The Cancer Advisory Panel for Complementary and Alternative Medicine (CAPCAM) convened on September 18, 2000, at the Pooks Hill Marriott, Bethesda, Maryland. The meeting was closed to the public 9:00 a.m. until 1 p.m. as provided in Sections 552b(c)(4) and 552b(c)(6), Title 5 U.S. Code, and section 10(d) of Public law 92-463, for the review, discussion, and evaluation of proprietary and related information. The meeting was open to the public from 1 p.m. until adjournment. Richard Nahin, Ph.D., M.P.H., Executive Secretary of CAPCAM, called the meeting to order.
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CAPCAM Members Present
Michael Hawkins, M.D., Chair
Peter L. Choyke, M.D.
Ian D. Coulter, Ph.D.
James S. Gordon, M.D.
David J. Hufford, Ph.D.
Frances A. Jacobs, R.N.
Ralph Moss, Ph.D.
Susan K. Quella, R.N.
Douglas L. Weed, M.D., Ph.D.
Lauren V. Wood, M.D.
Jeffrey D. White, M.D., Ex Officio Member
AD HOC Members
Mitchell R. Hammer, Ph.D.
Marguerite Evans, M.A.
Christine Goertz, D.C., Ph.D.
Anita Greene, M.A.,
Camille Hoover, MBA
Doug Hussey, NCCAM,
Morgan Jackson, MPH, MD
Richard Nahin, MPH, Ph.D.
Mary Ann Richardson, Dr.PH
Wendy Smith, Ph.D.
Stephen Straus, M.D.
Steve Ayre, M.D.
Ross Hauser, M.D.
Donato Perez Garcia, Jr., M.D.
Closed Portion (9:00 a.m. - 1:00 p.m.)
I. Call to Order
was called to order by Richard Nahin, MPH, Ph.D., Executive Secretary
of CAPCAM. Dr. Nahin reviewed NIH rules concerning confidentiality and
conflict of interest.
II. Best Case Series Presentation: Insulin Potentiation Therapy
morning session was closed to the public for reasons of patient confidentiality.
Open Portion (1:00 p.m. - 5:00 p.m.)
Call to Order and Meeting Procedures
explained for those present that there would be a continuation of the
morning discussion without specifying the details that made it necessary
to close that session. He then reviewed the rest of the agenda. The goal
of the meeting was for the panel to make one of three recommendations:
that there is sufficient data for further research by NIH; that no further
research is warranted; or, that there is insufficient data to recommend
additional steps, in which case it might be useful for the presenters
to offer additional information.
explained that the topic under discussion was insulin potentiation therapy
(IPT). That morning, Dr. Ayre had made a presentation and the panel reviewed
three cases. This therapy employs insulin with low doses of chemotherapy,
which, according to Dr. Ayre, changes the permeability of cancer cell
membranes and makes cells more sensitive to chemotherapy. In two and possibly
three of the cases, the panel felt there was evidence of improvement.
Given the confounding aspects of chemotherapy administration, it did not
appear useful to continue to focus on those three cases. Hence, the remainder
of the day would be spentdiscussing the next research steps.
explained that his clinic sees 40 to 50 patients each day, as well as
two or three new cancer patients each week who are seeking alternative
medicine. He said that under the insulin potentiation therapy, the patients
do not suffer side effects from chemotherapy, and even end-stage patients
feel much better after two or three sessions. So as a natural health care
provider, he is comfortable doing this treatment because of the lack of
asked about providing patients for a study, Dr. Hauser explained that
because many of his patients are in HMOs and PPOs, they cannot receive
this therapy, even though the cost is much less than that of conventional
treatment. Dr. Hufford suggested that 10 dramatic cases with substantial
progress would be convincing. The effects would need to be large to overcome
the issue of dosage. Dr. Hauser said that results thus far have been very
good, but doing a study would require enrolling many patients prior to
their receiving standard therapy. Dr. Ayre felt this was doable. He said
they could provide a significant numbers of cases of newly diagnosed patients,
and would participate in recruitment and provide other help to participating
practitioners. Dr. Ayre would like to see a safe trial period of three
weeks, then if the patients show no improvement, channel them back to
conventional treatment. Dr. Hufford said that recruitment should not be
specific to the study, as it would be a challenge from an ethical standpoint.
They could, however, document current practice.
added that the FDA might require moment-to-moment blood glucose monitoring.
