You might have noticed that I didn’t produce a post last week, something that’s unusual for me, given how prolific I have been in the blogosphere. One reason was personal. The other reason was that last weekend I was attending the annual meeting of the American Society of Clinical Oncology (ASCO) meeting in Chicago. I also must confess that, while I was there, I caused a bit of a stir on the meeting hashtag (#ASCO14) in the name of science-based medicine (SBM) on Twitter under my handle @gorskon. (What? You aren’t following me on Twitter? Get thee hence to my Twitter feed and add me. I’ll wait. Did you do it yet? Good. Now we can move on.) Of course, I know what you’re thinking: Cuddly, lovable me? Causing trouble? Making sure that I’ll almost certainly never be invited to be an official social media doc or to participate in panels on social media at ASCO, despite my extensive experience blogging, using Twitter, and just in general being a pain in the rear online to those who promote quackery and quackademic medicine? Perish the thought!
Of course, it was for just that reason that I was making a bit of a stir on Twitter. ASCO is one of the biggest (if not the biggest) and most organized oncology meetings out there, and there were several people considered “social media rock stars” in the world of oncology such as Mike Thompson, Deanna Attai, Matthew Katz, and Robert Miller live Tweeting the meeting, along with those viewed, correctly or incorrectly, as lesser lights, such as myself. In any case, on Sunday I noticed that a lot of people, including the official ASCO Twitter feed @ASCO, were Tweeting and re-Tweeting a link to this official story from ASCO, “Integrative Oncology Can Add Benefit to Traditional Cancer Treatments.” It was a description of a session that had been held on Saturday morning, Integrative Oncology: The Evidence Base, which, unfortunately, I had missed due to circumstances entirely beyond my control. Fortunately, however, ASCO is benevolent (not to mention that it also justifies the high cost of meeting registration) by providing immediate access to recordings of every major session, not to mention the slide sets used. If I couldn’t be there in person, at least I could cruise on over to the ASCO website and use my access to the 2014 virtual meeting to see what sort of quackademic medicine was being featured at ASCO.
There were three presenters and a panel discussion. Two of the presenters I was well familiar with, making me sad that I had missed the opportunity to be in the same room with them. First up, was Barrie Cassileth, PhD, whom we have met several times before and who is a big name in “integrative oncology,” as befits her position as the chief of the integrative medicine service and current holder of the Laurance S. Rockefeller Chair in Integrative Medicine at one of the greatest cancer centers in the world, Memorial Sloan-Kettering Cancer Center and her having founded the Society for Integrative Oncology (SIO), her topic being an introduction and overview, entitled, appropriately enough, “Integrative Oncology: Overview.” Next up was another big name whom we have met before, Lorenzo Cohen, PhD, who is basically Dr. Cassileth’s counterpart over at the other most famous cancer center in the US, the University of Texas M.D. Anderson Cancer Center, holding the titles of Professor and Director of the Integrative Medicine Program and having co-founded SIO with Dr. Cassileth. His topic was “Mind-Body Practices in Cancer.” Finally, to complete the trio, there was Michelle Harvie, PhD, with whom I am not familiar. She described on the website of the research institute where she works, the Manchester Breast Centre, as a research dietitian at the Genesis Breast Cancer Prevention Centre, University Hospital South Manchester Trust. She’s obviously nowhere near as big a name as Drs. Cohen and Cassileth, but she’s sure enough working on it.
Dr. Barrie Cassileth: “Integrative oncology isn’t quackery. Really, it isn’t!”
Dr. Cassileth seems to have a bit of a chip on her shoulder over “integrative oncology.” Clearly, she resents its being referred to as quackery, quackademic medicine, and not science-based. Indeed, of late, she has labored mightily to try to convince oncologists that “integrative” oncology isn’t cancer quackery, something I first noticed her doing with vehemence a couple of years ago in a review article that was, in part, a broadside against cancer quackery, such as Essiac, the German New Medicine, Entelev, shark cartilage, oxygen therapies, energy therapies, electrical devices (such as Hulda Clark’s “zapper,” prayer, and “healers” using therapeutic touch. That part of her article was something that anyone supporting SBM could appreciate. She also did, as I phrased it, question the “central dogma” of “complementary and alternative medicine” (CAM) or, as I like to call it, “wishing makes it so.” Unfortunately, some of that central dogma was evident in Dr. Cohen’s talk, as I will discuss in the next section. Much to my disappointment, there was no throwdown in the panel discussion between Dr. Cassileth and Dr. Cohen over this.
