$3.7 million to study quack medicine at a leading cancer center

Sometimes I'm not sure whether the best response to pseudoscience is to ignore it, or to patiently try to explain why it's wrong, or to get mad.

This week I'm mad.

My anger and frustration was triggered by a tweet from Memorial Sloan-Kettering's Integrative Medicine account, shown here:

For those who don't know, Memorial Sloan-Kettering Cancer Center is one of the world's leading cancer centers, both for treatment and research. If you are diagnosed with cancer, MSK is one of the best places to go.

But not everything at MSK is world class. Unfortunately, they have an "integrative medicine" center that offers a mixture of therapies ranging from helpful to benign to useless. One of their biggest activities is acupuncture, which they claim offers a wide range of benefits to cancer patients.

The MSK tweet shown here was boasting about a new, $3.7 million study funded by NIH to study the effect of acupuncture on pain that cancer patients experience from chemotherapy and bone-marrow transplants.

Here's why I'm mad: cancer patients are extremely vulnerable, often suffering the most frightening and difficult experience of their lives. They are completely dependent on medical experts to help them. When a place like MSK suggests a treatment, patients take it very seriously–as they should. But they really have no choice: a cancer patient cannot easily look for a second opinion, or switch hospitals or doctors. Even if they have the money (and cancer treatment is extremely expensive), switching hospitals might involve a long interruption with no treatment, during which they could die, and it might also involve traveling far from their home.

Offering these patients ineffective treatments based on pseudoscience–and make no mistake, that's what acupuncture is–is immoral. Now, I strongly suspect that the MSK's "integrative medicine" doctors sincerely believe that acupuncture works. Their director, Jun Mao, is clearly a true believer, as explained in this profile of him on the MSK website. But that doesn't make it okay.

I've written about acupuncture many times before (here, here, here, and here, for example), but let me explain afresh why it is nonsense.

Acupuncture is based on a pre-scientific notion, invented long before humans understood physiology, chemistry, neurology, or even basic physics, which posits that a mysterious life force, called "qi," flows through the body on energy lines called meridians. As explained in this article by MSK's Jun Mao:

"According to traditional Chinese medicine ... interruption or obstruction of qi was believed to make one vulnerable to illness. The insertion of needles at specific meridian acupoints was thought to regulate the flow of qi, thus producing therapeutic benefit."

Today we know that none of this exists. There is no qi, and there are no meridians. In that same article, Jun Mao continued by admitting that

"the ideas of qi and meridians are inconsistent with the modern understanding of human anatomy and physiology."

And yet this is what they offer to patients at MSK.

Just to be certain, I read one of the latest studies from MSK, published early this year, which claims to show that acupuncture relieves nausea, drowsiness, and lack of appetite in multiple myeloma patients who were going through stem cell transplants.

It's a mess: totally unconvincing, and a textbook case of p-hacking (or data dredging). The paper describes a very small study, with just 60 patients total, in which they measured literally dozens of possible outcomes: overall symptom score at 3 different time points, a different score at 3 time points, each of 13 symptoms individually, and more. I counted 24 different p-values, most of them not even close to significant, but they fixated on the 3 that reached statistical significance. The two groups of 30 patients weren't properly balanced: the sham acupuncture group started out with more severe symptoms according to their own scoring metric, and Figure 2 in the paper makes it pretty clear that there was no genuine difference in the effects of real versus sham acupuncture.

But they got it published (in a mediocre journal), so now they point to it as "proof" that acupuncture works for cancer patients. This study, bad as it is, appears to be the basis of the $3.7 million NIH grant that they're now going to use, they say, in "a larger study in 300 patients to confirm these previous findings."

And there you go: the goal of the new study, according to the scientists themselves, is not to see if the treatment works, but to confirm their pre-existing belief that acupuncture works. Or, as one scientist remarked on Twitter, "they already have a result in mind, the whole wording of this suggests that they EXPECT a positive outcome. How did this get funded exactly?"

Good question.

So I'm mad. I'm mad that NIH is spending millions of dollars on yet another study of a quack treatment (acupuncture) that should have been abandoned decades ago, but that persists because people make money off it. (And, as others have explained in detail, acupuncture is actually a huge scam that former Chinese dictator Mao Zedong foisted on his own people, because he couldn't afford to offer them real medicine. For a good exposé of Chairman Mao's scam, see this 2013 Slate piece.)

