MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

bogus claims

A cognitive bias known as the Dunning-Kruger Effect has, I think, considerable relevance in alternative medicine. The effect means that, the less you know, the less able you are to recognize how little you know, and the less likely you are to recognize your limitations. Consequently, your confidence in yourself is inflated and you believe you are more competent than your opponent. Expressed differently:

  • Incompetence prevents the recognition of incompetence.
  • Too stupid to doubt.

Even though the phenomenon of illusory superiority is today attributed to David Dunning and Justin Kruger, many others before them have alluded to the phenomenon:

Image result for dunning kruger effect

The relevance of the Dunning Kruger Effect to alternative medicine seems obvious, I think. Here we are confronted with all sorts of practitioners who believe they know it all, can treat any condition, alleviate the ‘root cause’ of all ills, etc., etc. Many of my previous posts on this blog have dealt with aspects of this problem. And with unfailing regularity, the discussions brought some individuals badly affected by the Dunning-Kruger Effect to the fore. Typically, they go on and on and on… consumed by their inflated confidence and trapped by their incompetence to realise their incompetence. And typically, they find an audience who is gullible enough to applaud them.

They often remind me of a cartoon I once saw:

The little graph below explains it all quite neatly:

Image result for dunning kruger effect

The novice lacks knowledge but, as he acquires a modicum of (pseudo-)knowledge, he gets a boost of confidence. An experienced person has enough knowledge to know that he knows very little; therefore his confidence is relatively low. When experience and knowledge combine to become wisdom, confidence grows and we might be talking to a real expert. Oddly, in terms of confidence, the novice can score higher than even the wisest expert.

To some extent, this simple graph even explains the popularity of many forms of quackery: they are being promoted by people who know very little but are bursting with confidence. And it is this high level of confidence that tends to impress the gullible public who then eagerly adopt the quackery.

Where the graph is somewhat misleading, I think, is where it might give the impression that there is an automatic and necessary transition from novice to expert (from left to right on the X-axis). In many individuals, this development does occur but, sadly, in many others it does not. The evangelical believers in alternative medicine, I fear, usually belong to the latter, sad category.

If I am correct, the Dunning Kruger Effect can therefore partly explain 1) the inflated confidence of proponents of alternative medicine, as well as 2) the current popularity of quackery.

Recently, I was asked about the ‘Dorn Method’. In alternative medicine, it sometimes seems that everyone who manages to write his family name correctly has inaugurated his very own therapy. It is therefore a tall order to aim at blogging about them all. But that’s been my goal all along, and after more than 1 000 posts, I am still far from achieving it.

So, what is the Dorn Method?

A website dedicated to it provides some first-hand information. Here are a few extracts (numbers in brackets were inserted by me and refer to my comments below):

START OF QUOTE

Developed by Dieter Dorn in the 1970’s in the South of Germany, it is now fast becoming the widest used therapy for Back Pain and many Spinal Disorders in Germany (1).

The Dorn Method ist presented under different names like Dornmethod, Dorntherapy, Dorn Spinal Therapy, Dorn-Breuss Method, Dorn-XXname-method and (should) have as ‘core’ the same basic principles.

There are many supporters of the Dorn Method (2) but also Critics (see: Dorn controversy) and because it is a free (3) Method and therefore not bound to clear defined rules and regulations, this issue will not change so quickly.

The Method is featured in numerous books and medical expositions (4), taught to medical students in some universities (5), covered by most private medical insurances (6) and more and more recognized in general (7).

However because it is fairly new and not developed by a Medical Professional it is often still considered an alternative Healing Method and it is meant to stay FREE of becoming a registered trademark, following the wish of the Founder Dieter Dorn (†2011) who did NOT execute his sole right to register this Method as the founder, this Method must become socalled Folk Medicine.

As of now only licensed Therapists, Non Medical Practitioners (in Germany called Heilpraktiker (Healing Practitioners with Government recognition) (8), Physical Therapists or Medical Doctors are authorized to practice with government license, but luckily the Dorn Method is mainly a True Self Help Method therefore all other Dorn Method Practitioners can legally help others by sharing it in this way (9).

What conditions can be treated with the Dorn Method? Every disease, even up to the psychological domain can be treated (positively influenced) unless an illness had already led to irreversible damages at organs (10). The main areas of application are: Muscle-Skeletal Disorders (incl. Back Pain, Sciatica, Scoliosis, Joint-Pain, Muscular Tensions, Migraines etc.)

END OF QUOTE

My brief comments:

  1. This is a gross exaggeration.
  2. Clearly another exaggeration.
  3. Not ‘free’ in the sense of costing nothing, surely!
  4. Yet another exaggeration.
  5. I very much doubt that.
  6. I also have difficulties believing this statement.
  7. I see no evidence for this.
  8. We have repeatedly discussed the Heilpraktiker on this blog, see for instance here, here and here.
  9. Sorry, but I fail to understand the meaning of this statement.
  10. I am always sceptical of claims of this nature.

