Quackademic medicine versus cancer quackery: The central dogma ...

Since I seem to be on a roll the last few days discussing cancer quackery, I thought I?d just go with it at least one more day. Frequently, when I get on these rolls laying down the Insolence, both Respectful and not-so-Respectful, over antivaccine quackery I start whining about how I need to change topics, but not this time around, not this topic. It takes a lot more than what I?ve posted lately to make me feel as though I need a change of pace. Besides, for whatever reason, the blog fodder is flying at me fast and furious, whether it be the dubious testimonial I discussed yesterday, yet another deconstruction of the moral bankruptcy that is Stanislaw Burzynski, or my take on the sheer quackery that is ?naturopathic oncology.? The first rule of blogging is that you don?t talk about blogging. Oh, wait. That?s not it. I talk about blogging all the time. The first rule of blogging is: When the world is throwing easy blogging material at you, for cryin? out loud, go for it. Yeah, that?s it.

So I?m going for it.

The blog fodder this time around comes in the form of three articles that appeared in ONCOLOGY: Perspectives on Best Practices, an open-access journal about?well, oncology. All three of them are about cancer quackery. Shockingly, in the first article, by Barrie Cassileth, director of all woo integrative oncology at Memorial Sloan-Kettering Cancer Center, and IIan R. Yarett, actually uses the word ?quackery? in its title: Cancer Quackery: The Persistent Popularity of Useless, Irrational ?Alternative? Treatments. In it, Cassileth provides a rather standard discussion of bogus cancer treatments that almost could have been written by Orac, were it not for the complete and utter lack of snark, even the subtle snark that academics sneak into papers. She does, however, complain that quacks have appropriated the term ?complementary? in order to ?use it incorrectly.? This complaint derives from how many of these cancer quacks don?t actually advocate using their nostrums in addition to conventional therapy but rather in lieu of science-based medicine. Personally, I find this amusing, given that quackademics have no one to blame but themselves for this, given the specific modalities they have tried to ?integrate? with science-based medicine. It rather reminds me of the ?intelligent design? creationists, craving respectability and crowing to high heaven that they aren?t pseudoscientists but real ?scientists,? taking umbrage at being lumped together with fundamentalist creationists who believe that the earth was created 6,000 years ago with all animals in their current forms. No, Cassileth seems to be saying, we don?t associate with that riff-raff. They?re fundamentalist loons. We?re scientists!

I?ll give her some credit for this article, though, and why not? Cassileth lists a fairly standard bunch of quack treatments, the majority of which have been covered on this blog at one time or another, and rips into them. The litany should be familiar: laetrile, shark cartilage, Entelev/Cantron (which I recently discussed, with the comment thread afterward having swollen as of this writing to nearly 1,100 entries), various oxygen therapies (such as hyperbaric oxygen or various means of administering hydrogen peroxide, ?energy therapies,? which Cassileth admits have no evidence to support them. Given that admission, one wonders why reiki, which is a form of ?energy therapy,? is offered at MSKCC. Come to think of it, acupuncture is also a form of ?energy healing? as well, given its claim to be able to manipulate the flow of qi through the body to healing intent, and MSKCC offers acupuncture as well. That doesn?t stop Cassileth from making the dubious claim that acupuncture and other woo have ?been shown to be safe and effective as adjunctive treatments for managing pain, nausea, stress, and many other symptoms, and for supporting patient well-being in general,? whatever ?supporting patient well-being in general? means.

There are other weaknesses. For instance, no mention is made of Gerson therapy, and it is that particular form of quackery, as well as its many variants (such as the Gonzalez protocol and other treatments that loosely fall under the rubric of ?metabolic therapies? and often include such lovely interventions as coffee enemas), that is arguably the cancer quackery most heavily promoted right now; that is, unless high dose vitamin C, which never seems to stay dead no matter how many scientific stakes are driven into its heart, isn?t the most common quackery. One could only wish that, like the vampires on True Blood, such quackeries would explode into a disgusting blob of blood and tissue when the stake of science is driven through their hearts, but sadly this never seems to happen. Her omissions aside, I can?t be too hard on Cassileth. Her article is actually pretty good, by and large, if you can ignore that she is in charge of bringing quackademic medicine into one of the greatest cancer centers in the world. She also makes this statement:

Many alternative approaches to healing are premised on the concept of the mind/body connection, and specifically on the theory that patients can harness the power of their mind to heal their physical ills.[4] Many mind/body techniques, such as meditation and biofeedback, have been shown to reduce stress and promote relaxation, and are effectively and appropriately used as complementary therapies today. However, some proponents of these techniques overpromise, suggesting that emotional stress or other emotional issues can cause diseases like cancer and that correction of these deficiencies through mind-body therapies can effectively treat major illnesses. Such claims are unsupported.

