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Jacobson et al
Cancer Outcomes at the Hufeland
(Complementary/Alternative Medicine) Klinik:
A Best-Case Series Review
Judith S. Jacobson, DrPH, MBA, Victor R. Grann, MD, MPH, Michael A. Gnatt, MD, Hanina Hibshoosh, MD, John H. M. Austin, MD, Wil iam S. Mil ar, MD, and Alfred I. Neugut, MD, PhD Purpose: A best-case series review is an efficient tool
herbal agents and specific CAM procedures have been with which to screen complex complementary and
undertaken or completed. The most successful alternative treatments for cancer as candidates for
candidates for research funds have been investigators further study. Study Design: The National Cancer
who proposed studies of standardized single- Institute and other agencies have adopted the best-case
modality interventions for which conventional series method to evaluate cancer treatments involving
research methods are well suited. Claims regarding complementary and alternative medicine (CAM) for
the benefits of complex treatments customized to further study. The authors conducted a best-case series
review of the Hufeland Klinik. Established in 1985 in
each patient are more difficult to evaluate. Many Bad Mergentheim, Germany, this facility treats more
cancer clinics outside the United States provide such than 500 cancer patients per year. Hufeland treatment
treatments, especially to patients who have failed includes dietary modification, injections, ozone
therapy, active fever therapy, psychotherapy, and
Few providers at CAM cancer clinics have research sometimes
low-dose
training or even a reliable charting system,2 but some chemotherapy. The goal of the treatment is to prolong
are willing to allow outside investigators to study their survival and to maintain good quality of life. Methods:
treatments and results. Because conventional clinical The clinic provided summaries of 27 cases in which
research methods cannot be readily applied to the patients with longer than expected survival had agreed
assessment of most CAM cancer clinics, the best-case to make their medical records available for review.
The review involved pathologic confirmation of disease
series method has come into use to identify those and radiologic confirmation of complete response (CR)
facilities whose patients might have fared better than or partial response (PR) not attributable to
expected and to evaluate them as candidates for conventional treatment. Results: Based on the
summaries and an exhaustive 2-year search for medical
First proposed by the Office of Technology Assess- records, slides, and imaging data, 12 of 27 cases were
ment in 1990, the best-case series method was adopted selected for full review, and 5 (3 CRs and 2 PRs) were
by the National Cancer Institute (NCI) in 1991 for pre- judged best cases. Conclusion: Most patients with
liminary evaluation of complex CAM cancer therapies common cancers receive conventional treatment
for which claims of efficacy were made. The NCI before coming to Hufeland, and many are treated with
Office of Cancer Complementary and Alternative chemotherapy and/or hormonal therapy while there.
Hence, only a few could be considered for review. With 5
Medicine Web site publishes the guidelines "The of 12 patients showing a treatment response, the
Preparation of Best Case Series and the Conduct of authors conclude that the Hufeland treatment
Pilot Clinical Trials Using CAM Modalities."4 The merits further study. They also recommend the
development of criteria with which to evaluate best-
JSJ, VRG, and AIN are in the Department of Epidemiology, case series reviews of complex CAM treatments for
Mailman School of Public Health; VRG and AIN are in the patients with advanced cancer.
