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There should be no such thing as alternative or integrative medicine. There should only be medicine with strong evidence supporting efficacy and safety.--Dr. David Gorski
What is integrative oncology? The answer to that question depends on who you ask. If you ask me, then I'd tell you that integrative oncology is the treatment of cancer patients with science-based medicine while offering patients access to some sensible practices such as exercise and meditation aimed at reducing pain, nausea, and anxiety, while improving well-being with nutritional service or advice. Unfortunately, integrative oncology also includes some practices, such as naturopathy and energy healing, that are nonsense despite the claim by supporters of integrative oncology that these practices are "evidence-based."*
My definition is biased by my prior belief that naturopathy and all magical thinking about the natural, as well as all forms of energy medicine are nonsense. I realize that many people benefit from their beliefs in nonsense. Such beliefs make people happy, make them feel special, and give meaning to their lives by making them feel connected to a caring universe that has purposes built in by some sort of spiritual energy or being. By calling naturopathy and energy medicine nonsense I don't mean to imply that there are not many satisfied customers of those practices. What I mean by calling them nonsense is that they're not based on a sensible interpretation of what we know about nature and our bodies from the various sciences.
Integrative oncology, at its best, includes not only science-based treatments that try to eliminate or reduce the number of cancerous cells in a patient. It also includes activities that try to eliminate or reduce pain, nausea, stress, anxiety, or depression. Oncological palliative care need not include only medications but may also include such things as massage, exercise, yoga, meditation, and other relaxation techniques. Also, many cancer patients suffer from various kinds of vitamin or mineral deficiencies. Nutritional advice is essential for such patients. Involving naturopaths or energy healers in integrative oncology is more likely to provide unnecessary and wasteful activity on patients who would be better served in other ways. Deluding patients by encouraging them to believe that there is a "natural" diet that will cure their cancer is immoral.
It has become fashionable to refer to activities like massage or meditation as kinds of therapy. This medicalization of non-medical procedures is widespread and I see no way to stop it. Massage is now massage therapy. Learning to relax by listening to music or visualizing serene scenes is now music therapy or visualization therapy or mind-body medicine. I suppose if a clown comes to the children's cancer ward to bring a little cheer into the lives of young patients that would be clown therapy. (No joke, there is an association for applied and therapeutic humor. This medicalization of funnytude seems to be at least as old as the Bible: Prov. 17:22: "A cheerful heart is a good medicine, but a downcast spirit dries up the bones."*) Many people consider prayer a kind of alternative medicine. I don't. I don't consider it any kind of medicine at all, though it is a fact that many if not most people who are diagnosed with cancer start praying. Let those pray who want to pray, but don't call it medicine or therapy.
My nutritionist is not treating my cancer. If I get a massage to help me relax, I am not having my cancer treated. When I exercise I am not treating my cancer with exercise therapy. If I engage in tai chi, yoga, or meditation for my well-being, I am not treating my cancer with alternative medicine. Call me crazy but I don't see any reason to consider nutrition, exercise, yoga, meditation, massage, visualization, prayer, or other relaxation techniques to be "alternative" or "complementary" medicine. They are not in the same league as naturopathy, homeopathy, chelation therapy, and the many varieties of energy healing that are part of what is called integrative oncology. As long as the tai chi, yoga, and meditation don't reference magical energy forces and are stripped of any superfluous metaphysical baggage, I have no objection to them.
