Trojan horse: Selling “integrative oncology” as science-based

I write a lot about “integrative medicine,” particularly “integrative oncology.” The reason, of course, is because I view integrative medicine as the integration of pseudoscience and quackery into medicine. It’s also label that “rebrands” perfectly good science-based lifestyle medicine, such as nutrition, exercise, and other lifestyle interventions, as somehow being “alternative” or “integrative”. It also uses them as a facade to cloak or disguise all the pseudoscience and quackery, like reiki, acupuncture, naturopathy, and the like. It’s not for nothing that one of my favorite metaphors for “integrative medicine” is the Trojan horse. Lifestyle medicine is the horse. Academic medical centers—and, increasingly, community hospitals—bring the horse in, and once it’s there the quackery leaps out to capture the fortress.

I was reminded yet again of this when Jann Bellamy sent me a link to a review article in the Journal of Oncology Practice, a clinical journal published by the American Society of Clinical Oncology. It comes from the integrative oncology group at one of the premier cancer hospitals of the world, the Memorial Sloan-Kettering Cancer Center. It’s by Shelly Latte-Naor, the Director of Mind-Body Medicine there—there exists such a title?—and Jun J. Mao, the Chief of the Integrative Medicine Service there and former president of the Society for Integrative Oncology, an organization I’ve written about quite a few times and one that, as I’m sure you can guess, doesn’t like me very much. In any event, the article is entitled “Putting Integrative Oncology Into Practice: Concepts and Approaches“, and it’s a blueprint for a Trojan horse to do exactly that.

Let’s look at the rebranding right in the first sentence of the abstract:

Unmet symptom needs and a desire for holistic health approaches or even cure are among the motivations patients have for seeking out complementary and alternative medicine. Using complementary and alternative medicine instead of conventional cancer treatment can have a negative impact on clinical outcomes and survival. Integrative oncology is a patient-centered, evidence-informed field of comprehensive cancer care that uses mind-body practices, natural products, and lifestyle modifications from different traditions alongside conventional cancer treatments. It prioritizes safety and best available evidence to offer appropriate therapeutic interventions along with conventional care.

First, there’s the canard of “unmet medical needs,” which is a frequent justification used by integrative medicine advocates, that somehow conventional medicine is not meeting patient’s needs. Of course, no one claims that conventional medicine meets every patient needs or that there is no such thing as unmet medical needs. The canard is in the argument that to meet these unmet needs, you need to embrace pseudoscience and quackery. In any event, I should be grateful that Latte-Naor and Mao actually cited the recent study showing an association between CAM use and decreased survival in cancer patients. On the other hand, the authors try to use this as a justification for integrative medicine, ignoring completely the history of integrative medicine and how it is merely a rebranding of CAM. Of course, they said CAM use “instead” of conventional medicine, never mind that CAM use is by definition using alternative medicine alongside conventional medicine. It’s almost as though the authors are trying to “rebrand” CAM as just alternative medicine.

Here’s the main rebranding. “Complementary and alternative medicine” (i.e., CAM) is exactly the same thing as integrative medicine. There is no difference. Integrative medicine is just another term for CAM. Up until around the late 1990s or so, what we now know as integrative medicine was called CAM. Beginning around 20 years ago there was a conscious, concerted, and prolonged effort on the part of CAM advocates and practitioners to rename CAM “integrative medicine.” As I put it at the time, no longer were CAM practitioners content to have their favorite quackery be merely “complementary” to real medicine. After all, “complementary” implied a subsidiary position. Medicine was the cake, and their wares were just the icing. That wasn’t good enough. They craved respect. They wanted to be co-equals with physicians and science- and evidence-based medicine. The term “integrative medicine” (IM) served their purpose perfectly. No longer were their treatments merely “complementary” to real medicine. Now they were “integrating” their treatments with those of science- and evidence-based medicine! The implication, the very, very, very intentional implication, was that alternative medicine was co-equal to science- and evidence-based medicine, an equal partner in the “integrating”. The same process is going on today in that “integrative medicine” is falling out of favor as a name in favor of “integrative health”. The reason, I suspect, is that integrative medicine advocates want to sell their specialty as “wellness” too and that “medicine” is a less friendly word than “health”.

Next up, the “integrative medicine is science, ma-an” trope:

The practice of integrative oncology stands in contrast to the use of alternative medicine, which is often based on unsubstantiated claims and can involve rejection of conventional medical treatment. The use of alternative medicine in lieu of conventional treatment has been associated with decreased survival in the cancer setting.⁵ Integrative oncology prioritizes safety and best available evidence to offer appropriate therapeutic interventions along with conventional care. The commitment to rigorous scientific research and evidence-informed practice in cancer care was strongly emphasized by the foundation of the Society for Integrative Oncology (SIO) in 2003 and the release of the first set of general clinical practice guidelines in 2009, followed by two other cancer-specific guidelines thereafter.^6-9 Most recently, ASCO endorsed SIO clinical guidelines for women with breast cancer.¹⁰

Yes, the authors are definitely doing some major language twisting, rebranding CAM to mean “alternative medicine” in one sentence while tacitly ignoring the way CAM had been rebranded and reborn as “integrative medicine.” In any event, integrative medicine specialists and advocates love to contrast all that quackery in alternative medicine with their supposedly science-based specialty. As for the clinical practice guidelines published by the SIO, I’ve deconstructed them before, as well as ASCO’s endorsement of them. The quackery is leaping out of the Trojan horse.

