[Severe disciplinary measures in the Millecam case: important precedent for revising the rules of conduct by scientific associations and the KNMG]. / Strenge tuchtrechtelijke maatregelen in de zaak-Millecam: belangrijke jurisprudentie voor het aanscherpen van de gedragsregels door de wetenschappelijke verenigingen en de KNMG.

The popular 45-year-old Dutch actress Sylvia Millecam died in August 2001 from untreated advanced breast cancer. She refused standard medical treatment and sought solace in many alternative healers, including three medical physicians. The Dutch Healthcare Inspection accused the three physicians of malpractice and asked the Medical Disciplinary Tribunal to pass judgment. In April 2006 one physician was struck from the physician register and the other two were suspended for 1 year and 6 months, respectively. These unusually severe measures were based mainly on the fact that they had neglected professional standards as defined by specialty boards, they had presented themselves as professional physicians and they had not tried hard enough to convince Millecam of the need for standard treatment. The Tribunal did not accept the strong desire of the patient to undergo only alternative treatment as a defence. Notably, the judgment of the Tribunal seems to be more severe than the present bylaws of medical-scientific bodies and the Dutch Medical Association (KNMG), which are apparently too lenient regarding the use of alternative treatments by their members.

[The hidden treasure-chests of the regional cancer registries]. / De verborgen schatkamers van de integrale kankercentra.

For physicians and patients, knowledge of the treatment results of individual hospitals is of great importance as it is known that hospitals with more experience perform better. Oncological characteristics of cancer patients in the Netherlands are collected by the nine Comprehensive Cancer Centres. The data are available from each affiliated hospital but remain anonymous. A plea is made for more transparency by requiring that the Comprehensive Cancer Centers place their data in the public domain.

[The measures proposed by the Dutch Healthcare Inspectorate after the death of Sylvia Millecam and her treatment by practitioners of alternative medicine]. / De voorgestelde maatregelen van de Inspectie voor de Gezondheidszorg naar aanleiding van de dood van Sylvia Millecam en haar behandeling door alternatieve genezers.

As a result of the illness and treatment of the Dutch comedian Sylvia Millecam, who died of the consequences of an untreated mammary carcinoma following a quest for help from a series of practitioners of alternative medicine, the Dutch Healthcare Inspectorate has proposed measures designed to prevent a repetition of such a shortcoming in the delivered care. The measures include the compulsory registration of practitioners of alternative medicine, the restriction of diagnostic procedures to regular physicians, the obligation to co-operate with the best possible treatment for the patient in question, mutual exchange of information between practitioners of regular and alternative medicine, and a compulsory protocol regarding the therapeutic agreement with the patient if the regular route is not followed. How feasible these measures are remains a question. A positive aspect of the report is the attention given to the shortcomings in the care provided by the alternative circuit and the deterrent effect of the present case.

[Less use of alternative treatments by cancer patients in 2002 than in 1999]. / Minder gebruik van alternatieve behandelingen door kankerpatiënten in 2002 dan in 1999.

OBJECTIVE: To determine the use of alternative diets and other alternative treatments in 2002 compared to 1999. DESIGN: Descriptive, questionnaire. METHOD: During the period 13-26 May 2002 a survey was held among all patients visiting the outpatient clinic of the Netherlands Cancer Institute/Antoni van Leeuwenhoek hospital, Amsterdam, the Netherlands. Patients were asked about their current and past use of alternative therapies, their reasons for using these therapies, the way they were informed about these therapies and the expenses involved. The data were compared with the results of a similar study during the period 15-19 March 1999. RESULTS: Of the 729 patients who fulfilled the inclusion criteria, 66 (9%) declined to participate in the study. Of the remaining 663 patients (average age 58.5 years; 28% male), 131 (20%) used an alternative therapy. Of these, 43 patients (7%) used an alternative diet, mainly the Houtsmuller diet, and 88 patients (13%) used a mixture of alternative therapies such as homeopathy, vitamins and herbs. In 1999, 131 patients (30%) used an alternative form of treatment, 51 (13%) of whom used a diet. Of the 43 users of diets in 2002, 11 (26%) believed that the diet would slow down the disease process; in 1999 this was 53% (27/51). Of the 131 users of alternative therapies in 2002, 55% had been made aware of the possibilities of alternative treatments via family and friends. Internet and TV played a minor role as a source of information. 33 (79%) of the diet users informed their physician or nurse about the use. The diet users spent an average of 170 euro per month on their diets. CONCLUSION: Both the percentage of cancer patients who used an alternative diet and the percentage of diet users who believed that a diet could affect the course of the disease were reduced by half compared to three years earlier.

Late effects of adjuvant chemotherapy on cognitive function: a follow-up study in breast cancer patients.