Many of these ideas were promoted by a former Yale surgeon, a popular author who advocated special cancer patient support groups in his books. The importance of a positive attitude was stressed, as was the idea that disease could spring from unmet emotional needs. This belief anguished many cancer patients, who assumed responsibility for getting cancer because of an imperfect emotional status. Among alternative modalities, the mind/body approach has been especially persistent over time, possibly in part because it resonates with the American notion of rugged individualism.[4]

Of course, none of this stops MSKCC from offering ?mind-body? services. I guess it?s OK to Cassileth because she doesn?t promise that such woo will cure the cancer. OK, I?ll stop with the snark (at least the snark directed at Cassileth). She?s basically correct that there is no evidence that these therapies can impact the natural history of cancer and produce a survival benefit, and I give her props for carpet-bombing the quackery that is the German New Medicine.

Cassileth?s article was accompanied by not one, but two, additional commentaries, both of which didn?t take issue with the criticism of specific cancer quackeries, such as Entelev, but rather with her statement above about mind-body ?healing.? Neither of the commentators were happy that Cassileth had questioned the central dogma of alternative medicine, which is what I?ve been discussing the last couple of days. That central dogma is that if you wish for it hard enough your mind can heal you of anything. The corollary of this central dogma is that if you are ill it is your fault for not having the right ?intent,? attitude, and thoughts and therefore not doing the right things and/or not believing hard enough. It?s not for nothing that I have likened alternative medicine to religion or the New Age woo that is The Secret, and these authors simply reinforce that view. First up is radiation oncologist and practitioner of ?integrative oncology? Brian D. Lawenda, MD, who pens Quackery, Placebos, and Other Thoughts: An Integrative Oncologist?s Perspective.

In the first part of his article, Lawenda protests loudly, arguing that ?not all therapies categorized as ?alternative,? ?nonconventional,? or ?unconventional? are completely ineffective.? I suppose it depends on what you mean by ?completely ineffective.? Personally, when I say ?completely ineffective,? I mean ?indistinguishable from placebo.? That?s the usual definition of ?ineffective? in medical circles, and it is a description that applies to the vast majority of ?integrative oncology,? including acupuncture, therapeutic touch, reiki, and the like. In the case of acupuncture, for instance, it doesn?t matter where you stick the needles or even if you stick the needles in at all (a toothpick twirled against the skin will do as well or better). In other words, in the case of acupuncture, the effects are entirely nonspecific. Indeed, Lawenda?s claim that these therapies are being used in an ?evidence-based? manner is almost as overblown as the claims that quacks make; real ?evidence-based? use of the vast majority of these modalities would be not to use them at all. They don?t work. That doesn?t stop Lawenda from advocating placebo medicine. But first he has to remonstrate with Cassileth over her characterization of ?mind-body? medicine:

One area of controversy that comes up often in integrative oncology circles is whether or not there is an association between chronic stress and cancer-specific outcomes. Dr. Cassileth asserts that the association between chronic stress and cancer development, progression, and recurrence has not been definitively established. Those who support this view might categorize as quackery the claim that stress reduction (eg, through lifestyle changes, mind-body therapies, etc) can improve cancer-specific outcomes.

Those who believe that chronic stress and cancer are linked cite data that support this claim. In particular, there are clinical studies[7] that report improvements in cancer-specific outcomes in patients who are taught stress management techniques. Furthermore, researchers continue to identify chronic stress as a causative factor in numerous pathophysiologic processes that are known to be associated with the development, progression, and recurrence of various cancers (eg, stimulation of systemic inflammation and oxidation, impairment of immune function, increases in insulin resistance and weight gain, etc).[8]

Lawenda overstates his case massively. The evidence that improving ?attitude? improves cancer-specific survival is of shockingly low quality. There?s just no ?there? there. As I?ve said before, that?s not to say that psychotherapy and other modalities designed to improve a patient?s mood and mental state might not be useful. Certainly, they can improve quality of life, used in the proper situation. However, there just isn?t any evidence that is even mildly convincing that such modalities can improve a patient?s chances of surviving his cancer.

I also know that Lawenda is laying down pure, grade-A woo when I see him retreating into the favorite alt-med trope, ?absence of evidence is not evidence of absence? and claiming that ?many alternative therapies, once believed by conventional medical practitioners to be merely placebos, have now been shown to have proven therapeutic value (eg, acupuncture, numerous botanical extracts, meditation).? Well, no. Acupuncture has not been convincingly shown to have therapeutic value for any condition, and it?s no surprise that botanical extracts might be effective for some things; they are, after all, drugs. Adulterated drugs with lots of impurities whose potency can vary widely from lot to lot, but drugs nonetheless. He even attacks antidepressants based on more recent evidence suggesting that they might not be as effective as previously thought and in some cases might not be better than placebo, an idea ably countered by James Coyne.

