Note from the editor: Since today is a holiday in the U.S., I had planned on taking the day off. Then I saw the subject of today’s post and had to respond. Also, please remember that, as always, the usual disclaimers apply. This letter represents my opinion, and my opinion alone. It does not represent the view or opinion of my university or cancer center—or anyone else, for that matter, other than me.
Francis S. Collins, MD, PhD
Director, National Institutes of Health
Dear Dr. Collins:
I am normally not one for writing open letters, but in this case I feel compelled to make an exception. This letter will have little or nothing to do with what seems to be the usual criticism leveled against you, namely your intense religious faith and claims. Personally, as a physician and scientist I don’t much care about what religion you follow and, unlike some writers such as Sam Harris, most definitely do not consider your strong Christian faith a disqualification for holding the position that you now hold. All I care about in an NIH director is how well he or she shepherds the scientific mission of the NIH and runs the organization. As a past (and hopefully future) NIH grantee, I want the NIH to fund and support only the most rigorous science and to be a well-run organization. Thus far in your tenure, I haven’t seen any anything major to worry about on that score.
Recently, however, I was very disappointed to discover that you will be the keynote speaker at the 8th International Conference of the Society of Integrative Oncology (SIO) in November. I hope that, when you agreed to accept this speaking engagement, you didn’t know just what it is that what you were accepting or what the Society for Integrative Oncology is, other than a professional society that was interested in hearing your views on faith and spirituality in cancer. In brief, it is our position that “integrative oncology” is a discipline that, at its core, is dedicated to “integrating” pseudoscience with science. No doubt you will think I am exaggerating, but I am not, as I hope to demonstrate. Worse, by agreeing to speak to the SIO, you will be providing it with the imprimatur of your position as NIH director. The NIH, as you know, is the most respected biomedical research institution in the U.S., if not the world, and that respect rubs off wherever you speak.
So, what is “integrative oncology” and why does it concern me as a cancer surgeon and researcher? I have already discussed it in considerable detail, as has my co-blogger Dr. Kimball Atwood, but I will try to summarize again. On multiple occasions, I’ve referred to “integrative oncology” as a “Trojan horse” that is allowing pseudoscience to infiltrate medical schools and academic medical centers. Here is what I mean. Whenever you see discussions of “integrative medicine” (IM) and in particular “integrative oncology,” chances are, the modalities under discussion will usually focus on various dietary changes and lifestyle interventions, such as exercise. Often recommended exercise comes in the form of yoga, tai chi, and other disciplines that tend to be infused with concepts from Eastern mysticism, such as qi (“life energy”). Other modalities featured often include herbal remedies. In other words, “integrative oncology” rebrands modalities that have no reason not to be counted as part of science-based medicine as “alternative” or “integrative” and points to them as having some promise. After all, if you strip away the Eastern mysticism from yoga and tai chi, among others, all you have left is low impact exercise, and there is no reason to consider low impact exercise to be anything “alternative” or “integrative.” Exercise and diet are within the purview of science-based medicine. Herbal remedies are nothing more than a rebranding of the perfectly science-based subdiscipline of pharmacology known as pharmacognosy. Advocates of CAM/IM then lump together pseudoscience like reiki, “therapeutic touch, acupuncture, naturopathy, and even homeopathy with sensible lifestyle interventions, such as diet and exercise, making the association that, if diet and exercise are “alternative” and work, so, too, do modalities that can at best be considered quackery, such as homeopathy.
Perhaps the best place to begin is with the SIO’s very own practice guidelines, which, I submit to you, represent a masterful package of rebranding of perfectly science-based modalities, such as lifestyle interventions and changes in diet, which are then tied to “energy healing” quackery as if there were an equivalent evidentiary basis to support them. For instance, some of the recommendations of the SIO are, as Dr. Atwood put it, embarrassingly obvious. For example:
- Recommendation 1: Inquire about the use of complementary and alternative therapies as a routine part of initial evaluations of cancer patients. Grade of recommendation: 1C
- Recommendation 6: The application of deep or intense pressure is not recommended near cancer lesions or enlarged lymph nodes, radiation field sites, medical devices (such as indwelling intravenous catheters), or anatomic distortions such as postoperative changes or in patients with a bleeding tendency. Grade of recommendation: 2B
- Recommendation 7: Regular physical activities can play many positive roles in cancer care. Patients should be referred to a qualifi ed exercise specialist for guidelines on physical activity to promote basic health. Grade of recommendation: 1B (1A for breast cancer survivors post-therapy for QoL)
- Recommendation 15: It is recommended that patients be advised regarding proper nutrition to promote basic health. Grade of recommendation: 1B
What is “alternative” about any of these recommendations? Nothing. Physicians routinely ask what supplements or “alternative” therapies their patients are using. It’s simply mind-numbingly obvious common sense not to use deep massage or pressure near cancer lesions, enlarged lymph nodes, radiation field sites, or near medical devices, such as Portacaths or other indwelling implantable devices. What physician would not recommend proper nutrition or regular physical activity, as much as the patient can tolerate, under the guidance of an exercise specialist? Then, coupled with the above sensible recommendations, we find this:
- Recommendation 3: Mind-body modalities are recommended as part of a multidisciplinary approach to reduce anxiety, mood disturbance, chronic pain, and improve QoL. Grade of recommendation: 1B
- Recommendation 8: Therapies based on a philosophy of bioenergy fields are safe and may provide some benefi t for reducing stress and enhancing QoL. There is limited evidence as to their effi cacy for symptom management, including reducing pain and fatigue. Grade of recommendation: 1B for reducing anxiety; 1C for pain, fatigue, and other symptom management
I find it most interesting to note what the SIO considers “1B” evidence:
Strong recommendation, moderate-quality evidence
How on earth can one reasonably make a “strong recommendation” on “moderate-quality” evidence, even assuming one agrees that the evidence is “moderate-quality”? The SIO defines “moderate quality” evidence as:
RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies.
