Respectful Insolence

In the well over nine years that I’ve been blogging, there’s one tried and true, completely reliable topic to blog about, one that I can almost always find. I’m referring, of course, to the credulous news story about pseudoscience. The pseudoscience can be quackery, creationism, anthropogenic global warming denialist arguments, or whatever; inevitably, there will be some journalist, somewhere, who will fall for it and write a story that basically toes the line that supporters of pseudoscience like to see. Given that I pay the most attention to medicine, I notice this phenomenon the most when applied to quackery and, as I like to call it, quackademic medicine.

Two messages are constant in such credulous stories about the infiltration of quackery into mainstream medicine. The first message is that it’s not quackery, even though you and I know that it is. The second message is that it’s becoming enormously popular, embraced not just by patients but by physicians, the latter of whom are putting their imprimatur of medical authority on these modalities. The subtext to these two messages is that all these “alternative” treatments, this “complementary and alternative medicine” (CAM), this “integrative medicine” is something new and wonderful that should be not just tolerated but celebrated. A perfect example of such lazy, credulous reporting popped up in my Google Alerts yesterday. At first I thought I’d ignore it, but it kept irritating me, to the point that I decided, what the heck, it’s deserving of some not-so-Respectful Insolence. And so it shall receive some.

The article, by Elizabeth Payne, appeared in The Ottawa Citizen under the title, Patients, doctors embracing alternative medicine in battle against cancer: Naturopathy, acupuncture among techniques increasingly being used alongside established treatments. Yes, I’m sure regular readers can tell that such a title is akin to waving the proverbial red cape in front of the bull. Unfortunately, the story doesn’t “disappoint.” It’s every bit the mess I expected it to be when I read the title. It begins with the story of a woo-loving patient named Jennifer Miriguay, who is in the middle of her second battle with breast cancer and wanted to “take control of her health.” Man, I hate that cliche, but it’s a cliche that seems to appear in just about every one of these articles about the infiltration of quackery into mainstream medicine. Why is it that embracing quackery is “taking control of your health”? On a strictly trivial level, I suppose that it is, but in exactly the wrong way. Think of it this way. Taking control of your health does not require embracing quackery, but the unrelenting message from those who promote quackery is that it does and infiltrates the discourse about CAM or “integrative medicine,” or whatever the term du jour is. This embrace of quackery led to:

Her appointment with a naturopath at the Ottawa Integrative Cancer Centre was a “watershed,” she says. But Miriguay said she feared her oncologist wouldn’t be as positive about her embrace of naturopathy and acupuncture while being treated for metastatic breast cancer.

She was wrong. Her doctor didn’t balk, telling her he wished all his patients would take diet and nutrition as seriously.

The 41-year-old mother of two is part of a quiet, but significant, shift that is breaking down walls between traditional medicine and complementary therapies for treating cancer.

It’s a movement cancer patients have long pushed for, often to be met with negative or uncertain responses from their doctors. But that is changing. And a nondescript Hintonburg clinic is part of the shift.

No, it’s a shift that is breaking down the walls between quackery and science-based medicine by “integrating” quackery with conventional medicine. Contrary to what this writer seems to think, this is not a good thing. Even worse is that this article reads far more like an advertisement for the Ottawa Integrative Cancer Centre (OICC) than it does a news story. In fact, it reads like a PR reaction to a negative story that circulated about the clinic last week. The story mentions that a patient died after being taken from the clinic to a hospital, but then goes right into a statement that the police had determined that the death of a patient in the late stages of cancer was not suspicious. The original story appeared on April 4, and I haven’t been able to find out much since then. I can only assume that the authorities didn’t find anything. Patients with advanced cancer are prone to dying suddenly, whether they’re undergoing conventional therapy or naturopathic therapy. Without knowing the specifics of what treatments this patient was undergoing, I simply can’t comment.

I can comment, however, on this:

The clinic is supported by doctors, including Shailendra Verma, a medical oncologist at The Ottawa Hospital, who sees the importance to patients of breaking down barriers between conventional and complementary cancer therapies. It is also supported by the Ottawa Regional Cancer Foundation.

Verma, who is a scientific adviser to OICC, calls it a much-needed bridge.

“For far too long, disciplines have worked in isolation without communication and our patients have often felt caught between differing therapeutic philosophies, often to their detriment.”

