The Danger of Choosing Alternative Therapies over Conventional Care

Posted on August 26, 2012 by skeptvet

One of the most common responses to criticisms of alternative medicine is that, whether it is effective or not, at least it can’t do any harm. There is ample evidence, unfortunately, that this is not true. Any therapy with a potential benefit also has potential harms, so if CAM interventions do anything at all, one would expect some side effects. But even for those that are completely ineffective, there are risks.

Some of these risks are direct. Herbal remedies and supplements can be toxic or contain toxic contaminants (1, 2, 3). And other CAM therapies can be directly harmful, such as chiropractic (4), herbal remedies (5), and even acupuncture (6). But even for therapies that are inherently safe because they contain no active ingredients, such as homeopathy (7), there are indirect risks. Avoiding effective conventional therapies because of a false belief in the value of alternatives can lead to significant harm. A new study illustrates this in women with breast cancer.

Kurian Joseph, Sebastian Vrouwe, Anmmd Kamruzzaman, Ali Balbaid, David Fenton, Richard Berendt, Edward Yu and Patricia Tai. Outcome analysis of breast cancer patients who declined evidence-based treatment.World Journal of Surgical Oncology 2012, 10:118.

This study compared the survival of women diagnosed with breast cancer for those who accepted standard medical care and those who did not. The authors concluded:

A total of 185 (1.2%) patients refused standard treatment…The 5-year overall survival rates were 43.2% (95% CI: 32.0 to 54.4%) for those who refused standard treatments and 81.9% (95% CI: 76.9 to 86.9%) for those who received them. The corresponding values for the disease-specific survival were 46.2% (95% CI: 34.9 to 57.6%) vs. 84.7% (95% CI: 80.0 to 89.4%).

Women who declined primary standard treatment had significantly worse survival than those who received standard treatments.

Of the women who declined care, 54% pursued some form of alternative therapy instead, and overall 5-year survival for this group was 57.4% (95% CI: 42.7 to 72.1%).

It is important not to over interpret these results. To begin with, the number of women who refused standard treatment was very small, which suggests that most understand the value of conventional therapy for this disease. And of those who refused treatment, many may have done so for reasons having nothing to do with their beliefs about conventional versus alternative therapies. There are many perfectly sound reasons for choosing not to pursue treatment depending on the extent of disease, the chances of benefit and harm from therapy, and personal circumstances and values. No clear reason was given for almost half of the women who refused, so it is impossible to know whether or not CAM played any role in their decision or their outcomes.

And choosing CAM instead of conventional therapy may not have been the only reason for the difference in survival between women who did or did not have standard treatment. Women who were sicker, had more advanced disease, or had other diseases as well may have been less inclined to pursue therapy, and also more likely to die sooner than women with a better chance of a good outcome with standard treatment.

And women who pursued CAM therapy instead of standard treatment did do slightly better than women for whom no reason for refusing traditional care was given (57.4% 5-year survival versus 43.2% 5-year survival). This would make sense if women who refused all care, even CAM, did so because they had more aggressive or advanced disease or other health problems.

However, there is no question that women who chose standard treatment did far better than those who choose CAM. The difference in 5-year survival between CAM (57.4%) and standard care (81.9%) was huge and unequivocal. And while the specific CAM used was not known in each case, overall there is no reason from these data to believe CAM in general has anything like the efficacy of conventional breast cancer treatment. If there is some form of CAM that performs as well as conventional care, no one has yet presented the data to show this, so claims that this is a legitimate alternative and that refusing standard care is a reasonable choice for women who want to treat their disease are not supported by any evidence and are, in fact, contradicted by the evidence of this and other similar studies (8, 9)

This is yet another study which emphasizes that importance of not substituting unproven alternative therapies for science-based medical care. While investigating the possibility that some plausible alternative therapies may have benefit is reasonable, choosing CAM over standard care is not and is likely to result in real harm.

Posted in General, Miscellaneous CAVM | 2 Comments

The Pseudoscience of Veterinary Chiropractic

Posted on August 19, 2012 by skeptvet

The defining characteristic of pseudoscience is an idea which sounds scientific, which claims to be scientific, but which isn’t actually based on legitimate scientific research or is theoretically inconsistent which established scientific knowledge. There can be some subjectivity in the characterization of something as pseudoscience, and of course no one promoting an idea would ever accept the label for their own beliefs. However, an article I recently read concerning veterinary chiropractic exemplifies many key features of a pseudoscientific idea.

Maler, MM. Overview of veterinary chiropractic and its use in pediatric exotic patients. Vet Clin Exot Anim. 2012;15:299-310

The article spends a great deal of time describing the Vertebral Subluxation (VS), which the author states “is at the core of chiropractic theory, and its detection and correction are central to chiropractic practice.” The only problem with this claim is that the vertebral subluxation, as defined by chiropractic theory doesn’t exist. (1, 2, 3)

Historically, chiropractors defined the VS as a misalignment of bones in the spine, leading to interruption in the flow of “innate intelligence,” a magical spiritual force responsible for normal health. Of course, no scientific evaluation of such a supernatural force is possible, and to gain the appearance of scientific legitimacy, most chiropractors gradually moved away from this concept and argued that the misalignment of vertebrae damaged health by impinging on nerves leaving the spine. This theory makes some sense when used to explain musculoskeletal pain, though it doesn’t make any sense when used to justify chiropractic as a treatment for ear infections, asthma, allergies, or other such complaints.

As it turned out, however, chiropractors have never been able to demonstrate that the bones they are supposedly adjusting into proper position were ever out of position. In other words, they have never been able to show any misalignment in the spine treatable by their form of manipulation. Studies involving imaging, such as x-rays, don’t show the misalignments, and when radiologists or chiropractors look at x–rays of patients diagnosed with a VS on physical examination, they can’t consistently find a lesion in the area identified as abnormal during the exam.

In response to this failure, chiropractors have once again modified the definition of the VS, this time describing the subluxation not as a misalignment of bones but a “a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ function and general health.” How’s that for a definition vague enough to qualify as a horoscope? Basically, chiropractors are now saying that a VS cannot be seen or measured or identified in any way other than the subjective impression of a chiropractor during an examination, yet it is still an appropriate basis for an entire approach to maintaining health and treating innumerable diseases.

But the situation is even worse than it sounds. When chiropractors examine the same patient multiple times, they cannot consistently locate a VS in the same location each time. And when multiple chiropractors examine the same patient, they all claim to find abnormalities in different places. So they can’t even agree with themselves or each other on where a VS is in any particular patient. Again, it is hard to imagine such a nebulous entity being the foundation of comprehensive healthcare approach, much less one claimed to be scientific in its foundations.

To their credit, a growing minority of chiropractors recognize that the VS is a myth and seek to identify legitimate, scientific explanations for the limited but well-demonstrated benefits of chiropractic therapy in treating lower back pain. Such evidence-based chiropractors have been trying to reform their profession since the 1960s, with pretty limited success. Some of the most conclusive evidence against the existence of the VS comes from chiropractors themselves applying truly scientific methods to the evaluation of this pseudoscientific concept.

A review of the literature which appeared in a chiropractic journal in 2009 evaluated the research evidence concerning the VS to see if it met standard criteria for a cause-effect relationship between the VS and disease.

Miritz TA. Morgan L. Wyatt LH. Greene L. An epidemiological examination of the subluxation construct using Hill’s criteria of causation. Chiropr Osteopat 2009;2:17-13.

The criteria for causation in epidemiology are strength (strength of association), consistency, specificity, temporality (temporal sequence), dose response, experimental evidence, biological plausibility, coherence, and analogy. Applied to the subluxation all of these criteria remain for the most part unfulfilled.

There is a significant lack of evidence to fulfill the basic criteria of causation. This lack of crucial supportive epidemiologic evidence prohibits the accurate promulgation of the chiropractic subluxation.

The fact that in over 100 years since the beginnings of chiropractic no one has been able to demonstrate the existence of the foundational concept for the method, the vertebral subluxation, doesn’t prevent the author of the veterinary clinics article from describing it in detail, with diagrams and lots of scientific terminology. She then goes on to make a wide variety of therapeutic claims, identifying chiropractic as a successful intervention for disease in exotic species.

