As I’ve discussed on this blog more times than I can remember over the last decade, I’m not a fan of so-called “integrative medicine” because it involves “integrating” pseudoscience and quackery such as homeopathy and acupuncture with real, science-based medicine (SBM) and co-opting basically all dietary, lifestyle, and non-pharmacologic interventions as somehow being “alternative” and therefore “integrative” when in fact they are and always have been a part of SBM. (Particularly annoying is how integrative medicine advocates are also co-opting the opioid crisis to promote the coverage of quackery like acupuncture by insurers as part of the solution to the problem.) Because I’m a surgeon specializing in treating breast cancer, I particularly detest the bastard offspring of “integrative medicine” known as “integrative oncology,” to the point that I even managed to publish a peer-reviewed commentary in Nature Reviews Cancer explaining why, contrary to how proponents like the Society for Integrative Oncology (SIO) portray it, integrative oncology is far from being the “best of both worlds,” even as they have a hard time defining just what their specialty actually is.
So when I saw a press release drop in my email in box last week about a “Special Focus Issue” of one of the flagship journals for “complementary and alternative medicine” (CAM), “integrative medicine,” or whatever you want to call it these days, I took notice. The journal is The Journal of Alternative and Complementary Medicine (JACM), which is edited by our old “friend” John Weeks, you know, the guy who once compared me to Donald Trump, thus guaranteeing that we will never be friends. The issue is a Special Focus Issue on Integrative Oncology:
A series of fascinating and thought-provoking articles from North America, Europe, the Middle East, and Asia – 6 invited reviews, 13 original research articles, 7 commentaries, and 2 editorials – have been selected to appear in this Special Focus Issue by Guest Editors Moshe Frenkel, MD, University of Texas Medical Branch, Director of the Complementary and Integrative Medicine Unit at Meir Medical Center, Israel and Lynda Balneaves, PhD RN, President of the Society for Integrative Oncology and Associate Professor, Rady Faculty of Health Sciences, University of Manitoba, Canada.
Yes, it’s a lot to go through, 28 articles. Fortunately, I don’t have to go through it all, and if I decide after writing this that I didn’t cover as much of the issue as I think I should have, I can always do a followup post in a week or two and tie up any loose ends that might be left (and, given how much there is to read here, there will be loose ends). The issue will be available free online until October 24; so you can read it if you wish. Naturally, I’ll tend to gravitate towards articles involving my own specialty, but certainly not exclusively. I’ll also probably (mostly) ignore the “original research articles,” because I’m more interested in what advocates want to do with integrative oncology than I am in the usual dubious research used to support integrating quackery with medicine or co-opting diet or exercise as somehow “integrative.”
Before I discuss the content, I think it’s worth briefly discussing the editors. Most of our regular readers probably know who John Weeks is. He’s been a relentless activist for incorporating pseudoscience and quackery into medicine, first in the form of CAM or integrative medicine. He’s been mentioned or the main subject in quite a few posts here and at my not-so-super-secret other blog, such as the aforementioned time when he compared advocates of SBM, including Tim Caulfield, Steve Novella, and myself, to Donald Trump, leading Steve to note drily, “I wonder if it’s time to extend Godwin’s law to include gratuitous references to Trump.” (Of course, this was two years ago, a month before Trump was elected President; so with the benefit of hindsight I respond, “Hell, yes!”)
I first noticed Mr. Weeks as editor of The Integrator Blog, one of the most vociferous boosters of CAM or “integrative medicine” on the Internet. Mr. Weeks is not a scientist or physician—or even a practitioner of one of the alternative medicine “disciplines” whose “integration” into real medicine he favors; yet somehow he was appointed editor of JACM in 2016, despite having no relevant experience as an editor and writer that would qualify him to be the editor of an academic medical journal. He is, however, very good at propaganda and promotion, and that the JACM valued those skills over the skills of an actual scientist or academic physician to the point of hiring someone like Mr. Weeks as editor should tell you all you need to know about the academic rigor of the journal.
