I’m a cancer surgeon.
I started out as a general surgeon, but my passion and scientific interest goaded me into specializing in cancer. Ultimately, I ended up subspecializing even more, ultimately becoming a breast cancer surgeon, but through it all cancer, not just breast cancer, has remained my clinical and scientific passion. So has science-based medicine. Developed as a response to the concept of “evidence-based medicine” (EBM), SBM postulates that clinical care should be based on the best science available, including the consideration of basic sciences and prior probability. EBM relegates such considerations to the lowest rung of the ladder of data and elevates the randomized clinical trial to the highest form of data. This latter aspect of EBM is not what I generally have a problem with; rather it is how EBM treats randomized clinical trials as the be-all and end-all of evidence, which means that a single clinical trial of homeopathy that appears to be positive counts for more than all the hundreds of years of firmly founded chemistry, physics, and biology that say that homeopathy can’t work as homepaths claim it can. To overturn so much history and science requires far more than a barely statistically significant effect observed in a randomized clinical trial. The same holds true for other forms of magic that fall under the rubric of “complementary and alternative medicine” (CAM), such as reiki (which is faith healing that substitutes Eastern mysticism for Christianity as its religious basis) and therapeutic touch (which is not touch at all) that have managed to coopt EBM and claim to be “evidence-based.”
As Harriet Hall says, it’s Tooth Fairy science.
Not too long ago I wrote a post about something called “integrative oncology,” which I referred to as “quackademic medicine triumphant.” “Integrative oncology” is the oncology subspecialty of “integrative medicine” (IM), which is the latest incarnation of CAM that seeks to “integrate” pseudoscience into scientific medicine. In my post, the hallowed M.D. Anderson Cancer Center, whose faculty really and truly should know better given the incredible scientists and practitioners of scientific medicine who work there, received the majority of my ire. In particular, I singled out Lorenzo Cohen MD, PhD (whose latter PhD degree demonstrates conclusively that a PhD does not guarantee freedom from woo) for promoting “integrative oncology” at the University of Texas M. D. Anderson Cancer Center, and,, even worse, for promoting “energy therapies,” which include the aforementioned woo known as reiki and therapeutic touch.
A reader sent me a post that Dr. Cohen wrote for Cancerwise, the M.D. Anderson Cancer blog, entitled Integrative Medicine Versus Alternative Medicine: Why It’s Important to Know the Difference. All I can say (to begin with) is: Wow. The abuse of language and science to support magic is strong in this one. Very strong. One wonders if Dr. Cohen was–shall we say?–made aware of the criticisms coming his way from me, both here and at my other blog. One also wonders if someone mentioned to him that he was prominently featured in a talk I gave to the Chicago Skeptics about four weeks ago. Or maybe Orac is simply engaging in some of his usual hubris, to have the temerity to think that such a prominent and well-funded CAM researcher would even notice (much less give a rodent’s posterior about) two humble blogs and a talk to about 40-50 skeptics in a pub.
Whether he noticed me or not, whether I was the source or not, Dr. Cohen is not pleased at some criticism his precious integrative oncology has received:
People often do not make a distinction between the terms integrative medicine and alternative medicine. Below is the mission statement of the Society for Integrative Oncology (http://www.integrativeonc.org):
The Society for Integrative Oncology (SIO) is a non-profit, multi-disciplinary organization of professionals dedicated to studying and facilitating cancer treatment and the recovery process through the use of integrated complementary therapeutic options. Such options include natural and botanical products, nutrition, acupuncture, massage, mind-body therapies, and other complementary modalities. Our mission is to educate oncology professionals, patients, caregivers, and relevant others about the scientific validity, clinical benefits, toxicities, and limitations of state-of-the-art integrative therapies. SIO provides a forum for presentation, discussion, and peer review of evidence-based research in the discipline. We advocate for responsible public policy and the highest standards of practice in integrative medicine through appropriate training and the certification of health care professionals.
You will note that the word “alternative” is not contained in the mission statement because the SIO is not a proponent of alternative therapies in lieu of conventional evidenced-based medicine. This is also true of most academic organizations including MD Anderson, Memorial Sloan Kettering Cancer Center, Dana-Farber Cancer Institute, University of California, San Francisco, and others.
