MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Cancer

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This systematic review summarized the evidence of the effects of dance/movement therapy (DMT) on mental health outcomes and quality of life in breast cancer patients.

Ninety-four articles were found. Only empirical interventional studies (N = 6) were selected for the review:

  • randomised controlled trials (RCT) (n = 5)
  • non-RCT (n = 1).

Data from 6 studies including 385 participants who had been diagnosed with breast cancer, were of an average age of 55.7 years, and had participated in DMT programmes for 3–24 weeks were analysed.

In each study, the main outcomes that were measured were

  • quality of life,
  • physical activity,
  • stress,
  • emotional and social well-being.

Different questionnaires were used for the evaluation of outcomes. The mental health of the participants who received DMT intervention improved: they reported a better quality of life and decreased stress, symptoms, and fatigue.

The authors concluded that DMT could be successfully used as a complimentary therapy in addition to standard cancer treatment for improving the quality of life and mental health of women who have been diagnosed with breast cancer. More research is needed to evaluate the complexity of the impact of complimentary therapies. It is possible that DMT could be more effective if used with other therapies.

The American Dance Therapy Association defines DMT as a multidimensional approach that integrates body awareness, creative expression, and the psychotherapeutic use of movement to promote the emotional, social, cognitive, and physical integration of the individual to improve health and well-being. The European Association of Dance Movement Therapy adds “spiritual integration” to this list. The types of dance used in the primary studies varied (from traditional Greek to belly dancing), and for none was there more than one study. No study of eurythmy (the anthroposophical dance therapy) was included.

I do not find it hard to imagine that DMT helps some cancer patients. Yet, I find the rigor of both the review and the primary studies somewhat wanting. The review authors, for instance, claimed that they followed the PRISMA guidelines; this is, however, not the case. The primary studies tested DMT mostly against no therapy at all which means that no attempts were made to control for non-specific effects.

I think the most obvious conclusion is that, during their supportive care, cancer patients can benefit from

  • attention,
  • empathy
  • movement,
  • self-expression,
  • social interaction,
  • etc.

This, however, is not the same as claiming that DMT is the best option for them.

This review investigated whether mind-body therapies are effective for relieving cancer-related pain in adults, since at least one-third of adults with cancer are affected by moderate or severe pain.

The authors searched for all randomized or quasi-randomized controlled trials that included adults (≥18 years) with cancer-related pain who were treated with:

  • mindfulness,
  • hypnosis,
  • yoga,
  • guided imagery,
  • progressive muscle relaxation.

The primary outcome was pain intensity.

A total of 40 primary studies involving 3569 participants were found. The meta-analysis included 24 studies (2404 participants) and showed a significant effect of -0.39 (95% CI -0.62 to -0.16) with considerable heterogeneity (I2 = 86.3%, p < 0.001). After excluding four “outlier” studies in sensitivity analyses, the effect size remained significant but became weaker. There was a high risk of bias in all studies, for example, performance bias due to lack of participant blinding. Patients in multiple settings were included but many studies were of low quality.

The authors concluded that mind-body therapies may be effective in improving cancer pain, but the quality of the evidence is low. There is a need for further high-quality clinical trials.

These conclusions are broadly correct. I can confirm this because I recently summarized the evidence in a book and arrived at very similar conclusions. If I had to criticize the review, it would be for not including all mind-body therapies for which there is evidence from clinical trials. In my book, I was able to include the following additional treatments:

  • Autogenic training
  • Music therapy
  • Qigong
  • Tai chi

The effects of these treatments are about the same regardless of which one we use. This might lead us to suspect that they work not via specific but via non-specific effects, e.g. placebo.

Psychosocial distress, depression, or anxiety are frequent problems of women after a breast cancer diagnosis and treatment. Many try so-called alternative medicine (SCAM) in an attempt to deal with them. But is this effective?

The purpose of this study was to assess the potential benefit of lavender oil as a perioperative adjunct to improve anxiety, depression, pain, and sleep in women undergoing microvascular breast reconstruction.

