Old wine poured into a newer skin: The Society for Integrative Oncology updates its clinical guidelines for breast cancer [Respectful Insolence]

“Integrative medicine” is a term for a form of medicine in which pseudoscience and quackery are “integrated” with real medicine. Unfortunately, as Mark Crislip puts it, when you mix cow pie with apple pie, it doesn’t make the cow pie better; it makes the apple pie worse. Unfortunately these days, there’s a lot of cow pie being mixed with apple pie. Worse, it’s gotten to the point where integrative medicine is subspecializing. For instance, there is now a specialty known as “integrative oncology,” which particularly burns me. Indeed, supportive care oncology has been very susceptible to the woo embraced by integrative oncology, to the point where naturopaths are involved, and when naturopaths are involved quackery such as homeopathy is involved.

Two years ago, the Society for Integrative Oncology, the main society promoting the integration of pseudoscience into science-based oncology, published a monograph in the Journal of the National Cancer Institute (JNCI) with guidelines for what it referred to as the evidence-based supportive care of breast cancer patients. I referred to it at the time as “old wine in a new skin.” Well, leave it to the SIO not to be able to leave bad enough alone, as it’s come up with what I like to refer to as SIO Clinical Guidelines 2: Electric Boogaloo. It comes in the form of an article by Heather Greenlee et al published in CA: A Cancer Journal for Clinicians and entitled Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment.

Its author list includes MDs, some of them respected, like Debu Tripathy, but it also contains quacks like an acupuncturist named Misha Cohen. It also contains three naturopaths, starting with the first author, Heather Greenlee. Dugald Seely is on the author list again, as well. We’ve met Seely before on multiple occasions. Indeed, he’s quite the flush little naturopathic quack, complete with millions of dollars donated by an anonymous donor to fund “integrative oncology” research at the Ottawa Integrative Cancer Center (OICC). Then there’s Suzanna Zick, who’s even worse than a naturopath. She’s a naturopath at my alma mater, the University of Michigan Medical School. It always depresses me to contemplate that U. of M. actually has a naturopath working for it, but, then, it also has an anthroposophic medicine program. So I guess it’s not a stretch any more for there to be naturopaths there.

Let’s get back to the clinical guidelines and systematic review, such as they are. To show just how debased medicine has become in accepting woo as “evidence-based,” you can even answer questions about the article and earn CME for learning. One thing I can’t figure out is why this group felt the need to update the guidelines a mere two years later, and this explanation doesn’t help:

In November 2014, the Society for Integrative Oncology (SIO) published clinical practice guidelines to inform both clinicians and patients on the use of integrative therapies during breast cancer treatment and to treat breast cancer treatment-related symptoms.[9] The SIO adapted methods established by the US Preventive Services Task Force[10] to develop graded recommendations on the use of specific integrative therapies for defined clinical indications based on the strength of available evidence concerning associated benefits and harms. The 2014 clinical practice guidelines were derived from a systematic review of randomized clinical trials published between 1990 and 2013 and organized by specific clinical conditions (eg, anxiety/stress, fatigue). This review provides an updated set of clinical practice guidelines based on a current, systematic literature review of randomized controlled trials (RCTs) published through December 2015 along with detailed definitions of integrative therapies and clinical outcomes of interest, a detailed summary of the literature upon which the clinical practice guidelines are based, and suggestions for how appropriate therapies may be integrated into clinical practice.

So my first reaction was: Really? You needed to publish again just to add two years’ worth of new trials to the guidelines? Do the new trials add much to the recommendations from the previous iteration of these guidelines? Do they change the recommendations in any substantive way? What do Greenlee et al mean by “recommendations,” anyway. It’s not what you would normally think:

Of note, it is important to define the use of the term recommendation in these clinical practice guidelines. In many settings, a clinical guideline recommendation suggests that it should be used as the standard of care and is favorable or equal compared with all other options based on best clinical evidence for benefit/risk ratio. Here, in the setting of integrative oncology, we use the term recommendation to conclude that the therapy should be considered as a viable but not singular option for the management of a specific symptom or side effect. Few studies have conducted a head-to-head comparison of a given integrative therapy against a conventional treatment, and most integrative therapies are used in conjunction with standard therapy and have been studied in this manner. Moreover, combination-based approaches and the interactions of the numerous permutations of integrative and conventional treatments have not been formally investigated, such that recommendations must account for this limitation of our knowledge. Despite these limitations to evaluating the use of integrative therapies in the oncology setting, there is a body of well conducted trials of specific therapies for specific conditions that provides sufficient evidence to warrant recommendations on the therapies as viable options for treating specific conditions.

