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From the Townsend Letter for Doctors & Patients
August/September 2004

 

War on Cancer
ASCO Meeting
briefed by Ralph W. Moss, PhD

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I have just returned from the 40th annual meeting of the American Society for Clinical Oncology (ASCO). The meeting coincided with my 30th anniversary in the cancer field, as I was hired as science writer at Memorial Sloan-Kettering Cancer Center on June 3, 1974. And so this trip was a very good time for me to reflect on the status of complementary and alternative medicine (CAM) and the changes that I have witnessed in the war on cancer over the past three decades.

The first word that comes to mind in reference to ASCO's meeting is "huge." There were over 25,000 participants, mostly medical oncologists, and they took over New Orleans' cavernous 1.1 million square foot Convention Center. They came to lecture and be lectured to about the latest advances in cancer treatment. In addition to the gargantuan plenary sessions, there were hundreds of smaller sessions and approximately 1,500 poster and oral presentations, and 8,500 other research summaries given as Abstracts. Oncologists swarmed around the towering commercial exhibits, read and discussed the latest research and of course schmoozed, dined and did whatever professionals do when they assemble for a collegial good time.

Although I was aware of the featured papers I was more interested in gathering information on unusual, unconventional and out-of-the mainstream treatments than on those that grabbed the headlines. I must say that I came away disappointed.
The takeaway message of the meeting, repeated in a thousand stories, was that "little by little, new targeted therapies are helping cancer patients live longer, even if they do not offer miraculous cures…" (Borden 2004).

The New York Times, on its front page, featured an anecdote about a single patient who appeared to have benefited from a new Bayer drug in a clinical trial (Pollack 2004a). I guess I have been down this road too many times in the last 30 years to put my faith in such anecdotes, until I see the promising results confirmed in rigorous clinical trials. In the meantime the public is kept from seeing the real picture which is that advanced cancer is no more curable today than it was 30 years ago, a sobering truth that was fully examined in a recent Fortune magazine article: Click or go here for a discussion of the Fortune article: http://www.cancerdecisions.com/040404.html

There are a million clever ways to dance around this central fact, but none of them can ultimately obscure this depressing truth.

You would think that in the face of this conspicuous lack of success the oncology profession would be eager to reach out for new ideas and concepts. And, as I have shown throughout my career, there are abundant new ideas in the world of CAM. But instead of welcoming CAM, they react to it as if it were a competitive challenge rather than an opportunity.

The majority of presentations at ASCO still concern cytotoxic chemotherapy, but the new twist is to add 'targeted' drugs, such as Iressa and Erbitux, to the mix. The existence of these new targeted drugs does raise some interesting possibilities, but one shouldn't put all one's eggs in one basket. The typical treatment protocol used to be based on the hypothesis 'What happens if we add drug A to conventional drugs B and C?' Now the question has become, 'What happens if we add targeted agent A to conventional drugs B, C and D?' The differences in outcome are tiny. Meanwhile, the combinations become more complicated and much more expensive — too expensive, The New York Times even suggested, for society ultimately to bear.

Meager Findings
Something radically new is needed. But, once again, the number of presentations on non-toxic or alternative treatments was meager. First, a word of caution. Like the three blind men studying the elephant, everyone comes away from a meeting this huge with their own distinct impression. Although I spent three days at the meeting I readily admit that I might have missed a few relevant presentations. (The Meeting Program itself runs to 341 pages and the Proceedings total over 1,000.) Nevertheless, the absence of CAM was conspicuous — and somewhat mystifying, also, in view of the fact that CAM treatments for cancer are generally acknowledged to be extremely important to patients and to society as a whole. For instance, a study presented at this year's ASCO meeting showed that fully "91% of patients surveyed reported using at least one CT [complementary therapy, ed.] since diagnosis" (Yates 2004). Ninety-one percent! Yet despite this, I found only a single lecture (out of many hundreds) that included a discussion of CAM. This was the Saturday (June 5th) presentation on "Complementary and Palliative Care for the Treatment of Pediatric Cancer." Two speakers talked at length about palliative care as a distinct issue. Only one speaker, Kara Kelly, MD, an Assistant Professor of Pediatrics at Columbia University, New York, and co-chair of the Complementary Therapies Committee of the Children's Oncology Group (COG), then spoke about complementary medicine.

Although Dr. Kelly is a reasonable voice in the field of academic CAM studies, I found her presentation downbeat. She emphasized the negative aspects of the topic, such as potentially adverse interactions of herbs and conventional drugs, while de-emphasizing the positive impact that vitamins and herbs might have for patients. At the end, however, she did concede that CAM could be useful to mitigate the side effects of conventional treatment. She cited research done at Columbia showing that lower blood levels of antioxidants were associated with increased adverse effects of chemotherapy (Barclay 2004). I felt like a single crumb had fallen off the vast ASCO banquet table.

