Respectful Insolence

ResearchBlogging.orgHas it really been that long?

More than two years ago, I wrote a post entitled Death by Alternative Medicine: Who’s to Blame? 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, if ture, would have made it no longer even possibly curable. My discussion centered on what the obligation of physicians are 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 centered on the reaction of one oncologist who stated that it is the collected “our fault” (as in all the physicians who saw her) that she ended up this way because “we” had failed to persuade her that what she was doing would at the very least delay her treatment and make it much harder to treat her when her tumor did progress to the point where she realized that whatever woo she had chose was not working and at the very worse cost her her life. Even more compelling and sad, this patient was young, in her late 30s, and had three young children. Her husband had even filed for divorce and custody of the children on the quite reasonable, but no doubt painful to come to, basis that she would soon no longer be able to take care of them and had rebuffed all attempts to persuade her to accept science- and evidence-based medical care that could still possibly save her life.

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 one 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 overall survival and breast cancer-related mortality. I can speculate about several posisble reasons for this, although I don’t know how valid my guesses are as to why. The first reason may be that–thankfully–relatively few women use alternative medicine primarily or exclusively to treat their breast cancers. It can’t be overstated how this is a very good thing. Also, those who do use only alternative medicine probably drop off the radar screen of their “conventinal” doctors, and it is difficult, if not impossible, to capture data regarding their outcomes. All too often they stick with their alternative healers until the end, going from one to another as their tumors eat through their skin and ravage their bodies. 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:

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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 very small tumors might 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 is impossible to rule out selection bias, but, as the authors point out, this is one case where doing a randomized study is 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.

But what about alternative medicine?

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, specifically the 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:

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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 primary 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. Ernst, as you might recall, was formerly a CAM advocate. 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 he 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, and small effects are 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 me 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. Few people with metastatic pancreatic cancer survive more than one year (Patrick Swayze is one of those lucky few), fewer still longer than two; lots of women with even metastatic breast cancer do.

Putting it all together, even given the relative paucity of studies, I conclude that there is nonetheless no compelling evidence for a significant survival benefit due to any “alternative” therapy, nor is there even 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. The vast majority of them are retrospective and difficult to interpret, and what evidence is out there is that alternative medicine use among breast 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 that some of them 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.

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 false dichotomy. Unfortunately, it’s a false dichotomy that can kill.

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. 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

Comments

  1. #1 Samurai Scientist
    March 23, 2009

    While I get your point, the jury is still out on ACCs. It should be noted that diet has been shown to play a role in cancer risk rates.

    As for surgery, yes it saves lives. But it’s also much more painful than ACCs, and it’s only helpful for about 10% of the people who undergo the procedure. That means 9 out of 10 may be undergoing an unnecessary surgery to give the one person a better chance. Similarly, a Norwegian study found that many small tumors caught in mammograms regress given time. as you noted.

    So the question really becomes, once we’re relying on the statistics, is conventional slash-and-burn worth the price?

  2. #2 AnthonyK
    March 23, 2009

    Ummm, very interesting. It prompts me to ask a medical question, no doubt a very important one: if a tumour mestastising is essentially the deadly stage of cancer, what makes it do so and how can we tell? Is this simply the difference between “benign” and “malign”?
    Ignorance on my part I know, but confessing it seems to be the best way of fixing it.

  3. #3 Hubert
    March 23, 2009

    We hope that now all want to be involved in the medical system is improved, but not because they think the medical system is very much less come to trust that these events will reduce the cost and benefit millions of people throughout the country, and they say that things in findrxonline.com improved from 60% in recent weeks, hopefully this is the case ..

  4. #4 Paul
    March 23, 2009

    Thanks for posting that Orac, it makes very interesting reading.

    The lack of evidence for so-called “alternative therapies” (if they actually worked they wouldn’t be alternative) and the degree of wishful thinking amongst supporters of such therapies is something to behold.

