More Than a Minor Headache: The Stem Cell Snake Oil Problem vs. Legitimate Research

Just two weeks ago, the headlines from Bloomberg News offered a glowing view of the prospects for stem cell therapies and the industry. The story in the online publication, which counts nearly 9 million readers monthly, said,

"Stem cell crusader sparks new hope....Regenerative medicine could be a $120 billion industry by 2030"

But only three days later, that article was overwhelmed by a wave of stories with a much different flavor. They carried reports of unproven therapies, possibilities of fraud, lack of regulation and fearful, expensive consequences for desperate patients.

That theme continued even as recently as this past weekend as The Economist carried a piece headlined,

"A dish called hope: The flourishing, unregulated industry in expensive, experimental treatments"

So which is it? Hope for legitimate cures and oodles of cash for stem cell companies? Or "hope" for treatments that do not work and have sometimes damaged both the bodies and wallets of the patients?

The situation is more than a minor public relations headache for the supporters of stem cell research, be they patients, stem cell companies or the $3 billion California stem cell agency, which is on a campaign to ease federal regulation of stem cell clinical trials.

For all practical purposes, the public generally does not make much of distinction between the legitimate research conducted by institutions such as Stanford and the so-called "miracles" reported about the late hockey great Gordie Howe and others. It all goes into the same cognitive bag. The stories about mysterious and fearsome tumors found in little-known patients attract little widespread attention.

But UC Davis scientist Paul Knoepfler and bioethicist Leigh Turner of the University of Minnesota ripped open that bag with their study last month that reported for the first time that nearly 600 dubious stem cell clinics are peddling their unproven therapies across the country.  Their report supported the view that the stem cell field is rife with snake oil merchants. For the general public, which does not delve deeply into medical research, the perspective could well be described as, "You seen one stem cell therapy, you seen 'em all."

Does this mean that these clinics should be ignored and shoved quietly off into a corner in order to avoid besmirching legitimate efforts? Of course not. It certainly appears that the FDA and other  state regulatory bodies can do a better job. But stiffer regulations are not going to come anytime soon, despite an FDA hearing on the topic in September.

However, the situation DOES mean that folks like Knoepfler and Turner should continue to speak out along with many other scientists who do not want their efforts blackened by the snake oil men. Researchers can work with their institutions' PR departments to place op-ed pieces, find speaking engagements and gin up TV and radio interviews. Blogs, like the one produced by Knoepfler, can be started. The International Society for Stem Cell Research should revive its public education efforts to help patients and the general public understand the facts about stem cell research. It should also reinvigorate its warnings about dubious therapies, which were throttled back a few years ago, reportedly after legal threats were made.

California's stem cell agency has a special concern. It is trying to "de-risk" development of therapies  by a variety of means and lure biotech and Big Pharma into the stem cell game in a bigger way. This summer the agency is offering $75 million to entice a private partner into the state's first-ever, public-private partnership to create a stem cell cure.

The private sector has shied away from the stem cell business, as the stem cell agency's CEO, Randy Mills, has remarked on multiple occasions. One of the reasons involves the public climate and perception of the field. It is hard for companies to invest hundreds of millions of dollars or billions when the stem cell field is burdened with public perception and regulatory obstacles.

Selling the stem cell story in a realistic way is not necessarily an easy task. Nuances must be respected, but excitement is also needed. Balancing it all is a challenge for the men and women in the trenches. But without a good push, development of therapies will be slower, and, as Mills has noted, people will undoubtedly die who likely would have benefited from a more timely treatment.

'False Hopes, Sizable Profits' -- The Nation's Largely Unregulated Stem Cell Clinics

Locations of stem cell clinics identified in Knoepfler/Turner study
Graphic by Cell Stem Cell 

The biggest stem cell story in the country this week reported that at least 570 dubious stem cell clinics exist throughout the nation that could pose a danger to both the pocketbooks and health of patients.

California led the nation with 113 clinics, with Beverly Hills having the most (18) of any city. The clinics promise to cure or ease afflictions ranging from autism to Alzheimers through the use of scientifically untested treatments.