In the Question and Answer session that followed, one angry doctor assailed parents who expressed a desire to use CAM for their children. These people, he claimed, were actually suffering from a psychopathology (a fancy word for mental disease), and had what he called "control issues" vis-à-vis their doctors. (The topic is sensitive since doctors in the US have the legal ability to force pediatric patients to submit to chemo and other conventional treatments.) He also said that doctors who offered alternative treatments were motivated by greed (a charge I considered hypocritical considering the intimate ties of ASCO and many of its members with the pharmaceutical industry). There was embarrassed silence at the podium, and none of the three speakers — good people all — saw fit to challenge these intemperate remarks.

Posters No Better
The poster sessions filled one section of the vast convention hall. I thought for sure I would find some interesting and unusual presentations there. But this was not the case. On two consecutive days I squeezed my way past most of the posters. Whenever appropriate, I spoke to the presenters.

One of the first was Catriona McNeil, MD, a young doctor from New South Wales, Australia whose poster presentation warned against the "delay in conventional breast cancer treatment associated with alternative therapy usage" (Abstract #593). This poster contained some of the most grisly pictures of untreated breast cancers I have ever seen. Really in-your-face stuff. Her presentation concerned six patients who had been treated at two Sydney hospitals, and who had delayed conventional treatment in order to try alternatives. Three of them died while the other three were still alive and possibly cured by conventional means.

Now, I happen to believe that women who have curable breast cancers should accept conventional treatment and use alternative treatments only as adjuncts. And I certainly have known a few women over the years who I think made tragic choices in this regard, some of whom lost their lives in the process. So I would be the last person to say that this is not a potential problem. But exactly how big a problem is it?

According to the impression given by these Australian doctors, it is a huge one. "Alternative therapies," the presentation cautioned, "are used by between 28% and 83% of women with breast cancer, but their impact is causing deleterious delay in commencing empirically validated conventional therapies…."

This young doctor, thinking I was a fellow oncologist, began to confide in me on what she presumed was our shared desire to limit the use of CAM treatments! I corrected her misunderstanding and explained my position. I then asked how frequently this problem actually occurred. She didn't know, but volunteered that there were at least 6 oncologists involved and each of them saw about 200 new patients per year. So they see about 1,200 new patients per year. Since the study ranged over a four-year period, the patient base from which these six cases were drawn was approximately 4,800 patients. Thus, the "deleterious delay" affected 0.125 percent of the total patient population. This is obviously a miniscule proportion of the total number of women treated, a fact not pointed out in the presentation. Quite the opposite, the authors drew global conclusions about "a medico-political climate that favors accommodation of non-traditional adjuncts to cancer therapy." Dr. McNeil indicated that alternative medicine was so popular that many oncologists feared to criticize it.

What amazed me was that Dr. McNeil and her colleagues considered this problem serious enough to do a study, create a grisly poster, and then travel 10,000 miles to warn their American and international colleagues about this imminent danger. This more or less set the tone for the other CAM-related presentations that I saw and read.

One researcher at Massachusetts General Hospital, Brian D. Lawenda, MD, did present an interesting and objective poster (Abstract #9601) on how vitamin E and EGCG (an antioxidant compound in green tea) might modify the effects of radiation. The premise of the study was, however, a negative one, i.e. that "dietary antioxidants may play an antagonistic role during radiation treatment (RT)" In fact, the opposite is true. As I explained in my book,
Antioxidants and Cancer, most studies show not an antagonistic but a harmless or synergistic interaction when antioxidants are given concurrently with conventional treatment.

Be that as it may, Dr. Lawenda and his Boston colleagues implanted cancer cells into the legs of mice, and then gave them either vitamin E or EGCG. There was a small and statistically non-significant 4 percent increase in the radiation dose necessary to control 50% of the tumors locally (the so-called TCD50). But EGCG by itself significantly decreased the tumor growth rate by 10 percent. There was also less general toxicity when animals were administered these nutrients: less than half of the EGCG-treated mice had to have their limbs removed after radiation treatment (9.8 percent vs. 23.8 percent in the control animals). For patients, this could translate into a rather significant benefit from a simple and non-toxic regimen involving taking the equivalent of 2-3 cups of green tea per day. (This was an animal study and so the usual limitations of such studies apply.)
The paper concluded that "adverse [radiation therapy]-related soft tissue reactions occurred less frequently with antioxidant supplementation…." Although Dr. Lawenda seemed especially eager to explore the issue of antioxidants' possibly negative impact on the TCD50, he was clear that the takeaway message was the dramatic lowering of the toxicity of the treatment. This was the most positive thing I heard about any CAM treatment at the convention. Sadly, while some of the 'targeted' treatment posters were so crowded that you had to fight your way in, New York subway-style, just to read them, Lawenda's study was completely unattended during the time I visited it.