In any case, this same insistence that integrative medicine is evidence-based, in contrast to all that other cancer quackery, bubbled up again near the end of Dr. Cassileth’s talk in the form of a series of slides, one of which can be seen here, in which Dr. Cassileth, to her credit, emphasizes that alternative medicine is mostly quackery. In the accompanying article on the ASCO website, Cassileth says:
The first step in unraveling the beneficial from the detrimental may be a new understanding of the terminology used to describe these additive therapies, Barrie Cassileth, PhD, of the Memorial Sloan Kettering Cancer Center said during the session. Whereas complementary and adjunctive therapies may have beneficial therapeutic effects, it would be inappropriate to allow them to replace traditional interventions. The term ‘alternative treatments’ more aptly describes those modalities that proffer to replace medical or surgical intervention—although the word quackery may be even more fitting, Dr. Cassileth added.
To me, the “money slide” in the whole series was:
And that’s what bothers Dr. Cassileth the most. To her, quacks are “usurping” or co-opting the term “integrative oncology” in order to peddle cancer quackery. Of course, that’s not the way I saw it. The way I see it is that “integrative oncology” is integrating quackery into oncology. To paraphrase one of my Tweets at the meeting, the only thing “integrative” oncology adds to traditional cancer treatments is pseudoscience. To that, I now add that, if anyone is usurping or co-opting anything, it’s practitioners of “integrative oncology” and “integrative medicine.” They are co-opting perfectly science-based modalities, such as exercise and diet as somehow being “alternative” (word choice intentional, because something has to be “alternative” to fit into the paradigm of “integrating” non-standard therapies into conventional medicine) and then giving the appearance of “integrating them” into conventional medicine when they are already part of conventional medicine.
Indeed, it is not a coincidence that Dr. Cassileth broke down “integrative oncology” into six categories that the session would address:
- Meditation and other “mind-body” therapies (Dr. Cohen)
- Optimal nutrition, special diets, and supplements (Dr. Harvie)
- Massage therapies
- Music therapy
- Acupuncture treatment
Tellingly, Dr. Cassileth spent more effort discussing acupuncture, citing more studies, than she did for any other treatment listed above. It’s understandable that she didn’t discuss mind-body” treatments or nutrition, given that other speakers were going to address these, but, compared to acupuncture, she barely touched on massage and music therapy. She did discuss exercise a bit more, but, of course, from my perspective part of the reason she didn’t discuss exercise more is because it’s largely uncontroversial that at least mild-to-moderate exercise benefits cancer patients and that obesity is associated with a growing list of cancers. Again, there’s nothing “integrative,” “complementary,” or “alternative” about exercise. It’s science-based medicine. The same is true of nutrition. As for massage and music, I tend to agree with our co-editor and co-blogger Kimball Atwood, who simply says that he has no objection to massage, as long as there’s no medical contraindication, because it feels good, and what’s wrong with making patients feel better using something non-invasive? Back in the old days, we used to call such services “supportive” services, things done for patients to take their minds off being in the hospital and the sometimes painful and invasive treatments they require. The problem only comes when something like massage or music is “medicalized,” as in claiming that it treats specific diseases, or “woo-ified,” an all-too-common phenomenon for massage in particular in which massage becomes coupled or conflated with various forms of “energy healing.”
But what about the acupuncture studies? None of the studies presented by Dr. Cassileth provided any compelling evidence that acupuncture is anything more than what Steve Novella and David Colquhoun called it, a theatrical placebo. To this, I would add, given the claims that acupuncture can work to relieve symptoms or reverse virtually everything, be it infertility, nausea and vomiting from chemotherapy, pain, xerostomia, hot flashes, insomnia, lymphedema, and peripheral neuropathy due to certain chemotherapy drugs like taxol, chances are that means that it works for nothing. Dr. Cassileth’s presentation included the usual studies such as this study with no sham acupuncture control claiming that acupuncture relieved symptoms due to neck dissection. Indeed, in the discussion, Dr. Cassileth justifies this design thusly:
For our control arm, we opted for a pragmatic rather than a placebo control. A pragmatic control arm has the advantage of providing an estimate of effect size most consistent with the questions of greatest interest facing patients and clinicians. These questions include: What effects will an acupuncture referral have on a patient’s pain, and will the patient use less pain medication as a result? One disadvantage of a pragmatic comparison of acupuncture with usual care concerns lack of blinding and potential placebo effect.