Dr. Hawkins explained that the nature of the study population will influence
how the FDA views the study. A study of women who are likely to recover
from breast cancer will receive more scrutiny than one of patients who
can no longer be cured. Dr. Gordon explained that it will take years to
know the results of a study of those who have early stage disease, so
a study of end-stage patients would be advisable. He suggested that they
could study patients in the late stages of cancer who have not yet been
treated, or those who have diseases such as pancreatic cancer, in which
treatment does not have much effect. Advanced stage cancer patients will
produce the most dramatic results. Dr. Moss added that for pancreatic
cancer, chemotherapy is given primarily for palliative effects. The most
likely positive outcome would be to show that this therapy is as good
as standard chemotherapy but significantly less toxic, which would be
a major contribution to humanity and medicine. He did not think they should
put resources into a prospective case series. On the other hand, chemotherapy
shrinks tumors, so they ought to compare the insulin potentiation therapy
with conventional chemotherapy.
said that to do such a comparison requires much more in the way of resources
than keeping track of the next 20 patients treated. If six or seven were
to have a dramatic response with few or no side effects, a clinical trial
could be conducted to compare IPT to conventional chemotherapy. But to
leap to a comparison study with the data now in hand now will not work.
Dr. Hufford's proposal
is the least costly step at this point. Even a 50 percent shrinkage in
tumor size would be significant. A key element of this approach would
be to identify patients before they are treated with conventional chemotherapy.
Dr. Hawkins added that ultimately, they would be looking for anti-tumor
activity. They would be able to get an objective measure of shrinkage
on CT scans, as well as other standard components. Once they have the
experience of 20 patients to examine, they can see where they are and
move on. Dr. Weed added that at this point, they are simply interested
in documenting what happens, in order to determine if there is enough
information to justify proceeding further. It would be helpful to have
a prospective study that gathers more information. Dr. Moss agreed, and
noted that standard quality of life measurements would test the thesis
that this treatment has little or no toxicity. If it has significant toxicity,
the appeal is much less.
suggested that animal studies would be simple to evaluate and the least
expensive thing they could do. But the others still preferred to see a
better case series. Dr. Nahin asked if an institutional review board (IRB)
would be needed by the investigators. Dr. Ayre said that he has access
to an IRB, which approved his protocol back in 1997. Dr. Hammer advised
that if NIH were to support a prospective study, some expertise and resources
should be devoted to assisting the researchers in doing it so that it
meets NIH criteria. Dr. Hufford agreed that it would be best to give guidance
now, and not pick apart a proposal later. Others agreed. Dr. White suggested
including a mechanism by which NIH can actively participate in the data
asked if the committee felt there should be efforts to move forward. Approval
of such action was unanimous; the committee approved going forward while
offering help to make sure the data collected are those NIH needs. Dr.
White explained that NCI does not have a formalized process for providing
such assistance, but instead does so on a case-by-case basis. Discussion
of a concurrent animal study produced no real enthusiasm, although several
committee members noted that animal studies could help underpin future
A Systematic Approach to Identifying Case Series of Promising CAM Therapies
for the Treatment of Cancer
gave a presentation based on his work at RAND, with the premise that a
more systematic approach to data collection might yield a larger sample
of promising CAM cancer therapies for consideration by CAPCAM. One available
method to such an approach is a literature review followed by synthesis
and analysis. This begins with a search of databases, then a review of
citations and abstracts. Articles receive quality scores, the synthesis
leads to a meta-analysis, and finally the researcher reports the evidence.
In an example, Dr. Coulter discussed such an approach as applied to oncology
and mind-body studies. The literature review produced 110 studies. Of
these, there were 19 possible comparative studies, 19 case studies, 17
reviews, 5 historical studies, 1 case report, 47 pieces that were unclear.
A quality review entails either giving a Jadad score or conducting a detailed
approach is systematic evaluation of random charts at CAM practices. As
an example of the approach applied to practice-based studies of CAM, Dr.
