Apologetics for chelation therapy in The Atlantic

As I sat down to do my final post for this week, I perused my list of posts thus far and was amazed to discover that I hadn’t done a single post on vaccines. After all that nonsense the other week, where I spent more than a week blogging about nothing but the antivaccine movement, I thought this a refreshing change. So I figured I’d keep the momentum going, at least for today (I’m sure the subject will come up next week sometime) and stick with a topic that doesn’t involve vaccines. That topic, I hate to say, is another frequent topic of this blog, namely the infiltration of quackery into academic medicine.

First up, there is good news. I can’t resist mentioning that a most excellent review article by someone you know and either love or hate on the topic “integrative oncology” was published yesterday in Nature Reviews Cancer, a journal with an impact factor between that of JAMA and The Lancet. Unfortunately, it’s behind a paywall, but those of you who have university access can get it. Let’s just say the author is...less than enthusiastic about the infiltration of quackery into oncology. If you can, read, enjoy, learn. [ADDENDUM: I just learned that this article is available to all registered Nature.com users, no subscription necessary. So, if you want it, all you have to do is to register a Nature.com login.]

Unfortunately, nearly the very same day that I discovered that this paper was hitting print (online at least), I came across an article in The Atlantic. You remember The Atlantic, don’t you? It’s become a font of bad medical reporting, something I first noticed during the H1N1 influenza pandemic in 2009, when it published a risibly, execrably bad bit of hero worship of a flu vaccine “skeptic,” Dr. Thomas Jefferson written by Shannon Brownlee and Jeanne Lenzer. The Atlantic is also notable for an even more credulous bit of nonsense about the “triumph of New Age medicine” a couple of years later. This time around is not quite as bad as that, but only marginally so.

Medical academia is rapidly turning into medical quackademia. Both involve topics I’ve written about multiple times before, one of them about a travesty of a clinical trial that, almost more than any other, illustrates the pernicious influence of quackademic medicine in medical academia. I’m referring, of course, to the Trial To Assess Chelation Therapy (TACT), a multi-institution $30 million clinical trial designed to test whether the quackery known as chelation therapy, which is favored by naturopaths and various other practitioners of “alternative,” is an effective treatment for atherosclerotic cardiovascular disease. Of course, the results of the trial, taken as a whole, were negative. There was one subgroup, diabetics, where a positive effect was seemingly found, but that result was not convincing. Everything else was negative. Negative, negative, negative! Yours truly, Orac, was even accused of being “shrill and brutish” for criticizing the trial as utterly unethical, unscientific, and pure quackery. Chelation therapy itself is not quackery per se. It’s a useful treatment when there is documented acute heavy metal poisoning (no, I don’t mean listening to too much GWAR, although that might do it), but for anything else, be it heart disease, cancer, autism, or the number of other diseases that quacks attribute to “heavy metal toxicity” it’s quackery.

All of this background explains why I was disturbed to see an article in The Atlantic by James Hamblin entitled There Is No “Alternative Medicine.” In part, it’s a message that I’ve been promoting ever since I started this blog: That the entire concept of “alternative medicine” is bogus. Specifically, I reject the entire concept. Either medicine is scientifically proven, unproven, or disproven. The vast majority of what falls under the rubric of “alternative medicine” falls under the latter two categories: Unproven or disproven. Unfortunately, Hamblin’s article betrays its title. Or maybe subverts it. I’m still not sure. Either way, it’s bad.

TACT aside, chelation therapy is at best unproven, and Hamblin reports its results all wrong, essentially regurgitating Lamas’ claims for it even though the study was negative, negative, negative, with the possible exception of the subgroup of diabetic patients, where there are good reasons to doubt that finding. As I’ve repeated time and time again since TACT was published, boosters of chelation therapy believe the results of TACT and take them at face value, they should immediately stop administering chelation therapy to any patients except diabetics. (Of course, they shouldn’t be administering it to diabetics either.) Nothing of the sort has happened.

