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“Integrative” oncology: Trojan horse, quackademic medicine, or both?

One of the main topics that we’ve covered here on this blog over the last couple of years is the relatively rapid, seemingly relentless infiltration of pseudoscience into what should be bastions of science-based medicine (SBM), namely medical schools and academic medical centers promoted by academics who should, but apparently don’t, know better. From the very beginning, we’ve written numerous posts about this infiltration and how it has been facilitated by a variety of factors, including changes in the culture of medical academia and our own culture in general, not to mention a dedicated cadre of ideologues such as the Bravewell Collaboration, whose purpose is to blur the lines between science and pseudoscience and promote the “integration” of quackery into science-based medicine. Certainly promoters of what Dr. Robert W. Donnell termed “quackademic medicine” wouldn’t put it that way, but I would. Indeed, promoters of quackademic medicine scored a major victory last month, when a credulous piece of tripe about acupuncture passing as a review article managed to find its way into the New England Journal Medicine, a misstep that was promptly skewered by Mark Crislip, Steve Novella, and myself. It’s rare for more than two of us to write about the same topic, but it was earned by a mistake as dire as the editors of the NEJM allowing rank pseudoscience to sully its normally science-based pages.

Today, I want to riff a bit on one aspect of this phenomenon. As a cancer surgeon, I’ve dedicated myself to treating patients with cancer and then subspecialized even further, dedicating myself to the surgical treatment of breast cancer. Consequently, the interface of so-called “complementary and alternative medicine” (CAM) in the treatment of cancer both interests and appalls me. The reason for my horror at the application of CAM to cancer patients, as you might expect, is that cancer is a disease that is highly feared and can be highly deadly, depending upon the specific kind of cancer. Cancer patients deserve nothing less than the best science-based evidence that we have to offer, free of pseudoscience. Yet in even the most highly respected cancer centers, such as M.D. Anderson Cancer Center and Memorial Sloan-Kettering Cancer Center, there are departments or divisions of what is increasingly called “integrative oncology.” The claim behind “integrative oncology” is that it is “integrating the best of science-based and ‘alternative’ medicine,” but in reality all too often it is “integrating” quackery with science-based medicine. I have yet to hear an explanation of how “integrating” pseudoscience or nonscience into science-based oncology benefits cancer patients, but, then, that’s probably just the nasty old reductionist in me. Let’s find out.

“Integrative oncology”

I was reminded by the level of “progress” in integrating woo into oncology last week when the July 25 issue of HemeOnc Today showed up. Right there on the front page I saw a story Integrative oncology combines conventional, CAM therapies, with a subtitle reading “This growing medical discipline incorporates methods such as yoga, acupuncture and stress management.” And so it does. But I worry that that’s just the beginning:

The National Center for Complementary and Alternative Medicine defines integrative medicine as treatment that combines conventional medicine with complementary and alternative therapies that have been reported to be safe and effective after being studied in patients.

Lorenzo Cohen, MD, PhD, of M.D. Anderson Cancer Center is conducting a phase 3 trial of the effects of yoga on women with breast cancer.

“Integrative medicine is a philosophy based on treating patients by focusing on the whole person and using both conventional and complementary therapies in a multidisciplinary care fashion,” Lorenzo Cohen, MD, PhD, director and professor of the Integrative Medicine Program at The University of Texas M.D. Anderson Cancer Center, told HemOnc Today.

“It is similar to complementary medicine, but one key difference is that there is an open communication between practitioners of the different traditions,” he said.

“Between the traditions”? Note the clever use of language that Kimball Atwood is so fond of pointing out. Note how Dr. Cohen equates “conventional” and “alternative” therapies (the latter of which he calls “complementary”) as though they had equal validity and equal efficacy. It’s just two different traditions! What’s the problem with bringing them together, and integrating one into the other? It’s the best of both worlds, right?

Also notice another thing. I’ve referred to certain aspects of CAM, sometimes called “integrative medicine” (IM) and, in this case called “integrative oncology” (IO), as a “Trojan horse” to bring woo into medical schools and academic medical centers. Most — but not all — academic medical centers do not use hard core quackery like homeopathy, although many appear to be using a modality just as bad, reiki, which happens to be Dr. Mehmet Oz’s favorite modality. In any case, whenever you see discussions of “integrative medicine” and in particular “integrative oncology,” chances are, the modalities discussed generally include yoga, various dietary modalities, exercise, and, quite frequently, acupuncture. Sometimes, they include various herbal remedies. In other words, “integrative oncology” rebrands modalities that have no reason not to be counted as part of science-based medicine as “alternative” or “integrative” and points to them as having some promise. They then lump together pseudoscience like reiki and acupuncture with the rebranded modalities, such as herbal therapies. This story demonstrates exactly what I mean in this passage:

According to Cohen, integrative medicine includes a plethora of therapies and methods but can be most easily classified into five categories: biologically based therapies, mind/body medicine, manipulative body-based practices, energy medicine and whole medical systems.

Biologically based therapies include ingestibles such as herbs and supplements, megadoses of vitamins or specialized diets. Mind/body medicine consists of techniques that typically help with stress management. These techniques include meditation, yoga, guided imagery and other forms of relaxation, according to Cohen. Manipulative body-based practices include therapies such as massage, medical acupuncture and chiropractic work.

The most controversial area of integrative medicine, according to Cohen, is energy medicine, which includes techniques such as healing touch, Reiki, a Japanese form of energy healing, or the use of magnets for healing. Healing touch techniques such as Reiki and Qigong, an ancient Chinese healing therapy, are based on the theory that human beings are energetic bodies and certain individuals with specific training can emit energy into another person for therapeutic purpose.

