Last week, I discussed a monograph published in the Journal of the National Cancer Institute Monographs entitled Clinical Practice Guidelines on the Use of Integrative Therapies as Supportive Care in Patients Treated for Breast Cancer. As you might remember, I was completely unimpressed. However, those guidelines were not the only thing in that particular JNCI monograph. There were lots of other articles, and, given that some of them show just how deeply quackery has insinuated itself into oncology in the form of "integrative oncology," I thought it was worth revisiting one more time.
Sometimes, it's hard not to get the feeling that bloggers promoting science-based medicine are trying to hold back the tide in terms the infiltration of pseudoscience and quackery into conventional medicine, a term I like to refer to as quackademic medicine. In most cases, this infiltration occurs under the rubric of "complementary and alternative medicine" (CAM), which these days is increasingly referred to as "integrative medicine," the better to banish any impression of inferior status implied by the name "CAM" and replace it with the implication of a happy, harmonious "integration" of the "best of both worlds." (As I like to point out, analogies to another "best of both worlds" are hard to resist.) Of course, as my good buddy Mark Crislip has put it, the passionate protestations of CAM advocates otherwise notwithstanding, integrating cow pie with apple pie doesn't make the cow pie better. Rather, it makes the apple pie worse.
Not that you'd get that idea from anything in the monograph, much of which is far more selling integrative oncology than anything else.
It might be useful to point out where I first found out about this monograph, which was from Josephine Briggs, the director of the National Center for Complementary and Alternative Medicine (NCCAM) herself, on the NCCAM blog in a post entitled "The Evidence Base for Integrative Approaches to Cancer Care", in which she touts her perspective piece in the monograph entitled "Building the Evidence Base for Integrative Approaches to Care of Cancer Survivors." In an introductory article, Jun J. Mao and Lorenzo Cohen of the Department of Family Medicine and Community Health, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania and the University of Texas M.D. Anderson Cancer Center, respectively, line up this monograph thusly:
Cancer survivors, millions in number, often struggle to manage the physical as well as emotional, social, and spiritual consequences of their cancer and its necessary conventional treatments (1). Many individuals, like Josh Mailman (2), choose to incorporate complementary and integrative medicine therapies such as meditation, acupuncture, yoga, and diet into their cancer treatment with the goal of gaining a sense of control and being more active participants in their care. By doing so, they seek to improve their outcomes, including reducing the side effects of conventional cancer treatments and improving their quality of life and survival. More than ever before, cancer survivors desire the evidence-based integration of complementary and integrative medicine into conventional cancer care not only to treat their cancer but also to help in the healing of mind, body, and spirit.
Yes, it's true. Thanks to the efficacy of real medicine, real oncology, there are now millions of people alive today who have survived cancer. This is a wonderful thing, unprecedented in medicine. It is also true that there are survivorship issues, both physical and psychological, that need to be tended to. These include a myriad of issues, including lasting sequelae of cancer and the treatments that eradicated it that impact quality of life, as well as psychological issues.
As is usual in such propaganda, the argument is made that patients are crying out for the "integration" of CAM into conventional care. This is, as many of us have pointed out over the years on SBM, at best an exaggeration that results from the co-opting of conventional, science-based interventions, such as diet and lifestyle changes, exercise, and pharmacognosy, as being somehow "alternative," "complementary," or "holistic" when they are nothing of the sort. Whether most CAM advocates realize it or not (and I doubt the authors of the articles making up this monograph and most prominent quackademics realize it), this co-optation serves the purpose of providing a sheen of respectability to the—shall we say?—less reputable, more pseudoscientific modalities that are routinely lumped in with CAM, such as reiki and other forms of "energy healing," acupuncture and other traditional Chinese medicine, and naturopathy—even homeopathy. In any case, if you look at how prevalent the use of CAM is the numbers for hard-core alternative medicine, such as homeopathy, acupuncture, reiki, and the like remain very low (single digit percentages); the illusion of popularity is produced by lumping in supplements (pharmacognosy), diet and lifestyle interventions, and a vague "spirituality" into the mix. CAM/"integrative medicine" is not a scientific or medical construct, it's an ideological construct, a marketing tool.