Yup, which makes me ask: Why even bother doing this study? It shows nothing, Jon Snow. (Sorry. Game of Thrones is getting exciting as it nears the season finale.) She also cited a study indicating that acupuncture is helpful for post-surgery lymphedema in breast cancer patients, a conclusion that I characterized as: Keep those acupuncture needles away from my lymphedematous arm!
Other studies presented included a meta-analysis from 2005 that demonstrates the principle of GIGO as well as most acupuncture meta-analyses do with respect to relief of chemotherapy-induced nausea and vomiting. A more recent Cochrane meta-analysis, although still mildly positive, was a lot less so, concluding, “Overall, acupuncture-point stimulation of all methods combined reduced the incidence of acute vomiting (RR = 0.82; 95% confidence interval (CI) 0.69 to 0.99; P = 0.04), but not acute or delayed nausea severity compared to control.” That would be barely statistically significant, with the relative risk coming close to including 1.0. GIGO, indeed, plus theatrical placeboes!
If the studies she cited were the best that Dr. Cassileth could come up with for acupuncture, either she wasn’t trying very hard, or the evidence base stinks because acupuncture is nothing more than a theatrical placebo. Take your pick, but I pick the latter. In any case, there was nothing in Dr. Cassileth’s talk to change my opinion of either integrative oncology or acupuncture. “Rebranding” the others, such as diet and exercise, as being “additive,” “nonpharmacological,” or somehow “integrative” doesn’t change the fact that what Dr. Cassileth was doing was the same thing that “integrative practitioners” have been doing for a couple of decades now: Rebranding science-based modalities as somehow “integrative” or “alternative.” It is admirable that Dr. Cassileth can and does on occasion attack quackery in a way that would do SBM proud. Unfortunately, it is equally frustrating that she doesn’t seem to grasp that much of the “integrative” oncology she promotes, such as acupuncture, is based on the very same pre-scientific, vitalistic concepts as the cancer quackery she so rightly detests.
Dr. Lorenzo Cohen: Wishing makes it so!
Of all the modalities that Dr. Cassileth introduced in the first talk, the two that have traditionally been considered “alternative” were acupuncture, which she discussed, and various “mind-body” modalities, which Dr. Cohen discussed. I’ve discussed on multiple occasions how M.D. Anderson, sadly, has delved deeply into woo. Unfortunately, Dr. Cohen is the Delver-in-Chief, and he showed why in his talk. He’s definitely good. Sadly, what he’s good at is “integrating” pseudoscience into science-based medicine. He’s also good at “rebranding.”
One thing that has always bothered me about so-called “mind-body” modalities is the dualism inherent in the very name used to categorize these modalities. Think about it. The very term “mind-body” implies that the mind is somehow separate from the body. The assumption behind such modalities seems to be that training the “mind” to control what the “body” is doing will result in prolonged survival in cancer patients. It’s the very concept that Dr. James Coyne argued so eloquently against on this very blog a couple of years ago. To be honest, it’s also a concept that Dr. Cassileth herself argued against in the very same review article that got her into hot water with the “integrative medicine” crowd a couple of years ago as well. Let’s just cite some of her words:
Many of these ideas were promoted by a former Yale surgeon, a popular author who advocated special cancer patient support groups in his books. The importance of a positive attitude was stressed, as was the idea that disease could spring from unmet emotional needs. This belief anguished many cancer patients, who assumed responsibility for getting cancer because of an imperfect emotional status. Among alternative modalities, the mind/body approach has been especially persistent over time, possibly in part because it resonates with the American notion of rugged individualism.
To be fair, in the article Cassileth stated that there were “complementary” therapies that could improve quality of life, but she also stated that some promoters of “mind-body” treatments “overpromise,” by “suggesting that emotional stress or other emotional issues can cause diseases like cancer and that correction of these deficiencies through mind-body therapies can effectively treat major illnesses.”
