I often wonder just how much I annoy people when the topic of alternative medicine (alt med) comes up. In general, if someone says something I don’t agree with, I let it slide. When it comes to alt med, however, I don’t seem to have the same restraint. It’s unfortunate really, as it comes up surprisingly often, and my position comes across as pretty extreme.People ask “What’s the harm?”, and point out that “Even if it doesn’t do anything, people feel better having tried it”. I empathise with this position, but completely disagree. The point I try to make is that if we accept the use of alt med, we legitimize it, making people more likely to choose it over conventional medicine.
The focus of this post is cancer patients who put all their trust in alt med. While it's true that most people use alt med alongside real medicine, the popularity of, and belief in, the alt med movement means that it is inevitable that some people will ignore mainstream medicine in favour of alternatives.Unfortunately this does happen, and it happens regularly enough for us to study it. A few months ago, researchers from Yale published a paper looking into the outcomes for cancer patients who chose alt med over conventional treatment.The authors chose four types of cancer to look at: breast, prostate, lung and bowel. Additionally, they chose patients who had early stage disease, so had a good chance of surviving their cancer.Before I get on to the results of their study, one interesting thing to note is that the researchers show that the patients who rejected conventional treatment were more likely to be younger, healthier, more highly educated, and female. These are the patients who would be expected to have better outcomes than other cancer patients, to survive longer and to have fewer complications. However, that is not what the researchers found.Unsurprisingly, the patients who chose alternative medicine were far more likely to die from their cancer than those who didn’t. In the case of breast cancer, alt med users were nearly 6-times as likely to die. In colorectal cancer they were 5-times as likely. In lung cancer they were twice as likely. To put it simply, choosing alternative medicine above conventional therapy kills cancer patients.So, if 100 women with breast cancer were on conventional therapy, 13 would be expected to be killed by their cancer in the 5 years after diagnosis. If the same women were on alternative medicine instead, 41 of them would be expected to be killed over the same time. It is a damning example of the damage alt med can do.
As always, there are a few caveats with this study. One is that these patients completely rejected conventional therapy. Patients who combined it with conventional therapy were included in the conventional arm, so this study can't say anything about the benefits/damage of that situation.It is also likely that these numbers quoted above are an underestimation. Patients who started using alternative medicine, but switched to conventional therapy (when they realise it was not working) will have been counted in the conventional therapy group, meaning that in reality the use of alt med is probably doing even more damage than described in this paper.This all brings me back to my original point. When people give alt med a sheen of validity by claiming it works, it starts to be seen as a true alternative to our tried and tested treatments. The reality is that it simply isn't. As long as it has some legitimacy, a proportion of the population will use it instead of real medicine, at best wasting money, and at worst seriously damaging their own health. I argue with people about alt med because if I don’t, I feel like I am tacitly agreeing that it has some clinical use, when I know it is not true.To paraphrase an old saying, you know what they call alternative medicine that has been shown to work? MEDICINE. And real medicine saves lives.
Eggs, cancer, and motivated reasoning
The following headline in the The Daily Express caught my attention this week:
“Ovarian cancer - could EGGS be the cause of disease? Vegan charity research REVEALED”Express.co.uk 14th March 2017
The article goes on to explain that a Bristol based charity called Viva! Health has urged consumers not to eat eggs, claiming that one egg a week increases cancer risk by up to 70%. According to their own website, Viva! Health is a science-based health and nutrition charity, and being “science-based” you would expect them to have sufficient evidence to make a claim as eye-catching as the one above. So is this the case?
