Cancer Treatment Centers of America: Revisiting the epitome of “integrative” cancer care

Three weeks ago, I mentioned in a post that the week of October 7 to 14 was declared by our very own United States Senate to be Naturopathic Medicine Week, which I declared unilaterally through my power as managing editor of Science-Based Medicine (for what that’s worth) to be Quackery Week. One wonders where the Senate found the time to consider and vote for S.Res.221, which reads:

S.Res.221 – A resolution designating the week of October 7 through October 13, 2013, as “Naturopathic Medicine Week” to recognize the value of naturopathic medicine in providing safe, effective, and affordable health care.

I know, I know, it probably took all of five minutes to consider and vote for this, thanks to Sen. Barbara Mikulski (D-MD), who sponsored it. In any case, as October 7 approached, I thought about how I could keep my promise to blog about naturopathy this week, and I came up with a way to do it. It’s a bit roundabout, but I think it fits. The idea derives from a discussion I was having a while back about one of my “favorite” hospitals, namely the Cancer Treatment Centers of America, in which a colleague of mine questioned why there were so many CTCA ads on NPR and why CTCA is sponsoring shows on PBS such as the upcoming The Emperor of All Maladies by Ken Burns. Although I can’t wait to see this particular series, I am a bit worried that the infiltration of quackademic medicine will make an appearance, given that CTCA is a major sponsor.

Of course, PBS has come under fire here at SBM for doing more than airing acknowledgments from CTCA. There are several examples, such as its running of infomercials for Daniel Amen and Mark Hyman, as well as the local Colorado PBS station running, in essence, an infomercial for Stanislaw Burzynski, complete with Burzynski’s very own propagandist, Eric Merola. Let’s just say that, when it comes to medicine, PBS isn’t exactly as scientifically rigorous as it once was.

With this as my entry point, I noted that CTCA is very much into “naturopathic oncology” and that it’s been over three years since I’ve written about this. Given that this is Naturopathic Medicine Week 2013, this seemed like an excellent way to begin, with a recap and update on the nonsensical therapies that CTCA provides. In many ways, CTCA is the very epitome of “integrative medicine,” and I don’t mean that in a good way. (Actually, there is no good way to be the epitome of “integrative medicine,” which “integrates” pseudoscience and quackery with real medicine.) Then, late last year, it was revealed that Richard Stephenson, the founder of CTCA, is also one of the primary funding sources for Freedom Works, a right-wing Tea Party organization that was a major player in the 2012 elections. It was an interesting little tidbit in that it is yet another reminder that the tendency towards medical woo is not limited to the stereotypical crunchy granola-eating left wing fringe. Be that as it may, let’s take a look at what CTCA is offering these days. When I did this, I found a lot of the same ol’ same ol’, but one new development that echoes another frequent topic of this blog.

“Integrating” pseudoscience with science

The first thing I noticed when looking at the list of treatments that CTCA offers is that there is no segregation between the woo and the real medicine. Acupuncture, naturopathic medicine, “mind-body” medicine, and chiropractic are all “integrated” seamlessly into the list with chemotherapy, surgical oncology, and radiation oncology. The next thing I noticed is that the woo is also highly “integrated” into the national leadership of CTCA. For example, Katherine Anderson is the National Director, Naturopathic Medicine and Director, Naturopathic Medicine, Southwestern Regional Medical Center, while the Chief Information Officer is Timothy Birdsall, a naturopath who was Vice President, Integrative Medicine, and National Director of Naturopathic Medicine & Research from 2002 to 2012 and was named as the physician of the year by the American Association of Naturopathic Physicians (and who was also quite adept at spinning negative studies about his favorite supplements). Then there are James Rosenberg, National Director of Chiropractic Care; Carolyn Lammersfeld, Vice President of Integrative Medicine; Katherine Puckett, National Director of Mind-Body Medicine, and Director of the Department of Mind-Body Medicine; and Karen Gilbert, National Director of Oncology Rehabilitation, who also boasts of being certified in Lymphatic Drainage Therapy and Auriculotherapy. One notes that auriculotherapy is basically ear acupuncture based on the idea that the ear is a microsystem which reflects the entire brain represented on the auricle, the outer portion of the ear. Yes, it’s basically the same sort of quackery that Col. (Dr.) Richard Niemtzow offers our troops as “battlefield acupuncture.” What’s really depressing to see, however, is that a formerly well-respected surgical oncologist, Edgar Staren, is the President and CEO, Medicine and Science, and President and CEO, Western Regional Medical Center. I used to see him present from time to time at surgical meetings. In fact, I might even have met him in person back in the 1990s when I was looking for a job near the end of my fellowship and interviewed at Rush University Medical Center.