Even though I consider much of what is done in the name of integrative oncology to be nonsense, this approach might still be better for some patients than the kind of standard care they may get from a conventional HMO or medical center. Let me try to explain. Nobody goes to a homeopath, a naturopath, or acupuncturist to heal a broken arm or leg. Even the most religious or spiritual person shouldn't care whether the orthopedist's religious or spiritual beliefs harmonize with one's own beliefs. Treating cancer is different than treating a broken bone. If you have a cycling accident and see your arm dangling at the elbow joint--an arm that won't respond to your will and from which emanates a pain unlike any you have ever felt--your doctor won't be the first to tell you that it is broken. If you have cancer, however, you many go for years without suspecting it. You may find out you have cancer over the phone, as I did when my HMO primary care physician called and told me that a CT scan showed I had pancreatic cancer that had spread to my liver. I would not call this approach humane or patient-centered. It did not get much better when, after an endoscopic ultrasound (EUS) and PET scan, I met with my HMO assigned oncologist who deadpanned that I had a neuroendocrine carcinoma that probably started in the pancreas and had spread to the liver.
Looking back after nine months, what I would have preferred was that my primary care physician had called me in for a meeting, letting me know on the phone only that something showed up on the CT scan that he needed to discuss with me and my wife. At that meeting I would like to have been told that the scan showed indications of tumors in the area of my pancreas, spleen, and colon, as well as on my liver. More tests would be needed to know exactly what was going on. There would be no point in going over statistics or past experience with similar scans. Not now, anyway. At that point, I would like to have been told that there was a range of possibilities of what was going on and that my HMO was ready to provide the best possible treatment and care no matter what was found. Presenting best and not-so-best scenarios would have been appropriate. I might have an aggressive form of pancreatic cancer that had metastasized and for which there might be treatment available (whether and what kind would depend on the extent and nature of the original tumor and metastases). At the other extreme, I might have a neuroendocrine cancer that is slow-growing and treatable. Surgery, chemotherapy, embolization, or other treatments could extend my life for years rather than months. A biopsy would be necessary to determine what kind of cancer I had and what treatment would be appropriate for me.
But that's not what happened. I was told over the phone by my primary care physician that a biopsy had been scheduled. I met my HMO gastroenterologist a few minutes before the biopsy and shortly afterward to discuss what he had found. He took great pains to explain to me and my wife why he couldn't get a tissue sample from my pancreas and had to be satisfied with a liver tissue sample only. He treated us with dignity and humanity. He had what they call 'an excellent bedside manner.' To this day I appreciate the way he treated us even more than his excellence and competence as a physician.
Looking back, what I wish had happened is that a pathologist had done a thorough analysis and evaluation of the tissue sample and met with an oncologist, my gastroenterologist, a surgeon, and the radiologists who did my CT and PET scans. Together, they would have gone over my reports and decided what to recommend to me. (You might call such a procedure integrated oncology.**) I would then have met with my oncologist who would have told me what the various medical procedures I'd undergone showed and what treatment or treatments the group--call it the Cancer Board--recommended and why. I would have been given a detailed prognosis and assurance that the care I was about to receive was the best that medical science had to offer. At that meeting there would have been an assistant who would inform me that the medical staff understands the impact of a cancer diagnosis on a person and on that person's immediate family. Proof of this understanding would be given in the form of assurance that the staff was there to provide various kinds of support, should I need it. I might need emotional support. I might need financial support. I might need spiritual or religious support. I might need help with dealing with pain. I might need end-of-life support. I would expect detailed information on these various kinds of support to have been given at the initial meeting with the oncologist, and I would have been better served had I at least been assured that the oncologist and support staff realized the potential upheaval a cancer diagnosis could bring and made sure I knew that services for all of the above concerns were available and would be discussed with me at another meeting.
Instead, I was told by my oncologist I had cancer and my options were no treatment or choose between two forms of chemotherapy I knew nothing about. But before I started on the chemotherapy I would have to attend a class for cancer patients about to start on chemotherapy. A nurse would go over the possible side effects from various kinds of chemo drugs (people with different kinds of cancers would be attending the same class), as well as things like support groups, social workers, and nutrition.
