Cancer Treatment Centers of America, naturopathy, and “naturopathic oncology”

Note: Parts of this post have appeared elsewhere, but not in this form.

If there’s one aspect of so-called “alternative medicine” and “complementary and alternative medicine” (CAM) is that its practitioners tout as being a huge advantage over what they often refer to sneeringly as “conventional” or “scientific” medicine is that — or so its practitioners claim — alt-med treats the “whole patient,” that it’s “wholistic” in a way that the evil reductionist “Western” science-based medicine can’t be. Supposedly, we reductionistic, unimaginative physicians only focus on disease and ignore the “whole patient.” Of course, to me this claim is belied by the hectoring to which my own primary care physician has subjected me about my horrible diet and lack of exercise on pretty much every visit I’ve had with her, but then maybe she’s an anomaly, along with PalMD and pretty much every other primary care doctor I’ve ever dealt with. Anecdotal experience, I know, but since alt-med mavens appear to value anecdotal evidence above pretty much all else I thought it appropriate to mention here. Also belying the claim of alt-med practitioners that they “individualize” treatments to their patients in a way that science-based medicine does not is the maddening tendency of various alt-med modalities to settle on just One True Cause of All Disease, be it liver flukes as the One True Cause of Cancer, heavy metal toxicity as the One True Cause of cancer, autism, and various other diseases, or “allergies,” acid, or obstruction of the flow of qi as the One True Cause of All Disease.

Given the claim of “wholism” that is such an advertising gimmick among many of the varieties of woo, I’m always interested when I see evidence that alt-med is imitating its envied and disliked reductionistic competition. True, this is nothing new, given how alt-med has tried to seek legitimacy by taking on the mantle of science-based medicine wherever it can. Examples include the National Center for Complementary and Alternative Medicine (NCCAM), various organizations that try to confer legitimacy to pseudoscience by providing “certification” in various flavors of woo, and moves to push state medical boards to go further than that and confer legally protected status to practitioners by actually licensing them. This latter tactic has been very successful in that many states now license acupuncturists, while some states even license naturopaths and “homeopathic physicians,” the latter of which I find quite amusing because the term perfectly encapsulates what must remain of such a physician’s medical training after being diluted to 30C with woo. The only difference is that, unlike what is claimed with homeopathy, diluting MD medical knowledge with woo does not make it stronger. In terms of naturopathy, though, one of the most alarming aspects of the infiltration of naturopaths into the health care system is that some states in the U.S. and provinces in Canada are seriously considering allowing them to prescribe real pharmaceutical medications, even though they lack the training and knowledge to use such drugs safely.

Imagine my combination of bemusement and alarm, then, when I learned of a new specialty of pseudoscience, namely the field of naturopathic oncology.

Be afraid. Be very afraid. (I know I was when I first encountered this specialty.)

Naturopathy versus science-based medicine

Before I discuss naturopathic oncology, it’s probably useful for me to do a quick recap of what naturopathy tends to believe about disease and use for therapies. If you want an idea of the sorts of woo that are considered “mainstream” by naturopaths, a perfect place to go is to the AANP blog, which discusses the upcomming AANP Convention in Portland, OR from August 11-15. According to the AANP blog this year’s woo-fest will be “one of the best gatherings to date.” Given that the speakers are listed in alphabetical order, I couldn’t help but notice immediately as I perused the list of speakers a talk by a naturopath named Mikhael Adams, BSc, ND, who will be giving a talk entitled Viruses & Pandemics in the 21 st Century: Truth or Dare and the Case for Nature Cure. His talk is described thusly:

This presentation will explore the researched and documented facts relating to viruses and pandemics in the modern age and the vaccinations offered to prevent them, as well the immense toxic burden the average human presents with and its effects on the immune system. Historically, Nature Cure has provided us with a template for repairing and maintaining the “self-healing” and “auto-regulating” mechanisms of our body. This presentation will focus on updated, detailed, effective, and successful “Nature Cure” for today’s chronic conditions.

Connoisseurs of CAM language will recognized immediately a number of code words and phrases in this paragraph, chief among them being the “immense toxic burden” and how it allegedly destroys our immune systems. It’s highly unlikely, of course, that Adams will present anything resembling actual scientific evidence to support his claims of an “immense toxic burden,” but previous experience tells me that it’s extremely likely that he will be laying down a swath of anti-vaccine propaganda, given his reference to “facts” relating to viruses, pandemics, and vaccinations, particularly given how deeply imbedded anti-vaccine beliefs are in naturopathy (only 20% of whom even recommend vaccination), coupled with the belief that uncharacterized (and often unnamed) “toxins” are responsible for most disease.

