I’ve written a fair amount about the “medical specialty” known as naturopathic oncology. The reason, of course, is that I’m an oncologic surgeon; my entire career involves taking care of cancer patients and doing cancer research. As a result, I don’t like to see a “profession” as rife with pseudoscience and quackery as naturopathy attempt to create a “specialty” devoted to taking care of cancer patients. Of course, I don’t like to see naturopaths take care of any patients, but their taking care of cancer patients bothers me more. I first noticed that naturopaths were forming this subspecialty back in 2010, when I encountered naturopathic oncology in the context of the “integrative oncology” quackery being offered by the for-profit Cancer Treatment Centers of America. I even learned that naturopathic oncologists have their own board certification. Those who have this certification can be identified by the letters after their name, FABNO, which stands for “Fellow of the American Board of Naturopathic Oncology”. (Personally, I’ve always said that I think it should really stand for “FAB? NO!”) Of course, given the panoply of dubious therapies, some of them contradictory to each other, that naturopaths use, I really wonder what the certifying examination is like. When, for instance, do you choose megadoses of vitamin C over acupuncture or vice-versa? But I digress. Such are the questions that come up when quacks pretend that theirs is a real specialty while naturopathic oncologists use treatments like cesium chloride to treat cancer.
If there’s one area of oncology that deals with the most vulnerable of patients, it’s pediatric oncology. Fortunately, childhood cancer is uncommon, but it’s not that uncommon. Over 15,000 children a year are diagnosed with cancer (compared to 1.7 million adults). Also fortunately, thanks to advances in the multimodality therapy of childhood cancer, since the 1950s, when most childhood cancers were a death sentence, the survival has improved from 58% in the mid-1970s to well over 80% now. Of note, none of that improvement had anything to do with naturopaths, but rather science-based medicine and the very high level of participation of pediatric cancer sufferers in clinical trials. Unfortunately, even though they can’t define a science-based standard of care (how could they, given their specialty), apparently naturopaths nonetheless want a piece of the pediatric oncology pie. I discovered that when Jann Bellamy sent me a link to an article in Integrative Cancer Therapies, “Naturopathic Oncology Care for Pediatric Cancers: A Practice Survey“. The article is by Athanasios Psihogios, ND (Not-A-Doctor), Jullie K. Ennis, PhD, and Dugald Seely, ND (Not-A-Doctor), MSc, FABNO (FAB? NO!). We’ve met Dugald Seely before. Sadly, he seems to have some pull in the Society for Integrative Oncology, having co-authored SIO’s breast cancer care guidelines. He’s also managed to score some serious cash to do dubious clinical trials of naturopathic interventions in cancer ($7 million total between two grants).
So let’s see what Seely (who’s the corresponding author) and his colleagues have to say about naturopathic interventions in pediatric cancer. Naturally they can’t help but do what authors of nearly all articles about “integrative” medicine do, and appeal to popularity as a justification for their undertaking:
A recent survey of pediatric specialty outpatient clinics in Canada found that 61% of pediatric oncology patients use some form of complementary and alternative medicine (CAM).1 CAM use decisions by patients and their families are often self-directed and independent of the conventional oncology team. Furthermore, only 77% of CAM users informed their physician of this use and only 57% consulted a pharmacist.1 This may, in part, be due to the lack of mechanisms at the institutional level for conventional care providers to assist their patients in making informed decisions when it comes to CAM therapies and practitioners.2 While CAM use remains high, the literature indicates that significant gaps exist in research.3,4 The high prevalence of use, potential for harm, and lack of evidence and resources warrants further research in order to meet the evidentiary demand for CAM efficacy and safety.
This is the first survey to our knowledge that examines current practice in the naturopathic medical community regarding pediatric oncology. Naturopathic oncology, provided by licensed naturopathic doctors (NDs), aims to improve quality of life, manage side effects, facilitate recovery, prevent recurrence, and educate the patient regarding adopting a healthy lifestyle.5 Naturopathic oncology practice is not to be provided as an alternative form of medicine but ideally in conjunction and inclusive of conventional oncology care in a manner consistent with integrative oncology.6
How many times have I seen passages that read almost identically to the two paragraphs quoted above? I’ve lost count. The message is always the same: Patients are doing it, usually a majority of patients. Of course, that majority usually comes about by widening the definition of CAM to include so much that of course a majority of patients use CAM when defined that way! For instance, the study cited above looked at multivitamins, vitamin C, cold remedies, teething remedies, calcium, faith healing, massage, chiropractic, and relaxation, with by far the most commonly used “CAM” intervention being multivitamins and vitamin C. Having thus inflated the percentage of patients using “CAM”, CAM boosters then use that large number to argue that we should study these interventions.