The interesting thing about this article is that it focuses on Gervasio Lamas, MD, the chief of Columbia University’s cardiology division at Mount Sinai Medical Center in Miami Beach. What bothers me about this particular article is that Hamblin falls for the trap of false balance, with a dollop of the exaggeration known as “science was wrong before,” all lending the false impression that Lamas and his fellow supporters of chelation therapy (and, yes, from the article it’s now clear that that’s an accurate characterization of Lamas’ views) and critics of chelation therapy as quackery are on the same ground. It’s an infuriating format that I’ve railed against in medical stories pretty much ever since I started blogging, one that’s used to give the impression of false equivalence between antivaccine loons and those who refute them, for instance. Indeed, this balance so belies the title of the article that one wonders whether it was tacked on by an editor. On the other hand, in context, the title seems to be arguing that perhaps chelation therapy isn’t “alternative” any more and is therefore, as I alluded to earlier, subverting a common skeptic statement about alternative medicine.

Indeed, Hamblin portrays the the criticisms of TACT as dogmatic cardiologists closing ranks to discredit the study, portraying them as close-minded doctors who reject anything that doesn't fit easily into their world-view, while Lamas, who’s become a convert, is portrayed as having started out dogmatically against chelation therapy (that word is even used by him elsewhere in Hamblin’s story to describe his response to a patient inquiring about chelation therapy in 1999) but then “opened his mind”:

Critics used these points to cast doubt on Lamas’s findings. Even before the study was completed, self-appointed medical watchdogs published blistering critiques, highlighting the fact that more than half of the clinics in the study practiced alternative medicine, and some offered notoriously unscientific treatments. When Lamas’s results were published in The Journal of the American Medical Association last year, they were accompanied by a scathing editorial from Steven Nissen, the chairman for cardiovascular medicine at the Cleveland Clinic, who called the study a dangerous failure.

Nissen had perused the Web sites of the clinics involved in the trial, and was appalled. “They offer every bizarre treatment possible,” he told me, from stem-cell therapy for growing breasts, to treating diabetes with cinnamon. “They’re warning people not to get immunized. These are the same people that are going to be doing a high-quality scientific trial? You gotta be kidding.” Nissen is adamant that Lamas’s study will be seen as an endorsement of chelation and will lead to a public-health “catastrophe.”

And, of course, Nissen was right. TACT is being spun throughout the community of quacks as a big win for chelation therapy, validation of their views, and justification to continue using chelation therapy. As for the number of quack clinics with no experience running rigorous clinical trials that were used as centers for TACT, I’ve talked about R. W. Donnell's Magical Mystery Tour of NCCAM Chelation Study Sites, Part I, Part II, Part III, Part IV, Part V, Part VI, and Part VII, and Kimball Atwood described some of the problems with these sites as well. As Dr. Donnell points out, only 12 of the 110 TACT study sites were academic medical centers. That’s not the huge problem. The huge problem is that many of the study sites were highly dubious clinics touting highly dubious therapies, including heavy metal analysis for chronic fatigue, intravenous infusions of vitamins and minerals, antiaging therapies, assessment of hormone status by saliva testing, and much more. Dr. Donnell also points out that the blinding of the study groups to local investigators was likely to have been faulty. So right off the bat, this study was dubious for so many reasons, not the least of which was that some of its site investigators were felons, a problem blithely dismissed by the NIH as being in essence irrelevant to whether the study could be done in a safe and scientifically rigorous manner.

Particularly disturbing is how Lamas intentionally put a weasel word into the conclusion of the JAMA article reporting the results of TACT:

Lamas and his co-authors anticipated pushback, and the study’s conclusion is guarded. He read aloud to me from the copy on his bookcase: “These results provide evidence to guide further research but are not sufficient to support the routine use of chelation therapy.”

“That’s a huge word, routine,” I said.

“I fought for that word. I spoke with the editor in chief of JAMA and said, ‘Listen, you gotta give the clinician a way out.’ So they let routine stay in. I, personally, have no routine patients.”