Department of Medicine; HH is in the Department of Pathology; JHMA and WSM are in the Department of Radiology; JSJ, VRG, HH, JHMA, WSM, and AIN are in the Herbert Irving Keywords: cancer; best-case series; complementary; alternative; Comprehensive Cancer Center, College of Physicians and holistic; complete response; partial response; survival Surgeons; and MAG is in the Department of Medicine, St. Luke's-Roosevelt Hospital Center, Columbia University, New York, New York. In the past decade, support for research on comple- Correspondence: Victor R. Grann, MD, MPH, Department of
mentary and alternative medicine (CAM) for cancer Epidemiology, Mailman School of Public Health, 722 West 168th has grown dramatically, and numerous clinical trials of Street, R734, New York, NY 10032. E-mail: vrg2@columbia .edu. INTEGRATIVE CANCER THERAPIES 4(2); 2005 pp. 156-167 Cancer Outcomes in a Best-Case Series
guidelines allow practitioners to select for review any formed consent and permission to obtain medical cases that exemplify what their treatment can do for records from the participating patients, and provided cancer patients and specify that every best case must a summary of each case. The reviewers eliminated meet the following 4 entry criteria: cases that, based on the summary, did not fulfill best-case criteria. For the remainder, in addition to • The diagnosis of cancer must be well documented. reviewing the records on file at the Hufeland Klinik, • There must be evidence that cancer was present at the we requested medical records including pathology time the unconventional treatment was started. slides and radiologic examinations from all the other • The patient must have received the unconventional institutions where the patient had received diagnostic treatment according to the alternative practitioner's assessment or cancer treatment. After document texts were translated into English, the cases were reviewed • The patient must not have received, recently or con by the investigative team, including oncologists, currently, another therapy with the potential to affect pathologists, and radiologists at the Herbert Irving Comprehensive Cancer Center of the College of Best cases also must fulfill at least 1 of the Physicians and Surgeons, Columbia University. The purpose of the pathology review was to confirm the cancer diagnosis of each case. Radiologists reviewed • Complete response (CR): complete disappearance of imaging studies in various formats to assess patients' all evidence of tumor for a set number of weeks. status before and after the Hufeland Klinik treatment. • Partial response (PR): decrease by >50% in the sum of The team then identified those cases that fit the best- the products of the perpendicular diameters of all measured lesions in the absence of progression of any The Practitioner
sites or the appearance of any new lesions for a set number of weeks. Wolfgang Woeppel, MD, graduated from the medical school at the University of Wuerzburg (Bavaria, Many cases proposed for a best-case series are those Germany) in 1971. Board certified in internal involving longer than expected survival based on medicine (1978) and naturopathy (1984), he also data for age and stage from the medical literature or a studied acupuncture and neural therapy. From 1976 population-based registry, such as the NCI's to 1982, he was a senior physician in the Department Surveillance, Epidemiology, and End Results of Internal Medicine at Mosbach Regional Hospital database. However, although survival with good (Baden, Germany). From 1982 to 1984, he worked quality of life is the primary aim of cancer treatment, with Josef M. Issels, MD, who developed and it is not interpret-able as evidence of efficacy in an practiced a holistic approach to cancer therapy, at the uncontrolled case series.5 Ringberg Klinik in Tegernsee, in the Bavarian In this report, we describe the results of our Alps of Germany.6 Dr Issels's theories and methods assessment of a best-case series submitted by have greatly influenced alternative cancer treatment Wolfgang Woeppel, MD, founder and director of the programs in Europe and Mexico.' Hufeland Klinik in Bad Mergentheim, Germany, to The Hufeland Klinik