Viva! Health claim that eggs are linked to ovarian and prostate cancer in two ways. First, the high cholesterol levels promote these cancers; and second, choline in eggs is linked to prostate cancer. They give references to scientific publications as evidence, but these publications show nothing of the sort. The journal article they point to regarding cholesterol explicitly states that any association between egg consumption and ovarian cancer risk is not due to the cholesterol in eggs. A quick look at the literature also shows that if there is any link between egg consumption and breast or prostate cancer, it is tiny. A similar pattern holds true for the link between choline and prostate cancer. The research that Viva! Health use to support their claim actually shows the opposite, that choline from eggs is not associated with cancer. It’s pretty clear, there’s nothing to worry about.It took me roughly six minutes to debunk both of these claims, using the identical publications that Viva! Health used to support their claims, so an obvious question is how a charity that clearly thinks of itself as “science-based” could come to the opposite conclusion to me. There is a well-known phenomenon in psychology called motivated reasoning. It describes a process by which someone who holds a particular belief seeks out information that confirms what they already believe, rather than rationally assessing the evidence.It is a fascinating mental trick that we are all guilty of. We all cling to different beliefs with different strengths. If I was to tell you that plastic bags are more environmentally friendly than cloth bags (unless the cloth bag is used more than 130 times), you are likely to look at the evidence and relatively quickly change your view without a huge amount of argument. On the other hand, if I was to say that immigration is economically bad for a country (or good depending on your point of view), you are far more likely to argue with me and ultimately reject that argument. Although both the plastic v cloth and the immigration arguments are contentious and depend on the studies you look at, the likelihood is that you reacted differently to each.A lot of recent research has started to dissect these distinct types of beliefs. We have normal beliefs that change with additional information, but we also have a set of beliefs that form the core of our identities. These often take the form of religious or political views, and when these beliefs are challenged we don’t take a rational approach. Instead we employ motivated reasoning, dismissing awkward facts and cherry picking the ones that agree with us. Indeed, if one of these core beliefs is challenged, it is likely that the belief will be ultimately strengthened rather than weakened by the challenge, something called the backfire effect.Motivated reasoning is extraordinarily common in pseudoscience. Topics like climate change and vaccine safety have decades of reputable research behind them, but despite this, deniers ignore the body of evidence and scientific consensus, deciding to rely on small bits of circumstantial evidence or simple untruths to “prove” their points. There seems to be very little we can do to convince people who hold these beliefs so tightly. However, the majority of the population doesn’t have beliefs like this at the core of their identity. They may have heard the arguments and be unsure about the topic, but with clear evidence and explanation, most people will make the right decisions. This is exactly why it is so important to talk about science and to educate people in how to recognize false claims.Motivated reasoning may be behind the Viva! Health claim that eggs cause cancer. They are a charity dedicated to promoting veganism, so it is entirely plausible that their beliefs regarding non-vegan foods are central to their identity. Alternatively however, they may just understand that if you link something to cancer (whether it is true or not), you are far more likely to make it into the papers, and have random bloggers talk about you!
What happens when we don't publish clinical trials
The last blog I posted emphasised the importance of publishing all clinical trials. The story of Lorcainide is a stark warning of what happens when we don’t.In 1980 a cardiologist in Nottingham named Alan Cowley carried out a small clinical trial of a drug called Lorcainide. It was known at the time that heart attacks could cause irregular heartbeats in patients (known as arrhythmia), and these arrhythmias often lead to early death. Lorcainide had been shown to suppress arrhythmia, so it made sense that patients who came to hospital with a heart attack should be treated with the drug. Cowley and his colleagues carried out a small trial with 95 patients, and tested them to see whether they were getting more or fewer arrhythmias. The drug worked, lowering the frequency of serious arrhythmia.The doctors noticed something else however. Of the 48 patients on the drug, 9 had died, compared to only 1 patient on the placebo. This was a very small trial, so the doctors weren’t overly alarmed. It’s not surprising that 10 patients died in the study; these are patients who are presenting with heart attacks after all. It was just worrying that there was such an imbalance between the groups. The doctors chalked it up to bad luck, and viewed their trial as a success.At the time, this was a perfectly valid opinion. The study had