Special pleading for “integrative oncology”

I don’t recall how many times I’ve said lately that I detest the term “integrative medicine.” As I’ve pointed out time and time again, it’s the preferred “successor,” if you will, to the term “complementary and alternative medicine” (CAM) (at least among the woo-friendly). After all, as I’ve pointed out before, it just won’t do to have the fashionable quackery du jour be considered as only being “complementary” or “alternative” to real medicine. That implies at best that it has a subsidiary role to real medicine and at worst that it is not real medicine, being “alternative” and all. The whole “complementary” bit is a bummer, too, as it implies that the real medicine is the cake and the woo is but the icing applied to it. Either way, if you’re a quack of the academic variety (or, as I like to call them, quackademics) or of the straight up quacky variety, you’d want to have a term that doesn’t imply a subsidiary status to medicine, a term that makes it seem as though you actually have something on par with scientific medicine.

Enter the term “integrative medicine.”

It’s so fuzzy, so happy, so light! Best of all (if you’re a quack), it doesn’t imply that your quackery is in any way inferior to real medicine. After all, you’re “integrating” your favorite woo with medicine, or, as IM advocates like to claim, providing patients with the “best of both worlds.” How one figures out what the best of CAMworld or IMworld is without–oh, you know, some…science!–I have yet to figure out, but CAM/IM advocates are convinced they’re combining the best of the world of “Western,” “allopathic,” “scientific” medicine with the “best” of CAM/IM, however they managed to figure that out. (Usually, it’s just the practitioner’s favorite woo or sets of woo).

Of all the forms of CAM/IM that irritate me the most, there’s one form that irritates me more than the others. You see, it turns out that CAM/IM has begun to fragment into specialties, which is perhaps the only way it resembles real medicine. It’s even formed a specialty known as “integrative oncology,” the very thought of which sends chills down my spine. I’ve written extensively about it before; so I won’t retread that ground. Well, I won’t retread it much, anyway. When you’ve been blogging almost every day for nearly seven years, it’s hard not to repeat yourself somewhat from time to time; consider it the price necessary to bring the newbies up to speed. Be that as it may, you know that it’s like waving the proverbial red cape in front of me to entitle a post something like Reductionistic Science and the Evolution of Integrative Oncology, yet that’s exactly what a man by the name of Glen Sabin did.

He begins by pointing out that the randomized, double-blind placebo-controlled clinical trial is ” considered the most reliable scientific process to measure efficaciousness of drugs and medical interventions.” This is one of those statement’s that almost true, but not quite. While it’s true that randomized, placebo-controlled trials are generally considered the “gold standard” for evidence in certain interventions, they are not the be-all and end-all of clinical evidence. Some questions can’t be studied in a trial like that. For other questions, using a placebo control is unethical. For still others, a clinical trial is not necessary at all to know that an intervention can’t possibly work. Unfortunately for Sabin, nearly all studies that fall into the latter category also fall under the rubric of CAM/IM. Think homeopathy. Think reiki. Think pretty much any form of “energy medicine.” None of this stops Sabin from citing the Institute of Medicine thusly:

On February 25-27, 2009, the Institute of Medicine, with support from the Bravewell Collaborative, convened the Summit on Integrative Medicine and the Health of the Public in Washington, DC. The stated goal of the conference was to advance the science, understanding, and progress of integrative medicine–“healthcare that addresses together the mental, emotional, and physical aspects of the healing process”.

Hoo-boy. I remember this conference. I blogged this conference, at least tangentially, because the Four Horsemen of the Woo-pocalypse (Drs. Andrew Weil, Dean Ornish, Mark Hyman, and Mehmet Oz) struck in two locations, the IOM and in the very halls of Congress itself, thanks to the intervention of the woo-friendly creator of the scientific monstrosity known as the National Center for Complementary and Alternative Medicine (NCCAM) himself, Senator Tom Harkin (D-IA). Basically, the conference was a huge mistake by the IOM, as it served mainly to showcase speakers spouting the same sort of nonsense co-opting modalities that are properly science-based, such as diet and exercise, and rebranding them as CAM in the classic “bait and switch.”

