What is Francis Collins doing speaking to the Society for Integrative Oncology?

I saw this story on Friday and almost couldn’t wait the weekend to blog about it. However, since the conference that was brought to my attention isn’t until November, I ultimately decided that it would keep. At least until now.

This story is about Francis Collins, the director of the National Institutes of Health. Unlike some bloggers, personally, as a physician and scientist I don’t much care about what religion Dr. Collins ascribes to. Unlike some writers such as Sam Harris, most definitely do not consider his strong Christian faith a disqualification for holding the position that he now holds. All I care about in an NIH director is how well he or she shepherds the scientific mission of the NIH and runs the organization. As a supporter of science-based medicine, I just want the NIH to fund and support only the most rigorous science and to be a well-run organization. Thus far in Dr. Collins’ tenure, I haven’t seen any anything major to worry about on that score, although I have had some disagreements with Dr. Collins’ five themes for the NIH.

Recently, however, I was very disappointed to discover that Dr. Collins will be the keynote speaker at the 8th International Conference of the Society of Integrative Oncology (SIO) in November. I rather suspect that he didn’t know just what it is that what he was accepting or what the Society for Integrative Oncology is, other than a professional society. At least, I hope that is the case. From my perspective, “integrative oncology” is a discipline that, at its core, is dedicated to “integrating” pseudoscience with science, and by agreeing to speak to the SIO Dr. Collins will be unwittingly providing it with the imprimatur of his position as NIH director.

To se what I’m talking about, it’s time to revisit the whole discipline of “integrative oncology.” So, what is “integrative oncology” and why does it concern me as a cancer surgeon and researcher? I have already discussed this particular in extreme detail, referring to it as quackademic medicine victorious, and so it is. On multiple occasions, I’ve also referred to “integrative oncology” as a “Trojan horse” that is allowing pseudoscience to infiltrate medical schools and academic medical centers. Here’s what I mean. Whenever you see discussions of “integrative medicine” and in particular “integrative oncology,” chances are, the modalities under discussion will usually focus primarily on various dietary changes and lifestyle interventions, such as exercise. Often recommended exercise comes in the form of yoga, tai chi, and other disciplines that tend to be infused with concepts from Eastern mysticism, such as qi (“life energy”). Other modalities featured often include herbal remedies. In other words, “integrative oncology” in essence “rebrands” modalities that have no reason not to be counted as part of science-based medicine as being somehow “alternative” or “integrative” and points to them as having some promise. After all, if you strip away the Eastern mysticism from yoga and tai chi, among others, all you have left is low impact exercise, and there is no reason to consider low impact exercise to be anything “alternative” or “integrative.” Exercise and diet are within the purview of science-based medicine. Herbal remedies are nothing more than a rebranding of the perfectly science-based subdiscipline of pharmacology known as pharmacognosy. Advocates of CAM/IM then lump together pseudoscience like reiki, “therapeutic touch, acupuncture, naturopathy, and even homeopathy with sensible lifestyle interventions, such as diet and exercise, making the association that, if diet and exercise are “alternative” and work, so, too, do modalities that can at best be considered quackery, such as homeopathy.

Perhaps the best place to begin is with the SIO’s very own practice guidelines. These guidelines represent a masterful package of rebranding of perfectly science-based modalities, such as lifestyle interventions and changes in diet, which are then tied to “energy healing” quackery as if there were an equivalent evidentiary basis to support them. For instance, some of the recommendations of the SIO are, as Dr. Atwood put it, embarrassingly obvious. For example, here are a few selected guidelines to show you what I mean:

  • Recommendation 1: Inquire about the use of complementary and alternative therapies as a routine part of initial evaluations of cancer patients. Grade of recommendation: 1C
  • Recommendation 6: The application of deep or intense pressure is not recommended near cancer lesions or enlarged lymph nodes, radiation field sites, medical devices (such as indwelling intravenous catheters), or anatomic distortions such as postoperative changes or in patients with a bleeding tendency. Grade of recommendation: 2B
  • Recommendation 7: Regular physical activities can play many positive roles in cancer care. Patients should be referred to a qualifi ed exercise specialist for guidelines on physical activity to promote basic health. Grade of recommendation: 1B (1A for breast cancer survivors post-therapy for QoL)
  • Recommendation 15: It is recommended that patients be advised regarding proper nutrition to promote basic health. Grade of recommendation: 1B

