No proof for alleged health benefits of DC-CIK

Cancer treatments are associated more often with diminishing beauty than its enhancement. Hair loss and raw, peeling skin immediately spring to mind as common side effects of radio- and chemotherapy. But lately, another regimen has come under the spotlight - DC-CIK injections - being used to achieve more youthful looks. Beauty salons have offered the procedure claiming it would give clients whiter, younger-looking skin with finer pores, while strengthening their immune system. But four women, who each reportedly paid about HK$50,000 for the treatment at DR Beauty chain, wound up in hospital suffering from septic shock. One eventually died from the onset, induced by a bacterial infection.

So what is DC-CIK? Short for dendritic cells and cytokine-induced killer cells, it is a form of immunotherapy that has been in existence for about 10 years, although it has never been used in Hong Kong as a cancer therapy, says Dr Raymond Liang Hin-suen, president of the Hong Kong Academy of Medicine. While some clinical trials show that it has some effect in prolonging survival, particularly in patients with kidney cancer and melanoma, DC-CIK remains an experimental treatment, even for fighting cancer, he says.

"There's no evidence that this type of treatment works for other purposes such as improving your health, skin condition or preventing cancers," says Liang, who is also director of the Comprehensive Oncology Centre at Hong Kong Sanatorium and Hospital. Indeed, several experts in immunotherapy and cosmetic surgery were unaware of the DC-CIK cocktail, or its application in aesthetic regimens.

Dendritic cells and killer cells are types of immune cells. Dendritic cells are present in most tissues of the body, particularly stationed at "outposts" such as the skin. Dendritic cells act like sentries of the immune system and deliver key information about invading pathogens, which in turn helps activate killer cells - a type of white blood cell - to fend off the infectious agents. In DC-CIK immunotherapy, blood extracted from the body is cultured with a mix of proteins called cytokines, which stimulate the production of killer and dendritic cells.

The idea is that injecting this activated cocktail back into the body will boost the ability of the immune system to fight cancer cells, Liang explains.

But such a combination is largely unknown in Europe, says Laurence Chaperot, a researcher at the Albert Bonniot Institute in France. "DC, yes, CIK, yes, but not their association," says Chaperot, who has been studying the use of dendritic cells in immunotherapy for more than a decade. "In Europe, these two kinds of cells are usually not used together, but it seems to be the case in China, as you can see on clinicaltrials.gov."

Run by the US National Institutes of Health, this website lists eight clinical trials in progress, one in Thailand and the rest in China, in Beijing, Qingdao and Fuzhou.

Dr Ren Jun, director of Beijing Cancer Hospital's Medical Oncology Department and also director of the city's Capital Medical University Cancer Centre, is principal investigator for four of the seven studies. Asked about the link between DC-CIK and better looks, Ren says he has "no idea of such beauty issues". Neither does Chaperot. He has not found any argument that could suggest that such cell therapies would have an effect on the skin, he says. "[It's] very intriguing."

Indeed, Dr Walter King Wing-keung, president of the Hong Kong Association of Cosmetic Surgery, says he had not heard of DC-CIK being used for cosmetic reasons until reports emerged of the four women being admitted to hospital after receiving treatment.

"In theory, it may be a way of stimulating the immune system to mop up dying, ageing cells," King says. But he has not come across any Western literature that explains the process or proves its efficacy.

"There's good rationale behind the whole concept of stem-cell treatments making people feel healthier and look younger, and, hypothetically, it makes a convincing story," says Dr Andrew Burd, professor of plastic, reconstructive and aesthetic surgery at Chinese University of Hong Kong. Without evidence of efficacy, however, "it's just not appropriate" to provide the procedure, Burd says. "That sort of treatment needs to be given in a research environment."

