Respectful Insolence

I was disturbed several months ago when I learned that the director of the National Institutes of Health, Francis Collins, had agreed to be the keynote speaker at the Eight International Society for Integrative Oncology Conference in Cleveland, OH. I say “doubly” disturbed because it disturbed me that Francis Collins would agree to speak at such a function and, perhaps even more, because the host institution was Case Western Reserve University, the institution where I both completed my surgery residency and my PhD in Physiology and Biophysics. Sadly, it now appears that my old stomping grounds at University Hospitals has been thoroughly infiltrated with quackademic medicine, as evidenced by this clinical trial of reiki for psoriasis that’s making the rounds of news services and the offering of acupuncture, reiki, and even reflexology at various UH facilities through the University Hospitals Connor Integrative Medicine Network. Let me tell you, there was none of this pseudoscience going on when I finished my residency there in 1996. Seeing it there now provokes a reaction in me not unlike Sylvester Junior’s reaction when his father Sylvester embarrasses him, particularly when I noted that the director of the CWRU Comprehensive Cancer Center, Dr. Stanton L. Gerson, was to give one of the keynote talks, entitled, “The Future of Integrative Oncology.” (Hint for those of you not familiar with classic Looney Tunes cartoons: A paper bag is involved.) I guess that by expressing my extreme disappointment and embarrassment that the institution where I learned to become a surgeon has during the last 15 years gone woo, I’ve probably just killed any opportunity I might have to work at the Case Comprehensive Cancer Center ever again. Oh, well, add it to the list, along with Beth Israel and my alma mater the University of Michigan.)

Back when I first learned about it, I thought about blogging the meeting, but without much concrete to go on, all I could do was to write a critical post about his decision to accept the offer to be the keynote speaker at the Society for Integrative Oncology (SIO). Then yesterday I saw popping up in my e-mail a notice from the American Society of Clinical Oncology (ASCO), along with a link to a story in its publication The ASCO Post entitled NIH Director Calls for Rigorous Evaluation of Integrative Medicine to Provide Evidence of Efficacy.

Et tu, Dr. Collins?

Francis Collins “gets it” about as well as Josephine Briggs

We here at SBM have written frequently and copiously about the National Center for Complemnatary and Alternative Medicine, a.k.a. NCCAM, a.k.a. the Barad-dûr to SBM’s Minas Tirith. OK, I exaggerate. Just a bit. NCCAM director Josephine Briggs is a real scientist, and I have no doubt that she wants to make NCCAM more scientifically rigorous than it has been in the past. Unfortunately, NCCAM is a political, not a scientific, construct, because CAM is an ideological, not a scientific, construct. There is nothing tying together the disparate “disciplines,” treatments, and woo lumped together under the rubric of CAM/IM other than that they either (1) have not been scientifically demonstrated to have efficacy; (2) have been demonstrated not to have efficacy; or (3) are diet and exercise or other interventions that should fall under the purview of SBM but have been co-opted by CAM/IM believers along with the woo because they are modalities that have proven health benefits and including them along with all the pseudoscience makes the pseudoscience seem more plausible. It’s not for nothing that I frequently refer to diet, nutrition, and pharmacognosy as the “Trojan horses” of CAM. These modalities have more than a modicum of plausibility (although it should be pointed out that the way they are represented by CAM often does not, vastly overselling the benefits or fusing science-based recommendations with pseudoscience). “Energy healing,” acupuncture, reiki, the vast majority of TCM, Ayurveda, and many other modalities that fall under the CAM umbrella do not, and that is the problem.

Unfortunately, it’s quite obvious that Collins does not “get” this. Although he changed the title of his talk from the original title of “Faith, Spirituality and Science in Oncology,” the actual talk he gave, entitled “Seeking Out the Most Effective Interventions for Cancer Prevention and Treatment,” still falls hook, line, and sinker for one of the favorite arguments of CAM proponents, the argumentum ad populum (i.e., appeal to popularity):

“Many new frontiers exist in integrative medicine,” NIH Director Francis Collins, MD, PhD, stated in his keynote address at the Eighth International Conference of the Society for Integrative Oncology (SIO) in Cleveland. “The evidence is overwhelming that these approaches are being used by many individuals in the United States, including those with cancer,” he said. “For wellness, immune function, and pain-related symptoms, there is a significant increase in interest among cancer survivors compared to other people who use complementary and alternative medicine.”

Survey data show that over a lifetime, complementary and alternative medicine (CAM) is used by “65% of cancer survivors vs 53% of noncancer respondents,” he said. When questioned about motivations to use CAM, cancer survivors “are more likely to be using this because they are unhappy that medical treatments have not helped them or because it has been recommended by the provider,” he noted.

