Skip to content

Evolutionary aspects of cancer - Mel Greaves

On my book reviews page there is a review of Cancer: The Evolutionary Legacy by Mel Greaves. Anyone who is interested in this important topic should see Greaves's lecture to an audience of biologists published in 2013.

Greaves is Professor of Cell Biology at the Institute of Cell Biology in London. Two important messages emerge from his lecture. One is that the fundamental importance of Darwninian evolution for our understanding of disease in general and cancer in particular is still not fully recognised, and the other - which is a consequence of the first - is that much of the research in cancer treaement at present is missing the real point and is unlikely to provide a lot of benefit. The research effort needs to be directed differently. We also need to do more to achieve early treatment and improve prevention, both of which are achievable right now. The treatment of more advanced cancers is likely always to be difficult.

The history of the RCT

Many of us probably think of the randomised controlled trial (RCT) as a largely British invention dating from shortly after the second world war, but an interesting short paper in the NEJM shows that its antecedents go back much further (The Emergence of the Randomized, Controlled Trial: Laura E. Bothwell, Ph.D., and Scott H. Podolsky, M.D. N Engl J Med 2016; 375:501-504 August 11, 2016 DOI: 10.1056/NEJMp1604635).

RCTs thus represent the most recent outgrowth of a long history of attempts to adjudicate therapeutic efficacy. Their immediate ancestor, alternate-allocation trials, emerged as part of a trend toward empiricism and systematization in medicine and in response to the need for more rigorous assessment of a rapidly expanding array of experimental treatments. Alternate allocation represented a significant advancement for addressing clinical research bias -- but one that had limitations as long as it allowed foreknowledge of treatment allocation. Concealed random allocation merged s the solution to these limitations, and RCTs were soon supported by crucial public funding and scientific regulatory nfrastructures.

This open-access paper is well worth reading.

The priesthood of public health

Richard Lehman has a blog about medical research at; extracts from this appear as Research Update each week in the BMJ.

On 16 July 2016 Dr Lehman had a nice comment on a recent JAMA article on "the theology of eating fat", in which he referred to diet pundits as "the priestbood of public health". The occasion was a recently published large-scale study of nurses and doctors in the USA, which concluded that saturated fat is bad for you.and polyunsaturated fat is good. Lehman's comment is that it "doesn't provide the priestbood with very much to preach about in my opinion".

The Greek government is endorsing homeopathy

My wife has provided this item of information from the Greek news.

A medical furore is going on because the government has appointed an eleven-member committee composed of ten doctors and one pharmacist, all of them homoeopaths, to pronounce on whether homoeopathy should be officially recognised as a valid treatment in Greece with requirements set for the qualifications needed to practise.

Dead against this are the majority of the medical community, who point out the unsuitability of the committee and the lack of evidence that homoeopathy is anything other than placebo.

From religious quarters there are also complaints that all complementary medicine is based on mystical and other undesirable ideas, all of which are considered heretical by the Orthodox Church, and as such should not be given
official recognition in an Orthodox country.

Of course, one reason for the government's enthusiasm for this idea may be the fact that homeopathic medicines are relatively cheap.

Book review: Do No Harm, by Henry Marsh

Henry Marsh is a neurosurgeon who has headed his department at a London hospital for many years and has worked in the Ukraine to help set up neurosurgery there. In this book he provides an extraordinarily vivid account of his work and its emotional impact both on himself and on his patients and their relatives. The book consists of a large number of short chapters, each of which tells a story usually linked to a particular kind of brain abnormality. Some chapters are autobiographical and tell us about events in Marsh's own life and how he came to study medicine and become a neurosurgeon.

Patients, Marsh says, invest their doctors with superhuman qualities as a way of overcoming their fears when undergoing surgery.

The reality, of course, is entirely different. Doctors are human like the rest of us. Much of what happens in hospitals is a matter of luck, both good and bad; success and failure are often out of the doctor's control. Knowing when not to operate is just as important as knowing how to operate, and is a more difficult skill to acquire.


In Memoriam: Dr Felix Mann 1931-2014

Felix Mann

The death earlier this month of Dr Felix Mann after a long illness marked the end of an era for me, as it no doubt did for many doctors who learnt acupuncture from him in the 1970s. I first met him when I attended his course in 1977. At that time I was interested in oriental philosophies and that made me want to learn acupuncture, but I had no idea how to go about it. Then I happened to talk to a consultant who was head of the Migraine Clinic and who had recently done Felix's course. She told me it was worth while, so I registered for it.

