Old wine in a new skin: The Society for Integrative Oncology issues guidelines for breast cancer

It should come as a surprise to no one that I’m not exactly a fan of “integrative oncology”—or integrative medicine, or “complementary and alternative medicine” (CAM), or whatever its proponents want to call it these days. After all, I’ve spent nearly ten years writing this blog and nearly seven years running another blog dedicated to promoting the scientific basis of medicine, and just this year managed to publish a lengthy commentary in a high impact journal criticizing the very concept of integrative oncology. Unfortunately, it seems to be the equivalent of the proverbial pissing in the ocean, as the flood of CAM quackademic medicine continues unabated. So it was just before the Thanksgiving holiday, when I learned from the director of the National Center for Complementary and Alternative Medicine (NCCAM), Dr. Josephine Briggs, that the Journal of the National Cancer Institute had published an issue consisting of nothing but a monograph on the evidence base for “integrative oncology.”

I had to take a look.

Unfortunately, there are too many articles in this monograph to cover them all in this post. In particular, there were a couple of clinical trials that demonstrate quite aptly the problems with integrative oncology as a concept. Perhaps, if nothing else grabs my attention, I will take a look at them later this week. In the meantime, what I really wanted to concentrate on what was clearly intended as the centerpiece of this monograph, a set of clinical guidelines by Heather Greenlee, Lynda G. Balneaves, Linda E. Carlson, Misha Cohen, Gary Deng, Dawn Hershman, Matthew Mumber, Jane Perlmutter, Dugald Seely, Ananda Sen, Suzanna M. Zick, Debu Tripathy, for the Society for Integrative Oncology Guidelines Working Group entitled Clinical Practice Guidelines on the Use of Integrative Therapies as Supportive Care in Patients Treated for Breast Cancer. This is, after all, where the “rubber hits the road,” so to speak, in which the SIO ranks integrative oncology interventions based on what its guidelines working group considers to be the best existing evidence. The results, it turns out, are not surprising to someone rooted in science-based medicine. I’ll show you what I mean.

First of all, let’s look at how the guidelines were developed. First, SIO started with a working group, an expert panel, if you will, made up of members possessing expertise in medical oncology, radiation oncology, nursing, psychology, naturopathic medicine, traditional Chinese medicine, acupuncture, epidemiology, biostatistics, and patient advocacy. One wonders where the homeopaths and reiki masters were, although certainly naturopathy encompasses at least homeopathy, given how integral homeopathy is to naturopathy. In particular, one wonders why there doesn’t appear to be a chiropractor on the panel, given the popularity of chiropractic, which is at least as “respectable” as naturopathy or traditional Chinese medicine and has the added advantage that some musculoskeletal manipulation might actually provide some relief for low back pain. (Read Sam Homola’s excellent posts to learn what chiropractic, stripped of its vitalism, might be able to accomplish when strictly limited to musculoskeletal pain such as low back pain.) As I like to say, chiropractors are undertrained physical therapists with delusions of grandeur, but they are popular, and there’s no reason I can see for the SIO to leave them off the panel, at least not compared with TCM practitioners and naturopaths, as they did actually do a search for chiropractic, as shown in the supplemental data. (Spoiler alert: None of the chiropractic modalities were found to have sufficient evidence to make a recommendation.)

It is, however, telling to look at the list of excluded modalities:

Several interventions were excluded for the following reasons. Some have already been well summarized by other groups [eg, diet (22,23), physical activity (22–24)], while others already have a large evidence-base and are often no longer included in the definition of integrative or complementary interventions as they have become mainstream [eg, cognitive-behavioral therapy (25), psychoeducation (26), counseling (27), and support groups (26)]. Others were in early or pilot stages of research (eg, attention restoration therapy) or were not considered integrative interventions for the purposes of these guidelines (eg, prayer, spirituality).