As Steve Novella has pointed out, the appeal to popularity is the most ubiquitous argument used in CAM apologetics. In brief, it argues that, because CAM is seemingly popular, there must be something to it and we should study it. If you look at the figures, on the surface Collins’ figures appear to be correct. However, such figures are hugely inflated by inclusion of things like massage, vitamins and supplements, yoga, and prayer. That’s how studies of tai chi in fibromyalgia, for instance, make it into the New England Journal of Medicine labeled as “CAM” when in fact they are merely studies that demonstrate that gentle exercise appears to be helpful in alleviating fibromyalgia symptoms. As Steve also pointed out, most hard-core CAM modalities are actually used by a very small percentage of the population, with most falling in single digit percentages. For example, acupuncture use is around 6.5%; Ayurveda, 0.6%; chelation therapy, 0.3%; energy healing, 1.7%; naturopathy, 1.5%; and homeopathy, 3.7%. These are hardly impressive numbers. In addition, these numbers are not significantly different from numbers reported 10 or 20 years ago – belying the claim that CAM use is increasing. In any case, the number I usually see for the percentage of cancer patients reporting having used CAM is less than 50%. I don’t know where Collins got his figure of 65%.

In fact, while looking for the source of Collins’ information, I found this recent meta-analysis that, while claiming to find that CAM usage among cancer patients is increasing, still only estimated it at 40% in American patients, way lower than the 65% claimed by Dr. Collins. It’s actually a fairly maddening study in that the definition of CAM therapies for purposes of inclusion in the various studies is not listed in the paper. Rather, it’s listed in an online supplement mentioned in the paper that I couldn’t find. In any case, particularly interesting to me was this passage in the discussion:

Surveys that restricted CAM use to certain categories or treatments yielded lower prevalence estimates than surveys that did not. This is exemplified by the study from Abu Realh et al,120 who confined their definition of CAM use to mind-body approaches, counseling, and attendance to self-help groups and found that 12% of respondents were “CAM users.” Accordingly, studies with broad definitions of CAM use tended to inflate estimates: for example, many of the included surveys with very high usage rates had integrated prayer and exercise defined as CAM, and the usage rate would have been approximately halved if these therapies had not been included. We planned to systematically address the question of how different definitions for the term CAM would influence the results in surveys. However, this was not feasible because authors seldom stated how they defined CAM for the purpose of their study. Moreover, even in studies from the same country, in which the same type of definition was used, the CAM treatments included varied substantially.

It’s a shame that Dr. Collins apparently either doesn’t recognize such distinctions or was too unconcerned to look more in depth into whether claims of CAM use in cancer patients by CAM advocates are accurate. They are, as Steve and I have pointed out, hugely inflated by the inclusion of modalities that aren’t really medicine (prayer, for instance) or through the inclusion of of modalities that are arguably not CAM, such as vitamin use (which might or might not be science-based depending upon the specific use), exercise, and nutrition. Even sensationalistic news coverage comes up with lower estimates than Collins did. Next up on Collins’ hit parade is a citation of a study from M. D. Anderson Cancer Center that reports that 52% of cancer patients are using CAM during phase I trials, but that 23% don’t disclose that information to trialists. This is indeed a disturbing figure, but it is not a justification for NCCAM, a specialty known as “integrative oncology,” or CAM itself. Rather, it’s a figure that tells us that we should do more research in drug interactions with natural products, something that could easily be done under the auspices of non-CAM funding mechanisms in the NIH.

In fact, I find this whole line of argument confusing. Collins went on to proclaim how the goals of NCCAM are “very much aligned” with those of the SIO and then used the following as his examples:

“We need to do this research, not only to find out what works, but to find out what interventions actually may be harmful,” no matter how unlikely that may seem, Dr. Collins commented. For example, he pointed to the story of beta-carotene in cancer prevention. In the 1980s, epidemiologic evidence suggested that beta-carotene might decrease lung cancer risk. Double-blind clinical trials were initiated, and in the 1990s, those trials showed that “not only is beta-carotene not protective, it actually increased lung cancer risk–16% in one study and 28% in another–and so the studies were halted.” A follow-up study in 2004 corroborated those results.

