Aug 29 2008
Should Medical Journals Inform Readers if a Book Reviewer can’t be Objective?
At the end of last week’s post I suggested that book reviewer Donald Abrams and the New England Journal of Medicine had withheld information useful for evaluating Abrams’ review: that he is the Secretary/Treasurer of the Society for Integrative Oncology (SIO), the organization of which Lorenzo Cohen, the first editor of the book that Abrams reviewed,* is President. I also promised to look at material from the book and from the Society’s website in order to discover “data that will allow even the most conventional oncologists to appreciate [the value of 'integrative' methods].”
There is little question that Abrams and Cohen know each other, or at least that Abrams couldn’t have been expected to write an entirely objective review of Cohen’s book. Abrams is the Program Chair for the Society’s upcoming 5th International Conference, sponsored by the American Cancer Society. He and Cohen will be sharing the stage for the “Intro/Welcome.” Does it matter that most NEJM readers wouldn’t have learned of this association by reading the review? Probably not, in the case of readers who are well-versed in the misleading language of “CAM.”
I believe that most readers of medical journals are not so sophisticated. Otherwise, how could it have been so easy for “CAM” literature to seep through the usual evaluative filters, not only in medical schools and government but in the editorial boardrooms of prestigious journals? For anyone from the Journal who might be following this thread, Dr. Sampson’s satirical but deadly serious account of “how we did it” is obligatory reading.
Do “Integrative Oncology” Methods have Value?
Now let’s take a look at what Dr. Cohen’s book and the SIO are up to. The book’s introduction and table of contents are available on Amazon.com. The introduction contains the usual, misleading assertions and falsehoods that are ubiquitous in “CAM” promotions. I’ve added a few hyperlinks:
Many medical centers within the United States have formalized integrative medicine programs to help guide patients in the use of CAM and to provide CAM services…
Complementary and alternative medicine (CAM) has been defined by the National Center for Complementary and Alternative Medicine (NCCAM)…
The NCCAM is dedicated to exploring complementary and alternative healing practices in the context of rigorous science…
…using well-established tools of rigorous scientific design, conduct, and oversight.
[Integrative medicine] strives to integrate the best complementary and conventional modalities using a multidisciplinary approach through integrative services.
The Consortium of Academic Health Centers for Integrative Medicine has recently defined integrative medicine as the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, [etc.]
People who use complementary therapies are often seeking a more holistic and noninvasive approach to preventing and managing disease. They use CAM to maintain wellness, improve quality of life, assist in managing disease- and treatment-related side effects, boost the immune system, increase hope, and gain a sense of control.
Since 1991, the NCI [National Cancer Institute] has utilized [the Best Case Series Program] to evaluate data from CAM practitioners with the same rigorous scientific methods employed in evaluating treatment responses with conventional medicine.
What ”CAM” practices are we talking about here?
Complementary therapies typically used include mind-body approaches such as meditation, guided imagery, music, art, other expressive arts, and other behavioral techniques; energy-based therapies that seek to affect proposed bio-energy fields, whose existence is not yet experimentally proven, that surround and penetrate the human body. These can be individual therapies done through self-practice (e.g., Yoga, Tai Chi, or internal Qigong), manipulation of electromagnetic waves through the use of magnets, or through the use of the energy of individual practitioners (e.g., external Qigong, Reiki, Healing Touch); body-manipulative systems such as chiropractic and massage; alternative medical systems such as traditional Chinese medicine, homeopathy, and Ayurveda (Indian-based medicine); and biologically based approaches such as nutrition, herbal/plant, animal/mineral, or other products.