the National Foundation for Alternative Medicine Established by Dr Woeppel in 1985, the Hufeland (NFAM). Since 1998, NFAM has been visiting clinics Klinik has treated more than 3000 inpatients and 500 that use CAM and inviting them to submit best cases. outpatients and currently treats about 500 inpatients Of some 60 clinics reviewed in the first 2 years of and 120 outpatients per year. The Klinik is located in this program, the Hufeland Klinik was found to be Bad Mergentheim, a well-known health resort area the most rigorous in its record keeping. Hufeland also famous for its mineral springs, in southwestern has an international reputation that draws patients Germany near Heidelberg, Frankfurt, and from the United States as well as other countries. For Nuremberg. those reasons, it was selected for review. Most patients who come to Hufeland have cancer. Hufeland treats all malignant diseases except acute leukemias, regardless of stage and prognosis. The Klinik also treats patients with some other diseases; it Review Procedure
treats adults and children older than 5 years. The study was approved by the Columbia Presbyterian Medical Center Institutional Review Board. Dr The Philosophy
Woeppel selected the cases for review, obtained in- According to theories first described by Alfred Pischinger,8 the body's most important systems (eg, the autonomic nervous system, hormones, blood and Jacobson et al
lymph vessels, and connective tissue) comprise an fruit. They are allowed (but not encouraged) to eat 1 interdependent network. Dr Woeppel views cancer as serving of meat or fish per week. Frequent small meals involving both cells and their interaction with this are recommended for seriously ill patients. Patients network, which constitutes their environment. Under are encouraged to avoid tobacco, caffeine, and conditions such as infection and psychological alcohol. distress, the environment may cease to prevent cancer cells from proliferating. Under more favorable Physical therapy. Nearly every day, patients receive conditions, the environment may become conducive hydrotherapy (cold water treatments and hot to apoptosis or redifferentiation of cancer cells. showers),16 reflexology,17 massages,18 or special Treatment at Hufeland, therefore, does not primarily treatments with electric fields. target the tumor, as conventional cancer treatment Oxygen therapy. For at least 2 hours each day, most does, but focuses on the tumor's environment. patients inhale oxygen; they continue to do so after The Treatment
Upon admission, each patient is examined by a physician and has an electrocardiogram, ultrasound Psychotherapy. Dr Woeppel states, "Anyone for imaging, routine laboratory studies, and, in some whom life is unconsciously a burden logically has no cases, a chest x-ray. Depending on the results of these real reason to get well, and his autonomic nervous studies, patients may receive the basic treatment alone system is programmed for death." Therefore, or with fever therapy or conventional treatment. Hufeland offers patients a variety of approaches to help reduce the undesirable stress in their lives. Dr Basic Treatment
Woeppel conducts weekly group hypnosis sessions to Basic treatment consists of the following. influence the unconscious and to support the patient's Biological treatment. All patients receive daily will to get healthy again. A psychologist and an art of therapist offer individual and group therapy sessions. homeopathic agents, vitamins, and herbal agents and Other modalities include deep relaxation exercises, nonspecific immune stimulators (echinacea, '" respiratory biofeedback, imagery, color therapy, mistletoe, fresh thymus," and microbial extracts). group singing, and walks and hikes. Proteolytic pancreatic enzymes; probiotics (symbiotic intestinal bacterial flora supplements); vitamins A, C, Pain relief. Hufeland emphasizes the importance of E; and selenium are administered orally. Twice a complete pain relief. Conventional analgesics, as well
week, patients receive ozone therapy (autologous as acupuncture, therapeutic local anesthesia, infrared
blood is incubated with a mixture of oxygen and (warming) therapy, subcutaneous carbon dioxide
ozone and/or irradiated by ultraviolet light and then injections, and physical therapy are used for pain
reinfused)12 followed by an intravenous infusion. The relief.