This is, of course, a massive straw man coupled with a non sequitur. No one seriously argues that scientists shouldn’t try to find out what works and what doesn’t. In addition, the examples Collins cites are not in any way “alternative,” “integrative,” or “complementary.” Beta-carotene is a chemical found in some foods that can act as a drug or nutrient. There was preliminary epidemiological evidence suggesting that beta-carotene might decrease the risk of lung cancer. Scientists then did what scientists do: They performed randomized, double-blind clinical trials to test the hypothesis, which seemed plausible when the trials were initiated. Unfortunately, the results of these clinical trials turned out not to be what had been anticipated; not only did beta-carotene not prevent lung cancer, but it increased the risk of dying of lung cancer in smokers. How this relates to “CAM” or “IM” is tenuous at best. This is SBM at work. The same is true of the other example cited by Collins, that of vitamin E and selenium as preventatives for prostate cancer that, when tested in randomized clinical trials, actually slightly increased the risk of prostate cancer. So, while I agree with Collins that “That’s the kind of data we need if we are going to be giving rational recommendations to patients and providers about how to practice better prevention and treatment,” I disagree that such studies are in fact “integrative” or “alternative” or “complementary” or whatever CAM proponents like to call such supplementation these days. They are, in fact, SBM. Beta-carotene and the vitamin E/selenium combination are simply proposed therapies that had a modicum of plausibility to them as a preventative strategy for different cancers that failed when tested in rigorous randomized clinical trials. This happens all the time in SBM; it’s why we do clinical trials.

In essence, whether he knows it or not, Collins has fallen for the old “bait and switch” of CAM/IM, just as NCCAM director Josephine Briggs has.

“Personalized” medicine and CAM

I’ve written many times before about how CAM co-opts the idea of “personalized medicine” for itself when in fact what “personalized medicine” means in CAM tends to involve practitioners “making it up as they go along” and the co-opting of the term as a strategy to attack evidence-based medicine as being “one size fits all.” Some, such as Dr. Stanislaw Burzynski, co-opt the term as a science-y-sounding way to make his very own “make it up as you go along” mish-mash of targeted cancer therapies, antineoplastons, and chemotherapy sound as though he knows what he’s doing.

Collins, disappointingly, buys into this frame. Whether he does this knowingly or unknowingly, I don’t know. (I suspect the latter.) First, he touts NIH initiatives, such as the Cancer Genome Atlas, a project that will sequence the genomes of many cancers and try to draw conclusions about the genetic abnormalities that drive cancer growth and determine responsiveness to various therapies. It’s an ambitious (and risky project that has almost nothing to do with CAM, although CAM proponents have tried to claim such projects as their own, the most hilariously off-base example being so-called Ayurvedomics. This is a strategy that appears to be echoed in one of the talks given at the SIO conference by Jeffrey A. Dusek, PhD, entitled, “Mind-Body Strategies and Epigenetics.” In any case, Collins points out how “big numbers” are needed to be able to draw any useful correlations and understandings of patterns of genetic derangements in various cancers. No doubt this is true, but it is also irrelevant to CAM, as is this example he cites:

As “a dramatic example” of the new targeted, personalized approach to cancer treatment, Dr. Collins described the case of a woman, a nonsmoker who was diagnosed with very aggressive, stage IV non-small cell lung cancer in both lungs about 4 years ago. Following standard chemotherapy, she participated in a clinical trial with crizotinib (Xalkori). Prominent lung metastases shown on x-ray in July 2009 “were essentially gone by November 2009,” Dr. Collins reported. “So she has had a dramatic response, and she continues to do extremely well,” he added.

“Of course this drug doesn’t work for everybody with this kind of lung cancer. So what’s the difference? It depends on whether the particular cancer has a fusion involving the ALK gene,” Dr. Collins explained. “Crizotinib was not developed with that particular target in mind, but it turned out after the fact that this was going to be a very responsive situation.” The success of crizotinib when used in a targeted personalized approach led to its approval by the FDA several months ago. Yet the drug may not have been approved if it “had been tried on thousands of people with lung cancer without having stratified them by the specific molecular findings,” Dr. Collins said.

Triumphs such as these are promising harbingers of a potential new age of personalized medicine and illustrate the potential power of such approaches. They do not, however, illustrate anything about CAM. Neither does the other example cited, that of a promising new approach of modulating the immune system to stimulate a patient’s own cells to attack cancer cells in chronic lymphocytic leukemia. This sort of science-based immunotherapy is related to claims of “boosting the immune system” promoted by CAM aficionados only by coincidence or in the way that the germ theory of disease as understood today is related to miasma theory from 200 years ago. Yet Collins seems to think that these promising avenues in the science-based treatment of cancer are somehow related to “integrative oncology.” In fact, he falls for the “bait and switch” even harder:

“We also have great excitement about a new era in therapeutics based on natural remedies,” Dr. Collins said. The NCI has an ongoing program looking for anticancer activity in extracts from plants, marine invertebrates, and microbes. “We are also seeking opportunities by looking at traditional medicines, many of them from China, for how we can decrease the side effects of treatment.”

All of which is pharmacognosy, not “CAM,” As David Kroll pointed out not too long ago:

But pharmacognosy – the study of natural products – is *not* alternative medicine. It is, in fact, the basis for at least 25% of our prescription drugs and up to 60% of some classes of over-the-counter drugs.

