The use of complementary medicine by cancer patients raises serious concerns

I came across an article that looked at complementary medicine use in people receiving palliative cancer treatment in Lyon, France. It found that the vast majority (90%) of this patient group used complementary medicine. This raises a number of serious concerns that I’d like to explore further.

Effectiveness

To start with, let’s make something really clear: There are no alternative or complementary approaches that are effective for the treatment of cancer itself. None. What about when these alternative approaches are used as complementary to (along with) conventional treatments? Even in this situation, there is still very little evidence that they provide any benefit whether that be for the symptoms of cancer or to help manage side effects of conventional treatments. For instance, acupuncture is sometimes used to help with cancer-related pain but a recent review concluded that “there are insufficient high-quality RCTs to judge the efficacy of acupuncture for cancer-related pain”. Put more simply, acupuncture hasn’t been shown to be effective for cancer pain. There is a reason why these alternative or complementary treatments haven’t been accepted by mainstream medicine even though they have been tried for a long time: they don’t work.

Safety

Use of complementary treatments by people undergoing palliative cancer care raises a number of risks. Firstly, there is the risk from the treatments themselves. No treatment is without risk, in spite of what some practitioners may claim. Probably more importantly, there are also a number of indirect risks. For instance, the complementary treatment may interact with mainstream treatments reducing their effectiveness or increasing side effects. What’s particularly concerning is the number of people who use complementary treatments without telling their doctor. In this study half of respondents had not disclosed their use of complementary medicine to their oncologist. This is concerning as it doesn’t allow the doctor to have a complete picture all of the treatments being used. When someone is experiencing particular symptoms is this due to the cancer itself, the conventional treatment or side effects from the complementary treatment that the doctor doesn’t know about? It’s very important that if you use complementary treatments you tell your doctor, regardless of how “safe” or innocuous these treatments may appear.

Cost

Within this study, about a third of patients said that it was difficult to manage financially some of the time, all of the time or that it was impossible. Yet, 90% of the people studied are spending money on complementary treatments. Some people are therefore spending money on completely ineffective complementary treatments when they are facing financial hardship. If they realised how ineffective these treatments are, would they still spend the money or would they put the money towards the costs of daily living instead?

Deception

Cancer patients use complementary treatments for a variety of reasons. However, according to the paper, some people say that they are using these treatments for “assisting in stimulating the body’s ability to fight the cancer” and “trying to do everything that can help their treatment or recovery”. None of the complementary treatments being used can help with these things and this raises the question of why members of the public end up believing that they could. Whilst there will be a range of reasons it seems probable that the original source of this misinformation is the complementary medicine practitioners themselves. Indeed this particular paper, as well as several of those that it references, paints the benefits of complementary treatments in an unjustifiably positive light. For instance, it suggests that aromatherapy “is considered a popular form of alternative medicine to treat various conditions, both internally and externally”. Popular it may well be, effective it certainly isn’t. Unfortunately, the paper authors forgot to mention the latter. They further make the unsubstantiated claim that osteopathy is beneficial for a range of cancer-related complaints. The “evidence” they provide to support this? A study of just 16 patients where the patients were asked what they thought osteopathy had helped with. No actual objective evidence at all. Members of the public are therefore being deceived into using complementary treatments based on unsubstantiated claims.

Potential for rejection of conventional treatments

There are a number of issues with a cancer patient using alternative approaches as complementary to their mainstream treatment but what happens if they are persuaded to use an alternative approach instead of their mainstream treatment? That’s when things get really bad. A study from 2017 found that the death rate from cancer was significantly higher when cancer patients chose to use only alternative treatments.

Conclusions

Many people who are diagnosed with cancer use some form of alternative or complementary treatments. There are a number of serious issues with using these treatments including lack of effectiveness, safety concerns, cost and the potential for rejection of conventional treatments. If somebody with cancer wants to go for a complementary therapy because they find it relaxing and enjoyable then provided they are fully informed of any risks this doesn’t present any particular concerns. What does need to stop is the promotion of these therapies as any form of “treatment” with any specific health benefit. They don’t provide that and it is high time that measures were put in place to protect members of the public from being deceived into believing that they do.