By now, we all are keen to know what evidence there might be to suggest that the Dorn Method works. The website of the Dorn Method claims that there are 4 different strands of evidence:

START OF QUOTE

1. A new form of manual therapy and self help method which is basically unknown in conventional medicine until now, with absolutely revolutionary new knowledge. It concerns for example the manual adjustment of a difference in length of legs as a consequence of a combination of subluxation of the hip-joint (subluxation=partly luxated=misaligned) and a subluxation of the joints of sacrum (Ilio-sacral joint) and possible knee and ankle joints. The longer leg is considered the ‘problem’-leg and Not the shorter leg as believed in classical medicine and chiropractic.

2. The osteopathic knowledge that there is a connection of each vertebra and its appropriate  spinal segment to certain inner organs. That means that when there are damages at these structures, disturbances of organic functions are the consequence, which again are the base for the arising of diseases.

3. The knowledge of the Chinese medicine, especially of acupuncture and meridian science that the organic functions are stirred and leveled, also among each other, via the vegetative nervous system

4. The natural-scientific  knowledge of anatomy, physiology, physics, chemistry and other domains.

END OF QUOTE

One does not need to be a master in critical thinking to realise that these 4 strands amount to precisely NOTHING in terms of evidence for the Dorn Method. I therefore conducted several searches and have to report that, to the best of my knowledge, there is not a jot of evidence to suggest that the Dorm Method is more than hocus-pocus.

In case you wonder what actually happens when a patient – unaware of this lack of evidence – consults a clinician using the Dorn Method, the above website provides us with some interesting details:

START OF QUOTE

First the patients leg length is controlled and if necessary corrected in a laying position. The hip joint is brought to a (more or less) 90 degree position and the leg is then brought back to its straight position while guiding the bones back into its original place with gentle pressure.

picture link to dorn therapy pictures

This can be done by the patient and it is absolutely safe, easy and painless!

The treatment of Knees and Ankles should then follow with the same principals: Gentle pressure towards the Joint while moving it from a bended to a more straight position.

After the legs the pelvis is checked for misalignment and also corrected if necessary in standing position.

Followed by the lumbar vertebrae and lower thoracic columns, also while standing upright.

Then the upper thoracic vertebrae are checked, corrected if necessary, and finally the cervical vertebrae, usually in a sitting position.

The treatment often is continued by the controlling and correction of other joints like the shoulders, elbow, hands and others like the jaw or collarbone.

END OF QUOTE

Even if we disregard the poor English used throughout the text, we cannot possibly escape the conclusion that the Dorn Method is pure nonsense. So, why do some practitioners practice it?

The answer to this question is, of course, simple: There is money in it!

“Average fees for Dorn Therapy sessions range from about 40€ to 100€ or more…  Average fees for Dorn Method Seminars range from about 180€ to 400€ in most developed countries for a two day basic or review or advanced training.”

SAY NO MORE!

 

 

 

This announcement caught my eye:

START OF 1st QUOTE

Dr Patrick Vickers of the Northern Baja Gerson Centre, Mexico will deliver a two hour riveting lecture of ‘The American Experience of Dr Max Gerson, M.D.’

The lecture will present the indisputable science supporting the Gerson Therapy and its ability to reverse advanced disease.

Dr Vickers will explain the history and the politics of both medical and governmental authorities and their relentless attempts to surpress this information, keeping it from the world.

‘Dr Max Gerson, Censored for Curing Cancer’

“I see in Dr Max Gerson, one of the most eminent geniuses in medical history” Nobel Prize Laureate, Dr Albert Schweitzer.

END OF 1st QUOTE

Who is this man, Dr Patrik Vickers, I asked myself. And soon I found a CV in his own words:

START OF 2nd QUOTE

Dr. Patrick Vickers is the Director and Founder of the Northern Baja Gerson Clinic. His mission is to provide patients with the highest quality and standard of care available in the world today for the treatment of advanced (and non-advanced) degenerative disease. His dedication and commitment to the development of advanced protocols has led to the realization of exponentially greater results in healing disease. Dr. Vickers, along with his highly trained staff, provides patients with the education, support, and resources to achieve optimal health.

Dr. Patrick was born and raised outside of Milwaukee, Wisconsin. At the age of 11 years old, after witnessing a miraculous recovery from a chiropractic adjustment, Dr. Patrick’s passion for natural medicine was born.

Giving up careers in professional golf and entertainment, Dr. Patrick obtained his undergraduate degrees from the University of Wisconsin-Madison and Life University before going on to receive his doctorate in Chiropractic from New York Chiropractic College in 1997.

While a student at New York Chiropractic College(NYCC), Dr. Patrick befriended Charlotte Gerson, the last living daughter of Dr. Max Gerson, M.D. who Nobel Peace Prize Winner, Dr. Albert Schweitzer called, ” One of the most eminent geniuses in medical history. “

Dr. Gerson, murdered in 1959, remains the most censured doctor in the history of medicine as he was reversing virtually every degenerative disease known to man, including TERMINAL cancer…

END OF 2nd QUOTE

I have to admit, I find all this quite upsetting!

Not because the ticket for the lecture costs just over £27.

Not because exploitation of vulnerable patients by quacks always annoys me.

Not even because the announcement is probably unlawful, according to the UK ‘cancer act’.