Coulter told of a chiropractic study that involved 5 sites, 25 practices,
and a random selection of files. There were many challenges: identification
of providers; recruitment; office format; the state of the files themselves;
use of results; and politics. One of the central issues was finding providers,
because there was no central source providing a list. Recruitment was
also a tremendous task. Each state addresses the issue of chiropractors
differently, and there are multiple membership organizations. In addition,
the CAM community is a small one; word travels fast, so they had to explain
clearly what they were doing to avoid misperceptions. CAM practitioners
tend to practice in modest settings, rather than elaborate offices, which
meant that their offices were not always easy to work in - sometimes files
are kept in a broom closet, for example, and sometimes there is no real
waiting room. To obtain a random selection of files, the RAND researchers
measured the files as through they were books in book case, used a random
table generator to tell which files to take, and accounted for "fat file"
bias to avoid taking just the thick files.
abstracted every case to acquire the denominators. All of the cases were
randomly chosen, to get estimates of the types of conditions represented
in the practice. The researchers did complete information extraction on
the low back pain cases. They found that the quality of the information
in the files varied; workers comp cases were the most complete, because
any file likely to be reviewed had more detail. In the end, Dr. Coulter
felt that the data RAND acquired were of good quality. In conclusion,
he noted that the literature-based search will only capture what is in
the literature already, and much CAM information is unpublished. Practice-based
research in CAM is possible, but it is difficult, time-consuming, and
costly. He also recommended considering foreign language sources in the
Dr. Coulter noted that it is naive for researchers to ignore the politics
of CAM. CAM providers are sensitive regarding their reputations, and are
wary of being seen as quacks. In this chiropractic study, the headlines
that reported the results focused on the negative. But RAND has a policy
that if the company is misquoted, they will reply to the media in question
and even take legal action in order to combat misinterpretation. Therefore,
this study was possible because of trust built up through this policy.
noted that for many CAM approaches, there is little or nothing in the
way of literature, and what does exist is often of poor quality. Dr. White
explained that his office has developed a list of direct contacts for
the purpose of mailings, and these contacts were gathered from alternative
medicine directories. Dr. Coulter noted that RAND preformed the previously
mentioned study with a fully dedicated staff of 6 abstracters and 4 investigators,
along with volunteers. The research team consisted of 10 during the first
year, then about 5 for 2 more years. Dr. Weed suggested that for a case
series, it would not take that much effort to find out what already exists.
Dr. Hufford added that it would be useful to have a best case series of
conventional treatment in order to gauge the results of CAM studies.
observed that the CAPCAM process is frustrating, because the original
purpose of the committee was to find if anything was being missed, and
he has a sense that that is still the case. He felt they were drifting
further and further from the core purpose to identify treatments that
are used by the public and that may have promise. Dr. Gordon suggested
that despite the excellent job NCI has done, there should be more people
involved in the work of looking at practices and taking next steps. The
main advance, in his opinion, is that CAPCAM exists; he feels he can at
least refer people to others in the group. He would like to see CAPCAM
fortified in order to move ahead and address more of these issues. Dr.
Nahin suggested that there might be dissatisfaction with the speed with
which the committee is seeing best cases. He felt that Dr. Coulter's presentation
illustrated a good model and showed what could be done. One of the issues
is getting data from practices to the panel. Even when there is a concerted
effort, it does not always produce useful data in the correct volume and
quality. Dr. Gordon added that CAM practices need a bridging mechanism
that can pull them together. Dr. Hammer observed that the kinds of issues
that have been problematic are those that have involved contacting practitioners
and working with them to obtain complete cases. It is possible that there
is a need for more effort in this area, for they are dealing with people
who have gaps in their knowledge, and the result is a lack of follow-through.
He felt the committee was really discussing a process issue, and that
the concern was missed opportunities.
explained that it is hard to assess what the biggest problems are in obtaining
data. Just raising awareness is not sufficient. Practitioners do not always
know who he is and are not always willing to participate in the process.
Dr. Ayre agreed, noting that many health organizations are unaware of
CAPCAM's existence or efforts. He suggested that an effort be made to
attend professional organization meetings and inform the membership. He
noted that he belongs to two natural medicine physician organizations,
and doctors within those groups were astounded that he was going to NIH.
