One of the main topics that I’ve covered over the last four or five of laying down a swath of not-so-Respectful Insolence directed at pseudoscience is the relatively rapid, seemingly relentless infiltration of pseudoscience into what should be bastions of science-based medicine (SBM), namely medical schools and academic medical centers promoted by academics who should, but apparently don’t, know better. This infiltration has been facilitated by a variety of factors, including changes in the culture of medical academia and our own culture in general, not to mention a dedicated cadre of ideologues such as the Bravewell Collaboration, whose purpose is to blur the lines between science and pseudoscience and promote the “integration” of quackery into science-based medicine. Certainly promoters of what Dr. Robert W. Donnell termed “quackademic medicine” wouldn’t put it that way, but I would. (“Quackademic medicine,” by the way, is a beautiful term to describe this phenomenon that I dearly wish I could claim to be the one to have coined but, alas, cannot.) Indeed, promoters of quackademic medicine scored a major victory last month, when a credulous piece of tripe about acupuncture passing as a review article managed to find its way into the New England Journal Medicine, a misstep that was promptly skewered by Mark Crislip, Steve Novella, and myself, among others.
Today, I want to riff a bit on one aspect of this phenomenon. As a cancer surgeon, I’ve dedicated myself to treating patients with cancer and then subspecialized even further, dedicating myself to the surgical treatment of breast cancer. Consequently, the interface of so-called “complementary and alternative medicine” (CAM) in the treatment of cancer both interests and appalls me. The reason for my horror at the application of CAM to cancer patients, as you might expect, is that cancer is a disease that is highly feared and can be highly deadly, depending upon the specific kind of cancer. Cancer patients deserve nothing less than the best science-based evidence that we have to offer, free of pseudoscience. Yet in even the most highly respected cancer centers, such as M.D. Anderson Cancer Center and Memorial Sloan-Kettering Cancer Center, there are departments or divisions of what is increasingly called “integrative oncology.” The claim behind “integrative oncology” is that it is “integrating the best of science-based and ‘alternative’ medicine,” but in reality all too often it is “integrating” quackery with science-based medicine. I have yet to hear an explanation of how “integrating” pseudoscience or nonscience into science-based oncology benefits cancer patients, but, then, that’s probably just the nasty old reductionist in me. Let’s find out.
I was reminded by the level of “progress” in integrating woo into oncology last month when the July 25 issue of HemeOnc Today showed up. Right there on the front page I saw a story Integrative oncology combines conventional, CAM therapies, with a subtitle reading “This growing medical discipline incorporates methods such as yoga, acupuncture and stress management.” And so it does. But I worry that that’s just the beginning:
The National Center for Complementary and Alternative Medicine defines integrative medicine as treatment that combines conventional medicine with complementary and alternative therapies that have been reported to be safe and effective after being studied in patients.
Lorenzo Cohen, MD, PhD, of M.D. Anderson Cancer Center is conducting a phase 3 trial of the effects of yoga on women with breast cancer.
“Integrative medicine is a philosophy based on treating patients by focusing on the whole person and using both conventional and complementary therapies in a multidisciplinary care fashion,” Lorenzo Cohen, MD, PhD, director and professor of the Integrative Medicine Program at The University of Texas M.D. Anderson Cancer Center, told HemOnc Today.
“It is similar to complementary medicine, but one key difference is that there is an open communication between practitioners of the different traditions,” he said.
“Between the traditions”? Note the clever use of language that Kimball Atwood is so fond of pointing out. Note how Dr. Cohen equates “conventional” and “alternative” therapies (the latter of which he calls “complementary”) as though they had equal validity and equal efficacy. It’s just two different traditions! What’s the problem with bringing them together, and integrating one into the other? It’s the best of both worlds, right?