I find it upsetting because there is simply no good evidence that the Gerson therapy does anything to cancer patients other than making them die earlier, poorer and more miserable (the fact that Prince Charles is a fan makes it only worse). And I do not believe that the lecture will present indisputable evidence to the contrary – lectures almost never do. Evidence has to be presented in peer-reviewed publications, independently confirmed and scrutinised. And, as far as I can see, Vickers has not authored a single peer-reviewed article [however, he thrives on anecdotal stories via youtube (worth watching, if you want to hear pure BS)].

But mostly I find it upsetting because it is almost inevitable that some desperate cancer patients will believe ‘Dr’ Vickers. And if they do, they will have to pay a very high price.

This survey assessed chiropractic (DC) and naturopathic “doctors”‘ (ND) knowledge, attitudes, and behaviour with respect to the pediatric patients in their practice. Cross-sectional surveys were developed in collaboration with DC and ND educators. Surveys were sent to randomly selected DCs and NDs in Ontario, Canada in 2004, and a national online survey was conducted in 2014. Data were analyzed using descriptive statistics, t-tests, non-parametric tests, and linear regression.

Response rates for DCs were n = 172 (34%) in 2004, n = 553 (15.5%) in 2014, and for NDs, n = 171 (36%) in 2004, n = 162 (7%) in 2014. In 2014, 366 (78.4%) of DCs and 83 (61%) of NDs saw one or more paediatric patients per week. Paediatric training was rated as inadequate by most respondents in both 2004 and 2014, with most respondents (n = 643, 89.9%) seeking post-graduate training by 2014. About half of DCs (51.7% in 2004, 49.2% in 2014) and one fifth of NDs (21% in 2004 and 23% in 2014) reported they received no hands-on clinical paediatric training. Only a minority of practitioners felt their hands-on paediatric training was adequate (somewhat or very) for their needs: DCs: 10.6% in 2004, 15.6% in 2014; NDs: 10% in 2004 and 19% in 2014. Respondents’ comfort in treating children and youth is based on experience and post-graduate training. Both DCs and NDs that see children and youth in their practices address a broad array of paediatric health concerns, from well child care and preventative health, to mild and serious illness.

The authors included two ‘case studies’ of conditions frequently treated by DCs and NDs:

Case study 1: colic

DC practitioners’ primary treatment focus (314 respondents) would be to use spinal manipulation (78.3%) if physical assessment suggests utility, diet changes (14.6% for child, 6.1% for mom if breast feeding), and massage (16.9%). ND practitioners (95 respondents) would assess and treat primarily with diet changes (62% for child including prescribing probiotics; 48% for mom if breast feeding), homeopathy (46%), weak herbal or tea preparations (19%), and use topical castor oil (packs or massage) (18%). In 2014, 65.9% of DCs and 59% of NDs believe (somewhat or very much) that concurrent treatment by a medical practitioner would be of benefit; 64.0% of DCs and 60% of NDs would refer the patient to another health care practitioner (practitioner type not specified).

Case study 2: acute otitis media

In 2014, almost all practitioners identified this as otitis media (in 2004, the DCs had a profession-specific question); DCs were more cautious about the value of their care for it relative to the NDs (DCs, 46.2% care will help patient very much, NDs, 95%). For treatment, DCs would primarily use spinal manipulation (98.5%) if indicated after assessment, massage (19.5%), dietary modifications (17.6%), and 3.8% would specifically refer to an MD for an antibiotic prescription. ND-preferred treatments were NHP products (79%), dietary modifications (66%), ear drops (60%), homeopathic remedies (18%), and 10% would prescribe antibiotics right away or after a few days. In 2014, 86.3% of DCs and 75% of NDs believe the patient would benefit (somewhat or very much) from concurrent treatment by a conventional medical practitioner; 81.7% of DCs and 58% of NDs would refer the patient to another health care provider.

The authors concluded that although the response rate in 2014 is low, the concerns identified a decade earlier remain. The majority of responding DCs and NDs see infants, children, and youth for a variety of health conditions and issues, but self-assess their undergraduate paediatric training as inadequate. We encourage augmented paediatric educational content be included as core curriculum for DCs and NDs and suggest collaboration with institutions/organizations with expertise in paediatric education to facilitate curriculum development, especially in areas that affect patient safety.

I find these data positively scary:

  • Despite calling themselves ‘doctors’, they are nothing of the sort.
  • DCs and NCs are not adequately educated or trained to treat children.
  • They nevertheless often do so, presumably because this constitutes a significant part of their income.
  • Even if they felt confident to be adequately trained, we need to remember that their therapeutic repertoire is wholly useless for treating sick children effectively and responsibly.
  • Therefore, harm to children is almost inevitable.
  • To this, we must add the risk of incompetent advice from CDs and NDs – just think of immunisations.

The only conclusion I can draw is this: chiropractors and naturopaths should keep their hands off our kids!