BACKGROUND: Neuropsychological examinations have shown an elevated risk for cognitive impairment 2 years after therapy in breast cancer patients randomized to receive adjuvant high-dose cyclophosphamide, thiotepa, carboplatin (CTC) chemotherapy compared with a non-treated control group of stage I breast cancer patients. Patients randomized to receive standard-dose fluorouracil, epirubicin, cyclophosphamide (FEC) chemotherapy showed no elevated risk compared with controls. However, breast cancer patients treated with conventional cyclophosphamide, methotrexate, 5-fluorouracil (CMF) chemotherapy showed a higher risk of cognitive impairment. The present study was designed to obtain a greater insight into these long-term neuropsychological sequelae following chemotherapy and their course in time. PATIENTS AND METHODS: At 4 years post-therapy, 22 of the original 34 CTC patients, 23 of 36 FEC patients, 31 of 39 CMF patients and 27 of 34 control patients were re-examined with neuropsychological tests. RESULTS: Improvement in performance was observed in all chemotherapy groups, whereas in the control group there was a slight deterioration in test results. A differential attrition was observed among the groups, with a relatively high percentage of initially cognitively impaired patients from the CTC group dropping out due to factors related to disease progression. CONCLUSIONS: The results suggest that cognitive dysfunction following adjuvant chemotherapy in breast cancer patients may be transient. Additional studies are needed to investigate the differential attrition of patients with cognitive impairment.

Neurophysiological evaluation of late effects of adjuvant high-dose chemotherapy on cognitive function.

OBJECTIVES: To evaluate late neurotoxicity of adjuvant high-dose (HD) chemotherapy versus standard-dose (SD) chemotherapy by event-related potentials (ERP) and quantitative electroencephalography (qEEG). PATIENTS AND METHODS: From a randomized study in high-risk breast cancer patients on the efficacy of high-dose versus standard-dose adjuvant chemotherapy, late effects on cognitive functioning were analyzed by neuropsychological tests. Cognitive impairment was found in 32% of the HD group, 17% of the SD group and in 9% of a control group of stage I breast cancer patients not treated with chemotherapy. In 17 consecutive patients in the HD group and 16 consecutive patients in the SD group neurophysiological tests were performed, consisting of P300 and qEEG. Results of patients treated with chemotherapy were compared with results of 14 control patients not treated with chemotherapy. All patients were tested two years after treatment. RESULTS: Asymmetry of the alpha rhythm of > or =0.5 Hz was found in 7 HD patients, 2 SD patients and in none of the control patients (p = 0.01). No differences were found between the groups with regard to frequency of alpha rhythm, alpha blocking and latency of P300. No correlation was found between neurophysiological parameters and neuropsychological performance, except for an overall relation between the P300 latencies and the total number of deviant test scores. CONCLUSION: Although the neurophysiological differences are subtle and the relation with the cognitive functioning in individual patients as measured by the neuropsychological examination is equivocal, the results suggest that there is neurophysiological support for cognitive dysfunction as a late complication of high-dose systemic chemotherapy in breast cancer.

[Definition of 'quack' in the public debate on alternative medicine]. / De definitie van 'kwakzalver' in het publieke debat over alternatieve behandelwijzen.

In May 1999 the Amsterdam Court of Justice decided that a retired internist and propagandist of his own alternative cancer therapy, could rightfully be called a quack by his critics. Recently this judgment was reversed on appeal. The first court used the medical definition of quackery: a treatment of which the supposed benefits are unsubstantiated. The court of appeal, however, took into consideration that to the general public calling someone a quack is an indication that this person is a swindler and practises medicine unlawfully. This definition is supported by the most authoritative Dutch dictionary. Apparently a different semantic interpretation of the term quack has led to these strongly diverging verdicts. The terms quack and quackery are indispensable in the public debate on alternative medicine.

[Complementary therapies in the hospital:'if you can't beat them, join them'?]. / Complementaire geneeswijzen in het ziekenhuis: 'if you can't beat them, join them'?

Some major cancer hospitals in the United States have established a department for complementary medicine as a service to their patients. Surveys in the Netherlands have shown that notably nursing staff and consumers consider the availability of complementary therapy in health care to be very important. Nevertheless, this appears to be an undesirable development as the effectiveness of these therapies has not been demonstrated and the therapists involved might interfere with regular patient therapy.

[Increased use of alternative diets and other alternative treatments for cancer patients: Houtsmuller (diet) is in, Moerman (diet) is out]. / Meer gebruik van alternatieve diëten en van andere alternatieve behandelingen door kankerpatiënten: Houtsmuller is in, Moerman is uit.

OBJECTIVE: To determine the prevalence of use of alternative diets and other alternative therapies by cancer patients DESIGN: Descriptive, questionnaire. METHOD: During one week, a written survey was held among all 429 patients visiting the outpatient cancer clinic of the Antoni van Leeuwenhoek hospital, Amsterdam, the Netherlands. Patients were asked about their use of alternative therapies both current and in the past, their reasons for using these therapies and the extra expenses involved. A total of 405 patients participated in the study. RESULTS: In all, 121 (30%) patients used an alternative therapy. Of the 51 patients (13%) using an alternative diet, 63% were using the Houtsmuller diet. Twelve years ago, 8% of patients used an alternative diet, which was in most cases the Moerman diet; the Houtsmuller diet did not yet exist. Seventy patients (17%) were using other alternative therapies, such as homeopathy, vitamins, herbs and paranormal therapies. The costs of especially the Houtsmuller diet, including supplements, were considerable: patients paid about Dfl. 480 monthly, expenses not covered by insurance. More than half the patients using a diet believed it would cure them, delay tumour progress or both. CONCLUSION: Compared with 12 years ago, the number of cancer patients using alternative diets and other alternative therapies had increased by about 80%. The Houtsmuller diet was used by 63% of patients using alternative diets and had, consequently, supplanted the Moerman diet.