And:

What worries me more is how pharmacognosy is approached by NCCAM and how damaging their supported studies can be in leading us to dismiss potentially useful botanical medicines. In attempting to show political supporters the benefits of alternative medicines, NCCAM seems to spend a disproportionate share of their appropriation on expensive clinical trials. My concern has been that clinical trials are warranted when sufficient basic science has been conducted. However, the rush to clinical trials has instead led to multiple clinical trials failures.

The problem, of course, is that NCCAM and “integrative oncology” are not about pharmacognosy, other than “rebranding” it and fusing it with pseudoscience. They are about magical thinking and what Harriet Hall likes to call tooth fairy science. Dr. Briggs might have brought more scientific rigor and a more true pharmacognosy-like approach to NCCAM for the moment, but she will not be NCCAM director forever. One day she will retire or move on. When that happens, the institutional inertia will likely cause NCCAM to revert to its old ways.

What Francis Collins doesn’t know about “integrative oncology”

One of the reasons that quackademic medicine can flourish is that respected scientists like Francis Collins do not understand what it is about. That’s because in general they are unaware of what “integrative medicine” is all about, and many quackademics are quite good at cloaking their woo in convincing-sounding scientific language. Certainly, they have donned the language of evidence-based medicine and of “patient-centered” care like the proverbial cloak of invisibility in the Harry Potter novels and movies to hide the pseudoscience, as Kimball Atwood so eloquently described and I reiterated. I won’t retread old ground other than to point out that “integrative” oncology in reality means “integrating” quackery and pseudoscience into science-based medicine. I will, however, take a look at the agenda for the SIO meeting at which Collins was the keynote speaker.

A brief perusal of the SIO meeting program reveals a few tidbits, in no particular order, some with and some without my comment:

  1. Gillian Flower; Kieran Cooley; Dugald Seely. Adjunctive cancer care at the Canadian College of Naturopathic Medicine: A prospective, longitudinal, observational cohort study. One notes that “naturopathic oncology” includes homeopathy and a variety of other forms of quackery. Too bad the abstract is not online. In any case, one notes that the lead author Gillian Flower offers acupuncture, high dose intravenous vitamin therapy, acupuncture, and bogus “electrodermal testing” in her practice.
  2. Garrett Sullivan; Qi Chen; Ping Chen; Julia Chapman; Mark Levine; Jeanne Drisko. Prospective randomized phase I/IIa pilot trial to assess safety and benefit administering high-dose intravenous ascorbate in combination with chemotherapy in newly diagnosed advanced stage III or Stage IV ovarian cancer. That’s high dose intravenous vitamin C, people.
  3. Lucille Marchand, Diana Wilkie, Jun Mao, Kimberly Fleisher (Discussant: William Collinge). Moderated panel 6. Massage and Energy Therapy Research.
  4. Alejandro Chaoul; Kelly Bieger; Tenzin Rinpoche; Amy Spelman; Christina Meyers; Deborah Fry; Ideen Zeinali; Banu Arun; Janna Taylor. Tibetan Sound Meditation Improves Cognitive Dysfunction, Mental Health, and Spirituality in Women with Breast Cancer.
  5. Barrie Cassileth; Amy Matecki; K. Simon Yeung; Carmencita Mercado-Poe; Marci Coleton; Lisa Bailey; James Lozada; Martha Tracy; Gary Cecchi. Safety of Acupuncture for Upper Extremity Lymphedema in Breast Cancer Patients: Lessons from two major Medical Centers. Define “safety.” As a surgeon who sees a fair number of patients with lymphedema due to breast cancer surgery, the thought of sticking needles into the lymphedematous limb causes me to shudder, given how prone limbs with lymphedema are to infection and how–shall we say?–unconcerned about sterile technique most acupuncturists are. (Just ask Mark Crislip if you don’t believe me.)

I could go on, given that there is a lot more there, but I’ll wind up with my favorite session of all, one that I might have actually been interested in attending. Yes, I’m talking about the Integrative Tumor Board. For those of you not familiar with what a tumor board is, it’s a meeting where all the relevant specialties are together in one room to discuss the cases of individual cancer patients in order to formulate the best evidence-based treatment plan that the multidisciplinary team can come up with. Of course, this tumor board has a bit…laxer definition of “specialty.” This tumor board includes two medical oncologists (one of whom is the medical director of the M.D. Anderson Integrative Medicine Center), an MD/acupuncturist, a naturopath from Bastyr university, a nutritionist from Nutritional Solutions (now there’s an idea for a future post!) and a nurse who is interested in “mind-body” medicine. One notes that there are no surgeons, no radiation oncologists, and no genetics counselors, most of whom tend to be on tumor boards, depending upon the tumor type. One wonders what sorts of cases this tumor board discussed and what recommendations its members gave for the cases chosen to be presented.