But what does CTCA offer in terms of “integrative” treatments these days? I wandered over to the section on integrative oncology services, and this is what I found. Naturally, I couldn’t resist heading first to the section on naturopathic medicine, particularly given that this is naturopathic medicine week. This is what CTCA touts, after declaring that naturopathic clinicians are “specialists in natural health care who use natural, non-toxic therapies to support the whole person and encourage the self-healing process”:

Throughout your treatment, your naturopathic clinician will recommend natural therapies to support your immune system and reduce any treatment-related side effects, including:

• Herbal and botanical preparations, including herbal extracts and teas.
• Dietary supplements, including vitamins, minerals and amino acids.
• Homeopathic remedies, extremely low doses of plant extracts and minerals that gently strengthen the body’s healing and immune response.
• Physical therapy and exercise therapy, including massage and other gentle techniques used on deep muscles and joints for therapeutic purposes.
• Hydrotherapy, which prescribes water-based approaches like hot and cold wraps, and other therapies.
• Lifestyle counseling. Many medical conditions can be treated with exercise, improved sleep, stress reduction techniques, as well as foods and nutritional supplements.
• Acupuncture. Your naturopathic clinician may also recommend incorporating acupuncture into your treatment plan.

It’s rather amazing here how so many of the things that are wrong with “integrative oncology” are right there on a single page. Look at the list of therapies. They range from the purest quackery (homeopathy) to what should be science-based medicine (physical therapy and exercise therapy) and everything in between. I realize that most readers of SBM know what homeopathy is and why it is quackery, but in case there are new readers seeing this, I’ll briefly recap. Homeopathy postulates two main ideas, both of which have no basis in science: First that you relieve symptoms by using a substance that causes the symptom being treated, and, second, that diluting a substance makes it stronger. Of course, the substance must be diluted with strong shaking (known as “succussion” in homeopathy lingo) between each serial dilution step. Most homeopathic remedies are diluted so much that there is almost certainly nothing left of the original remedy. For example, Avogadro’s number (the number of molecules in a mole of a substance) is on the order of 6 x 10²³. A typical homeopathic dilution is represented as “C,” where each “C” equals a 1:100 dilution. So, a 1C dilution is a 1:100 dilution; a 2C dilution is a 1:10,000 dilution (100 x 100); and so on. If you get to 12C, you’re talking a 10²⁴ dilution, which is already greater than Avogadro’s number. That means that it’s unlikely that more than one molecule of the substance remains, and that assumes the homeopath started with a mole of the substance being diluted, which is rarely the case. Usually the homeopath starts with much less. Now consider that typical homeopathic dilutions are 30C (10⁶⁰), more than 10³⁶ orders of magnitude greater than Avogadro’s number, and just how quacky homeopathy is comes into focus. Sure, homeopaths will wave their hands about the “memory or water” or “nanoparticles,” but in reality homeopathy is nothing more than magical thinking. The same is largely true for acupuncture, which is nothing more than a theatrical placebo, and studies claiming otherwise are uniformly unconvincing.

