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.

Integrative Health Convention 2019: A collection of unsuitable, unproven and potentially harmful treatments

On 5^th and 6^th October 2019 it’s the annual Integrative Health Convention. From QiGong to Homeopathy to Reflexology to Acupuncture and many more this really is quite the collection of unsuitable, unproven and potentially harmful treatments.

The convention aims to “show you how complementary therapy, self-care, and medicine are already working together successfully to improve health outcomes, reduce workload, limit overprescribing, and manage stress and workload, as well as resulting in a possible reduction in national health spending.” On the face of it this is a worthy aim. Improving health outcomes whilst reducing workload and costs to the NHS would be great if it could be achieved. Self-care is also clearly an important part of managing many health conditions. However, it’s already used alongside medicine in conventional healthcare. All that this convention therefore offers is the addition of complementary therapy. Most complementary therapies are not effective, carry risks and are carried out by practitioners who lack adequate skills in diagnosis and treatment. It is therefore hard to see how this convention can have a positive impact on public health.

Let’s look at just a small sample of the therapies being discussed at the convention:

• “Transforming responses to Stress with Integrative QiGong”. QiGong is a branch of Traditional Chinese Medicine (TCM). Like many aspects of TCM it is focused on the “life force” Qi (or Chi). Qi has never been shown to actually exist and therefore QiGong is highly implausible. There is no good evidence that QiGong has any health benefit.
• “Integrating Acupuncture – Western Medical Acupuncture, Traditional Chinese Acupuncture and Future Avenues in Acupuncture”. Like QiGong, acupuncture is a branch of Traditional Chinese Medicine. It is also based on the concepts of Qi and meridians, neither of which actually exists. Acupuncture has little or no evidence of effectiveness for any health condition. The perceived benefits of acupuncture are probably due to non-specific treatment effects, e.g. the relaxing environment and attention provided by the acupuncturist rather than the actual acupuncture treatment. This has led to acupuncture being called a “theatrical placebo”.
• “Reflexology: What is it and what is the evidence?” Reflexology is based on the

  

  An actual map of the feet

  mistaken belief that different parts of the feet correspond to different parts of the body. Reflexologists believe that by pressing on different parts of the feet they can bring about changes in other parts of the body. This is nonsense. Reflexology is a foot massage, nothing more, nothing less. As to the evidence, that’s very clear: It has not been shown to provide any benefit for any health condition.

• “Homeopathy explained – How does homeopathy work & How to use it at Home?” Homeopathy is made up of many strange beliefs such as the “memory” of water and “like cures like”. It conflicts directly with many aspects of science. Homeopathy has been extensively tested and not found to be effective for any health condition. For instance, see the NHMRC report on homeopathy. Put simply, homeopathy doesn’t work and there is no plausible mechanism by which it could. Recommending people to use homeopathy at home carries a number of risks, most importantly the potential to delay more effective treatments. In some situations this could have serious consequences.

  

  Does this look like a valid medical treatment?

• “The Successful Integration of Reiki into NHS Hospitals.” Reiki is a form of energy healing in which a “universal energy” is believed to be transferred through the palms of the practitioner to the patient in order to encourage healing. It’s based on the assumptions of Traditional Chinese Medicine including the existence of Qi. Qi has never been shown to actually exist and there is no plausible mechanism by which Reiki could work. When tested in clinical trials it has not been shown to provide any health benefits. Far from being a success, any use of Reiki in the NHS would therefore be a disaster and an appalling waste of scarce NHS resources.
• “An introduction to aromatherapy and essential oils.” Aromatherapy and essential oils are not medical treatments and have not been shown to provide any benefit for any health condition. Yes, they may be relaxing, particularly when combined with a pleasant environment, but they don’t have any medicinal properties and shouldn’t have any place in a conference about health. They also carry side effects, as does any treatment.

Conclusions

Most of the treatments being discussed at this convention are based on pre-scientific beliefs, are biologically implausible, lack evidence of effectiveness and carry risks. None of them should have any place in the treatment of any health condition.

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.

 

The Good Thinking Society is challenging the Professional Standards Authority’s reaccreditation of the Society of Homeopaths. Why is this important?