This is, of course, a massive straw man argument. Indeed, in this article, Dr. Cohen tilts at windmills with a ferocity that would alarm even Sancho Panza. The criticism, of course, that we supporters of SBM level is not that proponents of “integrative” medicine or oncology advocate using woo instead of real medicine. It’s that many of the nostrums they propose to use in addition to real medicine have no basis in science (and, in fact, are based on prescientific notions of disease), do not improve patient care, and, in fact, waste time and resources, as well as in some cases potentially cause harm. Even worse, they erode the scientific basis of medicine, as “integrative” medicine co-opts science-based modalities such as diet and exercise or the pharmacology of natural products (pharmacognosy), infusing them with pseudoscience and thereby making them into woo, too. Quackademic medicine blurs the lines between science-based medicine and pseudoscience-based medicine to the point that even many physicians begin to have trouble telling one from the other.
The straw men and deceptive (probably self-deceptive) language continue throughout the post. After assuring us that “integrative” oncologists only embrace “evidence-based” interventions and that they are “wholly committed to quality research in the area of integrative cancer therapies” (both points that no one, including myself, is arguing against), Dr. Cohen tries to point to the Society of Integrative Oncology’s “evidence-based” guidelines as evidence that there really, truly is good evidence for the efficacy of CAM therapies in oncology. What’s in those guidelines, though, is really mostly what I consider to be utterly conventional science-based medicine co-opted and rebranded as CAM, modalities such as diet, exercise, and relaxation therapies, with the real woo (such as reiki and “energy medicine”) seemingly tacked on as an afterthought. (You know, the 2009 “evidence-based” integrative oncology guidelines would make the basis for a good post; or maybe I should wait for the 2010 guidelines to come out.) He then proceeds with a tirade against his critics that includes gambits that wouldn’t be out of place on Mike Adams’ NaturalNews.com website in its more sane moments:
One of the other challenges of research in this area is that with the exception of the natural product clinical trials, it is difficult to develop studies using the gold standard double-blind, placebo-controlled design. However, even using single-blind designs, it is possible to at least determine if the patients remained blinded to group assignment and assess patients’ baseline treatment expectations. This can help to account for placebo effects. Often, in double-blind, placebo-controlled trials of conventional medicine patients are clearly “unblinded” when they experience negative drug effects and adverse events that are not experienced with the placebo treatment. Typically, it is unheard of to assess if patients remained blinded throughout a trial of conventional medicine. This unblinding is rarely questioned or even reported.
Well, that depends upon the trial, actually. Blinding is generally taken very seriously; that’s the default, and it’s simply assumed. For instance, in this trial, there was a slight difference in the labels that, if the labels were closely examined, could have led the pharmacists to be unblinded as to which vials contained placebo and which contained the study drug, leading to what was characterized as a “remote possibility that unblinding information…could have been revealed to the pharmacist.” Even the “remote possibility” that the first 130 patients recruited could have been unblinded to the pharmacists preparing the drugs because of a differences in the label led to those patients being excluded and a fresh batch of 130 patients being enrolled to replace them. The original 130 patients were included in the safety analysis but excluded from the efficacy analysis. To the extent that Dr. Cohen is advocating for more rigorous reporting I can’t criticize him, but to the extent that he comes across as complaining that a more rigorous standard is being demanded of CAM, I call him out on that because that is what he appears to be doing. In reality, what is being demanded of CAM is the same standard that should be and generally is demanded of SBM–and Dr. Cohen doesn’t like it.
This leads him to an amazing tu quoque argument:
It is uncommon to find scientists or practitioners who support evidence-based medicine unsupportive of well-designed clinical trials. However, this can sometimes still happen in designing, conducting, and publishing integrative oncology clinical trials. Scientific observation should never be trumped by a personal belief. In fact, substituting one’s own belief instead of supporting rigorous research and scientific observation is similar to what alternative medicine practitioners advocate – deliver or withhold treatments without evidence to support that action.
Even though it was very late when I wrote this because I was so exhausted that I fell asleep on the couch right after getting home from work and eating dinner, with the consequence that at 3 AM I’m wide awake hoping that blogging will tire me out enough to allow me to get some sleep (can’t sleep, clowns will eat me), I almost spit up my iced tea when I read this. It’s also a massive straw man argument, leading me to steal the phrase “pyromaniac in a field of straw men” to describe Dr. Cohen. Either that, or at the risk of becoming too repetitive, I could reuse one of my favorite images and describe Dr. Cohen as taking a flamethrower to a burning man-sized man of straw.
