By Robert Verkerk PhD, founder, executive & scientific director, ANH-Intl
Did you hear that cancer patients who refuse conventional cancer treatment and opt for alternative medicine are twice as likely to die than patients who use only conventional treatments (chemotherapy, radiotherapy, surgery or hormone therapy)?
The news is out and about, on BBC News in the UK and Medical News Today in the USA to mention just two of the media channels. But you’ll find out here that the news is fake. You could say the research article by a Yale team with declared conflicts of interest published in JAMA Oncology provided an ideal opportunity for bit of timely CAM (complementary and alternative medicine) bashing.
A piece in the Guardian by Matthew d'Ancona was given the irresistible title, “From Andrew Wakefield to Brexiteers, snake-oil salesmen are keeping us sick.” Why not go for a three-in-one when you think the opportunity is there!
How was the study conducted?
Firstly, let’s remember the study was an observational one. When these are done in the field of complementary or alternative medicine and they yield positive results, authorities generally say they’re not worth the paper they’re written on. Observational studies, they say, subsist one step from the bottom of the pecking order in the evidence hierarchy of ‘evidence-based medicine’ and therefore have little or no authority. When the shoe's on the other foot, it's a big research group from a well-established US university and the findings can be used to bash CAM (even in the absence of direct evidence), the 'rules' appear different.
The Yale team went to the US National Cancer Database which includes an impressive almost 2 million cases. But it’s made up only of data derived from Commission on Cancer–accredited hospitals in the USA. It absolutely doesn’t include any of the leading centres or clinics specialising in complementary or integrative medicine in the USA.
Of this very large number of nearly 2 million, the researchers could only find a tiny number of cases (281 or a miniscule 0.014%) who fitted the criteria of being cancer patients with stage I, II or III cancer who had also used one or more so-called “unproven therapy delivered by nonmedical personnel” along with one conventional treatment (chemotherapy, radiotherapy, surgery or hormone therapy). Amazingly, the unproven therapies are not coded sufficiently to allow any further information to be gleaned about which therapies were used. But the authors made mention of them as “including herbs and botanicals, vitamins and minerals, traditional Chinese medicine, homeopathy, and naturopathy, as well as specialized diets”.
They also cite other research that shows “Patients with cancer choose to use CM to improve their quality of life and feel more hopeful”, that “Past research has shown that CM therapies such as massage, acupuncture, yoga, and meditation can improve quality of life” and “it is estimated that between 48% and 88% of patients with cancer have reported the use of CAM as part of their therapy". These figures a stunning 3,500 to 6,300 times greater than the proportion of complementary medicine users found in the National Cancer Database – so there is a very strong chance the 281 subjects on which the conclusions are based are not representative.
So what did the researchers find? Firstly, this tiny group of complementary medicine users were more likely to be female, were likely more educated, and had higher incomes than those who used conventional treatments only. Wait for it, they were also more likely to have breast or colorectal cancer, the two cancers that kill most women, while having private insurance, stage III (vs stage I) cancer and lower levels of comorbidity (other illnesses). Geography played its hand as well: they were more likely to live in the Intermountain West or Pacific West of the USA.
The principle finding was that when monitored over 7-years, patients who used complementary medicine had a marginally worse 5-year survival for all cancers studied (breast, prostate, bowel, colorectal, lung) at 82.2% versus 86.6%, the difference being statistically significant. Most of this difference was caused by slightly higher risk of death in users of complementary medicine with breast cancer, the difference being only marginal with colorectal cancer. There were no significant differences among those with lung or prostate cancer.
The second major finding – downplayed by the media – was that when the researchers statistically adjusted the model for treatment refusal and delay from diagnosis to treatment, they found no association between use of complementary medicine and risk of death. This is what delivered their headline that it was conventional treatment refusal that caused an increased risk of death. Crucially, what this means is that there was no evidence whatsoever that the use of complementary medicine itself increased risk of death. Sadly, many who will have read the title of the paper, the abstract or the news articles emanating from the PR spin will have been given the impression that complementary medicine itself will reduce a cancer patient’s survival.