I have no problem with legitimate scientific and medical disciplines communicating, the better to serve and care for patients. In fact, I applaud and encourage it. It’s often been true in the past that different specialties work in their own little silos, not communicating adequately. This is becoming less and less true, as cancer care becomes more and more interdisciplinary, but that’s not the point, and that’s not what bothers me. Where I have a problem is when that “communication” involves lending legitimacy to pseudoscience, such as the various forms of quackery that are at the heart of naturopathy, such that they are treated as co-equals with science-based medicine. It needs to be emphasized that these “differing therapeutic philosophies” have an incredibly wide chasm between them. It’s the difference between science and pseudoscience, medicine and quackery. What’s detrimental, in this case, is not shutting out naturopaths. It’s letting them in and treating them as legitimate health care professionals.

Given this credulous advertisement for the OICC, I thought I’d mosey on over to its website and see what sorts of treatments it offers. Sadly, I wasn’t surprised. Certainly, there is the usual stuff, like exercise, massage therapy, “psychosocial support,” yoga, lymphedema and lymphatic drainage, and “nutrition.” In addition to this seemingly benign, “gateway” woo, there’s naturopathy, a veritable cornucopia of different quack techniques based on pseudoscience, vitalism, and prescientific thinking; acupuncture (of course!); and reflexology (or, as I like to call it, a foot and hand massage with delusions of grandeur).

There’s more than just that, though. The OICC offers intravenous vitamin C therapy, which is unapproved, unproven, and, as administered by naturopaths, basically cancer quackery. Intravenous vitamin C, however, isn’t what surprised me. What surprised me is that the OICC offers intravenous dichloroacetate (DCA). You remember DCA, don’t you? It’s a small molecule drug that was tested in an animal model of cancer and had impressive anticancer activity in that model. In response to that rodent study, scammers popped up selling DCA to desperate cancer patients. The man, Jim Tassano, was a pesticide salesman who, as far as I can tell, purchased DCA from China and synthesized some of it on his own. (It’s a simple molecule, not that difficult to make for a chemist.) Ultimately, he was shut down by the FDA, but who knows what damage he did in the meantime?

These patients self-reported their results but, as all too often is the case in such self-selected support groups, they didn’t have an understanding of cancer, how to determine response, or clinical trials, which led even the best educated among them to misinterpret their results. Indeed, a husband-wife team in Edmonton even began offering DCA themselves. Ultimately, there was a human clinical trial, a phase I trial in glioblastoma. The results were not unpromising, but they were hardly earth-shattering. At the time, I pointed out how initially highly promising results in animal studies all too often disappoint in actual human studies. It happens. In fact, it happens far more often than the same miraculous results are observed in human clinical trials. That’s why we academic physicians have learned to temper our optimism and be very skeptical of preclinical studies in animals.

And the OICC is administering it to cancer patients. I don’t know what the law regarding approval of drugs and off-label prescribing is, but this is off-label prescribing on par with Stanislaw Burzynski prescribing phenylbutyrate off-label for cancer, in order to generate antineoplastons. There’s no strong evidence (yet) that DCA is effective against advanced cancers, just a preliminary phase I trial that produced biochemical evidence suggesting possible efficacy. There are some ongoing clinical trials right now, two in head and neck cancer. There’s a study that was terminated for “higher than expected risk and safety concerns the study should be closed” and a study that was withdrawn before it started accruing.

In other words, there’s no justification for anyone, much less a bunch of naturopaths at the OICC, to be administering DCA to cancer patients outside of the context of a clinical trial.

Finally, it turns out that we’ve met the executive director before Dugald Seely, ND, FABNO, who practices the “integrative” modality known as “naturopathic oncology,” or, as I like to call it, “integrating” cancer quackery into oncology, which Seely reported, although not using such language. He’s also tried to convince people that adding naturopathic treatment to the treatment of cardiovascular disease can result in improved Framingham risk scores. It didn’t, at least not as touted.

So what we have, in the end, is an article that is, in effect, an advertisement for the OICC, that ignores just how much quackery is in “naturopathic oncology,” and that touts what naturopaths told the reporter, namely how “integrative medicine” and alternative therapies are becoming mainstream. There is a grain of truth in that; otherwise, I wouldn’t be doing what I’m doing. But, make no mistake, it’s a minority of physicians who embrace this pseudoscience. The problem is that the vast majority of physicians, even as they realize it’s pseudoscience, are shruggies and do nothing about it.

Comments

  1. #1 Todd W.
    http://www.harpocratesspeaks.com
    April 15, 2014

    The real problem is that the administrators at these hospitals don’t care. Is there any chance of showing them that this stuff is crap and contributes nothing but warm fuzzies for their patients? No objective benefit?

    Granted, like I mentioned in another thread, some of these clinical offerings of pseuoscientific BS may be due to the efforts of wealthy donors. If so, it may be impossible to root out the nonsense, particularly if those wealthy donors also support non-woo-oriented programs.