The study is the first effort to get a handle on the size of an industry that has been little regulated by the Food and Drug Administration (FDA) but appears to promise almost miraculous results.

Results of the study were reported yesterday in the Washington Post, the Los Angeles Times, Fox News, The Sacramento Bee and many other outlets.  A search at midday today on Google turned up 7,230 citations, including articles in France, Mexico and Italy.

One of the authors of the study from the journal Cell Stem Cell is Paul Knoepfler, a stem cell scientist at UC Davis.  He has long campaigned for more action dealing with some of these clinics. In September 2015, he wrote on his blog about what he called "predatory clinics."

"These clinics prey on vulnerable patients and their families. The clinics use hope as a marketing tool. A weapon.

"As the number of such clinics has mushroomed in the US and elsewhere the risk to both patients and to the larger stem cell community proportionately rises too. We are in a situation today where the dangers from such clinics have never been higher."

Co-author of the study, Leigh Turner of the University of Minnesota, said in an article in The Bee by Adam Ashton,

"The problem is that so much of the information that’s provided by the industry, so many of the marketing claims being made, they’re not particularly accurate. They’re not trustworthy, and they don’t have any meaningful science behind them."

In a story by Karen Kaplan in the Los Angeles Times, Turner said,

"There is an obvious need for the FDA, FTC (Federal Trade Commission), state medical boards and other regulatory bodies to play a more effective role in regulating the marketplace for stem cell interventions.' Without it, these clinics are able "to peddle false hope for sizable profits.'"

Randy Mills, president of California's $3 billion stem cell agency, said in The Bee that the Knoepfler/Turner study "highlighted a 'broken system' at the FDA that lets some clinics proceed with almost no oversight while requiring others to undergo studies that could tie up their services for decades. He said there are likely far more clinics offering stem cell therapies than Knoepfler and Turner identified, with many of them operating discreetly.

"'There’s so much stuff going on today, but it’s going on because that’s the system the FDA set up and that’s the system the FDA incentivizes,' he said."

Knoepfler noted a bit of irony yesterday concerning the study in a posting on his blog, The Niche. He wrote, 

"I’m glancing over at the (Scientific American) article (on the study) just now and BOOM I see an ad for a stem cell clinic appear at the top and it is even one of the ones in the database we created for our article. The ad is focused on selling stem cells to treat autism in children, an area that raises a lot of questions.

"How can it be a good thing to have an ad for a stem cell clinic right next to the article about the challenge of stem cell clinics in America? The way the web works these days, perhaps it isn’t so surprising that articles having anything to do with stem cells will often be accompanied by ads for stem cell clinics. This one just really stuck out to me today because of the context."

Google and other media outlets routinely place advertisements for these stem cell clinics on many Web sites and blogs, including this one. Some of the newspapers carrying stories about the Knoepfler study also carry ads for such clinics. 

Inside STAP: New Yorker's Long Look at the Flap and its Implications

Over the weekend, the New Yorker published online a bang-up and thorough account of the STAP stem cell scandal of 2014. which stretched across the Pacific from Japan to Boston.

The subhead on the story said,

“Rivalries, intrigue, and fraud in the world of stem-cell research”

The piece was authored by Dana Goodyear, a writer for the New Yorker who also teaches writing at the University of Southern California.

UC Davis stem cell researcher Paul Knoepfler, who carried on his blog early and lengthy pieces on the STAP flap, today said of the article:

“It’s a long, fascinating look inside of STAP, the tangled and ultimately tragic scientific implosion that created and then brought down two Nature papers and some careers.”

Goodyear’s article brought out much fresh material, including a more detailed look at the history of the STAP research than has been previously published. The piece also contained probably enough scientific detail to satisfy the experts in the field.