The course was held in Felix's consulting rooms in the large house he had bought in Devonshire Place, in the West End of London. It lasted five days. There were fourteen of us. We sat in a semicircle on rather hard chairs while Felix stood in the middle and talked to us. From time to time patients would arrive to tell their stories and be treated. This was what I was expecting, but there was an early surprise.

Before starting the course we were supposed to read Felix's books. At that time they were based on traditional Chinese acupuncture and I don't think that any of us made very much of them. But this didn't matter because the first thing that Felix said to us was "I don't believe this stuff any more."

I have to admit that my initial reaction was disappointment, since, as I've said, it was an interest in Eastern ideas that had prompted me to learn acupuncture in the first place. But it was undoubtedly a relief to hear that I didn't need to struggle with all this complicated esoteric stuff, and later I was very grateful to Felix. Probably I should have come to a similar conclusion eventually, but he saved me a great deal of time. After the course I set up an acupuncture service at The Royal London Hospital for Integrated Medicine using the methods I had learnt from Felix. Modern medical acupuncture is still one of the main forms of treatment used there.

From our present standpoint in the second decade of the 21st century it is perhaps difficult to realise just how radical Felix's "acupuncture revolution" was. In the late 1950s people thought of acupuncture — if they thought of it at all — wholly in traditional Chinese terms. To describe it in the way he did required Felix to rethink everything he had been taught about acupuncture by all the 'experts' he had encountered.

Felix's acupuncture career

Acupuncture had been practised by quite a number of British doctors in the 1820s but had later fizzled out. By the twentieth century it was virtually unknown here, although it was still used quite extensively in mainland Europe, especially France and Germany. By this time it had become quite traditional, although that had not been the case in the nineteenth century.

As a young doctor Felix travelled abroad to widen his experience; this was easy for him because he was a good linguist and had plenty of contacts in Europe. He saw acupuncture being used and was impressed by the results, which made him want to learn it himself. He studied at Montpellier in the south of France and at Munich and Vienna. Later, he even studied Chinese with the help of sinologists in Britain so as to be able to read the classic texts. So his subsequent abandonment of the traditional system wasn't due to lack of knowledge. It was based instead on fresh thinking and exact clinical observation.

By the time I met him in 1977 he had rejected practically all the traditional ideas about acupuncture. He now regarded it as a means of altering the activity of the nervous system and as a treatment that could be explained in terms of the modern understanding of anatomy and physiology. There was no need to talk about qi or yin and yang.

According to his new view, neither acupuncture points nor the so-called meridians exist as they are usually understood. Great precision in locating 'points' is unnecessary; instead we should be thinking of areas. In many cases these could be quite large: for example, in some patients needling anywhere below the knee might have the same effect as using the classic point Liver 3 (Felix's favourite site).

He introduced other departures from tradition as well. One was the use of periosteal (bone) needling, both to treat joint pain such as that due to arthritis and also to produce more generalised effects in a wide area. Another was his recognition of a subset of patients who responded particularly strongly to acupuncture, whom he designated strong reactors. Disorders that usually don't respond to acupuncture might do so in a strong reactor. But if a strong reactor were treated too vigorously the result could be a worsening of the symptoms or a feeling of general malaise lasting for some hours or even days.

As time went by Felix came to believe that many traditionalists over-treated their patients. Increasingly he favoured very gentle treatment, with the insertion of few needles — sometime only one — and the duration of needling being brief: seldom more than a minute or two and quite often just a few seconds.

While these ideas usually horrified traditionalists they were certainly easier for doctors trained in modern medicine to understand and accept. This was fortunate because more now wanted to learn. Felix had started teaching acupuncture to doctors in the 1960s although at first few came forward to learn. But in the 1970s the numbers increased, partly because attitudes to unorthodox treatments were beginning to change but also because advances in the scientific understanding of pain were making acupuncture seem more comprehensible in modern terms. Another influence was President Nixon's visit to China in 1972, which aroused interest in acupuncture on the part of a number of prominent British and American doctors.

Felix's former students constituted an informal medical acupuncture society. He used to circulate a yearly newsletter and each year, in November, he held an acupuncture meeting in his rooms for 70 doctors. There would be seven or eight speakers, usually including Peter Nathan, a well-known neurologist, and Felix provided an excellent lunch, with wine. Attendance was free to his former students; others paid a small fee which cannot have come even near to covering Felix's expenditure.