This was a prospective, single-blinded, randomized, controlled trial of 49 patients undergoing microvascular breast reconstruction. Patients were randomized to receive lavender oil or a placebo (coconut oil) throughout their period of hospitalization. The effect of lavender oil on perioperative stress, anxiety, depression, sleep, and pain was measured using the hospital anxiety and depression scale, Richards-Campbell Sleep Questionnaire, and the visual analogue scale.

Twenty-seven patients were assigned to the lavender group and 22 patients were assigned to the control group. No significant differences were seen in the perioperative setting between the groups with regard to anxiety (p = 0.82), depression, sleep, or pain scores. No adverse events were noted, and no significant differences in surgery-related complications were observed. When evaluating the entire cohort, postoperative anxiety scores were significantly lower than preoperative scores, while depression scores were significantly higher postoperatively as compared with preoperatively.

The authors concluded that, in the setting of microvascular breast reconstruction, lavender oil and aromatherapy had no significant adverse events or complications; however, there were no measurable advantages pertaining to metrics of depression, anxiety, sleep, or pain as compared with the control group.

One could argue that the sample size of the trial was too low to pick up small differences in the outcome measures. Yet, even then, the findings do not suggest that the treatment did make a large enough difference to justify the effort and expense of the treatment.

One could also argue that – who cares? – if a patient wants aromatherapy (or another SCAM that is harmless), why not? The answer to this is the fact that researchers have the ethical duty to identify the most effective treatment, and clinicians have the ethical duty to employ not just any odd therapy but the one that works demonstrably best. Seen from this perspective, the place of SCAM in cancer care seems far less certain than many enthusiasts try to make us believe.

This review summarized the available evidence on so-called alternative medicine (SCAM) used with radiotherapy. Systematic literature searches identified studies on the use of SCAM during radiotherapy. Inclusion required the following criteria: the study was interventional, SCAM was for human patients with cancer, and SCAM was administered concurrently with radiotherapy. Data points of interest were collected from included studies. A subset was identified as high-quality using the Jadad scale. Fisher’s exact test was used to assess the association between study results, outcome measured, and type of SCAM.

Overall, 163 articles met inclusion. Of these, 68 (41.7%) were considered high-quality trials. Articles published per year increased over time. Frequently identified therapies were biologically based therapies (47.9%), mind-body therapies (23.3%), and alternative medical systems (13.5%). Within the subset of high-quality trials, 60.0% of studies reported a favorable change with SCAM while 40.0% reported no change. No studies reported an unfavorable change. Commonly assessed outcome types were patient-reported (41.1%) and provider-reported (21.5%). The rate of favorable change did not differ based on the type of SCAM or outcome measured.

The authors concluded that concurrent SCAM may reduce radiotherapy-induced toxicities and improve quality of life, suggesting that physicians should discuss SCAM with patients receiving radiotherapy. This review provides a broad overview of investigations on SCAM use during radiotherapy and can inform how radiation oncologists advise their patients about SCAM.

In my recent book, I have reviewed the somewhat broader issue of SCAM for palliative and supportive care. My conclusions are broadly in agreement with the above review:

… some forms of SCAM—by no means all— benefit cancer patients in multiple ways… four important points:
• The volume of the evidence for SCAM in palliative and supportive cancer care is currently by no means large.
• The primary studies are often methodologically weak and their findings are contradictory.
• Several forms of SCAM have the potential to be useful in palliative and supportive cancer care.
• Therefore, generalisations are problematic, and it is wise to go by the current best evidence …

One particular finding of the new review struck me as intriguing: The rate of favorable change did not differ based on the type of SCAM. Combined with the fact that most studies are less than rigorous and fail to control for non-specific effects, this indicates to me that, in cancer palliation (and perhaps in other areas as well), SCAM works mostly via non-specific effects. In other words, patients feel better not because the treatment per se was effective but because they needed the extra care, attention, and empathy.