This, of course, is why the authors start out their list of integrative medicine with perfectly reasonable, science-based lifestyle interventions, such as exercise and physical activity, lifestyle modifications, diet, sleep, stress management, quitting smoking, not consuming too much alcohol or using illicit drugs. No one’s going to argue with those interventions as being useful. Indeed, those sorts of interventions are already part of conventional medicine and always have been. One can assert that these modalities have been underemphasized in medicine in favor of pharmaceuticals, and there is a reasonable debate to be had there. However, underutilization of lifestyle medicine in conventional medicine is a reason, but, I argue, not the primary justification for the existence of integrative medicine. The primary reason for including them in “integrative medicine” is to provide scientific cover for all the quackery that integrative medicine integrates with science-based medicine.

The next broad category of interventions listed includes “mind-body” interventions. That is, of course, a category name that I abhor, because embedded in it is an unjustified assumption of mind-body dualism. Here, the authors start listing the more dubious therapies, mixing them in with more reasonable therapies for which there is some evidence, such as massage, yoga (a form of exercise), and Tai Chi (another form of exercise.)

Here’s what they say about acupuncture:

Acupuncture is a therapy that originated from traditional Chinese medicine. It uses sterile thin needles that are inserted at specific points on the body and subsequently stimulated, either manually or electrically, to manage symptoms. Animal studies have found that acupuncture can stimulate the brain to release endogenous opioids, serotonin, and dopamine. Functional imaging studies in humans have also found that acupuncture can modulate multiple brain regions involved in cognition and emotion. The National Comprehensive Cancer Network Guidelines recommend the use of acupuncture for pain, fatigue, nausea, vomiting, and hot flashes, and in the setting of palliative care and survivorship.³⁰ More than 80% of National Cancer Institute–designated comprehensive cancer centers recommend acupuncture for symptom management.³¹

Yes, that is unfortunate. Thus far, my cancer center doesn’t have an acupuncture program yet, but I live in fear of the “integrative medicine” bug biting someone in the leadership. Indeed, I’m amazed it hasn’t hit there yet. Elsewhere, however, quackery has infiltrated the vast majority of NCI-designated cancer centers, unfortunately. Of course, I’ve discussed acupuncture on this blog more times than I can remember, and it’s not for nothing that Steve Novella and David Colquhoun once referred to it as a “theatrical placebo.” That’s exactly what acupuncture is. Sure, advocates will trot out meta-analyses that claim to show that acupuncture works better than a placebo intervention, but they don’t really show that. The bottom line is that it doesn’t matter where you stick the needles. It doesn’t matter even if you stick the needles into the skin. Acupuncture “works” all the same. That’s why, as hard as they try to show that acupuncture “works”, whenever they do rigorous clinical trials, they fail.

Indeed, I like to point out that the embrace of acupuncture by integrative oncology disqualifies integrative oncologists from claiming that their specialty is in any way science-based. If it were truly science-based, it wouldn’t endorse acupuncture. None of that stops Latte-Naor and Mao from finishing with an invocation of the “it’s science, ma-an” gambit:

A key feature distinguishing integrative oncology from alternative medicine is its foundation of evidence-informed practice. Evidence-based medicine as a concept emerged in the 1980s and has since transformed medical education and clinical practice.⁶⁰ It can be defined as the combined integration of the best available research evidence along with our clinical expertise while considering our patient’s values and circumstances (Fig 1B). As research begins to shed light on the safety and efficacy of complementary therapies, critical appraisal of the literature and ongoing learning is needed to incorporate these approaches into clinical practice. Using an evidence-informed approach allows clinicians to incorporate patients’ values and preferences along with their own clinical experience and current research evidence for therapeutic approaches (eg, medications or acupuncture for pain) to support a shared decision-making process for patients and families. Figure 2 shows a suggested algorithm of integrative therapy referral options that could help facilitate discussions on evidence-based approaches for patients with cancer.

Note that, other than acupuncture, the authors leave out the rank quackery in integrative medicine and oncology. Hospitals with integrative oncology and medicine programs all feature pseudoscience and quackery, such as functional medicine, traditional Chinese medicine, and homeopathy at the Cleveland Clinic; reiki, “detox,” and chelation therapy at George Washington University; reiki and other quackery at the University of Arizona; The One Quackery To Rule Them All, homeopathy, at the University of California, Irvine; and acupuncture, reiki, and even homeopathy apologia at Georgetown.

Basically, what Shelly Latte-Naor and Jun Mao are presenting is their idealized version of integrative medicine that brooks no quackery (other than acupuncture, of course), where every intervention used is rigorously science-based. This is a typical portrait of integrative medicine painted by academics. They are science-based; so they can’t imagine that their specialty would not be, even as it embraces quackery. This version of integrative medicine and oncology leaves out the pseudoscience and quackery that the specialty really embraces. It’s even worse than that. The Society for Integrative Oncology allows naturopaths to join, which is embracing far more quackery than just acupuncture, given that naturopathy is a veritable cornucopia of quackery. Indeed, the organization has even elected two naturopaths as its president in the past, Heather Greenlee and Suzanna Zick!

Until the specialty of integrative oncology gets rid of naturopaths, acupuncturists, and all the other quackery that it tolerates, Latte-Naor and Mao are deluding themselves in trying to portray their specialty as science-based. If you take away the quackery from integrative medicine and oncology, all that’s left is just lifestyle medicine without a compelling rationale to be its own separate specialty. It is and always will be quackademic medicine. The Trojan horse lives.

Of course, the “Trojan horse” of quackademic medicine—excuse me, integrative medicine—is more like the Trojan rabbit in Monty Python and the Holy Grail