Cancer patients are a uniquely vulnerable group. When patients are diagnosed with pneumonia or appendicitis, they expect to recover and they readily accept conventional treatment with antibiotics or surgery. They are not particularly vulnerable to false claims for other treatments. But when patients are diagnosed with cancer, they fear dying; and they fear it will be a slow, painful death. They fear that the treatment itself will add to their suffering—the so-called “cutting, burning and poisoning” of surgery, radiation, and chemotherapy. They often rebel against their fate in various ways, and may reject conventional treatment and seek a kinder, gentler, and more hopeful option elsewhere. When people are desperate, they will grasp at any straw. Even the most rational people will do irrational things when frightened by a life-threatening disease. Emotion rules, and critical thinking flies out the window. It is only natural that desperate people become susceptible to the deceptions of quacks and snake oil frauds. It is even more natural for them to turn to complementary and alternative medicine (CAM) because it is popular and is even endorsed by a subset of medical professionals.
CAM has much to offer cancer patients. But then, quackery has much to offer them too. Quackery offers them hope (albeit false), comforting beliefs, symptom relief (through the placebo phenomenon), the promise of “cures,” and a more palatable (but unfortunately ineffective) substitute for effective but unpleasant conventional treatments. No ethical physician would knowingly promote quack medical treatments for cancer patients; but in promoting CAM, some providers may be inadvertently doing what is not in their patients’ best interests.
Deceptive Terminology
What is CAM? It essentially comprises treatments that have not earned a place in conventional medicine. Complementary medicine is intended to be used along with conventional medicine; alternative medicine is intended to be used in place of conventional medicine. The field of CAM is vast: it includes methods that may work but have not been tested and methods that have been tested but have not generated sufficient evidence to have become part of conventional medicine. It also includes methods that have been tested and proven ineffective but that promoters still believe in because of personal experience, anecdotal evidence, rejection of scientific research, or misguided thinking.
As Marcia Angell and Jerome Kassirer famously said in The New England Journal of Medicine:
There cannot be two kinds of medicine—conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work.[i]
When CAM methods are proven to work, they become conventional. The separation between CAM and conventional medicine is a false one. According to the Yale neurologist Steven Novella:
CAM is a political/ideological entity, not a scientific one. It is an artificial category created for the purpose of promoting a diverse set of dubious, untested, or fraudulent health practices.[ii]
Another ill-conceived concept is “integrative medicine.” It claims to combine the best of CAM with conventional medicine and to treat the whole patient. Since the majority of unproven treatments do not pan out when tested, integrating unproven treatments with proven ones is likely to do more harm than good. Good clinicians have always treated the whole patient and employed all reasonable means to improve patient outcomes and relieve suffering. Integrative medicine tries to co-opt things such as exercise and nutrition that are not its unique province but are really part of conventional medicine.
And then there’s naturopathy. The six basic tenets of naturopathy are:
- first do no harm;
- physician as teacher;
- treat the whole person;
- prevention;
- healing power of nature;
- treat the cause.
Naturopathy can hardly claim to own these principles. They are basically the same principles of good medicine that are taught in medical schools. So despite their claim to offer something unique, naturopaths are actually only aspiring to do what good doctors everywhere aspire to do. The difference is that good medical doctors try to stick to evidence based treatments, whereas naturopaths do not. They typically embrace everything from homeopathy to reflexology.
Stephen Barrett has characterized the average naturopath as one who “combines commonsense health and nutrition measures and rational use of a few herbs with a huge variety of unscientific practices.” [iii]
Patients cared for by naturopaths are significantly less likely to have received recommended immunizations. The things naturopaths do that are good are not special, and the things they do that are special are not good.
A Lavish Smorgasbord of Offerings
A huge variety of CAM treatments have been advocated for preventing, curing, or treating cancer, for relieving both symptoms of cancer and symptoms of cancer treatment. The CAM-Cancer website[iv] attempts to evaluate the scientific evidence for CAM cancer treatments. It lists treatments under the following categories:
- Alternative medical systems: acupuncture, Chinese herbal medicine, homeopathy, and reflexology.
- Biologically-based practices: aloe vera, artemisia, black cohosh, boswellia, Breuss Cancer Cure, Cannabinoids, Carctol, co-enzyme Q10, dichloroacetate, Echinacea, Essiac, fermented wheat germ, Galavit, Gerson therapy, ginseng, green tea, insulin potentiation, IV high-dose vitamin C, lacto-ovo vegetarian diet, laetrile, Megamin, melatonin, milk vetch, mistletoe, Ornish diet and lifestyle, propagermanium, selenium, shark cartilage, shiitake, St. John’s Wort, Ukrain, and vitamin E.