intravenous infusion contains trace elements Fever Therapy
(magnesium, selenium, zinc), homeopathics, high- Patients who have no serious comorbid conditions dose vitamins, and plant- or microbial-derived may receive active fever therapy, in which Coley's alter toxins (bacterial lipopolysaccharides and other metabolism, and stimulate the nonspecific immune agents) are injected intravenously. Patients usually experience chills, nausea, vomiting, or headache The basic program also includes dental work to within about 20 minutes, along with a slow rise in eliminate mucosal pockets; dead, root-filled, or body temperature. The temperature should remain at impacted teeth; and, if possible, amalgams.13 If tonsils 40°C or higher for several hours." show signs of chronic inflammation, tonsillectomy is recommended." Conventional Modalities
Patients are also offered enemas, lime-blossom and In addition, patients without comorbid conditions other herbal teas, and herbal and homeopathic may receive surgery, chemotherapy, radiation therapy, remedies. Patients with constipation or digestive or hormonal therapy. The goal of such treatment is problems are encouraged to drink from Bad not so much to destroy the tumor as to suppress it Mergentheim's healing springs to activate bile flow enough to allow the host to keep it under control. Hence, patients who undergo chemotherapy at Diet. All patients follow a low-fat lactovegetarian Hufeland usually receive lower doses or a shorter diet high in vegetables and whole grains, with some course of treatment than they would under a conven- Cancer Outcomes in a Best-Case Series
tional protocol. Some patients receive chemotherapy
cancer case; and 1 melanoma case) were excluded because the presence of malignant disease was not electromagnetic field to about 43°C, applied either confirmed at the time treatment was initiated. Four locally (eg, to treat liver metastases, prostate cancer, cases (all 3 cases with advanced breast cancer and 1 or abdominal tumors) or to the whole body. Most with ovarian cancer) were excluded because they patients with b reast cancer or p ro state cancer received conventional therapy (hormonal therapy or chemotherapy) shortly before or during treatment at Hufeland, 3 because of disease progression (an ovarian cancer case) or lack of a partial response to Initially, Dr Woeppel submitted reports of 27 cancer treatment (a stomach cancer case and a lung cancer cases. Based on these reports, we selected 12 cases for case), and 1 (an ovarian cancer case) because slides review. Table 1 lists the 12 cases that were reviewed. Of were unavailable for pathology review. (In Germany, these, 5 met the criteria for best cases. slides may be discarded after 10 years.) Pathology Review
Discussion
histologic Since 1985, about 3000 individuals have been treated interpretation to that of the reviewing pathologist for for cancer at Hufeland. Although some of these each of the 12 potential best cases. In 6 of the 12 cases, patients achieved remission and remain well, many, the reviewing pathologist confirmed the original including all patients with metastatic breast cancer interpretation. In colon cancer case 1, the pathology or prostate cancer, were ineligible for inclusion in reviewer's diagnosis differed from that in the original the best-case series because they had received report regarding tumor type, but the differences were conventional and CAM treatment at Hufeland not relevant to prognosis.21 In ovarian cancer case 1, simultaneously. This exclusion limits best-case series the reviewer's diagnosis differed from the original review to patients who have cancers for which no regarding the site of origin and was more consistent conventional treatment is known, refuse conventional than the original wi t h t h e i n d o l e n t c o u r s e o f t h e treatment, or wait a sufficient time after receiving d i s e a s e . I n mediastinum cancer case 1, the conventional treatment for restaging to verify reviewer's diagnosis also differed slightly from that treatment failure. Yet many patients whose disease is in the original report regarding tumor type, but the spreading and not responding to treatment begin material was obtained by bronchoscopy and was too immediately to explore alternatives. Moreover, limited in quantity for a firm histologic diagnosis. although potential best cases cannot be evaluated In 3 of 4 brain tumor cases, the histologic diagnosis unless they have had repeat imag-ing just prior to differed. For this reason, the brain tumor cases were starting the CAM treatment, complete restaging is not also reviewed separately by a pathologist at the NCI always performed at this time in clinical practice. The (Table 2). The NCI reviewer noted that prior best-case series, therefore, shares many of the treatment with chemotherapy and/or radiation difficulties of any retrospective review. As Table 1 therapy in cases 1 and 3 made firm histologic shows, even the patients whose cases we reviewed diagnoses difficult. The differences between the wasted little time between failing (or being failed original pathologists and the reviewing pathologists by) conventional treatment and seeking did not appear to follow any specific pattern. The best-case series approach to CAM treatments Radiology Review