You’ll also notice that Adams is also a homeopath, and homeopathy is The One Quackery To Rule Them All. If you really want to get a feel for what kind of practitioner Mr. Adams is, though, you should check out the webpage of his group naturopathy practice, The Renascent Integral Health Center in Milton, Ontario, which describes its approach to patient care thusly:

The emphasis of treatment is placed on removing the blockages that keep the individual from being a self-healing, auto-regulating organism. Therapies are implemented that support the individual’s body, as it specifically responds to external stress, toxic challenges and energetic impressions held by the body, that have manifested into the current state of disease. Whether entering treatment at the centre, or having a Medical Intuitive Scan done by distance, the goal becomes to target disease by identifying and addressing the body’s underlying imbalances that have created its symptoms. To resolve the symptoms, Mikhael and Alison’s approaches go beyond the given diagnosis, to reinitiate the body’s ability to recognize the challenges it faces, and support its ability to resolve its state of disease.

It gets better. I didn’t really know for sure what Auricular Medicine or a “Medical Intuitive” scan is. Fortunately, Adams is happy to tell us, given that he has a “medical intuitive” on his staff, namely his wife Alison Feather Adams, who will “scan” you, either in person or over the phone, and tell you everything that’s wrong with you. Meanwhile, as best as I can figure it out, Auricular Medicine is reflexology, only with the “mappings” of various body parts and organs to the ears, rather than to the feet and hands. Here’s Adams’ description:

Auricular Medicine is an energetic reflex technique in which the pulse and filters are used to detect points on the ear. The points that show up on the ear can indicate the location of specific imbalances within the body. Through the use of filters we are able to identify specific dysfunctions within the body.

Auricular Medicine is a specialized field of Energetic Medicine…The Doctors in this clinic use Auricular Medicine as their key diagnostic tool and work with their clients to stimulate self-healing (vis medicatrix naturae) through assessment of the disease state, prevention of disease, evaluation of a client’s state of health, and treatment and care of client’s using means and substances that are in harmony with the client’s own self healing processes.

Auricular Medicine in conjunction with conventional medical tests can find and treat the cause of disease. Many conditions, acute and chronic, can be treated by Auricular Medicine.

I’m sure many diseases and conditions “can” be treated by Auricular Medicine. Whether they should be treated by Auricular Medicine or can be treated successfully with Auricular Medicine is another question entirely. I wonder if Adams uses Col. Niemtzow’s auricular acupuncture as well.

Perhaps my favorite talk at the AANP, at least judging by its title, will be the talk by Sharum Sharif, ND entitled Visual Homeopathy – Identifying a Person’s Constitutional Homeopathic Remedy in Minutes, which promises:

Patient and Hollywood videos will be used to demonstrate how to quickly identify a patient’s constitutional remedy by looking for simple behavioral cues and asking 2-5 questions. The presentation will be focused on the most common remedies accounting for the majority of the population of a general naturopathic clinic.

Who knew it was that easy? As a couple of questions, and pick out some water to treat your patient.

Overall, there appear to be at least seven homeopaths speaking. There’s also Matthew Baral, ND, who is a certified Defeat Autism Now! practitioner, and if there’s a richer source of autism and anti-vaccine quackery besides the roster of DAN! practitioners, I am unaware of it. There’s so much more than even this lengthy post can encompass. Woo that’s considered “mainstream” by the AANP is the environment from which the misbegotten specialty of “naturopathic oncology” sprang.

Naturopathic oncology

It’s not surprising that I first discovered the “discipline” of naturopathic oncology at the Seattle Cancer Treatment and Wellness Center, which is affiliated with the Cancer Treatment Centers of America. As a science-based physician and surgeon I really detest CTCA because it is expert at combining state-of-the-art science-based medicine with pseudoscience like naturopathy, chiropractic, and acupuncture, as well as scientifically tested modalities known not to be particularly helpful in the clinical management of cancer, such as chemotherapy resistance testing (which could be the topic of an entire post). Suffice it to say that the last of these was prominently featured in Suzanne Somers’ cancer book last year. In any case, CTCA covers a continuum from the boringly “conventional” (surgery, chemotherapy, and radiation) to the questionable (chemotherapy resistance testing) to pure pseudoscience (naturopathy, acupuncture, homeopathy) mixing them together to the point where it is difficult, if not impossible, for the average patient to know which is science-based and which is not.