As evidence for these claims, she cites quite a few textbooks and other writings of her fellow chiropractors, but virtually no relevant clinical trials. The author acknowledges this lack of research support but, in a technique common among practitioners of unproven approaches, she places the blame for this everywhere except on the chiropractic community:

Chiropractic research is in it’s infancy compared to traditional medicine largely due to lack of funding and proprietary interest in chiropractic as well as historical staunch opposition from the American Medical Association and other medical groups.

For a treatment approach that has been in existence for a century, with 50,000 licensed chiropractors in the U.S. alone, and with annual revenue for chiropractic treatment estimated at $10 billion in the U.S., it is hard to justify failing to subject the practice to rigorous scientific scrutiny due to lack of funds.

And while there once was organized opposition to chiropractic on the part of the American Medical Association, this vanished after an antitrust lawsuit finally settled in 1987. The judge found that while the AMA had a legitimate concern about the unscientific nature of chiropractic and the inadequate evidence for safety and efficacy, it did not have the right to organize a boycott against the practice. Organizations representing conventional healthcare providers have done nothing to stop chiropractors from pursuing rigorous scientific evidence to support the theory of the VS or the safety and efficacy of chiropractic treatment.

Yet despite all of that, the only convincing evidence that has emerged to support chiropractic treatment is in the care of humans with lower back pain, in which chiropractic is about as effective as conventional care. This does not justify the application of chiropractic for any other medical condition or the use of chiropractic in non-human animals without appropriate research to justify this. And it certainly does nothing to support the pseudoscientific nebulosity that is the vertebral subluxation. As long as chiropractors cling to this notion and make claims for their practices beyond what is justified by real evidence, the practice will continue to be a pseudoscientific one.

Posted in Chiropractic | 2 Comments

Ozone Therapy for Pets

Posted on August 12, 2012 by skeptvet

I’ve recently run across some advertising for the wonders of ozone therapy in pets. This is a treatment that hasn’t caught on much in veterinary medicine (fortunately), but I thought I’d take a look at it before it becomes the next big fad.

What Is It?
According to the Food and Drug Administration (FDA),

Ozone is a toxic gas with no known useful medical application in specific, adjunctive, or preventive therapy. In order for ozone to be effective as a germicide, it must be present in a concentration far greater than that which can be safely tolerated by man and animals.

According to the Environmental Protection Agency (EPA),

ozone is an air pollutant that is harmful to breathe and it damages crops, trees and other vegetation. It is a main ingredient of urban smog.

Ordinary oxygen gas consists of two oxygen atoms bound together, hence its chemical name O2. Ozone contains three oxygen atoms (O3), and is very reactive, breaking down spontaneously and combining readily with other chemicals. These oxidation reactions are the reason ozone can be used as a disinfectant, killing microorganisms through production of oxidative free radicals.

Proponents of ozone therapy claim that it can be medically beneficial in several ways. Its ability to kill microorganisms and other living cells has been claimed to make it useful for treating infectious diseases and cancer. It is also thought by some to increase the amount of oxygen available to tissues, which may be useful in preventing or treating disease, and to stimulate or modify the immune system in a beneficial way.

Ozone is employed in medical applications in multiple ways, including direct injection into blood, muscle, joints, or body cavities, autohaemotherapy (removing blood from the patient, exposing it to ozone, and then returning the blood to the patient’s body), insufflation of the rectum, vagina, or other body spaces with ozone gas, administration of ozone treated water or saline, and topical application of ozone gas or ozone-treated substances.

Does It Work?
There are pre-clinical, in vitro, studies of ozone applied to infectious organisms and cancer cells and demonstrating it can kill these. As I have often pointed out, however, so can bleach, hydrochloric acid, and many other substances which are not appropriate to give to patients as a form of therapy. A few animal model studies have also suggested a benefit in cancer treatment.

Several reviews have found little controlled clinical research showing beneficial effects in patients treated with ozone therapy. Here are some of the conclusions from these reviews:

Ozone’s use in medicine has been debated for decades, but references to its use were sporadic in the major medical journals. Most of the claims of its efficacy were anecdotal…Current data on the usage of ozone therapy as therapeutic options for various health conditions lacks sufficient safety and therapeutic advantage over available conventional therapeutic modalities…There is insufficient clinical evidence to recommend ozone therapy as a form of alternative treatment….(Health Technology Assessment Report: Ozone Therapy, Ministry of Health, Malaysia, December, 2005)

Given the high risk of bias in the available studies and lack of consistency between different outcome measures, there is no reliable evidence that application of ozone gas to the surface of decayed teeth stops or reverses the decay process. There is a fundamental need for more evidence of appropriate rigour and quality before the use of ozone can be accepted into mainstream primary dental care or can be considered a viable alternative to current methods for the management and treatment of dental caries. (Cochrane Reviews. Ozone therapy for treatment of dental caries. 2004)

Oxygenation therapists proposed that disease is caused by absence of oxygen and loss of cellular ability to use oxygen for “good energy” metabolism, detoxification, and immune system function. Oxygen therapies are proposed in order to restore the body’s ability to produce “good” energy, to “detoxify” metabolic poisons, and to kill invading organisms. However, over the five decades that have passed since this concept was proposed, scientists have shown that:

  1. Anerobic energy metabolism (fermentation) is not the cause of cancer.
  2. Koch’s glyoxylide does not exist.
  3. Ingestion, infusion, or injection of hydrogen peroxide cannot re-oxygenate the tissues of the body.
  4. Ozone-treated blood infused during autohemotherapy does not kill AIDS virus in vivo. (Green, S. Oxygenation therapy: Unproven treatments for cancer and AIDS. Quackwatch.org)

Ozone therapy has been recommended to treat many conditions. There are numerous anecdotes about successful treatment with ozone therapy, although effectiveness and safety have not been proven scientifically. (Ozone Therapy, Intelihealth article, Natural Standard and Harvard Medical School, 2008)

“Hyperoxygenation” therapy–also called “oxymedicine,” “bio-oxidative therapy,” “oxidative therapy,” and “oxidology”–is a method of cancer management based on the erroneous concept that cancer is caused by oxygen deficiency and can be cured by exposing cancer cells to more oxygen than they can tolerate. The most highly touted “hyperoxygenating” agents are hydrogen peroxide, germanium sesquioxide, and ozone. Although these compounds have been the subject of legitimate research, there is little or no evidence that they are effective for the treatment of any serious disease, and each has demonstrated potential for harm. Therefore, the American Cancer Society recommends that individuals with cancer not seek treatment from individuals promoting any form of hyperoxygenation therapy as an “alternative” to proven medical modalities. (Questionable methods of cancer management: Hydrogen peroxide and other “hyperoxygenation” therapies. CA Cancer Journal for Clinicians. 2008;43(1):47-56.)

There is limited research in veterinary species. A lab animal study of rabbits suggested a benefit for cancer. A couple of recent studies in cows from a single research group in Croatia found a possible benefit of ozone in treating retained placentas and urovagina and in improving reproductive efficiency. An uncontrolled case series in dogs reported improvements in signs of intervertebral disk disease after ozone therapy (though often patients with this disease get better with rest or only supportive care anyway).

As is always the case, there are numerous positive anecdotes claiming dramatic success in treating a wide range of diseases, but for well-established reasons, we cannot rely on these stories as a demonstration that this treatment is safe or effective (c.f. here and here). And there are a few clinical studies suggesting a benefit, all with significant limitations. The balance of the evidence, however, does not support the efficacy of ozone therapy for any condition. Given the miraculous results claimed for this treatment, it would not be difficult at all to generate dramatic clinical trial evidence, so the absence of this evidence, despite decades of use, strongly suggest that the anecdotes and testimonials cannot be trusted.

The underlying theories used to justify the treatment are also dubious. As Dr. Green establishes in his article on Quackwatch, it is not plausible that low oxygen levels are responsible for many of the diseases ozone therapy is supposed to treat, and it is not likely that ozone therapy significantly increases the oxygen available to tissues in a patient that is treated with it. And while the hype about the benefits of antioxidants does not appear justified, it is certainly possible that free radicals and oxidative stress could actually cause health problems in patients treated with a potent oxidizing agent like ozone. Which leads to the question…

Is It Safe?
There are anecdotal reports in the media and in the scientific literature of adverse effects and even death following ozone therapy. Patients have died from gas bubbles in their bloodstream following injectable ozone treatment, and patients have suffered injury from the injection of ozone and from the apparatus used to instill ozone rectally, vaginally, and into body cavities. Accidental infection with HIV and hepatitis virus have also been reported from contamination during autohaemotherapy.

