Tuesday, October 04, 2005

How to succeed at quackery?

I wish I had thought of it first, but fortunately for you, my readers Prometheus did: How to Succeed at Quackery Without Even Trying (Part 1). It's a must-read for anyone interested in skepticism with regards to the claims of alternative medicine. If you like the Respectful Insolence Orac lays down, you'll love this. An excerpt:
Ambiguity and vagueness are the greatest assets for a budding quack. When you pick your niche, be sure to find a disorder that is poorly defined or difficult to diagnose. Disorders that are not recognized by allopaths are excellent choices, since there is no way that anyone can accuse you of misdiagnosing them. The best are disorders that are purely imaginary, since the marks will be so appreciative when you don’t say that it’s “all in their head”.

Think long and hard before choosing a disorder that has a well-established and unambiguous diagnosis, unless you are willing to put in the time to convince people that the accepted diagnostic criteria are wrong. If you are just starting out, this may be too much work – save it for when you are an established quack. At all costs, avoid disorders that the mark can diagnose themselves – promising a “cure” for freckles will mean that you actually have to deliver on your promise. It is much better to pick complaints that are vague and subjective, like fatigue, malaise or depression.

Good choices: Chronic fatigue, Autism, Gulf War Syndrome

Bad choices: Fractures, Angina, Pneumonia
Indeed. However, I would have one minor nit to pick. Quacks are actually more than happy to take on some diseases that are well-established and have fairly unambiguous diagnostic criteria. For example, chelationists push their unproven "treatment" for atherosclerotic vascular and coronary artery disease. They'll even claim that it can save patients the need for bypass surgery. (Of course, they also push it for diseases like autism as well, with sometimes catastrophic results. Given the wide number of diseases for which chelation is advocated, I sometimes wonder if there is a disease that chelation can't cure!) Another problem is that a couple of the diseases that Prometheus lists as bad choices may not be as unambigous to diagnose as he implies. For example, angina isn't always a straightforward diagnosis (hence the ability of alties to get away with advocating chelation for heart disease). However, Prometheus is correct in that these diseases are more straightforward than diseases such as chronic fatigue sydrome or Gulf War Syndrome. He is also quite correct that vague diseases whose diagnositic criteria are not rock solid are better for quacks and that diseases for which conventional medicine doesn't have a good treatment are best of all.

I would also point out one additional "niche" that can be filled by a huge number of quacks: cancers that are primarily treated surgically. Take, for example, breast cancer. As a regular on misc.health.alternative named Dr. Peter Moran, an Australian surgeon, has pointed out, most breast cancers, even moderate sized ones, are cured surgically. (For small, stage I tumors this is even more frequently the case.) Indeed, up to 50% of women with breast cancer treated with lumpectomy alone will remain cancer free with no further treatment at 12 years. Sentinel lymph node biopsy or axillary dissection can define stage and identify patients at high risk of recurrence who would be be likely to benefit from more aggressive chemotherapy, but neither is strictly necessary for cure in early stage node-negative breast cancer. Chemotherapy and radiation therapy reduce the rates of recurrence. Without radiation therapy, for example, breast cancers treated with lumpectomy alone will recur in the breast 25-40% of the time. However, that means that most women treated with lumpectomy alone will not recur in the breast. In addition, estrogen blockade with Tamoxifen can significantly improve long-term survival over surgery alone in women whose tumors are estrogen receptor positive, as can chemotherapy in high risk patients, but these are adjuvant therapies, not the primary therapy. In some cases, particularly for early stage breast cancer, the absolute survival benefit from chemotherapy as a percentage is measured in the low single digits.

This is the reason quacks can get away with persuading women to forego chemotherapy and/or radiation often enough to make believers of some women like Sandra, resulting in their enthusiastic "testimonials." Dr. Moran put it quite well in relating an e-mail exchange that he had with a woman with breast cancer who claimed to have "cured" herself with alternative medical treatments:
Sandra: I cured myself of BC 5 years ago-- turned down all conventional therapy. Former RN too. there are many like me-- I have a long list of others who have down the same. The tide is turning . Please try not to discourage others. -------- RN"

PM: Tell me more about your history. I assume you had an excision-biopsy?

Sandra: Why?

PM: I take it from this response that you did have an excision biopsy, and if so, it is not true that you had no conventional medical treatment.

Sandra: No excisional biopsy! I won't waste my time with you. Please do not email again-- I will delete. I talk to many women's groups and have a strong medical background. Your approach is very sad and must be dscouraging to women you come in contact with. End fo discussion!
Of course, "Sandra" had indeed had an excisional biopsy, as her own "testimonial" on the Internet revealed. The reason Dr. Moran asked this is because an excisional biopsy that happens to get the entire tumor is, for all practical purposes, a lumpectomy. It has in essence treated the cancer surgically. Consequently, it was the excisional biopsy that cured Sandra, not any alternative medicine regime she took. Indeed, you will find that virtually all women who claim that alternative medicine "cured" them had at least an excisional biopsy, if not a formal lumpectomy (which takes more tissue in an attempt to get a generous margin of normal tissue around the tumor).