Thumbing through this issue of JNCI (metaphorically speaking, obviously; I read it online), I was struck at just how much the monograph within was constructed to promote the concept of "integrative oncology" rather than to critically examine the concepts at the heart of integrative oncology, all gussied up in descriptions of "building the evidence base" (as Dr. Briggs put it). I suppose this is not the least bit surprising, but it is disappointing that the JNCI would devote a whole monograph to such an endeavor. Even more disappointing (but, again, not surprising) is the revelation of just how much the National Cancer Institute (NCI) supports CAM studies, as described in an article by Jeffrey D. White, MD, Office of Cancer Complementary and Alternative Medicine, NCI, entitled "National Cancer Institute’s Support of Research to Further Integrative Oncology Practice". (Note the acronym, OCCAM, which, as I like to point out, is perhaps the world's most inappropriate acronym for a government agency.) The amount of research support for CAM in oncology (or "integrative oncology") through the OCCAM is laid out:
Both the absolute and proportional sizes of the National Cancer Institute’s (NCI’s) CAM research portfolio grew substantially in the early 2000s reaching a peak in FY2004 ($128.7 million; 2.7% of NCI’s appropriations). Over the intervening decade, NCI has annually supported over 300 intramural and extramural projects with some component of CAM research, with research costs totaling 80–120 million dollars annually (1). The great majority of these projects explore aspects of basic science or clinical cancer research; however, NCI also supports research to improve communication about CAM issues (2). The NCI’s Physician’s Data Query program also provides summaries of the literature about several CAM interventions with separate formats developed for healthcare practitioners and for patients (3).
I note that this is roughly the same size as NCCAM's annual budget, with year-to-year fluctuations. Indeed, in 2004, OCCAM received more funding that NCCAM. Overall, if you add up all the CAM expenditures from all the institutes that make up the National Institutes of Health (NIH) in FY2013, you'll find that it was nearly a half a billion dollars spent on the "integration" of pseudoscience with medicine by our federal government, half of that being administered by NCCAM and OCCAM. In any case, White's article is, inadvertently no doubt, a perfect example of how a perfectly respectable specialty like natural products pharmacology (pharmacognosy) has been co-opted as somehow "alternative" or "complementary":
NCI is the only institute at the National Institutes of Health with an office tasked with facilitating the growth of a CAM research portfolio and disseminating information on the topic. The Office of Cancer Complementary and Alternative Medicine (OCCAM), housed in the Division of Cancer Treatment and Diagnosis, works with various other components within NCI to accomplish these objectives. Among OCCAM’s activities is work done with laboratories in NCI’s Center for Cancer Research and the Natural Products Branch to establish collaborations with several international centers to screen novel natural products for anticancer activity and to train visiting postdoctoral fellows. This work is motivated by the recognition that traditional medical systems have been sources for identifying effective cancer therapeutics such as arsenic trioxide (5). OCCAM has also established unique opportunities for collaboration and dialog such as conferences about TCM and cancer and meetings to foster dialog and collaboration between CAM practitioners and cancer researchers.
Let's just put it this way. Traditional Chinese medicine is a construct that was retconned by Mao's regime to turn Chinese folk medicine that no educated Chinese wanted (because it was, by and large, quackery) into the "traditional Chinese medicine" to which academic medical centers such as M.D. Anderson and Memorial Sloan-Kettering Cancer Centers, not to mention the Cleveland Clinic, among others, devote considerable resources. It's amazing how much things have changed in 30 years with respect to the government's position on quackery.
Particularly troubling is how OCCAM is promoting "integrative oncology" beyond academic medical centers:
One major component of NCI’s clinical research activities is the work that takes place in the NCI Community Oncology Research Program (NCORP), formerly known as the Community Clinical Oncology Program. Approximately 30% of the clinical trials performed in this multicenter system for cancer prevention and symptom management studies are testing a CAM product (eg, ginger for chemotherapy induced nausea and vomiting) or other intervention (eg, acupuncture for cancer-associated fatigue) (4).
Let me repeat that: Nearly one-third of NCI-sponsored clinical trials through the NCORP are for "integrative oncology." Comparing the evidence base for integrative oncology to conventional oncology, it boggles the mind that such a huge chunk of an important resource for testing is diverted in this way. Meanwhile, the NCI still administers its "best case" series, in which alternative medical practitioners present what they consider to be their most convincing single cases or case series to the NCI in order to try to entice the NCI into showing interest. It is this misguided program that led to the NCI working with Stanislaw Burzynski in the 1990s and Nicholas Gonzalez in the late 1990s and early 2000s, as well as to support high dose intravenous vitamin C treatment for cancer. OCCAM indeed.
