BMC Cancer Journal: Open Access, Not Open to Critiques?

My fellow Scilogs Blogger Lee Turnpenny recently described his dissatisfaction with a pro-homeopathy research paper published in the Open Access journal, BMC Cancer.

The article, by a European group, is titled: “Classical homeopathy in the treatment of cancer patients – a prospective observational study of two independent cohorts“, rather deceptively in my opinion, because the title makes it seem that the study involves the use of homeopathic remedies in cancer. However, on close examination of the paper, it appears that the authors, Rostock et al., focus on something they define as ‘homeopathic care’ – rather than any putative efficacy of homeopathic nostra. Quoth the authors:

It is important to notice that we have not studied the effect of homeopathic remedies, but of homeopathic care. This comprises the whole setting of case taking, individualisation, finding the right remedy and following up on the perceived effects in multiple cycles of feedback and adjustment. It goes without saying that this is an intensive communicative, interactive process that operates via many different pathways, some of which are likely to be psychological and very general in the sense of a meaning response [34], some of which might be specific to homeopathic therapy and its usage of the remedies.

Very ably, Dr. Turnpenny picked apart several issues in the paper. But not content to remain idle, he, as appropriate for a veteran science communicator and member of the scientific community, attempted to pass on his timely comments and criticisms to the authors of the article. Having been unsuccessful at contacting the corresponding author (via the e-mail address provided for the purpose), he proceeded to leave his comments at the area designated for reader comments.

That was a while ago. His comment is still held up in moderation, as of today, March 16.

Inspired by Dr. Turnpenny’s original post, I went through the article in question, and soon realized that I shared his disappointment with this ‘research’. I had questions of my own, which – with an over-abundance of optimism – I proceeded to put in the commenting section, and received the same form acknowledgement and notification of my comment being under moderation via email from the journal’s editorial desk, as did Dr. Turnpenny. That was on February 22. Almost two weeks later, I find myself in the same boat as him. My comment, too, is held up for indefinite moderation. (I have appended a copy of my comment at the end of this post.)

I hadn’t realized commenting on an Open Access article was going to be so difficult. I have, after all, successfully commented earlier after articles in the PLoS journals, which have set new standards in Open Access publishing. This makes me wonder several things at once. Is this a way of stifling criticism? Have my comment (and that of Dr. Turnpenny’s as well) been censored because they were deemed critical of the study? It is hard to believe that BMC Cancer would engage in such dubious practices. Has the journal received the comments, and is now, in fact, scrambling to reach the authors to have them formulate a response before publishing the comments? That may be likely; it would be the model followed by a non-online, non-Open Access journal of the olden days. But then, this casts a shadow on the larger question of Open Access publication. To my mind, one of the major objectives of Open Access publishing is to have a wider audience engage in the discussion of the relative merits of a scientific paper. That would be an important Science Communication endeavor, and may, in addition, even lead to a unique solution to an oft-voiced fear with online publishing as such – the redundancy of print and production editors, and consequent loss of jobs. Now, there can be editors/moderators for online comments, interfacing between the investigators and their audience. From a science communication perspective, a great idea would be to have qualified editors who can create lay language summaries of research papers to go with their online versions. With the number of users who look up health- or science-related information online increasing by leaps and bounds (check, for example, this Open Access article by Davis and Walters: Journal of Medical Library Association, 2011 July; 99(3): 208–217), this would certainly be a great service to the tax-paying public.

The shoddy handling of the commenting system at BMC Cancer may not be representative of a systemic malaise. But they should shore up their communication performance if they wish to remain scientifically relevant in the age of Open Access. The lack of a functional commenting system did not, of course, stop the article from being marked “HIGHLY ACCESSED” – which, as far as I understand, is done by an algorithm that enumerates the times the article has been accessed online. BMC Cancer, therefore, in not dealing with the comments and questions with alacrity, is doing both the investigators and the reading public a great disservice; as of now, it seems to be doing little more than prodigiously promoting quackery.