According to one scientific review, “The risks of ozone therapy are played down by its proponents. Yet, numerous reports of serious complications, including hepatitis, and at least five fatalities have been reported.”(Ernst E (2001). A primer of complementary and alternative medicine commonly used by cancer patients. Med J Aust, Jun 4; 174(11): 611-2)

The indirect risk of using ozone therapy, if it is ineffective, is that serious disease can progress and the opportunity to treat with truly effective therapies can be lost if one delays conventional therapy in favor of ozone therapy. The FDA referred to this risk, as well as the more direct hazards mentioned above, when reporting its decision in 2009 to seize equipment used for ozone therapy from a company illegally selling these unapproved medical devices. The FDA considers medical use of ozone as an unapproved drug, which makes such use subject to prosecution.

And as mentioned before, ozone has been intensively investigated as a pollutant, and there are many studies reporting harmful effects in humans and veterinary species.

Bottom Line
The theoretical justifications for the medical use of ozone are weak and unproven. There are equally strong theoretical reasons why such use could be harmful.

Actually clinical research in humans is limited, but there is no consistent body of evidence to suggest ozone therapy is effective for any medical condition. There are anecdotal reports of injury, illness, and death caused by ozone therapy in humans.

The research is even more limited in veterinary species, and there is no consistent body of evidence to support the safety or effectiveness of ozone therapy for disease in dogs and cats.

Medical use of ozone is not approved in the U.S., and there have been prosecutions of individuals selling unapproved medical devices for use in ozone therapy.

Any use of ozone therapy in dogs and cats must be considered experimental and should only be conducted in the context of properly controlled, monitored, and approved clinical research trials. As with all unproven therapies, those selling ozone therapy will claim benefits and deny the risks. But in the absence of reliable information about the effects of ozone treatment, the chances of harming your pet are at least as good as the chances of helping them.

Posted in Miscellaneous CAVM | 41 Comments

The Three Most Dangerous Words in Medicine

Posted on August 7, 2012 by skeptvet

This slide presentation, and narrated video version, look briefly at the danger of relying on individual clinical experience rather than formal scientific research in making medical decisions.

Slide Presentation

Clinical Trials or Clinical Experience?

Posted in General | 2 Comments

Can Complementary and Alternative Medicine be Evidence-Based?

Posted on August 6, 2012 by skeptvet

This slide presentation, and the narrated video version, are part of a talk given at the annual convention of the American Veterinary Medical Association. The subject was whether or not one can apply the approach of evidence-based medicine to complementary and alternative medical practices. The presentation reviews some of the philosophical principles underlying both approaches and discusses potential areas of conflict between them.

A slightly more detailed examination of the subject will also be available as a commentary in the upcoming August 15th issue of the Journal of the American Veterinary Medical Association.

McKenzie, BA. Is complementary and alternative medicine compatible with evidence-based medicine? Journal of the American Veterinary Medical Association. 2012;241(4):421-6.

Slide Presentation (Powerpoint):

Can Complementary and Alternative Medicine be Evidence-Based Medicine?

 

 

 

Posted in General | 2 Comments

Dog Cancer Expert Steven Eisen: Bad Advice from an Unreliable Source (restored)

Posted on July 31, 2012 by skeptvet

The direct quotations from Dr. Eisen’s web sites were temporarily removed pending the outcome of a DMCA copyright complaint. Since no legal action was taken during the 14-day waiting period mandated under the DMCA, the original quotations have been restored.

Most of the individuals I write about who are promoting questionable veterinary medicine, or outright nonsense, are veterinarians. Such individuals have some claim to legitimacy and authority in recommending veterinary treatments, and so their voices tend to carry more weight than those of most lay people. This isn’t always a good thing since veterinarians are no less prone than anyone else to getting bad ideas stuck in our heads or to being misled by all the features of the world and our own brains that so easily fool us. Experts, that is individuals with recognized credentials and formal training in a specific area of medicine, do tend to have more factual knowledge in that subject. But they are not immune to making mistakes, so as always it is the ideas and the evidence that must be given the greatest way, not the authority of the individual.

Because advice from veterinarians is more likely to be trusted, even when it’s bad advice, I focus on these sources when pointing out why certain ideas, practices, or products are not supported by good evidence and science. However, once in a while I run across a particularly egregious example of misleading a negative advertising for alternative medicine that I feel obliged to challenge even though the source is not a veterinarian. Here’s a quick example of why I noticed this one:

If your dog has been given the heart-breaking diagnosis of terminal cancer… Just About EVERYTHING Your Vet Told You Is WRONG!

Don’t Let Deadly Mistakes Take Your Beloved Companion Away From You –There IS a Way to Save your Dog

Subtle, thoughtful argument, eh?

Steven Eisen is a “Holistic Dog Cancer Expert.” How did he get to be an expert? Well, according to his website first he read about holistic medicine in college, then he studied at the New Age Esalen Institute, and then he graduated from a college of chiropractic. Oh, and when his own dog got cancer he ignored his veterinarian’s advice and made up a bunch of stuff about diet and supplements, and since his dog lived longer than he says the vet predicted, he must have discovered the cure for dog cancer. Now, he would like you to buy the secret to curing cancer from him in the form of his book, Dog Cancer: The Holistic Answer.

I wasn’t willing to support the promotion of this nonsense by buying the book, but Dr. Eisen does offer some glimpses of his ideas on his web site and in a number of free videos. [except, of course, he will threaten to sue you if you tell anyone what he says in them]. These exhibit nearly all the warning signs of quackery, and Dr. Eisen doesn’t provide any evidence beyond his own opinion and the usual unreliable miracle stories for his claim that he has a simple, safe, effective therapy that scientific medicine either doesn’t know about or doesn’t want you to know about.

His primary web site, DogCancerAdvice.com, offers the usual sorts of unsubstantiated attacks on the ignorance and futility of conventional veterinary medicine. For example:

“The training of these professionals [veterinarians] has superbly equipped them to treat acute problems like infections, heartworm, and trauma. However, there are no standard veterinary protocols for dog cancer. The only treatments taught in veterinary school are the toxic ones…despite the scientific evidence that they are not effective. “

“Although some veterinarians claim to combine conventional and alternative dog cancer treatments, it’s rare to find one that has a thorough understanding of the principles of holistic medicine and holistic treatments for cancer in dogs. An issue that’s consistently ignored is that the two approaches are often incompatible because the underlying assumptions are worlds apart. If a gardener said he would take care of your lawn with both pesticides and organic methods, I think you would wonder about his expertise, his intelligence and/or his honesty.”

“If there were a brush fire in the forest, would it make sense to set the rest of the forest on fire? That is essentially the conventional approach to treating dog cancer.”

“Unfortunately, many have been following dangerously mistaken advice from their vets. The quality of your dog’s life can improve, and even be healed from cancer with the right information. “

“In vet speak, a dog with lymphoma is considered “cured” by conventional treatment if it survives 8 months.” [This is simply untrue. No veterinarian wuth any knowledge of cancer therapy would claim to be able to cure lymphoma. The word he’s looking for is “remission,” and the mean remission time for lymphoma with conventional treatment is about 10-14 months]

Dr. Eisen then gives detailed numbers showing so-called “holistic” treatment is cheaper than conventional cancer therapy, which seems a transparent attempt to prey on people who would like the best care possible for their pets but have significant financial limitations. He lists the potential side effects of conventional treatment without any information about how common or severe these might be and no mention of the benefits of treatment. And he finishes with the usual nonsense that Quote removed which basically says alternative cancer treatments work without any side effects. The bottom line:

“Not only are alternative treatments less toxic and more effective, they also cost just a fraction of what you would pay for conventional treatments. “

So a cheap, simple, effective cure for cancer with no risks or side effects which, for reasons we can only guess at, almost none of the veterinarians (or physicians, for that matter) know about or use. Hmmm, how likely does that seem to you? Well, let’s see what Dr. Eisen’s argument is.

1.      The Toxins Did It!

Part of being an expert in dog cancer is apparently being a toxicologist. Well, ok he’s not actually a toxicologist, but he says dog cancer is all about toxins, so we have to believe him, right?

Most of Dr. Eisen’s rant about toxins as a cause of cancer is indistinguishable from the usual oversimplified, mythologized nonsense about how the whole world is full of poisonous chemicals. The fact that some substances, both natural and human made, can cause disease, including cancer, in some people at some dose has nothing to do with the almost religious notions about contamination and purification behind the notion of “detoxification” as a treatment for disease.