been designed to analyse arrhythmias, not look at mortality. Furthermore, it was a tiny study, so they were justified in assuming the increased death was down to chance. Unfortunately however, what happened next ensured that the importance of this study would not be recognized.The doctors wrote an article describing their findings and tried to get it published. They submitted it to three different journals, but without success. At the same time, the company that made Lorcainide decided to discontinue it (for unrelated commercial reasons), so the doctors lost interest and decided not to publish their results.To be clear, they were trying to publish the study as a success. Lorcainide was able to decrease serious arrhythmias after a heart attack. But within the paper was the information about increased mortality, and this would have been noticed. If it had been published, the study may not have prevented prescription, but it would certainly have suggested the need for further study.Although Lorcainide was never brought to market, other similar anti-arrhythmia treatments were prescribed to heart attack patients throughout the 80s. However, in 1983 there was a review of the available literature that proposed that there was no benefit in using these drugs. The authors of that study actually suggested that there might even be increased death following treatment, but this harmful effect was too small to be sure it was real.In hindsight it is clear that this small effect on mortality was in fact bigger than was realised. That study looked at published data to come to their conclusion. However, they were missing an important clinical trial, one that was in fact sitting unpublished on a hospital desk. If they had access to this data, they may have come to a different conclusion, flagging up the danger years earlier than it was.Towards the end of the decade, after more trials were published, two studies were carried out, both of which suggested that these drugs were doing more harm than good. At this point the danger was realised, and prescriptions dropped. However, it is estimated that 20,000 to 75,000 people died every year because of the use of anti-arrhythmia medication.In 1993, 13 years after it was originally carried out, the clinical trial on Lorcainide was published. The authors pointed out that it was perfectly reasonable to assume the increased death was a matter of chance, and they are probably correct in that. Unfortunately, when they decided not to publish and leave their study to gather dust, they contributed to an unfolding tragedy. At the time, the need to publish all trials regardless of their results wasn’t appreciated, so whether they can be blamed for what happened is a difficult question. What is certain however is that as a result of not publishing hundreds of thousands of people died.Well carried out clinical trials are the bedrock of modern medicine, and unbelievably, we are still in a ridiculous situation where reporting and publishing of trials is patchy at best. Until this situation is corrected we are at risk of another catastrophe like Lorcainide. Sign the AllTrials petition here to register your support for reform.
Problems with clinical trials
Clinical trials are at the heart of our progress in medicine. If we have a new therapy, clinical trials tell us whether it is better than the current one. They measure outcomes, but also look out for side effects and unexpected consequences of taking the therapy. They are absolutely essential to our progress, and it is vital that they are carried out properly and transparently.In recent years there has been an increasing awareness that our current mechanism to ensure this happens has been failing miserably. This has led to the formation of the All Trials initiative, which is campaigning for reform of the system. A paper this week in F1000Research emphasises the extent of the problems with clinical trials at the moment.The authors took a look at trials in the clinicaltrials.gov database. This is a database run by the National Institutes of Health in the US, and the FDA require that all clinical trials report a summary of their results there within 12 months of completion. What the authors of this study did was pretty simple: they mined the data for trials that were finished and also for those that had published their results. By comparing the two, they could figure out who was failing to share their trial results, and who was publishing.
The study looked as far back as 2006, when it became a legal requirement for trial results to be published, so had a list of nearly 26,000 trials to analyse. The results were pretty stark. Over 45% of trials had not reported their results. This is a shocking but not unexpected finding. Previous studies had suggested such a high level of non-reporting, but this was the most thorough analysis to date.So why is it so important that results be published? Simply put, we need all the evidence about a treatment to understand its risks and benefits. The AllTrials campaign put it like this:
“If you tossed a coin 50 times, but only shared the outcome when it came up heads and you didn’t tell people how many times you had tossed it, you could make it look as if your coin always came up heads. This is very similar to the absurd situation that we permit in medicine, a situation that distorts the evidence and exposes patients to unnecessary risk that the wrong treatment may be prescribed.”