In 1980 matters were made more formal when the British Medical Acupuncture Society, constituted mainly by Felix's former students, was founded; he was its first President. It now has over 2000 members.

Felix's legacy

The fact that the acupuncture practised today by British health professionals is mostly non-traditional is largely thanks to Felix. Outside Britain the change has been more gradual. In much of Europe, apart from Sweden and Portugal, and in North and South America, traditional ideas are still influential. But the journal of the British Medical Acupuncture Society, Acupuncture in Medicine, is now a BMJ publication, so Felix's aim of making acupuncture an accepted form of treatment within mainstream medicine has mostly been accomplished. Perhaps most striking of all is the fact that an increasing number of the papers being submitted to the journal now come from China itself.

Felix wrote several books about his later view of acupuncture. The most important of these was Reinventing Acupuncture: A New Concept of Ancient Medicine. The first edition appeared in 1993 and the second in 2000. Here he described how his understanding of the treatment evolved and gave practical details of his methods. I still dip into it from time to time and continue to be impressed by how much my own experience agrees what he describes. All of us who use acupuncture today in a modern context are deeply indebted to him.

Requests for reprints of articles

I just received a request for a reprint of one of ny articles. I get these from time to time; strictly speaking I shouldn't send such reprints since they infringe the copyright of the journal, but I used to do it because the requests usually came from third-world countries where people presumably couldn't easily afford the payment.

But not once did any of these correspondents bother to thank me or even acknowledge receipt, which I take ill; it's a lot less trouble for them to reply than it is for me to find the article in question and attach it to my email. So now I no longer reply to such requests, especially when, as in today's case, the requester is a professor at a university hospital in Paris, who could no doubt easily afford the fee to the journal (which probably wouldn't come out of his own pocket anyway).

Homeopathy - a celebrity's endorsement or not?

The Faculty of Homeopathy is drawing the attention ot supporters to "an excellent article" in The Mail Online.

This link takes you to a page where the actress Michelle Collins, who has appeared in East Enders and Coronation Street, describes how she gave up conventional medicine and moved to homeopathy to help her anxiety and depression. This was successful and she now feels much better.

But what is odd about this recommendation by the Faculty is that the article has an inset with a "Expert View" by Dr Ellie Cannon, who says that she does not reommend homeopathy to her patients because more than 150 trials have failed to show that it works.

Homeopathy’s dilution theory – that water ‘remembers’ the active ingredients it comes into contact with – is implausible. If it were true, water would also remember other substances – bacteria, animal waste or the test-tube the remedy was made in.

So how do I explain the positive effects some people experience? Michelle had crucial time and input from a therapist who listened to her worries. It helped her develop a positive mental attitude about coping with her anxiety. I believe it is this that has led to the improvement in her condition.

The placebo effect is real and powerful. So even though the pills are inert, treatment will ease the symptoms of stress. That is why taking a remedy before a show helps to control the panic. But the pill itself could just as well be a sugar lump.

Given the traumatic times Michelle has had, it is so important that she has found something that works for her. But as a general solution for others it would not work.

I think that Dr Collins gets it exactly right here. Homeopathy is best regarded as a form of psychotherapy. Please see my book Homeopathy in Perspective.

Psychotherapy today uses many different theories but it originated with Freud and psychoanalysis. The psychiatrist Anthony Storr was sceptical about much psychoanalytic theory but nevertheless thought that psychoanalysis could have beneficial effects on patients.
. . .
Much or all of homeopathic theory may be mistaken, and the remedies themselves may have little objective efficacy or even none at all, but patients often get better nevertheless. To say that this is due to the placebo effect is to beg the question, because we have only hazy notions about how placebos work anyway. For many patients, especially those whose symptoms really arise from their life situation, merely stating their problems verbally is sometimes enough to put them in a new light and to suggest the direction to look for a solution. In such cases the therapist is merely a sounding board; indeed, even a computer will do as a listener for some people. Many others do need a human individual to interact with, however.

So is the therapist no more than a sympathetic friend? No; this is where the theory comes in. It often doesn’t matter much what a therapist’s theoretical beliefs are (provided they are not actually dangerous, of course); their function in many cases is not to be “right” but to provide a framework to keep the discussion in focus.

Michelle's endorsement illustrates this extremely well.

