MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

Barrie R. Cassileth died on Feb. 26 at an assisted-living home in Beverly Hills, California. I knew about Barrie because she was the 1st author of a most remarkable study published in 1991 in the prestigious NEJM. Here is the abstract:

Background: Cancer treatments without proved efficacy have achieved new levels of popularity, particularly among well-educated patients. The value of these therapies is vigorously debated.

Methods: We compared the length of survival and quality of life in patients who received treatment at a prominent unorthodox cancer clinic in addition to conventional treatment and in matched control patients from an academic cancer center who received only conventional treatment. All the patients had documented extensive malignant disease associated with a predicted median survival time of less than one year. The study sample consisted of 78 pairs of patients matched according to sex, race, age, diagnosis, and time from the diagnosis of metastatic or recurrent disease, who were enrolled over a period of 3 1/2 years. Periodic follow-up (approximately every two months) continued until death.

Results: There was no difference between the two patient groups in length of survival. Median survival for both groups was 15 months (P = 0.22; relative risk, 1.23; 95 percent confidence interval, 0.88 to 1.72). Quality-of-life scores were consistently better among conventionally treated patients from enrollment on.

Conclusions: For this sample of patients with extensive disease and for this particular unorthodox treatment regimen, conventional and unorthodox treatments produced similar results.

In 1995, I met her for the first time when we both served on an NIH panel, and we kept in contact. When I had flown to Boston for a conference she even drove from New York to see me and have a chat. In 1998, she asked me to come to New York because she needed to discuss something important with me and wanted my advice. It turned out that she had been offered to create the Integrative Medicine Service at Memorial Sloan Kettering Cancer Center in New York sponsored by Laurance Rockefeller. She was very much in two minds about accepting. Her fear was that she would have to become an advocate of alternative medicine. I tried to reassure her and pointed out that I did not exactly turn into an advocate after accepting the Exeter post.

In the end, she accepted and, in the years that followed, we met several times at conferences, became friends, and published a few papers together. I even persuaded her to come to one of our annual conferences at Exeter as a keynote speaker. By then, she had clearly become an advocate of complementary medicine.

What had happened?

Barrie was very keen to differentiate alternative from complementary therapies in cancer care. The former she sharply condemned, while advocating the latter for improving the quality of life of cancer patients. When we discussed these issues, I argued that the ‘alternative versus complementary’ was a somewhat artificial division and that the overlap was large. I also pointed out that some of the complementary treatments she was backing were not based on good evidence. In other words, our views had begun to differ. We remained friends but gradually drifted apart and eventually lost contact.

Barrie Joyce Rabinowitz was born on April 22, 1938, in Philadelphia. She attended Bennington College in Vermont and spent a summer teaching art in Pownal, Massachusetts. She graduated with a degree in social sciences in 1959, a year after marrying Peter Cassileth. Barrie received a master’s degree in psychology from Albert Einstein University and a Ph.D. in medical sociology in 1978 from the University of Pennsylvania, where Peter Cassileth was an oncologist. As part of her doctoral program, Barrie worked closely with adult leukemia patients. After being hired at Pennsylvania as an assistant professor, she helped establish one of the first palliative cancer care programs in the US. Before accepting the post at Slone-Kettering, she taught at Duke, Harvard, and the University of North Carolina. In 2003, she became the founding president of the Society for Integrative Oncology.

While at Slone-Kettering, Barrie published several excellent books and high-quality studies of complementary medicine. She kept on working well after the normal retirement age. Her last RCT was only published in 2018. Here is the abstract:

Purpose: Approximately 20% of breast cancer survivors develop breast cancer-related lymphedema (BCRL), and current therapies are limited. We compared acupuncture (AC) to usual care wait-list control (WL) for treatment of persistent BCRL.

Methods: Women with moderate BCRL lasting greater than six months were randomized to AC or WL. AC included twice weekly manual acupuncture over six weeks. We evaluated the difference in circumference and bioimpedance between affected and unaffected arms. Responders were defined as having a decrease in arm circumference difference greater than 30% from baseline. We used analysis of covariance for circumference and bioimpedance measurements and Fisher’s exact to determine the proportion of responders.

Results: Among 82 patients, 73 (89%) were evaluable for the primary endpoint (36 in AC, 37 in WL). 79 (96%) patients received lymphedema treatment before enrolling in our study; 67 (82%) underwent ongoing treatment during the trial. We found no significant difference between groups for arm circumference difference (0.38 cm greater reduction in AC vs. WL, 95% CI – 0.12 to 0.89, p = 0.14) or bioimpedance difference (1.06 greater reduction in AC vs. WL, 95% CI – 5.72 to 7.85, p = 0.8). There was also no difference in the proportion of responders: 17% AC versus 11% WL (6% difference, 95% CI – 10 to 22%, p = 0.5). No severe adverse events were reported.

Conclusions: Our acupuncture protocol appeared to be safe and well tolerated. However, it did not significantly reduce BCRL in pretreated patients receiving concurrent lymphedema treatment. This regimen does not improve upon conventional lymphedema treatment for breast cancer survivors with persistent BCRL.

Her contribution to our knowledge about complementary therapies is outstanding, and I am sure that her papers will be cited for decades to come. She will be missed and remembered as an innovator in the field of palliative cancer care.

Barrie had been married three times. Her third husband, Richard Cooper, who was the Director of the Center for the Future of the Healthcare Workforce and a Senior Fellow in the Leonard Davis Institute of Health Economics at the University of Pennsylvania, died in 2016. Barrie is survived by her siblings, Stephen and Ruth Rabinowitz; her daughters, Jodi Cassileth Greenspan and Wendy Cassileth; her son, Gregory Cassileth; and 6 grandchildren.

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