But what about Moshe Frenkel, MD? I haven’t really written about him here, although I did mention him briefly in a post about how it’s a myth that integrative oncology never recommends alternative treatments without conventional medicine. Let’s just say that Dr. Frenkel, who used to be the chief of the integrative oncology service at U.T-M.D. Anderson Cancer Center but is now back in private practice while still holding a clinical faculty appointment at the University of Texas Medical Branch at Galveston, with an additional affiliation with the Institute of Oncology Meir Medical Center, is a believer in homeopathy. Indeed, he once wrote an article entitled “Is There a Role for Homeopathy in Cancer Care? Questions and Challenges“, which was lovingly deconstructed by a friend of the blog. I first encountered him when he published a rather terrible study in which he tested homeopathic remedies against breast cancer cell lines and got a positive result, almost certainly because his methodology was so shoddy, as explained by both Rachel Dunlop and the aforementioned friend of the blog.
Then there’s Lynda Balneaves, PhD RN, Associate Professor, Rady Faculty of Health Sciences, University of Manitoba, Canada. We’ve met her before, too, specifically in her role as the current president of the SIO, as well as for her contribution to “integrative oncology” guidelines for breast cancer, trying (and failing) to define just what the heck “integrative oncology” actually is, and getting the American Society of Clinical Oncology (ASCO) to endorse SIO’s guidelines for breast cancer. I was particularly annoyed by her dismissal of “skeptics”:
I believe that there are certain people who are professional skeptics. That is the focus of their career. They have a vested interest in promoting that perspective. A lot of their criticisms, when you unpack them, are grounded in philosophical differences. From my experience in oncology, when I get those comments, their concern stems from an experience in which a patient was given bad advice and their therapy was not evidence-based. I respect that perspective. I have seen it myself.
However, these critiques sometimes may reflect ignorance about the current state of evidence that exists in integrative medicine. Many of the individuals who provide these critiques have no experience in integrative medicine research or practice. They have very limited knowledge of the therapies that exist and the evidence that supports them. Many of them have never worked with patients, particularly those with a cancer diagnosis who are looking for therapies that are going to preserve their hope, give them a sense of control, and perhaps manage some of the toxic side effects that many of our conventional therapies have.
Yes, basically she’s dismissing critics who don’t actually practice or research “integrative medicine”. Let me just say that, although we don’t practice integrative medicine here (mainly because we view much of it as quackery), all of us have extensive knowledge of the therapies that exist and the evidence that supports them (or, to put it more accurately, the lack of evidence that supports them). I personally work with cancer patients. That’s why I was profoundly offended by Balneaves’ ignorant dismissal of skeptics.
So, yes, we have true believers editing this Special Focus Issue.
The propaganda begins
The first article in the issue is, as is usually the case for Special Focus Issues like this, an introduction by the editors. In this case, the introduction is entitled “Integrative Oncology: An Essential Feature of High-Quality Cancer Care“. I laughed out loud when I read that title and couldn’t help but think in my head my usual riff on The Princess Bride: “High-quality cancer care. You keep using that term. I do not think it means what you think it means.” Especially if you think that adding pseudoscience to cancer care means “high quality.” One thing I did learn from this article is that there’s a new buzzword in town that appears to be the preferred term for describe CAM or “integrative medicine”, and it’s “complementary and integrative medicine”. Unfortunately the abbreviation for this term (CIM) doesn’t slip as nicely off the tongue as the abbreviation for one of the old terms (CAM, for complementary and alternative medicine). The term is also rather self-contradictory as well. After all “complementary” is supposed to mean “in addition to” and is a term that integrative medicine has been trying to get away from over the last couple of decades because it implies that what its practitioners are doing is not necessary but merely “complementary” to real medicine. That’s the entire reason why the term “integrative medicine” evolved in the first place!