Also notice another thing. I’ve referred to certain aspects of CAM, sometimes called “integrative medicine” (IM) and, in this case called “integrative oncology” (IO), as a “Trojan horse” to bring woo into medical schools and academic medical centers. Most — but not all — academic medical centers do not use hard core quackery like homeopathy, although many appear to be using a modality just as bad, reiki, which happens to be Dr. Mehmet Oz’s favorite modality. In any case, whenever you see discussions of “integrative medicine” and in particular “integrative oncology,” chances are, the modalities discussed generally include yoga, various dietary modalities, exercise, and, quite frequently, acupuncture. Sometimes, they include various herbal remedies. In other words, “integrative oncology” rebrands modalities that have no reason not to be counted as part of science-based medicine as “alternative” or “integrative” and points to them as having some promise. They then lump together pseudoscience like reiki and acupuncture with the rebranded modalities, such as herbal therapies. This story demonstrates exactly what I mean in this passage:
According to Cohen, integrative medicine includes a plethora of therapies and methods but can be most easily classified into five categories: biologically based therapies, mind/body medicine, manipulative body-based practices, energy medicine and whole medical systems.
Biologically based therapies include ingestibles such as herbs and supplements, megadoses of vitamins or specialized diets. Mind/body medicine consists of techniques that typically help with stress management. These techniques include meditation, yoga, guided imagery and other forms of relaxation, according to Cohen. Manipulative body-based practices include therapies such as massage, medical acupuncture and chiropractic work.
The most controversial area of integrative medicine, according to Cohen, is energy medicine, which includes techniques such as healing touch, Reiki, a Japanese form of energy healing, or the use of magnets for healing. Healing touch techniques such as Reiki and Qigong, an ancient Chinese healing therapy, are based on the theory that human beings are energetic bodies and certain individuals with specific training can emit energy into another person for therapeutic purpose.
I realize that HemeOnc Today isn’t the NEJM, but on the other hand, given how the NEJM recently fell for the pseudoscience that is acupuncture, maybe they aren’t so different after all. In any case, this entire article is the sort of credulous treatment that drives me crazy, particularly the last paragraph quoted above. Energy medicine isn’t just “controversial”: it’s quackery, pure and simple, and Dr. Cohen should know that. The best that can be said about so-called “energy medicine” is that it is religion, not science, or that the various modalities that fall under the rubric of “energy medicine” are based on a prescientific understanding of how the human body works and how diseases attack it. Some of them are not even “ancient.” Reiki, for instance, only dates back to 1922. It was invented by a man named Mikao Usui, who wanted to find out how Jesus healed the sick. His answer, reiki, is no more than faith healing; the only difference between it and what Benny Hinn does is that reiki is based on Eastern mysticism instead of Christian faith. None of this discussion of “energetic bodies” and the claims that practitioners can either channel some form of “universal energy” or manipulate the flow of human “life energy” for therapeutic intent belongs in science-based medicine, at least until someone can characterize the claimed energy and actually show that these practitioners can actually do anything other than wave their hands over patients.
Cohen also speaks of “whole medical systems.” In other words he refers to ancient medical systems, such as traditional Chinese medicine and Ayurvedic medicine, characterizing them as having “their own methods and techniques for diagnosing patients, prescribing treatments and following patients over time.” That much is certainly true, but none of these techniques were based on science, either. They were based on much the same thoughts that early “Western” medicine was based on. After all, when you come right down to it, “balancing” or “adjusting” the flow of qi is not that different than the idea that the four humors must be balanced or that disease comes from “contamination” due to miasmas. As Ben Kavoussi has pointed out, there isn’t that much difference between the concepts used to justify blood letting as a treatment for disease. Yet, somehow “integrative medicine” and CAM love modalities based on Eastern mysticism. Where’s the love for black bile, yellow bile, phlegm, and blood, which make just as much sense, from a science-based standpoint as the concept of qi? In fact, they make more sense, because they, at least, exist and can be observed.
The Trojan horse
Time and time again, when I observe integrative oncology programs, I notice that many of them heavily emphasize modalities like diet and exercise. Indeed, in the HemeOnc Today article, the various advocates and “experts” in integrative oncology emphasized time and time modalities like yoga:
Karen Mustian, PhD, MPH, assistant professor of radiation oncology and preventive medicine at the University of Rochester Medical Center, discussed the findings of a yoga study at the 2010 ASCO Annual Meeting, held in Chicago in June.