So what is naturopathic oncology? Apparently it’s an “emerging field” within naturopathy concerned with applying naturopathy to cancer. I don’t know about you, but to be an “emerging field” within naturopathy is akin to being an emerging new paranormal phenomenon in the field of parapsychology. But, then, I’m just one of those nasty, reductionistic, skeptical, scientific physicians, so what do I know? On the other hand, Kimball Atwood characterized naturopathy as a “pseudoscientific cult“; so maybe even Orac is not that nasty, at least not in comparison. Be that as it may, let’s take a look at a couple of definitions, written by naturopaths themselves. First, there’s the Oncology Association of Naturopathic Physicians (OncANP) (yes, there is an Oncology Association of Naturopathic Physicians). This is how OncANP defines “naturopathic oncology“:

Naturopathic oncology is the application of the art and science of naturopathic medicine to the field of cancer care and treatment. Naturopathic oncologists work both in hospital oncology settings and in private practices bringing their wisdom, perspective and experience to aid oncology treatment teams that seek the best positive outcomes for their patients.

It all sounds relatively benign; that is, unless you know what naturopathy is. OncANP tries to justify the “need” for naturopathic oncology thusly:

Aware that modern medicine has made little advance in its War on Cancer, many people with cancer choose to also include complementary and alternative medicine in their fight against cancer. They reach out and employ a wide range of therapies including meditation, prayer, acupuncture, herbal, botanical, nutritional, homeopathic, dietary and other holistic practices seeking benefit.

Naturopathic doctors and physicians are trained in accredited naturopathic medical schools in modern scientific nature cure. They are trained in both modern science and natural medicine. They emerge from their training well versed in the use of botanical medicine, homeopathy, diet, fasting, nutritional supplementation, orthomolecular medicine, psycho-immunology and other complementary and alternative medical techniques; they serve as capable guides for patients interested in exploring alternative medicine.

Those naturopathic doctors who choose to specialize in naturopathic oncology understand both the standard treatments employed by medical oncologists and how best to work with them in a collaborative model of cancer co-treatment. They are well aware of the multitude of ‘alternative therapies’ promoted to cure cancer and can help patients understand which might be useful and why.

Note the common CAM claim that we have made “little advance” in the War on Cancer used as a justification for offering pseudoscience. Most of the “therapies” offered are fairly benign, such as meditation and prayer, although I can’t figure out why meditation and prayer are represented as “therapies” rather than manifestations of religion. Of course, much of what else falls under rubric of “naturopathic medicine” and “naturopathic oncology” is pure pseudoscience, in particular, orthomolecular medicine, a construct popularized by the late Nobel Prize winner gone woo Linus Pauling, is pure quackery, advocating as it does megadoses of various vitamins and supplements. Given how late in his life Pauling had come to believe that megadoses of vitamin C would cure cancer (they don’t, alas), it’s not surprising that Pauling was attracted to this particular form of quackery.

Then there’s acupuncture, the Jack of All Trades in CAM. It’s one of those modalities that, it seems, can do anything. Treat pain? Acupuncture. Improve the success rate of in vitro fertilization? Acupuncture. Reduce menopausal symptoms in women with breast cancer requiring anti-estrogen therapy. Acupuncture. Got migraines? Acupuncture. Asthma, allergies, bronchitis, sinusitis, sore throat, laryngitis, colds and flu? Acupuncture. Irritable bowel, colitis, constipation, diarrhea, gastritis, heartburn, food allergies, ulcers? Acupuncture. Cystitis, menstrual cramps, irregular or heavy periods, infertility, menopausal symptoms? Acupuncture.

Death? Maybe acupuncture can allow one to rise from the dead more effectively than Jesus. I think you get the idea.