Of course, once again I must emphasize that diet and physical activity were never “alternative” or “integrative,” nor was cognitive-behavioral therapy, counseling, or support groups, although all of these were oversold as improving cancer survival, as our occasional guest blogger James Coyne has described. As for the rest, prayer and spirituality are religion, not science. Overall, this list of excluded therapies is perfect as an illustration of the arbitrariness and falseness and of the very concept of “integrative medicine,” as is the manner in which the SIO defined these therapies itself:

Complementary and alternative therapies are generally defined as any medical system, practice, or product that is not part of conventional medical care (13,14). Examples include natural products (ie, vitamins, minerals, botanicals, and fish oil) and mind–body practices (ie, yoga, meditation, acupuncture, and massage). Complementary medicine is the use of a therapy in conjunction with conventional medicine (14). Alternative medicine is the use of a therapy in place of conventional medicine. Integrative medicine is the use of evidence-based complementary practices in coordination with evidence-based conventional care. Integrative oncology refers to the use of complementary and integrative therapies in collaboration with conventional oncology care.

Again, natural products are part of conventional medical care. For instance, digoxin is derived from the foxglove plant, although, as I like to say, there is a reason we don’t recommend that patients with heart failure or arrhythmias don’t chew foxglove leaves to treat their heart condition. In terms of oncology, Taxol is derived from a substance in the bark of the Pacific Yew, and many chemotherapy agents were derived from natural products or the modification of natural products. The difference between using the “integrative oncology” version of natural products and the SBM version of natural products is that the “integrative” versions are crude, impure, and vary in activity from lot to lot.

Arbitrary and artificial definitions aside, the panel did an extensive literature search of nine databases (EMBASE, MEDLINE, PubMed, CINAHL, PsychINFO, Web of Science, SCOPUS, AMED, and Acutrial) from January 1, 1990 and December 31, 2013 and identified 4,900 articles, of which 203 were eligible for analysis because they were randomized controlled clinical trials of CAM interventions in breast cancer that met the inclusion criteria. It then ranked the interventions the Jadad scoring scale and a modified scale adapted from the Delphi scoring scale to result in a score from A to I defined as follows (click to embiggen):

SIOTable3

So what did the SIO find? Let’s put it this way. The results were most definitely…underwhelming. For example, the only grade A recommendations were for meditation, yoga, and relaxation with imagery for routine use for common conditions, including anxiety and mood disorders (Grade A). Notice that there are no grade A recommendations for anything having to do with pain, but only for symptoms with an even heavier subjective component, namely anxiety and mood. Of course, yoga is a form of exercise and therefore nothing out of the realm of conventional medicine, given the number of studies that have shown the benefits of exercise in cancer patients. Similarly, the only grade B recommendations included stress management, yoga, massage, music therapy, energy conservation, and meditation for stress reduction, anxiety, depression, fatigue, and quality of life. Interestingly, again, none of these, with the possible exception of meditation, can be considered in any way “alternative,” thus once again demonstrating how integrative oncology specifically and integrative medicine in general have co-opted treatments that should be considered conventional as somehow “alternative>” As for music therapy, massage, and the like, these represent modalities that I like to point to as examples of what we used to call supportive care that have been “medicalized” by CAM and turned into therapies when in reality they’re just activities and modalities that help patients feel a bit better or help pass the time, no specific effects intended. As for massage, it is rather disappointing that SIO lumped it together with “healing touch,” given that healing touch is a form of energy healing very much like reiki and thus total quackery, whereas massage at least has the benefit of feeling good to most patients.

As for the rest, surprisingly (given that this is an SIO document) but not surprisingly to anyone rooted in SBM, acupuncture does not appear as a modality in grade A or B, meaning that, at best, the SIO considers acupuncture for anything to be only worth recommending “selectively offering or providing this service to individual patients based on professional judgment and patient preferences” and deems that there “is at least moderate certainty that the net benefit is small.” Electroacupuncture (which is in reality TENS rebranded as acupuncture and acupressure are given a grade B recommendation for nausea and vomiting, but that’s about the best, and as I’ve discussed before that evidence is a bit shaky.