It’s extremely disappointing that Dr. Collins agreed to appear as the keynote speaker for the SIO conference, but it’s even more disappointing that, instead of using his forum to challenge the SIO to abandon pseudoscience, he instead fell right into their frame of co-opting science-based modalities as being somehow “alternative.” He even bragged about how much support the NIH has given to such research, pointing out that the Office of Cancer Complementary and Alternative Medicine (which has the unfortunate acronym OCCAM) in the National Cancer Institute has a budget even larger than that of NCCAM and saying:

While NCCAM is an important focus of efforts at NIH, other institutes within NIH also have initiatives in complementary and alternative medicine, Dr. Collins noted. “The NCI has the largest one by far,” he said, and “the budget for CAM in the NCI is actually slightly larger than the entire budget of NCCAM. The total investment that NIH makes in complementary and alternative medicine research in 1 year is about a half-billion dollars. I wish it was more, but I wish everything we are doing in biomedical research could be more,” he said.

As I’ve said before, I wish it were less (as in zero), and all the money wasted on pseudoscience or putting a pseudoscience spin on what should be SBM distributed to the rest of the NIH. There is nothing that NCCAM or OCCAM does that requires a special, dedicated office or center in the NIH. Unfortunately, Collins uses the dire funding situation of the NIH to make the wrong argument about CAM research funding:

“The opportunities for medical research have never been greater than they are right now, and yet the threat to the support of biomedical research has–in the memories of anybody who is currently working in the field–never been greater either,” Dr. Collins stated. He noted that in fiscal year 2011, “for only the second time in 40 years, the NIH budget sustained a real cut.” If the failure of the Joint Select Committee on Deficit Reduction (the so-called supercommittee) to cut $1.2 trillion from the budget results in sequestering of discretionary budgets, “a dramatic downturn in support for biomedical research” could occur in fiscal year 2013, Dr. Collins said.

We now know, of course, that the supercommittee did fail to come to an agreement and that sequestering of discretionary budgets is all but assured in 2013. To me that’s all the more reason that waste such as NCCAM and OCCAM should be rooted out of the NIH, in order to make the best possible use of the remaining funds. Look at it this way. Only the top 7% of new research grant applications to the NCI are currently being funded, down from the top 16% back when I got my R01 in 2005, with no improvement in sight. In some NIH institutes, I’ve been told, it’s only the top 5% being funded. Meanwhile, investigators used to have two opportunities to revise and resubmit rejected proposals; now they can only revise and resubmit once. When funding gets this tight, there are lots of innovative projects, chock full of good science, that don’t make the cut and don’t get funded. I fully agree with Dr. Collins that the case for funding medical research has never been stronger and that the threat to the NIH has never been greater. At least 20 years ago, which was the last time funding was so tight, there appeared to be hope that an end was in sight. Not so today.

I realize that Dr. Collins was tailoring his address to his audience. I also realize that Collins is not just a scientist and administrator, but a politician. He has to be to have become director of the NIH and to have held all the other prominent leadership positions he has held during his career. Even so, it’s hard not to come to the conclusion that, like so many physicians and scientists, he just doesn’t “get” the problem of CAM and pseudoscience infiltrating medicine. At least, I hope that’s the case. What would be worse is if he either didn’t care or supported it.

Comments

  1. #1 Dangerous Bacon
    January 23, 2012

    Unfortunately the NIH director also has to be a politician of sorts, and it is politically unwise to single out a division like NCCAM as deserving of funding cuts, especially when a powerful woo benefactor like Sen. Harkin would be offended and possibly decide to throw his weight in support of generalized funding cuts for NIH.

    An aside on yoga: there was a hilarious example of the “No True Scotsman” fallacy in the New York Times Magazine letters to the editor Sunday.

    Apparently the magazine’s article on yoga mentioned that people had sustained injuries practicing it. The letter writer (some sort of yoga expert) indignantly argued that if people had gotten injured, they either weren’t doing yoga or had been trained improperly, since No True Yoga is capable of injuring anyone.

    How often have we seen this fallacy applied to injuries or deaths associated with CAM (“They just weren’t doing it right!”?

  2. #2 harey
    January 23, 2012

    Amusingly, according to these definitions, I am a CAM user since I visit Pilates classes at my gym. The classes I go to are simply muscle training focusing on the upper body using own body weight, and it can be quite exhausting. Since I sit in front of a computer all day, I tend to think it helps my posture. I also just enjoy working out a few times a week. The teacher is very good, making sure that everybody is doing the exercises correctly and offering different exercise possibilities to people with injuries or those that are pregnant. There is also no woo-talk about energy flowing through the body or anything like that.