I can easily see why someone with cancer would prefer being treated at a center that offers integrative oncology if the treatment was not just patient-centered but also community-centered, i.e., recognizing that the patient is not an isolated individual but a part of a larger community that may include relationships with a spouse, children, work, and other individuals or groups. While it may be true that many long-established conventional science-based medical centers now have integrative oncology centers because of patient demand, some may also recognize that treating a cancer patient as part of a network of persons to be treated by a group of experts rather than as an individual with a medical problem to be treated by a single doctor is a better way to do medicine.
popularity of integrative oncology
Google "center for integrative oncology" and you will get nearly 20,000 hits. Here is a short list of some major health-care providers with centers for integrative oncology:
- The Simms/Mann-UCLA Center for Integrative Oncology
- The UCSD Center for Integrative Medicine (sponsored a conference on integrative oncology in 2013)
- Memorial Sloan Kettering Cancer Center
- MD Anderson Cancer Center
- San Diego Center for Integrative Oncology
- Oncology San Antonio
- Osher Center for Integrative Medicine at UC San Francisco, Harvard Medical School and Brigham and Women's Hospital, Northwestern University, and Vanderbilt University
- Block Center: Integrative Cancer Treatment
- The Mayo Clinic
All of these fine institutions claim to offer the best of both worlds: the best from the world of science-based medicine and the best from what is called CAM--complementary and alternative medicine. Some institutions call the latter 'safe and effective complementary therapies.' Some call exercise and relaxation techniques, such as yoga and meditation, "mind-body medicine." According to Margaret A. Chesney, Ph.D., Director of the UCSF Osher Center for Integrative Medicine: "Our Center strives to successfully integrate modern medicine, healthy lifestyle practices, and established healing approaches from around the globe, in an effort to meet the need for a new model of care and daily living that promotes healing and well-being of the whole person--mind, body and spirit." This all sounds very hopeful and healthy until you start unpacking the details and find that practices like naturopathy, acupuncture, gua sha, anthroposophic medicine, and reiki are being served up at the banquet along with chemotherapy and surgery, exercise and meditation. This integration of naturopathy and energy medicine with conventional cancer treatments is not just unscientific, it's dangerous and unhealthy. Former naturopathic doctor and Bastyr University graduate (2011), Britt Marie Hermes, says it better than I could:
Naturopathic medicine is a philosophy, a worldview, and even a lifestyle. It is not a real and distinct medical system....
For naturopaths, it does not matter if science refutes the traditional ways of healing. Because for naturopathic believers, what matters is not about what science says, but about beliefs in an alternative, magical healing force. Naturopathic medical beliefs include pseudoscientific ideas like vaccines cause more harm than good, any disease can be successfully treated with homeopathy, alternative cancer therapies are safe and effective, and nutrition can cure mental illness. These beliefs are dangerous and their promotion is unethical.
One of the first places to promote integrative oncology was the naturopathic school Bastyr University in Bothell, Washington. In 1998 Bastyr was given $50,000,000 by the U.S. government to be the home of our National Center for Complementary and Alternative Medicine (now known as The National Center for Complementary and Integrative Health [NCCIH]). (Dr. Chesney is a former deputy director of this outfit.) Congress approved the funds for the center and charged it with looking for ways to integrate traditional Chinese medicine, homeopathy, and Ayurvedic medicine into mainstream health care. Bastyr is now one of ten medical centers funded by the NCCIH (which is part of the National Institutes of Health) to train students in the practices of "complementary and alternative medicine (CAM) and/or integrative medicine (IM)." Today, Bastyr describes itself as a research center for integrative oncology, among other things (e.g., "leading innovation in natural health education"). Here is how the folks at Bastyr describe integrative oncology:
Integrative Oncology care is defined as comprehensive support for each stage of a cancer patient’s experience (from diagnosis to treatment decisions and restoration of immune function and health after completion of standard treatments). Patients can receive care from licensed naturopathic physicians, nutritionists and acupuncturists, all of whom have advanced oncology training.
