“Integrative medicine” further evolves into “evidence-based complementary medicine.” Nothing changes

One of these days I’m going to end up getting myself in trouble.

The reason, as I’ve only half-joked before, is that, even though I’m not even 50 yet, I’m already feeling like a dinosaur when it comes to “complementary and alternative medicine” (CAM) or, as it’s called more frequently now, “integrative medicine” (IM). These days, we now have the National Center for Complementary and Alternative Medicine (NCCAM), the Bravewell Collaborative, and a number of other forces are conspiring to “integrate” quackery with real medicine. As part of that task, it’s been necessary to rebrand quackery, a process that’s been going on for at least 20 years now. I described this evolution of quackery in what was a bit of a facetious post that strikes me in retrospect as being a bit pretentious when I reread it. Not that I’m incapable of pretentiousness; it’s in my blood, and at times it has to come out.

In any case, near the end of that post, I pointed out that CAM was rebranded because the very name contained the words “complementary” and “alternative,” both of which imply (correctly, as it turns out) that the quackery falling under the CAM rubric is inferior to science-based medicine, mere icing on the cake. Where real medicine does the real work of curing the patient, CAM is merely “complementary”; i.e., unnecessary but helpful. Of course, CAM is not only unnecessary but most of it is not particularly helpful (some of it can even be harmful). Calling it “integrative medicine” is a subtle change, but, I think, intentional. If you “integrate” something, it implies more equality. Indeed, practitioners of IM even come out and say that they’re “integrating” the “best of both worlds.” In reality, as I like to emphasize agains and again as something that can’t be repeated too often, IM is “integrating” quackery with medicine. I’ll also repeat what I said a couple of weeks ago after reading the words of a CAMster: CAM is indeed dead, but it is the CAMsters themselves who killed it. The killing of CAM was deliberate and calculated, with CAM replaced by IM. I speculated that it wouldn’t be long before even the term “integrative medicine” wouldn’t be enough.

I was more right than I realized.

So sayeth Barrie Cassileth, PhD, Chief of the Integrative Medicine Service at–depressingly–one of our greatest cancer centers, Memorial Sloan-Kettering:

During the 1960s and 1970s, the concept of a holistic approach to treating disease that took into account the body, mind, and spirit grew in patient popularity and morphed into two basic categories: alternative and complementary, which later became known by its acronym CAM (complementary and alternative medicine). However, because alternative therapy refers to unproven or disproven treatments that have no place in legitimate cancer care, integrative medicine experts, including Barrie R. Cassileth, PhD, Chief, Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center in New York, say the terminology is misleading and confusing and needs to be abandoned. Even the term “integrative medicine” can be misleading, said Dr. Cassileth, who instead uses a more accurate term to describe the practice of integrative oncology: evidence-based complementary medicine.

One wonders, one does, why Dr. Cassileth doesn’t eliminate the name “integrative medicine” from her own service at MSKCC, given that she’s the chief of the service, if she really thinks that the term is now outmoded. Of course, “Evidence-Based Complementary Medicine” Service would be kind of a clunky name, but I suppose it could be shortened to EBCM, which reminds me of ICBM, which reminds me of nuclear explosions. Sorry, I just can’t help it. I was, after all, raised during the Cold War and still remember the fallout shelter and air raid drills we had in grade school. Younger farts than this old fart probably won’t make such associations.

