Alternative therapies for CLL

First I have a confession. I very seldom censor comments to this blog, but yesterday I had a comment that promoted an alternative therapy for CLL. I did not think it was appropriate to give it the oxygen of publicity on this site, because I think that such alternative therapies, which often involve odd diets and dental clearance and strange supplements, don't do anything for CLL.

CLL is an infinitely variable disease in which spontaneous remissions occur. Patients with the mutated sub-type of CLL, in particular, find that their disease is to some degree subject to homeostatic control. This means that the things that influence normal B cells continue to have an effect on the CLL population. The best example is exercise. One of my patients is able to control his white cell count by running. He has produced impressive graphs which show that when he runs (and he runs enormous distances) his white count falls. But when it comes to the more aggressive subtypes, exercise does little or nothing to control the disease.

Exaggerated claims for lifestyle changes are made, and there is no doubt that most people eat too much, smoke too much and take too little exercise, but there is precious little evidence that changing your lifestyle will do much for your cancer. Anybody who smokes should certainly stop. Second cancers are probably more likely in CLL and it's foolhardy to court one of these by inhaling carcinogens. The evidence that diet influences cancer is much less than certain cancer charities will tell you. Food preserved with nitrites excepted, most dietary associations with cancer have not stood up to rigorous testing. This doesn't mean that I don't advocate healthy eating and regular exercise. Most people will feel better if they follow sensible dietary advice and take plenty of exercise and they will lower their blood pressure, have a trimmer figure and ward off heart disease and stroke.

What about dietary supplements? A normal diet contains everything that humans need to keep healthy. Megadoses of vitamins have been promoted by various individuals including a double Nobel Prize winner in Linus Pauling. The truth is that in most cases the excess vitamins are passed out in the urine. They are safe, but an expensive waste. The exceptions are fat-soluble vitamins A and D. When I was younger there was some laboratory evidence that these vitamins had a physiological effect on cells. The leukemic cell line, HL60, could be made to mature into neutrophils with vitamin A and into monocytes with vitamin D. Indeed, vitamin A derivatives have entered conventional medicine as treatments for acne and promyelocytic leukemia. However these derivatives can be very toxic when taken in excess and are even teratogenic and should not be taken during pregnancy.

Vitamin D is being used for the bone thinning that occurs after the menopause, because its primary action is to control calcium metabolism. Whether it has a role in cancer and in CLL in particular is controversial. Certainly, CLL patients with low levels of D3 have a poorer prognosis, but it is not clear whether this is cause or effect. Clinical trials of vitamin D3 supplements will give us an answer, but until then, those who have faith in D3 should monitor their serum calcium levels, since hypercalcemia can be lethal.

When I talk about a normal diet I mean one that includes meat and vegetables. People who don't eat meat either do so for religious reasons or from distaste at the idea of slaughtering animals or because they have fallen for the propaganda of the vegetarian industry. Strict Hindus are vegans. In rural India such people are likely to be iron deficient since iron from vegetables is poorly absorbed and is not well used for making blood cells. They do not become vitamin B12 deficient because their food is contaminated with bacteria which manufacture the vitamin. In the Western world vegans become vitamin B12 deficient eventually, though B12 stores can last for 20 years if the decision to become a vegan takes place after years on a normal diet. Iron deficiency is not so common because so many foods contain iron supplements. It is most likely to occur in teenage girls.

Some Christians, especially those of the green persuasion, become vegetarians. I'm not sure how they support this theologically, but to my mind the Bible is quite clear on the subject. In Genesis 9:3 God instructs Noah after the Flood: "Everything that lives and moves about will be food for you. Just as I gave you the green plants, I now give you everything." and in the New Testament St Peter's vision in Acts 10:11-15 not only abolishes any food laws, but seems to give the green light to bush tucker: "He saw heaven opened and something like a large sheet being let down to earth by its four corners. It contained all kinds of four-footed animals, as well as reptiles and birds. Then a voice told him, “Get up, Peter. Kill and eat.” “Surely not, Lord!” Peter replied. “I have never eaten anything impure or unclean.” The voice spoke to him a second time, “Do not call anything impure that God has made clean.”

How about herbal medicine? It is certainly true that many of our current drugs including aspirin, quinine, digoxin, atropine and vincristine are derived from plants. One of my old bosses had atrial fibrillation caused by thyrotoxicosis. When he played squash his heart would race, but he kept in the pocket of his shorts some dried foxglove leaves of which he would take a handful for the digitalis effect. That is the problem with herbs. They contain the active ingredient at variable concentrations and often antagonists to the active ingredient as well. Dosing is unpredictable. Better to extract the activity and purify it, then give the optimum dose which has been determined by a clinical trial. There may well be some way of using these active ingredients from herbs like curcumin and green tea, but the raw stuff is variable, weak and unpredictable in its effect.

The placebo effect plays a big part in the beneficial effect of alternative therapies. Practitioners are expert in utilizing it. Spending time with a patient with a good bedside manner and using a spectacular apparatus has an immense placebo effect. How does this work? My daughter thinks it is about neuro-immunology and there is some evidence for this. Pavlov's famous experiment of getting dogs to salivate at the sound of a horn, even when it is not rewarded by food, has been repeated for vaccine studies, so that an immune response can be generated at the sound of a horn, even when no vaccine is given. It is certainly possible that feeling good and optimistic about the future may influence the internal environment of growth factors, chemokines, cytokines, receptors and antibodies.

So I would not discourage people from seeking aromatherapy, exercise, green tea, acupuncture, massage or any other complementary treatment with this proviso: do not let it deter you from an established treatment when the time comes, and do not proselytize so vehemently that you send others on a guilt trip because they are not following your advice.