But I'm even more upset that doctors at one of the world's leading cancer centers are telling desperately ill patients, who trust them with their lives, that sticking needles into their bodies at bogus "acupuncture points" will relieve the pain and nausea of chemotherapy, or help them with other symptoms of cancer. I'm willing to bet that most MSK doctors don't believe any of this, but they don't want to invest the time or energy to try to stop it.

(I am somewhat reassured by the fact that MSK's Twitter account has nearly 75,000 followers, while it's integrative medicine Twitter account has just 110.)

Or perhaps they are "shruggies": doctors who don't believe in nonsense, but figure it's probably harmless so they don't really object. To them I suggest this: read Dr. Val Jones's account of how she too was a shruggie, until she realized that pseudoscience causes real harm.

And finally, let me point to this study in JAMA Oncology from last year, by doctors from Yale, which looked at the use of so-called complementary therapies among cancer patients. They found that

"Patients who received complementary medicine were more likely to refuse other conventional cancer treatment, and had a higher risk of death than no complementary medicine."

And also see this 2017 study from the Journal of the National Cancer Institute, which found that patients who used alternative medicine were 2.5 times more likely to die than patients who stuck to modern medical treatments.

That's right, Memorial Sloan-Kettering: patients who use non-traditional therapies are twice as likely to die. That's why I'm mad. This is not okay.

Alternative medicine quacks show their greedy side

Congress is on holiday this month, but the lobbyists are baiting their hooks, planning their strategies for how to get more money for themselves.

A growing lobby is Complementary and Alternative Medicine (CAM) providers, who have discovered a new opportunity to extract even more money from patients than they do already. They want the government to force insurance providers to pay for quack treatments, regardless of whether or not the treatments work. Any attempt to require evidence, they argue, amounts to discrimination.

Discrimination? Yes! We must not allow the government to exclude health care providers just because those providers don't cure anything.  The CAMmers argument boils down to this: we have patients who want our services.  The patients like us. In some cases, thanks to lobbying at the state level, we even have state-approved licenses. Therefore insurance companies must pay for our services.

Neat.

To be specific, the CAMmers are lobbying furiously to try to protect a special clause in the Affordable Care Act (Obamacare) that promises them a fertile new ground for making money from vulnerable patients.

The strategy is simple: require the government to fund any treatment that a patient wants, and dress this up as "patient choice."  Then if insurance companies resist paying for ineffective treatments, accuse them of discriminating against the poor, hapless "integrative medicine" providers.

Thus through a diabolical twist of illogic, if Obamacare doesn't cover homeopathy, or naturopathy, or acupuncture, or magnetic energy healing, or any other so-called alternative therapy, it's discrimination.

The mind boggles.

Why is this an issue now?  Because, unbeknownst to most people outside the Washington beltway, two pro-CAM lobbying groups slipped a clause into the ACA, section 2706, that attempts to force insurance providers to cover a wide range of quack practices.  This section requires that insurers

"shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable state law."

Sounds harmless, right?  Well, no.  This language was added to the ACA by Senator Tom Harkin, after heavy lobbying by the American Chiropractic Association and the Integrative Healthcare Policy Consortium.  In fact, it is virtually certain that lobbyists wrote the section, and Harkin simply inserted it into the law. The IHPC is a lobbying group dedicated to obtaining more government money for homeopathy, naturopathy, chiropractic, acupuncture, and a raft of other ineffective medical practices.

Section 2706 opens the door to anyone who provides what they claim is health care - no matter how ridiculous the claim - to file a lawsuit claiming discrimination if an insurance company won't pay for their services.  You could start offering dried bird poop for arthritis, call it "avian nature therapy," and if an insurer won't pay for it, you can sue.

Some in Congress have realized how truly bad an idea this is, and just a few weeks ago, a new bill was introduced to get rid of it, HR 2817.  The American Medical Association supports the new bill. This has some CAM proponents alarmed.

Over at the Huffington Post, John Weeks, an outspoken apologist for questionable medical practices, offers the predictable, whining claim that this is all about "discrimination" by legitimate health care providers (the big, bad AMA) against poor, defenseless integrative medicine providers.

Make no mistake: this is all about greed.  The CAM industry sees Obamacare as a chance to reap huge profits, by forcing insurance companies to pay for ineffective treatments, including many that are wildly implausible.