    By way of a contrast there’s a new paper in Nature Medicine about the anti-angiogenic drug Cilengitide, which has had disappointing results in recent clinical trials. Rather than dismiss the trial evidence or just giving up on it Andrew Reynolds and colleagues went back into the lab and determined why this drug failed to perform as expected, providing a new insight into the activity of inhibitors of alphavbeta3 and alphavbeta5 integrin that will help guide any future use of the drugs, and no doubt future drug design.

    http://www.nature.com/nm/journal/vaop/ncurrent/full/nm.1941.html#B13

  5. #5 Leslie Haber, MD
    March 23, 2009

    AnthonyK: “Metastasizing” is when a malignant tumor breaks out of it’s location and starts seeding around the body, building new tumors in remote locations. Yes, it is usually the end-stage of any malignancy, simply because at this point the cancer is out of control. And yes, it is a symptom of the “malignancy” of a tumor. Benign tumors don’t metastasize, but are also not aggressive in other ways.

    This a wonderful review. I have often wondered what the “state of the art” is regarding patients who opt out of traditional therapy. I’ve known several women who did so, all of whom are now dead. But that’s anecdotal, and not worth the paper the report isn’t printed on.

    I’ll pass this along to the next woman I meet who chooses macrobiotic diets or pseudohormone shots over surgery. Doubt it will make a dent, but I’ll try.

  6. #6 AnthonyK
    March 23, 2009

    World Death Rate Holding Steady At 100 Percent

    is the headline in this classic Onion article. And what, I want to know, is modern medicine, however evidence-based, doing about it?
    http://www.theonion.com/content/node/39236

  7. #7 David
    March 23, 2009

    excellent overview, Orac.

    The shocker here is the absence of evidence. I’ve never seen a simple prospective cohort series from any alternative clinic. Never a one like “we summarize the 1-year outcomes for 100 consecutive patients treated with coffee enemas…” I’m not asking for much, not for a controlled trial, or even a statistical analysis. Just a simple little registry. Nada. Zip.

    in medicine it’s said “the absence of evidence is not evidence of absence” but in this case, the absence of evidence is evidence of negligence.

  8. #8 beebeeo
    March 23, 2009

    @AnthonyK
    The difference between benign and malign is separate from metastis and no metastasis. Benign-malign depends on the histology of the tumour. For breast cancer it is true that metastasis is the most important factor to decide wether there is a chance to cure is metastasis. If metastasis has occured there is little chance that any intervention will be curative.
    “What makes it do so and how can we tell?”
    Well, I guess that is one of THE BIG questions of current breast cancer research. Breast cancer is a very diverse disease and the factors that drive different subtypes of breast cancers to metastasize will probably be different for each subtypes. Expression of some growth factors, transcription factors or some genetic alterations might be associated with metastasis and someone please correct me if I am wrong but I do not think there is currently a simple, well understood model that would explain metastasis in most breast cancers. However, if we could accurately predict whether a primary tumor would metastasize or not, we could probably decide whether it is necessary to give chemotherapy or hormone therapy on top of surgery or whether surgery could be enough and we can a spare a patient like this from the side effects of these therapies. Further, if we knew more about the mechanisms that meke a tumur metastasize we might be able to design therapies that specifically target these mechanisms.

  9. #9 madder
    March 23, 2009

    Thanks for another excellent post, Orac. I know some people who have started extolling the virtues of sCAM, and your material is always useful in our discussions.

    Re: the discussion about benign/malignant and metastasis vs. not, I’m reminded of the benign tumor of the parotid gland (benign mixed tumor; pleomorphic adenoma) which can exhibit benign metastasis if untreated. As an amateur, I too thought that this was an oxymoron. beebeeo and others, is the distinction in the extent to which the primary site and metastases are invasive of other tissues, as opposed to simply growing upon them like a mole on skin (keeping in mind the hazards of anatomical analogies)?

  10. #10 AnthonyK
    March 23, 2009

    different subtypes of breast cancers to metastasize will probably be different for each subtypes

    Thank you for the explanations. I kind of assume that somehow unifying the different types of (breast) cancer might help to find out what causes metastisization, what “turns it on” in a sense. But I’ll shut up now, and find out what I can about this.

  11. #11 AnnR
    March 23, 2009

    The bulk of women that I’ve run into online who’re considering alternative treatment are those who are self-pay and unable to take on the cost of radiation or chemo therapy.

    Now and then I run into someone who objects to chemo thearpy toxins in their body, but often that’s a code phrase for I couldn’t afford it anyway .