I realize that HemeOnc Today isn’t the NEJM, but on the other hand, given how the NEJM recently fell for the pseudoscience that is acupuncture, maybe they aren’t so different after all. In any case, this entire article is the sort of credulous treatment that drives me crazy, particularly the last paragraph quoted above. Energy medicine isn’t just “controversial”: it’s quackery, pure and simple, and Dr. Cohen should know that. The best that can be said about so-called “energy medicine” is that it is religion, not science, or that the various modalities that fall under the rubric of “energy medicine” are based on a prescientific understanding of how the human body works and how diseases attack it. Some of them are not even “ancient.” Reiki, for instance, only dates back to 1922. It was invented by a man named Mikao Usui, who wanted to find out how Jesus healed the sick. His answer, reiki, is no more than faith healing; the only difference between it and what Benny Hinn does is that reiki is based on Eastern mysticism instead of Christian faith. None of this discussion of “energetic bodies” and the claims that practitioners can either channel some form of “universal energy” or manipulate the flow of human “life energy” for therapeutic intent belongs in science-based medicine, at least until someone can characterize the claimed energy and actually show that these practitioners can actually do anything other than wave their hands over patients.

Cohen also speaks of “whole medical systems.” In other words he refers to ancient medical systems, such as traditional Chinese medicine and Ayurvedic medicine, characterizing them as having “their own methods and techniques for diagnosing patients, prescribing treatments and following patients over time.” That much is certainly true, but none of these techniques were based on science, either. They were based on much the same thoughts that early “Western” medicine was based on. After all, when you come right down to it, “balancing” or “adjusting” the flow of qi is not that different than the idea that the four humors must be balanced or that disease comes from “contamination” due to miasmas. As Ben Kavoussi has pointed out, there isn’t that much difference between the concepts used to justify blood letting as a treatment for disease. Yet, somehow “integrative medicine” and CAM love modalities based on Eastern mysticism. Where’s the love for black bile, yellow bile, phlegm, and blood, which make just as much sense, from a science-based standpoint as the concept of qi? In fact, they make more sense, because they, at least, exist and can be observed.

The Trojan horse

Time and time again, when I observe integrative oncology programs, I notice that many of them heavily emphasize modalities like diet and exercise. Indeed, in the HemeOnc Today article, the various advocates and “experts” in integrative oncology emphasized time and time modalities like yoga:

Karen Mustian, PhD, MPH, assistant professor of radiation oncology and preventive medicine at the University of Rochester Medical Center, discussed the findings of a yoga study at the 2010 ASCO Annual Meeting, held in Chicago in June.

Researchers enrolled 410 survivors of non-metastatic disease who participated in the Yoga for Cancer Survivors program. Survivors reported suffering from moderate or severe sleep disruption 2 months to 24 months after completing adjuvant therapy.

The participants were assigned to breathing exercises, 18 gentle Hatha and restorative yoga postures and meditation for 4 weeks with twice-weekly sessions.
Patients practicing yoga had greater improved sleep quality (22% vs. 12%), decreased incidence of clinically impaired sleep (31% vs. 16%) and less daytime sleepiness (29% vs. 5%) compared with those who did not practice yoga.

Adding to these findings, a study of the effects of yoga on women with breast cancer is also in the works. In April, Cohen received a $4.5 million grant to conduct a phase 3 trial in women with breast cancer to determine the improvement in physical function and quality of life during and after radiation treatment.

The results of the study presented at ASCO described above are, of course, utterly unsurprising. Would anyone expect that gentle exercise and meditation would harm quality of life and sleep quality? My guess is that substituting gentle exercise and prayer or non-yoga meditation would likely produce the same result. But yoga is “Eastern,” so it’s automatically way more cool than “Western” exercises. In any case, I bet I could save the NIH $4.5 million by predicting the results of Dr. Cohen’s study. Yes, yoga very likely will be found to improve physical functioning and quality of life, because, by and large, it is relatively gentle, low-impact flexibility exercise. In fact, in women who have undergone axillary dissection (removal of the lymph nodes under their arms), I would predict that yoga probably will decrease the incidence of impaired range of motion. The reason I make this latter prediction is because I already prescribe gentle stretching exercises to women who have undergone axillary surgery because it does decrease the incidence of impairments in range of motion. In fact, I would go so far as to predict that virtually any low impact exercise, be it yoga, Tai Chi, or simply low impact “Western” forms of exercise, such as walking and stretching, would produce the same results.

Oddly enough, I have been unaware of any investigators being awarded $4.5 million to study whether walking preceded by some gentle “limbering up” has all these effects in cancer patients. Why is that? This is the sort of stuff that is well-within the purview of science-based medicine, leading me to ask: Since when did exercise become “alternative” or “integrative”? Dr. Cohen’s study compares yoga versus “stretching/relaxation” (which is what I thought much of yoga was; so I’m not sure what the difference is) versus a wait list control group. So my being unaware of such a study is at an end, because apparently that’s just what Dr. Cohen will study. But does anyone think that the NIH would have funded such a study if it were about exercise and relaxation rather than yoga? My prediction for the outcome: the first two groups will both do better than the control group in terms of the outcome measures. I also wonder why on earth it will take $4.5 million and five years to answer this question. In any case, given the copious science already demonstrating that low impact exercise results in better quality of life outcomes for cancer patients, I would question the value, the “bang for the buck,” of spending $4.5 million in order to study an “alternative” or “complementary” therapy that is nothing more than a fancy form of stretching exercises and relaxation, the former of which is already known to be of benefit in cancer patients undergoing chemotherapy, surgery, and radiation. Surely such a study could be done for $1 million? Heck, for $4.5 million, I could start up a multi-investigator P01 with teams of investigators doing heavy duty basic science.

I know, I know. Sour apples. I really am in the wrong business.

The HemeOnc Today article, as credulous as it is, though, is merely an indication of just how far the concept of “integrative oncology” has gone. To appreciate just how far it has gone, I thought I’d peruse the websites of what are commonly accepted as two of the most respected institutions devoted to cancer in the United States, if not the world.

“Integrative oncology” invades and metastasizes

“Inspired” by the HemeOnc Today article, I decided to peruse the “integrative oncology” website of one of the two premier cancer centers in the country, that of the M.D. Anderson Cancer Center, as well as to take a peak at what the National Cancer Institute website says about various “alternative,” “complementary,” or “integrative” modalities. What many readers may not know is that the NCI has an Office of Cancer Complementary and Alternative Medicine (OCCAM, perhaps the most unfortunate acronym ever, given what it stands for). Moreover, OCCAM has a budget that is of approximately the same magnitude as that of the National Center for Complementary and Alternative Medicine (NCCAM), in the range of $121 million a year. Thus, OCCAM is potentially as large a force in studying and promoting CAM as NCCAM has ever been.

