Sunday, June 27, 2010

Anatomy of a Comment

Just over a week ago I wrote Why Haven't We Beaten Cancer Yet?. In which I concluded that the war on cancer won't be over soon. Someone named Dr. Ian Clements left a comment on my short blog post. The comment leaves me a little bewildered so I'd like to go through Dr. Clements points one at a time.
I am only going on your comments, rather than Dr Coussens.
Fair enough. I quoted from an article by Dr. Gorski where he talks about a presentation by Dr. Coussens. So I can't speak for or against Dr. Coussens with any authority. As I say in my Longer Web Manifesto I like reading and considering opinions and ideas that I don't agree with. I may agree with Dr. Coussens but I'm not sure. I haven't read any of his work, I haven't seen his presentation, and I certainly am not in a position to defend or attack what Dr. Coussens has said. So it makes sense to comment on what I've said instead.
There are several things wrong with this. Firstly, orthodox medicine makes similar misleading claims as CAM - but generally with far worse side-effects.
I'll assume that by CAM Dr. Clement is referring to Complementary and Alternative Medicine. As for "similar misleading claims" I'm not sure what he's getting at. The problem with most quacks and unproven alternative medicine claims is not just that they are misleading but also that they don't stop making claims when there is evidence proving them wrong. The struggle against homeopathy going on in Britain and around the world is a case in point. It doesn't seem to matter how much evidence is weighed against the quacks. In many cases they keep promoting useless or dangerous "cures".

I'll give the British chiropractors some credit compared to the homeopaths. When the evidence against chiropractic claims to cure various diseases started to make headlines the chiropractic association quickly told practitioners to remove these claims from websites and ads. Of course they shouldn't have made many of these claims in the first place but at least they pulled back to what they still think is a defensible position.

Is orthodox medicine incapable of making misleading claims? Of course not. Does orthodox medicine correct itself when a claim it makes is shown to be unproven, unfounded, or wrong? Do the claims and techniques change as new research is done and new treatments are found? Yes and yes. It may take a long time for change to take place but it happens eventually. Otherwise we'd still be treating cancer with the tools and techniques that existed in 1970. Or 1900. Or even before.

Is orthodox medicine capable of making claims that are known to be flat out wrong and dangerous? I'm sure it has happened. The fact that medical associations have removed doctor's licenses and that there are cases of true malpractice shows that. But you'll notice that orthodox medicine is at least trying to police and correct those people who are licensed to be doctors. What qualifications do I need to be a quack? Some alternative medicine groups have created associations and they do provide credentials and codes of conduct. The true quacks are the ones that don't think any monitoring or checking is necessary. And what, aside from the courts of law, will stop them from making malicious and dangerous mistakes?
Secondly, if orthodox cancer has improved so much, why are more people getting cancer and dieing of it?
I never said the war on cancer had been a complete success. The whole point of my post was that cancer is a more complex problem then was once thought. Research is ongoing. I don't think I ever said we'd won this war. I only said there have been advances in treatment over the last 40 years. So this doesn't even apply to what I wrote.
Yes, perhaps boosting the immune system may not always be good (tho; one can say that even more about chemo, radiation and surgery), by and large enhancing the immune system is helpful. Hence the huge increase attention to anti-cancer vaccines, which are inherently immune-boosting.
Dr. Gorski's quote warned against over simplifications. When it comes to boosting the immune system Dr. Gorski wrote that "As we’ve said before here, it’s a meaningless claim, because sometimes boosting the immune system is bad, as in autoimmune diseases." Neither in my post nor in the quote from Dr. Gorski's article did either of us say that boosting the immune system may not be useful in some cases. He was warning against overly simple claims.