Dr. Eisen lists a myriad of substances that are to blame for your pet’s disease, including vaccines, commercial pet food ingredients (including pretty much every part of the animal except muscle meat), bacteria as well as the antibiotics used to treat them, vaccines, flea and tick control products, and both tap water and bottled water (which are allegedly full of pharmaceuticals and that classic bugbear of quacks—fluoride). All of the accusations are presented as fact despite the absence of real data to support them. Nothing sells like fear!

Examples of Dr. Eisen’s sophisticated, thoughtful reasoning balancing risks and benefits include these remarks:

“If your dog has cancer, it is imperative that they never receive another vaccination. Not ever again for the rest of their life.”

“I can’t emphasize this too much. You need to eliminate the application of all commercial flea and tick products if you want to keep your dog healthy.”

2. My Diet is the Best!

Apparently, despite having no formal training in veterinary nutrition, Dr. Eisen is also an expert in cancer nutrition as well. With his usual abundance of confidence, and lack of evidence, he makes a number of claims about cancer and diet.

First, he recommends a homemade diet because, quote removed due to lega coplaint which basically says no commercial food is good for dogs with cancer. He dismisses the one cancer-specific diet on the market because of the usual myth about “byproducts” (the parts of the animal affluent Americans find yucky but that are routinely eaten by people in other cultures and universally enjoyed by wild and feral carnivores). And he completely ignores the strong evidence that homemade diets are almost always nutritionally incomplete.

Next he recommends a low-carbohydrate diet for dogs with cancer. There is some research which suggests carbohydrate restriction could have benefits for cancer patients. There is, as yet, no consistent body of evidence in humans or in dogs to indicate they actually do have benefits, so the idea is reasonable but still tentative.

He makes some arbitrary restrictions, such as banning pork as a protein source, and recommends a host of herbs which rumor, but no convincing scientific research, suggests might have anti-cancer properties. Despite the lack of any evidence to show this diet is nutritionally adequate, much less that it has a significant impact on the health or longevity of cancer patients, Dr. Eisen concludes, “This truly is healing food for your dog with cancer.”

Why? Apparently because he says so.

3.     #1 Worst Thing

Dr. Eisen states repeatedly, that cancer is growing more and more common in dogs. He bases this on reports indicating cancer is diagnosed more frequently now than ten or twenty years ago. This is likely true, though the data is not from very high quality controlled studies. Unfortunately, one area in which Dr. Eisen is not an expert is epidemiology, the study of the occurrence and causes of disease. He assumes simplistically that more cancer diagnosis means more cancer, which he then goes on to attribute, again based only on opinion, to a more toxic environment. However, more diagnosis of cancer does NOT mean that our dogs are sicker than they once were or that the environment is less healthy. Here are other reasons why cancer diagnoses can increase:

a. An Aging Population– Cancer occurs more frequently in older animals because it is frequently caused by defects in the control of cell division that accumulate over the lifetimes of many cells. The longer you live, the more times your cells have had to divide, and the more opportunities there are for the kinds of errors that can lead to cancer. Every epidemiologic study must account for differences in age between populations when comparing the rates of cancer and other disease. So if our pets are living longer as a result of better nutrition, disease prevention, and medical care, then we will see more dogs with cancer.

b. Better Control of Non-Cancerous Disease– For most of human history, almost half of all people born died before they reached adulthood. Very, very few of these children died of cancer, which is much more common in the elderly. They died mostly of malnutrition, infectious and parasitic diseases, and accidents. As science improved the quality of our food supply, provided the technology that raised our standard of living, and generated vaccines, antibiotics, pediatric and neonatal intensive care units, and all the other healthcare interventions that prevent these kinds of deaths, guess what happened? Yup, more people lived longer, the average age of the population increased, and cancer became a more common cause of death. NOT because the environment got more toxic but because it got healthier and safer! Cancer is one of the things you die of if you succeed in avoiding the age-old standards that used to kill most people.

The same is true for our pets. The very vaccines and pet foods and medicines Dr. Eisen condemns so blithely are responsible for reducing deaths from many non-cancer causes, leading to an increase in the number of cancers seen. This is a sign of past success for scientific medicine, and a challenge for the future. It is not a sign of the failure of conventional healthcare or the poisonous nature of the environment.

c. Better Diagnosis and Treatment– Diagnostic methods like ultrasound, CT scanners, and biopsies are becoming more accurate and more available all the time, and more people are willing to pay for tests to identify cancer in their dogs. This alone can increase the number of cancers diagnosed. And as we develop the ability to diagnose cancer more accurately and at an earlier stage, and as we find treatments for cancer which can (contrary to Dr. Eisen’s misleading claims) benefit cancer patients and even sometimes cure cancer, more people are willing to test their pets for these diseases and consider treating them.

I certainly wouldn’t claim that there is clear evidence cancer rates are not truly increasing. The reality is that we don’t have the appropriate epidemiological evidence to know. What is clear, however, is that the claim that there is more cancer due to increasingly toxic environments is absolutely without legitimate scientific support

So what does Dr. Esien say is the #1 Worst Thing for dogs with cancer? It’s not the commercial pet foods, flea and tick products, and tap water that he claims are contributing to a supposed cancer epidemic in dogs. Bad as these are, apparently they pale before the worst toxin of all–vaccines.

“The #1 worst thing you can do to a pet with cancer is to have them vaccinated.”

“Vaccines are loaded with toxic heavy metals like mercury and aluminum”

“Cancer is an auto-immune disease, so vaccines can cause cancer”

“Most vets administer vaccines routinely to our pets and tell you that they are safe, with very little risk. The fact is, nothing could be further from the truth.”

“Immunity is an all or nothing thing, either you have it or you don’t.”

“Any vaccination given to your dog will further impair their immune system and greatly reduce their likelihood of recovery.”

Now, there is nothing wrong with suggesting that vaccination may not be appropriate for dogs with cancer, or any other serious illness. It is widely accepted and routine to defer vaccination of dogs when they are ill. The problem with Dr. Esien’s diatribe about vaccination is that is takes this sensible recommendation and expands it into an indictment of vaccines as toxic and as a routine cause of cancer. It is like saying that because you shouldn’t drive while drunk, having a glass of wine with dinner is a major cause of auto accidents.

There are examples of vaccines being associated with an increased risk of some cancers. A type of cancer called a sarcoma can occur in between 1 out of 1,000 to 1 out of 10,000 cats vaccinated with an aluminum-containing rabies or feline leukemia vaccine. Such cancer is likely triggered by inflammation, which can also be induced by trauma, parasites, and many other causes. As a result of careful research identifying this problem (which we would not have found out about simply by casual observation or guessing), vaccines and vaccination practices have been altered to reduce this risk.

This example is often misused to suggest that vaccines in general are a risk factor for cancer in general, which is not the case. And such arguments ignore the fact that vaccinations save many, many lives. It is easier to sell an idea that is simplistic and makes the world seem like a place where all risks can be controlled and we can have the outcome we want so long as we do everything “right.” But the world we live in is more complicated than that, and anyone who tells you differently is selling something.

Dr. Eisen also belabors the fact that vaccine manufacturers state their vaccines should only be used in healthy animals. While I agree this is usually true, vaccine manufacturers also state their vaccines are safe and effective. Why does Dr. Eisen reject these claims and yet accept the recommendation not to give vaccines to ill dogs? Simply because it fits his personal beliefs about vaccination and cancer. He picks and chooses which information to accept and which to ignore not based on the strength of any evidence but on his personal prejudices. This is called confirmation bias.

Finally, Dr. Eisen also argues that vaccines aren’t effective in dogs with cancer based on manufacturer cautions about using them in immunocompromised individuals. This is a reasonable hypothesis, but one that has rarely been tested. The only specific study of the subject in dogs actually found no difference between the response to vaccination in dogs receiving chemotherapy and dogs not being treated for cancer.

Effects of chemotherapy on immune responses in dogs with cancer J Vet Intern Med. 2006 Mar-Apr;20(2):342-7. Claudia U Walter, Barbara J Biller, Susan E Lana, Annette M Bachand, Steven W Dow Animal Cancer Center, Department of Clinical Sciences, Colorado State University, Fort Collins 80523, USA.