Let’s start with M.D. Anderson first. On its website, it has a webpage called Complementary/Integrative Medicine Education Resources (CIMER). On the CIMER webpage, perhaps the most telling and useful “resource” is a page on therapies. On this page are links to several review articles authored by CIMER staff and physicians in the Integrative Medicine Program of the M.D. Anderson Cancer Center.

Whenever I take a look at a cancer center’s website, I go straight for the most hard core quackery to see what it says about it. Usually, I go straight for homeopathy. If a website concludes anything other than that homeopathy is pure quackery and that there is not a single molecule of active substance in most true hemopathic remedies (the dilution and succussion process having diluted it to nothing), then I know I’m dealing with quackademic medicine. Here’s an excerpt from what the great M.D. Anderson says about homeopathy:

The practice of homeopathy is based on its “law of similars” which proposes that “like cures like”. That is, a substance that causes specific symptoms in a healthy person is believed to ultimately relieve those same symptoms in a sick person. A few homeopathic physicians treat cancer by prescribing minute doses of tumors and carcinogenic substances.

The intent of homeopathic medicine is to help the body begin the healing process. Rather than focusing on a specific diagnosis, prescriptions are tailored to an entire set of symptoms and may vary between individuals with the same disease.

Significant reduction of some side effects of cancer treatments has been reported in two randomized controlled trials justifying further research with larger trials.

Current research includes a National Cancer Institute (NCI) clinical trial of a homeopathic substance for chemotherapy induced mucositis in children.

So far, not so good. The passage above is completely credulous, without the least bit of skepticism about the very basis of homeopathy. It reports homeopathy as a homeopath would report it, which makes me wonder if it was written by a homeopath. Particularly disturbing is the “detailed scientific review” of homeopathy. I’ll give the author credit because he at least mentions Avogadro’s number, but then credulously parrots the typical homeopath claim that water has “memory.” The article also cites primarily articles from that journal of pure woo, whose editorial standards I’ve lambasted here and elsewhere time and time again, the Journal of Alternative and Complementary Medicine, as well as homeopathy journals, such as the British Homeopathic Journal. It is beyond the scope of this post to explain why such journals are generally not good sources (perhaps I’ll do a post on that someday), but they aren’t. The only “real” journal article I saw was the infamous TRAUMEEL S study from 2001 looking at whether homeopathic TRAUMEEL S can alleviate stomatitis in children undergoing treatment for lymphoma and leukemia. (I shudder at the unethical nature of testing magic water in a clinical trial with children as the subjects.) In any case, this study reported a positive effect; however, one might also note this from the study itself:

TRAUMEEL S® is a homeopathic-complex remedy that has been sold over the counter in pharmacies in Germany, Austria, and Switzerland for over 50 years. It contains extracts from the following plants and minerals, all of them highly diluted (10−1–10−9 of the stem solution): Arnica montana, Calendula officinalis, Achillea millefolium, Matricaria chamomilla, Symphytum officinale, Atropa belladonna, Aconitum napellus, Bellis perennis, Hypericum perforatum, chinacea angustifolia, Echinacea purpurea, Hamamelis virginica, Mercurius solubilis, and Hepar sulfuris. Information from the manufacturer indicates that TRAUMEEL S is used normally to treat trauma, inflammation, and degenerative processes.

In other words, this is an herbal remedy in which there is still ingredient, given that even a 10-9 dilution is not enough to dilute away what’s in there. Why it’s even called homeopathic, I have a hard time figuring out, given that there are many herbs and minerals in there, with no rationale of “like curing like” obvious for them all. If TRAUMEEL S “works,” it’s not any sort of validation of homeopathy; all it shows is that maybe some of the herbs or minerals in the concoction have a beneficial effect. One also notes that this is a small study (N=30, 15 per group) and that the distribution of disease in the two groups was very different and that this study has never been replicated. Both Edzard Ernst and the Cochrane Reviews note this study but conclude that there is no evidence that homepathy is any better than placebo for cancer side effects.

But apparently not M.D. Anderson. M.D. Anderson appears to believe in magic. If you don’t believe me, just take a look at its review on reiki, including the “scientific evidence” for its efficacy in cancer patients, or its review on healing touch, which is more or less reiki shorn of explicit Eastern mysticism. Particularly nauseating is this introduction to “energy therapy” methods, which divides the very concept of energy itself into “Western” and “Eastern” notions of energy. (Silly me, I thought that energy was energy, and it was defined scientifically.) The author then postulates the “blending” of “Eastern” and “Western” concepts of energy thusly:

Modern physics has shown that light can exist as two interchangeable forms: a particle (form and structure) and a wave (movement and vibration). The rest of nature can also be experienced in the form of a particle and a wave. For example, water in the ocean is both particles of water and movement of coastal currents, thermal layers and tides. As in the ocean, the human body contains and is affected by energy that can be blocked, flow freely or vary in frequency. Various forms have been postulated:

  • An all-pervasive background frequency without form that extends beyond the limits of the body structure
  • Vertical energy flows that serve as conduits to external energy
  • Additional currents of energy with identifiable paths and patterns

The extent to which a background field extends beyond a person reportedly varies with each individual. Some people have said that they are sensitive to these fields – seeing or hearing these projections. Heat emanating from a body is one form of energy and one expression of that person’s energy field8.

Notice that no evidence is presented showing that these claims are valid.

The introduction concludes:

Contemporary energy therapies are only recent manifestations of a larger and more ancient body of energetic and spiritual concepts that are beyond the scope of these reviews of a few contemporary energetic healing practices. MD Anderson recognizes that physical healing is only part of the cancer treatment process and also offers spiritual support through many different programs such as the Chaplaincy Services — representing a wide range of faiths and spiritual beliefs — and the Place … of wellness — where people touched by cancer can enhance their quality of life with activities that help to heal the mind, body and spirit.

