah Fawcett and the late Coretta Scott King are among the thousands of people who have turned to alternative approaches to cancer treatment when conventional medicine has failed.

It’s often a last-ditch attempt to find a cure, one that brings the patient into a murky world of offshore clinics and unproven courses of treatment that are scorned by the medical establishment.

“I would [tell a patient considering alternative treatment] that they are signing their own death certificate,” said Barrie Cassileth, chief of the Integrative Medicine Department at the Memorial Sloan-Kettering Cancer Center. Cassileth has not treated Fawcett. “I would say they are wasting time they could otherwise spend happier and with their families.”

So would I, particularly in this case, because from what I can tell reading press reports Fawcett’s recurrence is very likely salvageable with conventional therapy. However, as always, it’s hard to tell exactly what is going on just from press reports.

Anal cancer is an uncommon cancer arising in the anus, where the mucus membrane of the rectum meets the anoderm, or the skin that runs partway up into the anus. It is different from rectal cancer in that the cell type from which it arises is not the columnar epithelial cell that lines the rectum, but rather squamous epithelial cells similar to the types of cells that line the vagina and urethra. In the “old” days, anal cancer was treated with radical surgery, specifically an operation called an abdominoperineal resection (APR). This operation involves removing the entire anus and rectum, sewing the resulting hole shut, and constructing a permanent colostomy. Not surprisingly, patients really hate having to undergo an operation that leaves them with a permanent colostomy.

Consequently, there was a major reason to look for a treatment regimen that didn’t involve an APR. These days, most anal cancer is treated with a chemotherapy and radiation therapy protocol known as the Nigro protocol, which is curative in the majority of cases. My guess is that was probably the treatment therapy that Fawcett underwent: an excisional biopsy to confirm the diagnosis and then treatment with the Nigro protocol. This is how her recurrence was described a few months ago:

Fawcett got the news after a routine three-month checkup in which doctors discovered a malignant polyp, smaller than a pea, says Nevius.

She was still weighing her treatment options when the National Enquirer reported the cancer’s return.

“She didn’t have a chance to tell some of her family yet,” says Nevius. “It is now clear that the tabloids are as invasive and malignant as cancer.”

Nevius says Fawcett has been in good health and is “not feeling the effects” of the recurrence. She has not settled on a treatment option, he says, but is considering having a small metalic “seed” placed in the area that will emit radiation.

The placement of such a radioactive seed is known as brachytherapy, which is not standard of care for recurrent rectal cancer. I hope they offered her this as part of a clinical trial, although it is not an unreasonable option to attempt to salvage a recurrence. The definitive salvage therapy for such a recurrence are generally one of two things. Second line therapy of more radiation and chemotherapy can be offered, but the last line of therapy for recurrent anal cancer, unfortunately, is surgical, specifically an APR. My guess–and I emphasize that it is nothing more than an educated guess with a little reading between the lines–is that Fawcett’s doctors told her she had to choose between more radiation, with more chances of local complications around the anus or an APR, and, like many patients do when faced with this operation, she freaked. Now she’s heading to Germany looking for “alternative” cancer therapies. In one way, I can’t blame her, but in another way I can’t help but share Dr. Cassileth’s fear that she is signing her own death warrant, given that salvage therapy after local recurrence of anal cancer ranges from 30-60%.

One thing that was very refreshing about this news report is that it included a number of quotes that were actually skeptical of alternative medicine, in marked contrast to the usual credulous treatments of alternative medicine claims that I see:

“[Alternative treatment] is a marking term that means anything anybody wants it to mean,” said Stephen Barrett, a retired psychiatrist who runs a site called quackwatch.com, which publishes information about alternative clinics. “It indicates it has not been proven, but people use it for different wants, and the implication by promoters is simply that it’s a legitimate alternative.”

Barrett, who has made it his job to warn cancer patients about the risks of alternative treatments, says he has spoken to people who have visited clinics in other countries and have suffered tremendously from unsanitary IVs and infections.

And:

“I think it’s human nature,” said Len Lichentheld, deputy chief medical officer for the American Cancer Society. “Human nature is such that we always want to believe there is something else and so people become vulnerable to claims that somebody has something that is going to work.”

“There are people who claim they’ve been helped, but you look at the data and you can’t substantiate many of the claims, but still many will spend the money to send their relatives for a ‘last try,'” said Lichentheld.

Of course, the article wasn’t all perfect. It did have a howler of a quote by Frank Cousineau, President of the Cancer Control Society. Quoth he:

But Cousineau maintains that getting new cancer treatments approved is expensive and time-consuming for these clinics, which is why they choose to keep them under wraps — not because they don’t work.

“I think the [clinics'] reputation is undeserved,” said Cousineau, who is not a licensed physician. “The process to get a therapy of any kind approved in the U.S. takes a long time and is extremely costly. Just because they aren’t approved doesn’t mean they aren’t working.”

Where have we heard that one before?

That’s right: Everywhere in the world of alternative medicine. It’s a standard excuse.

Personally, I hope that Fawcett has undergone conventional salvage therapy and is only now seeking out “alternatives.” I wouldn’t even mind if, as so many cancer patients who seek out alternative therapy after undergoing surgery or a partial course of conventional therapy do, she attributes her survival to the alternative, rather than her conventional therapy.

Comments

  1. #1 Ms. S
    October 8, 2007

    Wait a sec – did you just use the National Enquirer as a news source?! You could’ve at least gone for People.
    (My MLA / APA / teacher sensibilities are appalled, although the celebrity newslover in me is piqued and attentive…)

  2. #2 Doctor Smith
    October 8, 2007

    You know, I told her to lay off the anal sex, but did she listen? Noooo.