Remission Accomplished!
On the exhibit floor the picture got even worse. One booth bore the provocative title, "Remission Accomplished!" (I hope the "remission" quote that it accomplished lasts somewhat longer than the "mission" that Pres. Bush celebrated last May.)

This whole conference floor was a paean to the surging profitability of the new cancer medicine. As Andrew Pollack of
The New York Times made clear, the ASCO meeting has become the new trading floor of the whole biotech industry (Pollack 2004b). "Analysts, many of them with medical or science degrees, pack the meeting rooms and photograph the presentation posters with digital cameras" (ibid.).

According to the May 2004 issue of
Hem/Onc Today magazine, there are now over 500 indications being explored in hematology/oncology using new drugs. In five years the "hem/onc's pipeline grew by 43 percent." In other words, business is booming. On the floor, huge corporations jostled with one another for control of the best space, each with its two or three-story high triumphalist display. More than once, beautiful young women tried to entice me into their carpeted booths to receive information on their company's products. (A similar thing happened to me in the evening as I strolled with a colleague down the French Quarter's raucous Bourbon Street.)

Overall, the actual amount of serious research into CAM presented at ASCO is so small as to be nearly non-existent. Readers can check this for themselves by accessing the ASCO Knowledge Center search engine (accessible at http://asco.org/ac/1,1003,_12-002577,00.asp).

I entered some popular CAM-related topics in the search engine and here is what I came up with:

Topic Total Abstracts
Antioxidants
3
Ascorbic acid
1
CAM usage
8
Cartilage (any kind)
0
Chronomodulated chemotherapy
5
Herbs
1
Homeopathy
3
Hyperbaric oxygen
0
Hyperthermia
7
Insulin potentiated chemotherapy
0
Licorice
1
Lycopene
0
Melatonin
0
Metronomic chemotherapy
5
Mistletoe
1
Photodynamic therapy
1
Polarity therapy
1
Prayer
4
Radiofrequency ablation
11
Vitamins (in general)
27

As you can see, many popular topics in CAM are unmentioned among the 10,000 Abstracts. These include hyperbaric oxygen, lycopene, melatonin, Coley's toxins, the therapeutic use of cartilage extracts, and so forth. And forget about the more controversial topics of laetrile, Essiac tea, Hoxsey herbs, Rife machines, noni, mangosteen, etc. The public can expect no help from the cancer establishment in making difficult treatment decisions in these matters. It seems that as far as the oncology profession is concerned, such treatments are simply beneath their contempt.

And yet, even the numbers on the above list, scanty though they are, give a falsely positive impression of how much work is going on. Many of these citations actually refer to the same few papers. Plus, many of these are not original research but once-over-quickly surveys that mention a treatment only in passing. Thus, the number of genuine, original studies of the safety and effectiveness of CAM treatments is very small.
If we put the term "complementary medicine" into the same search engine (for the body of the text), we come up with the following numbers:

2004 Abstracts 9
2003 Abstracts 6
2002 Abstracts 2
2001 Abstracts
4
2000 Abstracts 0

So I guess we're making some progress. In fact, if this were 30 years ago, I would know exactly how to spin the story on behalf of the cancer establishment. "This year saw a 50% increase in CAM-related papers over last year." And technically I would be right! At the rate of an increased three extra papers per year, I can confidently predict that in a mere 300 years from now, CAM will have become a significant minority interest at ASCO meetings.

So, let's see. On the one hand, we know that between 60 to 90% of all cancer patients are now using some form of CAM, and interest continues to grow. One paper, reviewed by Dr. Kara Kelly, showed that 86% of patients reported satisfaction with their alternative treatments. But on the other hand, we have the painful spectacle of 25,000 oncologists with their heads in the sand, diligently avoiding serious study of those very topics that are of the greatest interest to their patients.

When the public and Congress rise up against this intolerable situation — and they will short-sighted oncologists will have no one to blame but themselves.

References
Barclay, Laura, MD. Many children with ALL deficient in antioxidant vitamins. Medscape Medical News, June 7, 2004. Accessed June 8, 2004 from: http://www.medscape.com/viewarticle/480092?src=mp
Borden, Bill and Pierson, Ransdell. New drugs chip away at cancer, Reuters, June 6, 2004. Accessed June 8, 2004 from: http://www.reuters.co.uk/newsArticle.jhtml?type=healthNews&storyID=5354434
& section=news
(2/20/05: Link not viable.)
Pollack, Andrew. Drugs may turn cancer into manageable disease.
The New York Times, June 6, 2004. Accessed June 8, 2004 from: http://www.nytimes.com/2004/06/06/health/06CANC.html (citedas 2004a)
Pollack, Andrew. Annual Cancer Conference Becomes Laboratory for Stocks.
The New York Times, June 8, 2004. Accessed June 8, 2004 from:
http://www.nytimes.com/2004/06/08/business/08pl ace.html (cited as 2004b).



 

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