Remember, this is the website of the M.D. Anderson Cancer Center, which is widely viewed to be one of the top two or three cancer centers in the United States, if not the world, and its Integrative Medicine Program appears to be based on magic more than anything else. Quackademic medicine, indeed.

Unfortunately, the NCI’s OCCAM website isn’t all that much better. Because I spent longer than anticipated going through the M.D. Anderson website, I’ll wrap it up fairly quickly. OCCAM has some fairly disturbing pages itself. For instance, its Categories of CAM Therapies is a simple list of CAM therapies with little discussion at all other than defining what they are in the way any woo-meister would be happy with. OCCAM is superior to M.D. Anderson’s CAM pages in that it does from time to time throw in passages like this:

Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. The existence of such fields has not yet been scientifically proven.

If there is no good science to show that these fields even exist, then why study trying to manipulate them? I never understood putting the cart before the horse like that. There’s a lot of that sort of stuff going on in the list of CAM therapies referenced by OCCAM, although a lot of the articles are in fact NCCAM articles. One article on a CAM therapy that is hosted by the NCI and apparently was written by NCI staff is entitled Questions and answers about acupuncture. Depressingly, it begins with a credulous discussion of qi and meridians that is credulous and full of magic. It also contains statements like:

Scientific studies on the use of acupuncture to treat cancer and side effects of cancer began only recently. Laboratory and animal studies suggest that acupuncture can reduce vomiting caused by chemotherapy and may help the immune system be stronger during chemotherapy. Animal studies support the use of electroacupuncture to relieve cancer pain.

And:

Human studies on the effect of acupuncture on the immune system of cancer patients showed that it improved immune system response.

One wonders just how critically the studies to which this article refers were evaluated. Certainly, the lists mix “electroacupuncture” (which is not acupuncture at all — as Mark says, where were those batteries in ancient China to hook up to the acupuncture needles?) with acupuncture studies. One wonders if this is another case of accepting the authors’ misinterpretation of their own results, as I discussed for one such study a couple of months ago. As for the effects of acupuncture on the immune system, the physician’s version of the review points out that all these studies were conducted in China, and, unfortunately, it’s well known that acupuncture studies from China tend to be overwhelmingly positive, in marked contrast to acupuncture studies from other countries, leading some writers of meta-analyses to question how to handle these studies. In any case, it would appear that the NCI, although its material on its website is not as credulous as that of M.D. Anderson, is not exactly a bastion of science when it comes to some “alternative” medical modalities.

Indeed, let me tell you a brief anecdote. Two years ago, at the AACR Meeting, I visited the NCI booth on the convention floor because I knew there was going to be a representative from OCCAM there. My confidence in the scientific rigor of the entire OCCAM enterprise was not boosted by the conversation I had there. In brief, after a brief (and neutral) conversation about what OCCAM does, I gently challenged the OCCAM representative regarding alternative medicine by pointing out that there really isn’t that much evidence for much of it and asking him if he could point me in the right direction. In particular, I asked him why one would think that a mixture of herbal medicines would do better than pharmaceuticals. He then began to pontificate about “royal herbs” and couldn’t provide a good rationale why anyone should conclude that impure mixtures of compounds would be more effective or reliable than pharmaceuticals. When he started going on about “emperor” herbs, “minister” herbs, and “assistant” herbs, I couldn’t take it anymore and looked for an opportunity to politely excuse myself.

“Integrative oncology”: The quackademic oncology that’s here to stay?

I first became aware of the phenomenon of quackademic medicine several years ago. Before then, I was blissfully ignorant. Over the last several years, in particular the last couple of years, I’ve become increasingly alarmed at just how much pseudoscience is finding its way into medical academia in general and into oncology in particular in the form of “integrative” oncology. When the websites of what have in the past been a bastion of science-based oncology, M.D. Anderson Cancer Center and the NCI, become infiltrated with this sort of pseudoscience, I become alarmed. But it’s far, far worse than that. I only picked two websites. There are many more out there, thanks to promoters of woo like the Bravewell Collaborative and others. I only picked on M.D. Anderson and the NCI because of their reputation for being much better than this, a reputation they are endangering by their embrace of woo. Cancer patients, as I say frequently, are among the most vulnerable of patients. Many of them are facing a very unpleasant death without treatment; seeing that they receive the most effective medicines and treatments we have, free of quackery, is a moral imperative, and I fear that we will soon be failing our patients. We now even have a Society of Integrative Oncology promoting the “integration” of pseudoscience into oncology.

The Trojan horse of herbals, diet, and exercise in the form of yoga may have breeched the walls of academia, bringing with it pseudoscience like acupuncture, reiki, and even homeopathy, but still I see reason for hope. Val Jones once coined the term “shruggie” for health care professionals who have seen the infiltration of pseudoscience into medicine and in essence shrug their shoulders, dismissing it as not being important or as not being their business if people choose quackery instead of science-based medicine. However, as the infiltration of pseudoscience reached a critical mass, it started to alarm even some of the shruggies. There has been pushback. We here at SBM like to think that we have been a significant part of that reaction, but we also know that there are many others, such as Edzard Ernst, Ben Goldacre, and Simon Singh. Even though a disturbing number of skeptics seem to have a blind spot when it comes to quackery, the broader skeptical movement appears to be taking more and more notice. I only hope that it’s not too late. When an admired and esteemed institution like M.D. Anderson goes woo, we have an uphill battle to reverse that.

Posted in: Acupuncture, Cancer, Homeopathy, Naturopathy

Leave a Comment (29) ↓

29 thoughts on ““Integrative” oncology: Trojan horse, quackademic medicine, or both?

  1. Steve S says:

    Excellent article and oh so very true. But integrative medicine in making its slimy way into all parts of medicine. One of my colleagues does it here and got a grant from Andrew Weil foundation to start it. It is now running our of money. I counter by teaching evolutionary medicine to my residents. So far the residents have told me that the evolutionary medicine is more interesting and useful than the woo taught by my colleague. And most of our residents are foreign medical graduates from the subcontinent.