Nonsense. This is like Lake Wobegone, “where all the women are strong, all the men are good looking, and all the children are above average.” Nearly every doctor has routine patients, and that’s a good thing! Indeed, it’s a good thing to be a “routine” patient! In fact, sometimes I tell my patients with “routine” breast cancers that their cancer is “run-of-the-mill.” I then tell them that this is not an insult, but rather an observation that is a good thing for them, because “run-of-the-mill” means the way is clear. I know how to treat it, and I have a high expectation of success. It’s the non-routine patients who have to worry more. They’re the ones whose cases are the subject of long arguments discussions at tumor board, uncertainty, and less of a likelihood of success. From a physician’s perspective, “non-routine” patients might be more interesting and intellectually challenging, but from a patient’s perspective being “non-routine” sucks. In any case, it’s clear hear that Lamas put that word in there so that he and other chelationists can justify chelation therapy for virtually anyone by simply labeling all their patients as “non-routine.” To hear Lamas so boldly admit what he did with that conclusion is shocking to me.

Hamblin the abuses the “science was wrong before” trope, letting Lamas get away with, well, nonsense:

Of course, even though it sometimes seems otherwise, the medical community is capable of reversing its positions in the face of new research. Taking estrogen after menopause once seemed to help prevent heart attacks, but research later showed the opposite. Doctors used to recommend low-fat diets; now we regret demonizing healthy fats. Lamas says unexpected results should be welcomed, because they give doctors a new handle on disease. One of his takeaways from this study is that environmental pollutants are a modifiable risk factor for cardiovascular disease. “Stated that way, it seems reasonable.”

Estrogen treatment for menopause and to prevent heart disease is a bad example. Its use in the medical community can almost be likened to the use of chelation therapy among quacks. It was widely adopted based on—shall we say?—less than rigorous evidence, a popularity that didn’t end until clinical research failed to confirm the health claims for it. Moreover, no one’s arguing that unexpected results are a bad thing. However, TACT is not an “unexpected” result. It was a negative trial, with the possible exception of diabetics, for whom, again, there is excellent reason to doubt the validity of the results. It does not, as Lamas claims, provide strong evidence that environmental pollutants are a modifiable risk factor for cardiovascular disease—at least not heavy metals. Remember, we already know that there are environmental factors that increase the risk of cardiovascular disease. Cigarette smoking and secondhand cigarette smoke are big ones, for instance. We do not know that the vague “heavy metal toxicity” (no, not GWAR again) claimed as the cause of heart disease by quacks is a “modifiable risk factor” for cardiovascular disease. Lamas is spouting BS based on the “science was wrong before” trope.

Hamblin, to his discredit, eats this stuff up. At one point, he cites a sympathetic article by cardiologists David Maron and Mark Hlatky that claims a “double standard,” with resistance to research on so-called “dubious quack cures,” contrasting it with their eager anticipation of studies on “de rigueur cures such as gene transfer or stem cell therapy.” Talk about massive false equivalence! Dubious quack cures are generally viewed as dubious quack cures because they have no science supporting them. There’s no doubt that gene transfer, stem cell therapy, and (if I might add another example to the list) genomics-targeted medicine (so-called “personalized medicine” or, more recently, “precision medicine”0 are enormously hyped, arguably overhyped. However, there is definite promise there, in marked contrast to chelation therapy, which is based on a false view of how cardiovascular disease develops and is stoichiometrically highly implausible.

None of this stops Lamas from announcing that he’s asked the NIH for more funding (of course!) to study chelation therapy in diabetics. Given the dire funding situation at the NIH, with paylines so low that scientists can’t find funding for worthy research, it will be a travesty if any study of chelation therapy is funded, a slap in the face to clinical and translational researchers doing good science rather than studying quackery like chelation therapy, but it wouldn’t surprise me if Lamas managed to score more NIH money to fund a followup study. Be that as it may, that’s not stopping him either from setting up a chelation therapy program at his own hospital, Columbia University’s cardiology division at Mount Sinai Medical Center in Miami Beach and administering chelation therapy there. It’s yet another triumph of quackademic medicine.