Treatment options include mind/body medicine, acupuncture, botanical medicine and nutritional support. In Integrative Oncology care doctors communicate with each participant's medical and radiation oncologists to ensure truly integrated care. The goal is to improve not just the quality of life of people living with cancer, but also to reduce the risk of cancer recurrence.
Again, this sounds good until you unpack the details. What do these people mean by "restoration of immune function and health"? What can any of this mean when there is absolutely no scientific grounding for naturopathy, which is a philosophy not a branch of medicine? Naturopathy is not just a philosophy, it's a vague and ambiguous philosophy. What naturopaths practice and what is taught at various naturopathic schools varies immensely. What seems to bind these folks together are a couple of beliefs, the main one being a belief in "the body's inherent ability to heal itself" and in the ability of naturopaths to "identify and remove obstacles to recovery" and "facilitate this healing ability in patients." How can such a belief system ever be integrated into effective and safe treatment of any cancer? Is there any oncologist who believes that the body will heal itself of cancer if only she identifies and removes obstacles to recovery? What would these "obstacles" be? The tumors themselves? No. According to naturopaths, to remove the tumors would be to deal with a symptom rather than the cause of the disease. Another belief of naturopaths is that the "naturopathic physician seeks to identify and remove the underlying causes of illness, rather than eliminate or merely suppress symptoms."* (This idea alone should disqualify naturopathy from being part of integrative oncology: if there is any value in what naturopathy has to offer the cancer patient it would be to help relieve symptoms.) I challenge any naturopath to reveal to the world their discovery of the cause of any one of the more than 200 kinds of cancer there are. Without knowing what causes any particular cancer, there is no way the naturopath can tell us what obstacles we need to remove so the body can heal itself. Surely we expect folks who make such grandiose claims to be able to tell us more than such things as "don't smoke."
The fact is that in most cases of cancer we may never know the cause or causes. We know in general that cancer is caused by a genetic mutation in a cell that involves shutting off the natural process of cell division and death. Cancerous cells don't die. They keep dividing but they do not die and make room for the new cells. This can happen for several different reasons, none of which can be avoided by removing the cause of the symptoms. If the cause is a genetic programming error in a single cell in a single organ and the tumor is detected before it metastasizes, surgery might be said to have removed the cause of the cancer and to have cured the patient. But that's clearly not what naturopaths have in mind when they talk about removing the cause. If the cause is a mutation in the cancerous cell that makes it appear noncancerous to the immune system, then we still have to remove the cancerous cell to remove the cause. There is no naturopathic treatment that can detect and remove cancerous cells. Nor is there any naturopathic treatment that can "boost the immune system" so that that system will recognize and kill cancer cells when they occur. Frankly, if my oncologist recommended that I see a naturopath to help with my cancer treatment, I'd fire my oncologist.
Despite my disdain for naturopaths, homeopaths, and energy healers and my discomfort at the idea of any such persons being involved in my cancer treatment, there are many cancer patients and apparently many doctors and nurses who believe in magical healing and want these folks as part of their oncology team. Like I said above, I have no objection to involving a masseuse, yoga or exercise instructors, or teachers of meditation and other relaxation techniques for dealing with stress, which can be a major problem for many cancer patients, as long as they leave their metaphysical baggage at the door. But it should be the patient's choice whether to use any of these therapies aimed at relieving pain or anxiety. A nutritionist should be a part of any oncological program, but don't call her a nutritional therapist. Some of us with cancer will need few, if any changes, to our diet. Neither our cancer nor our treatments will deplete us of essential nutrients to the point where we need a special diet or supplements. Some of us will have extreme nutritional deficiencies and these need to be addressed on a patient-by-patient basis.
Society for Integrative Oncology
Finally, there is a Society for Integrative Oncology (SIO) that deserves mention:
The mission of the Society for Integrative Oncology is to advance evidence-based, comprehensive, integrative healthcare to improve the lives of people affected by cancer.