Now let’s look at some of the other “integrative” treatments. They are a classic “rebranding” of science-based modalities as somehow being “alternative.” For example, physical therapy and exercise therapy have been well-accepted treatments for various musculoskeletal problems for a long time. There is nothing “alternative” or “integrative” about them. There is one caveat. Frequently, the “alternative” or “integrative” versions of these sorts of therapies get that way by “integrating” magical thinking into them. I can’t tell how much magical thinking has found its way into CTCA’s version of physical therapy and exercise therapy, but given who’s in charge of rehabilitation at CTCA (Karen Gilbert, certified in auriculotherapy and lymphatic drainage), I’m guessing that it’s probably a lot, particularly given the easy access to chiropractic and these recommendations for rehab:

Our massage therapists can help reduce your cancer-related pain and improve your quality of life during your cancer treatment. Some manual therapy options include:

• Traditional massage
• Stone therapy
• Myofacial release
• Soft tissue manipulation with passive stretching
• Aromatherapy
• Effleurage
• Friction
• Trigger point therapy
• Acupressure
• Reflexology
• Chiropractic care

Chiropractic care

Our chiropractors treat bone, muscle or joint pain, without the use of drugs or surgery. Chiropractic care can also help to relieve symptoms such as neuropathy, nausea and headaches.

Auriculotherapy

This painless, non-invasive form of oncology rehabilitation, which involves stimulation of the auricle of the external ear, can help alleviate some of the side effects of cancer treatments, such as pain, nausea or fatigue.

Yes, indeed. It’s all there. Chiropractic, myofascial release, aromatherapy, acupressure, and, quackery of quackeries as quacky as homeopathy, reflexology.

Then there’s lifestyle counseling, which is a vague one. That can range in science-based practices, from practical advice on how to lose weight to exercising more and getting more sleep, but note how CTCA mentions nutritional supplements. It’s become increasingly apparent over the last several years that nutritional supplements are not necessary except in very specific (and relatively uncommon) cases of specific nutritional deficiencies, as long as the person eats a varied diet. Moreover, most studies of nutritional supplements for specific health conditions, with the possible exception of vitamin D, have been resoundingly negative.

One thing becomes clear as you peruse the treatment options offered at CTCA for virtually any cancer, and that’s that naturopathic treatments are deeply embedded (or “integrated”) into everything that is done at CTCA. Indeed, if you click on almost any cancer in this list, you’ll see three buttons. For instance, under the section on breast cancer, there are three buttons:

• I’ve just been diagnosed
• I’m searching for treatment options
• I’m seeking integrative care

Also, take a look at this post on the CTCA blog about breast cancer awareness month. In it there’s a link to a page on naturopathic treatments for breast cancer, which recommends, in addition to the treatments in the list above, these treatments:

The following are additional ways naturopathic medicine can help combat side effects of breast cancer treatments:

• Some hormone therapies for breast cancer can weaken the bones. Your naturopathic clinician may recommend vitamin D to protect the bones.
• Chemotherapy for breast cancer may cause numbness or tingling in the hands and feet (peripheral neuropathy). Your naturopathic clinician can offer natural therapies to help treat this condition.
• To help you fight nausea and vomiting, your breast cancer naturopathic medicine team may suggest ginger, peppermint oil, tea, sea bands, acupuncture and homeopathic remedies.
• Some naturopathic remedies, such as green tea and melatonin, may help to decrease the risk of breast cancer recurrence.
• Some endocrine treatments that are recommended for women with breast cancer are given for at least five years and have side effects that naturopathic medicine can help address. This allows you to tolerate these treatments and continue with important therapies to help decrease risk of recurrence.

Then there is this video that recommends supplements to combat cancer- and treatment-related fatigue. Vitamin D, of course, is not anything unique to naturopathy; when indicated it should be a part of standard treatment, not something recommended by a naturopath as an adjunct. Second, acupuncture and homeopathic remedies do nothing for nausea, and the evidence suggesting that green tea might decrease the risk of breast cancer recurrence is weak at best. So is the evidence that naturopathic treatments can significantly alleviate the symptoms of estrogen deprivation due to anti-estrogen drugs used to treat hormone-positive breast cancer.

There’s so much more, of course, but I’m trying to train myself not to be as verbose as perhaps you’ve become accustomed to (anything over 5,000 words is too much). The bottom line is that CTCA is indeed the epitome of “integrative” oncology in the way it truly does seamlessly “integrate” woo with science-based medicine such that it’s difficult for patients to distinguish what is science-based and what is not. Indeed, even physicians sometimes have difficulty telling where the SBM ends and the woo begins, even as otherwise excellent physicians and surgeons actually working at CTCA fall for the common trope that somehow taking care of the “whole patient” and being “holistic” means embracing pseudoscience, even touting it as what “sets CTCA apart.”

