Respectful Insolence

Studying “disparities” in access to “complementary and alternative medicine”

CAM for cancer?

When it comes to the use of what is sometimes called “complementary and alternative medicine” (CAM) or, increasingly, “integrative medicine,” there is a certain narrative. It’s a narrative promoted by CAM proponents that does its best to convince the public that there is nothing unusual, untoward, or odd about CAM use, even though much of CAM consists of treatments that are based on prescientific concepts of human physiology and pathology, such as traditional Chinese medicine or homeopathy. In other words, it’s a narrative designed to “normalize” CAM usage (and therefore CAM practice), making it no different than the usage of treatments rooted in scientific medicine. And so it isn’t, at least, if you’re a CAM proponent.

Thus are born studies that spawn press releases like this one entitled Beliefs about complementary and alternative medicine predict use among patients with cancer:

A new study has shed light on how cancer patients’ attitudes and beliefs drive the use of complementary and alternative medicine. Published early online in CANCER, a peer-reviewed journal of the American Cancer Society, the findings may help hospitals develop more effective and accessible integrative oncology services for patients.

Although many cancer patients use complementary and alternative medicine, what drives this usage is unclear. To investigate, a team led by Jun Mao, MD and Joshua Bauml, MD, of the Abramson Cancer Center at the University of Pennsylvania’s Perelman School of Medicine, conducted a survey-based study in their institution’s thoracic, breast, and gastrointestinal medical oncology clinics.

The actual study can be found here, entitled Do attitudes and beliefs regarding complementary and alternative medicine impact its use among patients with cancer? A cross-sectional survey. It’s a study out of the Abramson Cancer Center at the University of Pennsylvania, and it’s a great example of studies designed to support the “normalization” of CAM treatments. Basically, it’s a glorified survey that concludes—brace yourself—that people use CAM if the expect benefit and the barriers to using it are not too great and that attitudes and beliefs towards CAM explain much more of the variance in CAM usage than clinical or demographic variables alone.

Or, as Dr. Mao is reported saying in the press release:

“We found that specific attitudes and beliefs — such as expectation of therapeutic benefits, patient-perceived barriers regarding cost and access, and opinions of patients’ physician and family members — may predict patients’ use of complementary and alternative medicine following cancer diagnoses,” said Dr. Mao. “We also found that these beliefs and attitudes varied by key socio-demographic factors such as sex, race, and education, which highlights the need for a more individualized approach when clinically integrating complementary and alternative medicine into conventional cancer care.”

Well, duh. I doubt anyone would use CAM (or any other medical intervention, be it science-based or, as in the case of CAM, pseudoscience-based) if he didn’t expect to benefit from it. That’s why people come to doctors. They want and expect to be made better, or at least to have their symptoms improved. That’s what medicine is for. It’s what we do, or at least try to do, as health care providers. They don’t expect to have no result or to get worse. The problem is not the motivation; the problem is that CAM or “integrative medicine” largely sells patients a bill of goods, goods patients are willing to buy given that there are Very Serious People in White Coats telling them that it’s all scientific.

To be fair, there were other findings in the survey, which was administered to 969 participants (for a response rate of 83%) that included patients with breast, lung, and gastrointestinal cancers. They used an instrument called Attitudes and Beliefs about CAM, or ABCAM (is that anything like Abacab?), which was developed by the same group and designed to evaluate specific behavioral predictors of CAM use based on the Theory of Planned Behavior. They also looked at CAM use since the cancer diagnosis. Interestingly, the authors intentionally left out spirituality and religion, which are often lumped together with CAM in order to make it seem as though far more people use CAM than actually do. After all, religiosity predominates in the US, at least, and if you can view praying to get well or other spiritual activities as somehow being CAM, then, yes, the vast majority of the population does appear to use CAM, particularly if you also co-opt science-based lifestyle interventions (such as exercise and diet) as also being CAM. It’s the appeal to popularity that CAM advocates love to use so much. Indeed, the authors use it right in the beginning of the article:

Cancer accounts for nearly 1 of every 4 deaths occurring in the United States, but recent advances in therapeutics have led to improved survival after diagnosis. As of January 1, 2012, there were approximately 13.7 million cancer survivors living in the United States, and this patient population is growing.2 To meet their unique needs, patients with cancer seek treatments both within and outside the standard allopathic paradigm. Indeed, up to 67% of cancer survivors use complementary and alternative medicine (CAM). Most CAM modalities are based on centuries-old traditions and have historically not been supported by modern evidence. However, more recently, there have been studies demonstrating efficacy for selected therapies in the treatment of multiple cancer-related toxicities.6-8 The evidence-based incorporation of these modalities into traditional cancer care is an emerging field, and is termed integrative oncology.9 Many leading academic cancer centers are developing integrative oncology centers to ensure that the research concerning CAM efficacy is performed in a scientifically rigorous fashion.