It's not just the government, of course. After all, the Society for Integrative Oncology is very much into promoting integrative oncology as well, as befits its name, as described in an article in the monograph by Susan Bauer-Wu, Suzanna Zick, Richard T. Lee, Lynda G. Balneaves and Heather Greenlee entitled "Advancing the Evidence Base and Transforming Cancer Care Through Interprofessional Collegiality: The Society for Integrative Oncology":
As an interdisciplinary and interprofessional society, SIO is uniquely poised to lead the “bench to bedside” efforts in integrative cancer care. SIO members are comprised of a variety of professionals including, but not limited to, conventional cancer clinicians (ie, medical oncologists, radiation oncologists, and oncology nurses), family medicine providers, naturopathic doctors, traditional Chinese medicine practitioners, mind–body therapists, nutritionists, patient advocates, and basic scientists. This diverse membership facilitates true clinical integration of complementary modalities because such change requires breadth of expertise and different perspectives, to listen and learn from one another while challenging each other’s assumptions and existing paradigms.
OK, hold it right there. Any medical society that allows naturopaths to be members and touts "integrating" their "expertise" into medicine has automatically lost any claim to scientific legitimacy, given that naturopathy consists of a veritable cornucopia of pretty much every quackery known to humankind, including homeopathy (which is required study for naturopathy students and the knowledge of which is tested in the NPLEX, the naturopathic certification examination). Just peruse Scott Gavura's Naturopathy vs. Science series, or any of a number of posts by myself or other SBM bloggers if you think I exaggerate. In particular, pay attention to what naturopaths say when they think no one's listening. Ditto traditional Chinese medicine practitioners, as has been explained many times here before. This is the essence of quackademic medicine, elevating practitioners of pseudoscientific medicine, medicine based on prescientific concepts of how the body works and diseases develop, and outright quackery to be equals with practitioners of science-based medicine.
But it's not just the SIO, unfortunately. In a commentary by Kevin D. Stein, Ted Gansler, Colleen Doyle, Rebecca Cowens-Alvarado, Virginia Krawiec, Carter Steger and Elvan C. Daniels entitled "Integrative Oncology and Wellness Considerations in Cancer Survivorship" the American Cancer Society has also weighed in. Yes, this is the same American Cancer Society that used to maintain a series on unproven methods in cancer treatment dedicated to examining cancer quackery—sadly abandoned over 20 years ago with the rise of CAM—but is now weighing in on "integrative oncology" and touting its research there. What the ACS writes is another perfect example of how "integrative oncology" has co-opted what should be science-based treatments, such as treatments involving exercise, nutrition, and life style modification:
The Society’s Nutrition and Physical Activity Guidelines for Cancer Survivors (2) are the foundation of communication, programmatic, and advocacy efforts designed to support survivors in their ability to make healthy lifestyle choices. Resources such as the What to Eat During Cancer Treatment cookbook, The Complete Guide to Nutrition For Cancer Survivors, and the online I Can Cope—Nutrition During Treatment help survivors manage nutrition-related side effects of treatment and maintain good nutritional status. The Society’s collaboration with the American College of Sports Medicine to create the Cancer Exercise Trainer certification helps survivors identify qualified exercise professionals to assist with setting and achieving physical activity goals, and our collaboration with the LiveSTRONG at the Y program provides local expertize to support survivors in being physically active.
No one would argue with these goals. There is nothing "alternative" or "integrative" about them. Now comes the quackery:
The ACS Extramural Grants department funds innovative research to advance the field of palliative care and symptom management, including integrative oncology. In addition to investigator-initiated mechanisms, the Society is also developing Requests For Applications to address how nutrition and physical activity influence survivors’ treatment, symptoms, weight, and QOL. Through Health Professional Training Grants, the Society funds clinicians and clinician-researchers working in the area of integrative oncology and has funded health professionals studying Reiki, mindfulness, acupuncture to treat hot flashes, and other integrative methods.