Naturopathic oncologists even have their own board certification, just like real oncologists. They even put the letters after their name, FABNO, which stands for “Fellow of the American Board of Naturopathic Oncology.” (Personally, I think it stands for “FAB? NO!”) Of course, given the panoply of dubious therapies, some of them contradictory to each other, that naturopaths use, I really wonder what the certifying test is like. When, for instance, do you choose megadoses of vitamin C over acupuncture or vice-versa? When do you choose live cell therapy over this supplement or that supplement? And what is the scientific evidence that any of it does cancer patients any good whatsoever? Especially homeopathy. (More on that in the next section.)

The mind boggles that this “specialty” has its own board certification. How long before naturopathic oncologists push for special privileges in the states that license naturopaths? It’s not even beyond my imagination to visualize them applying for, and getting, the prescribing power to administer chemotherapy along with their herbs, supplements, and other woo. Why would naturopathic oncologists even want this? Easy. For the same reason that naturopaths in general seem to be seeking prescribing power: Real drugs work, and if one mixes real drugs with naturopathy then patients will tend to attribute the success not to the evil pharmaceutical drug but rather to the naturopathic nostrum.

The Cancer Treatment Centers of America, naturopathic oncology, and other woo

I’ve often complained about the infiltration of what sometimes refer to as “quackademic medicine” into medical academia. Quackademic medicine, as you recall, is the term we use to describe how so many medical schools have taken to studying fairy dust treatments like reiki and acupuncture as though they are science-based, often justifying this study with the rationale that they are “ancient” treatments and that lots of people use them. Promoters of pseudoscience have even managed to carve out a whole center at that bastion of science-based medicine, the crown jewel of the biomedical research effort of the United States the National Institutes of Health. That center is the National Center for Complementary and Alternative Medicine (NCCAM).

While we’ve spent a lot of time on RI lamenting and doing my tiny part to combat the infiltration of pseudoscience into medical academia, we’ve spent comparatively little time on what is arguably an equally serious threat to science-based medicine. That is the infiltration of “integrative medicine” into private medical institutions that use integrative medicine as a marketing tool in order to distinguish themselves from the rest of the pack. Arguably, no hospital chain has been more successful at this than The Cancer Treatment Centers of America. Over more than 20 years, CTCA has built up a network of hospitals in suburban Chicago, Philadelphia, Tulsa, and suburban Phoenix, as well as a network of physician practice groups in Seattle and elsewhere. CTCA was founded in 1988 after its founder’s mother lost her battle with cancer, its mission being to “change the face of cancer.” Unfortunately, at least in its hospitals it is succeeding, and not in a good way. This is how CTCA describes its founder, Richard J. Stephenson’s, mission to find treatment for his mother:

After his mother’s diagnosis, Mr. Stephenson embarked on a mission to find the most advanced and effective cancer treatments available. He hoped his efforts would enable his mother to recover and remain an integral, irreplaceable part of his life and the lives of his children.

The Stephensons were sorely disappointed by what they found. What were regarded as world-renowned cancer treatment facilities were singularly focused on the clinical and technical aspects of cancer treatment, ignoring the individual needs of the patient and the multi-faceted nature of the disease. Tragically Mrs. Stephenson did not live to watch her grandchildren grow and mature.

To keep his mother’s memory and spirit alive, Richard vowed to change the face of cancer care. He selected a group of outstanding oncologists and challenged them to find a way to deliver whole-person cancer treatment in a compassionate, nurturing environment.

Death from cancer is tragic; it’s often painful and slow, and the sense of helplessness and loss that accompany watching the decline of a loved one to cancer is sometimes more than a person can bear. Mr. Stephenson might have done more good if he had dedicated his grief to founding truly science-based cancer hospitals that had ingrained in their culture caring and the “human touch.” Unfortunately, he appears to have confused compassion and the human touch with “integrating” pseudoscience into science-based medicine. Instead of producing an institution that could really transform cancer care by preventing the tendency of large institutions to become impersonal, he’s created a Frankenstein monster cobbled together using a lot of perfectly sound science-based treatments, including surgery, chemotherapy, and radiation with pure pseudoscience like naturopathy and traditional Chinese medicine bolted on like the head of the Frankenstein monster.