If this is true, it carries an important reminder for oncology: cancer patients are very vulnerable and need all the empathy and compassion they can get. Seen from this perspective, the popularity of SCAM would be a criticism of conventional medicine for not providing enough of it.

‘Survive Cancer’ is a UK charity that promotes and researches orthomolecular medicine in the treatment of cancer, septic shock, mental health, and other illnesses. They claim to provide information about research and trials and a multi-pronged treatment approach for sufferers of cancer. Specifically for cancer, they recommend the following ‘top ten‘ so-called alternative medicines (SCAMs):

  • Gerson
  • Vitamin C therapy
  • Anti-angiogenic therapy
  • Immunotherapy
  • Photodynamic-/Photo-therapy
  • Melatonin
  • Bisphosphonates (for bone cancer)
  • Coley’s toxins
  • Salvestrols
  • Pain management

Interesting?

Yes, because it is misleading to the extreme. Here, for example, is what they say about an old favorite of mine (and of Prince Charles):

Gerson Therapy

Max Gerson was a German doctor who in the early twentieth century devised an anti-cancer diet and regime based on radically altering the sodium/potassium ratio in the body for the better, thus allowing optimal cellular functions, and nutrition, coupled with intensive detoxification through the use of coffee enemas.

Coffee enemas (see Detox, in First Steps, 5 Rs of Cancer Survival,) are a scientifically established, and medically accepted, way of stimulating the production of glutathione-s-transferases, a major liver detoxifying enzyme family. The diet is vegetarian, low in protein, with fresh organic fruit and vegetable juices daily, and certain specified supplements, such as potassium, niacin and vitamin C. At the end of his life Gerson testified before Congress with the details of 50 cases he had cured. His daughter, Charlotte, has continued Gerson’s work in the U.S. However, she has not made an attempt to integrate modern nutritional state-of-the-art knowledge into the therapy. This is being done by Gar Hildebrand. A retrospective study showed that the Gerson therapy is much more effective than chemotherapy for ovarian cancer and melanoma, both particularly aggressive forms of cancer. Gerson himself had notable successes with various kinds of brain tumour, even after some neurological damage had occurred. Orthomolecular Oncology suggests combining Immunopower with Gerson as an update. We can also cite a remarkable case of a 11 year remission in Multiple Myeloma, another fast-moving, relentless cancer without conventional cure, otherwise conventionally untreated, achieved through a combination of Gerson and modern orthomolecular approaches. Gerson is a powerful, comprehensive therapy, still capable of producing cures, even in its unmodulated form. However, it requires great discipline, time, and extra assistance. Read Gerson’s book and/or contact the Gerson Institute for further details.

One does not need to be a genius to predict that cancer patients following this sort of advice, will significantly shorten their lives, diminish their quality of life and empty their bank account. One does, however, need to be a genius to predict when the UK charity commission is finally going to do something about the many UK charities that prey on vulnerable cancer patients.

PS

I almost forgot: the patrons of this charity are:

In so-called alternative medicine (SCAM), vitamin D is often recommended for a range of indications, including cancer prevention. Observational studies did indeed suggest that low vitamin D status may be a risk factor for cancer. On the basis of such evidence, a team of researchers sought to determine if vitamin D supplementation lowers the risk of cancer and precancers.

The Vitamin D and type 2 diabetes (D2d) cancer outcomes study (D2dCA) is an ancillary study to the D2d study, which was conducted at 22 academic medical centers in the United States. Participants had prediabetes and overweight/obesity and were free of cancer for the previous 5 years. Participants were randomized to receive vitamin D3 4000 IU daily or placebo. At scheduled study visits (4 times/year), cancer and precancer events were identified by questionnaires. Clinical data were collected and adjudicated for all reported events. Cox proportional hazard models compared the hazard ratio (HR) of incident cancers and precancers between groups.