for cancer requires pathologic confirmation of the Table 3 shows the results of the radiology review of the cancer diagnosis, evidence that cancer was present at available films and the radiologists' conclusions the time the CAM treatment was initiated, no recent regarding tumor response. Three patients were conventional treatment, and evidence of complete or judged to have a complete response and 3 to have a partial response. These requirements are reasonable partial response. However, in 1 of the latter (brain but not easy to fulfill. Old charts and scans are often cancer case 2), the patient had received radiation difficult to find. Scans that are not necessary for the therapy (without evidence of benefit at the time) patient's treatment might not be covered by shortly before c o m i n g t o H u f e l a n d a n d w a s t h e r e f o r e n o t categorized as a best case. insurance. And few CAM practitioners, especially those Table 4 lists the 15 cases that were excluded from who are not also conventional physicians, require the best-case series review. Of these, 7 (3 colon cancer patients to document their cancer diagnosis or cases, 1 stage III and 2 stage IV; 2 sarcoma cases; 1 lung interact routinely with the conventional physicians Table 1. Cases Reviewed for Best-Case Status
Oct 1987 2 subtotal resections, radi- Second bladder, right hydronephrosis, dilated right ureter Melanoma 2 (skin 35/M Apr 1991 Surgery: multiple resections skin, ec 1982, drainage procedures to Jan 1983 left hand, abnormal reflexes, reduced general condition Aug 1985 Subtotal resection, radia- RT Sep- Apr 1996 Surgery, mitomycin, then Aug 1996 Nov 1991 1 cycle epirubicin/cytoxan/ Mar 1992 Unresectable mediastinal 2001 through 1999, expired 2001; no Oct 1994 Surgery, 1 cycle ifosfamide, Nov 1994 PR = partial response; BCNU = 1,3 bis(2-chloroethyl)-1 -nitrosourea; NA = not applicable; CR = complete response; SQ = subcutaneous; MS = multiple sclerosis; RT = radiation therapy; CT = computed tomgraphy; MRI = magnetic resonance imaging. Jacobson et al
Table 2. Results of Pathology Review
Adenocarcinoma, poorly differentiated Pilocytic Adenosquamous carcinoma, poorly differentiated astrocytoma Anaplastic astrocytoma (grade III) Anaplastic astrocytoma (grade III) Mucinous Bronchogenic carcinoma in malignant mixed tumor Brain cancer cases 1 through 4 were rereviewed by Martha Quezado, MD, National Cancer Institute pathologist. Her diagnoses were brain 1: residual tumor high grade with gemistocytic features; brain 2: pineal parenchymal tumor of intermediate differentiation; brain 3: radiation changes with residual tumor, most likely high grade; brain 4: pilocytic astrocytoma. Due in part to legal and regulatory constraints on than would be expected for patients with the same the provision of unconventional cancer treatments in disease and stage. However, they are not the only the United States, many of the clinics that offer such Hufeland patients with better than expected survival, treatments are based elsewhere. Linguistic and and duration of survival is not a criterion for best-case cultural differences add to the difficulty of obtaining status. documentation for a best-case series. The best-case series methodology came into use as a Staff and consultants at the NFAM selected the tool for evaluating complex unconventional cancer Hufeland Klinik for review in part because its medical therapies as candidates for further study. Ideally, such records were far more complete and organized than preliminary reviews should be reasonably quick and those of most clinics they had visited. Dr Woeppel was inexpensive. Our team took more than 2 years to also highly cooperative in providing additional assemble the case records and to complete the records from Hufeland upon request. He obtained imaging and histology review. However, it is difficult authorization from patients for retrieval of additional to imagine how the Hufeland approach and that of documents, histology, and imaging material and other similar cancer clinics