What is “alternative” about any of these recommendations? Nothing. Physicians routinely ask what supplements or “alternative” therapies their patients are using. It’s simply mind-numbingly obvious common sense not to use deep massage or pressure near cancer lesions, enlarged lymph nodes, radiation field sites, or near medical devices, such as Portacaths or other indwelling implantable devices. What physician would not recommend proper nutrition or regular physical activity, as much as the patient can tolerate, under the guidance of an exercise specialist? Then, coupled with the above sensible recommendations, we find this:

  • Recommendation 3: Mind-body modalities are recommended as part of a multidisciplinary approach to reduce anxiety, mood disturbance, chronic pain, and improve QoL. Grade of recommendation: 1B
  • Recommendation 8: Therapies based on a philosophy of bioenergy fields are safe and may provide some benefi t for reducing stress and enhancing QoL. There is limited evidence as to their effi cacy for symptom management, including reducing pain and fatigue. Grade of recommendation: 1B for reducing anxiety; 1C for pain, fatigue, and other symptom management

I find it most interesting to note what the SIO considers “1B” evidence:

Strong recommendation, moderate-quality evidence

How on earth can one reasonably make a “strong recommendation” on “moderate-quality” evidence, even assuming one agrees that the evidence is “moderate-quality”? The SIO defines “moderate quality” evidence as:

RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies.

Confusingly, the SIO makes “strong recommendations” based on “moderate” evidence (level 1B). In other places, it makes “strong recommendations” based on “low or very low quality evidence” (level 1C). Doesn’t it make you wonder why the SIO decided to make up its own categories of evidence, rather than use accepted evidence-based medicine (EBM) categories of evidence? Certainly, I wonder. I also wonder how the SIO could categorize instructing patients “regarding proper nutrition to promote basic health” as only category 1B.

As for other recommendations made by the SIO, rating the evidence for “energy healing” methods–or, as the SIO calls them, “therapies based on a philosophy of bioenergy fields”–as grade 1B vastly overestimates the quality and quantity of evidence in favor of “energy healing” methods. “Energy healing” is quackery, based as it is on an unproven concept that there is an “energy field” or a “life energy” that can be manipulated by practitioners for therapeutic intent. Never mind that no scientist has ever been able to measure or detect these “energy fields,” find convincing evidence that they exist, or verify that practitioners can actually manipulate them to therapeutic purpose. Never mind that the very concept is based on a vitalistic, pre-scientific understanding of how the human body works and how disease develops. I note that “energy healing” methods also include acupuncture, whose premise is that sticking needles into the skin can somehow alter the flow of this life energy to healing effect. I also note that the totality of evidence regarding acupuncture is that it does no better than placebo when tested in well-designed randomized clinical trials. It doesn’t matter where the needles are placed or even whether the needles are placed. Indeed, even twirling toothpicks against the skin works as well as needles. Just type “acupuncture” in the search box of this blog, and you will be deluged in posts that (hopefully) will tell you all you need to know. Meanwhile, acupuncture apologists publish papers in which fanciful physiological mechanisms by which acupuncture allegedly works are proposed and poorly supported with evidence.

I note that the title of Dr. Collins’ talk is “Faith, Spirituality and Science in Oncology.” I find this unsurprising, because in the world of “alternative” medicine”–or whatever you want call it, be it “complementary and alternative medicine” (CAM) or “integrative medicine” (IM)– religious faith, “spirituality,” or whatever you want to call it, is often co-opted to serve quackery in a manner very similar to the manner in which diet and exercise have been co-opted. Reiki is an excellent example of this. It is one of the more prevalent of CAM/IM modalities, and it is currently being extensively used in cancer, even though the evidence base for it is virtually nonexistent. I have in the past referred to reiki as faith healing that substitutes Eastern mystical beliefs for Christian beliefs, and that is an accurate description. Consider: What is faith healing? It’s the belief that a healer can channel the power of God into the ill to heal them. Now what is reiki? Reiki involves channeling “energy” from what reiki masters call the “universal source” into the ill to heal them. Like faith healers, who assert that the power doesn’t come from them but from God, reiki masters assert that the power doesn’t come from them but rather from the “universal source.” Indeed, the founder of reiki, Dr. Mikao Usui explicitly patterned reiki on how Jesus healed:

Dr. Usui was a Christian minister in Japan, though Japanese. He was the head of a Christian Boys School in Japan. One day some of the students asked him if he believed in the miracles which Jesus did (healing, etc). Being a Christian minister he answered “Yes”. They asked if he knew how Jesus had done this, “No” he said…

With this he resolved to find the way in which Jesus had healed. This immediately set him on a journey of many years. Studying first at Christian schools in the US, for where else to learn of Jesus, but with no results. In the Christian schools the method was not known.