- Energy medicine: qigong and Reiki.
- Mind-body medicine: autogenic therapy, biofeedback, progressive muscle relaxation.
- Manipulative and body-based practices: Aromatherapy and massage.
That list is far from complete. Notable omissions include chiropractic, naturopathy, Ayurveda, hypnosis, therapeutic touch, guided imagery, and macrobiotic diet. Some CAM treatments promise to cure cancer, others promise palliation. Some of them have preliminary, limited, low quality evidence suggesting a possible benefit for some cancers; some have no basis in science; some are totally implausible and are even incompatible with known science (homeopathy); some have been proven not to work; some may have palliative psychological effects; some are outright scams (laetrile); some interfere with chemotherapy; and some have toxic effects and are frankly dangerous.
Any CAM methods claiming to cure cancer can be disregarded, at least provisionally until better evidence is proffered. If the current evidence were credible, oncologists would be enthusiastically adopting these methods. Many of the claims for palliation can also be provisionally rejected. A minority of the claims for palliation are at least somewhat plausible, but only in the sense of relieving subjective symptoms, not in the sense of objectively mitigating the effects of the disease.
It would be impossible to address all of these. I will just mention a few that might be of particular interest to some readers.
- Massage may be helpful, but is it really CAM? A study of 1,290 cancer patients who received massage therapy at Memorial Sloan-Kettering Cancer Center found that pain, anxiety, fatigue, and nausea decreased by 50% in patients who received massage, with benefits lasting up to 48 hours.[v]
- Guided imagery was once thought to improve outcomes in cancer patients, but the early research was flawed. It has been shown to improve the quality of life but not to extend life.[vi] It might help some patients feel better, but it can be unintentionally cruel. In some cases, patients have felt guilty when they failed to improve, seeing it as their personal failure. It amounts to make-believe and it is dishonest to present it to patients as something that has real effects on cancer cells.
- Prayer is undoubtedly comforting to the person who prays, but it has not been shown to have objective results like increased survival.
- Good nutrition is obviously important to cancer patients, but it should be part of mainstream medical care. The special diets and nutritional supplements recommended by CAM have not been shown to offer any objective benefits.
- Gerson therapy and its offshoot the Gonzalez protocol are particularly despicable. They take over the patient’s life with a complicated, time-consuming regimen of coffee enemas and supplements, pancreatic enzymes, thyroid hormone, and a difficult, unappetizing diet that includes 13 glasses of fresh, raw carrot/apple and green-leaf juices prepared hourly from fresh, organic fruits and vegetables. In a recent study[vii] comparing the Gonzalez protocol to chemotherapy for advanced pancreatic cancer, it shortened survival from 14 months to 4.3 months and reduced the quality of life. Yet it is still being offered to cancer patients, monopolizing their lives and increasing their suffering, providing unrealistic hopes, and depriving terminal patients of hospice care and of precious time with their families at the end of their lives.
Evaluating Evidence
Certain practitioners promote CAM for personal and profit-oriented reasons, where such therapies have been proven ineffective. Others promote it based on personal conviction or anecdotal and low level evidence, but we should be selective about what evidence we accept. As Joe Schwarcz has pointed out:
The world’s 6,500 odd peer-reviewed scientific journals disgorge an average of 4 scientific papers every minute of every day. That’s more than two million good, bad, and mostly mediocre papers every year! No surprise then that a study can be found to back up virtually any point of view.[viii]
The CAM trials often suffer from faulty design. They may not look for hard outcomes. They may use tests or questionnaires that have not been properly validated. They may not have adequate controls for ruling out placebo effects. Randomized trials summarized in systematic reviews and meta-analysis demonstrate mixed results due to factors like population heterogeneity and trial design. Many are not powered (the measure of the probability that the test will reject the null hypothesis when it is false; that is, that it will not lead to a false negative conclusion) adequately and are subject to Type I and Type II errors and bias.
When studies have mixed results, we resort to meta-analyses and systematic reviews, but the results are meaningless if the studies reviewed are of poor quality. And when the prior probability is low, we should require stronger results. As Carl Sagan said, “Extraordinary claims require extraordinary evidence.” It would take strong evidence indeed to justify the claims of homeopathy, since it would have to outweigh all the evidence for much of our established knowledge about physics, chemistry, and biology.