Also confusingly, the SIO makes “strong recommendations” based on “moderate” evidence (level 1B). In other places, it makes “strong recommendations” based on “low or very low quality evidence” (level 1C). Doesn’t it make you wonder why the SIO had to make up its own categories of evidence, rather than use accepted evidence-based medicine categories of evidence? Certainly, I wonder. I also wonder how the SIO could categorize instructing patients “regarding proper nutrition to promote basic health” as only category 1B.
As for other recommendations made by the SIO, rating the evidence for “energy healing” methods—or, as the SIO calls them, “therapies based on a philosophy of bioenergy fields”—as grade 1B vastly overestimates the quality and quantity of evidence in favor of “energy healing methods. Moreover these therapies are based on an unproven concept that there is an “energy field” or a “life energy” that can be manipulated for therapeutic intent. Never mind that no scientist has ever been able to measure or detect these “energy fields” or to verify that practitioners can actually manipulate them to therapeutic purpose. Never mind that the very concept is based on a vitalistic, pre-scientific understanding of how the human body works and how disease develops. I note that this includes acupuncture, whose premise is that sticking needles into the skin can somehow alter the flow of this life energy to healing effect. I also note that the totality of evidence regarding acupuncture is that it does no better than placebo when tested in well-designed randomized clinical trials. It doesn’t matter where the needles are placed or even whether the needles are placed. Indeed, even twirling toothpicks against the skin works as well as needles. Truly, as Steve Novella put it, acupuncture is the selling of nonspecific effects. Meanwhile, acupuncture apologists publish papers in which fanciful physiological mechanisms by which acupuncture allegedly works are proposed and poorly supported with evidence.
I note that the title of your talk is “Faith, Spirituality and Science in Oncology.” No doubt your intense religious faith is one reason why the SIO invited you. In actuality, in the world of “alternative” medicine,” “complementary and alternative medicine” (CAM), or IM (or whatever you want to call it), religious faith or “spirituality” is often co-opted to be the “foot in the door” for quackery in a manner very similar to how diet and exercise have been so co-opted. For example, are you familiar with reiki? It is one of the more prevalent of CAM/IM modalities, and it is currently being extensively used in cancer, even though the evidence base for it is virtually nonexistent. I have in the past referred to reiki many times as faith healing substituting Eastern mystical beliefs for Christian beliefs, and that is an accurate description. What is faith healing? It’s the belief that a healer can channel the power of God into the ill to heal them. What is reiki? Reiki involves channeling “energy” from what reiki masters call the “universal source” into the ill to heal them. Like faith healers, who assert that the power doesn’t come from them but from God, reiki masters assert that the power doesn’t come from them but rather from the “universal source.” Indeed, the founder of reiki, Dr. Mikao Usui explicitly patterned reiki on how Jesus healed:
Dr. Usui was a Christian minister in Japan, though Japanese. He was the head of a Christian Boys School in Japan. One day some of the students asked him if he believed in the miracles which Jesus did (healing, etc). Being a Christian minister he answered “Yes”. They asked if he knew how Jesus had done this, “No” he said…
With this he resolved to find the way in which Jesus had healed. This immediately set him on a journey of many years. Studying first at Christian schools in the US, for where else to learn of Jesus, but with no results. In the Christian schools the method was not known.
Dr. Usui even subjected himself to a 21 day fast on a mountain that very much resembled Jesus’ 40 days and 40 nights in the wilderness:
After a few more years of study, he felt he had come to an understanding and that to go further required serious meditation. He went to a nearby mountain declaring his intention to fast and meditate for 21 days and that if he did not come back they should come and get his body.
He went to the mountain and settled in with 21 stones with which to count the days. On the 21st day nothing had come as yet, and he turned over the last stone saying “Well, this is it, either I get the answer today or I do not”. At that moment on the horizon he could see a ball of light coming towards him. The first instinct was to get out of the way, but he realized this might just be what he was waiting for, so allowed it to hit him right in the face. As it struck him he was taken on a journey and shown bubbles of all the colors of the rainbow in which were the symbols of Reiki, the very same symbols in the writings he was studying but had been unable to understand. Now as he looked at them again, there was total understanding.