The Professional Standards Authority (PSA) say that they are “here to protect the public and help ensure their health and wellbeing by raising standards in the regulation and registration of people working in health and social care”. Within their activities they provide a set of accredited registers so that as a member of the public you can “choose a practitioner to meet your needs with confidence”. It would therefore be reasonable to expect that the PSA have vetted the providers of their accredited registers to ensure that the treatments their members offer to the public are suitable, effective and, most importantly, safe. However, it would appear that this is not always the case.  Some members of the Society of Homeopaths (SoH) offer a treatment called CEASE therapy. This is a treatment for autism based on the false premise that vaccinations cause autism and that this can be “cured” through a combination of homeopathy, high dose vitamin C and dietary restriction. The link between vaccines and autism has been thoroughly disproved; see this for instance, and there is no evidence that CEASE therapy provides any benefit. The PSA has acknowledged that CEASE therapy is potentially harmful and they are aware that this treatment continues to be provided by some members of the SoH. In order to protect the public, it would therefore be reasonable to expect the PSA to no longer accredit the SoH. In actual fact they have done quite the opposite and on 1^st April 2019 they approved accreditation of the SoH for a further year. This decision seems to be in direct conflict with the purpose of the PSA which is to protect the public. No child with autism should be subjected to CEASE therapy and it is very good that the Good Thinking Society is challenging this decision by the PSA via judicial review.

Wider implications

The particular issue here being addressed here is protecting people with autism from being exposed to the completely unsuitable CEASE therapy. This in itself is very important. However, this judicial review potentially has wider implications. It also brings into question whether regulation in the UK actually fulfils its key function of protecting the public or instead lends legitimacy to unproven, unsuitable and potentially harmful treatments. This is important as it would appear that the current approach of the PSA (and other regulators) is not effective in protecting the public from harm from unsuitable treatments.

How can you help?

Here are a few ideas of things that you could do to support the Good Thinking Society with their judicial review:

• Make a donation
• Share information about the campaign on social media, such as Twitter or Facebook.
• Raise awareness with local groups that provide support to people with autism and / or parents of children with autism such as charities or local parent carer forums.
• Get in touch with the Good Thinking Society to find out how else you could help.

Is homeopathy a suitable treatment for the flu?

We are approaching the main flu season in the UK, which the NHS considers to be December to March. I came across an interesting article “Does Oscillococcinum Work for the Flu? An Objective Review”. It’s not a bad article but there are some places where the science could be more thorough and it includes some inappropriate recommendations and conclusions. I therefore decided to undertake my own review of Oscillococcinum, and homeopathy in general, as a treatment for the flu.

What is the Flu?

The NHS website says “A bad bout of flu is much worse than a heavy cold. Flu symptoms come on suddenly and sometimes severely. They include fever, chills, headaches and aching muscles, as well as a cough and sore throat.” It also important to be aware that you are more likely to get complications from the flu than a cold. Unfortunately, members of the public sometimes use the terms “flu” and “cold” synonymously. In reality, they are very different things and the flu is a more serious illness than many people realise.

What is Oscillococcinum

Oscillococcinum is a homeopathic product manufactured and sold by Boiron. Boiron is the largest manufacturer of homeopathic products in the World. Boiron claims that Oscillococcinum “Temporarily relieves flu-like symptoms such as body aches, headache, fever, chills and fatigue” but does this claim stand up to scrutiny?

The listed active ingredient in Oscillococcinum is Anas barbariae 200CK HPUS. The active ingredient is made from the heart and liver of a wild duck. However, 200C specifies the way that the Anas barbariae is diluted. 1 part of the original ingredient is mixed with 100 parts of the inactive ingredients. This process is then repeated 200 times (200C). Such a huge dilution actually results in zero molecules of the original active ingredient being present in the final treatment. It is therefore a misnomer to describe Anas barbariae as the “active ingredient” because it isn’t actually present at all in the final product! (Note that the above article is incorrect on this point as it says that there’s “hardly a trace of the active ingredient”. That’s not correct. There is actually ZERO active ingredient). Like most homeopathic products, there is no active ingredient present and in the case of Oscillococcinum it contains nothing but sugar (lactose and sucrose).

