In June, an article in the Boston Globe covered yet another incursion of pseudoscience into a major academic medical center, this time at the Dana-Farber Cancer Institute. Dana-Farber, located just a couple of miles from the library where I’m writing this post, has provided world-class care for children and adults with cancer since 1947. It’s kind of a big deal.
Sidney Farber, already known as the “father” of pediatric pathology, was the first person to induce remission in pediatric acute lymphoblastic leukemia, which had a 100% mortality rate up to that point. He then went on to earn the title of “father” of modern chemotherapy by also curing Wilm’s tumor, a rare pediatric cancer of the kidneys. Farber, who was featured in the phenomenal book The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee, would almost certainly be opposed the double standard being employed to justify quackery in the facility bearing his name (or anywhere else).
To Farber, a scientific approach to treating pediatric cancer patients was paramount, even to the point where he at first refused to initiate the combination therapy that would open the age of modern chemotherapy because he wanted to protect children from a potentially haphazard rush to cure them. He wanted strict scientific protocols in place and assurances that the evidence would be followed regardless of the outcome, so that the intense desire to find a cure for children that otherwise faced only suffering and death would not add to that suffering.
Unfortunately, combining science-based medical care with medical fantasy is hardly new at Dana-Farber. The Leonard P. Zakim Center for Integrative Therapies has been doing this since the fall of 2000. Using marketing clichés such as “providing cancer patients and their families with the opportunity to take a more active role in their care,” the Zakim Center has increased the number of patients seen yearly from 778 in its first year to 4,000 in 2008.
In 2015, 3,000 patients received acupuncture or massage alone, with many more taking advantage of other services, such as art, music, meditation, nutrition, and various forms of exercise. In addition to the list of interventions that have been co-opted by and relabeled as alternative, pure quackery like reiki, reflexology, and the aforementioned acupuncture are also available for patients. The Zakim Center was also a founding member of the Society of Integrative Oncology. If you aren’t convinced that Dana-Farber has sold its soul and placed marketing over ethical patient care, here is a recent post from their Insight blog entitled “How Can Reflexology Help Cancer Patients?”
Another meaningless anecdote
The recent Boston Globe article, entitled “Easing a patient’s pain – even without proof it works”, discusses Dana-Farber’s $2 million “integrative therapies” expansion that will allow twice as many outpatient appointments for Zakim Center services. But not before providing the typical opening anecdote to hook the reader and prep their brain to ignore the lack of actual evidence, because kids with cancer = emotions:
Massage therapist Maria Barbara “Bambi” Mathay roamed the pediatric clinic at Dana-Farber Cancer Institute, looking for takers. It wasn’t long before she spotted Carlie Gonzalez, 15, wrapped in a yellow blanket and weary from seven months of chemotherapy.
The image of a predator stalking its prey, or a carnival barker attempting to entice passersby, comes to mind while reading that. These patients are, in a very real sense, vulnerable to predation and misinformation. But maybe that isn’t fair. I believe that Mathay believes that what she is doing is helpful, that it helps to relieve some of the intense pain and nausea children with cancer sometimes experience. But does it matter what she believes? It would be one thing if she were simply giving relaxing massages, but…
As the liquid dripped into her arm, Carlie rolled up a pant leg for a session of foot reflexology. “It kind of takes your mind off your stomach,” she said. While Mathay gently pressed on her toes, Carlie sleepily closed her eyes.
So rather than simply a calming foot rub and some pleasant conversation with a caring individual, which would be just fine, the patient is subjected to quackery and is being used as part of the propaganda that helps it spread. She even admits that the process simply distracts her from her nausea. Distraction is a well-known phenomenon that science-based healthcare professionals employ daily in the care of ill patients.
Distraction, or rather altering the attentional state via passive or active methods, has been established as effective in modulating response to both acute and chronic subjective symptoms, particularly pain, in a variety of circumstances that don’t require deception. We know that active distraction is usually more effective than having a patient simply watch TV or listen to music, for example. So you could argue that this patient would have been better off with an electronic game to play. Better yet, Dana-Farber could use the $2 million to hire more Child Life practitioners who can assess each patient individually to find what mode of distraction would best suit their personality and abilities. This would be a lot more holistic than a foot massaging unitasker.