Let me show you what I mean. I happen to have a few quick-and-dirty rules of thumb that allow me to rapidly identify a practice that is full of woo. These are just my opinion, but I find them fairly useful. One of these rules of thumb states that, if a CAM practitioner offers “detox foot baths” as one of his services, he’s a quack until proven otherwise (and he’s unlikely to be proven otherwise if he’s actually sufficiently cynical or enough of a true believer to charge for quackery like “detox foot baths”). I haven’t seen a naturopathic oncologist, either at CTCA or elsewhere, offer detox foot baths (yet), but I have seen them offer homeopathy, and I’ve seen them advertise it at CTCA. In my opinion, homeopathy is rank quackery; there’s just no other way to put it. In fact, these are the treatments that the naturopaths at CTCA offer:

  • Nutritional supplements, including vitamins, minerals and amino acids
  • Botanical medicine (the use of herbs)
  • Homeopathic medicine
  • Hydrotherapy

I’m always irritated when I see nutrition co-opted this way. If you go to the nutrition page of CTCA, you’ll find a lot of verbiage that sounds perfectly reasonable and science-based (albeit with exaggerated claims that science-based physicians don’t pay any attention to nutrition). It’s also claimed that malnutrition is one of the main causes of cancer death, accounting for perhaps one third of them, which is one of those claims that is superficially true but also ignores the fact that many cancers cause cachexia (wasting syndrome) by mechanisms that are poorly understood. Cachexia can’t be reversed just by providing nutritional support, nor can it be so easily prevented. Worse, CTCA uses the term “superfoods,” which is a marketing term designed to make claims about various foods far beyond what science will support. Certainly, it’s not a medical or scientific term, and it’s particularly annoying when CTCA claims that “superfoods” actually “fortify the immune system,” as that’s the same trivially meaningless claim made by woo peddlers of all stripes. In any case, the claim that CTCA is any better than any other cancer center at nutrition falls apart when I see things like this on its website:

According to the National Cancer Institute, 20% to 40% of cancer patients die from causes related to malnutrition, not from the cancer itself. CTCA chef Kenny Wagnor suggests loading your diet with anti-oxidants, which are found in bright colored foods such as berries. Chef Wagnor prepares a blackberry strudel packed with tasty berries and pecans — a great combination of cancer fighting foods!

At the risk of annoying certain readers, I will point out the logical fallacy here: non sequitur. It does not follow from the observation that 20-40% of cancer deaths are related to malnutrition that eating lots of antioxidants will help you beat cancer. In fact, it’s controversial whether antioxidants help or hinder chemotherapy; it probably does one or the other depending on the tumor type and the chemotherapy. My pet peeve about how CAM practitioners abuse nutrition as being somehow “alternative” and not considered important by scientific medicine, note how CTCA naturopaths actually offer homeopathy to cancer patients. Yes, cancer patients are being given magic water in order to relieve the side effects of their cancer therapy.

The coopting of science-based modalities like nutrition at CTCA doesn’t end there. It’s everywhere. For instance, look at the CTCA webpage on Oncology Rehabilitation. In addition to standard physical and occupational therapy treatments, CTCA also offers:

  • Swedish Massage
  • Reflexology
  • Lymphedema Massage
  • Myofascial Release

I certainly don’t have any problem with Swedish massage. It’s not a “therapy” per se, but there’s little doubt that it makes patients feel better. Lymphedema massage, if done according to science-based principles and not according to some “alternative” medicine techniques, is a valid technique to try to reduce the lymphedema that can occur as a complication of lymph node dissections performed for breast cancer and melanoma. However, reflexology is pseudoscience, as is myofascial release. Once again, CTCA is “integrating” woo with science. This is not surprising, given that its entire website is permeated with what Dr. Atwood would call the Weasel Words of Woo. Here is an example from the Bone Cancer Treatment page:

Your body is designed to inherently establish, maintain, and restore health. The healing process is ordered and intelligent; nature heals through the response of the life force. The role of the naturopathic practitioner is to facilitate and augment this process, to identify and remove obstacles to your health and recovery, to help your body maintain its healthy equilibrium, and to support the creation of a healthy internal and external environment for you.

Note the vitalism inherent in this brief passage, in which nature heals through the “life force.” This is not science. It has no place in science-based medicine.