Reiki is, as I've discussed more times than I can remember, faith healing that substitutes Eastern mysticism for Christianity as its core belief system, and acupuncture is nothing more than a theatrical placebo, as has been discussed on this blog more times than I care to catalogue. Yet reiki, which does not belong in a medical center, except perhaps if one allows reiki masters into hospitals in the same way priests and ministers are allowed into hospitals (i.e., as chaplains there to comfort patients, with no claim of being able to treat anything), is now found in academic medical centers, such as the Cleveland Clinic, the University of Arizona, and many other academic medical centers, and the ACS is funding studies of it.
How far the ACS has fallen, allowing its admirable initiatives in promoting better care of cancer survivors to be co-opted by quackery. Unfortunately, it is a conscious strategy on the part of integrative oncology advocates to promote the use of CAM to treat cancer survivors, as described in an article by Julia H. Rowland and Ann O’Mara entitled "Survivorship Care Planning: Unique Opportunity to Champion Integrative Oncology?" What choice do CAM advocates have, given that CAM has not been shown to increase survival, but to shoehorn it into oncology as "integrative oncology" by emphasizing using placebo medicine to ease symptoms in survivors. None of this stops Rowland and O'Mara from trying to imply that CAM can increase survival in cancer patients:
Within the spectrum of treating the lingering and late effects of cancer, some promising interventions are emerging. For example, ginseng and yoga have shown promise in symptom management trials of fatigue and sleep disturbances respectively, both chronic problems reported frequently by cancer survivors (5,6). Given the documented positive association between quality of life and survival, there is arguably an important role for CAM use in recovery and life after cancer.
After co-opting pharmacognosy and exercise as somehow "alternative," the next frontier for "integrative oncology" is to imply that it can somehow improve survival. This is the background against which the clinical guidelines for integrative oncology in breast cancer were written.
Proponents of "integrative oncology" are no doubt well-meaning practitioners who think they're doing good. They even go out of their way to condemn quackery, as though to demonstrate that what they embrace is not quackery. However, as they try to distance themselves from obvious cancer quackery, as Barrie Cassileth, who heads up the integrative medicine service at Memorial Sloan-Kettering Cancer Center, did not too long ago, they seem oblivious to the fact that much of what they accept as potentially part of integrative oncology, such as traditional Chinese medicine, acupuncture, reiki, naturopathy, and the like, is based on the very same pseudoscience and magical thinking that the quackery they condemn.
Just like vaccines are, to some degree, a victim of their own success, so, too it would appear that real, science-based oncology is a victim of its own success Unlike with vaccines, however, where battle lines are generally pro versus con, oncology has a lot of SCAM leeches who are trying to glom on for the money to be had. Sadly, these "well meaning practitioners" you mention fail to realize that money spent on SCAM quackery is money that cannot be spent on real medicine.
"This diverse membership facilitates true clinical integration of complementary modalities because such change requires breadth of expertise and different perspectives, to listen and learn from one another while challenging each other’s assumptions and existing paradigms."
Sounds to me like having all these people on the care team would lead to a god-awful cacophony of competing interests. "We're going to target this cancer with cyberknife treatment.:" "No, wait! You'll interrupt the flow of chi!!" "Yoga first!!!"
What a mess.
“Advancing the Evidence Base and Transforming Cancer Care Through Interprofessional Collegiality: The Society for Integrative Oncology“
Did I read that title right? Are they basically saying that they "know" (some of) this stuff works and are hunting for evidence that it does, regardless of prior plausibility? Because apart from things like diet and exercise which the alt-med crowd have coopted, their theories and treatments are either demonstrably false or non-falsifiable. Science only works that way in cartoons, not in the real world.
While it is a much smaller slice of federal funding, quackery is also funded at the USDA with their National Organic Program, Organic Cost Share program and Organic Research and Extension Initiative.
Quackery for medicine, food and agriculture from the federal government needs to be removed.
While a large amount of quackery goes on, the push to get science and tech involved with cancer treatment impresses me. 60 Minutes ran a halfway decent segment last night on (what I felt) the importance of entrepreneurship to promote treatment discovery. Granted, it also seemed a fair amount of a promotional piece to the benefit of one firm, and that's not how science really works for everyone. But, I still enjoyed the ideas.
Chemo isn't nearly as effective as it could be in certain types of cell behaviors, and has that overall deleterious effect on the body. In some trial cases, I feel, amounts to chemical torture on someone to get a 2-3 month data point, which a large amount of people quit anyway. Granted, homeopathic-whatever clearly serves little purpose other than maybe some palliative; why not just send a person home to drink hot honey tea all day long??
