Respectful Insolence

Special pleading for “integrative oncology”

I don’t recall how many times I’ve said lately that I detest the term “integrative medicine.” As I’ve pointed out time and time again, it’s the preferred “successor,” if you will, to the term “complementary and alternative medicine” (CAM) (at least among the woo-friendly). After all, as I’ve pointed out before, it just won’t do to have the fashionable quackery du jour be considered as only being “complementary” or “alternative” to real medicine. That implies at best that it has a subsidiary role to real medicine and at worst that it is not real medicine, being “alternative” and all. The whole “complementary” bit is a bummer, too, as it implies that the real medicine is the cake and the woo is but the icing applied to it. Either way, if you’re a quack of the academic variety (or, as I like to call them, quackademics) or of the straight up quacky variety, you’d want to have a term that doesn’t imply a subsidiary status to medicine, a term that makes it seem as though you actually have something on par with scientific medicine.

Enter the term “integrative medicine.”

It’s so fuzzy, so happy, so light! Best of all (if you’re a quack), it doesn’t imply that your quackery is in any way inferior to real medicine. After all, you’re “integrating” your favorite woo with medicine, or, as IM advocates like to claim, providing patients with the “best of both worlds.” How one figures out what the best of CAMworld or IMworld is without–oh, you know, some…science!–I have yet to figure out, but CAM/IM advocates are convinced they’re combining the best of the world of “Western,” “allopathic,” “scientific” medicine with the “best” of CAM/IM, however they managed to figure that out. (Usually, it’s just the practitioner’s favorite woo or sets of woo).

Of all the forms of CAM/IM that irritate me the most, there’s one form that irritates me more than the others. You see, it turns out that CAM/IM has begun to fragment into specialties, which is perhaps the only way it resembles real medicine. It’s even formed a specialty known as “integrative oncology,” the very thought of which sends chills down my spine. I’ve written extensively about it before; so I won’t retread that ground. Well, I won’t retread it much, anyway. When you’ve been blogging almost every day for nearly seven years, it’s hard not to repeat yourself somewhat from time to time; consider it the price necessary to bring the newbies up to speed. Be that as it may, you know that it’s like waving the proverbial red cape in front of me to entitle a post something like Reductionistic Science and the Evolution of Integrative Oncology, yet that’s exactly what a man by the name of Glen Sabin did.

He begins by pointing out that the randomized, double-blind placebo-controlled clinical trial is ” considered the most reliable scientific process to measure efficaciousness of drugs and medical interventions.” This is one of those statement’s that almost true, but not quite. While it’s true that randomized, placebo-controlled trials are generally considered the “gold standard” for evidence in certain interventions, they are not the be-all and end-all of clinical evidence. Some questions can’t be studied in a trial like that. For other questions, using a placebo control is unethical. For still others, a clinical trial is not necessary at all to know that an intervention can’t possibly work. Unfortunately for Sabin, nearly all studies that fall into the latter category also fall under the rubric of CAM/IM. Think homeopathy. Think reiki. Think pretty much any form of “energy medicine.” None of this stops Sabin from citing the Institute of Medicine thusly:

On February 25-27, 2009, the Institute of Medicine, with support from the Bravewell Collaborative, convened the Summit on Integrative Medicine and the Health of the Public in Washington, DC. The stated goal of the conference was to advance the science, understanding, and progress of integrative medicine–”healthcare that addresses together the mental, emotional, and physical aspects of the healing process”.

Hoo-boy. I remember this conference. I blogged this conference, at least tangentially, because the Four Horsemen of the Woo-pocalypse (Drs. Andrew Weil, Dean Ornish, Mark Hyman, and Mehmet Oz) struck in two locations, the IOM and in the very halls of Congress itself, thanks to the intervention of the woo-friendly creator of the scientific monstrosity known as the National Center for Complementary and Alternative Medicine (NCCAM) himself, Senator Tom Harkin (D-IA). Basically, the conference was a huge mistake by the IOM, as it served mainly to showcase speakers spouting the same sort of nonsense co-opting modalities that are properly science-based, such as diet and exercise, and rebranding them as CAM in the classic “bait and switch.”