This anecdote, as sweet as it is, is just another example of two very common problems we regularly encounter. On one hand, stories like this are part of a bait-and-switch tactic commonly used by proponents of integrating unproven and implausible interventions with conventional medical care. To the uninitiated this probably seems like a good thing. Reflexology may just be a fancy name for a good old fashioned foot rub after all. It isn’t until almost the end of the article, after most readers will have moved on to something else, that the author provides a brief and inaccurate explanation: “Practitioners believe that pressing spots on the foot that correspond to organs, glands, and other parts of the body can promote deeper relaxation.” That may be the sanitized version Dana-Farber promotes, but it isn’t what reflexology proponents in the real world (or even other academic institutions) are claiming.
The other problem is the utter cluelessness that the media tends to demonstrate when it comes to pseudoscience in medicine. The author of this Globe article, Liz Kowalczyk, is a healthcare and medicine journalist and was a finalist for the Pulitzer in 2013 but she has offered up to the public a pile of credulous tripe. It contains an iota of token skepticism sandwiched between two emotional anecdotes and a barrage of pro-quackery clichés. Why not include one of the many easily-available cases where a child was directly or indirectly harmed by unproven therapies? Why not avoid worthless anecdotes altogether and do your job as a journalist? If Kowalczyk can’t get this stuff right, what chance does the public have to find accurate information?
They don’t need no stinkin’ evidence!
The article continues with a seemingly endless stream of fallacies and blatant misinformation:
A growing body of research supports acupuncture as a treatment for pain and nausea in oncology patients, but few high-quality studies exist on the effectiveness of reflexology and reiki.
It is true that the body of acupuncture research continues to grow, however this is a very poor synopsis of it. As regular readers of Private-investigator-detective know, the most accurate interpretation of the acupuncture literature, and one that takes into account basic science, prior plausibility, and the use of effective controls, is that acupuncture doesn’t work for any condition in any patient. It is theatrical placebo that evokes greater expectation of benefit, and thus greater subjective response, when the practitioner puts on a better performance. The imprimatur of one of the most highly-respected cancer centers in the world certainly adds to the impression of legitimacy and thus likely increases any expectation of benefit.
It’s also true that few high-quality studies have looked into reflexology and reiki. Dana-Farber offers them anyway though. The statement is misleading however, in that we already know enough to say with confidence that these nonsense therapies offer no objective and specific benefit, at best eliciting only subjective placebo responses similar to that of acupuncture or playing with a therapy dog. The dog at least exists, as opposed to mystical human energy fields or an undetectable connection between your foot and your spleen.
Then there is the best sentence in the entire article:
The investment by Dana-Farber, a leading cancer treatment center, underscores a growing willingness among mainstream medical institutions nationally to offer complementary therapies that appear to help patients — even without definitive proof.
There it is, right there in all its glory. The author lumps everything together into the category of “complementary therapies,” another common mistake made by reporters who don’t understand the topic they are covering and often a calculated strategy used by proponents looking to get their foot in the door with co-opted science-based therapies like exercise and relaxation. Exercise doesn’t just “appear to help patients.” We know it does based on decades of high quality research. Acupuncture and its ilk have only the appearance to efficacy and these mainstream medical institutions have an ethical duty to be honest with patients. When a Dana-Farber physician recommends reflexology because it seems to work, without explaining the lack of plausibility and supporting evidence, they are violating that patient’s autonomy, or parent’s authority, to make medical decisions based on accurate information.
Why are academic medical centers opening promoting quackery?
Why would a major academic cancer center offer therapies, like acupuncture and reiki, without solid proof of benefit? Why would they risk taking a hit to their credibility? While I don’t know what is in the hearts of hospital administrators with certainty, it is very likely the result of a combination of marketing aspirations and the work of a vocal minority of believers with money and influence. But those influences needed fertile ground to take root.
As we have discussed before numerous times, the vast majority of physicians working at these centers know that reflexology and reiki are baloney but just aren’t interested in this issue. They have patients to treat and cancer to cure, which are admirable endeavors. With the addition of these integrative medicine centers, they still have research to do and cancer patients to treat, some of which may now be more likely to take part in risky alternative therapies or to forego conventional treatment altogether. These huge numbers of physicians and other healthcare professionals that are uninterested in quackery infiltrating their institutions deserve the lion’s share of the blame for it.