    The fun starts when Yoga teachers take over the class during holidays. None of them make sure the exercises are done correctly. Instead they claim that stretching the back muscles is good for detoxing and and that rolling around on your back helps the kidneys which is great since they control body temperature and therefore is a really good thing to do in the winter (?!?)…. You get the point.

    I am sure most exercise has benefits, even those modalities labeled as mind-body (is weight lifting mind-body too, btw? What makes Pilates mind-body?). But I am also convinced that exercise is more beneficial when led by a teacher that knows about anatomy and makes sure people don’t strain muscles than by a clueless woo-master. So, even the parts of ‘CAM’ that are beneficial could be much better and safer if they were done by actual professionals. Great selling point there: ‘CAM: we do some things that are in principle a good idea, but we do them very poorly.’

  3. #3 Denice Walter
    January 23, 2012

    I’ve come across woo-meisterly response to the SBM studies our esteemed host points out ( beta-carotene and vitamin E/ selenium; I should also mention deleterious effects associated with folic acid while I’m at it)- basically they call those studies flawed and serve up the usual fanciful objections ( e.g. the studies weren’t done with subjects who had good diets, were smokers, et al.) In the world of woo, vitamins can do no harm ( “Ever hear of people *die* of an overdose of supplements * unlike pharma drugs*?”, they shriek) because they are pure and natural or suchlike.

    Vitamin C megadoses and increased vitamin D are common “treatments” but I seem to be hearing a lot about more arcane substances being given in high doses: just off the top of my head- EGCG ( green tea), asian mushroom extracts ( remember commenter, prn?), phosphatidylserine, genesteine, sulphurafane, l-acetyl carnitine and probably a hundred more. They are chemicals isolated from foods or chemicals that the body makes all on its own given in large doses over long time periods. I don’t see how that is “natural”.

    There appears to be a rift amongst the woo web-meisters about the meaty issue of animal products: on one side are Weston Price, Natural Hygeine, raw milk, Adams and Mercola vs the vegans; however both camps have a tendency to deify phyto-chemicals like those above. Colin Campbell and Dean Ornish are idolised.

    -on a lighter note ( altho’ it’s dark of the moon): it’s the lunar new year ! The water dragon has emerged from his underworld grotto ushering in a new cycle of luck and transformation! Happy new year! ( Not that I believe in stuff like that but it’s an excuse for a dinner party at a restaurant on a dreary day).

  4. #4 Prometheus
    January 23, 2012

    Whenever I hear “CAM” advocates argue that their fantasy-based regimens are somehow valid because a large (but apparently undefined) percentage of people use them, I can’t help flashing back to that scene in Ghostbusters where, in response to Dean Yeager telling them that their funding was being cut, Bill Murray states, “But the kids love us!”.

    If popularity were any guide to what is good medical treatment, chocolate would be a literal panacea.

    Also, I note that the “Integrative Tumor Board” includes a “nutritionist”, not a dietician. I wonder if I can get a place on that board, since I recently (about two minutes ago) became a “certified nutritionist”. I typed up and printed out my certificate just now, so my credentials are just as valid as any other “nutritionist”.

    I begin to despair that the general population is sinking faster and faster into magical thinking, and it is even worse to see so many physicians either buying into this magical thinking process or “going along” to keep from looking “stodgy” or “old-fashioned”.

    Prometheus

  5. #5 Acleron
    January 23, 2012

    Your article and the comments indicate that there is an area of woo that deserves investigation.

    How much damage is caused by these non-treatments? There is lack of proper medical treatment in homeopathy and the others, carotid dissection in chiropractic manipulation, poisoning from herbal preparations.

    Let the media and politicians play with those figures.

  6. #6 Hinterlander
    January 23, 2012

    With integrated treatments a fence sitter or woo-leaning patient will just as likely attribute successful treatment to the nutritionist, or reiki rather than the medical team who, you know, actually treated them with actual science-based medicine.

    The minuscule good I can see in this is that at least the patient’s health is being monitored by real doctors while they undergo any chosen magic medicine. It’s unlikely that CAM will fade in popularity while we enjoy healthier, longer-lived lives.

  7. #7 Calli Arcale
    January 23, 2012

    This stood out for me, from Francis Collins:

    Survey data show that over a lifetime, complementary and alternative medicine (CAM) is used by “65% of cancer survivors vs 53% of noncancer respondents,” he said.

    Even as ridiculous as the “argumentum ad populum” is, what is this statistic even supposed to mean? Me, I find it encouraging — considering how much sicker cancer patients are (on average) than the general population, that the difference in CAM usage would be so small (65% versus 53%) suggests to me that most people don’t find CAM to be particularly beneficial. The difference is probably a set of people who, while they wouldn’t normally be CAM users, figured “what the hell, I don’t have anything to lose at this point” and gave it a shot. To me, this says that in fact CAM is not anywhere near as popular as it would like to be.

