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

Integrative oncology “integrates” quackery with oncology. Its practitioners, however, frequently delude themselves that their specialty is science-based. A recent review article by two integrative oncologists from Memorial Sloan-Kettering Cancer Center expresses that delusion perfectly.

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

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

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

I would suggest a modification to the CAM cake analogy.

The cake is core medicine. This saves lives and improves quality of life in a very real and measurable way.
The icing is useful extras such as physical therapy and life style recommendations (diet, exercise, etc). Both of these are useful in improving quality of life and may cause an increase in quantity of life.
Finally the candles and sparklers are the alternative medicine/CAM/Quackery. They serve no real purpose, and can cause real harm.

Anonymous Pseudonym writes,

Finally the candles and sparklers are the alternative medicine/CAM/Quackery. They serve no real purpose, and can cause real harm.

MJD says,

Tell a child at their five year birthday that only four candles deserve to be on the cake, thereafter, you have a trouble child.

@ Orac,

Sometimes, the mind needs coddling to affect the bodies well-being.

WTF? How is misrepresenting the reality of 5 yr old with 4 candles akin to removing the fake window dressing of CAM from the reality of clinically meaningful treatment?

No MJD. In this analogy (look it up, you should be able to find the term), there are no candles because it gave a friend of hers second degree burns on her face because when she leaned forward to blow them out, her hair caught on fire. To extend the analogy, more families lost their homes because the candle flames caught the curtains on fire and they lost the house. And a final really unlucky one had their dog poisoned by the sparklers.

Sometimes, the mind needs coddling to affect the bodies well-being.

Your “mind” already has the consistency of a soft-boiled egg.

Peter D. writes,

WTF?

MJD says,

At the end of Orac’s not-so-respectful post he references a “bunny” to prove a point. Why doesn’t anyone WTF Orac?

Q. How is Orac unlike a lit candle.

A. He’s not sensitive to the wind.

So, then, isn’t it time for real doctors to step up and start meeting some of those “unmet needs”? I’m actually of two minds about that. On the one hand, it seems the obvious way to counter the rise of all this woo. On the other hand, I have the sneaking suspicion that doctors have tried–and do try–to persuade people to take up lifestyle interventions, to little avail for the most part.

Then it gets more complicated. Doctors do not have the time to do it properly and offer the support that people need to really make changes and stick with them, and people SAY they want to “lose weight”, “exercise” and so on, but they don’t– and hey, buying cute yoga pants and lying on a mat “doing your best” is so much easier than real exercise–and it just “feels” better, you know–like spiritually.

There needs to be a new type of medical assistant, some sort of support person to coach and monitor people–and educate them about the simple, unvarnished facts of diet and exercise, because even though you often credit the woomeisters with offering diet advice, I would counter that most of that advice is rubbish and never mentions calories. It offers magic berries, supplements galore and yoga with no criteria, measurement or follow up. The middle-aged women I know who do yoga, do very little but spend the session explaining why this or that ache or pain prevents this or that movement. Mostly they like the New Age type setting (music, candles, calming decor) and it’s all a pretense of exercise beyond a bit of stretching. After yoga, they go to lunch and have a 900 calorie sandwich and at least a double serving of wine, all the while lamenting that they cannot lose weight no matter what they “try”, but hey, maybe this “keto” thing is worth a try?

I would agree that doctors usually will not have the time and, likely not the real expertise to advise on such subjects. That is why they can refer to dieticians, physiotherapists, exercise therapists, perhaps a kinesiologist or a specialist psychologist as needed. Heck, in some cases a good social worker would be worth their weight in gold.

No need for the quacking community to offer all sorts of crap treatments that may do more harm than good.

I hope I didn’t imply that woo is ever justified as an “alternative”. I agree that referrals should be a good option, but something seems to be lacking in that scenario–for the woo-inclined anyway.

I’d argue that it’s also time for the medical profession to be more clear that there are things they can not fix at the moment, but that research is (usually) being done to try to find solutions. I was not happy to be told there is no way to cure adhesions, nor that the medication choices to control the resultant pain will leave me with some mental fuzziness, but I was relieved to have a diagnosis (it had been some years coming), and I make the best of what I have as there is nothing else that will make any difference. There are plenty of people who value the truth, even when it isn’t what they want to hear.

and hey, buying cute yoga pants and lying on a mat “doing your best” is so much easier than real exercise–and it just “feels” better, you know–like spiritually.

Depending on the type of yoga, yoga can be pretty vigorous exercise.

Yes, a lot of yoga was borrowed from Swedish gymnastics training as a covert way of getting the Indian people in physical shape for an eventual revolt against the British.

But, I picture most of these people as more like the girl in the insurance video who is busy punching on her smartphone while she lazily pedals her exercise bike.

Fine, but which type of yoga do most middle-aged women (or anyone) practice? As far as I know, there is no standardization of what is even included in yoga, in the training of teachers, or any part of it.

Mimi, there are several schools of yoga which have varying levels of cardio intensity. Some schools are mostly about breath control, some schools are about holding a posture for a long time (5+ minutes) while other schools are about swift movement from posture to posture, and that’s before you get to hot yoga, yoga + barre, power yoga and so on.

It’s a bit like dance; tap is not flamenco is not ballet is not ballroom is not jazz is not Latin, but they’re all dance.