    It seems to me that in that situation one would be best off finding the money for a surgeon and trotting off to Walmart with a prescription for ongoing tamoxifen – which is on the $4 list.

  12. #12 Sid Schwab
    March 23, 2009

    Geez, Samurai Scientist, it might be time to fall on your sword. Using an article about prostate screening to refute a column on breast cancer therapy is a bit of a stretch, no? Likewise, Orac is discussing a very different universe of breast cancer than those found on mammograms.

    And declaring “the jury is still out on ACC” does not make it so. For one thing, “ACC” is about as specific as “animals.” For another, the jury, when it has heard the evidence on a specific modality — homeopathy, for example — has pretty uniformly said “guilty” of fraud or failure. Give them time. There’s lots of woo out there, and only so much time and money to give it its due.

  13. #13 Danio
    March 23, 2009

    It should be noted that diet has been shown to play a role in cancer risk rates.

    Right, and, as has been pointed out eleventy thousand times, nutritional adjustments usually aren’t alternative at all, unless you’re talking about only consuming lychee nuts mixed with ostrich serum, or something.

    So the question really becomes, once we’re relying on the statistics, is conventional slash-and-burn worth the price?

    You see 10 patients with early stage breast cancer. You know that surgery at this point will improve the outcome, and although you also realize that some of these 10 patients may have spontaneous regression of their tumors, or very slow growing tumors that might not ever make them sick before something else gets around to killing them, you have no way to predict which cases will progress and which won’t. How is it in any way ethical to withhold surgery as an option because some of the patients might NOT die without it? The ‘price’ of inaction is far greater in these situations, as it unnecessarily puts patients’ lives and health at risk.

  14. #14 Tsu Dho Nimh
    March 23, 2009

    As for cardiopulmonary resusitation, yes it saves lives. But it’s only helpful for less than 10% of the people who undergo the procedure. That means more than 9 out of 10 may be undergoing an unnecessary procedure to give the one person a better chance.

    By your logic, Sam, I should never do CPR because it doesn’t benefit 100% of those who get it, and if I do it right I’m going to break ribs and leave bruises. I should maybe just administer some Bachs Flower Remedy, do a couple of reiki passes over the meridians and call it good?

  15. #15 Orac
    March 23, 2009

    Geez, Samurai Scientist, it might be time to fall on your sword. Using an article about prostate screening to refute a column on breast cancer therapy is a bit of a stretch, no?

    Indeed. No wonder I was confused when I saw SamSci’s comment before had time to go back and click on his link. He’s comparing apples and oranges. Very dubious. In any case, SamSci, you’re full of crap about surgery and breast cancer. Sorry to be so blunt, but you just are.

    Oh, and I’m way ahead of you on the Norwegian study. I did a prolonged discussion of it when it came out:

    http://scienceblogs.com/insolence/2008/12/the_spontaneous_regression_of_breast_can.php

    The bottom line is that they almost certainly overestimated the number of breast cancers that regress, but that, yes, some small percentage of small breast cancers probably do regress. Remember, these were all mammographically detected cancers, not cancers detected as a lump, meaning they were all pretty small. Even so, again, as Danio points out, we don’t have any way of knowing which ones will progress (the vast majority, even if you accept the findings of the Norwegian study at face value) and which ones won’t. Given that, if you were a woman, would you gamble with at most (under the most wildly optimistic estimates for a subset of the smallest tumors) only a 20% chance that the cancer might spontaneously regress? I sure wouldn’t, and I’d be a fool to counsel my patients that it would be a good idea.

    You would have had a better point if you had discussed chemotherapy for early stage breast cancer. For stage I breast cancer, without chemotherapy the five year survival is in the 90% range. Adding chemotherapy improves that by about 2-3% on absolute terms (20-30% on relative terms; i.e., saving 2 or 3 out of the ten women who would have relapsed). There, in order to save the 2 or 3, 10 undergo cytotoxic chemotherapy. Actually, it’s worse than that if you “frame” it as treating 100 women in order to save two or three because, after all, the ones saved by surgery alone didn’t need chemotherapy and 7/100 would relapse in spite of chemotherapy. We’re basically targeting those two or three women out of 100 where chemotherapy might make a difference.