Alternative Medicine – A Critical Assessment of 150 Modalities: book review

Alternative Medicine – A Critical Assessment of 150 Modalities, written by Edzard Ernst, is a book focused on alternative medicine and sets out to provide a “comprehensive, critical yet fair summary of the evidence that is easily accessible to a lay-person”. It is split into two main parts. Part 1 looks at general issues relating to alternative medicine and part 2 goes into 150 alternative therapies and diagnostic methods. Overall, this is a very good book and anyone reading it is going to be much better informed about the (un)suitability of most types of alternative medicine than they were before starting.

In part 1 there are some real “nuggets” of information about what makes alternative medicine attractive, the problems with alternative medicine and the approaches that alternative medicine practitioners use to promote their treatments. I’ll go through each of the 6 chapters in a little more detail shortly but I’d like to whet your appetite with something I think is critically important: the indirect risks of alternative medicine. This is highlighted in section 3.2 “Alternative Medicine Is Risk-Free”. The book says “Indirect risks are not caused by the treatment per se but arise in the context in which therapy is given. If, for instance, a completely harmless but ineffective alternative treatment replaces a vital conventional one, the harmless therapy becomes life-threatening.” Personally, I think this is really important and I believe that if the general public fully understand the level of indirect risk that seeing a homeopath, chiropractor, osteopath, naturopath, acupuncturist or other alternative practitioner presents most people would never go to see one again.

The second part of the book (chapters 7-11) goes through 150 alternative therapies and diagnostic methods assessing each in turn for plausibility, efficacy, safety, cost, risk / benefit balance. It provides nice succinct summaries of many alternative therapies that you have probably heard of as well as a good number that you probably haven’t. Are you thinking about trying acupuncture, gua sha or chiropractic? Check out this section of the book first for a summary of each of these treatments and many more.

Chapter 1 Introduction

The first chapter highlights the large number of books on alternative medicine and how so many of them promote “bogus, potentially harmful treatments”. This book sets out to provide a “comprehensive, critical yet fair summary of the evidence that is easily accessible to a lay-person”. As the book itself says this is a large and challenging task. Is Edzard the right person to take this on? The book claims that he is, and I agree. He arguably has more knowledge and experience in this area than anyone else including having published more peer-reviewed articles on the subject.

This chapter also explains the way that each of the 150 modalities are evaluated and the rating system used to assess each of them in the five areas of plausibility, efficacy, safety, cost, risk / benefit balance. The rating system is deliberately simple which doesn’t allow for much subtlety:

Personally, I think this simple approach is appropriate for the intended aims of the book – to provide information that is easily accessible for the lay-person. This is a good introductory chapter.

Chapter 2 Why Evidence?

This chapter aims to answer the questions “What is evidence?” and “Why is it important?”. To start with, this chapter tackles the notion that a patient getting better isn’t necessarily a result of the treatment they are receiving. Put another way, correlation does not equal causation. The book offers a few alternative explanations for a patient improving after treatment:

• the natural history of the condition (most conditions get better, even if they are not treated at all)
• regression towards the mean (outliers tend to return to the mean when we re-check them)
• the placebo-effect (expectation and conditioning affect how we feel)
• concomitant treatments (people often take more than one treatment when ill)
• social desirability (patients tend to claim they are better simply to please their therapist)

I agree with all of these points. However, I think the book has lost track of its intended audience a bit here: the lay-person. Would a member of the public who has no particular experience with science be expected to understand all of the above? Take for instance “regression towards the mean (outliers tend to return to the mean when we re-check them)”. I don’t think that most people outside the science / medical community would understand the term “regression towards the mean” and even the explanation in brackets is still rather “sciencey”. Perhaps a better lay explanation would be something like: “People often go for a treatment when they are feeling at their worst. Because many conditions have fluctuating symptoms, it is likely that with time they will return to something more like their average symptoms even without treatment. ”

The book then looks at what is suitable as evidence and why it’s important. The book, correctly, suggests that controlled clinical trials are the best way of determining if a treatment caused the improvement and the treatment is therefore effective. The book acknowledges that clinical trials are not perfect (they aren’t) but they are the best way that we have of assessing treatment effectiveness.