could be initially assisted in the retrieval process, which nonetheless evaluated without such a case review. took 2 years. A strength of the methodology is that it permits the The most compelling candidates for a best-case evaluation of holistic, multimodality approaches. series are patients who have survived for many years However, having participated in this best-case series after their initial diagnosis. But for those patients, the review, Dr Woeppel has come to see some merit in documentation trail is often cold; specimens, slides, developing an evidence-based standardized treatment and films may have deteriorated or been lost; and that other cancer facilities could adopt. treating physicians may have retired or relocated. In Bringing the Hufeland approach in its present the Hufeland series, many of the computed form to the United States would not be easy. Some tomography scans that were reviewed by our elements of the program are not available in the radiologists came from first-generation scanners and United States because of Food and Drug were of limited quality; the settings of images on Administration regulations, physicians' lack of some magnetic resonance imaging studies posed training in certain methods, and lack of insurance additional challenges for the reviewing radiologists. coverage for them. Some of the digital images derived from The best-case methodology evaluates the success of radiographic films for the best-case series review a therapy in inducing a tumor response. But the were also of poor quality. Hufeland basic treatment program does not target the Among the cases submitted by Dr Woeppel but tumor and has no specific cytotoxic components. either not considered best cases or excluded from the Tumor response is, from Hufeland's perspective, review, were many who had arguably longer survival neither necessary nor sufficient; the Klinik's mission is than would be expected given their conventional to help patients to survive with good quality of life, treatment or their status at presentation.22,23 The 5 best and Dr Woeppel selected cases for review with that cases also improved clinically and survived longer Cancer Outcomes in a Best-Case Series
Table 3. Results of Radiology Review
Right pelvic mass ~5 cm, secondary moderate right hydrouteter and Ill-defined mass ~2 cm, hydroureter and hydronephrosis unchanged S/P subtotal resection, cannot exclude residual tumor Recent, evolving, right MCA infarct on CT; no evidence of tumor but no 5-cm bladder mass, dilated R ureter and R hydronephrosis R ureter questionably dilated distally, otherwise normal Soft tissue masses in SQ down to muscle in right medial thigh Defects same location, postoperative changes, melanoma may still be No evidence of malignancy chest, abdomen, pelvis; limited lung field evaluation due to data compression on transfer Abdominal CT: 3 metastatic foci persist in liver Abdominal CT: no evidence of metastatic disease Pineal tumor doubled in size involving adjoining structures, extending Pineal gland smaller, less enhancement; white matter lesions noted Minimal rim enhancement, moderate white matter edema Tumor in lateral thalamus, chiasm, and optic tracts Residual tumor optic chiasm and tracts but less compared with Jul No imaging review because of clinical progression in indolent tumor 3-mm round peripheral juxtapleural opacity, not solid; unclear if Not reviewed here because x-ray reports indicate no PR Cannot distinguish 3 cm x 2 cm pleural-based mass-like opacity R New medial pleural mass, 2 right midlung zone masses: progression CT = computed tomography; S/P = status post; MCA = middle cerebral artery; U/S = ultrasound; MRI = magnetic resonance imaging; SQ ■■ subcutaneous; NA = not applicable; PR = partial response; R = right. in mind. However, he understood the requirements of Research and Quality did not present response rates the review and accepted them. but recommended consideration of further study of The 27 cases that he selected were those in which both modalities. For 1 modality, 9 of 30 cases were patients survived longer than expected and agreed to judged to meet the criteria; for the other, 3 of 21 were provide access to their conventional medical records. similarly judged. In both reviews, the cases involved The 12 cases that we reviewed were those that cancers of several different organ/sites and a lengthy appeared to meet the NCI best-case series criteria effort to obtain medical records.24 based on the case summary. Where necessary, we then To calculate a response rate in our study, we would sought additional documentation. (We excluded only have had to review the charts of all 3000 cancer 1 case for lack of such documentation.) patients seen at Hufeland since 1985, to eliminate all Best-case series are not designed to permit those with recent or concurrent potentially curative calculation of a response rate. A recent report of 2 conventional treatment, to document the status of the best-case series prepared for the Agency for cancer at the time the patient first came to Hufeland, Healthcare INTEGRATIVE CANCER THERAPIES 4(2); 2005