Clearly there are physicians that believe in these interventions. The Globe article quotes Dr. Jennifer Ligibel, who is the director of the Zakim Center and a breast cancer specialist. I would love to eavesdrop on a conversation between her and David Gorski at the next ASCO conference. Ligibel provides a few examples of sloppy thinking and bogus rationalizations used by proponents of irregular medicine:
“Our cancer treatments have gotten better and patients are living longer than ever after diagnosis,” said Dr. Jennifer Ligibel, director of the Leonard P. Zakim Center for Integrative Therapies and a breast oncologist. “The flip side is our therapies have a lot of side effects. And traditional Western ways of trying to treat these side effects are pretty limited.”
Yes, science has helped many people avoid certain death from a cancer diagnosis and to live longer than doctors a generation or two removed would have dreamed possible, so let’s try something else? Of course science-based therapy has side effects. If it can alter physiology of the human body, it can alter the physiology of the human body, regardless of the intervention’s origins. In addition to demonstrating her bias and cultural ignorance by labeling science-based care as “Western,” she begs the very large question that alternative approaches are an improvement. If they were, the science would show it and we wouldn’t be having this discussion.
Many patients also are burdened with depression, and anxiety that the cancer will return.
This is undoubtedly true…so reiki? Perhaps providing your patients with counseling rather than nonsense would be a more effective intervention.
Ligibel said Dana-Farber will study different therapies and approaches — including whether 15-minute sessions during chemotherapy improve patients’ quality of life — in part to help guide other providers. “Without research it’s hard to know where resources should be devoted,” she said.
OAM NCCAM NCCIH has spent billions of dollars of taxpayer money investigating alternative medicine and has failed to provide high quality evidence that any of it works. And the studies they’ve funded showing it doesn’t are consistently ignored. There are already thousands of poorly-designed and controlled studies with positive results for believers to cling too, so what possible benefit could come from a few more? Sadly this comes across as just a transparent justification. In reality, we already have research and the basic science knowledge enough to confidently divert resources away from such medical misadventures.
Speaking of transparent justifications:
Ligibel said more research is needed to sort this out. “I struggle with the mechanism of a lot of these therapies, but I’ve seen them work for people,” she said.
Lorenzo Cohen, director of integrative medicine at MD Anderson said doctors don’t understand the biological mechanisms of these therapies, which is why there is debate. Still, he said, the risk of harm is nearly nonexistent, and if patients feel better “there is something to be said about that.”
There is debate because these therapies are blatant pseudoscience. And I wouldn’t exactly call it a debate. The existence of integrative medicine centers and believers within the medical profession doesn’t mean that there are two legitimate sides to this issue any more than the existence of the Discovery Institute means that there is a debate between evolutionary biologists and…irreducible complexionists?
We don’t understand the biological mechanism of acetaminophen, but we have clear evidence it reduces fever and has analgesic properties. We don’t understand the biological mechanism of IVIG in the treatment of Kawasaki disease, but it’s malpractice if you don’t give it because there is clear evidence that it substantially reduces the risk of serious injury to the coronary arteries. It doesn’t seem that they are “struggling with the mechanism of these therapies” as much as they are struggling to find something, anything to justify their use in the face of so much negative evidence and that they have already decided that these therapies are effective based on anecdotal experiences.
Conclusion: Fighting quackery in hospitals is hard
It’s 2016 and we continue to see quackery being integrated into our best academic centers, which I assume can now generate electricity from the spinning of the many medical pioneers who made them great centers of science and medical progress. Dana-Farber certainly won’t be the last to announce expansions such as the one written about in the featured Boston Globe article. Even Children’s Hospital of Philadelphia, home of Paul Offit, has caved and began offering acupuncture to children last month. It doesn’t look good for those of us struggling to push back.
I’m frequently at a loss when trying to come up with something positive to include in the conclusions to posts like this. Yes we should fight the good fight. We should try to reach out to others who are on the fence or who are skeptical and looking for like-minded folks and science-based information. Of course we should support organizations such as the Society for Private-investigator-detective and reach out to our government leaders. We should vote with our feet, when possible, and not support organizations that promote quackery with our business.
We should do all of these things as much as possible. Still, it is difficult to avoid a sense of helplessness. I am forced to focus on little accomplishments, such as when I discuss a concept such as this or one of the many we cover on SBM with a student and they get it. Every now and then one of them doesn’t just get it, but they are excited about it and they want to learn more. Maybe one day I’ll set someone on a path of skepticism that will result in meaningful change somewhere down the line. Sure it’s unlikely, but it’s a nice thought, and certainly a better one than what I’ve written about with the previous 2,600 or so words of this post.