  2. #2 Eric Lund
    April 15, 2014

    The second message is that it’s becoming enormously popular, embraced not just by patients but by physicians, the latter of whom are putting their imprimatur of medical authority on these modalities.

    One of the most insidious things about quackademic medicine is that a reasonable layperson may think it’s actually true. These “Opinions Differ Regarding Shape of Earth” news stories don’t help (and some days we’re lucky if the reporter acknowledges that there’s a “round earth” side of the “debate”).

    I hate that cliche

    Yes, it’s up there with “head him off at the pass”.

  3. #3 Denice Walter
    April 15, 2014

    When people feel helpless, they want to believe that their own actions can somehow counteract their current state: offering whimsy-based substitutes for SBM seems to take advantage of them. Shouldn’t ‘psycho-social’ intervention address that issue?

    I wonders and I wonders….
    if there are data which indicate how much
    – the addition of woo-ful specialities contributes to patients’ choice of using a particular facility
    – which woo is most lucrative
    – how much woo contributes to the bottom line: i.e. profit

    Wouldn’t that be ironic?
    If SB facilities added altie nonsense in order to make money.
    I thought that they were already rolling in it.

  4. #4 TBruce
    April 15, 2014

    From the OICC website:

    The OICC offers subsidized care to as many people as we can, but we are a charitable not-for-profit and receive no government funding, so our capacity to do so is limited.

    I’m glad to see that no tax money is involved (although I’m sure that the pressure is on). Unfortunately, charitable donations that could go to valuable support services will be pissed away on this nonsense.

    There’s also this:

    It (OICC) is also supported by the Ottawa Regional Cancer Foundation.

    They’re the same foundation that cancelled Jenny McCarthy’s appearance at a fundraiser last year, after negative public reaction blew up in their faces. Might be time to investigate how much donation money gets siphoned off to these quacks.

  5. #5 JerryA
    April 15, 2014

    I think the “patient taking control” line is slick marketing. IMNSHO, patients feel out of control because medicine is complicated. I’m a research biochemist and it has still taken me several years to come to the conclusion that one local orthopedic practice is dangerous. For most people, their lack of scientific or medical training must make them feel totally bewildered. However, “taking control” by adding or substituting quackery for medicine is like a driver letting an untrained passenger into the driver seat of a car. Sure, the passenger is now “in control”, but more likely than not they’re going into a ditch.

  6. #6 JerryA
    April 15, 2014

    p.s. I’m not saying patients should just sit back and let the doctor drive them anywhere. A patient really “taking control” would include asking for nonsurgical options, other medicine, or getting a second opinion, but here’s the catch- asking for scientifically proven options from medically trained personnel, not quacks. Unfortunately, naturopaths and homeopaths have realized this and gotten “licensed” or “certified”, so most people can’t tell the difference between UofM and UofWoo.

  7. #7 Renate
    April 15, 2014

    I rather let the surgeon in control. I’m not operating on myself, nor telling the doctor how he should to his job.

  8. #8 Mike
    April 15, 2014

    One of my friends is a former member of the multi-city concierge One Medical Group, which features “integrative medicine”.

    My friend said he was told that the alt med services “are there if people want to use them”

    My friend said he also asked one of the doctors about the alt med, who replied similar to the following: “well, I believe in science-based medicine, but there are guys who run the place who can bring in bucks from these other things and they help support the practice”

  9. #9 Sastra
    April 15, 2014

    The idea that adopting alternative medicine is “taking control” or “empowering” is at least partly grounded in the idea that it’s not mainstream. Be a rebel! You will be criticized, but you will stand tall and firm and not be swayed by negative voices as you make the choice which is right for you.

    It would be interesting to see what happens to that narrative if alt med ever really does become part of the Establishment. Scary, but interesting. It’s quite possible that all the fuzzy language concerning its spirituality might be enough to keep it edgy and personal.

  10. #10 Mephistopheles O'Brien
    April 15, 2014

    “head him off at the pass”

    That’s a very valid strategy if you want to catch someone and there is an obstacle (in this case, rugged terrain) that will limit hischoice of route for that portion of the trip. The problem with that strategy is that a) there must be a pass and b) you must be able to get there before your target.

    If the target is an experienced rider familiar with the area, then you’re unlikely to be able to head them off at the pass (unless, say, you sent your orders via telegraph). However, there are reasons you might well be successful at this including:
    – he is riding slowly in order to reduce the amount of dust and mask his trail
    – he is unfamiliar with the area and unlikely to take a direct route to the pass
    – you know a shortcut to the pass

  11. #11 Shay
    April 15, 2014

    MO’B — or you have a faster horse.