SBM is not “personal belief.” It is taking into account all the science, including the background basic science. No one–I repeat, no one–of whom I’m aware is opposing well-designed clinical trials. What I oppose is putting the cart before horse. Homeopathy, for instance, goes against so many well-established principles and theories in physics and chemistry that, for it to be true huge swaths of our very basic understanding of these disciplines would have to be not just wrong, but spectacularly wrong. A true scientist and skeptic never rejects the possibility out of hand that we are wrong about the science that declares homeopathy impossible, but, as Carl Sagan was fond of saying, extraordinary claims require extraordinary evidence, and homeopathy sure does make a whole lot of extraordinary claims. It is not “personal belief” to point that out, nor is it “personal belief” to point out that wobbly clinical trials in which placebo effects can easily result in false-positives are not enough to lead us to question hundreds of years worth of well-established science. Ditto reiki, acupuncture, therapeutic touch, and other forms of “energy medicine.” The bottom line is that one can always demand “more research.” That’s the default position of CAMsters when science doesn’t support their woo. If Dr. Cohen wants science to validate his woo, then he’d better cough up the evidence, rather than whining when skeptics point out that the CAMperor has no clothes.
Finally, Cohen uses the most tried and true gambit of CAMsters. Well, maybe the second most tried and true gambit after the pharma shill gambit. Yes, he pulls out the “science was wrong before” gambit:
If we simply followed people’s predictions and beliefs then the field of medicine would not be where it is today, as many medical discoveries went against what was commonly believed and/or predicted. A good historical example of this is the story of Dr. Ignaz Semmelweis who documented that washing hands with chlorinated lime solution prior to delivering a baby dramatically decreased the rate of puerperal fever. The germ theory of disease had not been developed at the time and Dr. Semmelweis was largely ignored, rejected or ridiculed.
Another good example in oncology is the late Dr. Judah Folkman who discovered angiogenesis and pioneered anti-angiogenic treatments. He also was initially dismissed and ridiculed by the medical community due to his ideas, which are now, of course, widely accepted.
Damn. Lots of woos invoke Semmelweis, but recently I’ve noted a new trend for them to invoke my scientific hero Judah Folkman in the same way. Dr. Folkman must be doing power backflips in his grave at the abuse of his good name. I suppose that Semmelweis is just too…1800s, and they need a more recent example of the alleged close-mindedness of scientists. Apparently building up the myth of Robin Warren and Barry Marshall’s supposed ostracism due to their proposal that H. pylori was the cause of peptic ulcers was not enough, and now they have to abuse Dr. Folkman. Of course, Folkman was never really seriously ostracized or marginalized for his ideas, although they were greeted with skepticism and criticized when he first published the hypothesis that angiogenesis is a target for cancer therapy in 1971. Rather, Dr. Folkman became one of the most revered figures in the field of surgery and remained so for over 30 years until his sudden and untimely death in 2008. More importantly, he proved himself to be right through 25 years of doing the hard work of science to test his hypotheses. His vindication came in the mid- to late-1990s, when he discovered the endogenous angiogenesis inhibitors angiostatin and endostatin and proved in mouse models that angiogenesis can be a viable target for anticancer therapy.
What Dr. Cohen is invoking, of course, is nothing more than the Galileo gambit. The problem is, as has been said so many times, that to wear the mantle of Galileo it is not enough to be criticized for ideas outside of the scientific mainstream. You must also be correct. Judah Folkman was correct, and he also did what true scientists do: He proved it through his research. That’s the way real scientists do it–scientists like Judah Folkman, who never publicly whined about how the scientific establishment wouldn’t believe him, which is in essence what Dr. Cohen is doing.
I’ve said time and time again that the co-opting of what should be science-based modalities by “integrative” medicine is a Trojan horse for the real woo, such as “energy healing” and homeopathy. Whether he realize it or not (I’m pretty sure he does not), Dr. Cohen concludes by making that explicit:
The field of integrative oncology continues its ascent as medicine shifts toward a more personalized care model. Delivering many common and accepted modalities such as diet, exercise, and stress management using a patient-centered, comprehensive approach is what distinguishes integrative medicine from reductionist and fragmented models of care. As more and more cancer survivors proactively participate in a patient-centered wellness approach, integrative oncology practitioners will continue to grow in numbers to meet this demand.
What, I ask, is “alternative” or CAM about diet, exercise, and stress management? Nothing. When done properly, it is SBM. Coopting it as “integrative” or “personalized care” is nothing more than marketing buzzwords. Of course, the unspoken but implied claim is that, if diet, exercise, and stress reduction are effective for improving health, which no SBM practitioner would argue, then the other woo advocated by Dr. Cohen (energy medicine) must also be effective.
The woo sits within the belly of the Trojan horse of diet and exercise, waiting to jump out and take over the fortresses of SBM. It’s already happening at M.D. Anderson.