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Alternative Medicine and Cancer
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ABOUT ANECDOTE The results of alternative cancer clinics bear little relationship to the claims that draw patients to them. We know this from their own published results (see here), numerous formal studies and enquiries, and the very sparseness of the anecdotal material (testimonial, case reports) they are able to produce. Yet the promoters of the methods, supporters and some clients maintain great faith in them on the basis of the anecdotal material. They say "we have seen things with our own eyes" . Conflicting opinion is attributed to conspiracy, or mindless bias. Or perhaps there is something wrong with the way scientists are looking at all the evidence. Cancer patients are caught between the opposing viewpoints. They may be unsure what to think when also badly wanting answers to a potentially mortal illness. Can we help them better understand it all? I shall try. Later we'll look at some better quality anecdotal material, of the type that can sometimes have sceptics scratching their heads. Why is that not convincing doctors, government institutions or health insurers that alternative methods are regularly curing cancer? Firstly, some clarification of the role that anecdotal evidence can play in advancing medical knowledge. I happen to agree with those who think that doctors can sometimes be a little arrogant and heavy handed in their "we know best" dealings with dubious methods (without necessarily being far off in their judgements). Is "it's only anecdotal evidence" a sufficient reason in itself to dismiss stories of cancer cures? The answer, surely, is definitely not. A great many important medical advances originated with a few anecdotal observations. You only have to think of milkmaids rumoured to be immune to smallpox, or the old woman apparently curing oedema with the foxglove (digitalis). Why, then, is anecdotal evidence generally looked down upon? Well, frankly, a lot of it is of little value, lying at the lowest possible extreme of evidence worthiness. Many cancer cures turn out to have no more substance than "I heard somewhere ----". Most personal testimonials don't hold water even on the information supplied (See a deceptive breast cancer testimonial with further examples in How to Read a Cancer Testimonial. Such evidence is deservedly not given much weight, not because it belongs to an ill-defined category of evidence called "anecdotal", but because it is obviously not reliable. We should, however, be prepared to explain why that is so. Dismissing evidence that others find highly significant without offering any reason other than that it is anecdotal, can raise hackles, end dialogue, and no one gets to learn anything. Inadequate airing of the precise grounds for rejecting anecdotal evidence may be partly why disputes concerning alternative cancer treatments look much the same now as they did fifty years ago, and, sadly, often concern the very same treatments. Allegations of insuperable bias and conspiracy against alternative cancer treatments are surely fuelled by this knowledge gap between the parties. I hope to show here how apparently overwhelming anecdotal material can paradoxically only serve to raise doubt. Another reason for a generally dim view of anecdote is that in very many medical contexts it IS virtually useless as evidence of a treatment effect. Some medical conditions, for example anxiety and depression, can get better by themselves or fluctuate wildly naturally, and are subject to somewhat arbitrary patient judgements such as "how am I feeling today as compared to three weeks ago?". It has been proved repeatedly that when given an inert or sham treatment ("placebo") up to fifty per cent of patients with such conditions will report feeling better later, even within the drab, uninspiring environment of the typical clinical trial. Anecdotal treatment successes with such conditions can assume immense personal significance for some patients and practitioners, especially when resonating with other personal beliefs. But tossing a coin or throwing darts at something will be as reliable a way of directing us towards better treatments, especially once the influence of personal biases is allowed for. Separating true treatment activity from the spurious or from placebo-related phenomena is very difficult with this kind of clinical material.. It requires sophisticated study design, perfect execution, and even then, in the end, depends upon rule-of-thumb statistical judgements. Cancer is completely different. Most cancerous states are easily measured. Some are so predictable, regardless of any placebo usage, that as many as 99.999% of them will progress to a sad conclusion without effective treatment. So long as the diagnosis seemed secure why on earth would well-documented and verifiable reports of cure or remission with this kind of cancer ever be dismissed as "just anecdote"? They shouldn't be and wouldn't be. Nevertheless, even with anecdotal data of adequate quality, occurring in an appropriate clinical setting, there is still the need for a minimum quantity. A single apparent cure of a bad cancer might spark some interest, but if attributed to a treatment that otherwise has no track record of ever curing cancer, doctors would probably wait to see if a second case can be produced before letting themselves get too excited The isolated case might yet prove to be a so-called spontaneous remission, or a rare misdiagnosis, or as yet unknown factors, or even an entirely different treatment that the patient forgot to mention when multiple measures are being applied, as is usual in alternative medical practice.. In alternative cancer practice most patients use multiple treatments, sometimes dozens of them. This is a further problem for those saying that it was their specific treatment that cured a cancer. It is not an insuperable problem, so long as they are able to do it again, and preferably yet again. I elsewhere challenge any alternative agency to produce even two or three cases with the desired qualities using any combination of alternative methods they wish. They should be able to produce them by the dozen, if some prevalent claims were true. We have arrived at a rough description of what good anecdotal evidence for a cancer cure might look like It would include patients with definite, measurable and normally very predictable cancer states. The cancer would be shown to regress or disappear with the treatment, as demonstrated by photography, x-ray, scans, or other reliable tests. This happens to be precisely what doctors look for when testing a potential new cancer treatment. All known active treatments against cancer can do this. Complicated clinical trials only come later, when treatments of known effectiveness have to be compared, or when measures directed purely at symptom relief, or at producing less obvious effects such as prolonging survival are being assessed. I have also suggested that rejecting anecdotal evidence without further explanation can be an unsatisfactory response to dubious claims. Let us now look at an example of some better quality anecdotal material. Some quality anecdotal evidence Dr Seymour Brenner MD presented the following five cases to the American Office of Technology Assessment when that body was looking for alternative cancer treatments worthy of further scientific assessment [1]. Brenner was a very experienced radiation oncologist (radiotherapist) and was very impressed by some of the results of the Revici treatment. This is fairly typical of the best that believers are seeing " with their very own eyes". There is the added bonus of endorsement by an experienced oncologist. Read them carefully.