Dr. Usui even subjected himself to a 21 day fast on a mountain that very much resembled Jesus’ 40 days and 40 nights in the wilderness, after which we have this description:

After returning from this experience he began back down the mountain and was, from this moment on, able to heal. This first day alone he healed an injured toe, his own starvation, an ailing tooth and the Abbots sickness, which was keeping him bedridden. These are known as the first four miracles.

Should science- and evidence-based medicine be concentrating on miracles and faith healing? I certainly don’t think so. Yet that is what most “energy healing” modalities (reiki, therapeutic touch, and, yes, acupuncture) boil down to, when stripped of all the “science-y” language used by apologists to justify them. If you don’t believe me that at the very core of reiki is religion, consider this. In 2009 the U.S. Conference of Catholic Bishops warned Roman Catholics to shun the eastern healing art of reiki because it’s dangerous to Christian spiritual health. Some Christians even view reiki as a sin. Moreover, huge swaths of other CAM/IM modalities are based on similar beliefs that are rooted in faith, spirituality, and even outright magic. The common CAM/IM modality of homeopathy, for example, is based on the concepts of sympathetic magic, and naturopathy, which many SIO practitioners recommend, requires homeopathy as part of its training, which is why many naturopaths are also homeopaths. The bottom line is that, no matter how much naturopaths try to defend themselves as being “scientific,” the entire discipline is anything but.

It appears to me that the SIO is trying to take advantage of Dr. Collins’ well-known religious faith in order to use his reputation as a scientist and as NIH director to claim for itself the mantle of scientific respectability that it does not merit. Instead of the usual “bait and switch” rebranding science-based modalities such as diet and exercise as “alternative,” the SIO is now rebranding religion and spirituality as somehow being “alternative medicine.” Because Dr. Collins is the only person who can represent the entire NIH, not just a single center in the NIH or an office in one institute in the NIH, which is why I’m so disturbed that he has agreed to speak at an organization that promotes the infiltration of quackademic medicine into medical schools. Cancer patients deserve the best in science- and evidence-based medicine. Unfortunately, “integrative” oncology” is nothing of the sort. It adds nothing to cancer care other than the rebranding of sensible treatments as “alternative” and the “integration” of unscientific, unproven, and potentially harmful “alternative” treatments with science-based treatments. Cancer patients deserve better.

Finally, I’ve criticized two institutions of the NIH for promoting and funding unscientific research, quackery even. These institutions include the National Center for Complementary and Alternative Medicine (NCCAM) and the National Cancer Institute’s (NCI) Office of Cancer Complementary and Alternative Therapy. Between NCCAM and OCCAM, the NIH spends a quarter of a billion dollars a year studying and promoting modalities that range from being sensible science-based treatments, such as diet and exercise, to modalities that can only be described as pure quackery (homeopathy, therapeutic touch, reiki, acupuncture, etc.). When budgets are this constrained, does the NIH have the luxury of spending a quarter of a billion dollars a year, or approximately 1% of the total NIH budget (with OCCAM representing approximately 3% of the total NCI budget) on research that is not only largely made up of either pseudoscience, vitalism, or or magical thinking interspersed with science-based modalities that CAM apologists try to rebrand as “alternative” or “integrative” but exceedingly unlikely ever to benefit patients? NCCAM alone has already spent over $2 billion since its inception in the 1990s and has yet to demonstrate convincingly that even a single “alternative” medicine modality provides concrete benefits greater than placebo effects.

I have no doubt that Dr. Collins wants to shape the NIH into a form that is dedicated to the best possible science we as a nation can support for the money and to promote that science. That’s why, in the end, I hope he will realize that speaking at the SIO conference does not serve that end, nor does continuing NIH support for NCCAM and OCCAM. I’ve said it before, and it bears repeating yet again. The division of medicine into “conventional” and “alternative,” “complementary and alternative,” or “integrative” medicine is a false dichotomy. There should be only medicine, and the scientific standards for determining what is and is not safe and effective medicine should be the same. Dr. Collins’ appearance at the SIO conference this November will only serve to support the false dichotomy that tries to foist unscientific medicine upon cancer patients as “integrative” medicine.