Does Oscillococcinum work?

When assessing effectiveness of a treatment, it’s not appropriate to merely give someone the treatment and see if they get better as this does not control for non-specific treatment effects. In the case of flu, most people will get better anyway without treatment. We therefore need to look at randomised controlled trials (RCTs) and systematic reviews that provide a more objective measure of treatment effectiveness. In the case of Oscillococcinum there is a Cochrane Systematic Review that assesses whether it is effective at preventing and treating flu. The authors (homeopaths) concluded that “There is insufficient good evidence to enable robust conclusions to be made about Oscillococcinum in the prevention or treatment of influenza and influenza‐like illness”. Translating this into more simplistic terms: There is no good evidence that Oscillococcinum is effective as a preventative or treatment of the flu.

There is also this Cochrane Review on the effectiveness of homeopathy for respiratory tract infections in children. According to the article, colds and flu are a common cause of respiratory infections. The authors concluded “We found no evidence to support the efficacy of homeopathic medicinal products for ARTIs in children. Adverse events were poorly reported, so conclusions about safety could not be drawn.”

When considering the evidence in its entirety, the message is clear: Oscillococcinum is not an effective treatment for the flu.

Is More Research Needed?

When a study is undertaken and doesn’t show positive results, sometimes the researchers suggest that “more research is needed”. This is something that happens particularly often in alternative medicine research and the focus seems to be “we didn’t get a positive result so we should try harder”. Does this make sense? In the context of homeopathy as a treatment for the flu we know:

1. It is so diluted that there is no active ingredient left in the final product
2. It is based on a rationale (like cures like) that does not stand up to scientific scrutiny
3. When scientifically tested it shows no evidence of a beneficial effect

The suggestion of doing more research in this situation just makes no sense. Homeopathy has no scientific basis and has repeatedly been shown to be ineffective. Continuing to research something like this is simply a waste of time and money.

The Placebo Effect

The article that prompted me to look into this more closely suggests that Oscillococcinum may provide a placebo effect. The placebo effect is present with all treatments to some extent and a treatment that only has a placebo effect isn’t an effective treatment. That’s why when assessing treatment effectiveness it’s important to test against a placebo. What we are looking for when testing the effectiveness of a treatment is a clear benefit over and above the placebo effect. In this case, Oscillococcinum doesn’t actually provide that – it’s indistinguishable from a placebo.

The article suggests “more research is required to determine if it may have a placebo effect”. This is very misleading. Treatments that only have a placebo effect should be discounted because they haven’t actually been shown to be effective. Treating people with something that is purely a placebo (like homeopathy) requires deception of patients and is unethical. It also deprives patients of more effective treatments.

Safety

The article suggests that Oscillococcinum is “Safe With Minimal Risk of Side Effects”. This is again highly misleading. There is, as far as I’m aware, no routine monitoring and reporting of adverse events from homeopathic treatment. Homeopathic treatments are also not regulated as closely as conventional medicines in many countries. This means that we don’t really know whether Oscillococcinum is safe or not.

There is a more important safety concern here, however. Unlike the common cold, the flu is a more serious virus and can result in severe complications in some cases. Treating someone with the flu with a homeopathic treatment, which is ineffective, presents risks because they are being deprived of more suitable treatments. Also, homeopaths (in most cases) are lay practitioners and are not medically qualified doctors. This presents an additional risk for patients as homeopaths are not qualified to diagnose and treat serious medical conditions.

There are therefore overall potentially serious risks with treating the flu with a homeopathic product like Oscillococcinum. It is highly misleading to suggest that it is “safe”.

Conclusion

Oscillococcinum contains no active ingredient, is based on principles that don’t stand up to scientific scrutiny and has not been shown to be effective as a treatment for the flu. Receiving treatment for the flu from a homeopath rather than a medical doctor presents risks for the patient. For these reasons, Oscillococcinum should not be recommended as a treatment for the flu. The same applies to other homeopathic products – there are none that have been shown to be effective for the flu.

What treatment should be used for the flu? Flu is a virus and the best way to prevent it is with the flu vaccine. If you do end up getting the flu, the NHS website provides advice about treatment and when to seek further advice.