That is exactly what Dr. Cohen suggested, albeit in a somewhat more subtle way than, say Ryke Geerd Hamer of German New Medicine fame, but, make no mistake, in his talk Dr. Cohen was arguing that mental states and stress contribute to cancer development and progression and that reversing those “bad” mental states can contribute to improved survival. Indeed, he started right out making that very argument, citing a study suggesting that depression is associated with decreased survival in cancer patients, an interesting but highly speculative eight year old review article on potential mechanisms by which stress can contribute to cancer (an article he kept coming back to again and again and again), a ten year old PNAS article contributed by Elizabeth Blackburn (a relatively newly converted proponent of “integrative medicine” whom we’ve met before) claiming that stress leads to shortened telomere length and thus diminished lifespan, and a study relating high social attachment to increased survival in ovarian cancer (which, ironically enough, also reported that “no significant association was found between access to instrumental social support and survival,” meaning that support groups weren’t correlated with increased survival). Why would he have mentioned these studies if he weren’t arguing that somehow the mind influences cancer mortality and that his “mind-body” interventions could potentially result in better survival?
I got the distinct feeling from Dr. Cohen’s talk that yoga is his big thing. He presented multiple studies of yoga in women with breast cancer. As I’ve said before, stripped of its spiritual elements, yoga is nothing more than a specific form of exercise involving stretching and various other body motions; so it’s not surprising that it would have potentially beneficial effects. Of course, that’s what Dr. Cohen noted, citing this recently published study from his group that compared women with breast cancer undergoing radiation therapy, dividing them into three groups: yoga, stretching exercises, and a wait list control. Of course, that means the study was not blinded, making it pretty much useless for saying much of anything about the effect of yoga, given that most of the measurements were subjective measurements of fatigue and health using self-reporting through survey tools. One change noted to be better in the yoga group was cortisol slope, which is a dubious measure, as Dr. Coyne and I have pointed out before. Cohen also cited another recent study that omitted the stretching control and was also similarly unblinded, that looked at inflammatory markers in the wait list control versus the yoga group. It reported much higher vitality and lower fatigue in the yoga group, along with a decrease in some inflammatory cytokines.
The list went on, including animal studies that related chronic stress to tumor progression, a progression that was reversed by beta blockers (drugs that block the effects of epinephrine signaling), an interesting finding, but one that hasn’t yet made it to the level that we recommend beta blockers for cancer patients. If this finding ends up being validated, it would then also become science-based medicine, and oncologists would start prescribing beta blockers to appropriate cancer patients, no woo needed.
Color me unimpressed. Also color me disappointed in that, yes, Dr. Cohen was arguing for exactly the sorts of contentions that Jim Coyne has refuted so well, both in the literature with his colleagues, and here on SBM.
Michelle Harvie: One of these things is not like the others
The last talk came from Dr. Michelle Harvie. To be honest, there’s really not a whole lot for me to say about it or to object to. Here are a couple of the key slides:
As I said, it’s hard for me to argue with most of this. It’s all pretty well evidence-based and unremarkable. She even showed data in which dietary interventions, including vegan diets, failed to arrest or slow the progress of prostate cancer, pointed out that the evidence that observational data regarding whether obesity and/or intentional weight loss has an effect on cancer progression is shaky at best (although it’s better for breast cancer and maybe prostate cancer), and cited a study that high fruit and vegetable intake appear not to affect the outcomes in breast cancer patients. She did point out, however, that a healthy diet can reduce overall mortality, but appears not to affect cancer-specific mortality much, if at all. That, of course, is not particularly surprising, given that healthy diets can definitely impact cardiovascular disease, diabetes, and other lifestyle-associated conditions. Basically, her overall message was that the data regarding diet and cancer survival are a lot less strong than we would like, although it is fairly clear that alcohol intake more than relatively low consumption, is associated with worse outcomes. She even cited an animal study in which nutraceuticals containing antioxidants decreased lifespan, pointed out that the evidence for ketogenic diets and cancer are inconclusive and that intermittent fasting probably has little effect on chemotherapy efficacy, and cited an abstract presented at ASCO that suggested that underweight patients with kidney cancer do worse than overweight patients.
In the end, Dr. Harvie’s talk was largely science-based medicine. Including it in a session on “integrative oncology” was nothing more than rebranding what should be a science-based modality, the effects of nutrition and diet on cancer treatment and survival, as being somehow “alternative” or “integrative.”