Note the appeal to antiquity (“based on centuries-old traditions”) and the CAM-speak (the “evidence-based incorporation of these modalities into traditional cancer care”). Particularly annoying is the claim that “integrative medicine” programs exist to “ensure that the research concerning CAM efficacy is performed in a scientifically rigorous fashion.” Long time readers will recall the numerous examples over the last decade where I showed that CAM research is, by and large, hardly “rigorous.” Indeed, when I discussed the strategic plan of the National Center for Complementary and Integrative Health (NCCIH, the government agency formerly known as the National Center for Complementary and Alternative Medicine, or the easier acronym NCCAM), I referred to it as basically saying “let’s do some real science for a change.”

In any case, what the authors also report the following.

Interestingly, the authors also referenced a previous study of theirs which looked at what kinds of CAM their cancer patients used, in this case lung cancer:

CAM use in cancer

Not surprisingly, vitamins, herbs, relaxation techniques, and diet were the top four. I was a little surprised that energy healing ranked so high, given that, of all the forms of “integrative medicine” or CAM, “energy healing” (e.g., therapeutic touch or reiki) is definitely one of the quackiest, if not the quackiest, but then I remembered how reiki programs have been springing up like so much kudzu all over even in NCI-designated comprehensive cancer centers. Then there’s massage, yoga, and the like, with homeopathy (the other quackiest of CAM modalities, along with reiki) bringing up the rear.

That oddity aside, one thing you have to remember is this: Studies like this are done for a purpose. For instance, when they are done for various conventional medicine modalities, it’s called health disparities research, which, as its name suggests, is designed to identify and remedy disparities in disease prevalence and health care based on race, socioeconomic status, gender, and the like. The idea in this particular variety of health disparities research is to identify various beliefs about treatment and perceived barriers to receiving it with the intent of developing and testing strategies to overcome them and eliminate the disparities identified. It’s an important area of medical research, given that there are often huge disparities in care based on socioeconomic factors and race, as I know all too well practicing at the cancer center that I practice at.

This is why I refer to research such as this as either evidence of or an effort to “normalize” CAM. If CAM is viewed as just another medical treatment in “conventional medicine,” then of course it’s only natural that researchers would want to study disparities in CAM care just like any other medical care. Indeed, the authors explicitly say as much, with this unwritten assumption underlying their conclusions:

In viewing CAM use as a health behavior that aims to improve specific cancer-related toxicities, we can potentially target attitudes and beliefs to develop patientcentered integration of CAM into usual cancer care. This would lead to broader access to CAM, and allow for further research into the efficacy of these treatment modalities. For example, patients with lung cancer have a high symptom burden compared with patients with other malignancies, but based purely on demographic factors classically associated with CAM use (eg, female sex and lack of a tobacco history), they may not be targeted for CAM interventions. However, our group has previously shown that CAM use among patients with lung cancer is comparable to that noted in population studies. The current study indicates that attitudes and beliefs regarding CAM may be an important force driving this discrepancy. By targeting integrative oncology programs based on attitudes and beliefs, we will be able to evaluate efficacy in the broadest population possible.

And:

Its limitations notwithstanding, the current study has several important implications. Although population studies have established clinical and demographic factors associated with CAM use, such analyses have limited ability to characterize why patients with cancer use CAM. For example, clinical and demographic factors fail to identify patients who are interested in CAM but who do not use services due to perceived barriers. The social demographic variations in attitudes and beliefs identified in the current study may serve as a foundation for the development of theory-driven interventions that can target the beliefs and attitudes that ultimately influence the use of CAM among patients with cancer. A better understanding of the psychological components of CAM use is essential to delivering comprehensive, patient-centered care. By targeting new integrative oncology programs based on attitudes and beliefs, rather than on clinical and demographic factors or existing use, we may be able to broaden access to these treatments.

Of course, the assumption underlying this study is that CAM use is a good thing that relieves cancer-related symptoms, when most of it is, as I frequently point out, pseudoscientific rubbish mixed with science-based modalities like diet and exercise, which have been “rebranded” somehow as being “alternative” or “integrative.” If you buy into that assumption, then of course disparities in CAM use are a bad thing that need to be eliminated (or at least minimized), so that all might have access to the wonders of CAM. Basically, this study, which is a perfectly fine study as far as health disparity studies go, is simply more evidence of how deeply embedded quackademic medicine has become in medical academia. It’s to the point where not only are major medical universities studying pseudoscientific treatments like energy healing and acupuncture but they’re trying to find out ways to eliminate “disparities” in access and usage to these treatments, just as though they were legitimate science-based medicine.

That profoundly depresses me.

ADDENDUM: Steve Novella has also commented on this study.