Placebo only used if risk of side effect low

Dear Dr. Roach: My wife and I have been taking glucosamine and chondroitin for several years for arthritis. We have found it to be very beneficial. Our ages are 80 and 82.

In a recent consumer magazine, there is an article about pain, including a paragraph about glucosamine and chondroitin. The article is negative about taking this supplement because of its side effects. The last sentence reads, “The American Academy of Orthopedic Surgeons doesn’t recommend glucosamine or chondroitin.” What are your recommendations regarding these supplements? — D. and J.R.

ANSWER: The data on glucosamine and chondroitin, which many people use for pain from osteoarthritis, is mixed. I reviewed the American Academy of Orthopaedic Surgeons’ website on these supplements, and find that I generally agree with its recommendations. It’s noted that many people get pain relief from taking them (often in combination), and that side effects are few. It is also noted that there is little good evidence that the supplements reverse joint damage from osteoarthritis. The academy is concerned, as I have been, that there is no testing or analysis of supplements by the Food and Drug Administration, and that a recent consumer laboratory found that almost half of supplements labeled “glucosamine/chondroitin” did not contain the labeled amount of ingredients.

I would point out that many people get a benefit because they expect to get a benefit. This phenomenon is known as the placebo effect. I am a proponent of using this effect in an ethical way. To me, this means informing a patient of the likelihood that a treatment will be effective (whether medication, supplement, surgery or other treatment) relative to no treatment or to placebo treatment, when that is known. If a treatment is known to be no better than placebo, that needs to be disclosed. However, since the effectiveness of placebo at reducing symptoms may be as high as 30 percent, many people still will get better with a placebo.

In my opinion, treatment that is only as good as a placebo or, as in this case, perhaps marginally better than placebo should be considered only if the risk of side effects is low, if the cost to the patient is low and, above all, if the patient is informed about the treatment’s effectiveness relative to placebo. A placebo is unethical when there are other effective treatments not offered to the patient.

Dear Dr. Roach: My husband (82) had prostate cancer surgery 11 years ago. His PSA goes up and down, mostly down, due to a Lupron shot. Does a higher PSA level mean cancer cells are present in the body? If so, how does lowering the PSA count treat cancer cells? Thank you for any insight you can give. — D.L.

ANSWER: After prostate surgery, there usually are no more normal prostate cancer cells. This is confirmed when the PSA level goes to zero after surgery. Since only prostate and prostate cancer cells make PSA, any amount of PSA present in the blood probably is coming from prostate cancer. The higher the PSA level, the more cancer cells in the body. If the Lupron (which blocks testosterone, a hormone that helps prostate cancer cells grow) reduces the PSA, it means it is effective at treating the prostate cancer cells. Sometimes we cannot cure the prostate cancer, but can keep its growth controlled for a prolonged time with treatment.

READERS: The booklet on the prostate gland discusses enlargement and cancer. Readers can obtain a copy by writing: Dr. Roach, Book No. 1001, 628 Virginia Drive, Orlando, FL 32803.

Enclose a check or money order (no cash) for $4.75 U.S./$6 Can. with the recipient’s printed name and address. Please allow four weeks for delivery.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or request an order form of available health newsletters at 628 Virginia Dr., Orlando, FL 32803. Health newsletters may be ordered from www.rbmamall.com.

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