    Of course, it’s the same problem; we don’t know enough yet to predict which specific patients are likely to benefit from chemotherapy and which don’t need it. But that’s changing. Various gene chip assays, such as the OncoType, are starting to give us the confidence to tell some women with low risk gene profiles that they can safely forego chemotherapy.

    In any case, it will be science that tells us which women can safely skip chemotherapy and which ones cannot. It will also be science that provides women with safer, less toxic targeted chemotherapy.

  16. #16 Calli Arcale
    March 23, 2009

    Not just that, Danio, but regardless of whether diet plays a role in cancer rates in the first place does diddly squat for a person who’s already *got* cancer. So far, the best alternative medicine can do is not-at-all-alternative advice for avoiding cancer in the first place. It doesn’t really help once you’ve already got cancer. Well, it can possibly improve your quality of life, but it won’t cure the cancer. If you have cancer, your choices are: do nothing and hope (useful for some cancers, but it’s hard to know which ones), surgery to remove the tumor(s), and drugs (i.e. chemo) to kill or inhibit remaining tumor cells.

    Andreas Katsulas, a fantastic actor beloved by “Babylon 5″ fans for his passionate portrayal of G’Kar, developed lung cancer. He had been an enthusiastic cigar smoker for many years. (His costars talked of often seeing him on break, still in full Narn costume with facial prosthetics and everything, enjoying a cigar.) When he was diagnosed, he immediately quit smoking and made a number of other improvements to his lifestyle. He happily told his friends how since he found out he was dying, he had never felt better in his life — it made a significant improvement to his quality of life. But it did nothing for the cancer, which was quite advanced already, and he died not long after.

    I guess the bottom line is that if you develop an untreatable cancer, those kinds of lifestyle changes can, at best, improve your enjoyment of what time remains to you. They are valuable from that perspective, but it is very wrong to promote them as equivalent to chemotherapy or surgery. They cannot cure cancer.

  17. #17 perceval
    March 23, 2009

    Y’know, Samurai Scientist, speaking as the granddaughter of two women who died of breast cancer, if the number-needed-to-treat is 10, I’d rather have the treatment. Don’t forget how much patients stand to lose …

  18. #18 MichaelS
    March 23, 2009

    Samurai Scientist, how about using secondary sources next time, rather than, well, I don’t quite know how to describe the NYT. And I’m awaiting results from any CAM clinical trial that does anything positive.

  19. #19 Danio
    March 23, 2009

    Excellent point, Calli. As Samurai’s wording dealt with ‘risk’, I based my response on the role of nutrition in cancer prevention, but I thank you for clarifying the boundaries of ‘prevention’ vs. ‘treatment’, as this is certainly an important limitation, and one which the alties regularly ignore.

    Did anyone ever see Paul Linke’s one man show “Time Flies When You’re Alive”, in which he describes his wife’s battle with terminal breast cancer? Said battle, such as it was, was waged largely through alternative treatments, with predictably poor results. She died at 37. It’s a powerful piece, and even though he doesn’t come right out and condemn the woo, his anger at her choices is quite apparent, and what I remember most clearly about the play. It’s been about 20 years since I’ve seen it, but it made an indelible impression on me.

  20. #20 Pete
    March 24, 2009

    The first reason may be that–thankfully–relatively few women use alternative medicine primarily or exclusively to treat their breast cancers. It can’t be understated how this is a very good thing.

    I think you mean “overstated”, right? As in, it’s impossible to state too strongly how this is a good thing. People often seem to get that the wrong way round.

  21. #21 Orac
    March 24, 2009

    God, I detest pedantic comments that consist of nothing other than nitpicking typos or little grammar or word usage errors. A huge, lengthy post, and all you have to say is that? Why did you bother?

  22. #22 Dangerous Bacon
    March 24, 2009

    The “slash-and-burn” attempted putdown of mainstream cancer treatment is woefully incomplete. The accepted terminology is “cut-burn-poison”, to take chemotherapy into account.

    The altie counterpart to this is, of course, the “dose-blather-croak” therapy scheme. Reputation salvage therapy after the patient’s disease progresses consists of liberal doses of conspiracy theory and “if only you’d gotten to me in time, before those conventional treatments weakened you beyond recall”.

