Sunday, 8 May 2016

After the vaccine scandal, now a cancer treatment scandal

Wei Zexi's parents

For someone ostensibly responsible for healthcare, China's health minister Li Bin is keeping a very low profile throughout a string of healthcare scandals. She was invisible during the recent scandal over 2 million doses of out-of-date vaccines that were widely distributed by dodgy wholesalers. Now she is also missing in action during the national uproar over the death of a 21-year old cancer patient Wei Zexi, who was duped into having an expensive and unproven cancer treatment at Beijing's Armed Police Corps Second Hospital.

As has already been widely reported, the hapless Wei found the hospital through its paid search results coming top in the search engine Baidu. Much of the commentary so far has been around the responsibility (or lack thereof) of Baidu and its dependence on shonky medical clinics for much of its paid search advertising revenue. There has also been a lot of adverse commentary about the role of the Putian network of private hospitals. As has been mentioned several times before on this blog, the Putian 'network' is a loose association of entrepreneurial clinics and hospitals offering healthcare services on the fringe of mainstream medicine - they specialise in 'monetiseable' services such as cosmetic surgery and fertility clinics. It therefore comes as little surprise to find they are implicated in the latest scandal.

With a synovial sarcoma, Wei Zexi is said to have paid 200,000 RMB (about US$30,000) for a novel "biological immunotherapy" treatment from the Putian-affiliated oncology unit at the Beijing Armed Police Corps Second Hospital. As a medical journalist who has been reporting on oncology for more than a decade I have to say I had never heard of the so called "DC-CIK immunotherapy" offered by the hospital. I did a bit of googling (not Baidu-ing) and looking through the peer-reviewed literature, and it soon became apparent that this is an experimental therapy that sounds impressively technical but has virtually no evidence or clinical trials to support its use.

The Beijing clinic claimed that the DC-CIK technique had been invented by Stanford university in California, but it didn't take Chinese reporters long to discover that the procedure is not being used at many reputable hospitals or institution in the US. A phone call to the developer of the technique at Stanford revealed that it is being used as an adjunctive (back up) treatment for some rare kinds of myeloproliferative diseases, but it is not a mainstream therapy. DC-CIK has also been reported in the Chinese/Hong Kong media as being used as a pseudoscientific and discredited cosmetic treatment.

So what is DC-CIK immunotherapy? It stands for "Dendritic Cells and Cytokine-Induced Killer" cell immunotherapy. Dendritic cells (DC) are basically part of the body's defence system against tumour cells - they present the antigen and activate the defensive T lymphocytes that kill tumor cells. Cytokine-induced killer cells (CIK),are the body's way of killing tumour cells - but they are non specific and need guidance to recognise the tumour cell as different from a healthy cells. In theory the coupling of these two systems should create the perfect tumour fighting team. But in practice... well, look at the fate of poor Wei Zexi. There have been no clinical trials of DC-CIK, so its use is essentially just guesswork.

Putian affiliate Chen Xinxian
Meanwhile back in the murky world of Putian clinics the journalists at Caixin have been doing some detective work and found that the dodgy hospital that milked Wei Zexi out of $30,000 for a useless pseudoscientific treatment is linked to a well known Putian duo called Chen Xinxian and Chen Xinxi and their company Shanghai Kangxin Hospital Investment Inc. Matching up business and internet records, Caixin found that the Chen brothers were involved in the running of 134 military hospitals around China. The PLA has basically subcontracted out its clinics to the Chen company

Caixin went further and tracked down about 20 other hospitals that are offering the DC-CIK procedure. When contacted by Caixin, many of the hospitals denied it or refused to comment, but Caixin found evidence that they were offering DC-CIK in the form of adverts and recruitment ads that sought staff to offer the treatment.

We thus have a situation in which many Chinese hospitals are exploiting cancer patients by charging them hundreds of thousands of RMB for unproven and dangerous treatments. Many of these hospitals are linked to the military and are thus out of the usual health department jurisdiction. It's notable, then, that this week has seen the Chinese central government declaring that the PLA will have to completely divest itself of commercial ventures such as its hospitals.

In the meantime, it's worth asking how - within a month of the vaccine scandal - China again find itself with having to address a major and widespread breakdown in the quality of its healthcare services. In a developed society such as Australia or Hong Kong, shonky medical practices are kept at bay by a series of checks and balances. Why would the DC-CIK scandal not have panned out in these societies?

1. If a clinic in Sydney or Hong Kong started advertising and offering DC-CIK to cancer patients, it would quickly come to the attention of the media, possibly by whistleblowers. Lack of press freedom in China - and fear of retribution against whistleblowers - means that this check is weak or missing.

2. Medical practitioners in developed countries also face scrutiny from their peers in the form of medical boards and general 'collegiate' links that make it clear what is accepted practice and what is not. An oncologist in Hong Kong or Sydney would be guided by professional guidelines on 'best practice' - and the use of DC-CIK would certainly not be construed as acceptable practice by a reasonable practitioner. The doctor would first warned by his peers and then brought before the medical board and struck off if he/she offered shonky treatments such as DC-CIK. This is obviously not happening in China, despite reports that the clinicians offering DC-CIK are retired or part time senior doctors.

3. There is obviously a problem with clinical governance in China - it is not identifying and addressing bad practice. In developed countries, bad doctors are also kept at bay by a mix of accreditation - having to meet defined professional standards - and also the threat of medicolegal action. This basically means that a doctor or clinic in Sydney or Hong Kong that offered a dodgy treatment like DC-CIK would have its ass sued off - and face a big compensation payout. But in China the jails are now full of lawyers who made the mistake of standing up for the rule of law.

4. And of course dodgy medical therapies are also kept at bay by advertising standards. If Google or a media outlet pushed a dodgy treatment like DC-CIK they would be prosecuted and fined for  deceptive advertising - or for promoting therapeutic claims that are not backed up by evidence. In China, however, Baidu is quick to censor words such as Dalai Lama, but is is given official blessing to rake in millions from advertising dodgy Putian clinics.

One final comment on the whole Wei Zexi/Putian/Baidu saga: it's worth noting that the President Xi Jinping is a former governor of Fujian and has close links to the region that includes Putian. He has gone on record as saying he considers the area his second home. Do the dodgy operators of Putian hospitals gain some degree of patronage and protection from their former provincial boss?

UPDATE: 14/5/2016

A search of PubMed shows there are virtually no clinical trials of DC-CIK published in major peer reviewed journals outside of China. Virtually all the studies are from Chinese centres and they are published in obscure Chinese-language publications. That's not to say there aren't any studies worth looking at. However, even one of the most reputable studies I was able to find showed only  a minimal effect of DC-CIK on cancer outcomes: in a two year study in lung cancer patients, the mortality difference at two years was 5%. In other words only one in 20 patients would still be alive as a result of treatment after two years. Put another way, for every 100 patients treated with DC-CIK, after two years 75 would be alive, whereas 70 would be alive if they received standard chemotherapy. Did the doctors treating Wei Zexi tell him that 19/20 patients would get no benefit for their 300,000 RMB?

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