  12. #12 Mephistopheles O'Brien
    April 15, 2014

    Shay – but if you have a faster horse, why aren’t you just chasing him? You’ll likely catch him on the way and give the rugged terrain a … er … pass.

  13. #13 Shay
    April 15, 2014

    Personally I prefer a 30-30 solution. You don’t get all sweaty and out of breath that way.

  14. #14 Mu
    April 15, 2014

    While a lot of the alternative/integrated approaches clearly have no merit, I disagree on the disdain for “unapproved, untested” therapies. As long as they have a scientifically reasonable mode of potentially working and you’re in the “recurring metastasized” stage of cancer, everything is better than hospice. A lifetime supply of DCA or phenylbutyrate can be had for $100 or less at Aldrich, go ahead, give it a shot. Of course, the tricky part is getting the material without falling for the $25,000 treatment trap offered by the quacks.

  15. #15 Calli Arcale
    http://fractalwonder.wordpress.com
    April 15, 2014

    Mephistopheles — I always had the impression it was because passes are usually chokepoints, and so a better place from which to stage an ambush.

  16. #16 Mephistopheles O'Brien
    April 15, 2014

    Calli Arcale – Precisely, and this is why I think it’s a good strategy. You need to be careful to get to the pass first; assuming you start off behind him and he knows your likely to chase him, that becomes problematic. Naturally, if he doesn’t know he’s being (or likely to be) chased, then the pass provides you a very good place at which to cut him off.

  17. #17 Marie
    April 15, 2014

    Good post. Just want to mention that not all cancer support groups are “gateway woo”. Some support groups prevent members from going to the dark side. Support groups are like any community, you have find the right fit. I initially went to one that was awful. I thought the meetings were just being held at a local mega-church, but they tried to convert members. And they weren’t trying to convert you to the “scientific method” if you get my drift.

    I am currently in a group that really helps members keep their heads on straight during the frightening process of cancer diagnosis & treatment. For example, not a week goes by that one member of my group doesn’t say to another, “I think you are confusing correlation with causation”. It makes me smile.

  18. #18 rs
    April 15, 2014

    M: “Thanks for showing me around the cockpit. Airplanes are really amazing things.”
    Pilot: “My pleasure.” He takes off his headset and stands.
    M: “Where are you going?”
    P: “Oh, well I’ll be leaving. You’re in charge now. I really do hope you were paying attention during the tour.”
    M: “Um, going? Going where?”
    P: “Oh, don’t worry. I have a parachute.”
    M: “What about me?”
    P: Gives M a stern look. “It’s time for you to take control of your journey M. Sure, I’m a professional with thousands of hours of accident-free flight time, but I know how much you feel the need to take control. I’ve already pointed the plane in the right direction so all you need to do is land.”
    M: “But…”
    P: “No ‘buts’ about it. Just be firm and take control. All you have to do is land and you’ll arrive safe and sound.” He is closing the door of the cockpit behind him.
    M: “I don’t know if I can handle this!”
    P: “I sure you’ll be fine. All you need is a bit of Payne management.” He smiles. “Let me know how it goes. Bye now.”

  19. #19 Sarah A
    April 15, 2014

    It occurs to me that hospitals and clinics that offer alt-med on the side are kind of like grocery stores that have a vending machine for lottery tickets. They know its basically a “stupid tax,” but as long as someone is paying it they might as well get their cut. Some would argue that the brief feeling of “maybe I’ll win big this time” is worth a couple of bucks, but the flip side of that is the relatively small (one hopes) number who get hooked and wind up gambling away their paychecks. Similarly, some would argue that the warm fuzzies alt-med provides is worth the extra money they pay, but the flip side of that is the relatively small (one hopes) number of people who reject SBM altogether and suffer or die needlessly (or, worse, inflict avoidable suffering or death on their children.)

  20. #20 reader
    April 15, 2014

    Several years ago, I saw bulk vitamin C powder offered for $4.50 per pound in a small shop. One cent per gram.

    When I hear doctors bandy that “vitamin C…expensive urine” line around, it’s hard to avoid thinking that they are poor doctors.

  21. #21 Dorothy
    Oz
    April 15, 2014

    I hate that “nutrition” becomes transformed from “eat lots of veggies and fruit, some whole grains and lean meat (or beans), minimize the fat, and really minimize the sweets” into some big, bloated dirigible of hocus-pocus that basically sets you up to buy endless supplies of supplements, a very expensive juicing machine, lots of “detox” supplies, and maybe some ear candles for good measure.

  22. #22 Narad
    April 15, 2014

    When I hear doctors bandy that “vitamin C…expensive urine” line around, it’s hard to avoid thinking that they are poor doctors.