When study results represent reality, further studies typically build quickly to a coherent body of evidence and result in a consensus. It took only eight years from the first suggestion of Helicobacter’s role in ulcers to the standard practice of treating ulcers with antibiotics. In contrast, after decades of studying acupuncture we are still seeing conflicting reports.
What about Acupuncture?
Doctors who realize CAM cannot offer a cure may still think it is useful in palliating symptoms. But is it really? The CAM treatment arguably supported by the best evidence is acupuncture for pain and nausea; and even in this best-case example, a rigorous evaluation of the evidence shows that it is still very questionable. Study results conflict with each other, and systematic reviews come to conflicting conclusions. When systematic reviews disagree, the next step is to do a systematic review of systematic reviews.
In the journal Pain, Ernst et al. recently published a systematic review of systematic reviews of acupuncture for pain.[ix] Fifty-seven systematic reviews met the criteria they set for inclusion in their analysis. They found a mix of negative, positive, and inconclusive results. There were only four conditions for which more than one systematic review reached the same conclusions, and only one of those four was positive (neck pain). They explained how inconsistencies, biases, conflicting conclusions, and recent high quality studies throw doubt on even the most positive reviews. The best acupuncture studies, using sham acupuncture controls such as a sheath with a retractable needle that does not penetrate the skin, have shown that it does not matter where you put the needle, it does not matter whether you penetrate the skin (touching with toothpicks worked just as well), and the one thing that really seems to matter is whether the patient believes in acupuncture and believes he got the real thing.
A position paper from the Center for Inquiry said:
It is becoming increasingly clear that the placebo effect accounts for much of the optimistic research on acupuncture published between the 1970s and 1990s. With the development of sham needles during the past decade—needles which retract like stage knives—researchers have since been able to more accurately assess the therapeutic effects of acupuncture. The result has been a complete unraveling of nearly all acupuncture claims…. The bulk of recent research strongly tends towards the hypothesis that acupuncture’s positive effects are mainly due to a built-in expectation bias.[x]
The CAM-Cancer website concluded that acupuncture “is not demonstrably effective in controlling cancer pain.” [xi]
No Credible Evidence for Any CAM?
In his book Snake Oil Science: The Truth about Complementary and Alternative Medicine, research methodologist R. Barker Bausell examines the published literature on CAM and concludes:
There is no compelling, credible scientific evidence to suggest that any CAM therapy benefits any medical condition or reduces any medical symptom (pain or otherwise) better than a placebo.[xii]
The National Cancer Institute warns: Be careful of products advertised by people or companies that:
- Make claims that they have a “cure”;
- Do not give specific information about how well their product works;
- Make claims only about positive results that have few side effects;
- Say they have clinical studies, but provide no proof or copies of the studies.
- Just remember, if it sounds too good to be true, it probably is.[xiii]
Patients often make the decision to use CAM without consulting a physician, but doctors may also decide to recommend CAM for their patients. If they do, they must be honest about the state of knowledge and follow ethical guidelines.
Sometimes Justified, Sometimes Not
There are some reasonable motivations for cancer patients to try CAM: To relieve pain, nausea and fatigue, relieve stress, ease worries, and give them a sense of empowerment of being able to do something to help themselves. But CAM is not so reasonable if it entails the loss of opportunity to benefit from conventional medical therapies that have an evidence base. It can result in false hopes, shorter survival, and lost opportunities for completion of life tasks.
Some patients reject the whole concept of evidence, rely on belief and faith, and have an idiosyncratic idea of “healing.” A patient featured in a recent documentary rejected conventional treatment that would almost certainly have cured her breast cancer, and instead relied on the ministrations of John of God, a Brazilian psychic surgeon and faith healer. Her cancer continued to advance, and she knew she was dying; but she defended her decision, saying she had been “healed” in some nebulous psychological sense.
There are other considerations. All too often, patients use CAM treatments without telling their doctors. Doctors cannot do their best for patients if they do not know all the medications they are taking or other treatments they are getting. The CAM therapies may be dangerous. Diet supplements can interact with conventional medications, can increase the risk of bleeding with surgery, and can reduce the effectiveness of chemotherapy. CAM can be expensive and may not be covered by insurance. Supplements and natural medicines are not required to meet the standards of prescription drugs but are regulated separately under the Diet Supplement Health and Education Act; they have frequently been found to contain contaminants or inadequate or excessive amounts of the labeled active ingredient.
