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...