In response to the suggestion of having an audit committee and contacting
specific groups, Drs. Nahin and White both agreed that this would be something
that could be delegated. Dr. Hufford added that one of the issues is that
CAM practitioners lack an equivalent to allopathic medical schools. He
would like to see more emphasis on education, resulting in doctoral theses
and an established cadre of skilled researchers familiar with the area.
explained that one of the key things he learned at RAND is how difficult
and important it is to build trust. The effort must be constant, and it
is time consuming and not always practical. CAPCAM must therefore make
choices and focus. Ms. Holloran asked how his experiences could be transferred
to help the committee. Dr. Coulter suggested first identifying case series,
then establishing a way to show what works. Dr. Hammer requested that
Dr. Coulter provide a blueprint of the steps he took. Dr. Richardson suggested
that what is needed is a system or mechanism to assist practitioners in
collecting and entering data. She added that NIH could develop an appropriate
mechanism to do this. Dr. Moss said that researchers must cultivate contacts
and connections, as trust does not happen overnight. The literature gives
a false impression of what is exciting and current in the field. Another
group is assembling this data, the National Foundation for Alternative
Medicine. Dr. Gordon cautioned that the work goes beyond just visiting
a practice. There is a tremendous amount of leg work involved. NCCAM and
the cancer centers should be encouraged to make efforts in this area.
Another issue is that of providing some kind of protection for these researchers.
Some are genuinely afraid of being accused of practicing medicine without
Wiley, a dermatologist from Oklahoma City, said that she was happy to
be able to attend. She noted that she found information about the meeting
on the NCCAM web site.
Update on NIH Initiatives for CAM and Cancer
reviewed NCCAM cancer activities. Two P50 cancer centers will be funded
soon: Johns Hopkins and the University of Pennsylvania. In addition, NCCAM
supports several investigator-initiated projects investigating CAM to
treat cancer (see the NCCAM web site for a list of funded projects: http://nccam.nih.gov).
in development will address CAM therapies for end of life, and phytoestrogens
(PE) and breast cancer. For the former, NCCAM will issue an RFA for R01s
and R21s to prevent and/or reduce side effects; prevent and manage symptoms;
and enhance psychological, social, and spiritual well-being. The breast
cancer studies, done as R01s, will have a strong pharmakinetic component,
evaluate PE supplements versus a PE-enriched diet, clarify the role of
PE, and gauge dosing.
asked about plans for Phase 1 and 2 studies. Dr. Richardson said that
this is being left up to the field, to move along in whatever therapies
are ready. Dr. Hufford asked about the extent to which the projects underway
are linking to the CAM community. Dr. Richardson explained that natural
medicine practitioners are very involved with hyperbaric oxygen. Dr. Nahin
added that NCCAM has been talking to Dr. Sun since his CAPCAM appearance
and has been trying to facilitate his study. Dr. White noted that Dr.
Sun wishes to be the principal investigator, and they are helping him
line up clinical oncology collaborators. The focus has been on helping
him with the quality of the proposal. They have reviewed his protocol
plans and made comments about what is necessary for improvement. Dr. Weed
raised the issue of prevention. With the large body of NCI research on
prevention and diet, he wondered if NCCAM was working with NCI in this
area. Dr. Richardson explained that they are working in that area.
the requirements of the NCCAM centers is that they do outreach to the
CAM community. Dr. Gordon observed that some centers are very good at
this, and others do very little. Dr. Hammer asked if any CAM centers have
recommended that certain practitioners bring their therapies to NIH. His
concern was that things might be falling through the cracks. Dr. Richardson
noted that the Texas center has sent groups to NCCAM. Dr. Nahin added
that some centers are newly funded, while the Texas center's funding has
just ended. Ms. Holloran asked if the specific research questions that
arose are the most significant ones. For example, the CAM community argues
for foods, not tablets, and many feel that soy supplements are dangerous.
She was concerned that the researchers were studying the wrong things
in the wrong form. Many CAM practitioners believe that healing action
takes place in food, and therefore NIH should study the food as used in
these practices. It seems clear that it would be easy to look at both.
Dr. Hufford agreed that this is where collaboration with the CAM community
comes in. The validity of a study requires that NIH examine practices
as they occur. But a parallel point is that collaboration is sometimes
problematic, because CAM practitioners often feel proprietary and fear
that conventional medicine will take over their innovations.
then gave a presentation about Cancer CAM information. The PDQ CAM summaries
are available by calling 1-800-Cancer or by going to the CancerNet website
(cancernet.nci.nih.gov). Topics include laetrile/amygdalin; cancel/Entelev;
shark and bovine cartilage; coenzyme Q10; hydrazine sulfate; and mistletoe.
