Utah Roots … and Herbs

DOI: 10.1200/JCO.2015.62.7505 Although I have lived the majority of my life in New Jersey, Utah has always felt like home. Three of my grandparents were multigenerational Utahns, of pioneer stock, and the other grandparent grew up in nearby Idaho. Our family disrupted this pattern when my father pursued a position as a materials science professor that eventually led him to Rutgers University. I had only two sisters, but our extended family, like most Mormon families, is substantial. I have 32 first cousins, and my wife (also from Idaho) has more than 50. Being the only oncologist our family knows, I have become aware of most relatives, relatives of relatives, or friends of relatives with cancer. Although I practice on the East Coast, I have a large virtual consulting service as a result of this extensive Utah and Idaho network. A random call or text message from a relative almost invariably means somebody they know has cancer. One such text was received last summer on a sweltering night in Alexandria, Virginia, where I now live. The text message was from a relative in Utah who asked, “any chance that somebody treating a melanoma with herbs will be OK”? I thought back to a patient I had just seen in my practice during the month before this text message. An educated man, an engineer at a military base, had used a recipe he found on the Internet to treat a melanoma on his left shoulder. He called the application a “slurry,” and said that it contained multiple herbs and also included eggplant and a flower called bloodroot. Applying this slurry induced a large scar on his left shoulder. More than 1 year later, he came to my office because of a 4-cm lymph node in his left axilla. A positron emission tomography scan revealed lung metastases. Utah is known as the epicenter of the natural supplement industry. It is, by some reports, the second biggest industry in the state. Many of these products are sold by multilevel marketing companies. Although these companies must, by law, tell you that there is no evidence of efficacy in cancer, much of the marketing is performed by their vast network of sales people. Many of these sales people are ostensibly customers who dabble in sales, with the goal of sharing these supplements, vitamins, or essential oils with friends and perhaps making a buck or two along the way. Although the executives of these pyramid-structured companies, perched in their offices with views of the Wasatch Mountains, are undoubtedly compliant with the law, many patients report that the downstream salespeople will often share testimonials of efficacy in cancer. The appeal of supplements for cancer treatment is by no means limited to the mountain states, but it seems to be especially common within my relatives’ social network. I made a call to this Utah relative, who told me what he knew of the situation. It was his sister-inlaw, whom I will call Katie for the purpose of the story, who had developed a nodular melanoma on her face. She was treating it topically and orally with a combination of herbs and had reported significant shrinkage. My relative explained that Katie had expressed some ambivalence toward the medical community and that she and her husband had sent a group e-mail to relatives to let them know that imploring them to see “a real doctor” would not be productive. Nonetheless, considering the perilous sounding melanoma, and my recent experience with the engineer, I resolved to insert myself into their situation. That night I wrote an e-mail, quite heartfelt, pleading them to reconsider. I pursued a more deferential approach, given that they sounded distrustful of physicians. Without being too forceful, I noted the gaps in my knowledge about herbal treatment but asked them to deeply consider the serious nature of the situation. Would they be amenable to being evaluated by both an herbalist and a dermatologist? They replied to my e-mail and wished to initiate a dialogue. For a better evaluation, they proposed a video call so that I could see the lesion. Our conversation took place with Katie and her husband Eric sitting on the couch in their living room. It was after 10:00 pm EST, and they had just put their daughter to bed. I had assumed they were relatively young but did not anticipate that they would appear to be not much beyond college age. They were attractive people, and the image on my smartphone screen resembled a photo from a clothing catalog. After an exchanged of niceties, they zoomed in on the lesion. The epicenter of the lesion was on her right forehead, just superior and lateral to her right JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 33 NUMBER 26 SEPTEMBER 1