Homeopaths, naturopaths, acupuncturists, reiki practitioners, energy healers, and other CAM practitioners don't want to subject their methods to rigorous tests of effectiveness.  They know that their methods have failed scientific scrutiny, time and time again.  So now they want to force health care providers to pay for anything the patient wants. "Our patients believe us," they argue, "so pay us."

Forcing health care providers to pay for anything a patient wants, even if it doesn't work, is guaranteed to drive up costs, without any benefit to patients.  Let's ditch this bogus "discrimination" clause in the ACA, and insist that all medical care be held to the same high, scientifically rigorous standards.

Poison for pain, the homeopathic way

At my local mega-grocery store last weekend, I happened to stroll down the aisle dedicated to homeopathic treatments.  I saw shelf after shelf of brightly colored packages, all claiming health benefits.  Most of these "medicines" were not cheap.

Amazing.  To an average shopper, all of these products look like real medicine.  The packaging is similar, the claims are similar, and it's all on display at a respectable grocery store.  The difference, though, is that none of these products do what they claim to do.  Thanks to a special exception for homeopathy created all the way back in 1938, none of the claims on these medicines need to be tested.  The homeopathy aisle is an organized, state-sanctioned scam.

The 1938 law was the brain child of a U.S. senator, Royal Copeland, who happened to be a homeopath.  Sen. Copeland inserted language into a major food and drug law that declared homeopathic preparations to be drugs.  It also allowed homeopaths themselves to maintain the official list of these drugs, called the Homeopathic Pharmacopeia.  Talk about the fox guarding the henhouse!  Thanks to aggressive lobbying by homeopaths, homeopathic ingredients are not subject to the normal review required of real drugs.  Most importantly, homeopathic drug makers do not have to prove their products are effective.

Homeopathy is based on the long-discredited beliefs of Samuel Hahnemann 200 years ago.  Hahnemann thought that "like cures like," as long as you dilute the substance sufficiently.  Thus caffeine will cure sleeplessness, poison ivy extract will cure an itch, and paralyzing plant toxins will cure pain.  None of this is true.

The other key principle of homeopathy is that the more you dilute something, the stronger its effect.  This is not only wrong, but it is exactly the opposite of what really happens.  Greater dosage levels, unsurprisingly, have stronger effects.  In Hahnemann's defense, science wasn't very far along when he came up with these notions.

Real medicine moved on long ago.  But homeopathy persists, because there is money to be made - lots of money.

Back to my grocery store.  Several shelves were filled with something called Topricin(R), which claims to relieve pain. Sounds like a medicine, right? Real drugs often use "cin" or "in" in their names because the word "medicine" itself ends with that sound.  Clever!  In front of me I saw Topricin for pain, Topricin foot cream, even Topricin for children. The Topricin packages and the company's website proclaim, in big letters, "Ideal Pain Relief", and in slightly less big letters: "Safe.  Effective. Free of Side Effects."  It also claims:

"Topricin's 11 homeopathic medicines are proven to be safe and effective for the elderly, pregnant, children, pregnant women and all skin types.  Experience Topricin's relief for damaged muscle, tendon, ligament, and nerve tissue."

This is simply not true.  It even seems to go beyond the bounds of what the (very weak) FDA regulations allow.  The website specifically claims that Topricin is effective for arthritis, back pain, bruises, bursitis, fibromyalgia, minor burns, tendinitis, and more.

Well, what is it?  Let's look at just two of the homeopathic ingredients in Topricin:

• Belladonna 6X................. Treats muscles spasms, night leg cramps
• Heloderma 8X................. Relief of burning pain in the hands and feet

Belladonna for pain?  Belladonna is one of the most toxic plants known to man.  Eating just a few small berries is lethal.  And the one study I could find showed that it has no clinical effect when used in a homeopathic preparation.  That's lucky for unwitting consumers: if it wasn't so diluted, Belladonna would make them very sick indeed.

Heloderma?  That's the venom from a gila monster.  Although rarely fatal, it causes severe pain, bleeding, nausea, and vomiting.  This is not something I would take for pain - and I certainly would never give it to children.

