chelation

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.

Comments

  1. #1 Old Rockin' Dave
    In a world of pain (bad back)
    September 19, 2014

    Your description of “routine” and “run of the mill” reminds of what one of my bosses used to tell patients: “The two words you never want to hear your doctor say are “That’s interesting!””

  2. #2 LW
    September 19, 2014

    Try three words: “Oh my God!”

    Fortunately the problem didn’t turn out to be as serious as that sounded.

  3. #3 Denice Walter
    September 19, 2014

    Oh Orac! I really hate to be the one to disturb this halcyon period of anti-vax-less bliss you’re enjoying but..
    hey, what do you think they pay me for?

    It appears that Kent Heckenlively has been permitted around an unsecured keyboard again which he utilises to implore CDC criminals to surrender and ‘fess up. ( AoA).

    And Jake has a brand new *bete noire*: Ivan Oransky.
    Autism Investigated’s editor illustrates what he does with his time. Funny when I started a doctorate I barely had any time for myself, let alone enough to harass people with serial e-mails and then write about it.

  4. #4 JLI
    Denmark
    September 19, 2014

    One of the chelationists who participated in the TACT-study (Terry Chapell) gave a one hour long presentation in Denmark, where he addressed some of the points of criticism: http://www.edta-patientforeningen.dk/ (second video from the top).

    At 23:33 he argues that there was no unblinding by saying:

    “At my clinic we thought we could tell who was getting the treatment and who wasn’t. In most of the cases I think we were right, but in a couple of cases we were wrong. We were fooled by the placebo too”.

    Wonder what those involved in the TACT study think a good placebo is?

    He doesn’t adress all the points of criticism raised, and he doesn’t refute them well. But he were among friends when giving his presentation.

  5. #5 RobRN
    September 19, 2014

    Yes… I let my Atlantic subscription lapse following that ridiculous New Age Medicine article!

  6. #6 herr doktor bimler
    September 19, 2014

    “These results provide evidence to guide further research

    So the only outcome of a $30 million research project is a request for another $30 million for more research?

    And Jake has a brand new *bete noire*: Ivan Oransky.
    He’s trying to get on the wrong side of Retraction Watch? This will not end well.

  7. #7 Denice Walter
    September 19, 2014

    @ herr doktor:

    I believe that currently he is on the wrong side of just about everybody with the possible exception of Hooker and White Rose. I wonder if he is happy or sad about what transpired today re AJW’s suit? Prabbaly, he’s confused.

  8. #8 Shay
    my office, staring out the window
    September 19, 2014

    What transpired today in re: AJW’s suit? Inquiring minds want to know.

  9. #9 Shay
    September 19, 2014

    Ooh, never mind. Just found it.

  10. #10 Patrick Arambula
    Phoenix, AZ
    September 19, 2014

    “…..chelation therapy, which is favored by naturopaths and various other practitioners of “alternative,” is an effective treatment for atherosclerotic cardiovascular disease.”
    Oh, my. Well at least it’s good to know they’re favoring all natural, more gentle alternatives that treat the disease and not just the symptoms like big harsh, pharma allopatho medicine……….don’t you know……

  11. #11 SteveJ
    September 19, 2014

    @Old Rockin’ Dave
    When I was in college, I caught hand, foot, and mouth disease. The first Student Health doctor didn’t know what I had, so he called in a couple more doctors. Eventually one of them looked it up in a book (This was in the early ’90s).

  12. #12 sadmar
    This Toilet Earth
    September 19, 2014

    Fortunately, a little GWAR goes a long way. The amazing healing powers of flatulence strained through the CuttleFish of Cthulu are embedded in this video clip, a guaranteed scum-o-pathic cure for constipation!

  13. #13 Old Rockin' Dave
    On the couch, waiting for the Percocet to kick in
    September 19, 2014

    SteveJ, that’s exactly what old Doctor N. was talking about. There is one phrase worse than any we’ve mentioned here so far: (Said by a very senior practitioner) “I’ve been doing this for fifty years, and I never thought I’d see one of these.” I once heard an old semi-retired hematologist say that, and he went back to the days when there were only six hematologists in all of North America. It was interesting for us on the clinical staff. It didn’t work out so well for the patient, I’m sorry to say.