Ah, “integrative medicine,” where even “recommendation” doesn’t mean what it does in real medicine. In clinical guidelines in real medicine, “recommendation” means just that: a recommendation to use the treatment in question, graded, of course, according to the strength of the evidence. Yet here in the world of integrative medicine, “recommendation” means something…squishier. One can’t help but make the analogy that integrative medicine’s evidence standard is squishier than that of real medicine. Oh, and the answer to that question of whether the new studies add much of anything to the 2014 clinical guidelines is, as I suspected, no, at least as far as I can tell. As was the case with the previous review, interventions are graded thusly:

Grades were based on strength of evidence, determined by the number of trials, quality of trials, magnitude of effect, statistical significance, sample size, consistency of results across studies, and whether the outcomes were primary or secondary. The highest grades (A and B) indicate that a specific therapy is recommended for a particular clinical indication. Grade A indicates there is high certainty that the net benefit is substantial, while grade B indicates there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Grade C indicates that the evidence is equivocal or that there is at least moderate certainty that the net benefit is small. The lowest grades (D, H, and I) indicate no demonstrated effect, suggest harm, or indicate that the current evidence is inconclusive, respectively.

Interestingly, this review does add something in that it defines each intervention more explicitly than the previous guidelines. Not surprisingly, the definition of acupuncture parrots the same sort of revisionist history that acupuncture advocates frequently repeat when justifying the practice. It is, in essence, an appeal to antiquity that paints acupuncture thusly:

Acupuncture involves the stimulation of specific points, (ie, acupoints) by penetrating the skin with thin, solid, metallic needles.[154, 155] A variation of acupuncture includes electroacupuncture, in which a small electric current is passed along acupuncture needles to provide a stronger stimulus than acupuncture alone, with distinct effects suggested by functional magnetic resonance imaging.[156, 157] Acupuncture has been practiced in Asia for thousands of years as a component of traditional medicine systems (eg, traditional forms of Chinese, Japanese, and Korean medicine) and is thought to stimulate the flow of a form of energy called qi (chee) throughout the body. Traditional Chinese acupuncture, which is commonly used in North America, requires needle manipulation to produce a de qi sensation (a soreness, fullness, heaviness, or local area distension[157, 158]), along with a period of rest with the needles in place.[159] It is posited that this removes energetic blockages, thus reestablishing homeostasis. The mechanisms for acupuncture’s effects are not well understood but are thought to function in part through modulation of specific neuronal/cortical pathways.[160]

It’s always a sad day when a respectable medical publication publishes papers that invoke vitalism in the form of the flow of “life energy” and suggests that this flow can be manipulated. Then there’s the revisionist history. Think about it. The claim is that acupuncture has been practiced “thousands of years,” most commonly for at least a couple of thousands of years. Yet two thousand years ago the technology to produce thin needles of the sort used by acupuncturists didn’t exist. In fact, it’s unclear when acupuncture in something resembling its current form evolved, but it appeared to have evolved from bloodletting. Harriet Hall once related the story of Dugald Christie, a Scottish surgeon who served as a missionary doctor in northeastern China from 1883 to 1913, and his experiences observing traditional Chinese medicine (TCM), including acupuncture. Let’s just say that acupuncture practiced 100 years ago was rather brutal. In fact, acupuncture began as nothing more than a Chinese version of bloodletting, very much like “Western” bloodletting and has been called “astrology with needles.” In reality, acupuncture and TCM achieved their current form under Chairman Mao Zedong, who promoted their use when he couldn’t supply enough doctors for his people and exported to the world, something China is still doing. It’s a history that’s been retconned, and Greenlee et al repeat that retconned revisionist history. No wonder there are so many forms of acupuncture.

Basically, there’s not much new in these guidelines. Relatively uncontroversial modalities like meditation, music therapy, stress management, and yoga are given the highest recommendations. However, acupuncture and its bastard offspring electroacupuncture (which really has no basis in TCM, given that there was no electricity hundreds or thousands of years ago to hook needles up to) consistently get B or C recommendations for several indications, despite acupuncture being nothing more than a theatrical placebo that hasn’t convincingly been shown to work for any clinical indication. That includes acupressure.

As is the case with most systematic reviews of integrative medicine, there are some head scratchers. For instance there’s this level C recommendation, meanding that they can be considered

Acupuncture,[49-51, 91, 92] healing touch,[93, 94] and stress management[36-38, 95, 96] can be considered for improving mood disturbance and depressive symptoms.

And:

Acupuncture,[119-124] healing touch,[93] hypnosis,[125, 126] and music therapy[31, 34] can be considered for the management of pain.

Healing touch is the rankest quackery. It’s energy medicine that postulates that practitioners can manipulate human life energy fields. It’s such a silly form of quackery that even a 12-year-old girl could disprove it.

Basically, these guidelines were even more unnecessary and pointless than the first set of guidelines published in 2014. It’s not as though clinical studies have advanced knowledge enough to justify a new set of guidelines, and these guidelines suffer from the same issue that integrative medicine itself suffers from, mixing cow pie with apple pie as though they were equivalent. I called the previous guidelines old wine in a new skin. Greenlee et al have just poured that old wine out of the new skin into a newer skin, seemingly expecting it to make the vinegary wine better.