Cancer patients sometimes look to so-called complementary and alternative therapies to combat the disease. But what role should these therapies play in cancer care? Phin Foster asks Professor Edzard Ernst, the UK’s first professor of complementary medicine.
Professor Edzard Ernst caused a stir when he turned his back on traditional medicine and became the UK’s first professor of complementary medicine, at the Peninsula Medical School. Since taking up the post in 1993, he has firmly stamped his academic pedigree on a role that many initially scoffed at.
Phin Foster: What is your philosophy on complementary and alternative medicine [CAM]?
Edzard Ernst: For 13 years, I have been trying to send out a consistent message: we need reliable evidence and to avoid double standards. Recently, the influential Royal Society (London) published a statement, which, I am delighted to say, reflects my message perfectly: "CAM, like conventional medicines, should be subject to careful evaluation of its effectiveness and safety. It is important that treatments… are properly tested and that patients do not receive misleading information. NHS provision for CAM… should be confined to treatments that are supported by… evidence of both effectiveness and safety."
PF: Is CAM used differently in cancer care in the UK, Europe and the US?
EE: CAM differs considerably from country to country. For example, in Germany about two-thirds of all cancer patients try mistletoe injections. In the UK or US, this treatment is hardly known – which is perhaps just as well, as the best evidence fails to suggest effectiveness. There are plenty of other examples of treatments that are CAM in one country and mainstream in another. I often wonder how helpful the term "CAM" is. It would be better, I think, to evaluate each modality on its own merits.
PF: How much of an issue is managing the expectations of patients and practitioners regarding CAM’s benefits?
EE: Patient expectation is one of the mechanisms of a placebo response. It can therefore have a hugely positive influence on clinical outcomes. It needs to be channelled wisely, however. To disappoint expectation, that is to raise false hopes, can be cruel and unethical. Practitioner expectation can be a good thing. But there is a point at which practitioners could mislead patients because they themselves are unrealistic.
PF: How sympathetic have oncologists been to your work? To what extent has their stance changed over time? And are there particularly successful ways of getting your point across?
EE: Initially the establishment was sceptical about my appointment. "Do we really need a witch doctor?" they seemed to ask themselves. But gradually oncologists realised that I am not a promoter but an evaluator of CAM. Once this message had sunk in, I had no problems at all with them – on the contrary, I got much valuable support. The best way to get your point across in science is to publish good science.
PF: In which areas of the treatment of cancer and its symptoms is CAM of direct benefit?
EE: There are now a great many websites on CAM. Many promote "alternative cancer cures", using shark cartilage, mistletoe and Essiac, for example, for which there is no good evidence of a benefit.
Generally speaking, CAM will never offer a cure for cancer. If this or that therapy were to show promise, it would be adopted by conventional oncological research without hesitation. If, after adequate testing, it proved to be effective, it would be a conventional treatment, not a CAM. In this sense, an alternative cancer cure is a contradiction in terms.
This kind of statement upsets many CAM enthusiasts, who conclude that I negate the value of CAM for cancer. However, this is not true. I have always said that CAM can be most valuable in palliative/supportive cancer care. Aromatherapy, massage therapy, acupuncture and other treatments may well improve the quality of life of cancer patients. This is important, but it is also important to say very clearly that all alternative cancer cures are quackery and therefore a danger to cancer patients.
PF: How satisfactory is CAM in cancer care, and how much does its quality vary?
EE: Depending on which survey you want to believe, 30–100% of cancer patients try some form of CAM. Is this satisfactory? In the light of the previous answer, this might be a cause for concern.
PF: In what cases can the placebo effect be positive, and in what scenarios can it be negative?
EE: Few things are as misunderstood in medicine as the placebo effect. Much of what we think is a placebo effect may be something else entirely: regression towards the mean or the result of positive practitioner-patient reactions, for example.
True placebo effects can be very positive for patients. This fact is sometimes used to justify the use of a CAM intervention that has no specific effects at all, such as spiritual healing. In such a case, it is important to realise that we don’t need a placebo to generate a placebo effect. Every therapy potentially comes with the free bonus of a placebo effect. Clinicians should be aware of this and should maximise the placebo effect with every treatment they administer.
We should not require spiritual healers to generate placebo effects. Oncologists should be able to do this – crucially with the added benefit of the specific effects of their treatments.
PF: Does more need to be done to educate and inform the public and the medical profession about the benefits of CAM in cancer care?
EE: Yes. There is so much misinformation about CAM. Most of the websites that I mentioned earlier are touting misinformation in a big and dangerous way. Oncologists might love or hate CAM, but they must inform their patients about this area responsibly – and that means on the basis of the best available evidence. Contrary to what doctors still believe, there is now a substantial amount of evidence on CAM.
Likewise patients need to be well informed to make reasonable decisions. Very disappointingly, a patient guide published by The Prince’s Foundation for Integrated Health, and funded by public money, reads like a totally uncritical advertisement for unproven or disproven therapies. This is a scandal, in my view.
PF: What changes would you like to see in the next ten years?
EE: In ten years we should have achieved the aims expressed in the statement by the Royal Society I mentioned earlier. We should also have sufficient research funds to fill the huge gaps in our current knowledge. Finally, we should have CAM researchers who no longer use science as a method for proving their pet therapies, but as a means of objectively testing them.
PF: Can you give any examples of blatant quackery?
EE: The recent Smallwood Report is an example. This was a report aimed at the UK health ministers, commissioned by Prince Charles and funded by Dame Porter. It tried to influence UK health policy by drawing conclusions on highly selected evidence that were misleading.
Unfortunately, my field is still rife with blatant quackery. I could go on for a while and mention many more names. One thing to remember is: if it sounds too good to be true, it probably is.
PF: In what ways has your outlook changed over the past 13 years?
EE: If I’m honest and outspoken, which I always try to be, sometimes to the point of foolishness, I should say that I started my job 13 years ago with the intention of being a good scientist. This met with plenty of flak from the CAM field. Subsequently, I went through a phase where I thought: I should build bridges, agree to compromises and sometimes even turn a blind eye. I now think that this was wrong, and I am back where I started. I still want to achieve as much good science as I can. But now I am far less bashful in speaking out against bad science, quackery and what sometimes appears like a conspiracy to mislead the public on CAM.
The last change was triggered by thinking long and hard about where my true allegiance lies. I conduct research to find out the truth, as all scientists do. This may sound pompous but, to me, it is meaningful. I am not in the business of pleasing this or that interest group, of maximising my income, or of getting a knighthood. I believe the truth about CAM will help patients avoid wasting valuable time and money – on mistletoe, for example – and concentrate on treatments that actually work and can save lives.