• 5/5/2008
  • Dublin, Ireland
  • M Amin et al.
  • Irish Medical Journal

Abstract
Most human beings will do almost anything to prolong their existence or to relieve the suffering of disease. Others will do anything to exploit these desires by selling what they claim to be pain killing remedies or life prolongation nostrums. We present three cases of head and neck cancer patients; two used complementary and alternative medicine (CAM) prior to presenting to our service and the third declined conventional treatment to seek CAM instead. We discuss here the diagnosis, the time delay between CAM and commencement of conventional treatment, and the outcome in each case. Our aim is to define Quacks and to heighten public awareness of the potential harm they can cause.

Introduction
In the face of the great leveller, Death, we are like children listening fearfully for the footsteps of doom, relieved only by the whisperings of hope. Quacks are peddlers of hope. Quackery is the promotion of false or unproven remedies for profit1. There is growing interest in complementary and alternative medicine at the present time; a significant number of cancer patients use complementary and alternative medicine (CAM) as adjunct therapies to their cancer treatment2,3. Eisenberg et al4 reported that one-third of the US population used some form of unconventional medicine and seventy-five percent of patients did not inform their physicians of this practice. Alternative therapies may include any unproven therapy or cure which is promoted as cancer treatment and is used in place of conventionally accepted oncological treatment. Complementary therapies are illustrated as adjuncts to mainstream cancer care for symptom management and to enhance quality of life5. Complementary and alternative medical practices include Traditional Chinese Medicine which includes acupuncture and herbs; homeopathy; naturopathy; herbal medicine; Ayurvedic medicine; mind-body medicine; massage and chiropractice.

Case Report 1
A 37 year old female presented to our department with a small T1N0 anterior tongue lesion which was virtually undetectable on MRI scan; biopsy confirmed squamous cell carcinoma. Unfortunately, the patient declined treatment by simple local excision. Instead, she went to the seventh son of a seventh son where she had topical poultice treatment, a paste of unknown substance that included plant extracts applied to the tongue lesion for one to two hours per day. She returned to our service several months later with a T3N2c lesion and underwent radical surgery. Unfortunately, she developed disseminated metastatic disease and passed away shortly afterwards.

Case Report 2
A 73 year old female presented to an alternative medical practitioner with a superficial skin lesion of the cheek. Over the next five years, he applied multiple poultices to this area. At initial presentation to our department five years later, she had a massive destructive squamous cell carcinoma which had extended medially and superiorly to include the maxilla and orbit. We carried out radical excision of cheek skin, maxilla and orbital exenteration, followed by radiotherapy. She remains disease free three years later.

Case Report 3
A 55 year old male presented to our service with a large preauricular mass, metastatic neck node and facial nerve palsy. He had been attending an alternative therapist for ten months and was treated with a herbal liquid drink taken once a day and also laying on of hands with prayers. Biopsy revealed a squamous cell carcinoma requiring excision of the ear and temporal bone with radial forearm flap reconstruction. He remains disease free three years later.

Discussion
A Medline search revealed only two dedicated reports of CAM used specifically in patients with head and neck cancer, one from Israel and one from USA6,7. The use of CAM among cancer patients varies depending on the type and site of the disease. In head and neck cancers, use of alternative therapies is reported to be around 15%8. Contrary to common perception, patients who pursue alternative therapies are likely to be well educated and from a higher socioeconomic group. This interest in CAM led the American Academy of Otolaryngology Head and Neck Surgery to establish a Committee on Alternative Medicine to serve as a resource for information regarding CAM practices that relate to otolaryngology and to make that information available to its members. The efficacy of CAM therapies remains questionable, in fact the research in these areas can be nonexistent or at best of poor quality. Patients seek CAM to address problems that may not be fully managed by conventional medicine (e.g. pain) or because CAM is often portrayed as having fewer side effects. Others may seek it for the holistic approach and the power of prayer or simply to feel that they are actively participating in controlling their disease process.

Head and neck cancer is unique in the way it debilitates patients and affects nutrition. It may also be associated with considerable morbidity, disfigurement and changes in facial features as part of the treatment process that may include tumour excision, flaps and radiotherapy. The prognosis for head and neck cancer remains poor (50% 5-year disease survival), despite advances in surgical technique, radiotherapy and chemotherapy7. Consequently, our patients are likely to seek alternative therapies that may appear to have fewer side effects9,10.

It is helpful to recognize warning signs of quackery which include claims of “miracle cures” and secret ingredients or processes7. Quack therapies may be categorized as those which cause direct harm, those which cause indirect harm by directing patients away from more effective therapies, and those which are harmless but economically fraudulent. Treatment delay associated with alternative medicine in Head and Neck cancer patients was first pointed out by Davis et al11 in 2006 and we can concur with these findings, as illustrated by the three cases presented. We believe that if medical advice had been sought initially or followed consequently, the likelihood of a positive outcome would have been much higher and in accordance with international survival rates.

Public interest in complementary and alternative medicine needs to be addressed seriously and statistics on the morbidity, mortality, incidence and prevalence of quackery in various specialities needs to be recorded and reported to a national system developed specifically to act against quackery. This may require the cooperation of the Irish Medicine Board, the Irish Medical Council, Department of Health, Department of Justice and Criminal Assets Bureau. We certainly have a moral and ethical obligation towards our patients and this may require us to spend more time communicating with them and exploring their concerns. We are currently instigating a national survey on the use of CAM among head and neck cancer patients in Ireland and we hope this will increase public awareness of the problem. It is also hoped that other specialties will provide their own perspective on the extent and magnitude of quackery in medicine.

References
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7. Benjamin F. Asher, Michael Seidman, Carl Snyderman. Complementary and Alternative Medicine in Otolaryngology. The Laryngoscope 2001; 111:1383-1389.
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9. Zeltzer L, Kellerman J, Ellenberg L, Dash J. Hypnosis for reduction of vomiting associated with chemotherapy and disease in adolescents with cancer. J Adolesc Health 1983; 4:77-84.
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11. Davis GE, Bryson CL, Yueh B, McDonell MB, Micek MA, Fihn SD. Treatment delay associated with alternative medicine use among veterans with head and neck cancer. Head & Neck 2006; 28:926-931.

Authors’ Acknowledgement
We would like to thank Ms. M. Codd, Oncology Specialist Nurse at St. James’s Hospital, Dublin, for her contribution to this study.

Authors:
M Amin, J Hughes, C Timon, J Kinsella

Authors’ affiliation:
Department of Otolaryngology, Head and Neck Cancer, St. James’s Hospital, James’s St, Dublin