Researchers enrolled 410 survivors of non-metastatic disease who participated in the Yoga for Cancer Survivors program. Survivors reported suffering from moderate or severe sleep disruption 2 months to 24 months after completing adjuvant therapy.
The participants were assigned to breathing exercises, 18 gentle Hatha and restorative yoga postures and meditation for 4 weeks with twice-weekly sessions.
Patients practicing yoga had greater improved sleep quality (22% vs. 12%), decreased incidence of clinically impaired sleep (31% vs. 16%) and less daytime sleepiness (29% vs. 5%) compared with those who did not practice yoga.
Adding to these findings, a study of the effects of yoga on women with breast cancer is also in the works. In April, Cohen received a $4.5 million grant to conduct a phase 3 trial in women with breast cancer to determine the improvement in physical function and quality of life during and after radiation treatment.
The results of the study presented at ASCO described above are, of course, utterly unsurprising and unremarkable, at least to me. Would anyone expect that gentle exercise and meditation would harm quality of life and sleep quality? My guess is that substituting gentle exercise and prayer or non-yoga meditation would likely produce very similar results. But yoga is “Eastern,” so, you know, it’s automatically way, way, way more cool than any boring old “Western” exercises. In any case, I bet I could save the NIH $4.5 million by predicting the results of Dr. Cohen’s study. Yes, yoga very likely will be found to improve physical functioning and quality of life, because, by and large as it is practiced in this country (I’m aware that yoga can be quite a workout if you do the more rigorous forms), yoga is relatively gentle, low-impact flexibility exercise. In fact, in women who have undergone axillary dissection (removal of the lymph nodes under their arms), I would predict that yoga probably will decrease the incidence of impaired range of motion. The reason I make this latter prediction is because I already prescribe gentle stretching exercises to women who have undergone axillary surgery because it does decrease the incidence of impairments in range of motion. In fact, I would go so far as to predict that virtually any low impact exercise, be it yoga, Tai Chi, or simply low impact “Western” forms of exercise, such as walking and stretching, would produce the same results.
Oddly enough, I have been unaware of any investigators being awarded $4.5 million to study whether walking preceded by some gentle “limbering up” has all these effects in cancer patients. Why is that? This is the sort of stuff that is well-within the purview of science-based medicine, leading me to ask: Since when did exercise become “alternative” or “integrative”? Dr. Cohen’s study compares yoga versus “stretching/relaxation” (which is what I thought much of yoga was; so I’m not sure what the difference is) versus a wait list control group. So my being unaware of such a study is at an end, because apparently that’s just what Dr. Cohen will study. But does anyone think that the NIH would have funded such a study if it were about exercise and relaxation rather than yoga? My prediction for the outcome: the first two groups will both do better than the control group in terms of the outcome measures. I also wonder why on earth it will take $4.5 million and five years to answer this question. In any case, given the copious science already demonstrating that low impact exercise results in better quality of life outcomes for cancer patients, I would question the value, the “bang for the buck,” of spending $4.5 million in order to study an “alternative” or “complementary” therapy that is nothing more than a fancy form of stretching exercises and relaxation, the former of which is already known to be of benefit in cancer patients undergoing chemotherapy, surgery, and radiation. Surely such a study could be done for $1 million? Heck, for $4.5 million, I could start up a multi-investigator P01 with teams of investigators doing heavy duty basic science.
I know, I know. Sour apples. I really am in the wrong business, at least when it comes to getting research funding. Figuring out how cancer cells grow and metastasize and how to stop them is really, really hard.
In any case, the HemeOnc Today article, as credulous as it is, though, is merely an indication of just how far the concept of “integrative oncology” has gone. To appreciate just how far it has gone, I thought I’d peruse the websites of what are commonly accepted as two of the most respected institutions devoted to cancer in the United States, if not the world.