  2. nybgrus says:

    I have recently been turned onto the blog by a good friend of mine at Chicago Medical School. This is my first post and I would like to start by saying what an excellent job you gentlemen have been doing here. I am thoroughly shocked and appalled by the level of pseudoscience and mysticism encroaching on ALL aspects of modern life, not just medicine. I have my own ideas as to why this may be the case (many, if not all, I am sure are not original) but I digress.

    In regards to this specific post, the one thing I would like to comment on is in regard to the application of yoga. I fully agree with your conclusions and find it very interesting to think of the “branding” of exercise as containing social and political (and fiduciary!) cachet. My sister in PR would love this. I would merely like to point out that yoga is in fact quite capable, and very much designed to be, quite an intense workout. Obviously one can scale it back (just as you can run 1 mile or 10) but if you follow yoga properly and do the poses correctly you end up engaging more muscles than Gray’s anatomy states there are! I do this once per week as part of a serious fitness regimen. However, it truly is just a very good workout. Comparing yoga to plyometrics to running to swimming to lifting weights is all looking at one core thing – physical activity and its benefits to overall health, strength, and flexibility. Different types of exercise have different strengths and weaknesses (you wouldn’t tell a granny to go bench pressing) but in the end any and all benefit from any of these boils down to the health benefits of being active and building muscular strength.

    In short – yoga is an excellent (really!) workout, but it does not have mystical powers to help cure cancer.

  3. So very true is right. Please also see “Patient-Centered Care” and the Society for Integrative Oncology. (Sorry about the shameless self-promotion).

  4. egstra says:

    I agree with nybgrus on the benefits of yoga… I find it great for improving balance and flexibility as well as helping to reduce stress. I can understand teaching it to any group for those reasons, and I suspect that many people are more likely to follow through with something structured like yoga than with general advice about stretching. As for benefits like enhancing the immune system or aligning my chakras… piffle.

    I should add that I’m a granny and consider bench pressing a basic component of my weight lifting program.

  5. DevoutCatalyst says:

    “…I would merely like to point out that yoga is in fact quite capable, and very much designed to be, quite an intense workout…”

    Nobody doubts that here. The archaic Charles Atlas set of asanas are also quite capable, cost you far less, are advertised in comic books, and have less prissiness attached to them; but they won’t cure cancer either. But they will allow you to kick sand in people’s faces, very impressive to the yoginis I’m sure.

  6. qetzal says:

    Isn’t it interesting how proponents of CAM will point to a few supposedly positive studies and proclaim, “See? That proves homeopathy, acupuncture, &tc., work!” As if a ‘positive’* study of one particular homeopathic, acupuncture, or other CAM intervention somehow validates the entire field.

    I wonder how the folks at CIMER & OCCAM would react if someone tried the same approach with drugs:

    Amoxicillin cures ear infections! See? That proves drugs work! So here: take this drug for your cancer. No, it’s not amoxicillin, and you don’t have an ear infection, but that’s OK. We know that drugs work!”

    That would definitely make things easier for drug development. No need for tedious clinical trials testing some new drug for a specific indication. We already know that drugs work, so we should just start using it, based on our clinical wisdom and holistic understanding.

    *Not that there could ever be a truly positive study of, e.g., homeopathy.

  7. “Why it’s even called homeopathic, I have a hard time figuring out.” I think it’s marketing. The manufacturer plays a clever game. Rather than emphasizing homeopathy as some products do, they actually play it down, because the product’s homeopathic identity is secure — it has long been the best-selling homeopathic potion. So they understate the homeopathy (it’s often barely there on the website, or on much of their packaging), so they also get a slice of a more mainstream market that assumes it’s a normal herbal remedy.

    I wrote a detailed critical analysis of Traumeel for consumers that emphasizes this very point: that Traumeel is definitely homeopathic, not herbal in any meaningful sense.

  8. windriven says:

    “I would question the value, the “bang for the buck,” of spending $4.5 million in order to study an “alternative” or “complementary” therapy that is nothing more than a fancy form of stretching exercises and relaxation, the former of which is already known to be of benefit in cancer patients undergoing chemotherapy, surgery, and radiation.”

    But of course you surely recognize that this is politically correct research funding. How better to burnish the sCAM image than by researching an issue where the answer is already known? And while:

    “My prediction for the outcome: the first two groups will both do better than the control group in terms of the outcome measures.”

    is a safe bet, an equally safe bet is that the popular press will key on yoga’s performance against control while ignoring the equivalence of yoga and other stretching and relaxation exercises.

    I am not suggesting that there is a conspiracy here, only an expression of the herd instinct. Lost in those thundering hoof beats is the death rattle of science as the foundation of medical practice.

    There was a time when the educated recognized an obligation to uphold standards of intellectual rigor. Now it would seem that intellectual rigor mortis is close enough.

  9. DonSelgin says:

    Dr. Gorski

    My wife is currently a patient at MD Anderson. Do you think it would help if patients complained to the higher-ups there?

  10. BKsea says:

    I’ve always felt that these “integrative” centers were mainly a marketing tool. Here in Seattle, cancer centers make heavy use of advertizing to promote their centers that combine the best of conventional therapies with naturopathic, etc. approaches. I suspect that the average cancer patient has no idea what it means, but who would not want to go to the center that has more than just boring conventional therapies?

    If another center started a marketing campaign saying they offered the best proven approaches without confusing, unproven and dangerous naturopathic, etc. approaches, then the bean counters would start dropping their “integrative” approaches like hot potatoes.

    In the end it is all about following the money.

    (Aside to qetzal: Great Point!)

  11. Maz says:

    As a San Franciscan, I was appalled to find out that University of California, San Francisco has its own integrative cancer treatment center. While they don’t explicitly embrace reiki, they sure do name-drop acupuncture, herbal remedies and “distance healing”.

    The one saving grace is that the center does not encourage the disuse of “Western” medicine. Still, even without dissing real medicine, their existence is enough to sow seeds of doubt in some people.

