Clinical Briefs

With Comments from John La Puma, MD, FACP

Educating Homeless Youth on Alternative Allopathic Care

February 1999; Volume 2: 22-23

Source: Breuner CC, et al. Alternative medicine use by homeless youth. Arch Pediatr Adolesc Med 1998;152:1071-1075.

Mainstream health care for homeless youth is often fragmented or unavailable. To evaluate the use of complementary and alternative medicine (CAM) by homeless youth who use our free clinic, we created a self-administered cross-sectional survey. Subjects included youth between the ages of 14 and 21 years receiving care at the 45th Street Clinic Youth Program in Seattle, Washington, between January 29, 1998 and March 5, 1998. Demographics, health issues, use frequency of different therapists or therapies, referral sources, and perceived effectiveness of treatment were included.

The response rate by patients was 96.3% (157/163) with an average respondent age of 18.5 years (range 14-21 years). Almost 30% of respondents were not homeless but estranged from families or had tentative housing arrangements; nearly 40% were male; nearly half had been homeless for less than a year; nearly two thirds had chronic health problems: e.g., asthma, back or stomach pain, headaches.

Eighty-one percent of respondents had used allopathic medicine within the past six months; 70.1% had used CAM. Vitamins, diet, and exercise were included as alternative, but even excluding them, 74% of respondents used herbs, 27% used acupuncture, 26% used meditation, 22% used aromatherapy, and 17% used homeopathy.

Referral to CAM practitioners most often came from friends (52.7%); some were self-referred (18%). The most common reason for using CAM was because it was "natural" (43.9%). Most of those who used alternative therapies (87.3%) believed they had been helped "some" or "a lot." Given a choice of providers to visit when they were ill, 51.7% report that they would seek care from a physician, 36.9% from a CAM provider, and 11.4% would treat themselves.

Care with CAM is frequently used and accepted by homeless youth. Cost-effectiveness and contributions to overall health care require additional evaluation. Integrating CAM into allopathic health centers may serve as an incentive to entice youth into mainstream health care.

COMMENT

In Chicago, the homeless live downtown, in the suburbs, under expressway eves, in door jams, and beside monuments. They have been swept away from the warmth of the airports and the El. Even as they keep moving they are hidden from view, sometimes right in front of us.

Some of these men and women are actually adolescents, who seldom come to conventional medical attention. The authors write "Money, consent, confidentiality, and alienation frequently present hurdles to receiving services. Mainstream allopathic care is often fragmented, not relevant to their needs or inaccessible ... Many homeless youth have been exploited or deceived by adults and mistrust health professionals and the traditional health care system."

The study finding of a 70% CAM use rate "...is similar to that of people with cystic fibrosis" (and nearly twice that of the general adult or pediatric population).

The study is uncontrolled and descriptive, and documents youths who came to a free clinic primarily for preventive, acute, and chronic allopathic care. The most worrisome finding here is that homeless youth perceive mainstream care as not "compassionate" and often prefer CAM to other treatments. They do perceive moral, personal, and psychological value in organic and natural therapies. The absence of promotion of CAM therapies to homeless people—those generally without shelter, role modeling, and high educational and socioeconomic levels—doesn’t seem to matter.

Recommendation

Integrating knowledge of alternative techniques may entice homeless youths to reconnect to allopathic care—which many of them need now, and are going to need as they age.


Effectiveness of Homeopathic Arnica

February 1999; Volume 2: 23-24

Source: Ernst E, Pittler MH. Efficacy of homeopathic arnica: A systematic review of placebo-controlled clinical trials. Arch Surg 1998;133:1187-1190.

The efficacy of homeopathic remedies has remained controversial. The homeopathic remedy most frequently studied in placebo-controlled clinical trials is Arnica montana.

To review systematically the clinical efficacy of homeopathic arnica, we performed computerized literature searches to retrieve all placebo-controlled studies on the subject. The following databases were searched: MEDLINE, EMBASE, CISCOM and the Cochrane Library. Data were extracted in a predefined, standardized fashion independently by both authors. There were no restrictions on the language of the publications.

Eight trials fulfilled all inclusion criteria. Trials of one potency against another, and studies of more than one remedy were excluded. Most trials were related to conditions associated with tissue trauma. Most of these studies were burdened with severe methodological flaws. On balance, they do not suggest that homeopathic arnica is more efficacious than placebo.

COMMENT

In his review of arnica for musculoskeletal injury, Dietz reports "Goethe claimed that Arnica saved his life after a serious fever. He described it as a plant of rapid healing ... If you suffer violence and injury, from fist, cudgel or blade, wondrous healing is high in this herb ... if the blood has lost its way in a bruise or an effusion, arnica will remind it of its proper courses.’ Swiss mountain climbers reportedly seek it out and chew it to relieve sore, tired muscles." (See Alternative Medicine Alert, April 1998, pp. 42-45.)

Ernst and colleagues have previously assessed homeopathy for postoperative ileus (positive results, published in J Clin Gastro 1997;25:628-633) and for delayed-onset muscle soreness (negative results, published in Perfusion 1998;11:4-8). Having performed a similar meta-analysis of arnica for the European Community, they report that the data (primarily for pain, soreness and bruising) are mixed. Four studies showed positive results; four showed negative ones. The more rigorous studies tended to be the ones with negative findings.