Over a median follow-up period of 2.9 years, among 2385 participants (mean age 60 years and 25-hydroxyvitamin D 28 ng/mL), there were 89 cases of cancer. The hazard ratio (HR) of incident cancer for vitamin D vs placebo was 1.07 (95% CI 0.70, 1.62). Of 241 participants with incident precancers, 239 had colorectal adenomatous polyps. The HR for colorectal polyps for vitamin D vs placebo was 0.83 (95% CI 0.64, 1.07).

The authors concluded that, in the D2d population of participants with prediabetes and overweight/obesity, not selected for vitamin D insufficiency, vitamin D supplementation did not have a significant effect on risk of incident cancer or colorectal polyps.

For some reason, the discussions about the value of vitamin D for any condition tend to be dominated by emotion rather than evidence. This is particularly true in the realm of SCAM. The trial is a significant step forward. It is rigorous and generates clear findings. Let’s hope it will contribute to a more rational debate about the value of vitamin D in cancer prevention.

I was asked by the ‘Science Media Centre’ (SMC) to provide a short comment on the following press release (which was embargoed until today):

Daily use of cannabidiol (‘CBD’) oil may be linked to lung cancer regression 

… The report authors describe the case of a woman in her 80s, diagnosed with non-small cell lung cancer. She also had mild chronic obstructive pulmonary disease (COPD), osteoarthritis, and high blood pressure, for which she was taking various drugs.

She was a smoker, getting through around a pack plus of cigarettes every week (68 packs/year).

Her tumour was 41 mm in size at diagnosis, with no evidence of local or further spread, so was suitable for conventional treatment of surgery, chemotherapy, and radiotherapy. But the woman refused treatment, so was placed under ‘watch and wait’ monitoring, which included regular CT scans every 3-6 months.

These showed that the tumour was progressively shrinking, reducing in size from 41 mm in June 2018 to 10 mm by February 2021, equal to an overall 76% reduction in maximum diameter, averaging 2.4% a month, say the report authors.

When contacted in 2019 to discuss her progress, the woman revealed that she had been taking CBD oil as an alternative self-treatment for her lung cancer since August 2018, shortly after her original diagnosis.

She had done so on the advice of a relative, after witnessing her husband struggle with the side effects of radiotherapy. She said she consistently took 0.5 ml of the oil, usually three times a day, but sometimes twice.

The supplier had advised that the main active ingredients were Δ9-­tetrahydrocannabinol (THC) at 19.5%, cannabidiol at around 20%, and tetrahydrocannabinolic acid (THCA) at around 24%.

The supplier also advised that hot food or drinks should be avoided when taking the oil as she might otherwise feel stoned. The woman said she had reduced appetite since taking the oil but had no other obvious ‘side effects’. There were no other changes to her prescribed meds, diet, or lifestyle. And she continued to smoke throughout.

This is just one case report, with only one other similar case reported, caution the authors. And it’s not clear which of the CBD oil ingredients might have been helpful.

“We are unable to confirm the full ingredients of the CBD oil that the patient was taking or to provide information on which of the ingredient(s) may be contributing to the observed tumour regression,” they point out.

And they emphasise: “Although there appears to be a relationship between the intake of CBD oil and the observed tumour regression, we are unable to conclusively confirm that the tumour regression is due to the patient taking CBD oil.”

Cannabis has a long ‘medicinal’ history in modern medicine, having been first introduced in 1842 for its analgesic, sedative, anti-inflammatory, antispasmodic and anticonvulsant effects. And it is widely believed that cannabinoids can help people with chronic pain, anxiety and sleep disorders; cannabinoids are also used in palliative care, the authors add.

“More research is needed to identify the actual mechanism of action, administration pathways, safe dosages, its effects on different types of cancer and any potential adverse side effects when using cannabinoids,” they conclude.