Lawenda?s rebuke, however, is nothing compared to what comes next. Remember Cassileth?s dismissal of the findings of a ?Yale surgeon? who claimed that support groups improved cancer survival? Here comes that Yale surgeon! Yes, indeed. It?s Bernie Siegel, and he?s pissed, proclaiming that The Key to Reducing Quackery Lies in Healing Patients and Treating Their Experience. Of course, his carefully cultivated image of being the ultimate nice guy and caring physician can?t be endangered; I only infer his annoyance from the tone of his response. I also infer a lot from the fact that, unlike Lawenda and Cassileth, who at least include some references taken from the peer-reviewed scientific literature to support their points, Siegel cites exactly one reference, and one reference only, Aleksandr Solzhenitsyn?s Cancer Ward. Lawenda cites mostly poor quality studies, but at least he tries by citing studies. Siegel, on the other hand, seems to think he is the Great and Powerful Oz (Dr. Oz or the Wizard of Oz, take your pick) and that you should just take his pronouncements on faith because he is so awesome. I will admit that Siegel probably has a point when he says that better communication could potentially reduce the incidence of cancer patients turning to quackery, but even making this reasonable point he overstates his case when he says that quackery would ?diminish greatly? if doctors would just learn to communicate better. There?s a lot more to the appeal of quackery than having a doctor who can?t communicate, much of which wouldn?t even come close to disappearing, even if every doctor turned into a Bernie Siegel clone with respect to showing incredible empathy to patients.

Siegel then dives right in, relying on the sheer force of that awesome empathy of his to rip Cassileth a new one for daring to criticize his work:

Our emotions govern our internal chemistry, and hope is therapeutic. We know that laughter enhances survival time in cancer patients, while loneliness has a negative effect. When a Yale graduate student did a study on our support group members and it showed increased survival time for the group?s members, his professor told him that couldn?t be true and made him change the control group so that everything came out equal. Doctors don?t study survival and the power of the mind.

Which is, of course, utter nonsense, leavened with more than a little conspiracy mongering. Doctors have been studying the ?power of the mind? and survival for a very long time. What Siegel doesn?t like is that they haven?t found that the mind is nearly as powerful as Siegel would like to believe. It?s a topic I?ve been writing about since the very beginning. There?s a reason for the central dogma of alternative medicine; it?s very appealing to believe that sheer force of will or thinking happy thoughts can heal us of serious diseases. Talk about the ultimate form of ?empowerment?!

Siegel then goes completely off the deep end:

The mind and energy will be therapies of the future. I know of patients who were not irradiated because the therapy machine was being repaired and no radioactive material was reinserted. The radiation therapist told me about it because he was feeling terrible. I told him he didn?t know what he was saying to me. ?You?d have to be an idiot to not know you weren?t treating people for a month?so obviously they had side effects and shrinking tumors, which was why you assumed they were being treated.? He said, ?Oh my God, you?re right.? I couldn?t get him to write an article about it. I also have patients who have no side effects because they get out of the way and let the radiation go to their tumor.

Yes, an unsubstantiated anecdote about an apparently incompetent radiation oncology tech who didn?t notice that his radiation machine wasn?t actually delivering radiation trumps evidence, apparently. (One wonders how the machine still functioned if its source wasn?t re-inserted. Most such machines have a warning light or won?t turn on if the source isn?t properly in place.) Siegel?s article is so full of alt-med tropes and a heaping? helpin? of what can best be described as pure woo. Besides recommending his own books (one of which I actually have on my shelf but have not gotten around to reading), Siegel recommends The Energy Cure: Unraveling the Mystery of Hands-On Healing by William Bengston, The Biology of Belief: Unleashing the Power of Consciousness, Matter & Miracles by Bruce Lipton, and The Psychobiology of Gene Expression by Ernest Rossi. Lipton, as you recall, is a cell biologist who abandoned ?conventional? biology after having some sort of mystical revelation about cells that led him to conclude that God must exist and that ?holistic? therapies work. I hadn?t heard of the other two, but Siegel describes Bengston thusly:

Bengston cured mice of cancer in a controlled study with the energy conducted through his hands. I was healed of an injury in the same way by healer Olga Worral many years ago. We definitely need to test potential therapies to verify whether or not they are useful, but we also have to keep an open mind to what might be possible, and we must understand that we are treating a patient?s experience and not just a disease.