The key observation was that the “majority of intervention/modality combinations (n = 138) did not have sufficient evidence to form specific recommendations (Grade I).” (Grade I means insufficient evidence.) I note that the supplemental document shows that homeopathy is one of those modalities, even though there is more than enough evidence on basic science considerations alone coupled with clinical trials that show no benefit above placebo to state that it is ineffective for basically everything. Ditto reflexology, which gets a grade I recommendation for most things, but a grade C recommendation for “improving quality of life among BC patients.” Meanwhile healing touch is given a grade C recommendation for “improving mood in BC patients undergoing chemotherapy.” Once again, healing touch is energy medicine quackery, much like reiki. In other words, little, if anything, in these clinical guidelines gives support for real “alternative” treatments, although they do give mild support for a few potentially science-based modalities rebranded as CAM/”integrative oncology.”

Amusingly, however, these new guidelines are much weaker in their recommendations than a previous set of SIO guidelines discussed by Kimball Atwood six years ago. Particularly notable is how far down the ladder of recommendation strength acupuncture has fallen since then, and the SIO, at least for breast cancer survivors, no longer recommends considering consulting a “qualified expert in CAM modality, such as an Doctor of Naturopathy (ND) who is board certified in naturopathic oncology, may be considered” when conventional therapies fail, but I’m actually not sure the SIO did this, because these guidelines are for cancer survivors. Either way, it would seem as though the more studies are examined and performed, the weaker SIO’s recommendations become, which is not surprising given that most “integrative” oncology modalities are placebo.

Of course, the real reason for this monograph is not so much a critical analysis of integrative oncology, although some of the authors do appear to try to do this. The real purpose is to use an ostensibly critical analysis buying into the false dichotomy of “integrative oncology” in order to rebrand potentially science-based modalities as “alternative” or “integrative” and to provide ammunition for advocates of “integrative oncology” to start “integrating” quackery with science-based medicine. As Benjamin Kligler and Margaret Chesney state in their article in the monograph entitled Academic Health Centers and the Growth of Integrative Medicine, referring to the Consortium of Academic Health Centers for Integrative Medicine (which I’ve discussed before many times, for example, here and here):

Many barriers—including reimbursement challenges—still exist in the effort to make integrative approaches available as part of routine care. With the publication of this monograph though, we take an important step in removing one of the barriers to integration: the availability of high-quality research evidence on the appropriate role of integrative medicine in cancer care. We are proud to be part of this effort and look forward to the many ways in which the Consortium can provide support and momentum for researchers and clinicians in oncology as we move forward.

Except that this monograph doesn’t really do anything of the sort. If anything, it confuses matters. Unfortunately, integrative oncologists have been far too successful in promoting this false dichotomy listed in the same article unironically:

The Consortium of Academic Health Centers for Integrative Medicine—an organization comprised of 57 academic health centers and health systems in North America—defines integrative medicine as follows:

Integrative Medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.

As this definition implies, although an openness to using therapies such as acupuncture or massage is a component of the integrative approach, integrative medicine goes far beyond simply combining the therapies previously described as “complementary/alternative medicine” with conventional care. It describes a change in philosophy, which expands our role beyond that of treating disease to reaffirm the commitment to treating the whole person. Almost more than anywhere else in medicine, the practice of oncology and the work of caring for a patient with cancer and their family clearly call for this approach and for a commitment to whole-person care. Lifestyle counseling, behavioral medicine interventions, and spiritual support all play critical roles in this integrative approach, alongside the use of other therapeutic strategies rooted in a rigorous evidence-based approach to the best conventional care. This is integrative medicine for cancer.

No, it is a false dichotomy. It is not necessary to “integrate” quackery like healing touch, naturopathy, or acupuncture with science-based conventional medicine in order to “reaffirm the commitment to treating the whole person” or expand a practitioner’s role “beyond that of treating disease.” A favorite saying of mine might be a bit of a cliche, but that’s OK. It’s a cliche that’s true. There is no such thing as “alternative,” “complementary,” or “integrative” medicine, nor should there be. Such medicine that is shown to be safe and effective scientifically ceases to be “alternative,” “complementary,” or “integrative” and becomes just medicine, and that is how it should be. Treatments that are truly effective and safe do not need the training wheels of a title like “alternative,” “complementary,” or “integrative.” They will stand on their own to scientific testing, no special protection required, and they shouldn’t be used until they have. Remember, as well meaning and sincere as its practitioners and champions are, “integrative oncology” is a Trojan horse that is depositing quackery right into the heart of academic medicine.