    Incidentally, I know of a physician who goes by the online handle of “Samurai Pathologist”, but he usually makes too much sense to be the “Samurai Scientist”.

  23. #23 eddie
    March 24, 2009

    Paranoid schitzophrenic, who fatally stabbed a cop, stopped taking his meds as he “preferred olive oil and prayer”!

    OT, sorry, but I just heard on the news.

  24. #24 Rolf
    March 24, 2009

    AnneR.
    I am shocked to read your comment: that people should be denied life-saving treatment (or treatment at all trying to save their lives) because of lack of money in a modern western country is just appalling.
    Note I live in Germany… so the situation on who gets what kind of medical treatment is totally different from the US. I really hope that the USA will get healthcare for all asap.

    I DO have met quite a lot of people who – from their expression of world-views – are firmly bolted in an alternative universe, where surgeons or the medical industry – “Schulmediziner” ((orthodox physicians my – bad- translation) – are bad per se and for whatever reason donot want to help their patients…

    Rolf

  25. #25 Samurai Scientist
    March 24, 2009

    @Orac/defenders,

    First off, I wrote my comment first thing in the morning while I was waiting to go to the bathroom and forgot to compliment you on an informative analysis and good post.

    …Orac is discussing a very different universe of breast cancer than those found on mammograms.

    I should have been more specific. My criticism of surgery was directed only at the type of surgeries I referenced, not all cancer surgery which has saved the lives of many loved ones of mine.

    Actually, it’s worse than that if you “frame” it as treating 100 women in order to save two or three because, after all, the ones saved by surgery alone didn’t need chemotherapy and 7/100 would relapse in spite of chemotherapy. We’re basically targeting those two or three women out of 100 where chemotherapy might make a difference.

    Yes, this is what i was getting at.

    @perceval,
    Y’know, Samurai Scientist, speaking as the granddaughter of two women who died of breast cancer, if the number-needed-to-treat is 10, I’d rather have the treatment. Don’t forget how much patients stand to lose …

    My aunt is in the same boat. She just had the surgery, and so should you. Genetics should be part of the calculation. But there should be a calculation, not an automatic rush to a possibly unnecessary surgery.

    Keep up the good blog.

  26. #26 Samurai Scientist
    March 24, 2009

    @Calli,
    Not just that, Danio, but regardless of whether diet plays a role in cancer rates in the first place does diddly squat for a person who’s already *got* cancer…. Andreas Katsulas…
    I guess the bottom line is that if you develop an untreatable cancer, those kinds of lifestyle changes can, at best, improve your enjoyment of what time remains to you. They are valuable from that perspective, but it is very wrong to promote them as equivalent to chemotherapy or surgery. They cannot cure cancer.

    Calli, I love B5, but the jury is still out on whether diet might be a therapeutic for cancer. As a molecular biologist, there is precedent. Google Valter Longo for an example, or Gerard Evan.

  27. #27 Kemist
    March 25, 2009

    Calli, I love B5, but the jury is still out on whether diet might be a therapeutic for cancer. As a molecular biologist, there is precedent. Google Valter Longo for an example, or Gerard Evan.

    There’s also this study I ran into not long ago (it’s an animal study, however):

    Carbohydrate restriction, prostate cancer growth, and the insulin-like growth factor axis

    It’s not really far-fetched to say that diet influences treatment outcome. It’s however premature to pretend we actually know how yet, which is what the alties do.

    I think there’s a place in the future for a therapeutic use of diet in combination with the drugs. But we have to get evidence for it, like any other modality. At which point it will become conventional medicine. Because if it can ameliorate outcomes, it also has the potential to worsen them.

    The study above, for example does a huge dietary manipulation, namely a no- (or extremely low)-carbohydrate ketogenic diet (beyond what is done in the fad Atkins diet). It is very hard to undergo such a diet, and the authors are aware of it.

    The experimentators already faced unexpected challenges during the study : the animals (which had to be force-fed) on the ketogenic diet had to be given more calories than the control group because they tended to lose weight. Even then, they were still significantly thinner than the control animals.