“Integrative oncology” invades and metastasizes
“Inspired” by the HemeOnc Today article, I decided to peruse the “integrative oncology” website of one of the two premier cancer centers in the country, that of the M.D. Anderson Cancer Center, as well as to take a peak at what the National Cancer Institute website says about various “alternative,” “complementary,” or “integrative” modalities. What many readers may not know is that the NCI has an Office of Cancer Complementary and Alternative Medicine (OCCAM, perhaps the most unfortunate acronym ever thought of, given what it stands for). Moreover, OCCAM has a budget that is of approximately the same magnitude as that of the National Center for Complementary and Alternative Medicine (NCCAM), in the range of $121 million a year. Thus, OCCAM is potentially as large a force in studying and promoting CAM as NCCAM has ever been.
Let’s start with M.D. Anderson first. On its website, it has a webpage called Complementary/Integrative Medicine Education Resources (CIMER). On the CIMER webpage, perhaps the most telling and useful “resource” is a page on therapies. On this page are links to several review articles authored by CIMER staff and physicians in the Integrative Medicine Program of the M.D. Anderson Cancer Center.
Whenever I take a look at a cancer center’s website, I go straight for the most hard core quackery to see what it says about it. Usually, I go straight for homeopathy. If a website concludes anything other than that homeopathy is pure quackery and that there is not a single molecule of active substance in most true hemopathic remedies (the dilution and succussion process having diluted it to nothing), then I know I’m dealing with quackademic medicine. Here’s an excerpt from what the great M.D. Anderson says about homeopathy:
The practice of homeopathy is based on its “law of similars” which proposes that “like cures like”. That is, a substance that causes specific symptoms in a healthy person is believed to ultimately relieve those same symptoms in a sick person. A few homeopathic physicians treat cancer by prescribing minute doses of tumors and carcinogenic substances.
The intent of homeopathic medicine is to help the body begin the healing process. Rather than focusing on a specific diagnosis, prescriptions are tailored to an entire set of symptoms and may vary between individuals with the same disease.
Significant reduction of some side effects of cancer treatments has been reported in two randomized controlled trials justifying further research with larger trials.
Current research includes a National Cancer Institute (NCI) clinical trial of a homeopathic substance for chemotherapy induced mucositis in children.
So far, not so good. The passage above is completely credulous, without the least bit of skepticism about the very basis of homeopathy. It reports homeopathy as a homeopath would report it, which makes me wonder if it was written by a homeopath. Particularly disturbing is the “detailed scientific review” of homeopathy. I’ll give the author credit because he at least mentions Avogadro’s number. That’s “science-y” and at least admits that there is a serious plausibility problem with homeopathy right from the get-go. Unfortunately, the article then credulously parrots the typical homeopath claim that water has “memory” and cites primarily articles from that journal of pure woo, whose editorial standards I’ve lambasted here and elsewhere time and time again, the Journal of Alternative and Complementary Medicine, as well as homeopathy journals, such as the British Homeopathic Journal. It is beyond the scope of this post to explain why such journals are generally not good sources (someday…someday), but they aren’t. The only “real” journal article I saw was the infamous TRAUMEEL S study from 2001 looking at whether homeopathic TRAUMEEL S can alleviate stomatitis in children undergoing treatment for lymphoma and leukemia. (I shudder at the unethical nature of testing magic water in a clinical trial with children as the subjects.) In any case, this study reported a positive effect; however, one might also note this from the study itself:
TRAUMEEL S® is a homeopathic-complex remedy that has been sold over the counter in pharmacies in Germany, Austria, and Switzerland for over 50 years. It contains extracts from the following plants and minerals, all of them highly diluted (10−1-10−9 of the stem solution): Arnica montana, Calendula officinalis, Achillea millefolium, Matricaria chamomilla, Symphytum officinale, Atropa belladonna, Aconitum napellus, Bellis perennis, Hypericum perforatum, chinacea angustifolia, Echinacea purpurea, Hamamelis virginica, Mercurius solubilis, and Hepar sulfuris. Information from the manufacturer indicates that TRAUMEEL S is used normally to treat trauma, inflammation, and degenerative processes.