But Goodyear also included thoughts on the stem field in general, issues related to scientific journals, hyper-competitiveness among researchers, replication of research and more. Here are a couple of excerpts from the article, which we highly recommend:

“The promises of stem-cell research lie at the core of human desires—to understand our origins and to cheat death—and there is a great deal of money and prestige at stake. It is a ruthlessly competitive field, susceptible to fantasy and correspondingly sensitive to bunglers. Human embryonic stem cells were first cultured in 1998; nearly twenty years later, basic assumptions about cell behavior are still routinely overturned. Andrew McMahon, a top researcher at the Broad Center for Regenerative Medicine and Stem Cell Research, at the University of Southern California, told me, “It’s not unusual to see something and not be able to explain it.” In reporting results, researchers must often craft a narrative to make sense of mysterious phenomena. What to ignore and what to privilege—that discernment can be the difference between brilliance and quackery, and between fame and obscurity.”

On the difficulties in replicating research findings:

“Many people believe this is partly the fault of the scientific journals. Along with the influential role that Nature has in shaping the trajectories of ideas, technologies, and careers, it is essentially a commercial enterprise. The editors like big stories, and for the right ones they take risks. Some observers complain that incentives to publish have a distorting effect, causing scientists to oversell data; a cutthroat culture sometimes leads researchers to publish intentionally incomplete or vague protocols. The perceived conflict between good science and prestige has become so pointed that, two years ago, Randy Schekman, a Nobel Prize-winning biologist, announced in the Guardian that he would no longer publish in Nature, Cell, or Science, which, he wrote, ‘aggressively curate their brands, in ways more conducive to selling subscriptions than to stimulating the most important research.’”

California's Trounson Wants to 'Shame' the 'Malefactors' of Stem Cell Medicine

Alan Trounson at Cornell
Cornell photo

The former president of the California stem cell agency, Alan Trounson, has kept busy since leaving his post last month. Just this week he authored an opinion piece in The Scientist. Earlier this month he was at Cornell decrying the lack of federal funding for research.

In his article in The Scientist, Trounson called for the outing of stem cell clinics that sell untested and expensive treatments to desperate people.  “Malefactors” is what he called them.

He wrote,

 “It is time that a ‘shame file’ of unregistered and unscientific treatment centers is constructed and widely communicated to warn patients of the dangers of these unregulated and inadequately managed therapies being offered internationally.”

Trounson suggested that the Institute of Medicine could host such a file and help protect uninformed patients. But he also said Alliance for Regenerative Medicine, an industry group that is also engaged in lobbying, could do better in helping to expose dubious stem cell clinics.

He said,

“While this organization and its members do not approve of unregistered clinical trials, they ought to be more active in ensuring the scientific integrity of all studies going forward.”

Trounson said that the $70 million Alpha clinic effort that he championed at the California stem cell agency is also aimed at tackling the problem. Grant applications in that program are due to be reviewed this fall. 

Trounson warned that fringe stem cell clinics damage the entire field.

“The activities of these medical tourism centers are a major barrier to the delivery of genuine cell therapeutic clinical trials by bringing the whole field of cell-based therapies into disrepute.”

At Cornell on June 6, Trounson, who is a senior scientific advisor at CIRM until the end of this month, was the keynote speaker for a symposium on stem cells that also featured broadcast journalist Charlie Rose.

The university put out an item on the appearance. Trounson was quoted as saying,

"The [federal] government looks handicapped in this area. You've got a budget situation where you cannot seem to put more money into research — in fact, less money is going into research. We have to convince the people elected to government that this is an incredible revolution and that we need to keep funding the science."

That could be a pitch for the California stem cell agency as well. It is scheduled to run out of money for new grants in less than three years and is currently looking at ways to develop new funding sources.

Art Caplan on Fake Stem Cell Research: 'Off-the-Rails Syndrome?'

One of the more prominent bioethicists in the nation, Art Caplan, is asking,

“Why so Much Fake, Unduplicable Stem Cell Research?”

Caplan weighed in on Medscape.com today, citing the STAP flap involving Japanese and American researchers as well as a scandal involving a false but widely accepted – for a time -- claim that a Korean scientist had cloned human embryos.

Caplan said,

“Stem cell research seems again and again to go off the rails when it comes to the ethics of research.”