The authors write that "no other homeopathic remedy has been subject to more controlled clinical trials. But the existing studies could be severely flawed ... small sample size and lack of test statistics are frequent." Indeed, arnica tablets and drops were used on different schedules in healthy volunteers, dental patients, orthopedic patients, inpatients, and outpatients.

Homeopathy is based on the "principle of similars" developed in the late 18th century. This principle states that clinical signs and symptoms a substance can cause in healthy volunteers can be cured by the same substance when they occur spontaneously in a sick person.

Although there are exceptions (and arnica is one of them), homeopathy generally attempts to treat the whole human being and not a specific condition. Hahnemann would no more have used homeopathy to treat trauma, the authors imply, than Drs. Cooley and DeBakey would use a bypass operation to change a patient’s lifestyle and fitness habits.

Dietz concludes "...clinicians could advise that many anecdotal stories of clinical success have been reported, that clinical studies have suggested a benefit for its use for the treatment and management of injuries but more needs to be done for the definitive answer. In addition, clinicians can feel confident that the use of homeopathic arnica preparations is safe and reports of dermatitis to arnica herbal ointments are rare."

Recommendation

Although homeopathic arnica cannot be recommended as therapeutic, the data from the best studies are too poor to conclude much of anything, except that homeopathic arnica is harmless.


Shark Cartilage Costly Last Resort for Cancer Patients

February 1999; Volume 2: 24

Source: Miller DR, et al. Phase I/II trial of the safety and efficacy of shark cartilage in the treatment of advanced cancer. J Clin Oncol 1998;16:3649-3655.

Patients with cancer and chronic inflammatory disorders have used shark cartilage (SC) preparations for many years. Preclinical studies that support beneficial effects are scanty, and reports of clinical trials have been anecdotal. The proposed mechanisms of antitumor action include direct or indirect inhibition of angiogenesis. Because of the emerging use of SC as an alternative to conventional cancer therapy, this trial was launched to evaluate SC safety and efficacy.

Sixty adult patients with advanced (stage III and IV) previously treated cancer were enrolled. Primaries were breast 16 patients; colorectal 16 patients; lung 14 patients; prostate 8 patients; non-Hodgkin’s lymphoma 3 patients; brain 1 patient; unknown 2 patients. Eligibility criteria included confirmation of diagnosis, resistance to conventional therapy, objective measurable disease, life expectancy of 12 weeks or greater, Eastern Cooperative Oncology Group (ECOG) performance status of 0-2, no recent or concomitant anticancer therapy, no prior SC, and informed consent. Patients underwent evaluation of the extent of disease, quality-of-life scoring, and hematologic, biochemical, and selected immune function studies at baseline and after six and 12 weeks of SC therapy. The dose of SC was 1 g/kg orally daily in three divided doses.

Ten of 60 patients were lost to follow-up or refused further treatment before the six-week evaluation. Three other patients with stable disease at six weeks were also unavailable. Of the 47 fully assessable patients, five were taken off the study because of gastrointestinal toxicity or intolerance to SC. Progressive disease occurred at six weeks in 22 patients and at 12 weeks in five patients. Five patients died of progressive disease while undergoing SC therapy. No complete or partial responses were noted.

Median time to tumor progression was 7 +/- 9.7 weeks (mean 11.4 weeks; range 3.7 - 45.7 weeks). Ten of 50 assessable patients, or 16.7% of the 60 intent-to-treat patients had stable disease for 12 weeks or more. The median time to tumor progression in this group was 27 weeks (mean 28.8 weeks; range 18.6 -45.7 weeks). In this group, quality-of-life scores improved in four patients, were unchanged in four patients, and declined in two patients. Twenty-one adverse effects were recorded, 14 of which were gastroenterologic (nausea, vomiting, constipation).

Under the specific conditions of this study, SC as a single agent was inactive in patients with advanced stage cancer and had no salutary effect on quality of life. The 16.7% rate of stable disease at 12 weeks was similar to rates in patients with advanced cancer treated with supportive care alone.

COMMENT

Sharks do not have bones, and according to one popular book, they don’t get cancer (or actually, not very often). What they do have is cartilage. Sharks are captured, and their fins are torn off for many purposes—soups, luck, and cancer treatment.

Shark cartilage is expensive—up to $700 monthly—and foul-tasting. In this initial, dose-determining, safety-assessing study, shark cartilage was dried into a powder, mixed into fruit juice, and enhanced with vanilla flavor. As with all over-the-counter dietary supplements, there is no FDA or other regulation of safety, efficacy, purity, or contaminants.

Some authors warn pregnant women and people with heart disease not to take shark cartilage, for fear of inhibiting angiogenesis. Laboratory isolates from shark cartilage are reported to be anti-angiogenic, but whether those isolates inhibit blood vessel growth in people’s advanced cancers is unknown. Purified anti-angiogenic factors, such as angiostatin and endostatin from other sources, however, are being evaluated as chemotherapeutic agents in phase I and II trials.

The authors cite one other published uncontrolled study, which claimed a "61% reduction in tumor size" but used no standard criteria to evaluate response.

Recommendation

If your cancer patient is near the end of life and wants to try shark cartilage to extend survival, it’s a long shot. It is not easy to take, there are no guarantees about its purity, and it is not cheap. Discourage its use outside of a research protocol that is available for your review. Aggressive palliative care that includes an excellent hospice and mind/body methods to manage symptoms and provide family respite are good options, but treatment plans are dependent on personal values.