Efficacy of the treatment aside, initial reports raise suspicions that the superbug Mycobacterium abscessus that infected the women may have been introduced during handling. Cell culture, which is conducted at DR Beauty's lab at the Hong Kong Science Park in Sha Tin, is a vulnerable phase. The killer cells are incubated at 37 degrees Celsius, or body temperature. "At that temperature, if there is any bacterial contamination, then you're growing the bacteria as well," Liang explains.

So is the procedure cosmetic, medical, or both? The DC-CIK procedure was reportedly carried out by a doctor not employed by DR Beauty, and this has raised questions about regulating the kind of services beauty salons can perform. A task force led by Health Department director Constance Chan Hon-yee has been formed to review the operations.

Liang, who is part of the task force, says the first step is to define what constitutes a medical procedure. By extension, any medical procedure that is not performed by a doctor would be deemed illegal. But other physicians doubt the feasibility of making such delineations.

"It would be very hard to have a definition that will work well. For example, if we define anything that draws blood or breaks skin as 'medical', how about extractions or ear piercings?" asks dermatology specialist Dr Tinny Ho Tin-yee. "Another example is machines like lasers and radiofrequency devices [for skin or hair]. There are now home-use versions, so one can't say those machines can't be used in beauty salons."

The distinction between cosmetic and medical treatments is still "very foggy", Burd says, citing as an example a person with acne who gets prescribed medication by their doctor. "People say it's medical, but one of the consequences is they'll look more beautiful. So there are medical treatments designed to make people look better."

Singapore seems to have succeeded in making the distinction. In 2008, the Singapore Medical Council (SMC) drew up guidelines on aesthetic practices which are jointly implemented with the Academy of Medicine and College of Family Physicians.

They require all procedures to be conducted by registered doctors. The guidelines sort treatments into two lists, based on the scientific evidence to support their use.

List A comprises treatments with a moderate to high level of evidence, or with local medical expert consensus that the procedure is well established. The treatments are further grouped into non-invasive, minimally invasive and invasive. List-A treatments include chemical peels, microdermabrasion, lasers, botox and filler injections, breast enhancement, brow lifts and liposuction, among others.

The guidelines also demand a minimum level of competence for each treatment, appropriate premises where the procedure can be carried out, and a requisite number of procedures that have been performed by the doctor. Doctors who don't have sufficient experience must get SMC approval before carrying out the procedures.

List B covers treatments for which there is little evidence and/or consensus they are well established or acceptable. These include mesotherapy, carboxytherapy, microneedling dermaroller, skin whitening injections, stem-cell activator protein for skin rejuvenation, negative pressure procedures (such as Vacustyler) and mechanised massage (such as "slidestyler" or "endermologie", for cellulite treatment).

Doctors who wish to perform any list-B procedures must show the circumstantial evidence for its use, and administer it using protocol similar to a research study. They are not allowed to advertise their services for these procedures.

In Hong Kong, medical opinion is divided on which procedures require a doctor's expertise. Burd argues that professionals such as nurses or trained beauticians should be allowed to administer certain invasive treatments, such as Botox. "If they're giving it routinely every day, they would be better at it than a doctor giving it once a month."

But King advises that invasive procedures such as those involving needles and knives, as well as those using lasers, intense pulse light, high energy radiofrequency and ultrasound therapies, should be performed by experienced and registered doctors.

With a range of views, and guidelines yet to be established in Hong Kong, perhaps the best protection is for consumers to make well-informed choices.

Ho advises consumers seeking cosmetic treatments to go to a clinic run by a doctor who has the expertise to assess the risks and benefits of a treatment.

Those requiring a dermatologist or plastic surgeon could check the list of registered specialists on the Medical Council's website mchk.org.hk Apart from that, Ho says, there is no official certification for doctors trained in cosmetic treatments.

"Most importantly, you should find someone who is experienced, knowledgeable about what they do, and who can give you a good and fair discussion of the pros and cons and possible side effects of a treatment," says Ho. "If you are not absolutely comfortable about a procedure or treatment, don't do it. These are all elective procedures. It's not like treating a heart attack. You won't suffer not having them."

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