Monday, December 21, 2009

The Placebo Effect of Surgery

In my recent comment...
"The human body has a spectacular ability to heal itself, when given time, clean food/water/air, and nurturing. Therapies, alternative and conventional, have an element of placebo. We think it was the chiropractor, the surgeon, the homeopathic remedy, the antibiotic that cured us. In actuality it was our body's natural healing apparatus."
I referred to surgery as having an element of placebo. It made me recall this passage from a book read long ago, "Health And Healing" by Dr. Andrew Weil. Here's an excerpt where he describes the placebo effect of surgery for angina:
"Angina pectoris had always been a medical problem until surgeons came up with operations to relieve it. One procedure that became fashionable in the 1950s was to open the chest and tie off the internal mammary artery, an artery supplying muscles of the inner chest wall. A branch of this vessel brings blood to the pericardium, the sac enclosing the heart. In theory, tying off the artery below this branch might increase blood flow to an ischemic heart. (The chest wall muscles can find alternative supplies.) Many patients reported disappearance or decrease of anginal pain on recovering from this traumatic operation.

As I explained in chapter 3, angina is notoriously responsive to placebo treatment. Might these patients have improved just because they underwent dramatic surgery? The ethics of controlled studies in this area are sticky, but eventually, a few surgeons put the procedure to a test by performing sham operations on some patients. The patients were told they were undergoing internal mammary artery ligation to bring new blood to their hearts, but, in fact, when their chests were opened, the artery was not tied off. The success rate of sham surgery in alleviating the symptoms of angina was equal to that of the real procedure, proving that this widely endorsed operation acted as a placebo treatment.

Undaunted, the surgeons next came up with a more elaborate procedure: internal mammary artery implant. They now cut the artery and inserted the cut end into a hole poked into the heart muscle, hoping it would sprout new branches to supplement the coronary arteries. Again, patients reported decreases in anginal pain. No one put this procedure to the test of comparison with sham surgery, but, since autopsy data later showed that the implanted arteries did not establish any new blood supplies in heart muscle, any success must also have been a placebo response."
Since Dr. Weil's writing, a more recent surgical intervention for angina - angioplasty with stenting (known under the umbrella term Percutaneous Coronary Intervention: PCI) - has also come into question. In a large clinical trial known as the COURAGE study, patients with chronic chest pain and "extensive coronary artery disease as seen on angiography" who received stents fared no better than those who received aspirin, statins, and/or blood-pressure-lowering drugs:

Optimal Medical Therapy with or without PCI for Stable Coronary Disease
Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE)
, New England Journal of Medicine, March, 2007
"Conclusions: As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy."
Dr. Steven Nissen, then President of the American College of Cardiology, said about these findings:1
"It does not relieve risk of heart attack and it is only marginally better at relieving angina, so why should you go on stenting?

We should reserve it for those that just don't do well on medical therapy or if they have symptoms that are interfering with lifestyle.

What happens when you put a stent in is you're attacking one narrowing in the artery, but it's not the narrowing that's going to cause the next heart attack," he explained. "It's the plaque developing everywhere else that's going to cause the next heart attack."
The study did find that "the degree of angina relief was significantly higher in the PCI group." Pain relief counts. But are the costs, risks, and side effects (Heart Surgery Can Damage The Brain) of heart surgery to achieve that pain relief worth it? When it doesn't reduce the risk for heart attack or premature death? Well, at least there are Lifestyle Changes.
1 Stents Don't Prevent Heart Attack or Death;
Landmark Study Suggests Widely Used Medical Device Is No Better Than Drugs at Saving Lives


Jim Purdy said...

I often have chest pain and tachycardia, for which doctors insist I must have a (second) stent and a ton of prescription medications. Instead, I have made most of the problem go away by avoiding caffeine and carbs. Maybe my remedy is a placebo also, but it's a lot less of a hassle than surgery and drugs.

Bix said...

I admire those who work at it. I learn from them. There are so many things you can do to avoid drugs and surgery. It's a pain in the butt! But there are rewards.

DebbyBruck said...

You are a super journalist. Thanks so much for your thoughts on the Placebo issue. Gives us all a lot to ponder.

Maybe we can think up less expensive ways to utilize the placebo effect for better health and less pain.