In other words, this is an herbal remedy in which there is still ingredient, given that even a 10-9 dilution is not enough to dilute away what’s in there. Why it’s even called homeopathic, I have a hard time figuring out, given that there are many herbs and minerals in there, with no rationale of “like curing like” obvious for them all. If TRAUMEEL S “works,” it’s not any sort of validation of homeopathy; all it shows is that maybe some of the herbs or minerals in the concoction have a beneficial effect. One also notes that this is a small study (N=30, 15 per group) and that the distribution of disease in the two groups was very different and that this study has never been replicated. Both Edzard Ernst and the Cochrane Reviews note this study but conclude that there is no evidence that homepathy is any better than placebo for cancer side effects.
But apparently not M.D. Anderson. M.D. Anderson appears to believe in magic. If you don’t believe me, just take a look at its review on reiki, including the “scientific evidence” for its efficacy in cancer patients, or its review on healing touch, which is more or less reiki shorn of the explicit Eastern mysticism. Particularly nauseating is this introduction to “energy therapy” methods, which divides the very concept of energy itself into “Western” and “Eastern” notions of energy. (Silly me, I thought that energy was energy, and it was defined scientifically.) The author then postulates the “blending” of “Eastern” and “Western” concepts of energy thusly:
Modern physics has shown that light can exist as two interchangeable forms: a particle (form and structure) and a wave (movement and vibration). The rest of nature can also be experienced in the form of a particle and a wave. For example, water in the ocean is both particles of water and movement of coastal currents, thermal layers and tides. As in the ocean, the human body contains and is affected by energy that can be blocked, flow freely or vary in frequency. Various forms have been postulated:
- An all-pervasive background frequency without form that extends beyond the limits of the body structure
- Vertical energy flows that serve as conduits to external energy
- Additional currents of energy with identifiable paths and patterns
The extent to which a background field extends beyond a person reportedly varies with each individual. Some people have said that they are sensitive to these fields – seeing or hearing these projections. Heat emanating from a body is one form of energy and one expression of that person’s energy field8.
Notice that no evidence is presented showing that these claims are valid.
The introduction concludes:
Contemporary energy therapies are only recent manifestations of a larger and more ancient body of energetic and spiritual concepts that are beyond the scope of these reviews of a few contemporary energetic healing practices. MD Anderson recognizes that physical healing is only part of the cancer treatment process and also offers spiritual support through many different programs such as the Chaplaincy Services — representing a wide range of faiths and spiritual beliefs — and the Place … of wellness — where people touched by cancer can enhance their quality of life with activities that help to heal the mind, body and spirit.
Remember, this is the website of the M.D. Anderson Cancer Center, which is widely viewed to be one of the top two or three cancer centers in the United States, if not the world, and its Integrative Medicine Program appears to be based on magic more than anything else. Quackademic medicine, indeed.
Unfortunately, the NCI’s OCCAM website isn’t all that much better. Because I spent longer than anticipated going through the M.D. Anderson website, I’ll wrap it up fairly quickly. OCCAM has some fairly disturbing pages itself. For instance, its Categories of CAM Therapies is a simple list of CAM therapies with little discussion at all other than defining what they are in the way any woo-meister would be happy with. OCCAM is superior to M.D. Anderson’s CAM pages in that it does from time to time throw in passages like this:
Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. The existence of such fields has not yet been scientifically proven.
If there is no good science to show that these fields even exist, then why study trying to manipulate them? I never understood putting the cart before the horse like that. There’s a lot of that sort of stuff going on in the list of CAM therapies referenced by OCCAM, although a lot of the articles are in fact NCCAM articles. One article on a CAM therapy that is hosted by the NCI and apparently was written by NCI staff is entitled Questions and answers about acupuncture. Depressingly, it begins with a credulous discussion of qi and meridians that is credulous and full of magic. It also contains statements like:
Scientific studies on the use of acupuncture to treat cancer and side effects of cancer began only recently. Laboratory and animal studies suggest that acupuncture can reduce vomiting caused by chemotherapy and may help the immune system be stronger during chemotherapy. Animal studies support the use of electroacupuncture to relieve cancer pain.