He continued,

“I think there are a couple of reasons why this particular area has gotten itself in so much hot water. One is that there is a relative shortage of funding. Because of the controversial nature of cloning -- getting stem cells from human embryos -- some avenues of funding have dried up, and it puts pressure on people to come up with other ways to try to make human stem cells. With less funding, there is more pressure. Sometimes people cut corners. I think that can lead to trouble.

“Another problem in the stem cell field is that if you can come up with a way to produce human stem cells without sacrificing or cloning embryos from humans, you are going to find yourself being a hero to the world. That is what happened in Japan.”

Caplan said,

“There is a lesson here: Until somebody replicates and until somebody can show that they can also do what has been alleged, there isn't a breakthrough. There is only confirmation and then breakthroughs. I think we have to be a lot more careful -- both in science and in media coverage -- before we start saying, 'Aha -- here is a single study, a single report, a presentation. Now we have shown that something can be done.'”

Caplan said,

“Another major problem in the stem cell field is that the number of people doing research in this area has shrunk. It is obviously of keen interest to come up with regenerative medicine solutions to all kinds of healthcare problems. I think a lot of post-docs and graduate students are saying, "I am not sure that I want to set my career track into a field that is sometimes controversial and where funding may be dipping." That may mean that there are fewer people to watch one another. It is not a big field, so maybe part of the reason that it keeps getting in trouble is less ability to do peer review.”

Our thoughts: There is no doubt some spectacular fraud has surfaced in stem cell research. But the problem of replication within stem cell research may not be entirely out of line with problems elsewhere in science. Los Angeles Times columnist Michael Hiltzik wrote last fall about a study by Amgen that examined 53 “landmark papers” in cancer research and blood biology. Only five could be proved valid, a shocking result, according to Amgen. Similar results were turned up by Bayer in Germany, Hiltzik said.

Additionally, as Caplan notes, the stem cell community is small and the hype is grand. With stupendous expectations come the likelihood that every missed shot – fraudulent or not – becomes an equally stupendous failure that is colored by suspicions of scientific misdeeds. Plus there are truly bogus practitioners at work, charging desperate people large sums for untested and potentially harmful treatments.

The mavens of science, those who control the medical schools and set the standards, may have some responsibility for some of the problems with replication. Writing May 8 on the blog of the Global Biological Standards Institute, scientist Beth Schachter touched on this in a post headlined, 

“What are science trainees learning about reproducibility?”

She asked one Ph.D. student at UC San Francisco what sort of training are he and his fellow students receiving on reproducibility and standards. The response?

“None.”

Primer and Paean: Consumer Guide to Stem Cells

The article today on xconomy.com had some intriguing elements: “secret online communities,” $100,000 payments to scam artists and talk of New York Times best-sellers – not to mention stem cells.

The article was about UC Davis researcher Paul Knoepfler and his new book, “Stem Cells: An Insider's Guide.” The story was written by Bernadette Tansey, a former San Francisco Chronicle reporter. Tansey said that Knoepfler's book “may never break into the New York Times best-seller ranks, but he still might make some publishing history.” She wrote,

“Knoepfler could be the only biology researcher ever to write a comprehensive consumer guide about the health care treatments being developed in his own field—complete with safety cautions.”

Tansey summarized Knoepfler's book as “a scientific primer and a paean to the promise of stem cell research.” She also said the stem cell researcher sees

“a growing network of secret online communities, as well as overt advertisements, (that) have spurred US patients to pay fortunes out of pocket to ill-trained physicians, who perform experimental procedures backed by little or no evidence.”

Knoepfler's greatest concern, Tansey said, “is for patients who have been lured by the false claims of dubious for-profit clinics to pay as much as $100,000 for unproven 'stem cell treatments.' These injections, he says, may actually consist of cells culled from pigs, cows, or sheep, and bear unknown risks such as contamination or immune system reactions.”

The California Stem Cell Report carried an item last month on Knoepfler and his book. We agree that it is quite helpful and accessible, especially for persons seeking more information about undergoing stem cell treatments.