The SMC published three invited comments:

Prof David Nutt, The Edmond J Safra Chair in Neuropsychopharmacology, Imperial College London, said: 

“This is one of many such promising single case reports of medical cannabis self-treatment for various cancers.  Such case reports are biologically credible given the adaptogenic nature of the endocannabinoid system.  A case report itself is not sufficient to give any form of proof that one thing caused the other – we need trials for that.  There are some controlled trials already started and more are required to properly explore the potential of medical cannabis in a range of cancers.”

Prof Edzard Ernst, Emeritus Professor of Complementary Medicine, University of Exeter, said: 

“Cannabinoids have been shown to reduce the size of prostate cancer tumours in animal models.  Previous case reports have yielded encouraging findings also in human cancers.  However, case reports cannot be considered to be reliable evidence, and there are currently no data from rigorous clinical trials to suggest that cannabis products will alter the natural history of any cancer.” 

Dr Tom Freeman, Senior Lecturer and Director of the Addiction and Mental Health Group, University of Bath, said: 

“These results are exciting and very encouraging for this patient.  However as a single case study the quality of scientific evidence is low and should not be used to change clinical practice.  People with lung cancer should always seek guidance from a healthcare professional when deciding on an appropriate treatment. 

“The product used by this patient reportedly contained high levels of THC (the intoxicating component of cannabis), and was sourced from outside the UK.  This type of product is very different to most CBD oils which predominantly contain CBD.  Unlike prescribed medicines, CBD wellness products lack assurance of quality, safety or efficacy and should not be used for medicinal purposes.”

The original paper has now been published and can be found here.

Last week, a naturopath who has been practicing naturopathy for more than three years, appeared in the Paris High Court. He is accused of “illegal practice of medicine” and of “usurpation of the title of doctor” after two of his cancer patients died.

Charles B. was diagnosed with testicular cancer in 2016 but wanted to avoid traditional medicine. In March 2017, he consulted the naturopath, Miguel B., who studied for fourteen years in the United States and has a degree in biochemistry and a doctorate in molecular medicine. He knew that his qualifications did not allow him to practice in France and presented himself as a naturopath. Knowing about his client’s cancer, Miguel B. drew up a health plan for him that included numerous fasts and purges to detox his body.

In the following months, the cancer spreads to the lungs and brain. Charles B. wrote to his naturopath in early February: “Great pain, don’t know what to do”. The naturopath continued his advice: “You should go on a diet, rest and purge in the evening. In court, Charles B.’s father recalled a conversation between his son and Miguel B. during which the latter had said to Charles B.: “It would be a pity if you were to undergo this chemotherapy.” On 22 February 2018, now weighing only 59 kg, Charles B. finally decided to start chemotherapy. But it was already too late, and he died on 18 December 2018, at the age of 41, of a cancer from which more than 98% of patients usually recover. Charles B.’s wife stated that the naturopath had told her husband that he would not need chemotherapy. She believes that the defendant is “responsible and even guilty” of her husband’s death.

The family of another patient of Miguel B. has also joined the case. Catherine F., who had been suffering from cervical cancer, died at the age of 39. She had followed, among other treatments, a fast recommended by the naturopath and was one of 149 further patients whose list was found on a USB stick belonging to the defendant.

 

 

They say, one has to try everything at least once – except line-dancing and incest. So, when I was invited to co-organize a petition, I considered it and thought: WHY NOT?

Here is the text (as translated by myself) of our petition to the German Medical Association:

 

 

Dear President Dr Reinhardt,

Dear Ms Lundershausen,

Mrs Held,

Dear Ms Johna,

We, the undersigned doctors, would like to draw your attention to the insistence of individual state medical associations on preserving “homeopathy” as a component of continuing medical education. We hope that you, by virtue of your office, will ensure a nationwide regulation so that this form of sham treatment [1], as has already happened in other European countries, can no longer call itself part of medicine.