From the book’s table of contents we can identify the authors. I’ll mention one with whom I am familiar. Chapter 3 is titled “Using Legal and Ethical Principles to Guide Clinical Decision in Complementary/Integrative Cancer Medicine.” Its author is lawyer Michael H. Cohen, who a few years ago was “Director of Legal Programs, Division for Research and Education in Complementary & Integrative Medical Therapies, Harvard Medical School.” He is also a Board Member at Large for the SIO. His views on modern medicine and implausible medical claims are apparent in these excerpts from his writings:
[B]iomedicine by and large perpetuates a delusional sense that a human being is only material–a three-dimensional substance locked in the physical body, amenable to mechanical interventions that are tightly controlled by a series of carefully circumscribed rules. Biomedicine encourages over-identification with the body: it is fear-based; disease induces desperation in the “race for the cure” rather than focus on “care of the soul.”
Health and healing can involve the highest of which a human being is capable. Near-death experiences, encounters with angels, and events that touch the individual’s interior castle and border on mysticism-these experiences manifest ‘light,’ in the sense of coming closer to that which is Supreme at the edges of our consciousness.In the purest sense, therapies from hypnosis to meditation aim to free the dis-eased seeker, and the culture as a whole, from the matrix of mechanism, reductionism, and other ills, to a realm where the human spirit finds rest. As Vasistha says: “Subdue the mind with the mind. Purify the mind by the mind. Destroy the mind by the mind.” When the mind is purified, the real can be grasped. Complementary and alternative therapies offer this possibility.
What about legal principles and clinical decision making?
Would legal structures be able to handle the notion that healing involves mind, body, emotions, and spirit, but also such other dimensions of the human experience as inter-species communication and greater sense of earth-consciousness (Gaia)?
Until recently Mr. Cohen was a member of the Advisory Board of the American Association for Health Freedom (AAHF), an organization committed to protecting snake oil salesmen from legal repercussions. I wonder if some of the other authors of the “integrative oncology” book and some of the other officers of the SIO—who go to great lengths to distinguish between “alternative” (dangerous!) and “complementary” (good!)—would be surprised to find that at least 3 of Mr. Cohen’s fellow AAHF Advisory Board members pitch Laetrile: Schachter, Mindell, and Rowen.
It’s hard to tell from the brochure what much of the content of the SIO’s 5th International Conference will be, but it includes “biofield therapies for symptom management during acute radiation treatment,” “immune enhancement,” “Traditional Chinese Medicine,” and “mind/body medicine.” A few of the Conference Planning Committee members look familiar; at least one is a crackpot who’s become “establishment” in this era of Anything Goes Medicine: naturopath Leanna Standish, a psychokinesis enthusiast and a long-time recipient of public research funds.
The abstracts from the 2007 conference verify that psychokinesis (PK)—the notion that the mind can act on an object from a distance—is an important part of the SIO’s agenda. Consider that “biofield therapies,” Therapeutic Touch, Reiki, and “External Qigong” are all examples of PK. One of the recurrent themes in “CAM,” which would be worth a few posts of its own, is the famous quotation of philosopher George Santayana: “Those who cannot remember the past are condemned to repeat it.” In this case the relevant past consists of more than a century of failed attempts to demonstrate PK before the term “CAM” was even coined.
The “Integrative Oncology Practice Guidelines”
The real meat of the Society for Integrative Oncology is found in the Society’s Integrative Oncology Practice Guidelines. This is a more sober document than the conference brochure. It is presented in a formal EBM sort of way, complete with an explanation of the “levels of evidence.” One of its Primary Authors is Andrew Vickers, a member of the Cochrane “CAM” Field, previously discussed here. It does not discuss or even acknowledge prior probability.