Inside Stem Cells: A Guide from a UC Davis Researcher

The Sacramento Bee today published an article on UC Davis stem cell researcher Paul Knoepfler and his new book, which explores the basics of stem cells and how to make good judgments concerning possible treatments.

The book, “Stem Cells: An Insider's Guide,” is aimed at a general audience while at the same time exploring the nuances of stem cell science.

Below is a copy of the article, which appeared on the main page of The Bee Web site early today and which was written by yours truly. In the print version of The Bee, the Knoepfler piece appeared on the same page as a New York Times story dealing with dubious stem cell treatments(Here is a link to the original version of the Times' piece.).

The Knoepfler story was also the No. 1 article that turned up this afternoon when the Google news category was searched using the term “stem cell.” It is likely to be published elsewhere in the coming weeks as it is circulated by the McClatchy News Service. 

UC Davis stem cell researcher warns consumers to beware of unproven or dangerous stem cell treatments

By David Jensen

Bee correspondent

PUBLISHED SUNDAY, SEP. 15, 2013

In his day job, UC Davis scientist Paul Knoepfler probes the inner workings of stem cells and cancer cells and what makes them behave the way they do.

On the side, the father of three daughters blogs about costly, unproven stem cell treatments and provides guidance for those seeking experimental therapies.

Knoepfler is a rare stem cell researcher who regularly explores the most problematic aspects of stem cell therapies on the Internet in full public gaze. He considers himself an advocate for patients as well as a scientist, having survived an aggressive form of prostate cancer at the age of 42.

Now 46, Knoepfler began his blog in 2010, shortly after his cancer was diagnosed. His blogging has encountered resistance from some colleagues, who are uncomfortable with such public endeavors. But he has polished and expanded the blog to the point that it has received international recognition. He will receive an award in December at the World Stem Cell Summit in San Diego for his advocacy efforts.

This month he moved beyond cyberspace and published “Stem Cells: An Insider’s Guide” (World Scientific Publishing). The book covers stem cells from A to Z and is aimed at the general reader, especially people considering stem cell therapy for themselves, a family member or friend.

The book comes during what has been described by Christopher Scott, a senior research scholar at Stanford University, as “an epidemic of transplant clinics offering so-called cures and therapies” both here and abroad. The international stem cell medical tourism business, widely promoted on the Internet, is taking in roughly $1 billion annually, according to an estimate in Stanford Medicine, a publication of the Stanford medical school.

Knoepfler is a believer in the potential and power of stem cells. But he says that some of the dubious stem cell treatments now being offered have resulted in deaths and injuries. Other unpleasant issues arise as well in stem cell research, including the tendency of some stem cells to generate cancer cells, and Knoepfler wants to talk about them.

“Too often in the academic section of the stem cell field, people pussyfoot around the most important issues or do not even dare talk about them at all,” says Knoepfler.

He is “not on some crusade to dissuade people from getting risky stem cell procedures,” but says safety and training need to be encouraged. Reckless behavior endangers the entire field, he says.

“There is no better illustration of the risks of unlicensed stem cell treatments administered by untrained doctors than the recently reported case of a woman who received a stem cell facelift, only to have bone grow in her eye,” he said, referring to a Scientific American report involving a Beverly Hills clinic.

To help patients, Knoepfler’s book begins with the basics: What are stem cells? He moves on to topics ranging from whether stem cells can treat baldness to whether they can help with afflictions such as Alzheimer’s, autism and arthritis. Along the way, he discusses the potential for regenerating limbs, made-to-order organ transplants and curing spinal paralysis, none of which have reached the stage where patients can be assured of using the techniques safely and effectively.

Stem cell treatments are not exactly new. They were first used in the 1950s in bone marrow transplants. More recently, what has excited researchers and the public are pluripotent stem cells, which have the ability to transform themselves into any part of the body. The full range of stem cells, however, includes adult, fetal, embryonic and induced pluripotent cells (iPS), which are also known as reprogrammed adult stem cells.