  14. #14 Politicalguineapig
    September 19, 2014

    SteveJ: My family still talks about the table full of cardiologists that met for lunch to discuss my dad’s heart. I’m sure that one of these days, someone is going to run into my family’s medical records and spend a few hours boggling. We’re normally a healthy bunch, we just get odd diseases.

    ORD: Also in things you don’t really want to hear: “Oh, a textbook case! Can I take pictures for my class?*

    *It was above the waist, so I didn’t find it as creepy as it sounds.

  15. #15 Old Rockin' dave
    September 20, 2014

    “Don’t worry, it’s probably not fatal.”
    “I have to report this to the Health Department, but they won’t ask for your name.”
    “This will make a great journal article.”
    “It can only be one of two things, so let’s concentrate on the one we can cure.”

    “Oh, this mask? It’s nothing.”
    “The NHL is going to have a day in your honor.”
    “Is it alright if we don’t shake hands?”
    “I don’t know if you were planning to have children…”
    “I found out what you have”, waves copy of Daily Mail..
    “There’s someone who knows how to cure this”, leads in Oprah Winfrey.

  16. #16 KayMarie
    September 20, 2014

    Add giggling uncontrollably to the list of things you don’t want to hear from your doctor, or the nurse.

    Although turns out it was a text book case. My Doc back home came in with the textbook to show me I looked just like the picture.

    And apparently my eyes do a normally subtle movement when you do the look at the pen and cover one or the other eye trick rather dramatically so I’ve been used as a training tool at more than one ophthalmologist’s office. Oh, that’s what I’m supposed to be looking for. *sigh*

  17. #17 Shay
    September 21, 2014

    “”Hmmm…curious. I’ve never seen that before.”

    Also something you never want to hear, especially from a physical therapist.

  18. #18 The Grouchybeast
    September 21, 2014

    “The last time I saw anyone with a case that bad, they were in hospital on a drip!”

    Luckily, the person who said that to me was only a trainee GP, so it was more that their experience (and bedside manner!) was lacking than that I was really all that ill. Still, not very reassuring for twelve-year-old me.

  19. #19 Narad
    September 21, 2014

    Luckily, the person who said that to me was only a trainee GP

    Note from the rheumatology department: “What’s the colchicine for?”

    I suspect that the resident PCP didn’t make that mistake again, after the laughter died down, or something.

  20. #20 squirrelelite
    September 21, 2014

    I’ll throw in the comment made while the doctors were chatting and I was lying on the mat waiting for a spinal tap.

    “Have you ever done one of these before?”

  21. #21 Denice Walter
    September 21, 2014

    ” This laceration looks EXACTLY like a jigsaw puzzle piece ”
    and
    ” In a few years, you won’t be able to see the scar at all- in the meanwhile, your hair is long enough to cover it”.

  22. #22 herr doktor bimler
    September 21, 2014

    Also in things you don’t really want to hear: “Oh, a textbook case! *

    The Doktorling Sonja heard that a few days ago… we had persuaded her to go to the Student Health Service with what turned out to be Erythema Nodosum. The nurse had never seen anything like it before, but the doctor was familiar with the condition, with a “fingers on one hand” comparison.

    We congratulated her for (1) living in a ‘House’ episode, and (2) acquiring a condition which sounds like a Harry Potter spell.

  23. #23 brook
    September 21, 2014

    In the nice recovery department – endocrinologist bounces into my room with med student in tow “How’s the diabetes?” she asks.
    “It’s a miracle,” I reply “no diabetes.” She does a double take. I explain I’m a thyroid patient. Doc looks at the med student and says “This is why you always look at the chart before you come in the room.”

  24. #24 Julian Frost
    Gauteng East Rand
    September 21, 2014

    Well, this doesn’t involve a doctor, but it does involve something you never want to hear.
    I had a painful spot near my anus, but couldn’t see what it was. I was living with my sister and her then-boyfriend (now her husband). I’m about to take a bath, and I ask my sister to take a look.
    Sister: “Okay.”
    I unwrap towel and bend over for her.
    Sister: “WOW! HOLY CRAP!”
    It was a big patch of raw skin, but it healed.

  25. #25 Narad
    September 21, 2014

    Derm: “It sounds like you did the right thing. Could you move your knee to the right?”

  26. #26 Chris
    September 22, 2014

    Also in things you don’t really want to hear:: “Sleep? What is sleep?”