We justify our request by the following facts:

  1. After the landmark vote in Bremen in September 2019 to remove “homeopathy” from the medical training regulations, 10 other state medical associations have so far followed Bremen’s example. For reasons of credibility and transparency, it would be desirable if the main features of the training content taught were not coordinated locally in the future, but centrally and uniformly across the country so that there is no “training tourism”. Because changes to a state’s own regulations of postgraduate training are only binding for the examination committee of the respective state, this does not affect national regulations but is reduced to only a symbolic character without sufficient effects on the portfolio of medical education nationwide.
  2. Medicine always works through the combination of a specifically effective part and non-specific placebo effects. By insisting on a pseudo-medical methodology – as is “homeopathy” represents in our opinion – patients are deprived of the specific effective part and often unnecessarily deprived of therapy appropriate to the indication. Tragically, it happens again and again that the “therapeutic window of opportunity” for an appropriate therapy is missed, tumors can grow to inoperable size, etc.
  3. Due to the insistence of individual state medical associations on the “homeopathic doctrine of healing” as part of the medical profession, we are increasingly exposed to the blanket accusation that, by tolerating this doctrine, we are supporting and promoting ways of thinking and world views that are detached from science. This is a dangerous situation, which in times of a pandemic manifests itself in misguided aggression reflected not just in vaccination skepticism and vaccination refusal, but also in unacceptable personal attacks and assaults on vaccinating colleagues in private practice.
[1] Homöopathie – die Fakten [unverdünnt] eBook : Ernst, Edzard, Bretthauer, Jutta: Amazon.de: Kindle-Shop

Responsible:

Dr. med. Dent. Hans-Werner Bertelsen

Prof. Dr. med. Edzard Ernst

George A. Rausche

You can sign the petition here:

Petition an die Bundesärztekammer › Sachverständiger kriminalistische Forensik, Foto- Videoforensik, digitale Forensik und der Identifikation lebender Personen nach Bildern (rauscher.xyz)

 

The authors of this review start their paper with the following statement:

Acupuncture has demonstrated effectiveness for symptom management among breast cancer survivors.

This, I think, begs the following question: if they already know that, why do they conduct a systematic review of the subject?

The answer becomes clear as we read thier article: they want to add another paper to the literature that shows they are correct in their assumption.

So, they do the searches and found 26 trials (2055 patients), of which 20 (1709 patients) could be included in the meta-analysis. Unsurprisingly, their results show that acupuncture was more effective than control groups in improving pain intensity [standardized mean difference (SMD) = -0.60, 95% confidence intervals (CI) -1.06 to -0.15], fatigue [SMD = -0.62, 95% CI -1.03 to -0.20], and hot flash severity [SMD = -0.52, 95% CI -0.82 to -0.22].  Compared with waitlist control and usual care groups, the acupuncture groups showed significant reductions in pain intensity, fatigue, depression, hot flash severity, and neuropathy. No serious adverse events were reported related to acupuncture intervention. Mild adverse events (i.e., bruising, pain, swelling, skin infection, hematoma, headache, menstrual bleeding) were reported in 11 studies.

The authors concluded that this systematic review and meta-analysis suggest that acupuncture significantly reduces multiple treatment-related symptoms compared with the usual care or waitlist control group among breast cancer survivors. The safety of acupuncture was inadequately reported in the included studies. Based on the available data, acupuncture seems to be generally a safe treatment with some mild adverse events. These findings provide evidence-based recommendations for incorporating acupuncture into clinical breast cancer symptom management. Due to the high risk of bias and blinding issues in some RCTs, more rigorous trials are needed to confirm the efficacy of acupuncture in reducing multiple treatment-related symptoms among breast cancer survivors.

Yes, I agree: this is an uncritical white-wash of the evidence. So, why do I bother to discuss this paper? After all, the acupuncture literature is littered with such nonsense.

Well, to my surprise, the results did contain a little gem after all.

A subgroup analysis of the data indicated that acupuncture showed no significant effects on any of the treatment-related symptoms compared with the sham acupuncture groups.

In other words, this paper confirms what has been discussed repeatedly on this blog (see for instance here, here, and here):

Acupuncture seems to be a placebo therapy!

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