    If you translate that in humans :
    1- Force-feeding a human is a pretty invasive and unpleasant treatment
    2- Many cancer patient already have cachexia, and this diet may worsen it
    3- This diet, which has been used in past years mainly for some forms of refractory epilepsia, is known to cause some amount of liver damage

    In fewer words, we’re very far from the easy, non-toxic, miraculous natural treatments alties pretend to.

  28. #28 Kemist
    March 25, 2009
  29. #29 Shon Alishah
    November 18, 2009

    Brilliant article, more money for the drug companies, and they will provide you more statistics and more lies. The fact remains that alternative therpay has saved more or less the same number of people, those save dby conventional therapies, but records and evidence are not maintained properly, just these people don’t have the resources to run expensive media campaigns, and sponsor hospital and doctors, and that is why people like you can ask questions like “where is the evidence?”, I can ask the same question show me where is the evidence that mistletoe doesn’t work for cancer patients? come on then lets see what are you made of? It a fact that drug companies are bigger than any other industry, and they just can’t accept that some fool could invent a radiowave machine and that could cure cancer, so for a machine like this which ois sitting in a looked room at MD Anderson, it will take decades before they will (IF) approve human trials, while people are dying everyday. Give Alternative Cancer Therapies the same sort of funding what is available to conventional therapies, and only then you can say it doesn’t work. I rest my case.

  30. #30 harley simpson
    September 19, 2010

    Re last comment,I have a 31 year old niece who has categorically refused conventional surgey in favour of diet. The tragedy is that the tumour had metastisised before detection and because of the internet decided to try natural therapy. She has a two year old son.
    I will let you know when she dies. Thanks to all those who who post false claims to sell their “alternate”products. I Do they realise they contribute to deaths?

  31. #31 KetoSiska
    November 10, 2010

    Related to the person commenting on the ketogenic diet – There are certainly some risks when it comes to ketogenic (low carb) type of nutrition, but it has effectively been used to treat various conditions, even epilepsy, so this should also be considered.

  32. #32 Shon Alishah
    February 1, 2011

    FAO: harley simpson

    Harley, using conventional therapy only 2.3% patients could survive 5 years or more. This is a fact and study conducted by the Australian Govt. The Alternative could work, although I dont think I should use this word, I rather say non-main streamline could work an does work, but more than onr protocols have to be applied at the same time. Just diet would not be enough for a patient of stage 2 or stage 3. Unfortunately there are no easy answers.

  33. #33 Orac
    February 1, 2011

    Nonsense:

    http://scienceblogs.com/insolence/2008/10/the_vitamin_c_empire_strikes_back.php (scroll down; the Australian study is discussed about midway through)

    Here’s some more:

    http://scienceblogs.com/insolence/2010/02/andreas_moritz_legal_intimidation_in_the.php

    No need to thank me.

  34. #34 Chris
    February 1, 2011

    Dear Necromancer Shon Alishah, do you have any real evidence for your claims? Or is this just on a list of websites that you decide to post your baseless opinions on about once a year?

  35. #35 Linda
    May 4, 2012

    A sincere, respectful question for Orac (and thanks for the blog):

    My sister-in-law, aged 43, has been diagnosed with multicentric, multifocal invasive lobular carcinoma. She has two tumors in one breast (1 cm plus satellites that radiate 4 more cm) and another Stage 2 size tumor. She has another tumor by ultrasound in the other breast. Right now, she seems she will choose ONLY holistic approaches (for all the reasons you listed above). Question: what is known about median survival in someone with multicentric lobular carcinoma with only holistic approaches (they include the ones you mentioned)? She actually has good health insurance. She will be spending a lot of cash on the holistic treatments. People who buy into the holistic approach literally are “buying” into it, in my view. Charlatans are preying on these people. My poor sister-in-law is a bright person, amazingly, with a lot of success in her life, but she has only a high school education and was working more than learning even in high school. She is easily influenced by a Hollywood mentality of organic foods and spiritual healing and well-being. What surprises me is that she actually went to real doctors for the diagnosis and sought multiple opinions. Why do people believe they even have cancer if they have so little faith in the doctors and conventional medicine? An enigma for me. I would say to her or do anything for her to allow her to avoid the painful death of breast cancer.

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