The practice of integrative medicine, the use of alternative medicine along with evidenced-based medicine, has infiltrated patient care in many institutions in recent years. This is of major concern for many reasons, but the most important is that the vast majority of these “interventions” are not based on scientific evidence or thought, and some claims violate basic scientific laws of physics or chemistry. In addition, many components of evidenced-based medicine, such as the importance of diet and exercise, have been re-branded as integrative or complementary care. No specialty or clinical focus of medicine appears to be immune, and at a hematology conference (10th International Congress on Myeloproliferative Neoplasms and Chronic Myeloid Leukemia) last fall this was further impressed upon me by a presentation by Ruben Mesa, MD. It was strikingly obvious and disconcerting that the “complementary” approaches were excused from the strict scientific rigor and level of evidence typical of modern scholarship in hematology.
Before delving into details, I wish to make clear that I do not consider Dr. Mesa, currently the director of UT Health Cancer Center San Antonio, to be a quack or health fraudster. He is in fact quite well respected in the myeloproliferative neoplasm (MPN) community and has helped contribute to collective medical knowledge, including work that helped lead to the approval of the first JAK2 (Janus Kinase) inhibitor, ruxlitonib. A good amount of his most recent work focuses on quality-of-life (QOL) issues; in MPNs these can be significant, as I know this first-hand. Long time readers may remember that I have been dealing with a MPN myself, a type of hematological cancer that (in very simple terms) results in excessive proliferation in red cells, platelets, and/or most white cells. Research into QOL issues is certainly a noble and respectful pursuit, but there is a downside – frequent exposure to patient suffering and the search for solutions can lead to desperation; this in turn often leads to credulity and thus sub-par research. The three “Non-pharmacological complimentary [sic] approaches” he presents are diet (nothing strange, not complementary); Acceptance and Commitment therapy (ACT), a third wave cognitive behavioral therapy drawing heavily from behaviorism, a bit strange but psychotherapy is not CAM either; and most specifically, yoga. I’ll examine yoga in detail for readers.
Yoga refers to a wide range of mystical beliefs and practices (built on top of and with many others) that range from very old to very new that had goals ranging from gaining invincibility in warriors to attaining Moksha (exemption to reincarnation) by the priestly classes.1 The yoga of current popular thought and practice, which I will discuss today, is about 100-150 years old. It was brought to the West due to the efforts of a few advocates; esoteric groups like the Theosophical Society, proponents of New Thought and New Age practices that sought to merge with other metaphysical concepts of healing. I term this post-Esalen medicine, after the center that had a tremendous effect on disseminating New Age, traditional, and “spiritual” ideas about health to the public.
With that in mind, it is quite clear that Western yoga is not the ancient wisdom-filled panacea that proponents push as an almost essential tool on an individual’s journey to “wellness” through “self-care”. In reality, outside of biased narratives, the modern practice appears to be little more than appropriation of religious and cultural practices, modified and diluted in the name of profits or other self-serving interests, with no regard to the historic, societal, or scientific reality.
Once the spiritual trappings are removed it is simply a form of exercise, a very complicated stretching and breathing regimen, but still exercise (theologians can debate whether it’s still yoga). Exercise is a vital part of health and has always been a part of care in real medicine, there’s nothing strange about it once baseless metaphysical claims are removed. The danger is that it is not taught or promoted this way. I am not recommending against exercise, any physical activity is healthier than none, and, if you can separate the metaphysics from the exercise I will even go as far as saying yoga is fine. The question now is, why is it being treated differently from other exercise, and can it actually “treat” anything? Let’s evaluate the evidence.
There are only a few articles on yoga in MPNs but Dr. Mesa is listed on most I could find. These articles examine the use of “online-streamed yoga” for symptom management, one specifically for fatigue and general QOL. We’ll look at a single-arm and a subsequent controlled study.2, 3, 4, 5 There are a plethora of problems with these, so many in fact that I’m doubtful Blood or Haematologica would have even passed them to peer-review, let alone publish, if they were on a less trendy topic.
Patients were selected through the internet through methods that employed avenues like social media, forums, and patient groups. Though recruiting in this way is not inherently bad, it can lead to the recruitment of people interested in the popular “Indo-chic” practice of yoga out of a fascination with the Eastern exotic (the authors admit to this recruitment limitation). In what seems to be a result of this, the participants fit well into the most typical CAM user demographic: middle-aged married white women with an undergraduate degree or higher (this also implies more disposable income). So with the exotic fascination combined with the ideal demographic group it shouldn’t come as a surprise that in the single-arm study3 (n= 55, 38 or 69% completed 12-week intervention) there was significant improvement in symptoms including sleep, fatigue, anxiety, and anxiety (of note is the fact patients with diagnosed mood disorders like depression and anxiety were ineligible for the study). Yet despite this only 13 subjects said they would continue with the intervention and only an anemic 37% of subjects completed intervention as prescribed (this is self-reported so very likely lower; patients lie) which was defined as 60 minutes or greater a week, which works out to only 8.57 minutes a day. Most importantly, “There were no significant differences in outcomes between those that averaged = 60 min/week of yoga”. Despite the above results not justifying further resource expenditure for continued research, it was embarked upon anyway.