These patients all supposedly had serious, even "incurable" cancer, and Revici made it go away. At first sight that is what the cases seem to show. But they don't -- not quite. Every case depends to some degree on
assumptions as to the very presence of cancer, or its state when the alternative treatment was
commenced, or as to the patient's prognosis, or as to what was truly responsible for the
favourable
outcomes. They are not unreasonable assumptions, mind you, which is why
the cases are impressive. If everything
was as the
stories are implying, such patients would nearly always fare badly without effective treatment. A lot
of such cases (and Brenner said he had five more) might carry considerable
weight -- if it were not for one other thing about them. It is this peculiarity that weakens the evidence. Even taking the cases at near face value, we are left unsure whether such "best cases" hand-picked out of a presumed very large number of failures (See footnote) are merely reflecting cancer's sometimes erratic behaviour at the fringes of normal oncological experience! For oncologists regularly get unusual outcomes too. Untreated cancer is predictable, but only over a range of from about 70% to about 99.999% for its various types and stages. Cancer can mostly be accurately diagnosed, categorised and staged, but we know mistakes are made in those quite regularly [4]. Also, every alternative method seems to be able to accumulate a few such cases over time, no matter how foolish, implausible or fraudulent they may appear. This reinforces suspicion that very occasional impressive cases are unrelated to the treatment. The "missing data" is an almost universal weakness of alternative cancer anecdotal material. We are constantly required to give the benefit of the doubt in small ways and wonder why. If a method can make so many presumed advanced cancers go away, why can't it ever be shown making a few actual advanced cancers go away (more on this in http://www.users.on.net/~pmoran/cancer/how_to_read_a_testimonial.htm )? The failure to document accurately what is going on within the patients denies us certainty as to the exact state or even the presence of active cancer when the alternative treatment was commenced, and also, importantly, whether the timing of any cancer remission is such as to allow it to be reasonably attributed to the method claimed. Indeed, "best cases" such as these from such a widely applied method strongly suggest that the method cannot cure patients with well-established cancer -- useful information for many.. Perhaps this is why Brenner himself goes on to express some uncertainty as to whether the Revici treatment can cure established cancer. He is mainly suggesting that the method should be investigated further.. We, on our part, are unable to say dogmatically that Revici doesn't ever work, merely that the data doesn't establish that it does. With alternative methods such as Revici's decades then typically go by without better material ever emerging, reinforcing negative opinion. Since even rumours of cancer cures attract intense public and media attention, it is most unlikely that methods that have been in widespread usage for a decade or more are ever now going to show that they can cure established cancer. That is how it looks to science. Frightened cancer patients may understandably look at things quite differently, and want to give dubious treatments a trial. But it is unquestionably in the best interests of all cancer patients that they should be demanding much higher standards of evidence from those offering them alternative cancer treatments.. The Assumptions We have so far been accepting hat everything is more or less as the stories imply, but I should give some examples of the assumptions I have suggested are being made in these cases. As an example of how cancer is less predictable than many assume, we can now largely discount the fourth case, the patient with inoperable lung cancer that lived on for nine years after palliative radiotherapy. We now know that palliative radiotherapy (i.e. not expected to cure) of lung cancer unexpectedly does lead to some ten-year survivors [2,3]. . The first of these studies was not published until 2000. Brenner, even as a radiation oncologist, did not know this when he stated that this could not happen, in 1990,. That case illustrates something else. We may not always have at the time all the information needed to assess the true significance of occasional remarkable cases. They can have a strong hold on our minds, but they in truth can never stand alone as automatic proof of the claimed treatment effect, even when of superb quality. Thus, I don't know quite know why the ovarian cancer patient did as well as she did and I would like more details about that case and to know whether any comparable cases exist. Two or three cases the same would certainly arouse interest and undoubtedly prompt further research, although there might still be that nagging doubt as to why equally advanced but more easily measured and followed up cancers than ovarian cannot be shown responding. Brenner did not describe the actual bladder pathology in the first case, as we would expect a doctor talking to other doctors to do automatically if he had any personal involvement with the case. He merely offers "what the doctors are supposed to have said". I have pointed out elsewhere that this is a common source of weakness in testimonial. It is very often a grossly distorted version of