I didn’t realize, though, that it had taken so long for the IOM to finally issue a report on this particular conference. The report itself is too long for me to discuss here. Perhaps I’ll do a post just on this report in the future, either here or at my other blog. For the moment, though, I’m going to concentrate more on how Sabin tries to use the IOM report more than on the actual report itself. There’s plenty there to go around, and, besides, why get only one post out of a source when you can get two? Sabin provides a “target-rich” environment without my having to take on a 200+ page report as well. For instance, as proponents of woo so frequently do, Sabin doesn’t think that the scientific methods as currently practiced is up to the task of examining his integrative quackademic medicine. He begins by providing a fact-free assertion:

The human mind and body, when confronted with malignancy, reacts with a complex set of physiological and psychological change that cannot be adequately addressed in isolation. As such, only whole person, multi-interventional synergistic approaches to scientific exploration will lead the way to 21st century personalized, integrative oncology care.

The buzzwords are all there. It sounds all science-y. But this is a meaningless paragraph. Does Sabin honestly think that scientists haven’t been studying the physiological and psychological changes that occur in response to malignancy? If he does, he’s completely ignorant of what has gone before; scientists have been studying the physiology of tumors and how they affect normal physiology for many decades, the psychology not as long but at least a few decades. I must tip my hat to Sabin, though, for combining more CAM buzzwords into a single sentence designed to make CAM sound scientific than I think I can recall ever having seen before. Putting the phrase “whole person, multi-interventional, synergistic approaches to scientific exploration” in the same sentence as “21st century personalized, integrative oncology care”? Brilliant! If you can’t dazzle ‘em with brilliance, baffle ‘em with…CAMspeak.

So what, exactly, is Sabin talking about when he lays this word salad upon us? Damned if I know. He doesn’t explain, nor do any of his sources to which he links, two of which come from that wretched hive of scum and quackery, The Huffington Post, including a post by Larry Dossey, Deepak Chopra (yes, Deepak Chopra), and Rustum Roy that I decontructed a long time ago. Instead, this is what he says:

Random controlled trials are here to stay, and rightfully so, but a lot has changed since the Flexner Report. Personalized medicine is growing and evolving: over 30 billion dollars annually are being spent in the U.S. on complementary health services and products, and consumers are embracing integrative healthcare practitioners like never before. In addition to the RCT, we need a human clinical trial research model specifically designed for whole systems research.

The best of western, allopathic medicine, especially acute emergency care and diagnostics, is arguably the finest in the world. But it is clear that our so-called science-based processes and methodologies that result in FDA approved drugs do not always allow the most useful and important study designs in integrative medicine to be funded and executed.

How generous of him. He acknowledges that RCTs are “here to stay.” Of course they’re here to stay! They’re the best way to minimize bias in studying a wide variety of medical interventions. But do we really need a “human clinical trial research model specifically designed for whole systems research”? What does “whole systems research” even mean? Clinical trials are whole systems research in that they study the effects of interventions on the whole system that is the human body! As far as “reductionistic Western medicine” not being able to study “complex, multifaceted therapies,” well, it can. Indeed, Tim Kreider gave two examples of scientists doing just that with tai chi for fibromyalgia and the use of cognitive behavioral therapy for ADHD. The same has been done for acupuncture studies as well, including the use of better sham needles, the study of the effect of practitioner-patient interactions, and more. Here’s the problem. The vast majority of CAM modalities are found to perform no better than placebo when tested under controlled conditions, and people like Sabin know it and don’t like it.