This society must have a different concept of 'evidence-based' than I do because it thinks naturopaths and energy healers should be part of the integrative oncology team. The current (March 2015) president and immediate past president are naturopaths. The current board consists of an OMD (Doctor of Oriental Medicine--these are the folks who think your tongue reveals the health of your internal organs) as well as several MDs and RNs. The founder of SIO was Barrie R. Cassileth, a Ph.D. in sociology whose main line of research is in complementary and alternative medicine. According to Wikipedia, she has published extensively on alternative cancer treatments. She founded the Integrative Medicine Service at the Memorial Sloan-Kettering Cancer Center, where she remains the chief and holds the Laurance S. Rockefeller Chair in Integrative Medicine.
One of the things SIO does is provide news and editorials on its website. For example, there was a recent news story (Feb 3, 2015) about the New York State attorney general’s office accusing GNC, Target, Walgreens, and Walmart of selling fraudulent and potentially dangerous herbal supplements. The charges were based on tests of top-selling store brands of herbal supplements that found four out of five of the products tested did not contain any of the herbs on their labels. The tests also showed that pills labeled medicinal herbs often contained little more than powdered rice, asparagus and house plants, and in some cases substances that could be dangerous to those with allergies.
One of the areas promoted by integrative oncology is the use of herbs and supplements as medicine. You would think that a primary concern of SIO would be the safety of herbs and that an editorial about the New York investigation would focus on issues people who use herbs to "help" them with their cancer should be concerned with. Rather than focus on safety or even on the larger issues of truth in labeling and lack of regulation on the purity and potency of herbs and supplements, the SIO editorial focused on the reliability of the tests used in the investigation. SIO cites The American Botanical Council's rebuke of the New York investigation, saying that "relying on DNA barcoding technology alone to validate botanicals is premature."
How reliable is DNA barcoding technology in authenticating botanical supplements?
While the Attorney General’s intentions may have been good, questions remain as to the conclusion of the study: that the botanical supplements were falsely labeled or dangerous until proven otherwise. However, DNA barcoding technology is relatively new, and questions remain regarding its accuracy; it is not the gold standard. It consists of identifying short DNA fragments, which are compared to a library of known plant and animal species. The test itself must be assessed further for its accuracy (the originators of the test at the University of Guelph claim 88% accuracy for supplements of plant and animal origin). It would help, for example, to do DNA barcoding on an extract to see if DNA is indeed found after processing, rather than assume the supplier is mislabeling or adulterating products on purpose. Similarly, it is unclear if “contaminants” are small fragments of DNA we might find in almost any product, rather than “fillers,” or if these other substances produce adverse effects.
From a scientific perspective, the veracity of the results would be strengthened by central review of the testing, multiple test centers, and the use of traditional testing methods as a control. In contrast to the current study, in two separate studies of Gingko biloba extracts done at other centers, evidence of Gingko extracts was indeed present in a majority of samples. While the rebuke from the Attorney General’s office was swift, with consumer confidence shaken, the debate is not yet settled.
Note that the editorial impresses on the reader that it is taking a scientific perspective, but the bottom line is that the writer objects to the undermining of consumer confidence in herbal supplements more than to the possibility that people aren't getting the herbs or the dosages they think they're getting. No mention is made of the fact that herbal supplements are not subjected to the kinds of regulations that pharmaceuticals are subjected to. It is basically an honor system that keeps supplement manufacturers from fraud and packing their products with dangerous fillers (e.g., sugar for diabetics and wheat in gluten-free products). The editorial does mention--in a section on A Call for More Oversight--that "It should be noted that despite FDA oversight, drug adverse events easily dwarf those from natural supplements." I think most of us already know that, in general, it is more dangerous to take pharmaceuticals than "natural" supplements, even adulterated supplements. But the issue here is fraud and its impact on safety.