In any event, after using the usual appeal to popularity fallacy to justify integrative oncology, Frenkel and Balneaves note:
As a result, integrative oncology has emerged as a scientific field that aims to address this interest through collaborative practice and rigorous research. Integrative oncology, as defined in a recent article, “is a patient-centered evidence-informed field of cancer care that utilizes mind and body practices, natural products, and/or lifestyle modifications from different traditions alongside conventional cancer treatments.11 Integrative oncology aims to optimize health, QOL, and clinical outcomes across the cancer care continuum and to empower people to prevent cancer and become active participants in their healthcare before, during, and beyond cancer treatment.”11 This field has grown rapidly in the past decade, and integrative oncology practice has emerged in North America, Europe, the Middle East, and Asia.5,12
As integrative oncology has developed as a clinical specialty, so too has research on the efficacy and safety of CIM therapies in cancer care. In the past decade, researchers and clinicians at numerous academic centers worldwide have examined the potential supportive role of integrative oncology in symptom management and enhancing the QOL of cancer patients and their families.13–15 In addition, recent studies suggest that CIM integration might have direct effect on survival.16,17 Research in integrative oncology has now reached the point that clinical guidelines focusing on the role of integrative practices are being developed and endorsed by leading oncology organizations, including the American Society of Clinical Oncology and the Society for Integrative Oncology.18
That last part, unfortunately, is true. However, this is the first time I’ve heard it claimed by advocates of integrative oncology that “CIM” might have a direct effect on survival; so I looked up references #16 and #17. Then my memory returned. This is nothing more than the usual rebranding of exercise, nutrition, and other lifestyle changes as being “integrative”. The references list a bunch of studies regarding diet, exercise, and survival, some of which didn’t appear to control for obvious confounders. The authors of one paper were entirely too credulous towards the evidence regarding psychsocial and “mind-body” interventions in breast cancer, apparently not examining the evidence as skeptically as our occasional guest contributor Jim Coyne did. In any event, the finding that better nutrition and exercise can improve survival in some cancers is neither novel nor particularly surprising.
Teaching integrative oncology
Not surprisingly, there is a lot of emphasis on “teaching” integrative oncology, or, as I look at it, proselytizing. For instance, there’s an article by Claudia Witt, whom we’ve met before. As Mark Crislip pointed out, she’s a believer in homeopathy and has published multiple articles on it, including one on homeopathy for back pain. Amusingly, she was the lead author on an SIO-commissioned article developing a definition for integrative oncology. The article is, of course, about training oncology physicians to advise their patients on complementary and integrative medicine. Of course, I’m all for such training, but my idea of what would constitute good training in this skill is very different from what integrative oncology advocates would think of as good training.
Suzanna Zick, on the other hand, the naturopath who, much to my shame, runs the integrative medicine program for the Department of Family Medicine at my alma mater, the University of Michigan, where credulous grand rounds on homeopathy are now a feature, has just the thing: her Integrative Oncology Scholars Program, which she touts as a “model for integrative oncology education.” The goal of the program is:
It has the joint goals of training 100 integrative oncology (IO) leaders over 4 years and facilitating partnerships between IO leaders and complementary practitioners within their communities. Eligible participants, who are designated as IOS, include a multidisciplinary selection of physicians, physician assistants, nurses, psychologists, social workers, physical or occupational therapists, and pharmacists, who are actively engaged in clinical oncology practice. IOS instructors are experts in the field of IO and/or adult education and reflect the multidisciplinary nature of the program with professions as diverse as patient advocates to oncology clinicians. Details on course instructors, program eligibility, and how to apply are available on the IOS Program website.
All I can say is that if the curriculum of this program is anything like the eLearning program in acupuncture offered by Zick’s department, it’s going to be a load of credulous nonsense. I do agree, though, with Mark Crislip, who in his usual sarcastic fashion observed, in essence, that if you want someone to teach prescientific mysticism and medicine, you couldn’t do better than a naturopath, and this program just started in August with its first 25 trainees.
Next up, John Weeks can’t resist contributing an article, “Expanding the Circle for the Care of People with Cancer“. In it, he takes some verbiage to settle a score regarding a study published in July by Skyler Johnson and his colleagues showing that CAM, CIM, or “integrative medicine” use was associated with poorer survival in several cancers. Mr. Weeks is not at all happy about it, not at all:
In the closing days of making selections among the outpouring of nearly 70 article submissions, a research-inspired story hit the mainstream media with a force that underscored just why this continued bridge building and circle expansion are needed. Picture yourself as an individual in the throes of fear amid a new cancer diagnosis. You pick up the New York Times and read this headline: “People who used herbs, acupuncture and other complementary treatments tended to die earlier than those who didn’t.” The message, broadcast through many of the world’s most powerful media channels, was quickly challenged by leading integrative oncologists as a major misclassification error. The differences in lifespan found were all due to patients delaying or refusing recommended care—thus choosing “alternatives” to treatment rather than “complementary” care that would be part of an integrative oncology strategy.6 Yet, there it was for anyone considering their choices: research from a respected medical school, Yale, in a pre-eminent journal, JAMA Oncology, misleading patients who, quite likely, received little or no guidance on integrative practices from the narrow healthcare team at the institution where they are receiving their powerful and damaging cancer treatments.