Make no mistake. The real purpose of this appeal to “wholistic” or “whole systems” research methods is not because current methods are so clearly inadequate to study CAM. They aren’t. The real reason Sabin and others are demanding “new” research methods to address “whole systems” is because their favored woo consistently fails when subjected to controlled scientific testing. Rather than doing what real scientists would do and concluding that their woo just doesn’t work, instead Sabin et al want to change the standards to something that (they think) their woo can pass. The only way to do that is to lower the standards, whether they admit it or not. My favorite example is how acupuncturists promote the use of “pragmatic trials,” which are clinical trials that are sometimes done after a treatment has been shown to be effective in proper, rigorous RCTs. Pragmatic trials generally aren’t randomized and are designed to test the efficacy of a therapy in “real world” conditions. Using them before a therapy is shown to work using RCTs is putting the proverbial cart before the horse, because pragmatic trials can definitely introduce more biases and more tendencies for false positive results.

In the end, the call for “whole systems” research is nothing different than that. It’s special pleading, asking that a different standard of evidence be applied to CAM than is applied to modalities that are part of science-based medicine. I reject such special pleading. As always I believe that there should be only one standard, that of science, and that it should apply equally to all treatments, wherever they came from. CAM modalities that can stand up to scientific testing will, as the old cliche goes, cease to be “alternative” and become simply “medicine.” When that happens, science-based practitioners will happily absorb rather than integrate such methods into science-based medicine.

Comments

  1. #1 nybgrus
    September 7, 2011

    Orac,

    I read through Sabin’s article and clicked through some of the links to read further. I could find nothing delineating whatsoever what this “whole systems” approach was. In fact, I found a section on the FON site stating quite clearly that current models both CAN and DO utilize and analyse whole systems… but somehow this new approach was necessary. Of course, what was different about the new approach was never explained nor why it was necessary (besides the slew of buzzwords flying around everywhere). So I wrote this comment and left it on Sabin’s article (though it didn’t show up below so I am not sure where it goes):

    What is “whole system research” and how does it differ from a clinical trial? The link you provide is only a brief link describing that FON wants to do this type of research but not what it actually is.

    The follow-thru links there lead to another section in which it is commented “As such, only whole person, multi-interventional synergistic approaches to scientific exploration will lead the way to 21st century personalized, integrative oncology care.” – without actually defining what “whole person, multi-interventional synergistic approaches” are. As best as I can glean, it seems to indicate using multiple dependent and independent variables at the same time and measuring outcomes, which include quality of life considerations. The page continues by saying:

    “While randomized trials can be and are used for whole systems research, new approaches are needed to design, collect, and analyze data from such trials: multidisciplinary teams are employed, and models regard patient outcomes from several viewpoints, including an emphasis on patients’ quality of life.”

    Since RCTs can be used (and are used) to study “whole systems” why are new approaches necessary, how do they differ, and what new would they bring to the scientific discourse? Looking further, it seems that the only difference elucidated is that “whole systems” approaches would be “addressing the body, mind, and soul.” Besides pre-supposing the existence of soul and a mind separate from the brain, how does the proffered approach intend to quantify and analyze such variables?

    Besides introducing multiple variables so as to obfuscate the outcomes I am unable to see what the material difference would be between currently employed methods of “whole systems” research and analysis and what FON and you are advocating.

    I would be quite grateful if you could clarify that for me, Mr. Sabin.

    Thank you!

    I also noted that on this page they list their 4 opening projects. CLL, Breast cancer remission, prostate cancer early remission, and chemotherapy support program. All of them are looking at dietary changes in each cancer… but they all point out they will be the first to research “full diet, exercise, and mind-body program” – whatever that means. For the last one they note:

    “The addition of supplements may also help to realign certain cancer-promoting physiological imbalances.”

    Below that they note:

    “Program designs combine allopathic interventions, exams, and diagnostics featuring biochemical and biomarker lab tests, and an array of innovative, evidence-based integrative oncology modalities.”