Abstract- Chemotherapy is assumed to be immunosuppressive; yet to the authors’ knowledge, the effects of common chemotherapy protocols on adaptive immune responses in dogs with cancer have not been fully evaluated. Therefore, a study was conducted to evaluate the effects of 2 common chemotherapy protocols on T- and B-cell numbers and humoral immune responses to de novo vaccination in dogs with cancer. Twenty-one dogs with cancer (12 with lymphoma, 9 with osteosarcoma) were enrolled in a prospective study to assess effects of doxorubicin versus multi-drug chemotherapy on adaptive immunity. Numbers of circulating T and B cells were assessed by flow cytometry, and antibody responses to de novo vaccination were assessed before, during, and after chemotherapy. The T- and B-cell numbers before treatment also were compared with those of healthy, age-matched, control dogs. Prior to treatment, dogs with cancer had significantly fewer (P < .05) CD4+ T cells and CD8+ T cells than did healthy dogs. Doxorubicin treatment did not cause a significant decrease in T- or B-cell numbers, whereas treatment with combination chemotherapy caused a significant and persistent decrease in B-cell numbers. Antibody titers after vaccination were not significantly different between control and chemotherapy-treated dogs. These findings suggest that chemotherapy may have less impact on T-cell numbers and ability to mount antibody responses in dogs with cancer than was previously anticipated, though dogs with lymphoma or osteosarcoma appear to be relatively T-cell deficient before initiation of chemotherapy.

So while there are good arguments for avoiding most vaccination of dogs with cancer, Dr. Eisen isn’t making them. He is simply asserting that vaccinating dogs with cancer is ineffective (which there is evidence may not be true) and harmful (for which there is no evidence at all). In short, he is making stuff up to suit his phobia about vaccines and toxins, and he is willing to borrow and misinterpret any information from any source to do make his case.

4.     Why Buy His Book?

“What I do is help people learn about holistic protocols for treating dog cancer so they can get their dogs better without the side effects and often life-threatening consequences of conventional treatments.”

Dr. Eisen makes the usual misleading arguments for why you should take his advice. He claims his dog lived longer than expected after being diagnosed with cancer, so that proves his treatment works. Such miracle testimonials are not, however, a reliable guide to what works and what doesn’t, for reasons I’ve discussed before. He talks about individualizing therapy, which is a common marketing ploy for alternative medicine that doesn’t mean what he wants you to think it means. And he claims that many of his recommendations are “scientifically proven,” which is another empty marketing phrase. And, with the usual ambivalence towards science that characterizes most promotion of pseudoscience, he claims it as a source of legitimacy while simultaneously deriding it as worthless:

“Limiting your treatment options for dog cancer only to those proven by scientific research could be harmful to your dog’s health.” [he then goes on to talk about how individual observations are often so obvious that clinical research isn’t necessary, which is only rarely true, and how “today’s profit-driven scientific community” isn’t interested in studying treatments which are inexpensive, which is an unjustified slur on veterinarians who are just as committed to the welfare of their patients as Dr. Eisen].

Dr. Eisen offers tidbits of advice on three web sites, dogcanceradvice(dot)com (which mostly serves to advertise the book), dogcanceracademy(dot)com (which has a couple of videos you can watch in exchange for your email address, which allows more direct marketing), and bestdogcures(dot)com, which is a subscription site open to those who buy the book. All of this is classic internet marketing, very similar to what Dr. Andrew Jones does for his Veterinary Secret book and site.

Bottom Line
Dr. Eisen is a chiropractor who claims to be an expert in veterinary nutrition, toxicology, and cancer therapy based on having read a lot of books and invented his own “holistic system” by selecting which information he wanted to believe and which he felt he could ignore. The core of his marketing strategy is 1) to generate fear, by claiming that cancer is an epidemic and that we are surrounded by cancer-causing toxins in the very food and medicine we trust to keep our dogs healthy and 2) to claim that veterinarians have only dangerous and ineffective cancer treatments to offer and are ignorant of, or deliberately ignore, proven safe and effective alternative treatments. He provides no evidence for any of these claims, only his opinion and some testimonials.

A few of his claims are distantly based in real science and then stretched and twisted to support a pseudoscientific approach. Most of his claims are completely made up and contradict well-established science. He gets away with this by offering the usual unjustifiable promise of something for nothing, of effective treatments, or even cures, for cancer that are easy to use, completely safe, and cost little.

His web sites manifest many of the classic warning signs of medical quackery, including:

Claims of miraculous results
Claims of special knowledge unknown to or ignored by mainstream medicine
Claims of scientific legitimacy without any actual research data
Claims of expertise with no relevant credentials
Claims of simple and easy solutions to complex, difficult problems
Reliance on testimonials as proof
Claims that disagreement is driven by ignorance, fear, or greed
Misleading and selective use of real facts mixed in with made-up claims

And I have little doubt that, once his followers see this article, these signs will be joined by the inevitable personal attack on the critic rather than substantive response to the criticism, lots or testimonials supporting Dr. Eisen’s approach, lots of claims about the fear, anger, ignorance, greed or, most ironic of all, the arrogance of anyone who dares to criticize someone who has declared themselves an expert and who claims to know better than everyone with actual training and expertise in the subjects he talks about (true followers rarely see the irony in this).

The saddest thing about this sort of nonsense is that it is far more accessible and palatable to people whose pets have cancer than legitimate scientific information from true experts in veterinary cancer treatment. The bulk of what pet owners find on the internet is marketing materials designed to feed on their hopes and fears while not honestly helping their pets. Compassionate care is not limited to bogus “holistic protocols” like Dr. Eisen’s, despite the fact that he markets himself more effectively than genuine experts. True compassionate care is treatment based on legitimate science, not made up out of myths, misinterpretations, and wishful thinking.

Here are some real experts with real information for you if your pet has cancer:

Veterinary Oncolink, University of Pennsylvania
Pet Owner’s Guide to Cancer, Cornell University
The Cancer Center at Cares Canine Cancer Library, National Canine Cancer Foundation Animal Cancer Center, Colorado State University

Posted in General | 12 Comments

Dr. Eisen Takes Legal Action to Suppress Criticism

Posted on July 30, 2012 by skeptvet

In the true spirit of quackery, which cannot bear criticism or the exposure of its absurdities, Dr. Steven Eisen has expeditiously taken action to suppress my criticism of his marketing himself as a dog cancer expert despite no formal training in veterinary medicine, oncology, or any of the other areas of medicine in which he gives advice to dog owners. He has written to my internet service provider claiming that my quotations from his web site constitute copyright infringement. Here is the notice that was forwarded to me:

Sent via email and fax

re: DMCA Notice of Copyright Infringement

To Whom It May Concern:

My name is Dr. Steven Eisen and I am President of Pet Love LLC. A website that your company hosts (according to WHOIS information) is infringing on at least one copyright owned by my company.

Copyrighted text and graphics from several pages of our websites were copied onto your servers without permission. The original material, to which we own exclusive copyrights, ca be found at:

a)     http://dogcanceradvice.com/about-the-book-2/

b)     http://dogcanceradvice.com/canine-cancer-information/dog-cancer-treatments/

c)     http://dogcanceradvice.com/canine-cancer-information/alternative-cancer-treatments-for-dogs/

d)     http://dogcanceracademy.com/cancer-causing-toxins/

e)     http://dogcanceracademy.com/the-dog-cancer-diet/

f)      http://dogcanceracademy.com/canine-cancer-vaccinations

The unauthorized and infringing copy can be found at:

http://skeptvet.com/Blog/2012/07/dog-cancer-expert-steven-eisen-bad-advice-from-an-unreliable-source/

This letter is official notice under Section 512© of the Digital Millenium Copyright Act (“DMCA”), and I seek the removal of the aforementioned infringing material from your servers. I request that you immediately notify the infringer of this notice and inform them of their duty to remove the infringing material immediately, and notify them to cease any further posting of infringing material to your server in the future.

I have a good faith belief that use of the copyrighted materials described above as allegedly infringing in not authorized by the copyright owner, its agent, or the law.

Under penalty of perjury, I certify that the information contained in this notification is both true and accurate, and I have the authority to act on behalf of the copyright(s) involved. I am providing this notice in good faith and with the reasonable belief that rights my company owns are being infringed. Should you wish to discuss this with me please contact me directly.

Thank you.