This is the title of an editorial by Alan Schmukler. You probably remember him; I have featured him before, for instance here, here, and here. This is what was recently on Schmukler’s mind (I have added a few references referring to comments of mine added below):

England’s National Health Service (NHS) is proposing that NHS doctors no longer be permitted to prescribe homeopathic remedies [1]… They claim lack of evidence for effectiveness. Anyone who’s been remotely conscious the last 10 years will see this as a pretext. Homeopathy is practiced by board certified physicians in clinics and hospitals around the world [2]. The massive Swiss review of homeopathy, found it effective, safe and economical, and the Swiss incorporated homeopathy into their national health care system [3]…

The reason given for banning homeopathy and these nutrients is a lie. Why would the NHS ban safe, effective and affordable healing methods? [4] Without these methods, all that is left are prescription drugs. Apparently, someone at the  NHS has an interest in pushing expensive prescription drugs [5], rather than safer and cheaper alternatives. That someone, also wishes to deny people freedom of choice in medicine [6]. I say “someone”, because organizations don’t make decisions, people do. Who is that someone?  In looking for a suspect, we might ask, who is the chief executive of the organization? Who introduced this plan and is promoting it? Who at the NHS has the political clout?  Who was it that recently declared: “Homeopathy is a placebo and a misuse of scarce NHS funds which could better be devoted to treatments that work”.

The quote is from Simon Stevens, NHS England’s chief executive. He got the job in 2014, after ten years as a top executive at UnitedHealth, the largest health insurance company in America. His past work experiences and current activities show that he favors privatization [7]. That would make him an odd choice to run a healthcare system based on socialized medicine. In fact, he has been moving the NHS towards privatization and the corporate, profit based American model. [8] The last thing a privatizer in healthcare would want, are non-proprietary medicines, for which you can’t charge exorbitant fees [9]. Banning homeopathy on the NHS is just one small part of a larger plan to maximize corporate profits by letting corporations own and control the health care system [10].  Before they can do this, they have to eliminate alternative methods of treatment.

Personally, I think Schmukler is wrong – here is why:

1 The current argument is not about what doctors are permitted to do, but about what the NHS should do with our tax money.

2 Argumentum ad populum

3 Oh dear! Anyone who uses this report as evidence must be desperate – see for instance here.

4 Why indeed? Except highly dilute homeopathic remedies are pure placebos.

5 Maybe ‘someone’ merely wants to use effective medications rather than placebos.

6 Freedom of choice is a nonsense, if it is not guided by sound evidence – see here.

7 No, that’s Jeremy Hunt! But in any case privatisation might be more profitable with homeopathy – much higher profit margins without any investment into R&D.

8 No, this is Hunt again!

9 Homeopathic remedies are ideal for making vast profits: no research, no development, no cost for raw material, etc., etc.

10 I am sure Boiron et al would not mind stepping into the gap.

I very much look forward to the next outburst of Alan Schmukler and hope he will manage to think a bit clearer by then.

We have discussed the NHMRC report on homeopathy several times – see, for instance, here, here and here. Perhaps understandably, homeopaths have great difficulties accepting its negative findings, and have complained about it ever since it was published. Now, a very detailed and well-researched analysis has become available of both the report and its criticism. Here I take the liberty to copy and (clumsily) translate its conclusions; if you can read German, I highly recommend studying the full document.

START OF MY TRANSLATION

The criticism of the NHMRC review is very voluminous and highlights many different aspects of the background, the methodology, the execution and the unwanted results from a homeopathic perspective. The very engaging discussions in the general public about this document and its flaws are, however, relatively meaningless: the NHMRC arrives at exactly the same conclusions as the employee of the Homeopathic Research Institute (HRI), Mathie, in his reviews of 2014 and 2017.

In both reviews, Mathie evaluated a total of 107 primary studies and found only 2 trials that could be rated as qualitatively good, that is to say constituting reliable evidence. Mathie did upgrade 2 further studies to the category of reliable evidence, however, this was in violation of the procedures proscribed in the study protocol.

The criticism of the NHMRC review was not able to make a single valid rebuttal. No condition could be identified for which homeopathy is clearly superior to placebo. This is all the more important, as Mathie avoided the mistakes that constituted the most prominent alleged criticisms of the NHMRC report.

  • Since Mathie and most of his co-authors are affiliated with organisations of homeopathy, an anti-homeopathy bias can be excluded.
  • Mathie conducted classic reviews and even differentiated between individualised and non-individualised homeopathy.
  • Mathie did not exclude studies below a certain sample size.

Yet, in both reviews, he draws the same conclusion.

In view of the truly independent replications of an employee of the HRI, we can be sure that there are, in fact, no solid proofs for the effectiveness of homeopathy. The claim of a  strong efficacy, equivalent to conventional medicines, that is made by homeopathy’s advocates is therefore not true.

END OF MY TRANSLATION

And here is the original German text:

Die Kritik an dem Review des NHMRC ist sehr umfangreich und beleuchtet sehr viele verschiedene Facetten über das Umfeld, die Methodik und die Durchführung sowie das aus Sicht der Homöopathen unerwünschte Ergebnis selbst. Die in der Öffentlichkeit sehr engagierte Diskussion um diese Arbeit und ihre möglichen Unzulänglichkeiten sind jedoch relativ bedeutungslos: Das NHMRC kommt zu genau dem gleichen Ergebnis wie Mathie als Mitarbeiter des HRI in seinen in 2014 und 2017 veröffentlichten systematischen Reviews:

Insgesamt hat Mathie in beiden Reviews 107 Einzelstudien untersucht und fand nur zwei Studien, die als qualitativ gut („low risk of bias“), also als zuverlässige Evidenz betrachtet werden können. Mathie hat zwar vier weitere Studien zur zuverlässigen Evidenz aufgewertet, was allerdings im Widerspruch zu den üblichen Vorgehensweisen steht und im Studienprotokoll nicht vorgesehen war.

