Sunday November 14, 2010
By Dr ALBERT LIM KOK HOOI

Hope in reality is the worst of all evils, because it prolongs the torments of man.

IN the last two months, two news items that made international headlines were linked by the themes of stem cells and hope.

Dr Robert Trossel started to give stem cell injections to patients with multiple sclerosis about a decade ago. This was and still is unproven therapy.

Dr Trossel's practices were highlighted in a BBC Newsnight investigation in 2006. The following year, he was suspended by the General Medical Council (GMC). A hearing of the GMC fitness to practise panel said that Dr Trossel had exaggerated the benefits of stem cell treatment based on "anecdotal and aspirational information".

Finally, the GMC took the decision to strike off Dr Trossel from the medical register for giving false hope to desperate patients, charging thousands of pounds for "pointless" and "unjustifiable" stem cell treatments. Dr Trossel can no longer practise medicine in the UK.

False hope. Is there any other kind? Is hope overrated? To some, it is the only thing to live for. They may go along with Oliver Goldsmith, who said, "Hope, like the gleaming Taper's light, adorns and cheers our way; and still, as darker grows the night, emits a brighter ray."

On the contrary, hope has its detractors, like Friedrich Nietzche, who said "Hope in reality is the worst of all evils, because it prolongs the torments of man."

I go along with Nietzche and the GMC. Patients with advanced incurable cancer or debilitating and progressive neurological disorders, like multiple sclerosis, need symptom control and rehabilitation. There is hope that good quality life can be prolonged. There is hope because promising research is under way. There is hope that life, however truncated it may be, can be satisfying and fulfilling.

But to promise a cure is to raise false hope. For a doctor to quote anecdotal treatment and results ("one off" stories) is to mislead patients into thinking that they can be cured. Often, all this is done with sanctimony.

The doctor says he is giving hope to his patients as if to say giving hope is the primary role of a doctor, however untruthful or misleading his utterances may be.

The second story also concerns stem cells and hope. But this time, it is hope built on a more solid foundation.

Researchers at the Shepherd Center, a spinal cord and brain injury centre in Atlanta, injected stem cells into a patient with a spinal cord injury.

This is the world's first approved clinical trial of a therapy derived from human embryonic stem cells. It is a Phase I trial or a trial of a treatment to test its safety. This trial will enroll up to 10 patients who have suffered spinal cord injuries. The researchers will inject the stem cells within 14 days of the injury.

If the treatment is shown to be safe and well tolerated, researchers will move on to test the treatment's effectiveness i.e. in a Phase II trial.

Finally the Phase III trial, or what is called a randomised controlled trial, will give us a definitive answer. In a Phase III trial, stem cell treatment will probably be compared to placebo as there is currently no effective treatment for spinal cord injury. Hundreds, or perhaps even thousands, of patients will be recruited for a Phase III trial.

Until a phase III trial is conducted and concluded, we will not know if stem cell therapy is indeed the treatment of choice for spinal cord injury. This means that we have to wait a few years, a decade perhaps, for the answer.

And yet stem cells are already used in many countries to treat spinal cord injury and other disorders as if this treatment is already proven.

Stem cell research is also about hope, but of a different kind.

I use the word hope here in a narrow sense. The scientific endeavour has pushed the frontiers of medicine outwards the last few hundred years. Slowly, methodically, but surely. I think it will do this again in the treatment of spinal cord injury.

Back to the clinical rather than the research scenario. When patients suffer a catastrophic illness – an illness needing intensive care, advanced cancer, spinal cord injury, and other debilitating neurological disorders – sometimes all they and their relatives have is hope.

We should not rob them of this by pooh-poohing every suggestion of theirs. But neither should we raise false hope. With false hope raised, a lot of money is spent and anguish amplified when all comes to nought. Patients should have a clear understanding of what to expect and how much can realistically be achieved. It is better to focus on the achievable benefits rather than spend time talking of unproven treatments.

Between the heady optimism of Goldsmith and the pessimism of Nietzche, the most practical approach may be found in this English proverb: "Hope for the best, but prepare for the worst."

Dr Albert Lim Kok Hooi is a consultant oncologist. For further information, e-mail starhealth@thestar.com.my.