I leave you with these thoughts: Is the provision of “Open Access” an end by and of itself? Or does an Open Access journal have the responsibility of providing a platform for meaningful exchange of scientific ideas amongst authors, other scientists and the public at large?

P.S. Before I disappear, let me leave you, dear reader, with this absolute joy of an essay on lay language summaries (a tad old, but still relevant) by scientist and my erstwhile blog colleague at Nature Blogs, Professor Stephen Curry. I promise, it will brighten your day.

Copy of my comment at the BMC Cancer website:

(Comment Title) No convincing evidence for efficacy of homeopathic care, let alone homeopathic treatment.

Comment:
I started reading this paper with interest, particularly since I was intrigued by the assertion by the authors that they wanted to focus on homeopathic care, and not the efficacy of homeopathic remedies per se (an interesting assertion pointed out by someone else). I found this study largely disappointing, scientifically speaking. Several points have been discussed in the blog this hyperlink points to. I made a few additional observations which indicate, to me, that this paper did not present convincing evidence for efficacy of homeopathic care as well.

I am slightly leery of using quality of life (QoL) measurements as a study variable. I am, of course, speaking from a privileged perspective, in that my definition of ‘quality of life’ (as a reasonably healthy individual) and a cancer patient’s definition of the same are bound to be dramatically different. But that difference, then, would directly speak to the difference in the perception of the efficacy of these alternative medicine (‘alt-med’) therapies between, say, my taking them and a cancer patient’s taking them. Surely that would impact a survey-based QoL measurements?

As others (most recently, Prof. Edzard Ernst) have discussed, it is likely that the creation of a feel-good factor is the principal goal of the alt-med therapies – which may even account for some of perceived efficacies of alt-med therapies. But, by that count, non-conventional approaches like Therapy Dogs are equally effective. Which means, there is no specificity of these alt-med treatments, if QoL is to be the sole arbiter.

An important point regarding the randomization mentioned in the article being discussed. Patients were not randomized in a blinded fashion. They chose homeopathic or conventional treatment. At entry, homeopathy patients were younger, more educated, and were more likely to be white collar workers or in self-employed jobs. Coming as they were from socieities in which homeopathy is accepted as a valid method of treatment, is it any wonder that the homeopathy arm would do better in the QoL surveys? The capacity of human beings to delude themselves is almost endless. This is one of the reason why these subjective estimates are very problematic. I’d have loved to see some objectively assessable diagnostic and prognostic information, such as, say, tumor status and progression, histopathology data, and so forth, which were not included in the paper.

Another question jumps to the mind. What was the placebo? I mean, after the randomization, in order to judge the efficacy of homeopathy over placebo, the patients would have to get exactly identical treatment (including interactions, conversations and palliative care) except for the variable being tested. From my reading of the paper, it appears that it was only homeopathy or no homeopathy. The authors refer to a book and a paper for the treatment regimens. Unfortunately, it is beyond my capacity to read non-English text. I couldn’t even find the abstract of the paper in PubMed.

Finally, it is good that the authors have consciously refrained from comparing the homeopathy arm and the conventional arm (as they indicate in the discussion). Else, the consistently higher proportion of death in the homeopathy arm (I cannot speak to the statistical treatment, not having the raw data at hand) would have required some explanation.

So, overall, even if the authors say that they focus on ‘homeopathic care’ rather than on ‘homeopathy remedies’, this paper doesn’t seem to address many of the pertinent questions.

Competing interests:
I have no competing financial interest. However, I am skeptical of homeopathy as a valid medical therapy and have written on that subject at various fora.

UPDATE 1: My comment was finally live at the BMC Cancer website on Sunday, March 10, 2013. Unfortunately, my blog colleague, Dr. Turnpenny, wasn’t so fortunate. Such a shame, this shoddy handling of comments by this journal.

UPDATE 2: The Executive Editor of BMC Cancer has responded to Dr. Turnpenny’s post.