Die Kritik am Review des NHMRC hat keinen einzigen Punkt fundiert widerlegen können. Man konnte keine Indikation finden, bei der sich die Homöopathie als klar über Placebo hinaus wirksam erwiesen hätte. Diese Punkte sind umso bedeutsamer, weil Mathie die am NHMRC hauptsächlich kritisierten Fehler nicht gemacht hat:

  • Als Mitarbeiter des HRI und mit Autoren, die überwiegend für Homöopathie-affine Organisationen arbeiten, ist eine Voreingenommenheit gegen die Homöopathie auszuschließen.
  • Mathie hat klassische Reviews ausgeführt, sogar getrennt zwischen einzelnen Ausprägungen (individualisierte Homöopathie und nicht-individualisierte Homöopathie).
  • Mathie hat keine Größenbeschränkung der Studien berücksichtigt.

Er kommt aber dennoch zweimal zum gleichen Ergebnis wie das NHMRC.

Angesichts der wirklich als unabhängig anzusehenden Bestätigung der Ergebnisse des NHMRC durch einen Mitarbeiter des Homeopathy Research Institute kann man sicher davon ausgehen, dass es tatsächlich keine belastbaren Wirkungsnachweise für die Homöopathie gibt und dass die von ihren Anhängern behauptete starke, der konventionellen Medizin gleichwertige oder gar überlegene Wirksamkeit der Homöopathie nicht gegeben ist.

I do apologise for my clumsy translation and once again encourage those who can to study the detailed original in full.

My conclusion of this (and indeed of virtually all criticism of homeopathy) is that homeopaths are just as unable to accept criticism as an evangelic believer is going to accept any rational argument against his belief. In other words, regardless of how convincing the evidence, homeopaths will always dismiss it – or, to put it in a nutshell: HOMEOPATHY IS A CULT.

The title of this post is a statement recently made in an article by Mike Adams in ‘Alternative Medicine News’:

The cancer industry goes to great lengths to deny patients access to any information that they might use to prevent, treat or cure cancer without requiring expensive (and highly toxic) medical interventions. That’s what makes the BMJ documentation of this curcumin cancer cure so astonishing: In years past, the BMJ never would have even tolerated the publishing of such a scientific assessment. So what changed? In truth, the evidence of natural cures for cancer is now so overwhelming that even the BMJ cannot remain in a state of denial without appearing to be hopelessly out of touch with scientific reality.

The story is based on one single patient who apparently was cured of cancer using curcumin (turmeric). The case was also recently (3/1/18) featured on BBC’s ‘YOU AND YOURS’ (http://www.bbc.co.uk/programmes/b09k0ng7) in a similarly uncritical way: no expert was asked to provide an evidence-based assessment and bring some reason into the discussion. Even the DAILY FAIL reported about the story, and predictably, critical assessment had to make way for sensationalism.

So what?

We hear about such nonsense almost every day!

True, but this case is different; it is based on a publication in the highly-respected BMJ (well, actually, it was the ‘BMJ CASE REPORTS’ and not the BMJ, as reported). Here is the article:

START OF QUOTE

A woman aged 57 years was initially diagnosed with monoclonal gammopathy of undetermined significance (MGUS) in 2007 following an incidental finding of M-protein (18 g/L) during investigation for hypertension.

Within 15 months, the patient had rapidly progressed to ISS stage 3 myeloma with M-protein 49 g/L, urinary protein 1.3 g/24-hour, Bence-Jones protein 1.0 g/24-hour, Hb 9.7 g/dL and increasing back pain. She initially declined antimyeloma treatment but 6 months later, following vertebral collapse at T5 and T12, started cyclophosphamide, thalidomide and dexamethasone (CTD) treatment. However, after a week, the patient was admitted with idiosyncratic syndrome including hyponatraemia, a fall in albumin and worsening of blood counts. She received red cell transfusion and her electrolyte abnormalities were carefully corrected.

Although there was evidence of a response to CTD (M-protein 34 g/L), bortezomib and dexamethasone treatment was initiated as an alternative, but this was discontinued after three cycles due to progressive disease (M-protein 49 g/L). The patient was then treated with lenalidomide and dexamethasone with the aim of reducing disease burden prior to high-dose therapy and autologous stem cell transplantation. Treatment was frequently interrupted and dose adjusted to account for neutropenia and despite a minor response after six cycles (starting M-protein 47 g/L, finishing M-protein 34 g/L), in October 2009, she proceeded with stem cell mobilisation. However, neither cyclophosphamide nor plerixafor/GCSF priming were successful. A bone marrow biopsy revealed 50% myeloma cells and a course of CTD was restarted with cautious titration of thalidomide.

The patient achieved a partial response with CTD retreatment over the course of 17 cycles (M-protein 13 g/L) with no further episodes of idiosyncratic syndrome. However, attempts to harvest stem cells in February 2011 and again there months later, both failed. By then, her M-protein had risen to 24 g/L and the patient was too neutropenic to be considered for a clinical trial.

