It would be difficult to be a Canadian and be unaware of the controversy regarding
endovascular treatment for multiple sclerosis (MS). Dr. Paolo Zamboni,

an Italian physician, has hypothesized that MS is caused by a newly

discovered abnormality of venous drainage from the brain that he has

called chronic cerebrospinal venous insufficiency (CCSVI), and that

endovascular treatment of CCSVI can markedly improve the symptoms of MS.^1,2

The endovascular treatment has been given the rather sensational name

“liberation procedure,” invoking the notion of “setting free.” The

overwhelming majority of MS researchers dismiss Dr. Zamboni’s findings

because they fly in the face of what is known about the etiology of MS,

and because of questions about the scientific quality of Dr. Zamboni’s

work. His studies of the association between CCSVI and MS have not been

consistently replicated, and his trial addressing the effectiveness of

endovascular treatment was not randomized. As well, although Zamboni

found no serious complications in 65 MS patients undergoing angioplasty

of the jugular veins, no large-scale study of complications has been

reported. These are important and valid criticisms.

The public profile of CCSVI in Canada was raised in the fall of 2009 by a relatively uncritical article in The Globe and Mail (Toronto), and an even more uncritical broadcast on the CTV public affairs program W5.^3,45 They demand that endovascular treatment be made available in Canada or,
at the very least, that a randomized trial of the procedure be started

immediately.

Both portrayed Dr. Zamboni as a pioneer whose theories were discounted

by conventional medicine and focused relatively little on the criticisms

of his studies. Many Canadians with MS, eager for an effective

treatment for this miserable disease, have been convinced by Dr.

Zamboni’s research, and by the testimonials of patients who have

travelled to other countries to receive the procedure. They accuse many

in the MS scientific community of being narrow minded, obsessed with

irrelevant scientific niceties, and/or of being in the clutches of the

pharmaceutical industry.

Into this perfect storm have marched the Canadian Institutes of Health Research (CIHR) and the Multiple Sclerosis Society of Canada. In
September of this year they released a summary of the deliberations of a

“Joint Invitational Meeting” of 15 clinical and scientific experts, 5

employees of the CIHR, 3 employees of the MS Society, and one

unidentified person with MS. The panel examined the scientific

literature relating CCSVI and MS, and decided that the evidence linking

CCSVI and MS was so unconvincing that it would be inappropriate at this

time to perform a clinical trial examining the benefits and risks of

endovascular treatment as a therapy for MS.⁶

Too often, health care interventions are introduced on the basis of poor scientific evidence. Therefore, what the CIHR and MS Society have
attempted to do seems admirable to those of us who are proponents of

evidence-based health care and evidence-informed policy-making. A review

and summary of all research that is relevant to important health policy

decisions by unbiased experts can be used by politicians and

policy-makers to make policy decisions, in this case whether to fund

endovascular treatment for CCSVI, either as part of a randomized trial

or through the publicly funded health care system. However, we suggest

that there are important lessons to be learned from this panel’s

experience that should be considered when constituting future panels

that address other issues that are at the intersection of science,

advocacy and policy-making.

Concerns have been raised about the membership of the expert panel.⁷ No proponents of the liberation procedure participated in the
Invitational Meeting, which seems odd. Most scientific experts have some

degree of conflict of interest, and these are usually dealt with by

publicly declaring them, not by excluding a particular point of view

from a panel. Conversely, the potential conflicts of interest of the

individuals who were on the panel were not described in the report, thus

allowing some to accuse the CIHR of attempting to hide their potential

biases.⁸

The panel recommended that no clinical trials of endovascular treatment for CSSVI should be conducted until the association between MS
and CCSVI has been firmly established. The rationale for this

recommendation is sensible: one should not expose MS patients to the

risks of endovascular therapy—which, although rare, can be fatal^9,10—

if there is no rational scientific reason to think that CCSVI causes

MS. However, the panel spent little time either justifying their

controversial recommendation or discussing potentially opposing points

of view. We believe that both the panel’s approach to the problem and

its membership were too narrow to completely fulfill its mandate.

It appears to us that the panel addressed three questions. The first question was whether current evidence establishes that patients with MS
have a higher frequency of CCSVI than patients without MS. The second

was whether current evidence establishes that the benefits of

endovascular treatment in patients with MS outweigh the risks. The third

was whether a publicly funded randomized trial of endovascular therapy

for MS should be initiated now.

The first two questions are largely ones of science, and are best addressed by highly qualified experts who represent the diversity of
views in the scientific community. However, we believe that although the

third question must be informed by science, it should be addressed

using a broader perspective. A clinical trial of endovascular treatment

funded by the CIHR or provincial governments would consume public

resources, which are clearly limited. Given the controversy, and given

the way this issue has galvanized the public, the decision about whether

to conduct a clinical trial should be informed by the public. We

believe that members of the public, beyond 3 employees of the MS Society

and one anonymous person with MS, should have been included on the

Joint Invitational Meeting panel. By “members of the public,” we do not

mean only patients with multiple sclerosis or advocates for MS

patients, but also thoughtful citizens without MS who can consider all

points of view, deliberate about them, and contribute to informed

recommendations.

If half a dozen or so such individuals had participated in the deliberations, they might have asked questions about why proponents of
the liberation procedure were not members of the panel, and they would

have contributed greatly to the discussion about the appropriateness of a

clinical trial in the face of poor scientific evidence supporting the

CCSVI hypothesis and uncertainty about the risks of endovascular therapy

(which appear to vary depending upon whether or not a stent is

inserted). They would likely have encouraged the panel to more fully

articulate the reasons why a clinical trial should not (or possibly

should) be conducted now, and might have had different views about how

to balance information about the risks and potential benefits of

angioplasty. A number of Canadians are now using their own resources to

travel to other countries to undergo endovascular treatment, performed

by surgical teams whose quality standards are not always clear. Would

these patients be better off, and policy-makers and the public better

informed, if a randomized trial were conducted now? If patients are

fully informed about current doubts regarding the association of CCSVI

and MS, as well as the limitations of Zamboni’s non-randomized trial of

endovascular treatment, and the potential side-effects of endovascular

treatment, should they be given the opportunity of participating in a

trial now? Of course, surgeons and interventional radiologists should

not participate in the trial if they feel that the current evidence

suggests they are likely to do more harm than good to their patients.

However, we know of reputable Canadian vascular surgeons who would

operate on MS patients in the context of a randomized trial.

Even had greater public membership on the panel not changed the recommendations made in the report at all, or had the committee not been
able to come to a consensus, the very fact that members of the public

were on the committee would likely have increased the legitimacy of the

report in the eyes of the public (although not in everyone’s).

The public pays for research funded by the CIHR and the MS Society of Canada, are affected by the findings, and are more likely to be
supportive of research in general if they feel that researchers are more

in touch with the community. The CIHR has itself, in reference to its

Stem Cell Oversight Committee, stated “Technical experts will provide

the Committee access to the latest scientific and ethical information,

and representatives from the general public will represent the views and

values of Canadians potentially affected by the new technologies.”¹¹

We agree with this statement and suggest that, in the future, members

of the public should be more actively involved in scientifically based,

but patient-relevant and emotionally charged, issues considered by the

CIHR, by other Canadian research organizations and by the provincial,

territorial and federal governments.