  8. #8 questioner
    January 23, 2012

    @Prometheus-
    I was confused about the titles “nutritionist” and “dietitian”-
    For any others who were here is the .gov requirements-
    http://www.bls.gov/oco/ocos077.htm

  9. #9 Grant
    January 23, 2012

    There is a place for prioritising funding by how reasonable each investigation would be. In this case, few would. (I am an advocate for true blue skies research, but it ought to be founded on a deep reading of the literature.)

    I wrote a very short post some time ago comparing the argumentum ad populum (arguing by an appeal to popularity) to the former popularity of mausoleums in Germany (linked on my name). Mausoleums were “hospitals for the dead”, where those who had died were ‘rested’ for several days to ensure that the dead were, in fact, dead. Unsurprisingly no-one recovered from death. I still think of this as a classic example of just how ridiculous argumentum ad populum is.

  10. #10 ken
    January 23, 2012

    Hmm-(From above link)
    “Retinoids are not currently used as a cancer treatment, with one notable exception. A relatively rare type of leukemia, promyelocytic leukemia, often responds to a combination of retinoic acid (a retinoid) and chemotherapy. Patients with this form of leukemia get high doses of a pure form of retinoic acid (derived from Vitamin A) under medical supervision. Treatment of promyelocytic leukemia does not include use of non-prescription vitamin A supplements or dietary changes intended to increase intake of this vitamin.”

  11. #11 Krebiozen
    January 23, 2012

    Prometheus and Questioner,
    I think the difference between a nutritionist and a dietitian is more clear-cut in some states and countries than others. I know that in the UK “dietitian” is a protected title, and only those registered with the Health Professions Council are allowed to use it. They have to prove they are qualified and maintain certain standards including continued professional development (and pay an annual fee of course) to stay registered with the HPC. In contrast, anyone can call themselves a nutritionist. This is the source of Dara O’Briain’s quip that dietitian is to nutritionist as dentist is to toothiologist (Dara is Irish, but works mainly in the UK).

  12. #12 lilady
    January 24, 2012

    About that “nutritionist” on the “Integrative Tumor Board”…

    “Jeanne M. Wallace, PhD, CNC is widely regarded as one of the nation’s most prominent experts in nutritional oncology. She is the founder and director of Nutritional Solutions which provides consulting to cancer patients throughout the U.S. and abroad about evidence-based dietary, nutritional and botanical support to complement conventional cancer care. She completed her undergrad studies magna cum laude at Boston University, earned her Nutrition Consulting degree at Bauman College in Santa Cruz, CA, and completed her PhD in Nutrition through American State University. She is board certified in Holistic Nutrition, and is a member of the Society of Integrative Oncology and the National Association of Nutrition Professionals.”

    Source: “Nutritional Solutions” website

    I don’t know what kind of undergrad studies she “completed at Boston University”, but her “Nutrition Consulting degree at Bauman College in Santa Cruz, CA,” took all of 18 months in the classroom and 700 credit hours…or can be obtained through a “distant learning” program.

    She has a PhD in Nutrition awarded by the “American State University”.

    American State University, Hawaii advertised itself as being “accredited” by the State of Hawaii and by other national higher education accreditation associations. It operated, totally without any accreditation and was a diploma mill. It’s proprietor Rudy Marn faced charges lodged against him and the American State University, paid fines for operating a diploma mill, was forced out of business in 1998 and went to Wyoming. In Wyoming, Rudy Marn opened another diploma mill, Hamilton University, which was closed by court order. Rudy Marn now is the proprietor of Richardson University in the Bahamas.

    IMO, Jeanne M. Wallace PhD is “well-qualified” to serve on the “Integrative Tumor Board”.

  13. #13 Prometheus
    January 24, 2012

    Apparently, in the US, only 46 states license dieticians, so there are – if I’ve done the maths correctly – 4 states where someone can call themselves a “dietician” without meeting some sort of licensing requirement.

    “Nutritionist”, however, is a term that can be used by pretty much anyone in any of the 50 states (plus the District of Columbia and various protectorates and etc.) without fear of being in violation of state licensing boards. When someone refers to themselves as a “nutritionist”, it is generally a fair assumption that they are unlicensed and most likely also lack the qualifications of a registered dietician.

    While Ms. Wallace (see comment #12) may have gone to the time and expense of getting diploma mill degrees, that is not a requirement for calling oneself a “nutritionist”. In fact, since my degrees are all from real, accredited universities (although none of them are in “nutrition”), I am actually more qualified than Ms. Wallace to be on the “Integrative Tumor Board”.