    Which, of course, is why the supplement racket is a multibillion-dollar industry.

  23. #23 Eric Lund
    April 15, 2014

    The problem with that strategy is that a) there must be a pass and b) you must be able to get there before your target.

    And that is why “head him off at the pass” is a cliche. (Have you not seen Blazing Saddles?) The pass minimizes the time/distance spent traversing rugged terrain, so if you’re close enough to one for it to be a factor, it will be hard to get there before the person you’re chasing without overtaking him. (Assuming he does run in that direction–he almost always has at least one other choice.)

    Same thing with “take control of one’s health”, from the original post. Sure, it’s a good idea if you can actually pull it off. If your lifestyle is causing you problems but there are no major underlying health issues, you have a good chance of pulling it off. If you have cancer, especially an advanced stage or a relapse (the latter is true of the described patient), it’s not so likely to work.

  24. #24 herr doktor bimler
    April 15, 2014

    Have you not seen Blazing Saddles?
    It’s a documentary, right?

  25. #25 Vicki
    April 15, 2014

    Mu–

    “Anything is better than hospice” pretty clearly implies “spending two months in unnecessary pain and then dying is better than dying after two months of hospice.” If whichever long-shot treatment it is causes no pain or serious discomfort on its own, doesn’t require the patient to do without useful painkillers or other palliative care, and doesn’t keep the patient from spending those last months with the people they love, then it might well be better than hospice. But part of why hospice exists is that there are treatments that isn’t true of.

  26. #26 herr doktor bimler
    April 15, 2014

    A lifetime supply of DCA or phenylbutyrate can be had for $100 or less at Aldrich, go ahead, give it a shot

    A life-time supply of placebo or your money back!

  27. #27 Mark Thorson
    April 15, 2014
  28. #28 Mephistopheles O'Brien
    April 15, 2014

    reader – I’m unsure – are you saying that the urine with vitamin C you paid for and flushed as excess to your body’s needs is more or less expensive than the urine without said vitamin C?

  29. #29 Mephistopheles O'Brien
    April 15, 2014

    @Mark Thorsen – because we all know that people who are dying should be able to enrich any vulture pursue any course of treatment that might have a good sales pitch give any chance of a cure.

  30. #30 AC
    April 19, 2014
  31. #31 squirrelelite
    April 19, 2014

    @AC,
    Since 13 of the 272 (4.77%) of the runners died and 33 of the 714 (4.62%) died, it’s not much of a protective difference.

    Others like the author of this blog are far more qualified than I am to comment on the statistical methods involved, for instance. But, I would want to look closely at the specifics of the individuals: severity of cancer, general health and other risk factors, cause of death, etc.

    There may be some other affect involved. People who exercise more will have their cardiovascular systems in better shape and are less likely to die of heart attacks, strokes, etc. And if you exercise for a set amount of time, running earns more METs and therefore is better for you. It seems they controlled for that.
    But, people who were in poorer general health may have been more likely to walk instead of run. I’m rather the exception to that since I take quite brisk 3-5 mile walks several times a week.

    If you want to compare numbers for walking and running, I found this calculator site:
    http://www.exrx.net/Calculators/WalkRunMETs.html
    It has links to several other calculators for comparing and testing yourself with various fitness activities.
    I saw I need to take a few more seconds off my 1 mile walk time to go up from the Good category to the Excellent category.

    Personally, I would guess the amount of energy expenditure is more important than the type of exercise. But, the conclusions in your second link seem to suggest that vigorous exercise is better than more casual exercise:

    “If I were a breast cancer survivor, I would certainly consider running or some other vigorous exercise over walking, and I wouldn’t just be doing the minimum, with the consequences and potential benefit being so great,” he adds
    Previous research from the national study showed that running was more effective than walking for weight loss. For many health benefits, however, running and walking appear to give the same benefits for the same amount of energy expenditure. These include lower risk for coronary heart disease, diabetes, hip replacements, as well as brain cancer. Running and walking also seem to be equally beneficial in the primary prevention of breast cancer.

  32. #32 AC
    April 23, 2014

    Sorry for the delayed thank you. I am extremely grateful, thank you squirrelelite :)

  33. #33 Daniella
    April 24, 2014

    Was disappointed about the “so called” new cure or potential cure as it isn’t really something so astonishing

  34. #34 squirrelelite
    April 24, 2014

    You’re welcome, AC!
    And good luck to you in your fight against breast cancer.

    You might also want to check out this web site for more information:
    http://www.sciencebasedmedicine.org/avastin-and-metastatic-breast-cancer-when-science-based-medicine-collides-with-fda-regulation/

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