Disturbing echoes of another major topic of this blog

I’m going to leave the topic of naturopathic oncology for the moment, because, if there’s anything about CTCA that’s new, it’s not the naturopathy. Rather, it’s a new service CTCA offers that sounds a lot like a service I’ve been writing about for the last year and a half offered by our old “friend” Stanislaw Burzynski, specifically, his “personalized gene-targeted cancer therapy.” It’s basically using genomic testing to try to pick combinations of targeted therapies and chemotherapy that are likely to be most effective on any individual patient’s cancer. Go back and read that post. Now take a gander at CTCA’s webpage on Genomic Tumor Assessment, which boldly states:

Every cancer is different. Genomic testing helps our doctors understand a patient’s cancer at the molecular level. Information about genomic changes that are unique to your individual cancer will help us determine treatments most likely to work for you. It’s the promise of precision cancer treatment — a focus on the individual tumor in the individual patient.

Take a look at the video on that page. It’s very slick. It uses lots of 3D graphics showing DNA double helices and cells dividing. It sounds very convincing. However, much of it is, when you come right down to it, repackaging of things that conventional doctors already do. For instance, there’s a long section about colorectal cancer and how we know the proteins that drive the growth of colon cancer and, depending upon whether key genes are mutated, know which chemotherapies to choose. Ditto for breast cancer, where if the HER2 oncogene is turned up to 11, so to speak, we have a drug that targets it. In reality, this part of the video looks as though it’s just referring to these oncogenes that we already test for in colon cancer, non-small cell lung cancer, and breast cancer. There are already commercially-available tests for mutations in these genes, for example this one from Quest Diagnostics. None of this is particularly new, at least not anymore. CTCA even admits as much for non-small cell lung cancer and breast cancer, albeit in the small print, where it says that these tests have been done for several years as “part of the standard care.”

Here’s where CTCA claims to go beyond this:

If you and your oncologist decide you are a candidate for genomic testing, the following steps are taken:

• CTCA collects a sample of your cancer tissue (if available) or a biopsy of your tumor and sends it to a respected genomic sequencing lab.
• Sophisticated laboratory methods will capture genomic information in the tumor cells. Scientists at the sequencing lab extract the DNA from your tissue or tumor sample.
• Genetic information is encoded as a sequence of nucleotides – guanine, adenine, thymine, and cytosine – which form the building blocks of DNA. Scientists at the lab then sequence the genes in your tissue or tumor sample to uncover the order of nucleotides.
• Sequencing the tumor’s genetic profile produces a large amount of data. Scientists at the lab analyze this data to identify mutations that are critical to certain functions of the tumor.

Your oncologist will review the test results to determine if the information is helpful in the selection of a good treatment option for you.

All of this sounds to me a lot like what the Burzynski Clinic does. The question then becomes: Is CTCA any better at it than Burzynski is, the latter of whom, through the arrogance of ignorance, either thinks he “pioneered” this field twenty years ago (and that cancer centers like M.D. Anderson are only now following in the footsteps of his brilliance) or lies about his expertise in genomic testing and gene-targeted cancer therapy? The information is way too sketchy on the website to tell for sure, but it’s instructive to compare how CTCA sells “precision” medicine to how M.D. Anderson portrays it in the description of its Institute for Personalized Cancer Therapy:

Our strategic plan for the Institute is focused on the goal of defining the new standard of patient care – making personalized cancer therapy standard over the next 5 years, revolutionizing the way we manage patients. To accomplish this goal, we will:

1. Rapidly implement the expanded molecular pathology laboratories, technology, instrumentation, and infrastructure for personalized clinical trials;
2. Develop best practices for obtaining and managing patient biopsies and specimens to implement personalized cancer therapy;
3. Position MD Anderson to lead the way in therapeutic clinical trials based on the underlying genomic and molecular alterations in individual patient’s cancers;
4. Establish broad internal and external collaborations and partnerships to enhance our ability to rapidly transform discoveries into clinical practice and standard of care.

