Monday, December 4, 2006

Alternative therapies in cancer in JCO: pediatric ethics & lack of evidence

Two from the latest Journal of Clinical Oncology

First is an opinion piece about parents refusing standard cancer treatments for children with favorable-prognosis cancer. They describe a case in which a 7 year old with ALL who was undergoing curative chemotherapy (expected 85% chance of a long-term cure), and whose parents stopped the chemotherapy and put the boy under the care of a MD who was also a licensed 'holistic' practitioner. Child protection was notified and declined to intervene, as was the state medical board (regarding the 'holistic' MD) who also declined to intervene. The boy's leukemia relapsed.

The article is mostly a gloss of the pertinent medical-ethical-legal issues. Some interesting points were made: 6 cases like this that have been reported in the legal and ethical literature & of those six, when a licensed physician is responsible for the 'alternative' therapies, the courts have sided with the parents, refusing to judge the relative merits of different medical interventions recommended by different licensed medical practitioners. They also noted that the public reaction to the above case was very supportive of the parents' right to choose therapy for their children. What is interesting here is that apparently the calculus used by the courts is based on the mere fact of there being a licensed physician willing to give the 'alternative' therapies. Medical evidence--the fact that as a scientific and professional community we can say, with broad consensus, that intervention X (chemotherapy and supportive care) is very likely to lead to outcome Y (not dying from cancer when you're 7 years old), and that we can say with equal consensus that there exists no evidence that certain interventions (so called 'holistic ones') will lead to that outcome--apparently doesn't particularly enter into the court's decisions. It's as if there being some guy with an MD and a DEA saying "I'll do this" creates sufficient doubt to warrant parents making a decision that is objectively inferior. The problem of course is where does one draw the line, and clearly a 16 year old requesting 'holistic' treatment is different than a very vulnerable 7 year old's parents doing the requesting, and as medical uncertainty increases, medicine's imperative to treat against parents' wishes decreases, but this case, personally, gives me the willies.

Second is a "systematic review" of complementary & alternative therapies in cancer pain. Following a theme from a post from last week, one could predict the findings prior to even reading the abstract ("there is a paucity of data"). Just to give you an idea of the 'quality' factor that these reviewers were dealing with, I'll highlight one sentence from the Results section: "Two trials were listed as RCTs but did not present any data about comparison with a control group." Ouch. I'll repeat that for emphasis...Ouch. One's not sure how to even to begin to comprehend how such a trial could be published in an ostensibly peer-reviewed venue. The major message, besides the lack of evidence, is that what little there is is suggestive that some mind-body modalities hold some promise (hypnosis, relaxation, etc.). There are general exhortations that there needs to be more, better research into CAM at the end. That is certainly true, but one also has to ask the "Public Health" question. That is--given that there are limited research dollars into cancer symptom management--from a public health standpoint where is the best place to be putting those dollars? Standard medical research? CAM? Research and public programming focused on systems change--changing systems of delivery of care etc in order to improve the management of cancer systems? If I was a betting man I'd say that the 3rd would give you the biggest bang for your buck, but that is clearly my bias--that the epidemic of poorly treated cancer pain is not primarily due to a problem of lack of research into analgesic therapies. As a society we are not obliged to throw our money at research which is likely not to show any benefit.

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