It is, of course, also interesting that Dr. Cassileth doesn’t choose to use the term “science-based complementary medicine.” I’ve discussed the difference between science-based medicine and evidence-based medicine before, and Dr. Cassileth seems to be perpetuating the difference. Remember, evidence-based medicine downplays prior plausibility based on basic science, relegating basic science considerations to the lowest rung on the evidence hierarchy, whereas science-based medicine does consider prior plausibility. I know I use the example of homeopathy often in trying to illustrate this, but it’s just so perfect an example. Homeopathy, as you recall, posits that (1) like cures like (i.e., you use a substance that causes a symptom in order to eliminate that symptoms) and (2) diluting such a remedy to the point of nonexistence (as in many orders of magnitude more than Avagadro’s number) makes it stronger. It’s pure magical thinking, invoking the ancient principles of sympathetic magic. Even so, because of the limitations in randomized clinical trials and the fact that, by design, at the very minimum 5% of such trials will be false positives because of where scientists choose by convention to set their measure of statistical significance, there are a number of false positive trials of homeopathy. Also, as John Ioannidis has shown us, in actuality it’s more than 5% of clinical trials that produce false positive results. Because evidence-based medicine fetishizes randomized clinical trials above all else, it just won’t allow scientists to reject homeopathy, because there are always equivocal trials to which woo-meisters can point as “evidence” that there might just be something to homeopathy. Contrast this to science-based medicine, where, because the principles of homeopathy violate well-established laws of physics, homeopathy can be relegated to being impossible; that is, until homeopaths produce evidence for it at least as compelling as all the evidence from physics, chemistry, and biochemistry that say homeopathy can’t work.

Here’s a hint: Equivocally “positive” clinical trials are not enough.

I realize that I just digressed into fairly well-trodden territory, but I felt I had to do it, because Dr. Cassileth said something in this interview that actually partially made sense:

By making the term evidence-based complementary medicine more commonplace, Dr. Cassileth is hoping to educate both medical professionals and patients about the helpful, appropriate complementary therapies that are available, and distinguish them from the all-too-available questionable approaches.

“If promoted techniques are found to be worthless or if they are patently absurd, such as homeopathy, they should be avoided. The medical world is in turmoil around these issues, and the public typically cannot tell the difference between viable interventions and quackery. I spend half my time studying whether complementary approaches relieve patients’ specific physical and emotional symptoms and the other half trying to get rid of quackery. It’s not an easy task,” said Dr. Cassileth.

Did Dr. Cassileth just characterize homeopathy as “patently absurd” and “useless”? Shockingly, she did! It’s rare indeed for an advocate of CAM/IM to characterize any alternative medical system as absurd. True, it’s completely appropriate to characterize homeopathy as absurd. It’s even refreshing to hear. There’s just one problem. As you might recall, Dr. Cassileth herself supports alternative medicine modalities every bit as ridiculous as homeopathy, having done a number of studies of acupuncture, including for hot flashes. When the study was negative, she tried to spin it as being due to acupuncture that was “not optimal.” She’s also proud of a study she’s doing on acupuncture right now:

We are also enthusiastic about our acupuncture research program, and we’re about to complete a study of acupuncture treatment for lymphedema. We first conducted a small pilot to make sure that acupuncture was safe. It was. The study had a stopping rule: achieving at least a 30% reduction in lymphedema in a minimum of 40% of patients. The study stopped very quickly. Now we are embarked on a larger pilot with a mechanism component.1 The regimen is two acupuncture treatments a week for 4 weeks and then monthly follow-up phone calls to make sure that no adverse late events occur. These are important areas of research for us.

I would argue that Dr. Cassileth is rather selective in what she considers to be “patently absurd” and that the principles of acupuncture are pretty darned absurd, arguably as absurd as those of homeopathy. Think about it. What’s the idea behind acupuncture? Basically, it’s vitalism, in which it is believed that sticking needles into certain parts of the body somehow “unblocks qi,” which is basically “life energy” or “vital force.” This qi flows through pathways known as meridians, which (of course) do not correspond to any known anatomic structures, no matter how much acupuncturists try to convince us that they do. What is less “patently absurd” about acupuncture than homeopathy? I’m having a hard time thinking of anything, other than the fact that acupuncture involves the insertion of actual needles into the skin and can therefore cause actual complications.