Then, of course, the naturopaths claim that naturopathic oncology can do all these wonderful things, such as managing side effects and facilitating recovery, citing the OncANP description of naturopathic oncology. Of course, there’s little evidence that naturopathy can do anything to facilitate recovery, outside of perhaps recommending exercise and a healthy diet, and there’s certainly no credible evidence that adding naturopathy to conventional cancer care prevents cancer recurrence after successful initial treatment. That claim is, quite simply, nonsense. Similarly, the claim that naturopathic oncology should never be used instead of real medicine but alongside real medicine flies in the face of the numerous examples I’ve written about over the years of naturopaths doing exactly the opposite and treating cancer patients themselves without any conventional oncology, always with disastrous results.
So what do Seely and colleagues want to find out? The goals of their survey are:
This survey gathered information from NDs who see patients with cancer regarding: (1) practitioner demographics (education, clinical practice, etc), (2) natural health product (NHP) use (recommendations, dosing, reasons for use, and contraindications), (3) nutrition counselling, (4) physical medicine interventions, and (5) mental-emotional treatments.
The primary objectives of this survey are the following: (1) to identify and enumerate the most common therapeutic recommendations (among the 4 principal domains); (2) to identify the principal reasons for use of the primary NHPs recommended; (3) to identify contraindications reported by the respondents regarding NHPs recommended; and (4) to identify characteristics of NDs focused in oncology with regard to their care of pediatric patients with cancer. A secondary objective of the survey was to identify similarities and differences between oncology-focused NDs who do and do not treat children with regard to their pediatric cancer care recommendations.
The first thing I learned that’s disturbing is that, of the 99 naturopath practices surveyed that treat cancer, 47.5% also treat pediatric cancer. That’s right, nearly half of the naturopaths also ply their quackery on children with cancer. Even more depressing, when the authors asked those who don’t treat children why they don’t treat children, this was the answer:
The most frequent reason reported by respondents to explain why they do not treat pediatric cancer cases was an absence of public demand (ie, patients and families/caregivers not seeking the direct care of an ND; 45.1%). Overall, 59.7% of non-treater respondents reported a need for evidence-related resources (dosing, safety, clinical data/research), and 35.8% required educational resources (training, conferences, mentorship). Further details from the survey respondents as to reasons for not treating pediatric cancer cases and the resources that would be needed to better support a change in this practice are outlined in Tables 2 and 3, respectively.
Of note, the second most frequently cited reason these naturopaths don’t treat children is that the institution or clinic they work at doesn’t allow it. Less than 20% cited lack of comfort treating children with cancer and only 12% cited lack of training. In other words, if those factors were overcome, a lot more naturopaths would be willing to treat children with cancer, and one of the cited purposes of this survey was to identify factors that, if overcome, would make naturopathy available to more children with cancer. Some of the factors identified in the survey included more educational resources and clinical evidence. Of course, given that naturopathy is a specialty rooted in prescientific vitalism that fuses a wide variety of quackery to some science-based lifestyle advice, that evidence is unlikely to be forthcoming any time soon. On the other hand, the naturopathic standard of evidence to adopt a treatment is not exactly rigorous. After all, naturopaths are all trained in homeopathy.