At this point, the patient began a daily regime of oral curcumin complexed with bioperine (to aid absorption), as a single dose of 8 g each evening on an empty stomach. A few months later, she also embarked on a once-weekly course of hyperbaric oxygen therapy (90 min at 2 ATA) which she has maintained ever since. Her paraprotein levels gradually declined to a nadir of 13 g/L, her blood counts steadily improved and there was no evidence of further progressive lytic bone disease.

Outcome and follow-up

The patient continues to take oral curcumin 8 g daily without further antimyeloma treatment. Over the last 60 months, her myeloma has remained stable with minimal fluctuation in paraprotein level, her blood counts lie within the normal range and she has maintained good quality of life throughout this period. Repeat bone imaging in 2014 identified multiple lucencies <1 cm in the right hip and degenerative changes in both hips, but these were attributed to osteoarthritis rather than the myeloma. Recent cytogenetic analysis revealed she had no abnormal cytogenetics by fluorescent in situ hybridisation.

Discussion

A small but significant number of myeloma patients consume dietary supplements in conjunction with conventional treatment primarily to help cope with the side effects of treatment, manage symptoms and enhance general well-being. Few, if any, use dietary supplementation as an alternative to standard antimyeloma therapy. Here, we describe a case in which curcumin has maintained long-term disease control in a multiply-relapsed myeloma patient. To the best of our knowledge, this is the first report in which curcumin has demonstrated an objective response in progressive disease in the absence of conventional treatment.

Curcumin is a polyphenol derived from the perennial herb Curcuma longa (turmeric) and has, for centuries, been used as a traditional Indian medicine. Several reports published over the two decades have claimed various health benefits of curcumin and this has led to its increasing popularity as a dietary supplement to prevent or treat a number of different diseases.

The biological activity of curcumin is indeed remarkable. It is a highly pleiotropic molecule which possesses natural antioxidant, anti-inflammatory, antiseptic and analgesic properties. More recently, it has demonstrated antiproliferative effects in a wide variety of tumour cells including myeloma cells and exerts its antiproliferative effects through multiple cellular targets that regulate cell growth and survival.

In vitro, curcumin prevents myeloma cell proliferation through inhibition of IL-6-induced STAT-3 phosphorylation and through modulation of the expression of NF-kB-associated proteins such as IkB〈,Bcl-2, Bcl-xL, cyclin D1 and IL-6 and apoptosis-related molecules including p53 and Bax. In other studies, curcumin was shown to circumvent resistance to dexamethasone, doxorubicin and melphalan as well as potentiate the effects of bortezomib, thalidomide and lenalidomide. Furthermore, curcumin-induced cell death was not influenced by myeloma molecular heterogeneity.

The antimyeloma effects of curcumin in the clinical setting however are less clear. Only one phase I/II study has evaluated curcumin treatment in myeloma patients. These patients were either asymptomatic, relapsed or had plateau phase disease. Treatment with curcumin downregulated the expression of NFkB, COX-2 and STAT3 in peripheral blood mononuclear cells, but no objective responses were observed in any subgroup of patients. This may be as a result of small sample size in this study, follow-up was limited to 3 months and clinical responses may have been observed with longer follow-up. However, downregulation of NFkB, COX-2 and STAT3 expression may not correlate with the clinical activity of curcumin and there may be further mechanisms of action that remain unclear, possibly through the modulation of another target. We would not be able to identify any patient-specific mechanisms of activity in this case study, as the patient has been taking curcumin for some time now and baseline bone marrow or peripheral blood samples are not available. However, in the setting of a clinical trial, it may be possible to use next-generation sequencing to help identify a mutation that may be a potential target for curcumin.

Another study examined its effects in preventing the progression of MGUS and smouldering myeloma to myeloma. The results showed that curcumin exerted a trace of biological activity with modest decreases in free light chain and paraprotein levels and a reduction in a marker of bone resorption with curcumin treatment, suggesting the therapeutic potential of curcumin in MGUS and smouldering myeloma. However, more studies are needed to address this further.

Whether such effects are observed in patients with active disease remains to be seen. The fact that our patient, who had advanced stage disease and was effectively salvaged while exclusively on curcumin, suggests a potential antimyeloma effect of curcumin. She continues to take daily curcumin and remains in a very satisfactory condition with good quality of life. This case provides further evidence of the potential benefit for curcumin in myeloma. We would recommend further evaluation of curcumin in myeloma patients in the context of a clinical trial.

END OF QUOTE

What should we make of this?

I think that much of the reporting around the story was grossly irresponsible. It is simply not possible to conclude that curcumin was the cause of the remission. It could be due to a whole host of other factors. And a case report is just an anecdote; it never can prove anything and can only be used to stimulate further research.

I fully agree with the authors of the case report: curcumin seems worthy of further investigation. But recommending it to patients for self-medication is vastly premature and quite simply dangerous, unethical and naïve bordering on stupid.

And, of course, the above-cited drivel of Mike Adams is just beyond the pale – the evidence for ‘alternative cancer cures‘ is very, very far from ‘overwhelming’; and the ‘cancer industry’ is doing what they can to determine whether turmeric or any other natural remedy can be used to treat cancer and other diseases.

If they are ever successful, the Adams of this world will shout ‘EXPLOITATION!!!’

If their endeavours are not successful, they will complain ‘CONSPIRACY!!!’