I'm not entirely a fan of using the immune system. I'd like to continue seeing targeted cellular reception approaches (nanotech), development of genomic IT, & interactive modeling to test models & solutions. Basically the things I saw last night in the tv segment. I'd really like to see that trojan horse concept continue to move forward and get put to the test in engaging tumor cells to pursue apoptosis. Probably the solution to aggressive tumors like glioblastoma multiforme may be found in targeted nanotech.
That the government puts relatively little money into viable scientific discovery is really discouraging. I've been told, more than a few times, really in order to work on promising (well funded) projects, that higher level of education would need to be sought outside of the United States. Discouraging. But yet it is still good to see these scientific discoveries trying to take hold on a big health problem.
"naturopathic doctors, traditional Chinese medicine practitioners, mind–body therapists, and basic scientists."
What, pray tell, is a "basic scientist"? Is it someone with a Masters Degree. In Science?
I would argue patients are crying out for the “integration” of diet and lifestyle changes, exercise, and pharmacognosy into conventional care, and patients see this as “complementary,” or “holistic” because sbm has done a poor job of putting such things forward in practice, largely due directly or indirectly to insurance company mandates.
I don't know how those millions of dollars are being allocated among the legit diet. exercise, lifestyle stuff vs woo, but there is such a need for better delivery and support of the former that anything spent on the latter is just a waste.
Perhaps TCM has a role in bettering the lives of cancer patients — I refer, of course, to Turner Classic Movies. They're showing 'Larceny, Inc.' and 'Stop, You're Killing Me' tomorrow, and 'Village of the Damned' on Wednesday. (I just pulled the first two titles for joke value as I haven't seen them. 'Village of the Damned' is a great movie.)
Like it or not, "integrative medicine" is the term people are going to use for making the legit diet. exercise, and lifestyle stuff more readily available to patients. As i commented before, the term has been validated without really being defined. The best strategy is to fight for the definition on sbm terms. That is, what is to be 'integrated' is not sbm and not-sbm, but sbm measures that treat the disease itself (e.g. for cancer: surgery, chemo, etc.) and sbm measures that support that with 'whole patient' care on diet. exercise, and lifestyle.
I hope no one would argue that our health care system does a good job of doing that now. So part of woo-fighting would seem to be sbmers admitting that the delivery system (which is controlled by bean counters, not actual doctors) has been doing a piss-poor job, and lobbying for reform. This would make the anti-woo stance all the more credible.
I've noted before that the bariatric surgeon who did my Rouen-Y several years back, has an sbm-holistic approach (though he doesn't call it that). His patients have to consult with dieticians, get clearance from clinical psychologists, and attend support groups before and after surgery or he won't cut. He has a much higher success rate than other stomach cutters, no doubt in part because he's a damn fine surgeon — as he'd be the first to tell you :-). But he's also absolutely sold on the necessity of the support stuff.
That's anecdotal, of course, but I wonder if studies could be done researching, not as clinical trials necessarily (ethics problems?) , but of outcomes comparing 1) just treatment of the disease, 2) treatment of disease + sbm-legit 'holistic' support, 3) treatment of disease + woo 'holistic' support. I.e., break down which elements of the various stuff being lumped under the 'integrative' rubric actually help enough to warrant support.
One might argue such studies are scientifically unnecessary, as we already know diet, exercise and counseling are good things, and reiki and acupuncture don't do what they claim, but (again) we're talking about policy, and that's poltiics, not science.
I can see only one very small advantage to "Integrative Oncolgy" - IF the healthcare organization is the ONLY place the patient seeks out woo, at least the oncology MDs will have it documented in the record and be aware of potential synergistic effects. And perhaps, by offering the Alt/CAM/Int nonsense in-house, they can hopefully keep the patients from seeking it elsewhere and being talked into totally eschewing real and proven medical care in favor of some sort of "miracle" cure the patient read about on Natural News.
Another deplorable aspect is the sick but slick "evidenced" part of the branding exercise.
When one goes to the studies which supposedly constitute the "evidence base" one finds studies being massaged, spun, wrung dry, turned upside down, shaken and declared good. Dross classified as spun gold.
Is there a way, when I choose my health care insurance, to ensure that quackery is not covered? Is that not the way to squelch the nonsense?