I think that overall this chapter is more science-focused than any other. That’s understandable as explaining what evidence is and why it’s important does require some science. However, I do wonder if members of the general public without any science background might find some of what’s in here a bit difficult to follow. Overall it’s still a decent chapter but perhaps some re-wording / additional explanation would have been beneficial in some parts?

Chapter 3 The Attractiveness of Alternative Medicine

Alternative medicine is undoubtedly popular and this chapter tackles a number of the unsubstantiated claims alternative medicine practitioners make in order to sell their services:

• Alternative medicine is effective
• Alternative medicine is risk free
• Alternative medicine is natural
• Alternative medicine is holistic
• Alternative medicine has stood the test of time
• Alternative medicine tackles the root causes of an illness
• Alternative medicine is inexpensive
• Alternative medicine is a small, innocent cottage industry
• Alternative practitioners are more human
• Conventional medicine does not live up to its promises

I often see alternative medicine practitioners making these sorts of claims. Edzard tackles each one in turn in his book. One point that he makes is of particular importance I think. He highlights that one important reason for the popularity of alternative medicine is the failings of conventional medicine (sections 3.10 & 3.11 in the book). That makes a lot of sense. How often do we see someone who has been told that their cancer is terminal going to a “cancer clinic” that offers fake “cures”. It’s unfortunate that sometimes there just aren’t solutions available through conventional medicine. When someone is told by a doctor that there is nothing that can be done to help them it’s entirely natural that they look elsewhere as they need someone to give them hope. That’s when alternative medicine practitioners step in and offer people false hope by claiming that they can help (even though they usually can’t).

Chapter 4 The Unattractiveness of Alternative Medicine

This chapter goes through the reasons why alternative medicine is unsuitable:

• It is not plausible
• There is no evidence
• The “Promised Land” for charlatans
• Pseudo-science

The book highlights the large number of papers that have been published about alternative medicine. In most cases, those trials that are of high quality fail to demonstrate that alternative medicine is effective.

This chapter and the previous one should help members of the public to know how to spot misleading claims.

Chapter 5 Ethical Problems in Alternative Medicine

Ethics is a complex and important topic in the context of any medical treatment, including alternative medicine. This chapter highlights the numerous ethical problems with alternative medicine including informed consent, neglect, competence, truth and risk / benefit analysis. Informed consent is a particular challenge for all types of alternative medicine. For a practitioner of alternative medicine to take true informed consent they would normally have to admit that their treatments are not particularly effective and that there are other better treatments available. As the book explains this would be bad for business and means that alternative medicine practitioners have a powerful conflict of interest that keeps them from adhering to the rules of informed consent and medical ethics. The book gives a very good example of potential encounters with a chiropractor to help explain this.

Chapter 6 Other Issues

This chapter picks up on other issues relating to alternative medicine that don’t fit in the earlier chapters including patient choice, science cannot explain and integrative medicine. I think the last part of the chapter is particularly interesting as it covers what conventional healthcare professionals could say when asked about alternative medicine by a patient. The book suggest four different approaches, some better than others. One of the challenges for conventional healthcare professionals is that they often lack sufficient knowledge about alternative medicine to be able to talk about the evidence (or lack of evidence) behind them. Whilst the book is aimed primarily at the lay person it may also be helpful for conventional healthcare professionals to inform themselves about the evidence and risks of alternative medicine.

Part 2

The second part of the book (chapters 7-11) goes through 150 alternative therapies and diagnostic methods assessing each in turn for plausibility, efficacy, safety, cost, risk / benefit balance. The breadth of modalities covered here is seriously impressive. I’ve been tackling misleading claims in alternative medicine for a number of years and there were a reasonable number of therapies and diagnostic methods that I’d never heard of such as Jin Shin Jyutsu, Kirlian Photography and Eurythmy. As far as I can tell, the assessment of each of the approaches is fair and objective. In fact, I would say that on occasions the assessment is quite generous in favour of some of the alternative therapies. It is certainly not the case that every alternative therapy is criticised. Some are given a positive assessment such as St John’s Wort, Alexander Technique (for chronic low back pain) and Feldenkrais Method.