    So basically, they are going to do real medicine, toss in their woo:

    “Changing the body’s internal environment using diet, exercise, and nutraceutical interventions to remedy imbalances in cancer-promoting physiological processes such as… Focus on anti-angiogenesis by tapping the powers of fruits, vegetables, and herbal medicines.”

    and then analyze it using their brand new and completely undefined “whole systems approach” and declare victory for whatever woo they are peddling hardest in that particular study. They sure love their “wholeness” though:

    “Achieving anti-cancer nutrition levels through a plant-based, whole foods diet.”

    Whole foods? I bet the store chain would love this.

  2. #2 Dangerous Bacon
    September 7, 2011

    I think the major buzz-term for quacks in general as we move forward (to use another buzz-phrase) will not be “integrative medicine”, but rather “personalized medicine”.

    It’s perfect. On the one hand it suggests that mainstream medicine is populated entirely by soulless automatons plugging everyone automatically into a set of diagnoses and treatments demanded by Big Pharma-dominated Science, while CAM/integrative medicine/woo focuses on the person. It also neatly fits into the popular woo concept that “everyone is different” and “what works for one person may not work for another”, so supplements and treatments that can’t meet evidence-based standards are just fine, because someone out there will insist that they worked for him/her.

  3. #3 Mu
    September 7, 2011

    I like this statement, he makes it sound like it’s a good thing:
    over 30 billion dollars annually are being spent in the U.S. on complementary health services and products
    I wonder how much health insurance for real treatments for the uninsured that would buy.

  4. #4 Denice Walter
    September 7, 2011

    In a way, don’t we already have *integrated* medicine, i.e. SBM ( including science-based psychology)? Because we do _not_ arbitrarily divide a person into mind vs body ( since all is based in physiological reality) and we do *not* use two different means of inquiry to investigate two disparate “substances”?

    I’ve always felt that while woo is the cherished darling of those who don’t quite “get” SBM ( physiology et al), those who can’t comprehend psychological phenomena ( as studied by scientific means) resort to the the mystical and religious realms. The “innovators” cited by our esteemed host seem intent on integrating a duality of woos – medical and psychological- giving you two forms of pseudo-science with which to waste people’s time, effort, and money.** I think that SBM is merely an after-thought for them.

    Here are two examples of pseudo-psych: a well-known woo-meister speaks about how his athletic prowess was once depleted and it *wasn’t* due to exercise or injury to the physical: it was rather, a depletion of *Chi*- something entirely different. He embarked upon remedial fasting and meditation and – after a month in the wilderness- * Voila!*: he got better! The Chi got re-plenished.

    So perhaps if I feel morose, it’s not the monsoons, it’s “depleted Chi”. Sure.

    On a personal level: a woo-ish acquaintance “explains” my own interest in other cultures and cuisine by… wait for it… reincarnation. He speculates that I have had past lives in China and India. Seriously. While I would cite family history and interests, as well as friends I made from this area of the world *plus* the fact that I really like curry. And tea.

    So they might use reincarnation to “explain” personality or abilities and ghosts to “explain” memory and attachment/ separation phenomena. ESP can be “explanatory” if you don’t understand how people learn and think.

    When our “integrators” suggest that their approach is needed because SBM cannot adequately address psychological issues concommitant with illnesses like cancer I think that it tells us volumes about their own limitations.

    ** Isn’t it interesting how woo-meisters always seem to provide more than one form of crappy therapy ? I wonder why?

  5. #5 cervantes
    September 7, 2011

    “healthcare that addresses together the mental, emotional, and physical aspects of the healing process”.

    That’s obviously a worthy goal, and of course it’s an even deeper level bait and switch. Physicians may not always give sufficient weight to every element, but there’s plenty of research and advocacy going on within medicine and medical research that is based on the bio-psycho-social view of the patient. The Patient Centered Outcomes Research Institute embodies this view as federal policy. To allow charlatans to get away with the claim that only they care about the whole person, and M.D.s don’t, would be the most egregious error.