Also, the New York investigation is just one of several that have found trouble in the herbal supplement market.update: January 21, 2016. The supplement industry is largely self-regulated and many of its products don't contain the ingredients that their labels say they do. This may explain why the best scientific studies of supplements have found no health benefits and some harm from the daily use of supplements. See Frontline's expose, "Supplements and Safety," transcript or film, which aired on January 19, 2016.
Here are links to just a few articles I have seen over the past few years taken from my page on supplements:
Herbal Remedies Can Cause Cardiac Problems Herbal medications such as St. John's wort and ginkgo biloba can affect the activity of prescription drugs, dampening or enhancing their effects. So can grapefruit juice.
Herbal Science International, Inc. Recalls Twelve Dietary Herbal Supplements Nationwide Because of Possible Health Risk Associated with Ephedra, Aristolochic Acid and Human Placenta
Stopper put on more herbal companies By Kirsty Needham and Jeni Porte
In short, I don't have much confidence in the SIO to be much of a watchdog when it comes to the safety and efficacy of herbal supplements, whether such supplements do or do not have a rightful place in cancer treatments.
best of both worlds?
Dr. David Gorski, a breast-cancer specialist and longtime critic of integrative oncology, writes in an opinion piece for Nature.com entitled Integrative oncology: really the best of both worlds?:
Is integrative oncology of value? To the extent that conventional medicine might underemphasize non-pharmaceutical health-promoting activities, such as lifestyle interventions and nutrition, integrative oncology could be argued to be useful in its reintroduction of an emphasis on consuming a balanced diet, exercising, and doing things that promote general wellness, some of which could conceivably at least improve the quality of life in cancer patients, if not their overall chances of surviving their disease. However, this reintroduction is not without a price, and it is questionable whether the claimed benefits are worth this price. Integrative oncology integrates unscientific practices into science-based medicine, and, worse, the pseudoscience at the heart of so many of the non-biologically based subdivisions of CAM is so pervasive, so embedded in the very fabric of integrative oncology, that it opens the door to clinical trials of dubious efficacy and the wasting of time and resources.*
I agree. To borrow from Dr. Harriet Hall's comments on naturopathy: The things integrative oncology does that are good are not special, and the things it does that are special are not good.
*note 1: Evidence-based medicine is not the same as science-based medicine. One difference between the two is that evidence-based medicine does not put a high value on prior plausibility. There is something inherently unhealthy about treating clinical trials of such things as the effects of prayer or dancing on rainfall or on healing at a distance --which have about zero plausibility--on par with various randomized double-blind controlled studies with large groups testing the effectiveness of a new drug. But see the entry on science-based medicine for a more detailed explanation of the difference between the two.
**note 2: Actually, I experienced this type of integrated oncology at Stanford Medical Center, where I went for a second opinion.
See also alternative health practices, complementary medicine, frontier medicine, holistic medicine, integrative medicine, National Center for Complementary and Integrative Health (NCCIH), natural cancer cures, quackery, supplements, and Energy Healing: Looking in All the Wrong Places.
Nissen, Steven E. MD. 2013. Concerns About Reliability in the Trial to Assess Chelation Therapy (TACT). JAMA. 309(12):1293-1294. "Execution of a high-quality RCT requires skilled investigators and study coordinators who understand these critical scientific principles. For TACT, more than 60% of patients were randomized at enrolling centers described as complementary and alternative medicine sites. Many of these centers have websites that describe their services, which include an array of unproven therapies ranging from stem cell therapy to regrow breasts after mastectomy, high-dose intravenous vitamin C to treat cancer, and use of cinnamon for treating diabetes to treatment of influenza with antimicrobial essential oils or homeopathic remedies (while warning patients not to undergo immunization). Other sites offer chelation to treat or cure a variety of conditions including autism in children. A common theme of these centers is evident—they appear to attempt to appeal to vulnerable patients who have challenging diseases by offering a variety of unscientific and unproven therapies. Whether a high-quality RCT can be performed at such sites is questionable."