    One of my family members was recently diagnosed with a very aggressive cancer. This is a terrible thing and my family is understandably desperate to try everything, especially since “traditional” doctors predict a poor outcome. I don’t want to make my family feel hopeless, but I had to speak up when they were considering some “integrative” treatments.

  12. qetzal says:

    I also wonder about the opportunity cost of these bogus ‘treatments.’ Every hour spent getting needles stuck in your meridians or having your energy field massaged as an hour that’s not available for something more productive, whether it’s being with family, researching possible clinical trials, or even just making sure your affairs are in order (if it’s come to that).

    Not that I want to tell cancer patients that they can’t decide the best use of their time for themselves. But most of them no doubt think that acupuncture & reiki must actually have some chance of helping. Otherwise, a place like MD Anderson wouldn’t offer them, right?

    Truly shameful!

  13. nybgrus says:

    @egstra: Rock on and stay fit!

  14. JMB says:

    There is an obvious economic incentive to supplying woo to cancer patients. One incentive is just the competition for cancer patients. Each cancer patient represents several thousand dollars of income from conventional SBM. If some cancer patients select an oncology center because they want woo in additional to SBM treatment, then the oncology center has significantly increased its income by attracting an additional 15% who will insist on woo. The other incentive is to charge the patients for the provided woo. The charges for woo may seem small compared to the charges for standard therapy. but the overhead and liability of supplying woo is basically miniscule compared to the cost of providing standard therapies.

    I find it troubling that some doctors are quick to provide dietary supplements without some understanding of possible interactions between those supplements and the effects of chemotherapy. Chemotherapy is toxic, hopefully more toxic to cancer cells than normal cells. Some supplements may actually reduce the toxicity. That would be like giving less than the tested effective dose of chemotherapeutic agent. I am not an expert on chemotherapeutic agents, so feel free to correct me. The answer to the question of interaction between dietary supplements and chemotherapeutic agents will be quite variable (because of variable metabolic pathways and mechanisms of toxicity), but should be considered if the interaction has not been studied.

  15. Dr Benway says:

    There is an obvious economic incentive to supplying woo to cancer patients.

    Then we must add to that incentive a meaningful cost if we’re to have any hope of stopping Infiltrative Medicine.

    The MBAs running our hospitals must be made to feel like bad people for the reiki and other nonsense. The MDs serving as useful idiots to the vitaministas, Scientologists, and other new agers must hear our derisive laughter.

  16. Alexie says:

    I’m undergoing cancer treatment in Woo Central, otherwise known as Germany. My doctors are ‘shruggies’ about about patients using alternative medicine – my oncologist says their studies show 80% of patients are going to use it. If that is the unfortunate case, then oncologists elsewhere may have to do what their German colleagues do – get a list of everything their patients are taking, to check for interactions.

    The biggest side effect of a belief in Woo, according to the same oncologist, is that they have a hard time getting patients to take their at-home medications. People who believe firmly in ‘natural’ treatments are kind of against drugs anyway, and know that chemotherapy is highly toxic, so they’re unwilling to add more drugs to the mix.

    I don’t know how it happens in the US, but it would have been very helpful to me if the oncologists had got in first with clear dietary advice. Other cancer patients tell me all sort of things about food and chemotherapy: no citrus, go for high protein, don’t go for protein, soy is good, soy is bad blah blah. I don’t have a clue.

    My point is, if Woo is so much on the rise that respectable cancer institutions are now supporting it, it would be helpful for us patients if the oncologists would now be super pro-active about providing clear lifestyle advice, above and beyond the normal medical advice.

  17. Stuartg says:

    I’ve watched the encroachment of CAM into oncology over the last few years with a degree of bemusement. There was almost no mention of CAM in my own medical education and I just did not know what to make of it. Initially I guess that I accepted its use because it seemed to be harmless and did not interfere with the medical treatment that I was able to offer my patients.

    My attitude changed a couple of years ago. My teenage son coned from obstructive hydrocephalus but nevertheless he survived decompressive surgery and then excision of the underlying astrocytoma. During his recovery, he asked me if any form of CAM would be able to help.

    I’ve since done extensive literature searches and reviews into CAM. I even went as far as a university paper on integration of CAM into medicine (I think I failed the paper by finding that there is no way to integrate the two!) I shared the results with my son who has been educated from birth in the scientific method. He also did some investigations when his schoolwork would allow.

    The results of our investigations correspond exactly with the opinions of the authors of this blog. Consequently my son has only been treated with SBM. He is not prepared to go anywhere near a woo practitioner, but he’s very polite and merely nods and smiles when someone suggests it. He’s recovering well and his worst problem right now is trying to decide which university to go to next year and what he should major in for his BSc!

    The whole thing has given me an attitude toward CAM in oncology, compared with my previously neutral stance.

    Now when I’m asked by patients, I give them a summarised scientific viewpoint on the efficacies of various forms of CAM, i.e. that none of them have anything more than a minimal effect. If they are receptive, I gently try to dissuade them and their families from trying any woo. If they persist with the woo then I see my task as dissuading them from partaking of any that would directly interfere with their SBM.

    Like Dr Gorski, I believe that there is no such thing as “integrative oncology.” The only thing that we should be offering our patients is SBM. Woo has no place in medicine as a whole and even less a place in oncology.

  18. JMB says:

    My exposure to CAM during medical school was limited to the “History of Medicine” course. That course was very popular because it provided comic relief in its description of ancient medicine (although some were horrific rather than comic). Those descriptions of CAM in history of medicine gave new meaning to the Hippocratic oath statement of, above all else, do no harm. Based on the Hippocratic oath, we would emphasize the scientific basis of medicine.

    Integrative medicine almost makes me laugh the way these guys can describe the pseudoscience concepts underlying various forms of CAM with a straight face. Unfortunately integrative medicine types are so serious about it, they want to define new scientific methods to validate CAM, and consequently change our scientific basis to pseudoscience.