This misclassification was symptom, not cause. Consider a group of male academics setting a curriculum in women’s studies, or of white people deciding how to involve people of color. The cause is the failure of the authors and the journal editors to have Thibault on their shoulder, urging them to expand their circle of collaboration. They did not need to look far to expand their circle and bring in an expert who knew something about the field on which they were passing a sort of life and death judgment. The American Society for Clinical Oncology has endorsed breast cancer guidelines from the SIO.7 The Journal of the National Cancer Institute partnered with SIO on an entire special issue.8 At the time of the Yale study, the late integrative oncologist Ather Ali, ND, MPH, was head of an integrative oncology program at a Yale teaching center for cancer treatment.
First off, Mr. Weeks points to Yale having a naturopath as the head of integrative oncology as though it were a good thing. It’s not, and I’m sure the fact that Yale had a naturopath running anything at Yale came close to giving our fearless leader Steve Novella a stroke. Naturopathy is quackery. We’ve written more articles and spilled more digital ink into the ether explaining why than there is room to recount here. It’s sad that Ali died at such a young age, but I wasn’t happy that he had a faculty appointment at Yale.
Ah, yes. Mr. Weeks does love his “no true Scotsman” fallacy. “No, no, no, it’s not us, the “respectable” ones advocating the integration of quackery into oncology”, Weeks seems to be saying. “We’d never do that.” Of course, the news stories I saw were careful to point out that this was an association, and Johnson and his coauthors themselves specifically chose patients who had used at least one conventional modality as part of their cancer treatment. They also did point out that the decreased survival observed appeared to be due to a higher tendency among those using CIM (I’ll give in and use the term Weeks likes to use, at least for this one post) to refuse at least one form of conventional therapy. I also pointed out that a common claim among “integrative oncology” advocates is that their addition of woo to the mix helps patients stay the course and make it through their treatments. As I said at the time, at the very least, the result of Johnson et al suggest that when the SIO or other CIM advocates claim that CIM is worthwhile because it keeps these patients undergoing conventional therapy, they’re either full of it or at the very least way, way, way overstating the case, and this bit of data further suggests that, even if integrative oncology does keep patients wanting “natural” therapies in the fold of SBM, it’s not doing a very good job of it. I was also amused by Weeks’ arrogance in claiming that, if only Johnson et al had consulted an integrative oncology expert, they could have avoided “embarrassing” themselves so.
But fear not. According to Mr. Weeks, integrative oncology shall overcome. He even invokes a name that quacks and pseudoscientists love to invoke when predicting that their beliefs will be vindicated, Thomas Kuhn and his book The Structure of Scientific Revolution, paraphrasing Kuhn and saying that “we see the most resistant behavior just before a paradigm shift occurs.” Maybe. Personally, I wish we saw more resistance to the creeping infiltration of quackery into oncology and medicine; from my perspective there hasn’t been nearly enough resistance, and resistance is declining, not increasing.
Exceptional responders and integrative oncology
If you want to get an idea, though, of the propaganda and how far it goes in this issue, you should check out Glenn Sabin’s contribution, “Exceptional Responders, Outliers, and Radical Remissions“. Oncologists use the term “exceptional responder” to describe a cancer patient whose response to therapy is, well, exceptional. That can range from complete remission where none is expected to a much better than expected response. The formal definition of an exceptional responder according to the National Cancer Institute is a patient with cancer who has:
- a complete response to a drug(s) where complete response is seen in less than 10% of patients receiving similar treatment; or
- a partial response lasting at least 6 months where such a response is seen in less than 10% of patients receiving similar treatment; or
- a complete or partial response that lasts longer than 3 times the median response duration in the literature for the treatment
Exceptional responders are a hot research topic in precision medicine initiatives, because scientists now believe they have the tools to start to figure out why some people respond so much better to certain drugs and use that information to try to improve our treatments. Glenn Sabin, you might remember, is a man who believes he cured himself of chronic lymphocytic leukemia (CLL) using only alternative medicine and lifestyle interventions and now advocates “N-of-1” trials of alternative medicine. As I’ve explained in great detail elsewhere, the quackery almost certainly wasn’t what resulted in his good fortune. It’s far more likely that he underwent a spontaneous remission, which, albeit rare in CLL, is not so rare as to be less likely than all the quackery Sabin used having cured him, especially since Sabin suffered from his disease for 20 years before it resolved. In any event, he argues thusly:
Researcher Kelly A. Turner, PhD, based her doctoral thesis4 on so-called spontaneous remission. Turner conducted interviews with scores of cancer patients and healers from around the world for her book Radical Remission.5 Through the book’s website, Turner and her team have captured hundreds of outlier cancer cases. It is this author’s opinion that many of these remarkable patient narratives should be vetted and certified as exceptional responders. A subset of these cases should be developed into high-quality, peer-reviewed, published, and indexed case reports. The most remarkable of these cases should consider enrolling into the NEER trial and future trials that are sure to follow.