Table 4. Cases Excluded From Best-Case Series Review
1985 Apr 1985 mastectomy; Sep 1988 and Dec 1988 resection of chest wall recurrences, Sep 1989 resection lymph node metastases; Oct- Nov 1989 radiation therapy; Oct 1989-Oct 1991 Zoladex; Dec 1991 resection lymph node metastases; Jan-May 1992, cyclophosphamide/methotrexate/5FU (CMF); Jun 1992-Jan 1994 tamoxifen; Feb 1994 radiation therapy; Feb 1995 and Jul 1995 lymph node resection; Sep 1995 skin biopsy, Oct-Nov 1995 RT skin metastases 1991 Oct 1991 left mastectomy, Nov 1991-1995 epirubicin/cyclophosphamide (FEC), velban/ 1996 Jun 1996 mastectomy, Jun-Nov 1996 4X EC, 1968 Nov 1968 total abominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO), adriamycin/cyclophosphamide (PAC); Apr 1985 radiation therapy to entire abdomen for tumor cells in peritoneal fluid 1982 Feb 1982 TAHBSO, omentum resection, Mar 1982 chemotherapy; Jan 1989 abdominal wall cycles; Nov 1991 extirpation of abdominal 1987 Jul 1987 surgery, Jul-Oct 1987 CMF chemo- therapy, Oct 1987 laparoscopy: biopsy positive carcinomatosis, Oct 1987 PAC chemotherapy 1989 Nov 1989 left pneumonectomy, Nov 1989-Feb vincristine (ACO) 3 X, Jul 1990 radiation 1995 Feb-Mar 1996 radiation therapy (60 Gy) Alive and well May No tumor response after 1988 Apr 1988 sigmoid resection, Oct 1988 liver Alive and well Feb No evidence of disease Jan 1991 hemicolectomy and resection liver No evidence of can- Alive and well Sep No metastasis; Jan 1993 resection liver, gall bladder, diaphragm metastasis; Feb-Jul 1993 active-specific-immune therapy; Jan 1995 resection liver and diaphragm metastases 1993 Sep 1993 hemicolectomy, Oct 1993-May 1994 1988 Jun 1988 right pelvic resection and arthroplasty; Jul 1988-Apr 1999 CESS-86-system chemotherapy; Aug 1995 wedge resection lung metastases; patient refused Apr 1992 tumor resection right thigh, Aug 1992 Jun 1993 resection left lung, Mar 1993 resection right lung, Jul-Nov 1992 chemotherapy epirubicin/ 1984 Jul 1984 resection SQ tumor left leg, Sep 1984 resection local recurrence, Feb 1986 excision large left inguinal lymph node metastasis 1996 Dec 1996 radiation therapy to rectal, pelvic RT = radiation therapy; CT = computed tomography; TAHBSO = total abdominal hysterectomy and bilateral salpingo-oophorectomy; SQ = subcutaneous; PR = partial response. Jacobson et al
and to identify all the CRs and PRs. To assess survival who use CAM are a heterogeneous group, and the as an outcome, we would need a comparison cohort claims made for treatments vary. Taking those and of patients similar in cancer organ/site, age, stage, other relevant factors into account will not be easy, but gender, date of diagnosis, and status of disease at the the difficulty should not deter us from trying to time the treatment group came to Hufeland but standardize the preliminary evaluation of complex receiving only conventional treatment. A prospective CAM treatments alleged to benefit cancer patients. study that purported to have such a comparison group collected data on the CAM cohort via Acknowledgments
interview and chart abstraction but used only chart We gratefully acknowledge the assistance we received review of the comparison group and was therefore from Wendy J. Verret, who served as project seriously biased.25 Appropriate comparison groups coordinator in the first year of the study, and from for prospective studies are hard to find. Most Martha Quezado, MD, who provided a second opinion patients who present at an inpatient CAM clinic do for the pathology review of the brain cancers. Funding so because they have reason to doubt that for this study was provided by the National Foundation conventional treatment will cure them. Even for Alternative Medicine, 5 Thomas Circle, matching on stage might not level the playing field Washington, DC. The contents of the article are solely unless additional markers and/or perceived risk of an the responsibility of the authors. The detailed case reports required by the NCI guidelines are available on Clinics such as Hufeland clearly seek to provide comfort and hope to patients with advanced disease who are not ready for exclusively palliative care. References
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