Why we don’t rate the study (or its interpretation)
We could descend into a very long rebuttal of the study, but felt a shorter list of key points of concern would be useful. So here they are:
The sample of complementary medicine users is unlikely to be representative of most people who use both conventional and non-conventional methods. It is well known, as cited by the authors themselves, that 48% to 88% of all cancer patients engage in the use of some form of alternative treatment
The around 4% increased risk of death among those who engaged in complementary medicine might have been statistically significant, but it is not necessarily very biologically or socially significant, especially given this small variance was down to delays in receiving treatment
There is no information at all available on the types of “unproven” therapies provided; not the type, the timing, the amount, who delivered it, was it self-administered, etc
The study evaluated 5-year survival across the most common forms of cancer and in whether or not complementary therapies were involved, the survival rates were high (>80%). It would have been more informative to evaluate 10-year survival (where data are available) given on average this is typically only around 50%
The study failed to look at effects of alternative treatments on quality of life, emotional health or other parameters that were independent of survival, despite evidence for their positive role, one acknowledged in the introduction of the paper
As the authors concede, the study is an observational study based on historic data from a pre-existent database and contains vast amounts of ‘noise’ in the form of uncontrolled and unknown sources of variance and confounding
The health status of individuals that chose complementary versus only conventional treatments is entirely unknown and unstudied. Who is to say that those who chose complementary medicine were not in a generally worse state of health, especially given that they were more likely to have stage III (than stage I) cancer
The abstract of the study (and hence the media reports about it) did not mention that the effect was not found at all with prostate and lung cancers and was mainly the result of differences with breast cancer and only to a slight extent with colorectal cancer
Three out of four of the authors had declared conflicts of interests, as follows: “Dr Park reported receiving honoraria from Varian Medical Systems Inc and RadOncQuestions LLC. Dr Gross reported receiving research funding from 21st Century Oncology, Johnson and Johnson, Medtronic, and Pfizer. Dr Yu reported receiving research funding from 21st Century Oncology and serving as a consultant for Augmenix".
Final note: the same authors published another study (“Use of Alternative Medicine for Cancer and Its Impact on Survival”) in 2017 based on the same dataset that attempted to ‘can’ alternative medicine treatments. It has many of the same limitations as the present study so the findings are in our view worthless and do not reflect what benefits or risks alternative medicine approaches might have for patients who select them diligently. What’s more the title is deeply misleading. The paper cannot establish “impact on survival”. A more appropriate title might have been: “Use of Alternative Medicine for Cancer and Its Association with Survival.” But that’s another story.
Given it’s #ThrowbackThursday, we thought you might be interested in the following stories…
Cancer orthodoxy takes note of alternative treatments
Has the time come for mainstream medicine to acknowledge the benefits of 'alternative' cancer therapies?
Here’s a compelling and emotional argument, published in June 2017, for trying a non-conventional cancer treatment on a patient who has run out of options from the official armoury.
“Only someone who is lucky enough to have never experienced the panic and angst generated by a diagnosis of cancer (or other life threatening condition) can contemplate ignoring complementary and integrative medicine.
It is easy for a doctor to dismiss it as unproven quackery, but very difficult then to give an answer to cancer patients in pain, with impossible nausea and vomiting, with drug-resistant permanent insomnia, with weight loss and cachexia, who are open to any reasonable solution in the hope of feeling better.”
So where do you think it came from. A reasonable guess would be the website of some site devoted to CAM (Complementary and Alternative Medicine) or maybe an American centre at a large hospital that takes a CIM (Complementary and Integrated Medicine) approach, using both drugs and natural treatments.
Censorship, quackery and the dissing of unproven cancer therapies
Why the status quo no longer serves cancer patients and what can be done to encourage research and trialling of promising, integrative cancer therapies
UK cancer conference attacked
Medical freedom of choice remains an aspiration rather than a reality for many. In no area is this more true than in cancer therapy. On Monday, the UK’s Telegraph newspaper lambasted a meeting held near Brighton on England’s south coast, in which various views about alternative cancer treatments were put forward. ANH-Intl’s Rob Verkerk also delivered a lecture at the request of the meeting’s organisers.
We are unable to comment on the nature or quality of other speakers as Rob’s presence at the meeting was restricted to his delivery of a presentation on major challenges facing orthodox medicine linked to its excessive reliance on pharmaceuticals and the limitations of methods used to prove efficacy. Proof of efficacy is reliant almost entirely on the gold standard of randomised controlled trials (RCTs), these increasingly being viewed as of limited value in evaluating multi-modality, integrative approaches that also attempt to maximise the effects of the therapeutic relationship (between practitioner and patient).