Yesterday, I heard my ‘good friend’ Dr Michael Dixon (see here, here and here, for example) talk on the BBC about the “new thing” in healthcare: social prescribing. He explained, for instance, that social prescribing could mean treating a diabetic not with medication but with auto-hypnosis and other alternative therapies. At that moment, I wasn’t even entirely sure what the term ‘social prescribing’ meant, I have to admit – so I did some reading.

What is social prescribing?

The UK ‘Social Prescribing Network‘ defines it thus:

Social Prescribing is a means of enabling GPs and other frontline healthcare professionals to refer patients to a link worker – to provide them with a face to face conversation during which they can learn about the possibilities and design their own personalised solutions, i.e. ‘co-produce’ their ‘social prescription’- so that people with social, emotional or practical needs are empowered to find solutions which will improve their health and wellbeing, often using services provided by the voluntary and community sector. It is an innovative and growing movement, with the potential to reduce the financial burden on the NHS and particularly on primary care.

Does social prescribing work?

The UK King’s Fund is mildly optimistic:

There is emerging evidence that social prescribing can lead to a range of positive health and well-being outcomes. Studies have pointed to improvements in areas such as quality of life and emotional wellbeing, mental and general wellbeing, and levels of depression and anxiety. For example, a study into a social prescribing project in Bristol found improvements in anxiety levels and in feelings about general health and quality of life. In general, social prescribing schemes appear to result in high levels of satisfaction from participants, primary care professionals and commissioners.

Social prescribing schemes may also lead to a reduction in the use of NHS services. A study of a scheme in Rotherham (a liaison service helping patients access support from more than 20 voluntary and community sector organisations), showed that for more than 8 in 10 patients referred to the scheme who were followed up three to four months later, there were reductions in NHS use in terms of accident and emergency (A&E) attendance, outpatient appointments and inpatient admissions. The Bristol study also showed reductions in general practice attendance rates for most people who had received the social prescription.

However, robust and systematic evidence on the effectiveness of social prescribing is very limited. Many studies are small scale, do not have a control group, focus on progress rather than outcomes, or relate to individual interventions rather than the social prescribing model. Much of the evidence available is qualitative, and relies on self-reported outcomes. Researchers have also highlighted the challenges of measuring the outcomes of complex interventions, or making meaningful comparisons between very different schemes.

Determining the cost, resource implications and cost effectiveness of social prescribing is particularly difficult. The Bristol study found that positive health and wellbeing outcomes came at a higher cost than routine GP care over the period of a year, but other research has highlighted the importance of looking at cost effectiveness over a longer period of time. Exploratory economic analysis of the Rotherham scheme, for example, suggested that the scheme could pay for itself over 18–24 months in terms of reduced NHS use….

END OF QUOTES

Is there no harder evidence at all?

The only Medline-listed controlled study seems to have been omitted by the King’s Fund – I wonder why. Perhaps because it fails to share the optimism? Here is its abstract:

Social prescribing is targeted at isolated and lonely patients. Practitioners and patients jointly develop bespoke well-being plans to promote social integration and or social reactivation. Our aim was to investigate: whether a social prescribing service could be implemented in a general practice (GP) setting and to evaluate its effect on well-being and primary care resource use. We used a mixed method evaluation approach using patient surveys with matched control groups and a qualitative interview study. The study was conducted in a mixed socio-economic, multi-ethnic, inner city London borough with socially isolated patients who frequently visited their GP. The intervention was implemented by ‘social prescribing coordinators’. Outcomes of interest were psychological and social well-being and health care resource use. At 8 months follow-up there were no differences between patients referred to social prescribing and the controls for general health, depression, anxiety and ‘positive and active engagement in life’. Social prescribing patients had high GP consultation rates, which fell in the year following referral. The qualitative study indicated that most patients had a positive experience with social prescribing but the service was not utilised to its full extent. Changes in general health and well-being following referral were very limited and comprehensive implementation was difficult to optimise. Although GP consultation rates fell, these may have reflected regression to the mean rather than changes related to the intervention. Whether social prescribing can contribute to the health of a nation for social and psychological wellbeing is still to be determined.

So, there is a lack of evidence for social prescribing. Yet, this is not why I feel uneasy about the promotion of this “new thing”. The more i think about it, the more I realise that social prescribing is just good care and decent medicine. It is what I was taught at med school 40 years ago. It therefore seems like a fancy name for something that should be obvious.

But why my unease?

The way I see it, it will be (and perhaps already is) used to smuggle bogus alternative therapies into the mainstream. In this way, it could turn out to serve the same purpose as did the boom in integrative/integrated medicine/healthcare: a smokescreen to incorporate treatments into medical routine which otherwise would not pass muster. If advocates of this approach, like Michael Dixon, subscribe to it, the danger of this happening is hard to deny.

The disservice to patients (and medical ethics) would then be obvious: diabetics unquestionably can benefit from a change of life-style (and to encourage them is part of good conventional medicine), but I very much doubt that they should replace their anti-diabetic medications with auto-hypnosis or other alternative therapies.

We should not have to repeat this! But, as it is currently topical and certainly true, let me tell you again:

DETOX IS BUNK!