As for teacher training, there are certifications. Two of my cousins who are yoga instructors actually went to India for training to get their teacher certification. I don’t know if there are any local or state regulations that a yoga teacher has to have a certification, but many who do will advertise it.

My coworker who is probably middle-aged does the serious fast-and-hard yoga. I prefer a slower pace because I don’t have the strength or flexibility to get in and out of all of the poses easily, but sometimes I end up super sweaty (or incredibly sore the next day).

Like most forms of exercise, at least some of what you get out of it is how much effort you put into it.

Two of my cousins who are yoga instructors actually went to India for training to get their teacher certification.

It’s unfortunate that people aren’t cutting to the chase and going straight to Swedish gymnastics.

Narad: well, only one of them is on the Swedish side of the family, so it might be harder for the other one (even if she looks more typically Swedish).

A long time ago all my cousins agreed to not judge each other’s career choices, since our aunts/uncles/parents will do that plenty for us, and there’s got to be some family solidarity somewhere.

Mimi – Maybe it’s because when docs do step up and try to address those “unmet needs” patients act as if doctors are criticizing their lifestyle choices and reflect that in patient satisfaction surveys. Or maybe it’s because patients don’t usually like to have to go for follow up visits to specialists for things that they think a primary care doc can do in their office. Or maybe it’s because there isn’t a billable code for taking additional 20 min for lifestyle guidance. Admins, ins cos, and patients generally tend to squash the good things docs can do.

The thing is, everybody knows what the good advice is. Eat more fruits and vegetables, lower your calories (more easily done by reducing calorie-dense fat and sugar) if your weight is too high, exercise regularly, don’t smoke. But that’s too boring for people to stick to.

Fad diets all have massive calorie restrictions hiding in their convoluted rules.

I don’t disagree, but it doesn’t help solve the growing attraction and legitimization of quackery. Doctors need to do more to respond appropriately. The problem is well described here, but solutions are lacking. That is my point. I’m sorry I’m being interpreted as blaming doctors. I’m not.

not consuming too much alcohol or…

… Black pudding? Paging Smut Clyde. I actually heard a radio story recently about a fellow who was making it with his own blood because he was a vegan, or something.

Using your own blood makes it vegan? But how if someone else eats it? And would cannibalism be vegan as well, or just if you eat a piece from your own body?

Using your own blood makes it vegan?

Back during my vegan phase in college, I was perfectly willing to eat, say, pepperoni pizza from the trash, as it no longer has the power to drive the industry of slaughter.

I now realize that certain heritage breeds (and the farms that raise them), y’know, depend upon this. But I digress; during this undergraduate phase, my two best friends bombed me by putting a can of Repo Man generic corned beef hash in the trash. I do not anger easily when it comes to friends, but the aftermath was not pretty.

I think the point of that is that he is not using other species for his own benefit. Most vegans act from a desire not to use animals for human benefit–the PETA approach. Others think, rightly or wrongly, that it is a “healthier” diet. Others, like me just find it a helpful way to control calories, cut emissions and not participate in factory farming.

“So, then, isn’t it time for real doctors to step up and start meeting some of those “unmet needs”?”

The major “unmet need” is that of cancer centers looking for new sources of income.

As noted in the following article, Duke Health charges patients $1,800 a year just for basic membership in its “Integrative Medicine Center”.

https://www.statnews.com/2017/03/07/alternative-medicine-hospitals-promote/

Science and evidence-based therapies are bo-oring. Holisticity and mysticism bring in the marks, um, patients.

I think you miss the point entirely–the patient’s point anyway. No one is advocating for what you describe, but how does that relate to people who leave the doctor’s office feeling that they have been largely ignored. They may be totally wrong about that, but off they go to the quack anyway. Maybe you are saying that if there were no quacks that wouldn’t happen, so I would agree that there should be much more done to stop quacks.

Yes, stop the quacks, however the long term solution is to end the belief in quackery. Otherwise there will always arise a supply to meet the demand, legal and illegal.

yes orac,,would be interesting to get your take on merks buying a australian cancer co ..viralytics who developed cavatak.. a imuno viros protocol this time last year they paid $394 million for it seems to have gone off the radar??here in oz gave great results & showed great promise ?? so when we are hammering quackers all the time,, one wonders what is going on?? did merk buy it to get it off the market or what?? to mix it with keytruda or ???? cheers from oz,,happy bob..

For once Bob has said something interesting. So, Bob, the latest data I can find on Cavatak (an oncolytic common cold virus) is that it has completed one Phase II trial, another Phase II trial is ongoing, and there are several Phase I trials that are combining Cavatak with other treatments (including Keytruda).

So, Bob, Cavatak hasn’t been taken off the market because it hasn’t been put on the market yet. As far as I can tell it doesn’t have approval anywhere yet, and given how many trials are ongoing it looks like there is a lot of hope for this treatment. It just takes a lot of time to run these studies and then analyze the results and present those results to the various regulatory agencies.

The bias here looks too thick to see reality. Some CAM things don’t strike me as obviously beneficial, or cost effective – I don’t bother trying them. Other CAM treatments were described well enough in the literature to appear likely to me as very beneficial with small risk and distinct, measurable changes to track.

Things like restoring and maintaining WBC, platelets and Hgb for years and years on chemo when normal chemo patients typically crashed in several months and often had debilities and disabilities. Or driving down mets and markers and maintaining life when everyone else with similar disease and locations died. And saving lots of money.

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