    Prometheus

  14. #14 Prometheus
    January 24, 2012

    Apparently, in the US, only 46 states license dieticians, so there are – if I’ve done the maths correctly – 4 states where someone can call themselves a “dietician” without meeting some sort of licensing requirement.

    “Nutritionist”, however, is a term that can be used by pretty much anyone in any of the 50 states (plus the District of Columbia and various protectorates and etc.) without fear of being in violation of state licensing boards. When someone refers to themselves as a “nutritionist”, it is generally a fair assumption that they are unlicensed and most likely also lack the qualifications of a registered dietician.

    While Ms. Wallace (see comment #12) may have gone to the time and expense of getting diploma mill degrees, that is not a requirement for calling oneself a “nutritionist”. In fact, since my degrees are all from real, accredited universities (although none of them are in “nutrition”), I am actually more qualified than Ms. Wallace to be on the “Integrative Tumor Board”.

    Prometheus

  15. #15 Krebiozen
    January 24, 2012

    Lilady/Prometheus,

    Bauman College – Holistic Nutrition and Culinary Arts? Say no more.

    Wikipedia says of Hamilton University “first established in Hawaii as American State University. It has since been closed by court order in Wyoming and has relocated to the Bahamas under the name Richardson University”. “When the CBS 60 Minutes video crew visited the campus, there was no evidence of any students or faculty, but three office workers present.”

    Short version – a toothiologist with a PhD in Toothiology is still a toothiologist, especially when the PhD is from Mickey Mouse University.

  16. #16 lilady
    January 24, 2012

    In my state “Registered Dieticians” are licensed. The minimum education requirement is bachelor degree awarded from an accredited college or university with clinical rotations in a health care setting.

    Every hospital that I am aware of does not hire anyone who is not a “registered dietician”. In less acute care settings, such as nursing homes or assisted living facilities, only registered dieticians are on staff.

    Matriculating into Hamburger U. and being awarded an advanced degree from that “institute of higher learning” (PhD-Flipping Burgers), would also qualify a person to be on the “Integrative Tumor Board”.

  17. #17 Calli Arcale
    January 24, 2012

    Mind you, Hamburger U is a real place whose education I’d prefer over that of, say, Richardson University. At least I’d have some assurance some actual education occurred, even if it is really just a big corporation’s training department, and even if that would primarily be in restaurant management.

    I’ve seen Hamburger U. I have relatives who live within walking distance. They did not attend. But there is a really nice McDonald’s right by it, and while visiting a few years ago, we made a point of eating there. ;-)

  18. #18 Glaxxon PharmaCOM Orbital
    January 24, 2012

    MESSAGE BEGINS ——————-

    Minion Walter,

    That was no “water dragon”, that was just me, I took the liberty of using your shower as the new waterless bathing units on the station were under repair. Sorry about shredding your new towels, they shall be replaced forthwith. Good luck anyway.

    Lord Draconis Zeneca, VC, iH7L

    Forward Mavoon of the Great Fleet, Suzerain of V’tar, Pharmaca Magna of Terra, Fresher than Springtime

    PharmaCOM Orbital HQ
    0010101101001
    —————————————— MESSAGE ENDS

  19. #19 herr doktor bimler
    January 24, 2012

    I had always imagined that Lord Draconis Zeneca would be somewhat larger.

  20. #20 alison
    January 24, 2012

    Um, herr doktor – I think you may just have made a serious tactical error…

  21. #21 DW
    January 24, 2012

    My dearest Lord Draconis,

    Oh what are a few towels between friends? However, when you were there did you happen to see Alec? One of the level 5 wonks- fair hair, 5’9″ tall, tended to ramble on too much about economic indices and market trends- but I did so like him! You didn’t … uh.. you know… I hope not. At any rate, if he’s gone, can I have his Jaguar?

    The other 5s send their regards ( and requests for raises, as per usual)- they are busily working on our latest manipulations of the mainstream media (CNNBBCCBCmatrix). Just wait! I love wonks!
    Much love; kiss kiss.
    Sincerely yours,
    DW, DL-8

  22. #22 Sheepmilker
    January 25, 2012

    You know, when you first mentioned the get together in a bar, I thought that in true BigPharma style you should respectfully ask Lord Draconis to pick up the tab. It would probably represent less than 0.00001 s of Pharma profit…

  23. #23 Mephistopheles O'Brien
    January 25, 2012

    @Sheepmilker,
    Surely you jest! One does not become Forward Mavoon of the Great Fleet, Suzerain of V’tar, Pharmaca Magna of Terra, etc. etc. etc. by picking up the tab!
    Minions who are in the know buy Lord Draconis drinks, then expense them. There have been many an evening that the shills and minions have “shopped for office supplies” under the jovial eye (and deadly claw) of their beloved/feared scaly overlord.

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