After the season of gluttony, it seems that half the population has fallen victim to the legion of alternative practitioners and entrepreneurs who claim that their particular form of quackery is ideally suited for detoxifying the body – and, sure enough, rid their clients of money instead of poisons. I have pointed out again and again why detox, as promoted in alternative medicine. is bogus and occasionally even harmful – see for instance here, here and here. And years ago, I published a review of the evidence on ‘alternative detox’ (AD); it concluded that “the principles of AD make no sense from a scientific perspective and there is no clinical evidence to support them. The promotion of AD treatments provides income for some entrepreneurs but has the potential to cause harm to patients and consumers. In alternative medicine, simplistic but incorrect concepts such as AD abound. All therapeutic claims should be scientifically tested before being advertised-and AD cannot be an exception.”

But I have, of course, many readers who do not trust a word I am putting on paper. So, please don’t take it from me, take it from others; read for example this recent article: 

Detox diets are popular dieting strategies that claim to facilitate toxin elimination and weight loss, thereby promoting health and well-being. The present review examines whether detox diets are necessary, what they involve, whether they are effective and whether they present any dangers. Although the detox industry is booming, there is very little clinical evidence to support the use of these diets. A handful of clinical studies have shown that commercial detox diets enhance liver detoxification and eliminate persistent organic pollutants from the body, although these studies are hampered by flawed methodologies and small sample sizes. There is preliminary evidence to suggest that certain foods such as coriander, nori and olestra have detoxification properties, although the majority of these studies have been performed in animals. To the best of our knowledge, no randomised controlled trials have been conducted to assess the effectiveness of commercial detox diets in humans. This is an area that deserves attention so that consumers can be informed of the potential benefits and risks of detox programmes.

To the best of our knowledge, no randomised controlled trials have been conducted to assess the effectiveness of commercial detox diets in humans. I think that says enough; and it applies not just to detox diets, it applies to all detox methods promoted in alternative medicine.

DETOX IS BUNK!

Save your hard-earned money for stuff that is proven to work.

How often have we heard the claim from proponents of alternative medicine that one strength of their approach is disease prevention (see for instance my previous post or this, this and this) and that conventional medicine neglects prevention almost completely? Such claims annoy me because they are demonstrably false.

I know, to some readers, this may seem like a bold statement; let me therefore try to justify it.

  1. So far, I have seen no good evidence that any alternative therapy might be effective in preventing any disease.
  2. Practically everything we know today about disease prevention originates from conventional medicine and science.
  3. There are thousands of papers that address prevention and, as far as I can see, they all originate from the realm of conventional medicine. Below is a list of just 7 recent reviews on the subject.

This paper is an update of the evidence for exercise as a prevention of heart failure. It concluded that exercise provides protective benefit in preventing HF (primary prevention). With HF present: exercise improvement with training provides benefits in HF (secondary prevention). The prediction of future in HF patients: exercise impairment, as a leading characteristic of HF, is used as a prognostic factor.

The aim of this review was to update evidence for the US Preventive Services Task Force on the benefits and harms of hormone therapy in reducing risks for chronic conditions. The authors found that hormone therapy for the primary prevention of chronic conditions in menopausal women is associated with some beneficial effects but also with a substantial increase of risks for harms. The available evidence regarding benefits and harms of early initiation of hormone therapy is inconclusive.

This paper reviewed the evidence for Implantable Cardiac Defibrillators (ICDs). The authors stated that individuals with stable ischemic heart disease (no recent myocardial infarction), especially those with inducible arrhythmias, seem to derive the highest mortality benefit from prophylactic ICD use.

These authors investigated whether neuromuscular and proprioceptive training is effective in preventing knee and anterior cruciate ligament (ACL) injuries. They concluded that neuromuscular and proprioceptive training appeared to decrease the incidence of injury to the knee and specifically the AC.

Other researchers summarized current evidence about real-world studies on apixaban for stroke prevention in atrial fibrillation. They concluded that the use of apixaban in real-life is associated with an overall similar effectiveness in reducing stroke and any thromboembolic events when compared with warfarin. A better safety profile was found with apixaban compared with warfarin, dabigatran, and rivaroxaban.

Finally, a review assessed the evidence of blood pressure (BP) lowering treatments as a means of reducing cardiovascular morbidity and mortality. The authors concluded that primary preventive BP lowering is associated with reduced risk for death and CVD if baseline SBP is 140 mm Hg or higher. At lower BP levels, treatment is not associated with any benefit in primary prevention but might offer additional protection in patients with CHD.

Testing preventative treatments is, of course, far from easy. Ideally, one would want to do an RCT, but often this is not possible, for instance, because the sample size would need to be prohibitively huge and the observation period prohibitively long (think of cholesterol-lowering for reducing cardiovascular risks, or smoking cessation for preventing cancer). Thus we rely frequently on other types of investigations such as epidemiological studies. This type of research is, however, rarely undertaken in alternative medicine, and when it does cover subjects related to this area, it is almost never done by proponents of alternative medicine.

The long and short of all this is depressingly simple: the often-heard claim that alternative medicine is strong on prevention is quite simply false. Proponents of alternative medicine like to talk about prevention (presumably because it is good for business), but when it comes to applying prevention and showing that their preventative interventions are effective, all this talk turns out to be little more than hot air.

I am sure – even hope – that some readers will disagree, and I look forward to their evidence proving me wrong.

 

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