Dr. Clement may be correct that there are times in which enhancing the immune system is useful. Many cancer treatments (chemo, radiation, etc) are very hard on the patient. Hopefully harder on the cancer of course. Even so my point is still valid. Oversimplifications aren't always useful and can be dangerous.
As to 'great advances in cancer treatment', see above. Many cancer survival rates are worse (bladder cancer, for instance); only a few rarer cancers have longer survival rates; and much increased survival rates are often due to earlier diagnosis rather than better treatments anyway.
 Now we have something I can check with numbers and statistics. Just before the numbers let me make a couple of points:
  1. If a survival rate is better due to "earlier diagnosis rather than better treatments" it is still a better survival rate. And it's orthodox medicine that promotes testing and techniques to make earlier diagnosis. If medicine catches more cancers early when they can be treated effectively that may well make the survival rates lower for the cases that aren't discovered until they have progressed further .
  2. Survival rates are different than determining how effective individual treatments are. Dr. Clements isn't claiming that treatments are less effective. He claims that "cancer survival rates are worse (vladder cancer, for instance)."
  3. I'm Canadian, I live in Canada, and since I don't know where Dr. Clements lives I'm using Canadian numbers where possible. (As an aside... I love the Public Health Agency of Canada. Numbers everywhere!).
So now on with the show. Let's look at some numbers. Rates are in deaths per 100,000 Canadians. The links go to graphs were the trends just pop out at you. These are population wide mortality numbers they are not survival rates. I'll get to those later. For most of us we'd like to know our chances of dying from a certain cancer. Or cancer in general.

Canadian bladder cancer mortality rates from 1984 to 2004. Males went from 8.06 to only 7.02. Women from 2.41 down to 2.01. Seems like it's more survivable now. So let's keep looking.

Canadian breast cancer mortality rates from 1984 to 2004. Males are staying close to constant. Women went from 30.73 to 23.11 deaths. Need more?

How about an example of why things aren't simple? Canadian lung cancer mortality rates from 1984 to 2004. Males from 80.16 down to 60.61 while females went 22.14 up to 36.09. Graphs can show trends but they don't tell the whole story. Why is the mortality rate for lung cancer in women going up? More female smokers? Unequal application of testing and treatment? (Though I point out men are still dying in larger numbers). If you look at the combined rate for men and women then it does look like the overall mortality rate hasn't changed over twenty years.

That unchanged lung cancer mortality rate does take into account earlier diagnosis and better treatments. Hence my point that the war on cancer isn't over yet.

You're chance of dying in Canada (the overall cancer mortality rate) has remained the almost the same for women (151.84 down to 146.96) and has gone down for men (248.09 down to 212.06). That's the number of due to cancer for each 100,000 Canadians. 

What about survival rates? After all mortality rates are the combination of the number of cases of a cancer and the survival rate of those they get the cancer. Survival rates tells us how many people who actually get the cancer go on to survive.

The best source of bladder cancer survival rates I found was from the American National Cancer Institute. I searched for (deep breath): 5-Year Relative Survival by Year DX, By Cancer Site (Urinary Bladder [Invasive & In Situ]), All Ages, All Races, Both Sexes, 1975-2002.  I don't have a permanent link to the resulting table but you can generate a graph or a table starting from this page.

The result? 74.3% 5-year survival rate in 1975 increased to 81.4% in 2002. Bladder cancer survival rates have increased over time!

There is much wrong with cancer research, not least that any new treatment takes decades to see whether there is an improvement. And if not, tough; but if there is, the alternatives meanwhile have continued wrongly. And during all this time most cancer sufferers have died (the average time between diagnosis and death is less than 5 years)
There's something wrong with waiting decades to see if there is an improvement? Do all clinical trials take that long? Do new treatments have to wait decades before being put into use if they are shown to be effective more quickly? Don't you want researchers to constantly look at years of data to determine what is working and what isn't? Aren't the treatments that are offered to patients constantly changing based on long term survival rate information, additional research, and all sorts of other numbers as well?

As for "And during this time most cancer sufferers have died (the average time between diagnosis and death is less that 5 years)" I think Dr. Clements' information is over 30 years out of date. Back at the National Cancer Institute I search for (deeper breath): 5-Year Relative Survival by Year DX, By Cancer Site (all sites combined), All Ages, All Races, Both Sexes, 1975-2002. The results?

  • In 1975 50.1% of people survived 5 years after diagnosis.
  • In 2002 68.5% of people survived 5 years after diagnosis.
Dr. Clements continues:
"There aren't necessarily simple and easy answers." There are well documented, but otherwise inexplicable, successes following simple treatments - at least as good as those of the orthodox treatments.
I'd like to know about those treatments he mentions. The ones that give "well documented, but otherwise inexplicable, successes following simple treatments...". I'm not being facetious. I'm being serious. I'd like to know what simple treatments work as well as orthodox medicine. If those treatments are as useful as current medical practice, if they have fewer side effects, and if they have been shown to work (in properly held clinical trials) I'd like to know why they aren't in use at the moment. Denying proven treatments to patients is scandalous and something we should investigate and uncover.