NCCAM/NCI CAM fact sheets are condensations of information from PDQ summaries
and will be available online and from other NCCAM and NCI information
NCI/NCCAM initiative solicited CAM cancer pilot projects through NCI-designated
cancer centers. Initiative goals include supporting projects with high
likelihood of developing into successful R01 applications; facilitating
development of continuous CAM research programs; and encouraging and supporting
collaborations between conventional cancer researchers and CAM researchers
best case series program has been moving forward. Between December 14
1999 and September 15 2000, there have been 22 inquiries, 6 planned submissions,
and 3 actual best case series submissions. Submission #1 resulted from
an initial contact made in September 1999. NCI received documentation
on two cases in March, documentation on one more in April and another
in June, and expected more cases by July. The first three cases were reviewed
in July while NCI waited for the pathology on the fourth case. Since no
further information was obtained on subsequent cases, approval was obtained
to schedule the presentation of the three complete cases to the CAPCAM.
(This was the IPT best case series discussed above.) Submission #2 came
from an initial contact in July 1999; clinical summaries and radiology
materials were received in May and June of 2000. In this series, four
cases have been received and two are eligible for review, with more data
on the remaining two forthcoming. The initial contact for the third submission
was made in June 2000. NCI received cases in July, but there were no pathology
slides; the submitter is obtaining more data. There are also two prospective,
single-arm clinical trials NCI has addressed. For one, preliminary data
was submitted in September 1999. NCI has requested further documentation
of patient responses. For the second, the initial contact was made in
June 2000; no data have been submitted yet.
the best case series program, NCI has sent out 152 letters since mid-December
1999. Information is available at the OCCAM web site (occam.nci.nih.gov)
as well. Dr. White has made conference presentations, has submitted journal
interviews and articles, and has placed advertisements in six journals.
NCI is now paying the travel and expenses for practitioners appearing
at CAPCAM meetings for the best case series, and is exploring the feasibility
of per case reimbursement for expenses incurred in preparing a best case
series. In terms of practice outcomes monitoring, there have been difficulties
with the Banerji project in Calcutta, India, in that there are ongoing
negotiations about the scope of the investigation. Joint NCI/NCCAM CAM
cancer clinical trials include a Phase 3 study of liquid shark cartilage
and a Phase 3 study of a powdered shark cartilage product. The study of
the Gonzalez/Kelley Regimen has had a problem with patients being unwilling
to be randomized; there are some remaining administrative issues to work
were questions about the Calcutta and Gonzalez studies, but Dr. Hawkins
reminded the committee that they should not discuss the cases openly at
this point. Dr. White offered to discuss the details with committee members
who contacted him personally. Dr. Nahin added that the issues are details
and not global. Ms. Holloran also asked about Mr. Angelo P. John, who
left his information at a previous meeting. Dr. White said that the case
is inactive because Mr John has not obtained any new data in two years.
The difficulties are largely due to the fact that Mr. John is not a practitioner
with an office or records, so he must approach practitioners as a consultant.
He does not supply documentation of disease and responses, nor does he
provide a specific therapy.
to questions, Dr. White explained that there is a template for submitting
BCS on the NCI website. In addition, when he attends conferences, he explains
the BCS process in detail. While he wants to make materials easily available,
he also wants practitioners to contact him directly, for the one-on-one
discussion is critical. Several CAPCAM members who had heard Dr. White
speak on this subject noted that he does an excellent job, particularly
in distinguishing the scientific perspective from the issue of medical
practice. A motion was passed to acknowledge and applaud Dr. White's efforts.
thanked the committee members for their time. He noted that the task before
them is not easy. But despite the long and complicated process of ramping
up, they now have a level of commitment and substantial resources beyond
what they had before. He added that Dr. White has spent many hours working
hard on the best case series. They are also asking for hard work and courage
from their researchers, and he commended Dr. Ayre and Dr. Perez Garcia
for their efforts. As NIH develops the sensitivities and sensibilities
necessary to move forward in this area, they will rely on collaboration
with others to help them understand what is needed. Discussions on the
best methods will continue. He challenged the committee to continue to
be as optimistic and collegial as they have been, and to try to develop
consensus, even though given the necessary diversity, they will not always
was set for the next meeting. Dr. Nahin said that members will be contacted
about a possible time in winter or spring once two to three additional
BCS have been completed. There being no further business, the meeting
was adjourned at 5 p.m.