After returning from this experience he began back down the mountain and was, from this moment on, able to heal. This first day alone he healed an injured toe, his own starvation, an ailing tooth and the Abbots sickness, which was keeping him bedridden. These are known as the first four miracles.
I would respectfully submit to you as a scientist and man of faith that science- and evidence-based medicine should not be concentrating on miracles and faith healing. Yet that is what most “energy healing” modalities (reiki, therapeutic touch, and, yes, acupuncture) boil down to. It’s not for nothing that in 2009 the U.S. Conference of Catholic Bishops warned Roman Catholics to shun the eastern healing art of reiki because it lacks scientific credibility and is dangerous to Christian spiritual health. Some Christians even view reiki as a sin. Moreover, huge swaths of other CAM/IM modalities are based on similar beliefs that are rooted in faith, spirituality, and even outright magic. The common CAM/IM modality of homeopathy, for example, is based on the concepts of sympathetic magic, and naturopathy, which many SIO practitioners recommend, requires homeopathy as part of its training, which is why many naturopaths are also homeopaths.
We at SBM have criticized two institutions of the NIH for promoting and funding unscientific research, quackery even. These institutions include the National Center for Complementary and Alternative Medicine (NCCAM) and the National Cancer Institute’s (NCI) Office of Cancer Complementary and Alternative Therapy. Indeed, Dr. Atwood once wrote an open letter similar to this to NCCAM director Dr. Josephine Briggs when she agreed to speak at the annual conference of the American Association of Naturopathic Physicians last year and for the same reason that I’m writing this open letter now. The difference is that Dr. Briggs’ decision to speak to the AANP was more understandable than your decision to speak to the SIO; the reason is that, as strenuously as I and my fellow bloggers at SBM might object, NCCAM exists to study and promote “alternative” medicine. Consequently, the AANP can reasonably be considered to be within Dr. Briggs’ bailiwick. Moreover, NCCAM is but one center in the huge institution that is the NIH; her appearing at the AANP conference last year says far less about the NIH’s position with respect to unscientific “alternative medicine” modalities than your appearing in front of the SIO does.
I submit to you that SIO is trying to take advantage of your well-known religious faith in order to use your reputation as a scientist and as NIH director to claim for itself the mantle of scientific respectability that it does not merit. Instead of “bait and switch” rebranding science-based modalities such as diet and exercise as “alternative,” the SIO is rebranding religion and spirituality as somehow being “alternative medicine.” That is why I conclude by asking you most respectfully to reconsider. You represent the entire NIH, not just a single center in the NIH or an office in one institute in the NIH. Where you speak matters, and it matters a whole lot more than where Dr. Briggs chooses to speak. If you believe that we here at SBM are exaggerating or being unfair, we and others stand ready to provide you with all the supporting material you might require to be persuaded that we are not. We all strongly believe, as no doubt you do, that cancer patients deserve the best in science- and evidence-based medicine. Unfortunately, “integrative” oncology” provides nothing of the sort. It adds nothing to cancer care other than the rebranding of sensible treatments as “alternative” and the “integration” of unscientific, unproven, and potentially harmful “alternative” treatments with science-based treatments.
Cancer patients deserve better.
Finally, in these days of tight budgets resulting in even tighter paylines not seen in nearly 20 years, with no improvement in sight, please think about this one last thing. Between NCCAM and OCCAM, the NIH spends a quarter of a billion dollars a year studying and promoting a hodgepodge of modalities that range from being sensible science-based treatments, such as diet and exercise, to modalities that can only be referred to as being based on magical thinking (homeopathy, therapeutic touch, reiki, acupuncture, etc.). When budgets are this constrained, does the NIH have the luxury of spending a quarter of a billion dollars a year, or approximately 1% of the total NIH budget, half of which is nearly 3% of the NCI budget, on research that is exceedingly unlikely ever to benefit patients? For example, NCCAM has already spent over $2 billion since its inception in the 1990s and has yet to demonstrate convincingly that a single “alternative” medicine modality provides concrete benefits greater than placebo effects.
You are a man of science and faith. Your current position is a scientific one, and I have no doubt that you want to shape the NIH into a form that is dedicated to the best possible science we can get for the money and to promote that science. I hope you will realize that speaking at the SIO conference does not serve that end, nor does continuing NIH support for NCCAM and OCCAM. The division of medicine into “conventional” and “alternative,” “complementary and alternative,” or “integrative” medicine is a false dichotomy. There should be only medicine, and the scientific standards for determining what is and is not safe and effective medicine should be the same. It is my sincere hope that you, as NIH director, will not by speaking at the SIO conference support the false dichotomy that tries to foist unscientific medicine upon cancer patients as “integrative” medicine.
David H. Gorski, MD, PhD