    Words uttered by my family doctor as I was just given the drugs to induce delivery of my first child… who showed up six hours later only with help from some forceps.

    The dear doctor’s own first child had arrived a few days later. Fortunately his second child showed up a few hours after my second kid, so he had had some sleep.

  27. #27 Chris
    September 22, 2014

    Aargh… don’t you read the comment before submitting Chris!? Silly woman…

    “had arrived a few days later earlier.”

  28. #28 sheepmilker
    September 22, 2014

    Nurse one: “Ooh, you should see the goo come out of this!”.
    Nurse two: “Can I have a go?”.

  29. #29 LW
    September 22, 2014

    ER doctor on examining chest X-ray: “You have the worst looking lungs I’ve ever seen.”

  30. #30 Jenora Feuer
    September 22, 2014

    On the discussion of ‘things you don’t want to hear from your doctor’, my brain automatically goes to the old Bill Cosby routine, ‘Oops’. As said by the surgeon, while the guy on the table is only under a local, and can hear everything… (Cosby having been a U.S. Navy Hospital Corpsman, he probably heard a few stories about that.)

    And I know someone who did end up being used as an example. It was one of those eye sensitivity problems that often ends up being misdiagnosed as a migraine, and this poor woman had been in and out of the hospital half a dozen times before a doctor asked the right questions, did a couple more checks, then asked, “Do you mind if I get a couple more people here?” He showed back up some time later with several residents in tow, described the condition she had, and pointed out to the others that in the unlikely event they ever ran into a case like this again, demonstrated on her the things to look for to distinguish it from a ‘simple’ migraine. (Happily, the new treatment worked, unlike the straight pain relievers.)

  31. #31 Old Rockin' Dave
    On the QT (if I'm reading this NY subway map right)
    September 22, 2014

    I was a teaching example for years, with mitral prolapse that had a very clear and characteristic click murmur. I helped to educate a generation of trainee physicians, PA’s, and NP’s.
    That’s all gone since endocarditis required me to get it replaced. It’s a bovine valve, but so far no veterinary students have asked to come hear it.

  32. #32 smitty
    October 6, 2014

    My gyno twice said, “Mmmmm, interesting” while attempting to do a uterine biopsy. Since a construction contractor once told me that “interesting” really mean “oops”, I was a little worried.

  33. […] Of course, as we know, chelation therapy for cardiovascular disease is also quackery, the recent clinical trial known as TACT […]

  34. #34 MikeManea
    October 11, 2014

    Hi, my name is Mike and I am currently working on a book called, ‘How to Debate Atheists.’ I have completed the first three chapters and would appreciate any feedback.
    http://mikemanea.com/unapologetics/how-to-debate-atheists/

  35. #35 Mephistopheles O'Brien
    October 11, 2014

    @LW

    ER doctor on examining chest X-ray: “You have the worst looking lungs I’ve ever seen.”

    I wouldn’t accept esthetic opinions from someone who can’t even pronounce his/her specialty and is reduced to making guttural noises.

  36. #36 Dangerous Bacon
    October 11, 2014

    “On the discussion of ‘things you don’t want to hear from your doctor’, my brain automatically goes to the old Bill Cosby routine, ‘Oops’. As said by the surgeon, while the guy on the table is only under a local, and can hear everything…”

    Two that stick out in my mind from when I was a med student observing and/or holding retractors during surgeries:

    “Oops, oops, oops, oops, oops.”

    and

    “BLOOD! blood blood blood”

    (the latter comment was by the surgeon doing a tonsillectomy. It all turned out fine in the end…)

  37. #37 LW
    October 11, 2014

    @Mephistopheles O’Brien: oh, he was actually quite coherent and repeated courses of antbiotics cleared up the pneumonia quite well. I missed two months of work though. You can bet I get my flu shot religiously, though. Flu shots are far from perfect, but they’re my best bet for avoiding going through that again.

  38. #38 Vicki
    October 11, 2014

    Mike:

    Ask on a site for believers/apologetics, not a thread on an unrelated topic here. You could find a writers group and see if someone is prepared to trade critiques. Or ask professional editors, if you’re willing to pay for the service. “Help me improve my book” is in fact a professional service, if you really mean that rather than “I bet you can’t find holes in my argument.”

  39. #39 Chris
    October 11, 2014

    Vicki, perhaps he should try asking at:
    http://freethoughtblogs.com/pharyngula/

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