  3. #3 wfjag
    October 8, 2007

    Dear Dr. Orac:

    Realizing that you are a cancer researcher, I’d still conclude that from the comments to the ABC News article, you’re loosing the fight for public opinion. The following was fairly typical of the comments to the article:

    “I cannot believe the hypocrisy of this article! Personally I have known dozens of people who submitted themselves to the conventional treatments of surgery and chemo, only to die horribly and slowly. Meanwhile, notice that they did NOT mention Suzanne Somers and Michael Milken, both of whom have successfully beat cancer with alternative therapies! Investigate the matter for yourself—don’t swallow this b.s. propaganda. ABC gets tons of money from Big Pharma and naturally they have a vested interest in making alternative treatment look bad. Everyone I know who has gone “Zen” or organic is still alive; the radiation/chemo/surgery folk are all dead!”

    According to many of the commentators, medical researchers and specialists who follow scientific principles are all shills of “Big Pharma” and hiding real “cures” for various conspiratorial reasons. The demonstrated successes of cancer research (e.g., St. Jude’s in Memphis) are ignored. Do you wonder why research funds are diverted by NIH to studying CAM, and CAM is increasingly being taught in medical schools? Facts aren’t considered. Rather, a few celebs who attribute their “cures” to CAM is all the authority needed. Who needs a study published in JAMA or the NEJM, when an interview in People is all the authority needed? You have my sympathy.

  4. #4 notmercury
    October 8, 2007

    Sorry Dr. Smith,
    Is that supposed to be funny?

  5. #5 Orac
    October 8, 2007

    Meanwhile, notice that they did NOT mention Suzanne Somers and Michael Milken, both of whom have successfully beat cancer with alternative therapies!

    Suzanne Somers was cured by surgery, not radiation therapy, as I pointed out nearly three years ago:

    The reason breast cancer testimonials sound so convincing is that most lay people don’t know a lot about the disease, particularly that surgery alone “cures” many breast cancers. Early stage cancers are cured by surgery alone more often than not, and a significant minority of patients with even large tumors and multiple positive lymph nodes can be expected to have long term survival with surgery alone.In the case of a lumpectomy, the local recurrence rate in the breast is in the 30-40% range. Radiation can reduce it to less than 10%. That means that women who forgo radiationare still more likely than not to avoid local recurrence in their breast, particularly if their tumor is small. As far as distant metastases, chemotherapy and hormonal therapy improve survival, but the effect is small in patients with early stage cancers and becomes more impressive with more advanced operable tumors. Because many breast cancer patients will do well with surgery alone, clinical trials with large numbers of patients are needed to find true treatment effects due to adjuvant therapies.

    These facts help to explain breast cancer survivors who have undergone surgery but decided to forego chemotherapy and/or radiation therapy in favor of “alternative” medicine (Suzanne Somers, for instance). When such patients are in a good prognosis group, where recurrence is uncommon, or have a more advanced tumor but are lucky enough not to recur, often they attribute their survival not to the primary surgery, but rather to whatever alternative therapy they have decided to take, even though it almost certainly had nothing to do with their survival. To them, it was the alternative medicine that “saved” them, not good old-fashioned surgery. In contrast, women who opt for alternative therapy and then recur obviously don’t provide good testimonials to sell alternative medicine, which is why you almost never hear about them.

    As a breast cancer survivor, however, she is truly tempting fate with her infatuation with “bioidentical” hormones, her use of which surely increases her chance of having her breast cancer recur.

    As for Michael Milken, I may have to look up his case. I’m not familiar with it.

  6. #6 Hans
    October 8, 2007

    I think “Doctor” Smith is showing his age.

    Just wait until puberty comes and goes, “Doctor,” and you’ll understand.

  7. #7 stewart
    October 8, 2007

    I can’t help but wonder if her cancer might have been prevented by the HPV vaccine, if it had been around at the right time, given the link of HPV to some anal and penile cancers, as well as cervical Cancer (or so I get from the intertubes).
    If woo worked, we wouldn’t have scientific medicine, because traditional cures of various sorts have been around forever.

  8. #8 Doc Jensen
    October 9, 2007

    Just got through with a resection of a gentleman just like that who had been diagnosed with stage III rectal cancer 4 years ago but decided to opt for homeopathy for treatment. Just did a resection for his small bowel obstruction (he is now approx 80 cm of nigh-necrotic small bowel less but with the original cancer still in place (which, BTW, does not improve with time). But he seems convinced that homeopathic medicine will ultimately save the day. He should be dying in a year, or so, from metastatic disease.

  9. #9 Uncle Dave
    October 9, 2007

    Curious, what are the early indications or symptoms for anal cancer? Similar to colorectal cancer?
    bleeding?

  10. #10 Phoebe
    October 9, 2007

    real doctors would never waste their time posting comments on this pathetic blog.

  11. #11 Orac
    October 9, 2007

    Ding, ding, ding, ding!

    We have a winner! Phoebe wins the prize for the most shopworn and unimaginative put-down.

    Gee, Phoebe, it’s not as though I’ve never heard that one before…

  12. #12 pat andrews
    February 3, 2008

    Hi i am a survivor from anal cancer i was end stage went thru chemo and radiation the tumor was greater than 5cc and had started to spread to vagial area radiation shrunk enough to operate doing great

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