As I have discussed in detail before, women who undergo lumpectomy and then decide to forgo chemotherapy and radiation in favor of alternative therapies tend to attribute their survival to the "alternative" therapy, not to the surgery:
When such patients are in a good prognosis group, where recurrence is uncommon, or have a more advanced tumor but are lucky enough not to recur, often they attribute their survival not to the primary surgery, but rather to whatever alternative therapy they have decided to take, even though it almost certainly had nothing to do with their survival. To them, it was the alternative medicine that "saved" them, not good old-fashioned surgery. In contrast, women who opt for alternative therapy and then recur obviously don't provide good testimonials to sell alternative medicine, which is why you almost never hear about them.
Unfortunately, because we do not yet have good enough prognostic indicators to tell exactly who will and will not benefit from more aggressive treatment, this means that many women are treated to save the lives of a relatively few. However, we are doing better, as the evolution of breast cancer treatment has been almost continually towards less aggressive surgical treatment (modified radical mastectomy instead of radical mastectomy, lumpectomy instead of mastectomy, sentinel lymph node biopsy instead of axillary dissection). The next frontier will be identifying women who do not need chemotherapy because they have low risk disease or those who may need even more aggressive chemotherapy because they are at high risk of relapse. Most women who provide these "alternative medicine" testimonials happen to be either the ones who have self-selected themselves to be at low risk or the patients at high risk of relapse who happened to be lucky. Not infrequently, they are patients who prematurely declare themselves "cured." Most breast cancer recurrences, whether local or metastatic, occur within five years, but there is still a significant relapse rate at 10 years and even later.

The bottom line is that early stage breast cancer, because it is so treatable and usually has such a good prognosis, is as fertile a niche for quacks as any that Prometheus has mentioned, because most patients will do pretty well. It is important to remember that many alternative medical treatments are not necessarily quackery and that, indeed, some might have utility in improving quality of life. However, none have yet been shown to provide a survival benefit in well-designed clinical trials. Unfortunately, though, there are too many "healers" out there who claims to be able to "cure" cancers without any plausible scientific rationale or clinical evidence to suggest that their methods do anything of the sort.

That little nit picking aside, I can't wait for Part 2 of Prometheus' series...

14 example(s) of insolence returned:


At 10/04/2005 1:32 PM, Blogger Pierce Wetter said...

As an alternative apprentice I have this to contribute:

My teacher always says he could make a lot more money if his treatments didn't work. Since mostly we treat people who have already tried Western medicine without any luck (we have no objection to Western medicine, BTW), they have a chronic problem. So as we treat them, they have to make changes to their lifestyle to deal with NOT having the problem any more.

That can be as traumatic or more as having the problem is alone. A good example is heroin addiction. We have a herbal treatment that is very effective with the physical components of heroin addiction. However, its useless unless the addict joins some sort of group to deal with all the other components. For instance, one addict went back to heroin because he couldn't deal with remembering all the things he'd done while addicted...

So that's one thing.

The thing I think you're missing in all this is that I think oncologists over-prescribe chemotherapy after surgery. Chemotherapy has its place, don't get me wrong, but its worth remembering that all medicines are poisons to some extent, and I think as an oncologist, you have to really consider: "Will the Chemo really help prevent more cancer, or will it just make the patient feel like shit?"

There are plenty of doctors who are a little too free with the prescription pad. Antibiotics are another thing that is hugely overprescribed. My dad ended up having to have a hernia operation this year because after some prophylactic doxycycline cleaned out his intestinal bacteria, he was getting terrible gas.

The reason alternative medicine exists is because patients need an alternative to bad doctoring.

 

At 10/04/2005 4:52 PM, Blogger decrepitoldfool said...

Pierce - "My dad ended up having to have a hernia operation this year because after some prophylactic doxycycline cleaned out his intestinal bacteria, he was getting terrible gas.

The reason alternative medicine exists is because patients need an alternative to bad doctoring."


Huh? Hernia surgery for gas? Tried "Beano?"

That said, if you suffer from chronic pain and fatigue as I do (no mystery: it comes from lack of sleep which comes from pain), doctors can be awfully clueless. Anything they can't diagnose is "depression" even if the patient is having a wonderful time being alive but would like less pain and a good night's sleep.

And having said that,, I tried chiropractic and various other remedies to no effect.

"Alternative medicine" is just an alternative to having a fuller, richer checking account.

 

At 10/04/2005 8:56 PM, Blogger Orac said...

I may have to steal that quote!

 

At 10/05/2005 10:15 AM, Blogger Rockstar Ryan said...

Doc Orac:

It saddens me that alties take credit for the great work physicians do - like the breast cancer creduloid. Anyway...