Prediabetic state in Britain - media storm

There was a lot of excitement in the media this week about a report in the BMJ which, we were told, said that there had been a huge increase in the incidence of prediabetes (blood sugar raised although not to the level of actual diabetes) in the British population since 2003. Now a third of us is in this state and before long the NHS will be swamped by a tsuname of patients with diabetes. So when my copy of the journal arrived I looked to find this item given a prominent place, probably with an editorial comment.

It turns out that the paper is published in the online journal BMJ Online. Its findings are summarised in the current print journal, which also cites a quite extensive comment by John Yudkin, emeritus professor medicine at University College, London. He questions the validity of the "prediabetes" diagnosis, calling it an example of "overdiagnosis". Most people with this "condition" will never develop diabetes The term is rejected both by NICE and the WHO. It "brings with it the the burden of disease labelling and risks of largely unproven interventions."

The media, of course, didn't mention any of this.

New anatomical term in Holby City

In yesterday's Holby City Harry, a junior doctor in training, told a patient that he had a fracture of his "tibula". You can see why Harry is currently experiencing some difficulty in completing his CT2 trainee year satisfactorily.

Fever as a cancer cure

My online article 'Miraculous' Cures? discusses various mechanisms that may explain spontaneous cures of cancer that are sometimes attributed to divine intervention. One of these is modification of the immune response by means of fever. This is an old idea that is now attracting renewed attention.

A cell biologist, Uwe Hobohm, believes it is time to revive the idea. Fever therapy was used successfully to treat cancer in the nineteenth century. Hobohm discusses the immunological basis for the treatment in New Scientist ('Hot, toxic and healing': 4 January 2014). Hobohm and his colleagues are currently testing the hypothesis in mice at two research centres in Germany. This is fascinating, although, as he says, we are a long way away from having this treatment approved for human patients.

Westerners' misconceptions about Chinese Medicine

When alien ideas are imported into a culture they are pretty well inevitably misunderstood. This happens in religion - how many Christians think of Christianity as a Near-Eastern religion? (There is the probably apocryphal remark by an American congressman: "If English was good enough for Jesus it's good enough for me.")

The same is true of medicine. The current enthusiasm for Chinese medicine is based on a pretty distorted view of what Chinese medicine actually is. One good source for correcting this misconception is Shigehisa Kurihama's book The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine.

Another that I've recently come across is Nigel Wiseman's Westerners' Alternative Health-Care Values Eclipsing a Wealth of Knowledge. available here.

This is a long scholarly discussion of the subject. The topics include:

- Western motives for adopting Chinese medicine
- Influences of spiritual, physical, and philosophical traditions of the Orient
- Inaccurate characterisations eclipsing a body of knowledgge
- Intuition
- The root problem and the solution

The 'solution' proposed is, in outline, more and better translation of the Chinese texts.

From Wiseman's conclusion:

Too often, Chinese medicine is prized for certain qualities judged to be lacking in Western medicine. There is a tendency to assume that any desirable qualities that Western medicine lacks must be present in Chinese medicine, and to project those qualities onto Chinese medicine. In the process of projecting ideas onto Chinese medicine, other features have been obscured. I have argued against the false assumption that clinical experience and intuition are exclusively features of Chinese medicine, while theory and book-learning are characteristics of Western medicine that are of little import to the traditional Chinese physician.

This is an important article for anyone who is seriously interested in Chinese medicine.

Evidence-based medicine

"What if we tried to practise medicine according to the best evidence, only to find that half of it was mssing?" asks Minerva, in today's BMJ. In fact, as she goes on to say, that is exactly our position. She lllustrates this by citing a Cochrane review of a treatment for venous leg ulcers using flavonoid supplements. A previous review had found some support for this although the trials were mostly not good quality. Now a better trial has come to light; it was conducted by the manufacturers and did not find evidence of better healing. it was left unpublished.

Advocates of unorthodox treatments are often criticised for not providing convincing evidence of efficacy, and this criticism is often justified. But what is usually glossed over is the fact that orthodox treatments are usually in not much better shape.

The previous week Minerva reported a Canadian randomised trial of naturopathy that was published in the Canadian Medical Journal. The "more orthodox facets" of this treatment were compared with usual care to reduce cardiovascular risk factors and body mass index. Naturopathy proved more effective, and the methodolocical failings were no greater than those that are found in many similar trials of orthodox treatments.

It's not that we don't need evience of effectiveness in medicine - we do - but it's a lot harder to come by than we often think.