MD, PhD, FMedSci, FSB, FRCP, FRCPEd

This recently published report provides updated clinical practice guidelines from the Society for Integrative Oncology on the use of integrative therapies for specific clinical indications during and after breast cancer treatment, including anxiety/stress, depression/mood disorders, fatigue, quality of life/physical functioning, chemotherapy-induced nausea and vomiting, lymphedema, chemotherapy-induced peripheral neuropathy, pain, and sleep disturbance.

The practice guidelines are based on a systematic literature review from 1990 through 2015. The recommendations are as follows:

  • Music therapy, meditation, stress management, and yoga are recommended for anxiety/stress reduction.
  • Meditation, relaxation, yoga, massage, and music therapy are recommended for depression/mood disorders.
  • Meditation and yoga are recommended to improve quality of life.
  • Acupressure and acupuncture are recommended for reducing chemotherapy-induced nausea and vomiting.
  • Acetyl-L-carnitine is not recommended to prevent chemotherapy-induced peripheral neuropathy due to a possibility of harm.
  • No strong evidence supports the use of ingested dietary supplements to manage breast cancer treatment-related side effects.

The authors conclude that there is a growing body of evidence supporting the use of integrative therapies, especially mind-body therapies, as effective supportive care strategies during breast cancer treatment. Many integrative practices, however, remain understudied, with insufficient evidence to be definitively recommended or avoided.

I have to admit that I am puzzled by this paper.

The first obvious point to make is that these treatments are not ‘integrative therapies’; they are alternative or complementary and I fail to see what is integrative about them.

The second point is that the positive recommendations are based on often poor-quality studies which did not control for placebo effects.

The third point is that the negative recommendations are woefully incomplete. There are many more alternative therapies for which there is no strong evidence.

The forth point is the conclusion implying that treatment supported by insufficient evidence should be avoided. I would not claim that any of the mentioned treatments is backed by SUFFICIENT evidence. Therefore, we should avoid them all, one might argue.

But these concerns are perhaps relatively trivial or far-fetched. More important is the fact that a very similar article been published in 2014. Here is the abstract:

Background

The majority of breast cancer patients use complementary and/or integrative therapies during and beyond cancer treatment to manage symptoms, prevent toxicities, and improve quality of life. Practice guidelines are needed to inform clinicians and patients about safe and effective therapies.

Methods

Following the Institute of Medicine’s guideline development process, a systematic review identified randomized controlled trials testing the use of integrative therapies for supportive care in patients receiving breast cancer treatment. Trials were included if the majority of participants had breast cancer and/or breast cancer patient results were reported separately, and outcomes were clinically relevant. Recommendations were organized by outcome and graded based upon a modified version of the US Preventive Services Task Force grading system.

Results

The search (January 1, 1990–December 31, 2013) identified 4900 articles, of which 203 were eligible for analysis. Meditation, yoga, and relaxation with imagery are recommended for routine use for common conditions, including anxiety and mood disorders (Grade A). Stress management, yoga, massage, music therapy, energy conservation, and meditation are recommended for stress reduction, anxiety, depression, fatigue, and quality of life (Grade B). Many interventions (n = 32) had weaker evidence of benefit (Grade C). Some interventions (n = 7) were deemed unlikely to provide any benefit (Grade D). Notably, only one intervention, acetyl-l-carnitine for the prevention of taxane-induced neuropathy, was identified as likely harmful (Grade H) as it was found to increase neuropathy. The majority of intervention/modality combinations (n = 138) did not have sufficient evidence to form specific recommendations (Grade I).

Conclusions

Specific integrative therapies can be recommended as evidence-based supportive care options during breast cancer treatment. Most integrative therapies require further investigation via well-designed controlled trials with meaningful outcomes.

I have harshly criticised this review on this blog in 2016. For instance, I voiced concern about the authors declaration of conflicts of interest and stated:

 

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

The just-published update has a different statement about conflicts of interest:

DISCLOSURES: Linda E. Carlson reports book royalties from New Harbinger and the American Psychological Association. Misha R. Cohen reports royalties from Health Concerns Inc., outside the submitted work. Matthew Mumber owns stock in I Thrive. All remaining authors report no conflicts of interest.

Is this much better than the previous statement? Was the previous statement therefore false?

I wonder.

What do you think?

4 Responses to The ‘Society for Integrative Oncology’ puzzles me yet again

  • A hobby remains a hobby and wellness remains wellness, also when you are a cancer patiënt. Don’t call these activities or treatments ‘therapy’ because it concerns cancer patients.

  • Regarding the authors, Heather Greenlee, Suzanna Zick, and Dugald Seely are naturopaths, and Misha Cohen is a TCM practitioner and acupuncturist, which could explain a lot. I’ve frequently criticized SIO for having naturopaths not just as members but in high-ranking positions within the organization. For instance, Zick is the immediate past president (meaning she was president of the SIO from 2015-2016), and Greenlee was president before her (2014-2015).

    I’ll tell you a little anecdote that might amuse you. After my critique of integrative oncology was published in Nature Reviews Cancer in 2014, the SIO wrote letters attacking it. In particular, they didn’t like my mention of homeopathy, which, they grudgingly admitted, was basically pseudoscience. Basically, their complaint was that they don’t do that any more. My response? If that’s the case, then why do they admit naturopaths and have them in high ranking positions in their society? The MDs in SIO seemed oblivious that you can’t have naturopathy without homeopathy, that homeopathy is an integral and major part of the curricula of naturopathy schools, and that the NPLEX–an exam that naturopaths have to pass to be licensed in states where naturopaths are licensed–has a section on homeopathy. I then twisted the blade by pointing out that Dugald Seely, who was a co-author of the first version of the SIO’s recommendations for the supportive care of breast cancer patients, was at the time the principal investigator for a clinical trial of homeopathy!

  • Hi Dr Ernst

    I came across your blog while searching for information on the multitude of so called complimentary therapies being offered to patients with live ending conditions. Im currently a cancer patient being treated for osteosarcoma. My treatment has included, surgery, radio and chemotherapy. The results have been mixed.

    What has angered me isn’t any of the shortcomings of these treatments, It is the constant and often overhelming bombardment of offers of every conceivable treatment in the field so called integrative rative therapies. Im my case these treatments are being advocated by my medical practitioners. This makes me really anger.

    I just wanted to say thank you to you for taking the time to highlight the dangers that these demeaning and degrading practices pose.

    I would like to finish my post with a personal anecdote. During my last round of treatment I was approached by a stranger while in hospital. He told be his name was master something or other. At the time I was being violently ill. He offered to lay hands on me and take away some of my pain. As I turned to see who was intruding into my personal misery I was again ill. I covered the “master” in a vile concoction. Seeing him standing there irate made me laugh uncontrollably. Momentarily my pain was eciplised. Perhaps Reiki does work.

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