Human studies on the effect of acupuncture on the immune system of cancer patients showed that it improved immune system response.
One wonders just how critically the studies to which this article refers were evaluated. Certainly, the lists mix “electroacupuncture” (which is not acupuncture at all — as Mark says, where were those batteries in ancient China to hook up to the acupuncture needles?) with acupuncture studies. One wonders if this is another case of accepting the authors’ misinterpretation of their own results, as I discussed for one such study a couple of months ago. As for the effects of acupuncture on the immune system, the physician’s version of the review points out that all these studies were conducted in China, and, unfortunately, it’s well known that acupuncture studies from China tend to be overwhelmingly positive, in marked contrast to acupuncture studies from other countries, leading some writers of meta-analyses to question how to handle these studies. In any case, it would appear that the NCI, although its material on its website is not as credulous as that of M.D. Anderson, is not exactly a bastion of science when it comes to some “alternative” medical modalities.
Indeed, let me tell you a brief anecdote. Two years ago, at the AACR Meeting, I visited the NCI booth on the convention floor because I knew there was going to be a representative from OCCAM there. My confidence in the scientific rigor of the entire OCCAM enterprise was not boosted by the conversation I had there. In brief, after a brief (and neutral) conversation about what OCCAM does, I gently challenged the OCCAM representative regarding alternative medicine by pointing out that there really isn’t that much evidence for much of it and asking him if he could point me in the right direction. In particular, I asked him why one would think that a mixture of herbal medicines would do better than pharmaceuticals. He then began to pontificate about “royal herbs” and couldn’t provide a good rationale why anyone should conclude that impure mixtures of compounds would be more effective or reliable than pharmaceuticals. When he started going on about “emperor” herbs, “minister” herbs, and “assistant” herbs, I couldn’t take it anymore and looked for an opportunity to politely excuse myself.
“Integrative oncology”: The quackademic oncology that’s here to stay?
I first became aware of the phenomenon of quackademic medicine several years ago. Before then, I was blissfully ignorant. Over the last several years, in particular the last couple of years, I’ve become increasingly alarmed at just how much pseudoscience is finding its way into medical academia in general and into oncology in particular in the form of “integrative” oncology. When the websites of what have in the past been a bastion of science-based oncology, M.D. Anderson Cancer Center and the NCI, become infiltrated with this sort of pseudoscience, I become alarmed. But it’s far, far worse than that. I only picked two websites. There are many more out there, thanks to promoters of woo like the Bravewell Collaborative and others. I only picked on M.D. Anderson and the NCI because of their reputation for being much better than this, a reputation they are endangering by their embrace of woo. Cancer patients, as I say frequently, are among the most vulnerable of patients. Many of them are facing a very unpleasant death without treatment; seeing that they receive the most effective medicines and treatments we have, free of quackery, is a moral imperative, and I fear that we will soon be failing our patients. We now even have a Society of Integrative Oncology promoting the “integration” of pseudoscience into oncology.
The Trojan horse of herbals, diet, and exercise in the form of yoga may have breeched the walls of academia, bringing with it pseudoscience like acupuncture, reiki, and even homeopathy, but still I see reason for hope. Val Jones once coined the term “shruggie” for health care professionals who have seen the infiltration of pseudoscience into medicine and in essence shrug their shoulders, dismissing it as not being important or as not being their business if people choose quackery instead of science-based medicine. However, as the infiltration of pseudoscience reached a critical mass, it started to alarm even some of the shruggies. There has been pushback. We here at SBM like to think that we have been a significant part of that reaction, but we also know that there are many others, such as Edzard Ernst, Ben Goldacre, and Simon Singh. Even though a disturbing number of skeptics seem to have a blind spot when it comes to quackery, the broader skeptical movement appears to be taking more and more notice. I only hope that it’s not too late. When an admired and esteemed institution like M.D. Anderson goes woo, the woo-meisters are not only at the gate, but they’ve stormed the bastions, driving defenders of SBM to the keep to make a last stand.