My teacher always says he could make a lot more money if his treatments didn't work.

They don't. Remember: What do you call alternative medicine that works?

Medicine.

 

At 10/05/2005 10:57 AM, Anonymous AndyD said...

To Pierce:

With regard to the over-prescription of Chemotherapy, you have to remember that normal medicine actually tests treatments before using them. With the current state of knowledge, the use of chemo after an operation may only benefit 5 out of 100 patients - but we don't know which 5. And those 5 people would certainly not claim to have being 'over treated' with hindsight (i.e. if they actually knew that they would otherwise have died).

 

At 10/05/2005 4:14 PM, Blogger clone3g said...

Rockstar: What do you call alternative medicine that works?
Medicine.


ROFL!

I read the first chapter of a book on treating cancer the natural way with macrobiotic, brown rice, organic, blah, blah, blah, diet. The author explained that she completed half of her chemotherapy and it made her so sick that she refused any more treatment then developed her diet. But there's no way that the months of chemo had anything to do with her remission?

She got lucky, went a few years without relapse, and had she completed the full course of chemo it would it have been over prescribed?

 

At 10/05/2005 4:58 PM, Blogger Rockstar Ryan said...

I'm glad you got a laugh! But I can't take credit. I heard that from a Skeptico post coincidentally referring to a Respectful Insolence post!

Both fascinating blogs, I might add.

 

At 10/05/2005 5:41 PM, Anonymous Anonymous said...

The quote about having a richer checking account? Forget about it! I have spent so much money on expensive vitamin supplements and proprietary blends that don't work. Plus alties are into saying, "Try this. Try that. No, maybe this. Maybe that." Before you know it, the grand experiment with supplements costs hundreds, if not thousands of dollars with no results. And many people have a medicine cabinet stocked with expensive supplements that are unproven-and unregulated. Who knows if you're actually getting vitamin B, or maybe you're getting a cheap placebo from a non-legitimate, greedy company. Alties don't provide answers any more than conventional docs do. Is chemotherapy the alpha and omega of cancer treatment? NO, it's only a hope...sure, the odds are perhaps higher that it MIGHT work in some cases. So it's a crap shoot no matter how you look at it. People get fed up with both sides of the camp, because neither alties nor conventional docs have answers--and people don't want to wait around for clinical trials that may be inconclusive in the end.

 

At 10/05/2005 5:46 PM, Anonymous Anonymous said...

The only thing I can agree with is that alties actually take the time to study a person's lifestyle, which is a known precursor to disease. So by helping people manage their lives more effectively, I think alties are way more on target than docs. For instance, why bother treating someone with diabetes if you're not going to say boo to them about how to eat better? I'm sick of the conventional doc who hands me a crappy one-page sheet on the diabetes diet, and says, "Good luck." I think alties do a better of job of being in touch with people, which is why a lot of patients like alties.

 

At 10/06/2005 1:26 AM, Anonymous HCN said...

If you have diabetes and you think the one sheet of information is insufficient... change doctors. Try a different kind, like a family doc.

Also, try actually reading the whole sheet. It may have references for more information. If it did not, check out the links that are available at www.medlineplus.gov .

I have high cholestoral... and yes, I did get a one sheet outline of suggestions. BUT... I also got an explanation of what the numbers meant, what to work on and an acknowledgment that life is unfair when my cheese/sausage/butter eating Dutch hubby has ridiculously low cholestoral.

You and I have to do similar things for our health: eat better, lose weight and exercise regularly (I swim 2 to 4 miles per week... it takes me about an hour per mile, slow but sure, I still get in the laps).

 

At 10/06/2005 5:38 PM, Anonymous HCN said...

Dear Anon:

I was browsing around the county's public health news page and found this link that might interest you:
http://www.metrokc.gov/health/reach/diabetes.htm

 

At 10/11/2005 10:40 AM, Anonymous Anonymous said...

While I don't agree that my chiropractor can cure all sorts of diseases with spinal adjustments, I can say that chiros CAN and DO offer relief for pinched nerves in my neck, doing that through spinal manipulation. "Conventional" medicine only offered drugs--pain meds & muscle relaxers--which of course did nothing to alleviate the cause of the pain.

As my grandfather used to say, "If doctors are so smart, why do *they* die?"

Garry K

 

At 10/15/2005 10:23 PM, Anonymous Anonymous said...

just to let everyone know, Chemo does make you feel like shit.

Thats how i found this page actually, trying to find ways of making myself feel better... nrly over, only 3 months left.

 

At 10/16/2005 2:35 PM, Blogger Orac said...

Oh, I'm quite aware that chemo makes patients feel crappy.

One of the hottest areas of research is how to identify more precisely patients who are and are not likely to benefit from chemotherapy, so that today's shotgun approach is no longer necessary.

The other hot area is coming up with chemotherapy regimens that are effective but don't have as nasty side effects.

 

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