MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Recently, I came across the ‘Clinical Practice Guidelines on the Use of Integrative Therapies as Supportive Care in Patients Treated for Breast Cancer’ published by the ‘Society for Integrative Oncology (SIO) Guidelines Working Group’. The mission of the SIO is to “advance evidence-based, comprehensive, integrative healthcare to improve the lives of people affected by cancer. The SIO has consistently encouraged rigorous scientific evaluation of both pre-clinical and clinical science, while advocating for the transformation of oncology care to integrate evidence-based complementary approaches. The vision of SIO is to have research inform the true integration of complementary modalities into oncology care, so that evidence-based complementary care is accessible and part of standard cancer care for all patients across the cancer continuum. As an interdisciplinary and inter-professional society, SIO is uniquely poised to lead the “bench to bedside” efforts in integrative cancer care.”

The aim of the ‘Clinical Practice Guidelines’ was to “inform clinicians and patients about the evidence supporting or discouraging the use of specific complementary and integrative therapies for defined outcomes during and beyond breast cancer treatment, including symptom management.”

This sounds like a most laudable aim. Therefore I studied the document carefully and was surprised to read their conclusions: “Specific integrative therapies can be recommended as evidence-based supportive care options during breast cancer treatment.”

How can this be? On this blog, we have repeatedly seen evidence to suggest that integrative medicine is little more than the admission of quackery into evidence-based healthcare. This got me wondering how their conclusion had been reached, and I checked the document even closer.

On the surface, it seemed well-made. A team of researchers first defined the treatments they wanted to look at, then they searched for RCTs, evaluated their quality, extracted their results, combined them into an overall verdict and wrote the whole thing up. In a word, they conducted what seems a proper systematic review.

Based on the findings of their review, they then issued recommendations which I thought were baffling in several respects. Let me just focus on three of the SIO’s recommendations dealing with acupuncture:

  1. “Acupuncture can be considered for treating anxiety concurrent with ongoing fatigue…” [only RCT (1) cited in support]
  2. “Acupuncture can be considered for improving depressive symptoms in women suffering from hot flashes…” [RCTs (1 and 2) cited in support] 
  3. “Acupuncture can be considered for treating anxiety concurrent with ongoing fatigue…” [only RCT (1) cited in support]
One or two studies as a basis for far-reaching guidelines? Yes, that would normally be a concern! But, at closer scrutiny, my worries about these recommendation turn out to be much more serious than this.

The actual RCT (1) cited in support of all three recommendations stated that the authors “randomly assigned 75 patients to usual care and 227 patients to acupuncture plus usual care…” As we have discussed often before on this blog and elsewhere, such a ‘A+B versus B study design’ will never generate a negative result, does not control for placebo-effects and is certainly not a valid test for the effectiveness of the treatment in question. Nevertheless, the authors of this study concluded that: “Acupuncture is an effective intervention for managing the symptom of cancer-related fatigue and improving patients’ quality of life.”

RCT (2) cited in support of recommendation number 2 seems to be a citation error; the study in question is not an acupuncture-trial and does not back the statement in question. I suspect they meant to cite their reference number 87 (instead of 88). This trial is an equivalence study where 50 patients were randomly assigned to receive 12 weeks of acupuncture (n = 25) or venlafaxine (n = 25) treatment for cancer-related hot flushes. Its results indicate that the two treatments generated the similar results. As the two therapies could also have been equally ineffective, it is impossible, in my view, to conclude that acupuncture is effective.

Finally, RCT (1) does in no way support recommendation number two. Yet RCT (1) and RCT (2) were both cited in support of this recommendation.

I have not systematically checked any other claims made in this document, but I get the impression that many other recommendations made here are based on similarly ‘liberal’ interpretations of the evidence. How can the ‘Society for Integrative Oncology’ use such dodgy pseudo-science for formulating potentially far-reaching guidelines?