It turns out that Bengston preaches exactly the sort of quackery that Cassileth quite correctly castigated, namely that energy healing can cure cancer! From his own website:

Can energy healing really cure cancer? Is it possible for you to heal someone?s terminal illness with your bare hands? Is the Western medical community ready for a fundamental change in its approach to treatment??Dr. William Bengston invites you to decide by taking a journey with him into the mystery and power of hands-on healing. Drawing on his 30 years of rigorous research, unbelievable results, and mind-bending questions, Bengston challenges us to totally rethink what we believe about our ability to heal.

As there so frequently is after a book advertisement, there are blurbs with people saying how great Bengston?s book is. Guess who gave Bengston a plug. Yes, Bernie Siegel. I must say, I had no idea that Siegel was so deep into woo. Elsewhere in his article he says he had chronic Lyme disease and was helped by homeopathic remedies. He even says that he ?knows they work? because of his ?experience of having the symptoms of the disease alleviated.? It doesn?t get much quackier than energy healing and homeopathy. They are the two most ridiculous quackeries out there, and Bernie Siegel is promoting them both.

Siegel concludes:

I was a pediatric surgeon and a general surgeon, and I know how powerful my words were to the children?and adults?who believed in me. I had no problem deceiving children into health by labeling vitamin pills as medications to prevent nausea and hair loss, or telling them the alcohol (Drug information on alcohol) sponge would numb their skin (and of course, sharing this with their parents, who helped empower their child?s belief). The mind and attitude are powerful healing forces. The mind and body do communicate, so I work with patients? dreams and drawings and have diagnosed illnesses from them. I have yet to meet a physician who was told in medical school that Carl Jung correctly diagnosed a brain tumor by interpreting a patient?s dream.

This may not seem related to the subject of quackery, but it is?because it is about how to train doctors so that they know how to provide hope and potential to patients and how to use the mind and placebo effects. Doctors? ?wordswordswords? can become ?swordswordswords? and kill or cure patients. I know a man who had cancer and needed cataract surgery so he could enjoy the life that remained to him with restored vision. His health plan denied the surgery because they expected him to die within 6 months and didn?t want to spend the money. He died in a week. The Lockerbie Bomber was released by the Scottish authorities because he was dying of cancer. He went back home to the Middle East and survived for over 3 years? and that is no coincidence.

Note the mind-body dualism (?the mind and body do communicate?). Of course they do, because the mind is the brain, and the brain is in constant communication with the body! That doesn?t mean you can think yourself healthy. Remember how I discussed some time ago the way that this increasing emphasis on placebo medicine among promoters of ?integrative medicine.? As I?ve said so many times before, the reason IM fans have taken this position is because they?re finally being forced to accept that high quality evidence shows that most alt-med nostrums rebranded as ?CAM? or ?integrative medicine? produce nonspecific effects no better than placebo. So these nonspecific effects get relabeled as the ?powerful placebo,? as proponents of ?integrating? quackery into real medicine pivot on the proverbial dime and say that?s how their favored therapies worked all along, by firing up placebo effects! It?s pure paternalism, as well, as I have discussed multiple times.

Siegel claims he?s ?unleashing the healing power? in each of us, but what he is really doing is advocating a return to the paternalistic, unquestioned, shaman-healer so common in so many societies in pre-scientific times. In ancient Egypt, physicians were also priests; both functions were one, which made sense given how little effective medicine there was. Praying to the gods for patients to get better was in most cases as good as anything those ancient physicians could do. Also notice how, to Siegel, apparently the end justifies the means. Siegel can deceive patients about vitamins and alcohol sponges because he thinks it?s all for a greater good, really believing that he is so all-powerful a shaman-healer that his words alone can have a huge effect in curing or killing patients. That?s how he appears to be justifying the deception. He needs to get a clue (and some humility) and realize that, although placebo effects are important confounders in clinical trials, it?s a huge stretch to ascribe such awesome power to their effects. What Siegel is describing is magic, not science; religion, not medicine. Thinking does not make it so.

Unfortunately, Cassileth doesn?t seem to realize that, at their core, the ?unconventional? aspects of the ?integrative medicine? that she is promoting are little or no different than what Siegel promotes. In essence, ?integrative medicine? is all about ?integrating? magical thinking into scientific medicine. Acupuncture, ?mind-body? interventions, reiki, and all the various quackademic medicine that has infiltrated medical academia relies on the same ideas, the same magical thinking, that we see on display from Bernie Siegel. Cassileth might think herself so much more rational and ?evidence-based? by attacking the most egregrious cancer quackery, but she?s only fooling herself.

Source: http://scienceblogs.com/insolence/2012/08/22/quackademic-medicine-versus-cancer-quackery/

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