Patients with advanced cancer sometimes travel to Mexico or other countries for last-ditch alternative treatments like Gerson therapy and die there away from home and family. Celebrities such as Coretta Scott King have pursued that route and their stories have been featured in the media. Desperate patients (or their desperate families) spend funds their family needs (even mortgaging their homes) to pursue a wild goose chase seeking that one doctor somewhere who might offer that elusive cure, a cure that does not exist.
Such odysseys have been justified by arguments that it does people good to have hope, and it does families good to know they have pursued every possible option. The counterargument is that facing reality is ultimately better for them, that it is important to come to terms with approaching death, say goodbye, make arrangements, and enjoy precious time with family. There is no need to raise false hopes: good medicine provides realistic hopes. Even when it cannot prolong life, it can hope to relieve symptoms and support a more meaningful, satisfying life while life lasts.
A Proposal
Instead of “conventional” and “alternative” categories, why not classify what we offer patients as “proven treatments,” “experimental treatments,” and “comfort measures”? If a treatment is unproven, why not say so instead of calling it “alternative.”
Comfort measures, which may be as simple as fluffing pillows or giving backrubs, can be heartily endorsed. Comfort measures do not make any unrealistic promises or unrealistic explanations. A caring nurse can provide human contact and sympathy and simply say “Let’s see if we can make you more comfortable.” Contrast that to the acupuncturist who claims that his needles will reliably relieve pain by adjusting the flow of qi through meridians. Or the homeopath who treats patients with water that is claimed to remember a former contact with a substance that in full strength can cause the same symptoms. Or the nurse who waves her hands over patients and claims she is smoothing out the wrinkles in their energy field.
Conclusion
Some CAM methods might eventually prove to be helpful in treating cancer, but the currently available evidence is not convincing. Some elements of CAM are promising, but others are arguably no better than quackery disguised under a more marketable name.
Cancer patients are frightened, vulnerable, desperate people who are willing to grasp at any straw. There will always be frauds, quacks, and salesmen who try to take advantage of them. Physicians who are well-meaning but misguided may inadvertently do their patients a disservice while trying to help them. Ethical, informed physicians will stick to effective science-based treatments whenever such treatments are available. When no such treatments are available, they may offer experimental treatments or even offer questionable, dubious treatments as a last resort. But they must make the status of those treatments clear to patients and not mislead them into believing a treatment has been proven effective when it hasn’t. The practice of prescribing a treatment only for its possible placebo effect is uniformly rejected by medical ethicists. Cancer patients have enough to cope with without people preying on their fears and persuading them to try dubious treatments by misleading them with biased, incomplete, or inaccurate information.
[i]Angell, Marcia; Kassirer, Jerome P. 1998. “Alternative Medicine: The Risks of Untested and Unregulated Remedies.” New England Journal of Medicine, 339(12): 839-84
[ii]http://www.sciencebasedmedicine.org/index.php/ national-health-interview-survey-2007-cam-use-by- adults/
[iii]http://www.quackwatch.org/01QuackeryRelated- Topics/Naturopathy/naturopathy.html
[iv]http://www.cam-cancer.org/CAM-Summaries
[v]http://www.ncbi.nlm.nih.gov/pubmed?term= 15336336
[vi]http://www.ncbi.nlm.nih.gov/pubmed?term= 10390006
[vii]http://jco.ascopubs.org/content/28/12/2058.abstract
[viii]http://www.mcgill.ca/newsroom/news/item/?item_id=177264
[ix]http://www.painjournalonline.com/article/S0304-3959(10)00689-5/abstract
[x]http://www.centerforinquiry.net/uploads/ attachments/Acupuncture_Final_Paper.pdf
[xi]http://www.cam-cancer.org/CAM-Summaries
[xii]Bausell, R. Barker. 2007. Snake Oil Science: The Truth About Complementary and Alternative Medicine. Oxford University Press.
[xiii]http://www.cancer.gov/cancertopics/cam/ thinking-about-CAM/page9
This article was originally published online in the journal Progress in Palliative Care, May 16, 2012. DOI:http://dx.doi.org/10.1179/1743291X12Y.0000000009 and was reprinted in Skeptic magazine