the facts, designed to make the testimonial more impressive. In this case, the surgery may have been advised to a patient with pre-invasive bladder papillomata recurring despite regular episodes of endoscopic destruction. These have a strong potential to develop into invasive cancer, but they can also be erratic in their behaviour. A single such case cannot establish that it was the Revici treatment that stopped them forming over the period described Also, for all we know also, the patient may have eventually required the recommended surgery or even died of bladder cancer. The second case is probably the weakest for me, since we have no direct knowledge as to the state of the cancer when Revici treated her. The fifth case is to do with a very rare tumour and made obscure by language that skirts around the question as to just what pathology was being dealt with later i.e. "nodules", "renal mass". It is being implied that this was "metastatic cancer" but why not just say so? We are never told what the "renal mass" was. If this was actually a primary renal cancer and the lung nodules were secondary to that rather than the giant cell tumour of bone then this could well be an example of the well-known spontaneous remissions that occur with renal cancer, even when it is metastatic. Brenner may well have had answers to some of these questions. The critical point I wished to get across was that even without such questions about individual cases there remains a significant gap between the very best "alternative" anecdotal material and the criteria that doctors use themselves when testing out a cancer treatment. But what about -------? I can't think of an example right now, but I think I have encountered other alternative case reports that do show clear cut cancer remissions of serious cancers at the same time as an alternative treatment is applied, and with no other obvious reason. These are exceedingly rare. They also don't favour any particular one of the dozens of alternative treatments now in use. Until an individual alternative method, or for that matter an alternative practitioner using any combination of methods they wish, is able to produce a small series of even two or three such cases out of their recent experience it remains difficult to believe that any of them are regularly curing established cancer. They should be able to do this quite easily if the usual claims were true. Blazing Away at the Barn Wall The weaknesses in alternative anecdotal material arises from the lack of method and forethought in the collection of evidence. This is, of course, one defining feature of anecdotal material Patients are treated in a haphazard fashion in the hope that cases will emerge that look good or can be made to look good on loose, ad hoc criteria. When there are no predefined criteria for determining treatment success there will be less effort at defining what exactly is being treated in the first place, or at keeping track of what is going on within the patient, even though both of these should be easily achieved with present technology. Most alternative cancer clinics also have very poor standards of record-keeping and follow-up [5].. As a result of the general lack of rigour, the involved parties are able to imprint their own biases, hopes and expectations on the data. In other scientific contexts such unplanned, ad hoc approaches to research have been likened to blazing away at the side of a barn with a shotgun and then drawing targets around the best-looking clusters. That is precisely what is happening here. It is what sustains all quackery, when it is not frankly fraudulent. If you have ever wondered how dozens of cancer cures could possibly be false even though supported by honest belief, this is why. Another potential consequence of the lack of method is that even if a treatment sometimes had an impact on cancer there may well be too many deficiencies in the data for it to be convincing. Quality clinical research is not primarily about all that baggage of control groups, placebos, double-blinding etc. It is about first deciding on the precise question you want answered, and then planning how to most reliably test it out. Cancer treatments are much easier to investigate than many other treatments, because we are dealing with a mostly predictable condition whose progress can be easily measured in most patients There is no real excuse for not being able to produce the top quality semi-anecdotal data we would expect from any effective cancer treatment. I offer some advice on how to do this elsewhere. A group of doctors were appointed to assess the Revici method, and published
results of a small prospective (planned) study in 1965 [6] Of
33 cases with established cancer 22 died. 8 left the study because they were
unimproved by the treatment. At the close of the study 15 months later
only 3 patients were still under Revici's care but all had signs of tumour
progression. Back References 1. Brenner's speech is recorded in full at http://gerson-research.org/docs/OTA-1990-2/index.html 2. Michael P. Mac Manus, Jane P. Matthews, Morikatsu Wada, Andrew Wirth, 4. These matters are dealt with in more detail in sections l and ll of What's so Hard about Showing a Cancer Cure Works? 5. Some data on this with references in What do Alternative Methods Really Do (the Inside Story) 6. David Lyall and Others: "Treatment of Cancer by the Method of Revici" . JAMA Oct 18, 1965;194:p165-166
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