I didn’t realize, though, that it had taken so long for the IOM to finally issue a report on this particular conference. The report itself is too long for me to discuss here. Perhaps I’ll do a post just on this report in the future, either here or at my other blog. For the moment, though, I’m going to concentrate more on how Sabin tries to use the IOM report more than on the actual report itself. There’s plenty there to go around, and, besides, why get only one post out of a source when you can get two? Sabin provides a “target-rich” environment without my having to take on a 200+ page report as well. For instance, as proponents of woo so frequently do, Sabin doesn’t think that the scientific methods as currently practiced is up to the task of examining his integrative quackademic medicine. He begins by providing a fact-free assertion:

The human mind and body, when confronted with malignancy, reacts with a complex set of physiological and psychological change that cannot be adequately addressed in isolation. As such, only whole person, multi-interventional synergistic approaches to scientific exploration will lead the way to 21st century personalized, integrative oncology care.

The buzzwords are all there. It sounds all science-y. But this is a meaningless paragraph. Does Sabin honestly think that scientists haven’t been studying the physiological and psychological changes that occur in response to malignancy? If he does, he’s completely ignorant of what has gone before; scientists have been studying the physiology of tumors and how they affect normal physiology for many decades, the psychology not as long but at least a few decades. I must tip my hat to Sabin, though, for combining more CAM buzzwords into a single sentence designed to make CAM sound scientific than I think I can recall ever having seen before. Putting the phrase “whole person, multi-interventional, synergistic approaches to scientific exploration” in the same sentence as “21st century personalized, integrative oncology care”? Brilliant! If you can’t dazzle ’em with brilliance, baffle ’em with…CAMspeak.

So what, exactly, is Sabin talking about when he lays this word salad upon us? Damned if I know. He doesn’t explain, nor do any of his sources to which he links, two of which come from that wretched hive of scum and quackery, The Huffington Post, including a post by Larry Dossey, Deepak Chopra (yes, Deepak Chopra), and Rustum Roy that I decontructed a long time ago. Instead, this is what he says:

Random controlled trials are here to stay, and rightfully so, but a lot has changed since the Flexner Report. Personalized medicine is growing and evolving: over 30 billion dollars annually are being spent in the U.S. on complementary health services and products, and consumers are embracing integrative healthcare practitioners like never before. In addition to the RCT, we need a human clinical trial research model specifically designed for whole systems research.

The best of western, allopathic medicine, especially acute emergency care and diagnostics, is arguably the finest in the world. But it is clear that our so-called science-based processes and methodologies that result in FDA approved drugs do not always allow the most useful and important study designs in integrative medicine to be funded and executed.

How generous of him. He acknowledges that RCTs are “here to stay.” Of course they’re here to stay! They’re the best way to minimize bias in studying a wide variety of medical interventions. But do we really need a “human clinical trial research model specifically designed for whole systems research”? What does “whole systems research” even mean? Clinical trials are whole systems research in that they study the effects of interventions on the whole system that is the human body! As far as “reductionistic Western medicine” not being able to study “complex, multifaceted therapies,” well, it can. Indeed, Tim Kreider gave two examples of scientists doing just that with tai chi for fibromyalgia and the use of cognitive behavioral therapy for ADHD. The same has been done for acupuncture studies as well, including the use of better sham needles, the study of the effect of practitioner-patient interactions, and more. Here’s the problem. The vast majority of CAM modalities are found to perform no better than placebo when tested under controlled conditions, and people like Sabin know it and don’t like it.

Make no mistake. The real purpose of this appeal to “wholistic” or “whole systems” research methods is not because current methods are so clearly inadequate to study CAM. They aren’t. The real reason Sabin and others are demanding “new” research methods to address “whole systems” is because their favored woo consistently fails when subjected to controlled scientific testing. Rather than doing what real scientists would do and concluding that their woo just doesn’t work, instead Sabin et al want to change the standards to something that (they think) their woo can pass. The only way to do that is to lower the standards, whether they admit it or not. My favorite example is how acupuncturists promote the use of “pragmatic trials,” which are clinical trials that are sometimes done after a treatment has been shown to be effective in proper, rigorous RCTs. Pragmatic trials generally aren’t randomized and are designed to test the efficacy of a therapy in “real world” conditions. Using them before a therapy is shown to work using RCTs is putting the proverbial cart before the horse, because pragmatic trials can definitely introduce more biases and more tendencies for false positive results.

In the end, the call for “whole systems” research is nothing different than that. It’s special pleading, asking that a different standard of evidence be applied to CAM than is applied to modalities that are part of science-based medicine. I reject such special pleading. As always I believe that there should be only one standard, that of science, and that it should apply equally to all treatments, wherever they came from. CAM modalities that can stand up to scientific testing will, as the old cliche goes, cease to be “alternative” and become simply “medicine.” When that happens, science-based practitioners will happily absorb rather than integrate such methods into science-based medicine.