Yet another bit of “rebranding,” this time at ASCO
As is frequently the case in sessions like this at academic medical meetings, the last part of the session was a 20 minute panel discussion, in which members of the audience asked questions. What was incredibly disappointing to me was how little there was in the way of any sort of challenge to the assertions made by panel members in their talks or the assumptions underlying those talks. There were questions about green tea and whether it was beneficial, whether yoga has any benefit in relieving the symptoms of chemotherapy, leading to Dr. Cohen promoting a poster discussion he was going to present in a couple of days reporting the results of just such a study, and a question about how to keep “patients honest” about the supplements they’re taking. All of these warnings about dietary supplements not always mixing well with chemotherapy are useful, but it doesn’t really address whether integrative oncology is evidence-based, particularly given the bon mot delivered by Dr. Cohen that somehow it’s better to get antioxidants from foods than from supplements, even though, if antioxidants truly do interfere with chemotherapy action in some cases, chemically it would be the same and only the dose might be different. There was a question on juicing, which was generally not recommended.
I will point out that there was one hilarious question, in which an audience member asked how one can differentiate who is a good acupuncturist who will get the sorts of results claimed in the randomized clinical trials, from an acupuncturist who is a “charlatan.” Dr. Cassileth answered by saying that—of course!—MSKCC has six acupuncturists on staff, making her lucky that she can count on all of them as being highly skilled and doesn’t have to worry about “charlatan” acupuncturists. She also fried yet another of my irony meters when she declared quackery to be a huge problem in acupuncture, proclaiming that there are many acupuncturists who are not well-trained and who are not trained to work with cancer patients and that there’s a big difference between treating adults who might have some “aches and pains” and treating cancer patients. I, of course, agree, but not in the way that Dr. Cassileth meant her statements. There is indeed a big difference between treating benign aches and pains, which will almost always get better, and treating patients with serious disease, like cancer patients, for whom acupuncture is pretty much never appropriate. Come to think of it, acupuncture is pretty much never appropriate for anyone, because it doesn’t work.
And, of course, MSKCC offers a 21 hour Internet course for acupuncturists teaching how to use acupuncture for cancer patients! At only $495, it’s a total bargain! Helpfully, Dr. Cohen chimed in about how there’s a national credentialing board for acupuncturists, and you can look up acupuncturists online to see if they are trained and skilled. Yes, that’ll totally keep you away from quacks and charlatans! Oh, wait. Acupuncture is quackery; so maybe that won’t work so well. Sadly, none of this stopped Dr. Cassileth from suggesting acupuncture for postoperative pain right after this question.
Integrative oncology: Wanting to have it both ways
After having indulged myself in this session, I left very disappointed. On the one hand, I wished that I could have made it to the actual session instead of having to review it online, even though, given the credulity of the questions and the utter lack of challenge by anyone to the scientific basis of what was presented, I’m not sure I would have had the guts to get up there and say what needed to be said. On the other hand, it’s very clear that, for ASCO at least, the session was planned to scream as loudly as possible, “Pay no attention to the man behind the curtain (or prior plausibility or biology)! Integrative oncology is science!” To do that, the session focused pretty tightly on actual science-based modalities, such as diet and exercise, that could easily be “rebranded as somehow being “alternative” or “integrative,” while cherry picking data selling acupuncture as more than an elaborate placebo and implying that “mind” can control body and improve cancer survival based on animal studies and highly selective observational evidence. In essence, Drs. Cassileth and Cohen want to have it both ways, claiming for “integrative oncology” anything about diet, stress, and exercise that might be science- and evidence-based, “rebranding” them and lumping them together with the woo, like acupuncture, which, as mightily as they strive to make it appear evidence-based, remains prescientific, vitalistic nonsense.
ASCO, like many other medical professional societies—I’m talking to you, American Academy of Pediatrics—has a problem. Quackademic medicine is not only infiltrating oncology in the form of “integrative oncology,” but it’s becoming increasingly accepted. It’s not for nothing that we frequently refer to diet and exercise (rebranded as “integrative medicine,” of course!) as a Trojan horse that, once in the fortress of science-based medicine, opens up to disgorge pseudoscience. Sadly, oncology is not immune, as the increasing popularity of “integrative oncology” demonstrates. Unfortunately, “integrating” pseudoscience into science-based oncology does no good for cancer patients, the imprimatur of MSKCC, M.D. Anderson, and, yes, ASCO, notwithstanding.