  6. #6 Militant Agnostic
    September 7, 2011

    Mu @2

    I like this statement, he makes it sound like it’s a good thing: over 30 billion dollars annually are being spent in the U.S. on complementary health services and products. I wonder how much health insurance for real treatments for the uninsured that would buy.

    This gives me a brilliant economic idea. Maybe the US could join the civilized world with universal health care by funding it through a tax on woo?

  7. When we talk about sCAM co-opting science based medicine modalities such as diet, nutrition, exercise, and stress reduction/relaxation, I think it’s important to at least occasionally mention that although these modalities are part of science based medicine, they way they are practiced or the underlying understanding of them in sCAM is generally not science based. It’s important to sometimes clarify for the people new to the discussion that we are not really acknowledging the essential validity of certain modalities under the label or umbrella of sCAM.

    In regards to these “overlapping” modalities, sCAM is frequently wrong, and when it is right, it is often for the wrong reasons and it carries the baggage of the BS along for the ride. (Yes tai-chi and yoga are effective forms of light exercise, but there’s nothing fundamentally special about them and the underlying philosophies are unneeded vitalistic woo.) This is why sCAM really has nothing worthwhile to offer, because those modalities are already practiced under science based medicine with a scientific basis. sCAM brings nothing useful to the table for these (or any other) aspects of health care.

    -Karl Withakay

  8. #8 herr doktor bimler
    September 7, 2011

    As such, only whole person, multi-interventional synergistic approaches to scientific exploration will lead the way to 21st century personalized, integrative oncology care.

    Would you take your car to a mechanic who promised to fix that fan-belt problem using personalized, integrative care based on whole-car, multi-interventional synergistic approaches to scientific exploration?

  9. #9 Militant Agnostic
    September 7, 2011

    If I am ever treated for cancer, I definitely want “personalized” medical care. I want my medical care personalized to exclude all woo.

  10. #10 Kathryn
    September 7, 2011

    @Dangerous Bacon,

    I hope woomeisters don’t co-opt “personalized medicine” because SBM personalized medicine (using genetics to predict pharmacologic responses for treatment) would be great. Right now it’s only practical for a few applications besides oncology.

    It does bother me that some of the groups promoting genetic testing make rather woo-ish claims about determining diet via genetics, or promote supplements. Laypeople aren’t going to know that’s woo.

    Kathryn

  11. #11 Derek
    September 7, 2011

    You know, if that quote from Sabin didn’t use medical-like language, I’d swear it was an example of the excesses of the business consulting profession trying to convince a corporation to part with their money for a different kind of woo.

  12. #12 lsm
    September 7, 2011

    If somehow woo is “integrated” with real medicine, I can only imagine how our health costs would skyrocket! It brings this to mind: a couple of months ago, when my mother-in-law was recently in the cancer center recovering from brain surgery, they kept bringing a big dog to visit her. Everyone raved about how wonderful the big dog was, and how it would help her. But for an 83-year old woman who was already overwhelmed with too much outside stimuli, the extra concern was unbelievably unhelpful and unwanted. The dog had a little bag for us to put our “donation” in so it could keep “working.

    If the dog represents CAM, and if CAM was actually working with real medicine, would I have been billed for the dog visits, whether I wanted them or not? I have to wonder if the real goal of “integrated medicine” is to integrate itself right into my bill.

    (disclaimer: I like dogs; I’m sure the therapy helps somewhere, but in this case the big dog was a symbol of big woo)

  13. #13 Blackheart
    September 9, 2011

    Wayne State’s School of Medicine exploring alternative therapies to reduce anxiety in children undergoing MRIs
    September 30, 2009

    http://research.wayne.edu/news.php?id=3529

    DETROIT— Three Wayne State University School of Medicine researchers will explore complementary and alternative medicine therapies to reduce anxiety in children undergoing magnetic resonance imaging studies.

