Modern Chemotherapy for Severe Mental Disorders in a Prayer Camp

I thank Prof Swaran Singh for drawing my attention to a randomised trial of traditional faith healing with chemotherapy versus traditional faith healing alone for patients with serious psychiatric disorders.[1] The study took place in a faith-based healing centre. Belief in spiritual origins for mental illness is common in many countries. A randomised trial was conducted to evaluate the additional benefits of pharmacotherapy for patients with a range of psychotic conditions. The outcome of the trial was based on the brief psychiatric rating scale. Patients in the intervention group had much better outcomes than patients in the control group over the first six weeks following randomisation. That is to say, adding chemotherapy to faith healing produced a marked improvement in outcome.

The interesting feature of this trial was that it combined modern medical treatment with traditional healing methods. Thus it is not a head-to-head of the two different approaches; rather it is a trial of both methods compared with traditional methods alone.

Although the study produces interesting findings, the traditional methods did not sit comfortably with the medical approach; for instance patients were often put in chains so that they could not escape or harm themselves or others. This invokes the deeper question about whether the two methods (allopathic and traditional) can really exist side-by-side on a routine basis. Many providers of psychiatric services would find it difficult to live with a situation in which patients for whom they felt responsible were also subjected to practices that they consider degrading, if not outright harmful. The question can be fairly asked as to whether medical practitioners in the study were endorsing or even colluding in these practices. I tackled the moral and epistemological Implications of trying to integrate enlightenment science and spiritual practices within the same system of care, in a recent news blog.[2] The above research paper seems to reinforce my opinion that integration of modern medicine and traditional practices is much more than simply a technical issue. While clinical trials such as the one cited above can produce useful information, they cannot, by themselves, resolve the deeper issues.

— Richard Lilford, CLAHRC WM Director

References:

1. Ofori-Atta A, Attafuah J, Jack H, et al. Joining Psychiatric Care and Faith Healing in a Prayer Camp in Ghana: Randomised trial. Br J Psychiatry. 2018; 212: 34-41.
2. Lilford RJ. Traditional Healers and Mental Health. NIHR CLAHRC West Midlands News Blog. 12 January 2018.

Intraperitoneal Chemotherapy for Ovarian Cancer

The CLAHRC WM Director hates ovarian cancer – it spreads throughout the abdominal cavity and is horrible to behold it at surgery. He has often wondered if topical chemotherapy could help control this dreaded disease. In the UK one in 52 women will be diagnosed with ovarian cancer within their lifetime, with around 7,400 new cases and around 4,100 deaths in 2014.[1] Standard treatment is surgery to excise the tumour, followed by intravenously administered chemotherapy, or vice-versa. Can topical (intraperitoneal) chemotherapy improve outcomes compared to the standard intravenous method? Previous research of combined intravenous and intraperitoneal chemotherapy has shown an increase in overall survival in patients with ovarian cancer, but there are a number of limitations that have affected widespread adoption. Researchers in the Netherlands conducted a study to see if delivering the intraperitoneal chemotherapy immediately after surgery could show similar effectiveness, while overcoming these limitations.[2]

This was a randomised trial of 245 patients with ovarian cancer who had already undergone three cycles of chemotherapy. Patients underwent surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) administered at the end of the procedure or not, followed by another three cycles of chemotherapy. HIPEC is where the abdomen is heated prior to applying the chemotherapy drugs. This hyperthermia results in a number of cellular reactions, including increasing the penetration of chemotherapy drugs into the tissue, impairing the ability of cancer cells to repair DNA, thus increasing their sensitivity, and inducing apoptosis.

Results showed significantly fewer deaths and disease recurrence in those patients who underwent HIPEC immediately during surgery, than in those who did not (hazard ratio 0.66, 95% CI 0.50-0.87; p=0.003). Further the patients in the HIPEC group had a median recurrence-free survival of 14.2 months, compared to 10.7 months. At follow-up (median of 4.7 years), 62% of patients who had undergone surgery without HIPEC had died, compared to 50% of patients who had received HIPEC (p=0.02). Median survival was 45.7 months compared to 33.9 months. Adverse events were similar in both groups.