Note the emphasis on research and implementation. M.D. Anderson understands that “precision medicine” is not yet ready for prime time and that we don’t know yet whether or by how much the use of this genomic data for each patient’s tumor will impact patient care and outcomes. That’s why it has a research institute to develop the infrastructure and methodology for carrying out clinical trials to test “personalized” or “precision” medicine. Indeed, there has been some criticism of a “genomic gold rush,” in which cancer centers are seemingly competing to be the “firstest with the mostest” when it comes to genomic medicine. Even optimists point out that medicine is a long way from deriving useful information from routine tumor sequencing, much less improving patient outcomes.

I suppose that, in light of how the big cancer centers are going all-in, it’s not surprising that a for-profit hospital chain would want to emulate them. After all, don’t think that cancer centers aren’t using their new genomic institutes as marketing tools. However, there is a difference. The big cancer centers are building their genomic institutes in order to do the research necessary that will ultimately validate (or fail to validate) specific hypotheses regarding the use of routine genomic testing of patient tumor samples. There is enough uncertainty that, given the huge expenses involved and the massive effort this sort of research project takes, some are questioning the wisdom of setting these institutes up when the finances of medicine are so constrained right now and cost-containment is the order of the day. Even so, the goal, clearly, is to do the clinical trials that desperately need to be done.

In contrast, CTCA is selling genomic testing and personalized therapy as though it were already validated, as though it’s as routine and simple as sending off a piece of the patient’s tumor, either from a biopsy or a surgical resection, to the genomics lab to have it work its magic on the specimen, be it cDNA microarray analysis or the more recent advanced techniques like next generation sequencing, and then reading off the results. The implication is that we already know how to use the terrabytes of data that result from a typical sequencing of a single tumor to pick the best chemotherapy and targeted drugs for their individual cancer. Sure, there are disclaimers, but the overall message, complete with this spiffy infographic, is that this is cutting edge and that it will help cancer patients who come to CTCA. While there might be much to criticize when it comes to the “genomic gold rush,” the intent is to find out whether these techniques and the information they yield can greatly improve cancer outcomes. Now look at CTCA’s section on clinical trials. I don’t see any testing its Genomic Tumor Assessment to see if it provides information resulting in improved outcomes. Why is this? Indeed, look at this article on CTCA’s social media campaign for its “Real people. Real Discoveries.” campaign:

By launching the “Real People. Real Discoveries.” Social Media Campaign, CTCA places emphasis on key aspects of its core care delivery of genomic tumor assessment by emphasizing the importance of the individual’s genetic response and the potential it has for determining the best course of medicine and treatment. This focus inherently drives thoughts of “hope” without a specific reference to the word itself.

Notice that there isn’t any mention that this is still considered experimental. Rather, it is a media campaign designed to “drive thoughts of ‘hope'” without actually using the word itself.

Naturopathy and CTCA: Joined at the hip forever?

I’d like to finish by coming back to the topic of naturopathy, which might seem strange after discussing the use of genomic testing as a marketing tool. This is, after all, naturopathic medicine week, which is why I chose this topic in the first place. However, it is very clear that naturopathy is so completely embedded in CTCA that it taints the entire enterprise irredeemably. As I mentioned before, the impetus for founder of CTCA Richard J. Stephenson, was the death of his mother, Mary Brown Stephenson, from cancer and his frustration with the current system. Tragically, as so many before have done, in his grief and frustration, Stephenson confused “holistic” care with an openness to quackery like naturopathy and incorporated such quackery into CTCA right from the beginning, “integrating” it with standard, even state-of-the-art, conventional cancer care to the point where you can’t always tell where the science ends and the quackery begins. (Well, except for the homeopathy.) Sadly, a lot of otherwise-talented doctors bought into the idea and have—if you’ll excuse the term—completely “integrated” themselves into the CTCA system. In doing so, they have become complicit in the blurring of the line between science and pseudoscience in medicine while believing that they are doing good for the patient by giving them “holistic care.”