I know none of the authors (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) of the document personally. They made the following collective statement about their conflicts of interest: “There are no financial conflicts of interest to disclose. We note that some authors have conducted/authored some of the studies included in the review.” I am a little puzzled to hear that they have no financial conflicts of interest (do not most of them earn their living by practising integrative medicine? Yes they do! The article informs us that: “A multidisciplinary panel of experts in oncology and integrative medicine was assembled to prepare these clinical practice guidelines. Panel members have expertise in medical oncology, radiation oncology, nursing, psychology, naturopathic medicine, traditional Chinese medicine, acupuncture, epidemiology, biostatistics, and patient advocacy.”). I also suspect they have other, potentially much stronger conflicts of interest. They belong to a group of people who seem to religiously believe in the largely nonsensical concept of integrative medicine. Integrating unproven treatments into healthcare must affect its quality in much the same way as the integration of cow pie into apple pie would affect the taste of the latter.

After considering all this carefully, I cannot help wondering whether these ‘Clinical Practice Guidelines’ by the ‘Society for Integrative Oncology’ are just full of honest errors or whether they amount to fraud and scientific misconduct.

WHATEVER THE ANSWER, THE GUIDELINES MUST BE RETRACTED, IF THIS SOCIETY WANTS TO AVOID LOSING ALL CREDIBILITY.

18 Responses to Is the ‘Society for Integrative Oncology’ guilty of fraud or scientific misconduct?

  • Depending on your understanding of ‘fraud’. My understanding is ‘both’.

  • We all know Minchin’s Law – by definition, alternative medicine either hasn’t been proven to work, or has been proven not to work – and we all know that the suborning of potentially valid complementary therapies under the umbrella of CAM was always a trick designed to impart a “halo effect” on treatments that have no good evidence.

    The problem for any proponent of any alternative to medicine has always been:

    1. They sincerely believe in the alternative treatment.
    2. They know it is alternative precisely due to lack of credible evidence.
    3. In order to reduce cognitive dissonance, they therefore have to conclude that there is something wrong with the normal process of evidence gathering.

    That’s why they keep trying to invent studies that show what they want them to show, and why they don’t feel the need to follow honest scientific protocols. They believe in the treatment, they know that rigorous research shows it to be bogus, so they conclude that something about the way of excluding bias, also excludes whatever magical factor it is that makes it “work”. Thus they have no problem with crap studies, because they are a necessary evil in order to show the obvious innate [geddit?] value of the things in which they believe.

    “Integrative” medicine will always love the A+B vs. B type of study design, for exactly the same reasons that alternative medicine became CAM: adding a valid therapy gives a positive (i.e. “correct”) result, and all positive results will be interpreted as validating the entire house of cards. Positive means it supports the whole thing, negative means the answer must have been wrong.

    I don’t know what can be done about this, as membership of the community of “integrative medicine” more or less demands that you drink this Kool-Aid and adopt of the same lax standards of evidence that all SCAM proponents use.

  • The Society for Integrative Oncology has never had any credibility in the first place.
    ‘IM’ (a mish-mash all known treatment modalities) is what once apon a time, long ago was called ‘medicine’.
    Regulated, scientific, modern medicine moved on. The modalities involved in ‘IM’ have been left behind and long lost their credibility.

    We are left with a group of practitioners who appear not to understand this and are deluded, or do understand and are quacks and/or do understand and are seeking to defraud. They won’t change, they’re in too deep.
    Sad.

  • One might say that if patient after acupuncture or whatever is feeling better, then why not? Unfortunately many perceive all health problems, especially all problems associated with one disease as equally significant. Alternative medicine helped (really?) to look at the life from the brighter side? Then it will certainly help against …

    • If you really believe the way to be happy in life is to lie constantly to yourself – and pay a whole sack of cash to kooks and grifters to lie constantly to you too – perhaps there’s something else in your life you should be fixing instead.

      • I don’t. And neither I believe in the strategy of shaming sp popular during my Soviet childhood, unfortunately, but cancer brings up a big problem: relatives that feel more helpless than the patient himself, but believe it is their duty to cheer him up although result is quite the opposite.