    I also fear for the patients who will lose their ability to choose what practitioner they would prefer. Just as some patients prefer CAM, there are others who want only SBM. Patients who want mainly SBM will no longer be able to select a practitioner based on their medical degree. Tolerance for CAM results in a dilemma for patients that is well articulated by Alexie.

  19. Sastra says:

    Since when did exercise become “alternative” or “integrative”?

    Probably around the same time ethics and aesthetics became “spiritual.”

    My dad has just dismissed his oncologist in order to go to an “integrative” cancer center. They have him on a strange, restrictive diet and over fifty pills a day. They’re also changing his chemo schedule. He doesn’t want to give me details, since he knows I’m skeptical. As far as he’s concerned, even if it’s all just placebo, it will help reduce his stress. Think positive.

    Reducing stress is good, but I suspect he and my mom both have inflated notions of how important stress-reduction and positive-thinking are when it comes to surviving cancer. Of course, at his age (80), and given the type and stage of cancer, it may just be a matter of making him comfortable. Getting into an argument with him is probably not a good idea.

    But 50 pills a day? Sheesh.

  20. therling says:

    Looking through the reiki website linked above, http://reiki.7gen.com/doreiki.htm, I found this curious statement:

    “Yes, you can Reiki your car! One trip to Mt. Shasta I swear the only way we made it to the top was sending Reiki through the gearshift and dashbord into the car.”

    I’m wondering when we can expect an “Integrative Mechanics” movement, for example, increasing our car repair bills by applying “energy medicine” during an oil change.

  21. g says:

    Everyone seems to be hung up on the details about complementary medicine studies while readily acknowledging that it doesn’t matter what type of yoga, massage, meditation, or exercise someone does as long as they see a benefit.

    In anti-depressant trials, there is always a dramatic, ~20% improvement with placebo. In fact, the placebo effect is growing in anti-depressant trials (JAMA. 2002 Apr 10;287(14):1840-7.
    Placebo response in studies of major depression: variable, substantial, and growing.
    Walsh BT, Seidman SN, Sysko R, Gould M), possibly because more people think that the drug will work.

    This highlights the power of perception and the mind. We are finding a greater influence of the mood on patient outcomes. After cancer, there is a 40% incidence of depression. After a heart attack, there is an increased incidence of depression, the severity of which negatively affects compliance and long term outcome. There is an association of depression and poor cardiovascular health. Depressed diabetics have more poorly controlled blood sugar.

    So if some alternative medicine makes someone feel better and they take better care of themselves, and this helps the most important person, THE PATIENT, then I don’t care if it is reiki, hatha, tantric (lol), transcendental, breathing, mindful, tai chi, or whatever. There are no side effects, aside from annoying close-minded people when you tell them about how great you feel from doing yoga.

    There is a need to actually pay for these studies to show, not that a particular method works better than another, but that alternative therapies are effective, inexpensive, and without side effects.

    It is ridiculous to think that making people feel better, through alternative therapies, is pseudoscience and quackery. Palliative care, just helping people be comfortable as calm, extends life by 3 months in patients with terminal lung cancer (http://www.nejm.org/doi/pdf/10.1056/NEJMe1004139). Any drug, with no side effects, that extended life by 3 months for terminal lung cancer would get approved and make billions. This was palliative care!! There was no drug and this is not quackery. The data are the data.

  22. JMB says:

    So if some alternative medicine makes someone feel better and they take better care of themselves, and this helps the most important person, THE PATIENT, then I don’t care if it is reiki, hatha, tantric (lol), transcendental, breathing, mindful, tai chi, or whatever.

    If you are a professional you should care about how the most cost effective therapy. If “reiki, hatha, tantric (lol), transcendental, breathing, mindful, tai chi, or whatever” are no more effective than a sugar pill (or simply time with a cherished friend), then how can you justify the more expensive therapies? If you are willing to deceive the patient, then use a saline injection, it’s cheaper. Walking around the block is cheaper than attending a yoga class.

    Furthermore, you have to have respect for the patient’s beliefs. Some of those remedies come from ancient belief systems that may be contrary to the patients belief systems. It is wrong to push your belief system on the patient.

  23. Joe says:

    @JMB on 21 Aug 2010 at 9:38 am “If you are a professional you should care about how the most cost effective therapy.”

    By definition, ineffective therapies are not cost-effective. Life doesn’t get any simpler than that.

  24. JMB says:

    @Joe

    If studies consistently show improvement in the placebo arm of a trial compared to no treatment, then should a placebo treatment be offered?

    g was using consistent observation of improvement in the placebo arms of trials of treatment of depression compared to the no treatment arms to justify all of the different forms of woo. While there is unresolved argument about the strength of placebo effect (because of its variability), I don’t think there is much argument about the ethics of the use of placebo effect. Either don’t use it because it is deceiving the patient, or offer the cheapest form of placebo with no baggage of a belief system (with the patient deciding if they will select a form of placebo that is more expensive, or fits in with their belief system). The patient should also be warned that no placebo treatment is worth draining their finances.

    If placebo effect was ineffective, there would be no use in including treatment by placebo in a clinical trial. There would be no reason for blinding the subject as to whether they are receiving the tested treatment. Instead of double blinded clinical trials, we would have single blinded clinical trials. Because of the variability of placebo effect, treatments with no mechanism of action other than placebo effect will occasionally be shown to have weak but statistically significant improvement in one trial, but not be consistently reproducible in subsequent trials.

  25. g says:

    I think that people should do whatever works for them. If it makes them feel better, then it is working! Trying to scientifically prove everything in the world is ridiculous and expensive. For instance, I really like mountain biking. I feel great when I do it. I love the exercise and the adrenaline. But some people don’t really like mountain biking. No one can doubt that mountain biking is good for me and makes me feel good. If we were to design a large-scale clinical trial to show the benefits of mountain biking, it would probably fail. You’d have a lot of people who don’t like the speeds or they don’t have the balance for mountain biking, and they’d drop out of the study. Then, you’d have side effects like post-workout nausea, tachycardia, and dizziness. Plus, there would be serious adverse events from wrecking. The study would be stopped! Mountain biking! But it is bloody obvious that mountain biking is good for me.