“Each type of stem cell has clinical promise for specific diseases, but also certain weaknesses. Some stem cells also stir controversy. For example, embryonic stem cells have been at the center of ethical debates for more than a dozen years,” Knoepfler writes.

Embryonic stem cells are derived from an embryo only a few days after fertilization and require destruction of the embryo. It was that type of process that triggered the federal restrictions – now rescinded by President Barack Obama – on federal funding of research using human embryonic stem cells. Some people believe that the process amounts to killing a human being, while others do not.

Knoepfler has come up with a battery of questions and “rights” that persons considering a stem cell treatment should address as they contemplate spending tens of thousands of dollars for treatments.

His “patient bill of rights” includes the right to treatment by a trained provider, the right to continuing follow-up and the right not to be charged to participate in a clinical trial.

Just this month, he added on his blog, ipscell.com, the top 10 questions that patients should ask. They include such areas as the details of the methods to be used and costs, the cell numbers and types, regulatory compliance by the provider, data supporting the cellular product’s effectiveness and data supporting its safety.

As for mainstream media reports and research papers that seem to promise miraculous cures, Knoepler says, “My advice to patients is to be cautious when reading papers on the clinical use of stem cells. Do not believe everything you read and avoid placing too much weight on any one paper. If something is real, it should be reproducible by multiple groups.”

One of the areas of Knoepfler’s research involves cancer stem cells, a topic of special interest to him because of his own encounter with the disease. “Even with something as wonderful as stem cells, there also can too much of a good thing. Stem cells can cause cancer and in certain conditions they can make cancer especially hard to cure,” he explains.

In the case of embryonic stem cells, he cites their ability to form an unusual tumor called a teratoma. Knoepfler, who was an English literature major as an undergraduate, says, “The name ‘teratoma‘ literally means ‘monster tumor,’ and there is good reason for that nomenclature. These tumors look monstrous when observed by eye, akin to an animal put into a developmental blender.”

Knoepfler did not use stem cell therapy to treat his cancer, but he says that as a cancer survivor he understands all too well why patients turn to it when they’re dealing with a life-threatening or life-changing medical condition.

“If you feel that your disease has put you in a place for which patience is not an option,” he says, “talk with your physician. Get second and maybe even third and fourth opinions before deciding whether or not to proceed.”

Knoepfler’s advice may not be appreciated by some of the firms he writes about, but others think well of him.

Jonathan Thomas, chairman of the $3 billion California stem cell agency, says the field needs more scientists like Knoepfler.

“It's hard to overstate the value of what Paul does,” Thomas said in an email.
“Paul is a powerful advocate for helping the public understand what research is being done, and why it is important. He is gifted at taking complex science and turning it into plain English so that anyone can understand what he's talking about.”

Knoepfler has received $2.2 million from the stem cell agency for his research, which is also funded by the federal government and other sources. He has been at UC Davis since 2006, part of the campus’ stem cell program, which has received $131 million in grants from the state stem cell agency since 2005, generating 333 research-related jobs.

Knoepfler, whose father was a physician and mother a counselor, sees a bright future for stem cells, indeed a “medical revolution.”

“Stem cells are today’s new frontier of medicine that will no doubt have an unimaginable impact on our lives, but even more so on the lives of many of our kids and grandchildren,” he said.

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Jensen is a retired Sacramento Bee journalist and has produced the California Stem Cell Report (californiastemcellreport.blogspot.com) on the Internet since 2005, writing nearly 3,600 items.

Flim-Flam Stem Cell Artists Targeted by CIRM

The California stem cell agency has joined with other prestigious stem cell organizations to help put a stop to the flim-flam artists that prey on desperate people by promising miracle cures from stem cell treatments.

The agency announced the action today on its blog, declaring that it has posted a new patient advisory document that provides a “ robust and detailed set of issues patients should consider when making treatment decisions.”

Don Gibbons, CIRM's senior science and education communications officer and author of the blog item, said the document addresses one of his special concerns: Internet “ads that come up on web searches and seem to be offering everything to everyone.”

Some of those ads can be found on many stem cell-related web sites, including this one, that carry ads that are placed there automatically by Google.