— Peter Chilton, Research Fellow

References:

1. Cancer Research UK. Ovarian Cancer Statistics. 2018.
2. van Driel WJ, Koole SN, Sikorska K, et al. Hyperthermic Intraperitoneal Chemotherapy in Ovarian Cancer. New Engl J Med. 2018; 378: 230-40.

Alternative Therapies for Cancer

We often read of cancer patients who forgo or delay traditional conventional options, such as chemotherapy, and instead opt for alternative therapies, such as spiritual healing or herbal remedies given by non-medical personnel. Unfortunately this can have serious survival implications for the patient – in many cases the treatment fails to stop the cancer. However, there is a paucity of actual clinical evidence on the use and effectiveness of alternative therapies. Step in Johnson and colleagues who examined the United States Cancer Database to compare the survival outcomes of patients who underwent alternative therapies with those who received conventional therapies for four cancer types (breast, prostate, lung and colorectal).[1] Although rare, they found 281 patients who had chosen alternative therapies exclusive of any other treatment – these patients were more likely to be younger, female, have a lower comorbidity score, higher income, higher education, and a more advanced cancer stage. When matched with patients who received conventional treatments (on cancer type, age, clinical stage, etc.), they found that alternative therapies were associated with significantly lower five-year survival overall – 78.3% of patients who underwent conventional therapies survived, compared to 54.7% of those who had alternative therapies only (hazard ratio 2.21, 95% CI 1.72-2.83). When looked at by cancer type increased hazard ratios were found for breast (HR 5.68, 95% CI 3.22-10.04), lung (HR 2.17, 95% CI 1.42-3.32) and colorectal cancer (HR 4.57, 1.66-12.61), but there was no significant difference for prostate cancer (HR1.68, 95% CI 0.68-4.17) – the authors suggest this may be because of the long natural history of prostate cancer and the short follow-up of the study.

By itself, undergoing alternative therapies isn’t likely to be harmful, but it should be taken in combination with conventional therapy, and health practitioners need to ensure that patients are fully aware of the impact of their decisions regarding cancer treatment.

— Peter Chilton, Research Fellow
Reference:

1. Johnson SB, Park HS, Gross CP, Yu JB. Use of Alternative Medicine for Cancer and Its Impact on Survival. J Natl Cancer Inst. 2017.

Important Ovarian Cancer Trial Sets Scene for Multiple Indication Review

Sean Kehoe and colleagues compared chemotherapy then surgery versus surgery then chemotherapy in a landmark trial of 552 women with advanced cancer of the ovary. Though not reaching significance on the frequentist test, there was a 13% advantage for the chemo-first protocol. In addition less surgical deaths were recorded in the chemo-first group, this time at a high level of statistical significance.[1] We have compared adjuvant chemotherapy versus no adjuvant chemotherapy across all cancers, showing that the hypothesis of a similar effect across all cancers is better supported than the hypothesis of different effects by cancer type.[2] It would be fascinating to compare chemotherapy versus surgery first trials in a multiple-indication review [3] across all cancers. Any takers?

— Richard Lilford, CLAHRC WM Director

References:

1. Kehoe S, Hook J, Nankivell M, et al. Primary chemotherapy versus primary surgery for newly diagnosed advanced ovarian cancer (CHORUS): an open-label, randomised, controlled, non-inferiority trial. Lancet. 2015; 386: 249-57.
2. Bowater RJ, Abdelmalik SM, Lilford RJ. Efficacy of adjuvant chemotherapy after surgery when considered over all cancer types: a synthesis of meta-analyses. Ann Surg Oncol. 2012;19(11):3343-50.
3. Chen YF, Hemming K, Chilton PJ, Gupta KK, Altman DG, Lilford RJ. Scientific hypotheses can be tested by comparing the effects of one treatment over many diseases in a systematic review. J Clin Epidemiol. 2014;67(12):1309-19.