    I think that alternative therapies should be complementary and not alternatives, if someone wants it. I don’t think that acupuncture can cure cancer or impact disease progression. But I do believe that acupuncture can calm people down and alleviate some types of pain (Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture. Goldman N, Chen M, Fujita T, Xu Q, Peng W, Liu W, Jensen TK, Pei Y, Wang F, Han X, Chen JF, Schnermann J, Takano T, Bekar L, Tieu K, Nedergaard M.
    Nat Neurosci. 2010 Jul;13(7):883-8.). So if someone who has cancer wants to do acupuncture, that is fabulous and I am all for it. If they say that it makes them feel better, then I believe them. But I would never say to stop taking their medication.

    Modern medicine has given us some wonderful tools, but it has also given us big egos. If we cannot understand how something works, we are distrustful of it, despite the bloody obvious evidence that it helps people. On average, living in social isolation will reduce life expectancy as much as a lifetime of smoking (http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000316). Just getting out and going to that single yoga class is beneficial. The specifics don’t matter as long as the person likes it. I don’t need a clinical trial of yoga, whatever type, to know that it helps people. However, we cannot say with certainty that yoga will help all people with cancer diagnosis-related anxiety, for example, but if someone said that it helps them, then it does.

    FYI-I’m not a medical doctor-I’m a scientist.

  26. David Gorski says:

    But I do believe that acupuncture can calm people down and alleviate some types of pain (Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture. Goldman N, Chen M, Fujita T, Xu Q, Peng W, Liu W, Jensen TK, Pei Y, Wang F, Han X, Chen JF, Schnermann J, Takano T, Bekar L, Tieu K, Nedergaard M.
    Nat Neurosci. 2010 Jul;13(7):883-8.).

    Another overhyped acupuncture study misinterpreted.

    Click the link, because, as usual, we were all over that study when it came out.

    Seriously. If you are a scientist, I find it rather disappointing that you didn’t immediately see that this study does not show what you think it shows. It’s basically a lot of sound and fury over acupuncture, signifying a whole lot of nothing.

  27. Lorie Anderson says:

    Quiz: Do you think the following statement was written by someone for or against homeopathy?

    “Samuel Hahnemann, MD, the 19th century inventor of homeopathy, used 30C dilutions for many diseases. This means that there is 1 molecule in “10 to the sixty” molecules of inert solvent. On average, this means you would have to give two billion doses of a 30C remedy per second to 6 billion people for 4 billion years in order to deliver a single molecule of the original material to any patient! ”

    If you guessed Against, you are wrong. It was written by Ralph W. Moss, PhD. , a well credentialed “science” writer. You’d think that someone who promotes and defends homeopathy would suffer a terrific cognitive dissonance migraine after figuring out what 30C means. (Oh, but it’s the memory of water, oh yeah, that makes it logical, riiiight.)

    But this is the most depressing part of his article, which begins:

    “A landmark paper on homeopathy and cancer has appeared in the February 2010 issue of the International Journal of Oncology. Scientists at the University of Texas M.D. Anderson Cancer Center (MDA), led by Moshe Frenkel, MD, have confirmed the ability of four homeopathic remedies to induce apoptosis (programmed cell death) in breast cancer cell lines in the laboratory. ”

    A mainstream journal and a major cancer treatment center that don’t consider implausibility – sigh.

  28. g says:

    @David Gorsky

    “Seriously. If you are a scientist, I find it rather disappointing that you didn’t immediately see that this study does not show what you think it shows.”

    And I am disappointed that you believe that you can read people’s minds.

    I’ll quote myself, “I don’t think that acupuncture can cure cancer or impact disease progression. But I do believe that acupuncture can calm people down and alleviate some types of pain.”

    That is a pretty vague statement and definitely not a broad endorsement of acupuncture. I’d have a hard time figuring out what someone thinks about that study, or acupuncture, from that statement.

    Not believing something because it has not been rigorously tested (or cannot be) and the exact mechanisms are not known, does not mean that it does not have value, or even the value that we think it should have. This is a case of not seeing the forest for the trees, of being lost in the details or the lack thereof.

    I’ll try to highlight my point a little better with a hypothetical situation:

    There is a woman who is having trouble becoming pregnant. She and her husband went to the doctor and were found to be healthy. They should have had no trouble conceiving. Yet they still could not conceive a child. Finally, she tried acupuncture. After 10 sessions, and a few months later, she became pregnant.

    From this situation, does acupuncture work? We definitely can’t say that acupuncture will help people with fertility problems. Stress about conceiving can reduce the likelihood of becoming pregnant, so maybe it calmed her down. But maybe she just didn’t become pregnant within the time frame that she wanted, and she simply became pregnant after she tried acupuncture.

    We cannot definitively say anything about acupuncture, except that she did not conceive, she tried acupuncture, and then she became pregnant. But what if we asked her if it worked. If she said yes, then acupuncture had value for her, despite the lack of compelling evidence. If she believes it helps, then it is valuable for her.

    So this is where things get sticky-subjectivity. Suppose we were to test meditation as an adjunct therapy to medication for generalized anxiety disorder. If our group was comprised of people who thought that anyone who meditates is a quack, then I doubt that you’d find a statistical improvement. But if our group was comprised of people who really thought that meditation would work, then you’d probably find that meditation helps.

    From a strict Western science standpoint, meditation will never be indicated for GAD. But does that mean that it doesn’t help? Well, it probably would depend on who tries it. That is where alternative therapies should be complementary, if someone wants it.

    I don’t think that alternative therapies should be indicated for a disease or a disorder, but I do think that they can have value in helping someone suffering from an ailment. If they believe that it is working, there is tremendous value in that. We may never know if it was a “placebo” or if it actually worked. But that doesn’t matter. Our egos and desire for understanding should not impinge on someone’s prerogative about their own health and well-being.

  29. Joe says:

    @JMB on 21 Aug 2010 at 12:23 pm, I am afraid you have delved further into philosophy than I care to go.

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