Integrative oncology delivered in academic settings has heretofore focused on supportive cancer care—utilizing lifestyle-based therapies, along with complementary interventions and agents—to mitigate the often-deleterious side effects of conventional care. There is a growing evidence base suggesting that these interventions and adherence to long-term positive behavior change may potentiate standard care, extend periods of disease-free survival, and possibly prolong overall survival.3 However, the academic integrative oncology field has heretofore not done enough to investigate and document exceptional responder cases. The author believes that this is a significant missed opportunity.
Only once investigators are curious enough to comprehensively investigate exceptional responders will they begin to understand how this may inform the evolution of precision medicine and the role of integrative oncology therein.
I’m all for studying exceptional responders, but Sabin seems to think that the various forms of quackery he espouses are part of the answer that explain why these patients were so fortunate and why their cancers regressed or didn’t progress, when it’s incredibly unlikely that the sorts of pseudoscientific treatments that Sabin believes to be effective had anything to do with it.
Show me the money
Finally, if there’s one thing that rankles “integrative medicine” practitioners, it’s that many of their services, such as they are, are not covered by government health plans like Medicare or Medicaid or by private insurance. (Insurance plan administrators are funny that way. They don’t like to pay for treatments that don’t work. Hell, they don’t like to pay for treatments that do work if they deem them too expensive.) Indeed, it’s long been a goal of various supporters of integrating quackery to get the quackery paid for, such as the manner in which advocates are on the verge of duping Oregon into paying for acupuncture treatments under the false pretense that it will decrease opioid use and, more importantly, abuse. This brings us to an article by Patricia Herman, “The Problematic Economics of Integrative Oncology“.
In this article, I found a frighteningly passage:
What can be done to improve the economics of integrative oncology?
There are several steps that can be taken to improve the economic impacts of integrative oncology, which will increase patient access and lower financial toxicity for patients. The first is a fairly simple step available to all integrative oncology practitioners: determine the cost of your care to patients. These data can be captured from clinical records even in the absence of a formal study, and these costs can be substantial. A recent article by Standish et al.24 reports on data collected from the medical records of (n = 324) breast cancer patients at six clinics directed by oncology board-certified naturopathic doctors in Washington State. Costs were estimated to be $1,594 per year for early stage breast cancer and $6,200 per year for stage 4 breast cancer patients. Across all patients in their study, 21% of these integrative oncology costs were out-of-pocket. Note that this percentage would be higher nationally because in Washington State coverage is available for every category of provider, including naturopathic physicians. Understanding these costs is important for improving costs to patients.
So in the state of Washington we have breast cancer patients paying up to $6,200 a year for snake oil, fairy dust, and quackery, all under the imprimatur of the state’s licensing board and its apparent law mandating insurance coverage for naturopaths. Of course, it would help a lot more if there were actual…oh, you know…evidence of efficacy. Herman recommends including a cost analysis in any randomized clinical trial of integrative medicine modalities undertaken, which is all well and good, but there’s no good scientific reason to do a lot of those studies in the first place given the extreme implausibility of many “CIM” modalities. In the end, she concludes:
The economics of integrative oncology are problematic because of the lack of good studies, the lack of historic incentives for efficiency, and the high cost of cancer care and its financial toxicity on patients. However, these problems can be overcome, with help from one good economic evaluation at a time.
Personally, my retort would be to forget about the economic analyses and just show your woo works first! In the meantime, stop integrating quackery into oncology.
There are so many more articles in this Special Focus Issue that I might have to revisit it before October 24, so that readers can check out the source material if they want to. In the meantime, know that this issue is advertising and propaganda, not science.