Dr. Steven Eisen

It is likely that my use of statements made on Dr. Eisen’s site constitutes fair use under copyright law, but that decision would need to be made by a judge in the course of a copyright infringement lawsuit. I am perfectly willing to argue that the fair use provisions apply here, since I believe the attempt to suppress criticism by Dr. Eisen is an illegitimate misuse of intellectual property law.

Unfortunately, my options under the Digital Millenium Copyright Act (DCMA) for response are not great. I can leave the material up, in which case my IP will shut down my entire domain within 48 hours. I can remove the quoted material. I can contest the complaint, in which case my IP will shut down my entire domain for 10 days. If Dr. Eisen doesn’t sue in that time, the domain is reopened. If he does, then it remains closed until the case is decided.

Such flagrant misuse of copyright law deserves to be contested, so I will be seeking legal advice on the best way to do so. In the meantime, if the site diappears for a while, you’ll know why.

7/31/2012 Update

I have temporarily removed the disputed material from the site and filed a DMCA counterclaim. Dr. Eisen now has 10 days to decide whether or not to file for an injunction. If he does not, the original material will be reposted. If he does, then a court will decide whether my use of his words in a journalistic critique on a public interest, non-profit web site constitutes fair use of copyrighted material.

 

JustHost Legal Team:

 

This letter is written in response to your notification to me of a complaint received about my web page(s). The disputed material has been temporarily removed pending a response to this counter complaint. Copies of the disputed material are appended to this counter complaint. The original page has been made private and password-protected and is not publically accessible. This page has been replaced at the URL below with a page that does not contain the disputed material. The page at which the disputed material appeared and from which it has now been removed is at the following URL: http://skeptvet.com/Blog/2012/07/dog-cancer-expert-steven-eisen-bad-advice-from-an-unreliable-source/

My response to this complaint is as follows: Allegations of Copyright Violation / Digital Millennium Copyright Act The claims of copyright violation should be rejected because:

> 

My use of the material is legally protected because it falls within the “fair use” provision of the copyright regulations, as defined in 17 USC 107. If the complainant disagrees that this is fair use, they are free to take up the matter with me directly, in the courts. You, the ISP, are under no obligation to settle this dispute, or to take any action to restrict my speech at the behest of this complainant. Furthermore, siding with the complainant in a manner that interferes with my lawful use of your facilities could constitute breach of contract on your part.

This communication to you is a DMCA counter notification letter as defined in 17 USC 512(g)(3): I declare, under penalty of perjury, that I have a good faith belief that the complaint of copyright violation is based on mistaken information, misidentification of the material in question, or deliberate misreading of the law.

 

Indemnification of Host or Registrar I agree to defend, indemnify and hold the host or registrar, its affiliates and its sponsors, partners, other co-branders and the respective directors, officers and employees of each harmless from and against any and all claims, losses, damages, liabilities and costs (including, without limitation, reasonable attorneys’ fees and court costs). My name, address, and telephone number are as follows:

I hereby consent to the jurisdiction of Federal District Court for the judicial district in which I reside (or, if my address is outside the United States, any judicial district in which you, the ISP, may be found). I agree to accept service of process from the complainant.

My actual or electronic signature follows:
 

Having received this counter notification, you are now obligated under 17 USC 512(g)(2)(B) to advise the complainant of this notice and to allow restoration of the material in dispute unless the complainant files suit against me within 10 days.

 

Posted in Law, Regulation, and Politics | 20 Comments

Medical Miracles: Should We Believe?

Posted on July 14, 2012 by skeptvet

Any time there is discussion of alternative medicine, of treatments that haven’t passed the test of rigorous scientific investigation (or even been tested at all), there are miracle stories. Testimonials, anecdotes, whatever you call them, they are tales of amazing recoveries from illness when everything tried had failed and all hope was lost. The comments on this blog contain many such stories for almost all of the products and methods I have questioned.

And such stories provide emotionally compelling evidence for the effectiveness of these interventions. If an owner has tried a hundred treatments for their pet, or been told there is no hope and nothing can save the animal, and then they try one more thing and their companion recovers, surely this means that final treatment must have worked? And yet, with all these testaments to the power of these alternative methods, I still have doubts. Let’s take a look at why that is.

There are a number of arguments against believing that testimonials prove anything about the effects of a medical treatment. Most of these, of course, will have no effect on the individual experiencing the miracle. It is in the nature of human beings to find their own experiences, and stories from others, deeply compelling, and sadly facts and logical arguments have little impact on that fundamentally emotional and irrational sense of certainty. Still, making the effort to understand the limitations of anecdotes has led us to this point in time, a point in which our medicine is more effective by far than any time in human history. So there is clearly value in understanding the problem of miracle stories even if many people will still find them compelling.

Things Aren’t Always What They Seem
The first classic argument is simply that things aren’t always what they seem. There are many reasons why the fact that a patient gets better after receiving a particular medical treatment doesn’t actually tell us the treatment made the patient better. The notion that if an action preceding an outcome means the action must have caused that outcome is known as the post hoc ergo propter hoc fallacy. In medicine, there is a long list of reasons why this kind of reasoning about causation isn’t trustworthy:

  1. Self-limiting Disease:

Most medical problems ultimately go away by themselves. Certainly minor ones nearly always do, and even major, life-threatening diseases like cancer resolve spontaneously despite our belief that they can’t or shouldn’t. It is natural to assume that whatever we did last, right before the patient got better, is the reason they got better. Natural, but not reliably true. 

  1. Regression to the Mean:

Chronic diseases, especially mysterious ones we don’t fully understand, tend to come and go. In addition to spontaneously going away altogether, which they can even after many years, they commonly tend to get better for a while then worse for a while and back and forth in an unpredictable cycle which we are always trying to understand and predict. Some stories of miraculous results from medical treatments are simply cases in which the patient was having a particularly bad run of symptoms and then felt better after getting treated.

If we systematically followed up all these stories, we would find a fair number of people whose symptoms returned despite continuing the supposedly effective treatment. Just like we find that almost any fad diet works for some people, and yet by a year most of them have gained back the weight they lost initially. Companies and practitioners selling alternative therapies, however, don’t make a point of systematically following up on all their satisfied customers’ testimonials to see which eventually got sick again. I wonder why that is? 

  1. Placebo Effect:

Everyone hates this one because it means you believe something which isn’t actually true. You use a treatment and feel better, but if it’s just a placebo and your disease isn’t actually any different, that means you must be crazy or stupid, right? No! Claiming that a perceived change is only the result of a placebo effect isn’t an insult to the patient. It is simply a fact that all human beings see want we want to see a fair portion of the time, and that sometimes we interpret what we see to mean something that it doesn’t really mean.

In the case of medical therapies, almost anything I give a client, they will perceive some improvement right after simply because we’ve done something and we know we are supposed to be looking hard for any sign of an effect, especially since we really want there to be one. Again, systematically following up all these early responses often reveals no meaningful change, but if you ask at the right time, the answer will almost always be positive and suitable for use as a testimonial.

  1. Misdiagnosis:

Sometimes, the reason a disease went away after an unconventional treatment (or a conventional one, for that matter) was used is because the disease was never there to begin with. Doctors aren’t perfect, and they sometimes diagnose diseases the patient doesn’t have. Any certainly people who aren’t trained medical professionals but who diagnose themselves or their pets are quite likely wrong a lot of the time. It’s easy to cure a disease that a patient didn’t have, so one of the first questions to ask about any miracle story is what hard, objective, tangible evidence is there to support the diagnosis? If your dog had cancer and it was cured by some kind of pseudoscientific nonsense like homeopathy, there had better be extensive imaging and before and after biopsies with long-term follow up before you start claiming homeopathy actually works and all the laws of physics and chemistry are mistakes.

You Can’t Prove It Isn’t a Miracle!
Another problem with miracle stories as proof that specific medical treatments actually work is that such stories can’t ever be proven wrong. And if something can’t be proven wrong no matter what, then you have to believe each and every one equally, which as we will see is probably the biggest problem with anecdotes.

Of course, the main reason you can’t disprove a miracle tale is psychological; cognitive dissonance is such a powerful and ubiquitous feature of the human brain, that it is almost impossible to convince someone they are wrong about a strongly emotional personal experience. Just as it is a great relief and comfort to know that you saved your beloved pet by using an unconventional therapy your vet said wouldn’t work, it is equally terrifying to believe that actually the therapy had nothing to do with your pet getting better and that not only did you waste your money and put your pet at unnecessary risk, but the world is ultimately unpredictable and uncontrollable and “As flies to wanton boys, are we to the gods. They kill us for their sport.” (King Lear) People cling to their miracles largely because these stories give them hope that bad things can be avoided or controlled if we just find the right things to do or believe.