So here’s where the rubber hits the road. What treatments do these “naturopathic oncologists” or naturopaths comfortable with treating pediatric cancer patients use to treat children? It is, as you would expect, the usual mixture of the potentially science-based (nutrition, exercise), the unproven, and quackery. For instance, here are the natural health products (NHP) that naturopaths reported using:
Eighty-four respondents provided complete information within the NHP domain (recommendations, reasons for use, reported contraindication, dosing, and administration). Eighteen NHPs were identified as primary recommendations (selected by >50% of those who do treat pediatric cancer cases): vitamin D (88.4%), fish-derived omega-3 (86.0%), probiotics (86.0%), vitamin C (79.1%), melatonin (76.7%), turmeric (Curcuma longa, curcumin extract; 74.4%), glutamine (72.1%), homeopathic Arnica (67.4%), Astragalus membranaceus (62.8%), magnesium (citrate, bisglycinate, etc; 62.8%), Coriolus versicolor (60.5%), zinc (58.1%), Boswellia serrata (frankincense; 53.5%), coenzyme Q10 (53.5%), ginger (Zingiber officinale; 53.5%), green tea (Camellia sinensis, epigallocatechin-3-gallate [EGCG]; 53.5%), reishi (Ganoderma lucidum; 53.5%), and vitamin B complex (53.5%; Table 4).
And why did they use these NHPs. Read, and weep:
Overall, 6 NHPs were primarily recommended for augmentation of the immune system (vitamin D, vitamin C, Astragalus membranaceus, Coriolus versicolor, Ganoderma lucidum, and zinc). Three NHPs were recommended primarily for anti-inflammatory effects (fish-derived omega-3, turmeric/curcumin, and Boswellia serrata). Two are primarily used for organ and tissue support (CoQ10 and homeopathic Arnica), which encompass endpoints such as postoperative recovery and cardiovascular support. Only one NHP was primarily recommended for antineoplastic activity (green tea/Camellia sinensis). All the remaining NHPs were primarily recommended for side effect–related endpoints; probiotics for gastrointestinal support (including diarrhea, constipation, and painful bowel movements), melatonin (insomnia and sleep quality), ginger (nausea/vomiting), magnesium for gastrointestinal support (including constipation and bowel movement regulation), and glutamine for general side effect management.
And what is the evidence that any of these NHPs do what naturopaths use them for? Slim to nonexistent, of course. Of course, homeopathic remedies are the purest quackery, given that homeopathy is The One Quackery To Rule Them All. I’ll (briefly, for me) explain why. Basically, homeopathy was invented by a German physician Samuel Hahnemann in 1796. Homeopathy is based on two “laws”. The first is the Law of Similars, which states that you treat a symptom using something that causes that symptom. Of course, there is no physiologic, biochemical, or medical basis for such a principle, and in fact what the first law of homeopathy resembles more than anything else is the principles of sympathetic magic, specifically Sir James George Frazer’s Law of Similarity as described in The Golden Bough (1922) as one of the implicit principles of sympathetic magic.
The second “law” of homeopathy, the Law of Infinitesimals, is even more ridiculous and pseudoscientific (or even mystical). This law states that homeopathic remedies become stronger with dilution. Indeed, the process of making a homeopathic remedy involves serial dilution, usually 1:100. The mother tincture (or original compound) is diluted 1:100 and then shaken vigorously (succussed), the succussion step being claimed to be necessary to “potentize” the remedy. After that, it’s diluted again in the same way. Each 1:100 dilution is designated by “C”, such that a 6C dilution equals six 1:100 dilutions. The problem comes with the higher dilutions. For instance, a 12C solution is on the order of a 10-24 dilution ((10-2)12 = 10-24). Many homeopathic remedies are on the order of 30C, which is a 10-60 dilution, or more than 1036-fold greater than Avogadro’s number. Some homeopathic remedies go up to 100C or more, or 10-200. Here’s a hint: The number of atoms in the known universe is estimated to be around 1078 to 1082. The math just doesn’t work, and remedies over around 12C are basically water. “Lesser” dilutions contain so little remedy that it’s highly unlikely that they have a pharmacological effect.
So what else besides NHPs do naturopaths use to treat children with cancer? Well, there’s nutrition. How can that be bad? Well, take a look:
Sixty-eight of the respondents selected nutrition recommendations that they would generally use in practice from a list provided. Primary nutrition recommendations (selected by >50% of all respondents) included the following: anti-inflammatory focused diet (77.9%), dairy restriction (66.2%), Mediterranean diet (66.2%), gluten restriction (61.8%), ketogenic diet (57.4%), and low glycemic diet (52.9%). No significant differences were found for any nutrition recommendation between treaters and non-treaters (Table 6).