  • As an aside, I’ve earned the enmity of SIO for this article in Nature Reviews Cancer:

    http://www.nature.com/nrc/journal/v14/n10/abs/nrc3822.html

    Particularly hilarious was SIO’s pique at my criticizing it for admitting naturopaths as members. (Indeed, a naturopath was one of the co-authors of the guidelines Prof. Ernst excoriates.) Another criticism was over my discussion of homeopathy in the paper. The SIO responded that there’s no way homeopathy could be a part of integrative oncology because it’s such obvious pseudoscience. My response was to point out that homeopathy is a major part of the training of naturopaths and that the NPLEX (the naturopathic licensing exam) tests naturopaths-to-be on homeopathy. Then I pointed out that Dugald Seely, the naturopath who is a co-author of the SIO guidelines, is the principle investigator of a clinical trial of homeopathy! Seriously, though. the SIO has no clue how much pseudoscience it is embracing. It really does think itself to be evidence- and science-based.

  • As Ernst rightly calls it, the article must be retracted. But what the hell is going on? Why the article appeared in the Journal of the National Cancer Institute in the first place is the biggest head-slapper. What happened in the peer review process is even more of a mystery, although we can guess what happened; the Editor obviously dropped the ball.

  • You people behave like a pack of hungry hounds, barking up the wrong tree. CAM and therapies like acupuncture are sought after only because conventional medicine too often makes patients suffer progressively, causing deformity, amputations, joint replacements, disability and premature deaths that are completely avoidable.

    Instead of learning to improve your knowledge and skill to secure improvement in health and wellbeing, and in the prevention, diagnosis and treatment of illness, and to safeguard life expectancy, your pack waste energy egging one another on to attack everything you choose not to understand.

    I do not know how many people die each year from homeopathy, acupuncture and all CAM therapies put together but NHS Information Centre reveals that conventional treatment results in killing 70-75,000 diabetic patients every year, including 24,000 deaths that can be avoided if the NHS provided better information, advice, management or treatment of this condition.

    http://www.bbc.co.uk/news/health-16147731

    In 2010/11, the NHS spent £9.8bn of taxpayers’ money, about 10% of the NHS’ annual budget, on treatment that killed 24,000 patients needlessly. The NHS then forced social services, employment support and local councils to find a further £13.9bn a year to pay for patients conventional medicine made disabled or unfit for work, until they die prematurely. £23.7bn a year is a lot of money to waste every year.

    http://www.nhs.uk/news/2012/04april/Pages/nhs-diabetes-costs-cases-rising.aspx

    Millions of Britons are suffering needlessly every day and hundreds of thousands are dying needlessly every year because there are many incurable conditions in conventional medicine.

    An incurable condition means that every drug and treatment available in conventional medicine is proved ineffective and harmful. If even one treatment is effective and safe, the condition cannot be said to be incurable.

    For example, MS is said to be incurable. Can anyone explain why the NHS subjects MS patients to expensive drugs to weaken their immune system when no effective or safe treatment exists?

    You don’t need to be a doctor to know that everyone dies when the immune system is weakened sufficiently. Every doctor knows that people with MS die early even though MS is not fatal. It is not rocket science that patients are killed by drugs and treatment doctors provide or fail to provide. If these drugs are effective and safe (as they all are proven effective and safe in robust clinical trials), no one would suffer progressively or die prematurely.

    Every doctor knows from NHS statistics that patients subjected to the same drugs that have always resulted in progressive suffering and in shortening life expectancy will continue to suffer progressively and die prematurely. Subjecting anyone to any treatment, knowing that the treatment has always resulted in shortening life expectancy is murder. Why do you people attack homeopaths and acupuncturists while you let so many doctors get away with murder scot-free? Why do you let people with MS die prematurely and do nothing?

    The driver of a train involved in 240 people dying needlessly will never be permitted to drive again, even if he is not prosecuted for murder or manslaughter.

    Every doctor knows that 24,000 patients will die needlessly each year yet they carry on subjecting patients to the same treatment that will result in killing another 24,000 patients this year and every year.

    This is the kind of madness you mindlessly support. Isn’t it insensitive and hypocritical to tell others what treatment they should have or not have, when you do nothing to prevent 24,000 people from dying needlessly from diabetes alone each year?

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