This is not an unfounded fear. In 1980, nine men died during a trial for a drug called Lorcainide, compared to only one in the placebo arm of the study. The manufacturer stopped the drug’s development (for commercial reasons rather than safety reasons), but crucially the researchers never managed to published the study. Over time other companies developed similar drugs, and they were prescribed throughout the 1980s. In 1993, the original researchers published their results, and the drug was removed from the market. Tragically, an estimated 20,000 to 75,000 people died every year from Lorcainide. It is essential that all the information is available when people’s health is on the line.A deeper look at the data published in this paper shows that some companies and institutions are a lot worse than others. This tool developed by the authors allows you to visualise this. The pharmaceutical company Sanofi, for example, has only published 150 of their 435 completed trials (35%). The Mayo Clinic, a prestigious Minnesota hospital and research centre, has not published 157 of their 312 trials (50%).Unfortunately, this issue has not been getting better with time. The most recent year that was analysed in this study was 2014, and in that year only 50% of trials were reported (see graph below), which is obviously unacceptable.
This is a major issue in medicine at the moment, and one it is vital to be aware of. I would urge you all to sign this petition on the AllTrials website. The sooner this situation is rectified, the better.
Can Wi-Fi make you sick?
A French court recently awarded a disability grant to a woman claiming to suffer from electromagnetic hypersensitivity. Sufferers define this as an illness caused by the radiation given out by everyday objects (Wi-Fi routers, mobile phones and power lines, for example), resulting in a wide range of non-specific symptoms, including headaches, fatigue and irregular heartbeats. There have been several lawsuits in the US from people claiming that their health has been affected by Wi-Fi (unsuccessful so far), and just this week in Massachusetts parents have sued a school, claiming that the Wi-Fi there made their son ill.
While sufferers may have very real symptoms, we can be extremely confident that they are not as a result of exposure to electromagnetic radiation, and all reliable evidence suggests that electromagnetic hypersensitivity does not exist as an illness. Many studies have now been conducted to test whether the everyday electromagnetic radiation is causing the symptoms that sufferers display.For example, trials have exposed sufferers to either electromagnetic radiation or not, and tested whether the patients can tell the difference (they can’t), or whether there are increased stress hormones in their blood (there isn’t). Alternatively, study participants’ can be given protective netting designed to shield them from electromagnetic fields, sham netting or no netting, and tested to see if their symptoms get any better when shielded (they don’t).A 2010 review of the literature gathered evidence of 46 published papers on electromagnetic hypersensitivity and stated that the authors were “unable to find any robust evidence to support the existence of (electro-magnetic hypersensitivity) as a biologic entity”. Furthermore, the WHO took into account a staggering 25,000 articles, published over the last 30 years, analysing the biological effects and medical applications of non-ionizing radiation and concluded that “current evidence does not confirm the existence of any health consequences from exposure to low level electromagnetic fields”.The most likely explanation is that these symptoms are caused by the nocebo effect. This is the opposite of the placebo effect, so rather than people feeling better when they think they have been given a treatment, they feel worse when they think they have been exposed to something harmful. The symptoms that they feel may be entirely real, but they are almost certainly psychological. In an experiment carried out in 2013, scientists showed half of their subjects an episode of the BBC series “Panorama,” which alleged that WiFi signals were harmful. They then exposed the whole group to a fake Wi-Fi signal and waited to see who would get sick. The ones who watched the documentary were far more likely to develop electromagnetic hypersensitivity symptoms, providing strong evidence that the nocebo effect plays a large role in this syndrome.The judge in the case in France accepted that the woman’s symptoms prevented her from working, but stopped short of recognising electromagnetic hypersensitivity as an illness. This however hasn’t stopped believers from claiming this as a major breakthrough which proves that it is not a psychiatric illness. It doesn’t help when so many news outlets report so credulously on this story. Unfortunately, this court case has given legitimacy to believers in this syndrome, which could have much wider consequences. An industry has sprung up, selling products that claim to protect people from this harmless radiation, exploiting sick and vulnerable people. Unfortunately, this court case will only make this easier.