When pediatric oncologists treat children with cancer, they have additional challenges other than just treating the cancer and managing side effects. They need to do everything they can to prevent the cancer and its treatment from adversely affecting the child’s growth and development. Needlessly putting children who are dealing with cancer and the toxic effects due to treatment on restrictive diets like the ketogenic diet (which is based on, in essence, starving the body to put it into ketosis), a gluten- and/or dairy-free diet, and the like is malpractice, as there is no evidence that these diets impact the course of cancer in children. There isn’t even particularly good evidence that the ketogenic diet, for instance, impacts the course of cancer in adults. Putting children with cancer on restrictive diets like the ketogenic diet is quackery and child abuse that worsen the child’s suffering by adding continual hunger to the mix while adding additional risk that the child will not meet growth and developmental milestones.
Next up, Seely and colleagues asked about physical interventions:
Sixty-eight respondents selected physical medicine interventions that they would generally recommend in practice from a list provided. Primary physical medicine recommendations (selected by >50% of all respondents) included the following: exercise (94.1%), acupuncture (77.9%), acupressure (72.1%), craniosacral therapy (69.1%), yoga (69.1%), hydrotherapy (67.6%), and massage therapy (66.2%). No significant differences were found for any physical medicine recommendation between treaters and non-treaters (Table 7).
Exercise is fine, if the child can do it given his disease. Yoga, hydrotherapy, and massage therapy are probably benign. (At least massage will make the child feel good, as long as it’s not too vigorous.) None of these will help the cancer, but are for the most part harmless. Acupuncture and acupressure are quackery, nothing but theatrical placebo, and sticking acupuncture needles into a child will traumatize that child for no good reason. Craniosacral therapy is alarming quackery.
Sixty-eight respondents selected mental-emotional interventions that they would generally recommend from a list provided. Primary mental-emotional recommendations (selected by >50% of all respondents) included the following: meditation (79.4%), art therapy (77.9%), mindfulness-based stress reduction (70.6%), music therapy (70.6%), visualization (67.6%), cognitive-behavioral therapy (61.8%), progressive muscle relaxation (57.4%), diaphragmatic breathing (55.9%), psychotherapy (54.4%), and reiki (52.9%). No significant differences were found for any mental-emotional physical medicine recommendation between treaters and non-treaters (Table 8).
Art and music therapy are what we in the biz used to call patient support interventions. They weren’t designed to treat anything, but they were viewed as helpful in that they would help patients pass the time in the hospital or while being treated. Meditation and mindfulness probably don’t do any harm, although their benefits, if any, are frequently exaggerated by proponents and it would only be older children who could do them anyway. Reiki, of course, is nothing more than faith healing that substitutes Eastern mysticism for Judeo-Christian faiths.
Of course, there’s nothing in this survey that I couldn’t have predicted. Naturopathy, as we’ve discussed more times than I can easily determine on this blog, is a vitalism-based “specialty” in which there is no form of quackery that its practitioners won’t embrace. Even the science-based modalities embraced by naturopaths don’t survive unscathed. Naturopaths always find a way to inject pseudoscience into even those, such as their recommendations for restrictive diets for children with cancer.
Seely concludes, as you and I always knew he would, with a call for “more research”:
According to our survey, approximately half of NDs who treat cancer include pediatric cases within their practice. Those who do not treat pediatric cancer patients state that they primarily require more clinical information before they would treat this population. While recommendations varied between responders, there appears to be a few main interventions that are consistently most recommended among the majority of respondents, including both treaters and non-treaters. There is a need to evaluate the safety and efficacy of the recommendations identified in this survey. Relevant evidence syntheses in this area of pediatric integrative oncology will help develop a safe and evidence-informed hospital-based IPOP.
It’s a rallying cry of quacks the world over, even though we already have far more than enough evidence to conclude that a large number of the treatments (e.g., reiki, restrictive diets, craniosacral therapy, homeopathy) used by “naturopathic oncologists” treating children with cancer are ineffective and/or pure pseudoscience, while even the unproven treatments have a low probability of being found efficacious based on what we already know. This is the strategy: Argue that these treatments are popular and then urge “more research” regarding the CAM treatments used. Of course, if that “research” is done by naturopaths, it will be of poor quality but usable (by them) to justify and market their quackery. It’s just that, in this case, the naturopaths are arguing to subject children with cancer to quackery.