Some of its recommendations are common sense and are either uncontroversial or embarrassingly obvious:
Recommendation 1: All patients with cancer should be asked specifically about their use of complementary and alternative therapies. Grade of recommendation: 1C
Recommendation 5: The application of deep or intense pressure is not recommended near cancer lesions or enlarged lymph nodes or anatomic distortions, such as postoperative changes, as well as in patients with a bleeding tendency. Grade of recommendation: 2B
Recommendation 14: It is recommended that dietary supplements, including both herbal product and megadoses of vitamins and minerals, be evaluated for side effects and potential interaction with other drugs. Those that are likely to interact with other drugs, including chemotherapeutic agents, should not be used concurrently with chemotherapy or radiation or prior to surgery. Grade of recommendation: 1B
Recommendation 17: It is recommended that patients be advised to avoid therapies promoted as ‘‘alternatives’’ to mainstream care. Grade of recommendation: 1A
Some are utterly “conventional”:
Recommendation 15: It is recommended that patients be referred to registered dietitians for guidelines on usual diets to promote basic health. Grade of recommendation: 1B
Some would likely detract from effective therapy, even if the authors think that they are advocating “integrative care,” and would likely be insulting to a sophisticated patient:
Recommendation 7: Acupuncture is recommended as a complementary therapy when pain is poorly controlled. Grade of recommendation: 1A
Some are ridiculous and and likely to be insulting to a sophisticated patient:
Recommendation 12: For patients suffering from symptoms such as dyspnea, fatigue, chemotherapy-induced neuropathy, or post-thoracotomy pain, a trial of acupuncture is recommended. Grade of recommendation: 2C
Some “strong recommendations” are wrong, even when considered from the formal EBM point of view:
Recommendation 9: Acupuncture is recommended as a complementary therapy when nausea and vomiting associated with chemotherapy or surgical anesthesia are poorly controlled or when side effects from other modalities, such as muscle spasm or dysfunction following head and neck surgery, are clinically significant. Grade of recommendation: 1B
Some are silly in the typical EBM-”CAM” sense of ignoring prior probability:
Recommendation 6: Therapies based on manipulation of putative bioenergy fields are safe but cannot be encouraged due to limited evidence on efficacy. Grade of recommendation: 1C
(And, er, who cares about “limited evidence of efficacy” if it makes some people feel better? Look at several of the other recommendations!)
Some are daft:
Recommendation 16: In cancer patients who either fail or decline antitumor therapies, it is recommended that use of botanical agents occur only in the context of clinical trials, recognized nutritional guidelines, or clinical evaluation of the risk/benefit ratio based upon available evidence. Referral to a qualified expert in CAM modality, such as an Doctor of Naturopathy (ND) who is board certified in naturopathic oncology, may be considered. Grade of recommendation: 1C
Do the Guidelines and the Book Reflect “Integrative Oncology Programs”?
Well, at least the Guidelines don’t mention homeopathy (although the “board certified” ND certainly will). But a big part of the book that Donald Abrams reviewed is a series of descriptions of the various “integrative oncology programs” at “leading cancer centers.” One of those is near me: the Dana Farber Cancer Institute.
It takes only a couple of clicks to find that “my” institute promotes homeopathy, psychokinesis, “mind healing,” “quantum healing,” and more, as explained by such luminaries as Dana Ullman, Andrew Weil, and Deepak Chopra.
I wonder why? Here’s a thought. One of the guidelines reflects a recurring theme in “CAM”:
Recommendation 2: All patients with cancer should receive guidance about the advantages and limitations of complementary therapies in an open, evidence-based, and patient-centered manner by a qualified professional. Grade of recommendation: 1C
It’s funny. I used to wonder what was meant by “patient-centered” (let’s see…as opposed to health care centered on the patient’s dog?). Now I know that when used in “CAM” contexts the term is a bait-and-switch deception. It was originally intended to imply a change in the doctor-patient relation, from its traditional paternalistic mode to a new physician-as-consultant mode, as explained by Steve Novella a couple of days ago. For some, however, it implies something else: that the physician ought to “respect” whatever the patient wants. Or more. After all, most patients don’t really know what to look for in a complementary therapy, so to speak, so we in the SIO are here to help!
* Integrative Oncology: Incorporating Complementary Medicine into Conventional Cancer Care. Edited by Lorenzo Cohen and Maurie Markman. 216 pp., illustrated. Totowa, NJ, Humana Press, 2008
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