What’s the Alternative? The Worldwide Web of Integrative Medicine

Ranjana Srivastava, F.R.A.C.P.
N Engl J Med 2012; 366:783-785March 1, 2012

Out of curiosity, an impressionable woman in her 30s attends an integrative medicine exhibition; having recently had a child, she’s been sleep-deprived and wants to investigate natural remedies. At the seminar, she wins a door prize — a blood test that promises to diagnose cancer. She was considering getting a blood test anyway and seizes this opportunity for a more comprehensive workup. After all, you can’t be too careful about avoiding cancer.

Weeks later, she receives a call from an apologetic but alarmed stranger telling her she has advanced cancer.
“How do you know?” she gasps.
“Your blood test is positive for circulating tumor cells.”
“What does that mean?” she cries.
He sends her a three-page report and tells her to seek immediate help. She spends a nail-biting week awaiting an appointment with the recommended integrative health expert. Glancing at the report, the expert declares, “You have advanced non–small-cell lung cancer. You need treatment now.” The woman is petrified: Has her teenage smoking habit come back to haunt her?
“Are you sure?” she asks.
“Absolutely. There are circulating tumor cells in your blood.”
Tears streaming down her face, the woman asks, “What now?”
The practitioner prescribes a 12-week course of intravenous vitamin C, at a cost of $6,000, paid up front. Without further discussion, an appointment is made.
The woman’s head is spinning. Who will look after her baby? How long does she have to live? Why her?

A scientist friend, however, expresses skepticism. “Shouldn’t you get a scan or something?” the friend asks.
The woman has her physician cousin arrange for a chest x-ray and CT scan. Lo and behold, two tiny nodules, 2 mm each in diameter, can be seen in her right lung. The report says, “Clinical correlation is recommended in the context of a smoking history.”
What to do now? Whom to trust? Someone suggests that surgeons today can remove the smallest of tumors. The woman seeks an appointment with a cardiothoracic surgeon and can’t get in soon enough. When she explains that she’s young and has cancer, the receptionist’s voice softens. “Maybe you can get your oncologist to call, dear.”

The hunt for a rapid cure brings the woman to my office. Relating her story, she shifts between self-assurance and sheepishness. “I know you find this incredible, but I need your help. I am dying of cancer.”
“There’s no evidence of cancer,” I reply, seeking to reassure her.
Instead, her tone sharpens: “But I have circulating tumor cells! How can you say that?”
Incredulous, I try to explain too many things. The blood test is a long way from being validated for clinical use. It was unscrupulous even to offer it. Does it make sense to her that it was sent to an unheard-of overseas laboratory for processing? Why did no one recommend that she see an oncologist?
Rolling her eyes, she counters, “I’ve heard that I need a PET scan. And if the spots light up, this test will have been my lifesaver.”
She is right on one count: the surgeon she sees orders a PET scan, saying he needs to be sure. She loses sleep over the results — the surgeon’s appointment is 2 weeks away, and she wants to schedule the operation. Feeling sympathetic, I tell her the PET scan was clear and the two small nodules seen on the first CT have disappeared; the radiologist thinks they were probably transient foci of inflammation.

But any relief the woman feels is ephemeral. “So what does that mean?” she asks. “The PET scan is faulty?”
“There is no cancer,” I reiterate.
“But someone has seen cancer cells,” she insists.
“That was not a validated test — not something we currently use to diagnose cancer,” I protest.
We go around in circles, and when we finish I suggest, hopefully, that the surgeon could follow up with her. Alas, the surgeon declines, and the woman wants neither to return to the integrative health practitioner nor to involve her family doctor: “I guess if I’m brewing a cancer,” she explains, “I want an oncologist to look after me.”
Amid my sea of patients dealing with actual cancer, I find her claim indulgent. But her anxiety is genuine, and it seems cruel to dismiss it. As a doctor, I’m struck by the ramifications of what an uninformed patient thought was just a blood test; but as a mother of young children, I empathize with her visceral fear for her future and that of her children.

She wants follow-up. Should she undergo regular CT surveillance indefinitely, or would the radiation be too toxic? Should the blood test be repeated at a respectable institution? “After all, I have had iron studies at three different labs, and they were roughly the same,” she reasons.
Like her, but for different reasons, I find her predicament maddening, as I reflect on a growing trend in medicine. How does one “disprove” a serious diagnosis once its specter has been raised by an unqualified “expert”?
At one time, the worst offense one encountered was someone prescribing a few herbs to a desperate patient who’d exhausted all other means of treatment. The usual thinking was, “At this stage, it can’t do any harm.” But insidiously and alarmingly, “alternative medicine” has crept from offering last-ditch treatments to making diagnoses. As the cancer armamentarium has expanded with targeted therapies, unscrupulous practitioners of alternative therapy have devised competing offers that sound at least as impressive to the average patient, who is often marginally health-literate and eager to embrace the promise of a cure without toxicity. But the radical, completely unregulated, and often dangerous options on offer can and do cause harm.
Just in the past year, my patients have discussed intravenous selenium, vitamin C, high-dose apricot kernel, ozone treatment, and microwave therapy as cures for their cancer. Most recently, a patient with bleeding from an occult cancer wasted 3 months seeking gel treatment after being advised that his iron-deficiency anemia was the result of a fungal invasion of his red cells.
The practitioners never write directly to oncologists and refuse to be accountable for their actions. Unauthorized to order tests, they tell patients, “Ask your doctor to do these bloods,” or “You need to have a scan to see whether the microwaves are working.”

Alternative therapies need meet no burden of proof except a patient’s gullibility. One never hears of alternative therapies that failed: the patient merely waited too long to try them. For every patient who openly discusses such treatments, there must be many who assume the treatments aren’t worth mentioning to “traditional” oncologists. After all, to make integrative health the multibillion-dollar industry it is, people must be supporting it; those people are our patients.
Physicians would be naive to ignore the elephant in the room. Integrative medicine comes in many forms — some useful, but many dangerous. It also comes at tremendous personal and societal cost. The initial expenditure may come from patients’ pockets, but often the health care system eventually inherits the problem. Although there’s probably no way of calculating the psychological cost, for many it is high and unending.
Oncologists generally avoid even mentioning alternative therapy, lest a whiff of interest in it contaminate their integrity. But to engage meaningfully with patients, we must know what they’re being offered and empower them to make good decisions. Patients should be gently reminded that if it sounds too good to be true, it probably is.
On a policy level, “alternative medicine” needs regulation. The phenomenon of questionable health practices is not limited to the developing world; my patient’s encounter occurred in a medically sophisticated city. Patients can even be duped at home, from the safety of their Internet connection.
If the measure of a good society is how it treats its sickest and most vulnerable, it is high time we paid attention to the elements in our society that are sorely missing the mark.
From the Department of Medical Oncology, Monash Medical Centre, Melbourne, VIC, Australia.

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