This section of the book is great for the reader to “dip into” when they want to find out about a particular therapy. It doesn’t go into any of them in great detail, and further reading would be needed here, but it serves as a great reference for a really wide range of alternative therapies and diagnostic methods.

Conclusion

Overall, I think this is an excellent book. It fills an important gap in the market to provide members of the public with objective information about a wide range of alternative medicine approaches. It should help to tackle the widespread misleading (promotional) information that exists around alternative medicine. Readers of this book will undoubtedly be much better informed about the reality of alternative medicine. I just hope the book receives the wide readership it deserves.

 

UK Health Centre: Misleading information about osteopathy, chiropractic, homeopathy and acupuncture all on one site

The UK Health Centre website says that it provides “Access to Health and Medical Information on the Internet”. However, this is not a site that just provides information. It has an appointment booking service and the focus seems to be primarily on providing information that encourages people to make bookings for private treatment. Unfortunately, the information is therefore somewhat biased and in some cases very misleading. Some of the information on the site is actually of a good quality and provides evidence based advice. One example of this would be the information on vaccines. The area where the advice is much more misleading is alternative medicine. This includes osteopathy, chiropractic, acupuncture, homeopathy and herbal remedies. Mixing this misleading information about alternative treatments with more accurate information about conventional medical treatments is likely to cause confusion for the general public and could result in them opting to take treatments that are completely unsuitable.

Osteopathy

The UK Health Centre website promotes osteopathy as a treatment for a wide range of medical conditions including:

• Whiplash
• Asthma and chest problems
• Diabetes
• Long term illness
• Stress
• Depression
• Tiredness
• Osteoporosis
• IBS
• Glue ear
• Infections
• Insomnia
• Growing pains
• Dysmenorrhoea (period pains)
• Issues specifically related to pregnancy (such as morning sickness, wounds from childbirth)
• Common infant problems (including colic, colds and teething pain)
• Conditions arising from oxygen deprivation during birth
• Monitoring baby’s growth and development
• General poor health

Osteopathy has not been shown to be effective for any of these conditions and therefore advertising such treatments breaches advertising regulations. It is in conflict with the guidance provided by the General Osteopathic Council (regulatory body for osteopathy in the UK), the Advertising Standards Authority and the Committee of Advertising Practice (http://www.osteopathy.org.uk/news-and-resources/document-library/practice-guidance/gosc-asa-cap-letter-to-osteopaths/ and https://www.asa.org.uk/asset/44783612-C34B-4084-9B8A7036F01C43D7/ ). This misleading information could result in someone booking an appointment with an osteopath when their treatments are completely unsuitable. Some of the conditions on the list, such as asthma, are serious medical conditions that should only be handled by a suitably qualified MEDICAL professional and definitely not an osteopath.

Chiropractic

Although less outrageous than the treatment claims made for osteopathy, the information provided about chiropractic is also misleading. The site suggests that chiropractic treatment can improve the immune system, provide a solution to fertility problems and also to treat asthma. None of these claims can be substantiated and this information is therefore misleading. Elsewhere it says “The National Institute for Health and Clinical Excellence (NICE) support the use of chiropractic for treatment of acute lower back pain as they have analysed the results of studies that prove its effectiveness in this area.” Actually, the recent NICE guidelines have downgraded the role of chiropractic in treatment of low back pain due to a lack of evidence for its effectiveness.

Besides treatment for specific medical conditions, the site has other misleading information about chiropractic such as “It is considered most beneficial to undergo chiropractic treatments on a regular basis in order to prevent future damage to the skeleton.” Wow! There is no evidence to suggest that chiropractic is suitable as a preventative treatment. Furthermore, suggesting that not having such treatment might result in “future damage to the skeleton” is blatant and unsubstantiated scaremongering to try and get people to take treatments.