Another reason miracle stories are unfalsifiable, which makes them largely useless as a form of evidence in science, is that they consist of very limited and selective information. By definition, anecdotes presented to show a treatment works contain only information that supports the effectiveness of the treatment. It wouldn’t be a miracle if at the end of the story the disease killed the patient. But does that mean there aren’t stories about the same treatment in which there was no benefit? Or even great harm? No, of course not. Testimonials are a form of “evidence” that is positive by definition, and that necessarily excludes negative evidence no matter how much of it might actually exist.

Of course, for a true believer, it would make no difference even if one could produce a story of failure for every single story of success. Cognitive dissonance would simply move the believer to say, “Well, maybe it doesn’t work for everybody, but it sure worked for me!” But for anyone trying to make an objective decision about how likely a particular therapy is to be effective, it is worth noting that testimonials and other anecdotes leave out all the stories that show the therapy failing, so they are an inherently biased kind of evidence.

Everything Works!
Though it doesn’t always show up on the typical lists of reasons why we shouldn’t trust miracle stories, to me the most damning argument against them is simply that they can be found supporting every medical treatment ever invented. On this blog alone, you can find a testimonial in the comments for nearly every product or therapy I have questioned, despite the fact that most of them have entirely different theories and methods by which they are supposed to work. And if you look at alternative medicine in general, there is not a single practice that you can’t find lots of people with powerful, emotional stories showing positive results.

But let’s go beyond the alternative therapies popular in the US today. Sure, there are plenty of testimonials for, say, Double Helix Water. How about for other kinds of magic water?

Homeopathy (after all, it’s just water)
Lourdes Water
Electron Water
pH Miracle Water
Kangen Water
Hexagon Water
Pranic Water
Ypsilanti Water
And even just Plain Water

So does every kind of water cure disease? Maybe the problem isn’t that testimonials aren’t unreliable. Maybe we’ve just stumbled across the fact that water itself is medicine? Ah, but I wonder then if we can find the same testimonials for every other therapy ever invented? Let’s see.

Christian Spiritual Healing
Islamic Spiritual Healing
Hindu Spiritual Healing
Christian Science Healing
Ancient Greek Healing
Ancient Roman Healing
Norse Magical Healing
Shamanic Healing
Theta Energy Healing
Ritual Child Sacrifice for Healing
Crystal Healing
Laser Healing
Bloodletting Healing
Magnetic Healing
Angel Therapy
Urine Therapy

Anyway, this list could be endless even without including the most popular alternative therapies. But it seems to suggest we should ask this question: If testimonials and miracle stories exist to support every medical treatment ever invented, does that mean every treatment works, or does it mean testimonials aren’t reliable?

Testimonials are useful only to generate hypotheses, or to illustrate theories that must be demonstrated by other means. By themselves, they prove nothing. Not only are they not reliable for all the reasons I’ve discussed, but if we accept them as compelling evidence, we commit ourselves to believing in everything at once, or simply arbitrarily choosing which stories to believe and which to doubt. This does not lead us to separating truth from error.

 

Posted in General | 10 Comments

What do Veterinarians Know About Nutrition?

Posted on July 8, 2012 by skeptvet

It is not unusual for people promoting unconventional, approaches to pet nutrition, such as raw diets, grain free foods, homemade diets, a preference for organic ingredients, and so on, to dismiss objections to these approaches made by veterinarians. These people will often claim that veterinarians know little about nutrition and that what they do know is mostly propaganda fed to them by commercial pet food manufacturers. Like most bad arguments, this one contains a few bits of truth mixed in with lots of unproven assumptions and fallacies.

Most veterinarians do have at least a semester course on nutrition in general. And a lot more information on the subject is scattered throughout other courses in vet school. So the idea that we know nothing about the subject is simply ridiculous. However, it is fair to acknowledge that most veterinarians are not “experts” in nutrition, if by this one means they have extensive specialized training in the subject. The real “experts” in this area are board-certified veterinary nutritionists, individuals who have advanced residency training in nutrition and have passed the board certification exam of the American College of Veterinary Nutrition.

Of course, as I always take great care to point out, expertise is no guarantee of never falling into error, particularly expertise based primarily on experience and a familiarity with the opinions of other experts rather than solid scientific research. Given the limited research data available on many important questions in small animal nutrition, even the real experts are often forced to rely on extrapolation from basic science or research in humans and their own clinical experience, which are important sources of information but always less reliable than studies specifically designed to answer these questions. Nevertheless, boarded nutritionists have a legitimate claim to expert status in this area. And as a group, they generally are skeptical of many of the alternative approaches to nutrition, as they should be give the paucity of data to support them As for the question of the role of the pet food industry in veterinary nutrition education, there is some truth to the claim that much of that education is sponsored by companies who make pet foods. Obviously, most veterinary nutritionists put their training to work researching and evaluating food for veterinary species, so the money and expertise in this area tends to concentrate in industry. And it is not entirely unreasonable to ask the question whether or not this influences the information veterinarians get about nutrition. It quite likely does.

This is not the same thing as saying that veterinarians are all lackeys or dupes of industry and unable to think critically for themselves, however. I am generally as skeptical and critical of pharmaceutical companies and mainstream pet food companies as I am of herb and supplement manufacturers and producers of alternative diets. All of them have both a genuine belief (most of the time) in their products, a genuine interest in the welfare of the animals they serve, and a high risk of bias and cognitive dissonance that impedes their ability to see and accept the flaws in their own reasoning or the data that contradicts their beliefs.

One should always be aware of bias, but that awareness does not justify ignoring the arguments or evidence coming from a source with potential bias, only evaluating it carefully and critically. The reason science is so much more successful than unaided reasoning is precisely because it is a method for compensating for human biases and other cognitive limitations that interfere with our seeing the truth. Mainstream pet food companies undoubtedly have biases, but often they also have good scientific data, which is rarely available for the alternative products and approaches. Ignoring this data in favor of opinion, theory, or personal experience is not a recipe for improving the state of veterinary nutrition.

The real issue is not so much what do general practice veterinarians know about nutrition as what is the evidence supporting the alternative theories and products being promoted? The accusation that vets know little about nutrition, even if it were true, doesn’t invalidate their criticisms. The classis ad hominem fallacy is the strategy of attacking a person and imaging that somehow this attack says anything about that person’s argument. It is the mirror image, in many ways, of the appeal to authority fallacy, which involves claiming some special wisdom or expertise on the part of a person making an argument and then imaging that claim somehow proves the argument. If proponents of raw diets or other unconventional nutritional approaches wish to make a case for their ideas, they have to do it based on logic and facts, not on the presumed expertise of supporters or the supposed ignorance of critics. As always, it is the ideas and the data that matter, not the people involved.

That said, there is a certain hypocrisy to many of these criticisms in that they come from sources with no particular right to claim expertise in nutrition anyway. Proponents of alternative nutritional practices are almost never boarded veterinary nutritionists. Often they are lay people who have labeled themselves as experts without even the training general practice veterinarians have in nutritional science. And while they may not be influenced by the mainstream pet food industry, this only means they are less subject to that particular bias, not that they don’t have other biases. People selling pet food or books on veterinary nutrition are all too often blind to the hypocrisy of claiming their opponents are under the influence of pet food companies while ignoring the fact that they make money selling their own ideas or products.

Others who frequently claim most veterinarians know little about nutrition are themselves general practice veterinarians or specialists in some aspect of veterinary medicine other than nutrition. It may very well be true that they are well-informed about nutrition because they have an interest in it, but this is not evidence that their arguments are true and those of their opponents are false. It is not even evidence that they know more about nutrition than their detractors, who may themselves have studied independently in the area. If you’re not a boarded nutritionist, you can’t claim to be an expert. And whether or not you are an expert, your ideas must stand or fall on their merits and the evidence, not on any presumed superiority in your knowledge over that of your critics.