In any case, I went and looked up Dr. Cassileth’s study, A safety and efficacy pilot study of acupuncture for the treatment of chronic lymphoedema. First off, it didn’t help that the study was published in Acupuncture in Medicine. CAM journals tend to be–shall we say?–not particularly rigorous. Dr. Cassileth’s paper fits right in. Basically, it’s an uncontrolled study of acupuncture in women with lymphedema due to breast cancer surgery. Practitioners of traditional Chinese medicine on staff at MSKCC treated nine women with lymphedema, and these were the results:

Study goals were met after nine subjects were treated: four women showed at least a 30% reduction in the extent of lymphoedema at 4 weeks when compared with their respective baseline values. No serious adverse events occurred during or after 73 treatment sessions.

Now hold on there, pardner.

I realize that this study was designed only to assess safety, but without a control group the 40% of women showing at least 30% decrease in lymphedema is a meaningless number. For one thing, four weeks is far too short a time period. Lymphedema can wax and wane over time; that several women at four weeks doesn’t mean much at all; doing nothing could well have yielded a similar result. There’s no way to know. Similarly, because lymphedema can wax and wane, single measurements are not particularly informative. Repeated measurements over time are needed. Finally, the most accurate way to measure lymphedema is not arm circumference, but rather water displacement. (The patient sticks her arm in a long bucket of water, and the amount of water displaced is measured.)

More importantly, when I looked at Table 2, which showed the characteristics of the women who had a “response” to acupuncture, I noticed something right away. The baseline difference in centimeters between the unaffected arm and the lymphedematous arm was much smaller in the responders (2.2 cm) than in the non-responders (6.4 cm). In other words, the women who “responded” to acupuncture had mild lymphedema, which is the sort of lymphedema that’s more likely to wax and wane. Basically, as far as telling us anything other than that they didn’t have any complications in nine patients; the study tells us little or nothing about acupuncture for lymphedema. Based on physiology and science alone, however, it’s incredibly implausible that acupuncture would do anything for lymphedema anyway.

Basically, Dr. Cassileth is trying to have it both ways. First, she’s trying to paint herself as a proponent of science, an enemy of quackery, even, describing a recent IM conference:

At the other end of the spectrum, in Europe and in other parts of the world, purveyors of bogus “treatments” have taken over the term “integrative medicine.” In Europe especially, integrative medicine and integrative oncology have become synonymous with quackery.

An important issue that emerged at this conference was the extent to which quackery is a huge problem throughout Europe and in other parts of the world. In the United States, where quackery has been prominent for many decades, it is a $40 billion-a-year business.

All of which makes me wonder how Dr. Cassileth defines “quackery,” when she believes that acupuncture works. She does realize, however, the power of language, as she laments the association of “integrative medicine” with quackery:

It also makes it very difficult for health-care professionals because they’re not always sure what the terms integrative medicine and integrative oncology imply. Words have meaning, and they can have a detrimental as well as clarifying impact. We fought very hard to get away from the term “alternative therapy” because there are no viable alternatives to mainstream cancer care. We have to clarify the terminology, and I am now referring to complementary therapies as “evidence-based complementary medicine.”

Dr. Cassileth’s right. Words have meaning, and language has power. That’s the very reason that “quackery” morphed into “alternative medicine,” “alternative medicine” morphed into “complementary and alternative medicine,” and “complementary and alternative medicine” morphed into “integrative medicine.” It’s the same reason that “integrative medicine” is now morphing into the clunkier, less sexy, “evidence-based complementary medicine.” The problem is that evidence is as evidence does, and the evidence being used to support quackery like acupuncture is no better than the evidence homeopaths use to try to support their woo. I’m glad to hear that Dr. Cassileth is worried about quackery; I’m not so glad to see that the main reason she’s worried about it is because she wants to protect the quackery she believes in from being tainted with all the other quackery. I would suggest that Dr. Cassileth needs to reassess exactly what it is that she means by “evidence-based complementary medicine” and consider adding some actual basic science considerations to the mix. I realize that she’s trying to be one of the good guys, but she’s become part of the problem.