Interestingly, they do highlight risks of chiropractic: http://www.healthcentre.org.uk/chiropractors/chiropractors-safety.html . What’s rather puzzling is that the site doesn’t consider similar risks of osteopathy even though many of the same risks apply to both.

Acupuncture

The UK Health Centre website recommends acupuncture or acupressure for a range of different conditions including:

• Tooth pain
• Other pain
• Muscle tightness
• Nausea
• Erectile dysfunction
• Bronchitis
• Anxiety
• Stress
• Drug use / alcoholism
• Overeating
• Fertility
• Conditions during pregnancy including tiredness, anxiety, tenderness in the breasts, varicose veins, induction of labour, to correct foetal position

Acupuncture hasn’t been shown to be effective for any of these conditions and claiming otherwise is misleading. This also conflicts with the Advertising Standards Authority guidelines for acupuncture.

It then goes on to say that effectiveness of acupuncture for some conditions is in a “grey area”. Conditions that it puts into this category include depression, neck pain, stroke, sciatica, tinnitus, asthma, addictions (substance abuse). However, there is no such thing as a “grey area” in treatment effectiveness. Either a treatment has been proven to work or it hasn’t – in this case it hasn’t and suggesting otherwise is misleading.

Like osteopathy, some of the items on the list are serious medical conditions that should only be handled by a suitably qualified MEDICAL professional and definitely not treated with acupuncture.

Homeopathy

The site suggests that homeopathy is an effective treatment for hay fever (http://www.healthcentre.org.uk/allergies/hay-fever-homeopathy.html ) and snoring (http://www.healthcentre.org.uk/sleep-disorders/snoring-natural-alternative-homeopathic.html ). It then goes on to say that homeopathy is the most suitable treatment during pregnancy (http://www.healthcentre.org.uk/sleep-disorders/snoring-natural-alternative-homeopathic.html ). None of these claims are backed by any sort of evidence and are misleading the general public into potentially taking a treatment that is completely ineffective.

Herbal Remedies

The UK Health Centre website suggests that herbal remedies are effective for allergies, menopause, erectile dysfunction, skin tags and sleep problems. There is no evidence to back up these claims and they are therefore misleading the general public.

Actions Taken and Next Steps

I contacted UK Health Centre in November 2016 to ask them to amend the misleading content on their site. In the first instance I opted to focus on the content about osteopathy to see if they would be willing to correct their site. If they responded positively I then planned to tackle the other issues. Here is the e-mail I sent:

“I’m following up on the information provided about osteopathy on your website. A number of the claims made about osteopathy on your site do not have evidence to support them and are therefore misleading prospective patients and the general public. Furthermore, making these kinds of claims breaches advertising regulations and is in conflict with the guidance provided by the General Osteopathic Council (regulatory body for osteopathy in the UK), the Advertising Standards Authority and the Committee of Advertising Practice. See this link for the guidance they provided to osteopaths: http://www.osteopathy.org.uk/news-and-resources/document-library/practice-guidance/gosc-asa-cap-letter-to-osteopaths/ Many of the pages on your site breach these guidelines and provide misleading advice. This includes references to treatment for whiplash, asthma and chest problems, stress, depression, tiredness, osteoporosis, IBS, glue ear, infections, growing pains, common infant problems and “general poor health”. Furthermore, your site suggests that preventative osteopathic treatment is appropriate and that “osteopathy can provide health benefits to most people”. However, there is no evidence to support either of these claims and therefore your site is misleading prospective patients and the general public.

Could you please remove all of your misleading articles about osteopathy from your website or amend them to make it clear what osteopathy can / cannot actually treat? I look forward to hearing from you.”

I received no response so sent a follow up in December 2016. Again there was no response. The information they provide is misleading the general public and has the potential to cause people to take unsuitable treatments. As such, the information on this site represents a risk to the public. I have therefore reported UK Health Centre to the Advertising Standards Authority (ASA). It will be interesting to see the outcome of this.