So I think it is fair to say that most general practice veterinarians have only a fairly general knowledge of veterinary nutrition. And it is fair to acknowledge that much of this information comes from a source with a significant risk of bias, that is the pet food industry. However, I see no evidence that proponents of alternative approaches to nutrition have a reason to claim they know more about nutrition than most veterinarians, or that they are free from biases of their own. Only boarded veterinary nutritionists can legitimately claim to be “experts,” and even this is no guarantee of perfect objectivity or the truth of everything they believe. Claims about who is or is not smart or informed enough to have an opinion on a subject are mostly a superficial distraction from the important elements of any debate, what are the arguments and data behind each position. Awareness of potential bias only serves to make one more careful and cautious in examining someone’s arguments and data, it doesn’t get one a free pass to ignore what they have to say.

Posted in Nutrition | 36 Comments

From SBM: Alternative Medicine Claims to “Individualize” Therapy, but Does It?

Posted on July 6, 2012 by skeptvet

Posted today on the Science-Based Medicine Blog

Testing the “Individualization” of CAM Treatments

 

One of the common claims of alternative medicine practitioners is that they individualize their treatment while conventional medicine treats all patients the same. This is nonsense on several levels, but it is also a common excuse for why randomized clinical trials cannot be performed, or cannot be viewed as reliable evidence, in evaluating some alternative therapies. However, some trials have been done that attempt to account for this supposed individualization of therapy, and generally they have failed to show a benefit to the supposedly individualized approach. One of those, involving Traditional Chinese Medicine (TCM) was recently discussed by Edzard Ernst, one of few, and most productive researchers in the CAM field applying an evidence-based approach.

Matthias Lechner, MD, Iva Steirer, MD, Benno Brinkhaus, MD, Yun Chen, CMD, Claudia Krist-Dungl, MS, Alexandra Koschier, MS, Martina Gantschacher, MA, Kurt Neumann, MS, and Andrea Zauner-Dungl, MD. Efficacy of Individualized Chinese Herbal Medication in Osteoarthrosis of Hip and Knee: A Double-Blind,Randomized-Controlled Clinical Study. The Journal of Alternative and Complementary Medicine. 2011;17(6): 539–547.

First, why is the notion that CAM is somehow more individualized than conventional care total nonsense? Well, to begin with, any good doctor considers the particular history, physical examination findings, diagnostic test results, known medical problems, and concurrent therapies of each patient. If individualized treatment simply means considering the unique circumstances and values of the particular patient you are treating, then all good medicine is individualized. That concept is even built into the common definitions of evidence-based medicine:

Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. (Sackett)

[EBM is] the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances.(Strauss)

However, when CAM practitioners claim that formal scientific research and science-based medicine ignore individual variation, they are usually referring to the practice of studying groups of patients under controlled conditions and then applying lessons learned from those studies to the care of individuals. They claim that since we are all snowflakes, utterly unique, what is learned from groups cannot tell us anything useful about individuals.

This argument fails most dramatically on the simple evidence of the tremendous effectiveness of science-based medicine. Tens of thousands of years of looking at patients one by one and trying to figure out based on those experiences what to do for the next patient failed to control or eliminate any common diseases or meaningfully improve the length and quality of human life and health. A couple of centuries of gradually relying on formal scientific research instead of such haphazard individual experiences has wiped out or dramatically reduced many common and deadly diseases, nearly doubled average life expectancy (at least for those who can afford to use science-based medicine), and in many other ways unequivocally improved our health. It requires deep self-delusion to deny that science works better than prescientific, unstructured ways of figuring out how to preserve and restore health.

On a more theoretical level, however, consider this. Statistics can indicate the probability of winning or losing a game of chance very precisely, on the group level. As an individual, of course, you can’t know with certainty whether you will win or lose if you go to Las Vegas and play these games because these statistics only describe what happens over the course of many trials, that is what will happen on average when large numbers of people play. They don’t predict for you, as a unique individual, what your results at blackjack or roulette will be. This is very much like the situation in science, where controlled studies look at outcomes on the level of the group but can’t precisely predict the results of a therapy in an individual patient.

And yet, casinos make enormous sums of money by playing the odds and expecting that most people will lose. This is a successful strategy for them. And many people lose, some with disastrous personal consequences, by imagining that they are exempt from the statistical rules that apply to groups and that some special individual factor will allow them to beat the odds. Choosing to believe that general statistical principles don’t apply to them because they are special and unique ruins people’s lives in Vegas, and in medicine. Choosing to play with or against the odds, as defined by formal research, is no guarantee, but it is much more likely to lead to a good outcome than imagining the odds don’t matter because each of us is unique.

Finally, when a CAM practitioner claims they treat every individual patient based on that patient’s unique characteristics and that science-based medicine treats all patients as if they were the same because it bases treatment guidelines on research done on groups, they are simply mistaken. If a series of controlled studies indicates that Treatment X is better than Treatment Y for a certain diseases, and if I use this to support giving patients with that disease Treatment X most of the time, then yes I am applying information gained from population research to individuals. I am playing the odds.

However, if a CAM practitioner looks at a patient and evaluates their particular characteristics and then decides on a specific treatment, where do they come up with the connection between the patient’s characteristics and the treatment? They use their personal experience, gained from seeing what happens with prior patients, or they use rules laid down by other practitioners based of their own experiences, or they rely on general rules based on the theoretical ideas behind the style of therapy they use. In other words, they extrapolate from observations made on other patients to the individual they are currently treating.

This is exactly the same as what a science-based practitioner does with one important difference: the generalizations that scientific medicine applies to individual patients come from formal, controlled research designed to compensate for the unreliability of individual observations and judgments, whereas the generalizations used by CAM come from informal, unstructured observations with no control for bias or the many common errors that mislead us when we study disease. CAM practitioners are using generalizations based on the study of groups to decide how to treat each new case, they are just relying on poorer quality group evidence.

Ok, so how does this apply to the clinical study that looked at supposedly individualized TCM herbal therapy for arthritis of the knee? Well, the study started by randomly assigning patients to either receive individualized herbal treatment based on the judgment of experienced practitioners in each case, or a standard herbal mixture believed, again based on past experience with groups of patients, not to have any benefits for arthritis. The experimental formula consisted of a number of herbs selected in advanced based on TCM theory which the investigators expected might be useful for the kind of disease they were studying. However, individual patients received particular combinations of these ingredients based on the judgment or practitioners at the time they were evaluated.

The control treatment (not really a placebo since it contained chemicals which might or might not have real physiological effects, since none have been thoroughly evaluated in scientific studies) was a collection of herbs not believed to have benefit for arthritis based on prior experience and TCM theory It was made to taste similar to the herbs pre-selected for the experimental treatment to help make it harder for patients to know which they were receiving. I can already hear the complaints of some herbalists that this makes it an inappropriate control since taste is one of the guiding principles for the use of herbs in some approaches to herbal medicine. I’ll leave that pseudoscientific objection aside for now since it’s not directly relevant to the point here.

Baseline characteristics were similar between the two groups of patients, and randomization and blinding appeared to be properly conducted. Overall the study was well-done methodologically, with a formal accounting of patients lost to follow-up and a reasonable effort to use standard and predefined outcome measures. 

So what were the results? Well, as is usual in a study looking at a subjective measure like pain, all patients improved. There was, however, no difference between those who received individualized treatment and a random herbal concoction not expected to have any effect on arthritis. This most likely indicates nothing happening here other than nonspecific effects associated with participating in a trial, including placebo, regression to the mean, the Hawthorne effect, and all the usual suspects that fool us in clinical trials, and in real life.

This study nicely illustrates several of the issues associated with supposed individualization of CAM treatment. First, it shows that such treatment is not, in any meaningful sense, any more individualized than good quality science-based medical treatment. Choosing a selection of herbs based on previous experience, historical use, tradition, and the unscientific theories of Traditional Chinese Medicine, and then selecting which of these herbs to give each patient based on the same prior experience and unscientific theory, is still applying generalizations based on groups to individuals. It simply uses generalizations based on unreliable sources of data.

The study also illustrates that individualizing therapy in this way doesn’t add any efficacy to the treatment. Not surprisingly, the study showed, as the others mentioned early have as well, that tailoring treatment to individuals based on generalizations derived from biased and unreliable sources of information leads to a therapy no more effective than randomly picking herbs out of a hat.

The difference between effective science-based medicine and ineffective medicine of any kind, conventional or alternative, is that the general principles used to guide therapy are derived from formal, controlled research that compensates for the weaknesses in our individual, informal, and unstructured judgment. If individualized medicine is just a code for using informal group observations instead of structured scientific ones to guide therapy, than it is not surprising that it doesn’t work any better than just making up a treatment haphazardly with no guiding principles at all.

 

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