I know that Big Pharma is often guilty of deceptive marketing, and I've criticized Pharma many times.  But CAM ("complementary and alternative") pharma is every bit as bad.  Big CAM takes advantage of generous laws to make medical claims with impunity, often skirting as close as possible to what the law permits.  And the Big CAM companies profit handsomely in the process.  Everything on the Topricin package - the name, the packaging, the claims - is designed to make the consumer think that it is an effective pain treatment.  It's not.  It's a modern package of snake oil.

Everything in this journal is wrong

Moxibustion at work.

In real science, we agonize over every detail.  When we publish a paper, we strive to get everything just right.  We qualify our findings, always allowing for the possibility that we might have missed something.

Oh, to be freed of the constraints of reality.  But fiction, alas, doesn't work in the real world.  Fantasy medicine is, well, a fantasy.  Or is it?  Let's enter the world of Complementary and Alternative Medicine.

Imagine a scientific journal in which every single article was wrong.  Not just an occasional mistake, as happens with many journals.  No, I'm talking about a publication where every single article has at least one fundamental flaw.

No, it's a real journal, published by BMJ, the publishers of the well-known journal by the same name (the British Medical Journal).  "Helping doctors make better decisions since 1840", they proclaim.  Then why, among their 40+ journals, do they publish Acupuncture in Medicine?

It appears - I can't prove this, but it seems to be so - that every single article in this journal is wrong.  Not just a little bit wrong, either.  Let's look at the "Editor's choice" article from the latest issue, which must be one of their best.  It's called "Using moxibustion in primary healthcare to correct non-vertex presentation: a multicentre randomised controlled trial".

In this study, a group of Spanish doctors looked at the use of moxibustion to correct a common problem in pregnancy known as a breech position - that's a baby that is turned the wrong way round in the mother, head up instead of down.  What, you may ask, is moxibustion?  Well, let me use the authors' explanation:

"The application of heat from the combustion of Artemisia vulgaris (moxibustion) for therapeutic purposes has long been used in China. Among other effects, it is believed to contribute to correcting the non-vertex presentation of the fetus when applied at a specific acupuncture point (BL67 Zhiyin) located at the outer corner of the little toenail."

That's right: you burn an herb (Artemisia) next to the little toenail of the pregnant mother, right next to an acupuncture point, and that's supposed to make baby flip right around so its head comes out first.

You can't make this stuff up.

These guys are serious.  They ran a study where they divided pregnant women into 3 groups, with about 135 women in each.  One group got moxibustion, another got "fake" moxibustion, where they burned the herb next to a different toe (really!), and the last group got standard care.

Amazingly, the doctors found that it works!  More of the women with moxibustion had babies born the right way round, head down, than in either of the other two groups.  To be precise, 79 babies in the moxibustion group came out the right way, versus 60 and 59 in the other two.  By the authors' own analysis, this difference was statistically significant.

Wow.  Maybe this stuff really does work.  And moxibustion is cheap and easy to administer.  Maybe this is the solution to our rising health care costs.

How to explain this result?  I see several possibilities:

1. The small effect was just a random variation, not due to the treatment.  Previous studies of exactly the same treatment (such as this one) showed that moxibustion did not work.  So either those studies are wrong, or this one is.
2. There was bias in how the women were assigned to treatment, and the effect can be explained by that.
3. The authors manipulated the data to make the numbers come out better.  (Quelle surprise! Not in a BMJ journal!)  Of course we can't prove this without much more investigation.
4. Burning an herb next to the little toe at just the right place - and nowhere else - stimulates a mystical "qi" pathway, and zaps that little baby back around the way he's supposed to be.

Hmmm, which seems the most likely?

OK, I admit it: I haven't read every single article in BMJ's acupuncture journal.  So I don't really know that they are all wrong.  But who has time to read all this bad science?  The latest issue has a disturbing number of articles about acupuncture for cancer, which I find particularly upsetting because that practice takes advantage of highly vulnerable patients.  It also includes an article on ear acupuncture, a practice invented out of whole cloth by an Army doctor in the U.S., who has been inflicting it on injured service members, as I've written about before.

Actually there is one article that seems plausible.  It reports a case of arterial hemorrhage caused by an acupuncture needle.  But we don't need to dwell on that.

Acupuncture in Medicine has all the trappings of a real journal, including an editorial board whose members work at respectable medical schools.  I know that BMJ wants us to believe it; after all, they make money on this stuff.  As for the journal itself: I can't bear to read any more.  It is just too painful.  Perhaps acupuncture would help.