[The national cancer fund (Koningin Wilhelmina Fonds) and the Houtsmuller-therapy for cancer]. / Het Koningin Wilhelmina Fonds en de Houtsmuller-therapie bij kanker.

Dr. Houtsmuller, a retired internist, introduced an anticancer diet ten years ago. He claimed to have cured himself from metastatic melanoma by following a diet consisting of healthy nutrients, large amounts of vitamins, minerals, antioxidants and shark cartilage powder in combination with psychological support. The efficacy of the therapy was never described in a scientific article. Currently about 63% of all cancer patients in the Netherlands using a diet use the Houtsmuller diet. The national cancer fund (Koningin Wilhelmina Fonds) invited him to speak at their 50-year commemorative symposium. Shortly before he admitted that his medical history did not mention metastatic melanoma. Dr. Houtsmuller has seriously damaged the position of physicians in the Netherlands by addressing patients directly without first seeking support from his scientific medical peers. Cancer organizations such as Koningin Wilhelmina Fonds are urged to properly inform the public about the real value or lack of value of alternative treatments in general and of alternative diets in particular.

Cognitive deficits after postoperative adjuvant chemotherapy for breast carcinoma.

BACKGROUND: A number of patients who have undergone adjuvant (CMF) chemotherapy for operative primary breast carcinoma have reported impaired cognitive function, sometimes even years after completion of therapy. The possible role of cytostatic treatment as a causative factor has scarcely been investigated. The objective of the current study was to examine the late effects on neuropsychologic functioning of CMF adjuvant chemotherapy given to patients with breast carcinoma. METHODS: Thirty-nine breast carcinoma patients who had been treated with adjuvant CMF (6 courses) followed (n = 20) by 3 years of tamoxifen 20 mg daily or not (n = 19) were examined with neuropsychologic tests and interviews. The control group consisted of 34 age-matched axillary lymph node negative breast carcinoma patients who received the same surgical and radiation therapy but no systemic adjuvant treatment. The CMF patients were examined a median of 1.9 years after the sixth CMF course, and the controls a median of 2.4 years after surgery of the primary tumor. RESULTS: Patients treated with CMF reported significantly more problems with concentration (31% vs. 6%, P = 0.007) and with memory (21% vs. 3%, P = 0.022) than the control patients. No relation was found between reported complaints and results on the neuropsychologic tests. Impairment in cognitive function was found in 28% of the patients treated with chemotherapy compared with 12% of the patients in the control group (odds ratio 6.4 [95% confidence interval 1.5-27.6] P = 0.013). Hormonal therapy had no influence on patients' self-reports of symptoms or cognitive function. Cognitive impairment following chemotherapy was noticed in a broad domain of functioning, including attention, mental flexibility, speed of information processing, visual memory, and motor function. CONCLUSIONS: Breast carcinoma patients treated with adjuvant CMF chemotherapy have a significantly higher risk of late cognitive impairment than breast carcinoma patients not treated with chemotherapy (OR 6.4). This cognitive impairment is unaffected by anxiety, depression, fatigue, and time since treatment, and not related to the self-reported complaints of cognitive dysfunction.

[Alternative treatments in cancer; extent and background of utilization]. / Alternatieve geneeswijzen bij kanker; omvang en achtergronden van het gebruik.

OBJECTIVE: To determine the prevalence of use of alternative cancer therapies, as well as the characteristics of the patients who use these therapies, and their experiences with them. DESIGN: Descriptive study. SETTING: Outpatient departments of several hospitals in North-Holland. METHOD: In total, 1091 patients were asked to participate in the study; 949 patients agreed (87%): 535 women (56%) and 414 men, with an average age of 62 years. The sample was stratified by diagnosis: 233 breast, 183 lung, 278 stomach/colon cancer and 255 patients with various other cancer diagnoses. A structured face-to-face interview and several written questionnaires were used. RESULTS: 2XOf the 949 patients, 9.4% were currently using an alternative therapy in addition to conventional treatment, and 5.8% had used an alternative treatment in the past but had subsequently stopped. Patients using alternative therapies were relatively younger and more highly educated than patients who chose not to use these therapies. Use of alternative therapies was more frequent among patients undergoing palliative treatment and patients who were actively dealing with the problems surrounding their disease. Only a minority of the patients believed they could be cured by the alternative therapy; the majority hoped it would help to slow the progression of their disease or strengthen their resistance. CONCLUSION: The motivation for seeking alternative treatment more often appears to be fear and uncertainty rather than belief in the efficacy of the treatment. For many patients the use of alternative therapies represents a means of dealing with the anxiety and stress surrounding their disease.