If those simple treatments haven't been shown to work effectively in clinical trials yet there is still hope. Proper clinical trials performed under supervision and with done with all the ethical standards required when working with real patients should be considered for any treatment that shows promise. Of course validating treatments takes time. Studies have to be carefully designed, properly funded, and well run. And clinical trials are expensive and only so many can be done at any time. Funding isn't unlimited. So treatments and therapies that have been shown to work in animal tests, or that are based on extensions of already proven research may end up getting priority over unproven and otherwise inexplicable treatments. Maybe effort should be placed into trying to explain those treatments so they will be taken seriously be the medical establishment that is trying to cure cancer.

Dr. Clements ends with:

I could go on (such as there are many cases of spontaneous remissions which are never investigated) about the purblindedness of the orthodox medical profession, hostile to anything from without.
Has no research been done into remission? There has been absolutely no work done on this topic? A quick search found that at Ovarian Cancer Canada's page on chemotherapy they say: Chemotherapy can stop cancer from spreading and dramatically slow the growth of cancer cells. This can help put cancer into remission enabling you to prolong your life. So treatment regimes can and do use the mechanisms of remission to help patients. 

Forgive me if at this point I don't spend too much time finding out if there has been research into "spontaneous remissions which are never investigated". Just a quick search found an article from Discover magazine in 2007 called The Body Can Beat Terminal Cancer - Sometimes. Which contains the following:
  • Call it remarkable, call it miraculous—such spontaneous remissions are as fascinating to physicians and scientists as they are rare. Doctors would like to understand cases like Matzke’s, who was given just 18 months to live but would survive another 18 years. And although a recurrence of the cancer—this time in his brain—would eventually claim his life on November 8, 1991, the fact that his lung tumor disappeared completely begs for an explanation.
Followed by this sensible statement about how hard it is to study spontaneous remissions:
  • Pinning down spontaneous remissions has been a little like chasing rainbows. It’s not even possible to say just how frequently such cases occur—estimates generally range from 1 in 60,000 to 1 in 100,000 patients. Many cases, when subjected to close scrutiny, prove not to have been remissions at all.
The article goes on at length on the subject. Remission, spontaneous or otherwise, is a part of ongoing medical research. As with many things being looked at it's more complicated than it initially appears.

As for the "purblindedness of the orthodox medical profession" may I point out that every current orthodox treatment started as an alternative to existing medical practice. Medicine is constantly changing with alternative views becoming current best practice. Anyone who has an alternative approach or treatment that can hold up to study and analysis, and which is shown to by more effective and less dangerous can be the person who helps create the new orthodoxy.

Let me summarize the highlights from the Canadian Cancer Society Fact Sheet for 2008:
  • For Canadian men:
    • Since 1988 the overall cancer death rate has been declining
    • The overall cancer incidence rate rose in the early 1990s then declined sharply
    • Incidence rates:
      • are up for thyroid and liver cancers
      • are down for lung, stomach, and larynx cancers
    • Death rates:
      • are up for liver cancer
      • are down for stomach, larynx, prostate, oral, and lung cancer
  • For Canadian women:
    • The overall death rate has been essentially stable since 1979. If lung cancer is excluded a major decline of 20% has occurred over the last 30 years
    • The overall cancer incidence rate has been increasing slowly (due to increasing incidence of lung cancer)
    • Incidence rates:
      • are up for lung and thyroid cancer
      • are down for brain, larynx, cervical, and stomach cancer
    • Death rates:
      • are down for Hodgkin lymphona, stomach, and cervical cancer
  • Overall in Canada in 2008:
    • 39% of women and 45% of men will develop cancer in their lifetimes
    • 24% of women and 29% of men will die from cancer
Orthodox medical science has made progress and yet, as my original post said, the war on cancer isn't over. It isn't as simple as "we are winning" or "we are losing".

Let me end with a quote I unfortunately can't find on the web because I heard it offline years ago. A cancer researcher was talking about the slow change in the level of fear brought on by a diagnosis of cancer. How patients still react strongly when they hear the word cancer but in many cases breathe easier when they learn what their chances are and what treatments are available. He summed up the slowly changing attitude society has about cancer by saying:

"Years ago we all knew someone who died of cancer. Today we all know someone who survived."


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Anonymous said...

I agree with most of your points, however some need to be discussed further, I will hold a small discussion with my buddies and perhaps I will ask you some advice soon.

- Rob

Anonymous said...

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Anonymous said...

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