April 19, 2010

outside the box

Most of my background is in cardiovascular and metabolic diseases. Cancer, I haven't a clue. But necessity is the mother of invention so I'm educating myself. Given my liberal arts background, I've never been one to see every detail as necessary. I'm much more of a big picture thinker. I assimilate. It's what I do. So when my brother started off treatment at MD Anderson, I felt he was in comfortable hands from a standard of care point of view. I walked out of the visits thinking, "this doc knows a helluva lot more than me" which is a good thing. I've had it be the opposite all too often and that's never a good thing.
As a physician, we're trained (supposedly) by two guiding principles.
#1 - First, do no harm. Very, very, very important. And it leads to the second principle.
#2 - practice what is dubbed "evidence based medicine". What does that mean? We only use what has gone through rigorous clinical trials and shown evidence to have an acceptable risk/reward profile. This is how drugs and therapies are approved and is the best system we have.
But what do you do when it's your brother's life you're fighting for? I trusted his doc on the chemo end. I could find no flaws in his logic. But what about so called alternative therapies? He didn't bring them up and shrugged his shoulders in response to them despite the fact that MD Anderson has a whole section devoted to ingestigating them. In a perfect world, there are no alternative therapies. There are those that work and those that don't. That's what evidence based medicine is about. But we live in the real world. Investors can't make money providing evidence that green tea can help with cancer. In no way am I critical of the pharmaceutical industry. They come up with some wonderful and creative treatments. But it'll only take one so far.
So we're left with less conclusive trials (usually epidemiological or observational) and as a physician, you're left with your two principles. Could this alternative therapy hurt? And what is the evidence that it might help? And that's what I've been spending a lot of my time on rather than studying. Which is an awfully long intro to this small study titled "Psychological improves survival for breast cancer patients: a randomized clincial trial." In a nutshell, this group took women with breast cancer and assigned them to psychological counseling plus the normal therapies or just the normal therapies. The group that received the adjunctive counseling survived longer. It was an extremely small study so by no means was it definitive. But the part that got me was an accompanying scathing editorial. The title says it all "Finding what is not there". They go on to find fault with the methodology of the study and rip it apart finally concluding it was a monumental waste of time.
Part of their critique of the methodology is valid but I suspect they're throwing the baby out with the bathwater. Saying something cannot be there because it doesn't add up is tantamount to idiocy. Don't believe me? Let me let you in on a dirty little secret. Drugs happen despite people, not because they make perfect sense. Let's take the statin drugs. You've all seen the commercials and probably know someone who's taking Lipitor. Best selling drugs of all time, period. They've reduced cardiovascular mortality substantially. Know what? They almost never happened. Two companies were pursuing them early on. The Japanese group pulled the plug on their program for reasons that weren't clear. It scared the bejebus out of Merck. They even flew over to Japan to try to find out the reason. No dice. Merck took a leap and went forward with what was then a controversial concept. Science sometimes requires that people move forward based on their hunch. If you wait for a definitive answer, you'll wait for eons. It'll never come. A leap of faith is sometimes required which is ultimately why I think our scientific culture is so resistant to outside ideas. They require us to expand our creativity and explore the obvious possibility that we don't know everything.


Steve Parker, M.D. said...

It doesn't seem so outlandish to me that psychological stress reduction techniques would lead to lower breast cancer recurrence and death rates.

The encouraging numbers in that study are phenomenal.

Now, someone needs to do a similar study to replicate or refute the original findings. Unless done already.


Isaac said...

I'm not aware of any follow up studies with larger numbers but it should certainly be hypothesis generating at the very least. But then Ornish's data hasn't exactly been received with open arms by the cardiovascular community either.