“Naturopathic oncology” versus science-based medicine

Given the vitalism and woo that permeate naturopathy in general, a small taste of which I just described above at the “official” yearly gathering of American naturopaths, it’s not surprising that “specialized” naturopathic oncologists, like naturopaths in general, are not too receptive to scientific testing of their “art.” Sure, they say they are, but when it comes right down to it, in contrast to science-based physicians, naturopaths can’t accept negative clinical trials. For example, take a look at what naturopath Timothy Birdsall, FABNO, who is Vice President of Integrative Medicine for CTCA, says about research finding that his favored therapies don’t work. In the American Association of Naturopathic Physicians’ blog, he wrote an essay earlier this month entitled The Problem With Research in response to clinical trial results showing that selenium doesn’t help patients with lung cancer. Here are some choice quotes:

To top it off, the reason I was out of the office last week was that I was attending the National Advisory Council for Complementary and Alternative Medicine, the advisory body to NIH’s NCCAM. On that council, we have talked about just this issue — why do therapies which seem to make biological and physiological sense, which have some epidemiologic data to support their use, and which naturopathic physicians (and other alternatively-minded practitioners) have been using for decades (or much longer), seem to fail in double blind, randomized clinical trials?

We science-based physicians ask ourselves the very same question time and time again. Many are the seemingly plausible therapies that, when tested in humans, failed to show benefit in cancer. Here’s the difference: when we see therapies, no matter how plausible, that fail in randomized clinical trials, we abandon them. True, it may take more time than we’d like. The process may be messier than we like, as some physicians who are wedded to these therapies are reluctant to give them up when science doesn’t support them. We then move on to try to figure out where our understanding of the biology went wrong. But abandon them we do. We don’t blame science and the randomized clinical trial (RCT), as Birdsall does. First, he trots out the favored canard of CAM practitioners everywhere and argues that RCTs “answer simple, straightforward questions” and (presumably) his woo isn’t simple. Of course, the question of whether selenium can, as he believes, be useful in treating lung cancer is actually a pretty simple, straightforward question not unlike the question of whether a certain chemotherapy can prolong survival or increase the cure rate of a cancer. Instead of realizing that, Birdsall attacks science:

And so I began to ponder the question, “What’s wrong with research?” A part of me becomes enraged at the reductionistic, allopathic, biomedical model, which breaks things down into components so small that all synergism, all interdependence is stripped away, and then declares those components to be ineffective. Another part argues that the wrong component was selected, or was a synthetic form (although in the lung cancer study, they used selenium yeast). But ultimately, I find myself becoming offended because I believe that these therapies work… Whoa! Believe? OK, but where is the role for evidence? I used to believe that stress caused gastric ulcers. And then along came Helicobacter pylori, and I had to change my belief to match the evidence.

Note the standard attack on “reductionism” and “allopathy” and the “biochemical model.” Then note the irony as Birdsall, while declaring that naturopathic oncologists must become science-based and train the next generation of naturopaths to be “great scientists” (I spit up my iced tea when I read that line), he proposes in essence destroying science in order to save it for naturopathy — or, more precisely, to use it to legitimize naturopathy:

Third, we should collaborate with other professions and institutions to craft the research models necessary to adequately perform “whole systems” naturopathic research. There are examples of this type of approach already existing in the health systems research literature which can be adapted to our needs. In the end, we must create and validate the tools to dethrone the randomized controlled trial as the gold standard, and construct new ways to validate clinical approaches to health issues. Much as the homeopaths of 2+ centuries ago created the proving as a way to better understand and utilize their remedies, we must refuse to be limited by the way conventional medicine views health and disease.

I would argue that invoking the magical techniques of people who believe that diluting a remedy makes it stronger and that water remembers all the good bits that have been in it but forgets all the urine and poo (as Tim Minchin so hilariously put it) is not the way to argue for science. Of course, the short version of this is: If RCTs don’t show that naturopathy works, we need to dethrone RCTs and make up our own research methods. Yes, I know RCTs have problems and limitations, but those problems and limitations don’t include not being able to answer the question of whether selenium and antioxidants can improve survival in lung cancer patients.

Sadly, it’s not just academia that is under siege by unscientific medical philosphies and treatment systems. True, academia sets the stage and promotes the spread of pseudoscience-based medicine because it is medical academia that does the research and trains the next generation of physicians. However, most medical care in this country is still provided by private physicians and private hospitals, and some private hospitals like CTCA have discovered that “integrating” pseudoscience-based medicine with science-based medicine can be a recipe for success. As “alternative” medicine infiltrates academia more and more, I fear that the stigma for offering these therapies will decrease more and more, leading to more hospitals and clinics like CTCA.