The controlled study2, 4 does not improve upon the single-arm in a significant way, it only further demonstrates the lack of usefulness and rigor. The recruitment method still focused on social media and patient groups, patients with mood disorders were still excluded, along with anyone that was already engaging in 150 minutes or more of physical activity a week (22 minutes per day). The subjective reporting of prescription adherence was shown to be lower than the objective measurement (but again, patients lie). Subjects were put into either the yoga group (n=27) or the control group (n=21), which was simply a wait-list. The intervention group, but not control group had blood work done at baseline and post study: a CBC (complete blood count), IL-6 (interleukin 6), and TNF-a (tumor necrosis factor alpha). The final two are inflammatory markers but to the best of my knowledge there is no proven causation that symptom burden is a direct result of their levels (the inclusion of these seems to be based off studies on inflammatory bowel disease).
The lack of testing in control subjects, the fact that the only significant change was in the levels of TNF-a with a result of -1.3 plus or minus 1.5, along with the uncertain meaning of these values seems to indicate a hollow attempt at presenting objective measures to increase credibility rather than the stated purpose of testing “blood draw feasibility”. The effect on symptom burden was reported from three online subjective self-report tools: the MPN symptom assessment form (MPN-SAF; 18 symptom questions on a 1-10 scale) as well as the MPN-SAF brief fatigue inventory (MPN-SAF fatigue; 9 fatigue related questions on a 1-10 scale), and the NIH PROMIS QOL (a single question out of 10 on the Global Health measure on QOL on a 5-1 scale). There were no significant differences at the end of the study in values of the more comprehensive surveys, the MPN-SAF and MPN-SAF fatigue. In fact, the only statistically significant result was from the NIH PROMIS scale – which is again only a single question from the 10 question global health scale. The study, as is typical in CAM or integrative medicine research, called for more research, justifying this with the QOL scale results and the reduction in TNF-a. The failure to demonstrate significant improvements was claimed to be due to not having enough subjects, specifically male subjects.
The lack of willingness to entertain, let alone accept the null hypothesis in the studies examined above is obvious and disconcerting but unfortunately unsurprising. The fact that limited philanthropic funds were used to finance the studies is all the more disappointing in such a small and underfunded field.
For those that may think that I’m being too harsh, and that it is possible maybe Dr. Mesa was simply interested in the exercise component and his involvement in the rebranding of standard medical recommendations as integrative or complementary was accidental, I have an important counterpoint. This article in the European Medical Journal: “The SIMM study: survey of integrative medicine in myeloproliferative neoplasms”. The study touted how effective “integrative medicine interventions” were at reducing symptom burden and how many cancer patients used it, and it did show that some interventions listed were quite effective. The problem is that 7/10 of interventions, the ones that actually worked, were not alternative or integrative. The article classifies the following as integrative: aerobic activity, massage (considered supportive care in real medicine), yoga (just exercise as I already discussed), nutrition, strength training (anaerobic exercise), acupuncture, meditation, breathing exercise, “chiropractice” [sic], and support groups. Only three of these can be considered alternative or integrative: acupuncture, which is based on meta-physics and is useless beyond a placebo; chiropractic care, based on non-scientific vitalist ideas and is only of comparable efficacy to massage or paracetamol for lower back problems; and meditation, which can be alternative or not depending on how this highly variable term is used.
The rebranding of standard care and recommendations of science-based medicine is dangerous as it only serves to provide a veneer of legitimacy to the complete nonsense promoted like energy healing (violates laws of physics and was disproven by a 9 year old girl in 1998) and thereby attract new customers, because that’s all patients are to the proponents, a source of income and/or a source of undeserved praise. Once all items appropriated from genuine medical care are removed, the alternative and integrative medicine fields seem to be composed of nothing but health fraud, willful ignorance, and significant delusion, none of which belong in hematological cancer care, nor cancer care, nor medicine in general.
- York M. Historical dictionary of New Age movements. Lanham, Md: Scarecrow Press; 2004.
- Eckert R, Huberty J, Dueck A, Kosiorek H, Larkey L, Mesa RA. A Pilot Study of Online Yoga to Improve Fatigue and Quality of Life in Myeloproliferative Neoplasm Patients. Blood. 2017 Dec 7;130(Suppl 1):3443–3443.
- Huberty J, Eckert R, Gowin K, Mitchell J, Dueck AC, Ginos BF, et al. Feasibility study of online yoga for symptom management in patients with myeloproliferative neoplasms. Haematologica. 2017 Oct 1;102(10):e384–8.
- Eckert, R. Myeloproliferative Neoplasm Patients [Internet]. [cited 2018 Jul 11].
- Huberty J, Eckert R, Gowin KL, Ginos B, Kosiorek HE, Dueck AC, et al. Online-Streamed Yoga As a Non-Pharmacologic Symptom Management Approach in Myeloproliferative Neoplasms. Blood. 2016 Dec 2;128(22):5478–5478.