    Ambika Mathur, Ph.D., associate dean of WSU’s Graduate School and professor of pediatrics in the School of Medicine; Deepak Kamat, M.D., Ph.D., professor and vice chairman of education in pediatrics; and Prashant Mahaja, M.D., associate professor of pediatrics, will use an $894,493 grant from the National Institutes of Health to fund their two-year study, “Comparison of the Effectiveness of CAM Therapies in Pediatric Patients Undergoing Sedation.”

    The grant comes via the National Center for Complementary and Alternative Medicine under the American Recovery and Reinvestment Act economic stimulus bill.

  14. #14 W. Kevin Vicklund
    September 9, 2011

    The three methods that will be tested in the study include passive music therapy, active music therapy with a certified music therapist and distraction procedures conducted by a child life specialist.

    Ah, more co-option of SBM in the name of CAM. It looks like NCCAM is finally realizing that it is going to have to fund real medical research in order to return positive results.

  15. #15 Mephistopheles O'Brien
    September 9, 2011

    So, wait – Muzak is CAM?

  16. #16 Composer99
    September 9, 2011

    Blackheart: That research relates to incorporating quackery into ontology how, exactly?

    It gets tiresome seeing apologists for sCAM threadjacking.

  17. #17 Vicki
    September 9, 2011

    Ism–

    They definitely ought to be personalizing treatment enough to ask before bringing a dog into a patient’s room: in addition to the overstimulus problem, some people are allergic to dogs (and aren’t going to have mentioned that when asked if they’re allergic to any antibiotics), and some are simply afraid of dogs.

    If it’s a medical treatment, they should be getting patient consent; if it’s not, large carnivores, however well-meaning, shouldn’t be brought into sick people’s hospital rooms unless the sick people want them there.

  18. #18 Knightly
    September 9, 2011

    I can definitely see why you’re against using woo or quackery in place of real medicine, but I have to ask, so long as the woo isn’t directly harmful then what does it matter as long as the patient gets the real medicine too?

    If they’re being treated by a real doctor using real science then it seems to me like the rest of it is really for their comfort. It’s clearly very unlikely (read: coincidental) that prayer by itself will cure cancer, but can you fault someone for praying before surgery, or during chemotherapy or radiation therapy?

  19. #19 Lawrence
    September 9, 2011

    Except when people start ascribing the cures / improvement in condition to the woo. Plus, the woo isn’t free – health care already costs too much, now you want to burden hospitals, etc. with the expense of hiring acupuncturists & reiki guys? And in some cases, those expenses would preclude perhaps the hiring of actual medical specialists.

    That’s a big part of the problem.

  20. #20 Vicki
    September 9, 2011

    If a patient wants to pray before surgery, that’s their business. Ditto if they want to ask friends all over the world to pray for them.

    If the doctors and/or nurses want to organize a prayer circle in the OR before operating on someone, that is at best a waste of time. If you’ve ever spent most of a day waiting around for an operating room to open up, you’ll know what the harm is. That’s aside from questions of patient confidence: as someone put it a while back, I don’t want a surgeon who prays to God, I want a surgeon who thinks s/he is God.

    Beyond that, most of this stuff isn’t free: it costs money, it uses up a patient’s energy (even little things like mixing up and drinking a “traditional Chinese” herb mixture, never mind trips to see an acupuncturist, chiropractor, homeopath, etc.), and it can distract people from getting real medicine. It’s hard enough deciding what if anything to buy for a cough without having the pharmacy shelves crowded with worthless homeopathic nostrums.

    Is anyone trying to keep track of the cost in patient discomfort of being interrupted by offers of reiki, or having to chase off prayers that they consider blasphemous (some years ago, a man in my social circle explicitly asked that is Christian friends pray for him, and his friends of other religions not do so), or the like?

  21. #21 Collin
    September 9, 2011

    You want a surgeon who thinks s/he is God and can dictate the laws of physics and doesn’t need to follow health and safety protocols?

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