$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.

Do we all need PSA tests?

Say your doctor offers to run a PSA test, which might detect early signs of prostate cancer.  The test is free to you, because insurance covers it.  And you're already getting a blood test to measure cholesterol, so the cancer test doesn't involve any extra pain.  Why not?  And by the way, the American Urological Association recommends regular PSA screening for all men over 40.  Based on this information (or less), millions of men get a PSA test every year.

But hold on.  Suppose your doctor tells you a different story.  First he explains that a recent, large-scale US study looked at the effect of annual PSA screening on more than 75,000 men, and found no benefit at all.  A separate large study in Europe showed a very small benefit, but only in 2 of the 7 countries participating in the study.  Suppose your doctor also explained that if you have a positive PSA test, there's an 80% chance that it will be false - that you won't have cancer.

Suppose your doctor also explained that "PSA-based screening leads to a substantial overdiagnosis of prostate tumors" and that treatment usually requires surgery.  The effects of treatment are serious: 20-30% of men treated with surgery and radiation suffer from long-term incontinence and erectile dysfunction.

Prostate cancer tends to grow so slowly that many men with prostate cancer should not be treated at all.  Unfortunately, once someone knows he has cancer, there's a very good chance he will elect treatment, even though we can't really tell if treatment will help.

Do you still want a PSA test?  Do you want one every year?

Well, after a thorough review of the evidence from multiple trials, the US Preventive Services Task Force recommended a few weeks ago that men not get PSA screening for prostate cancer.  They concluded:

"there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harms." (USPSTF, Annals of Internal Medicine, 22 May 2012)

This recommendation, although based on a thorough assessment of risks and benefits, was met with howls of protest from urologists, who conduct most of the prostate cancer screening and treatment in the U.S. and elsewhere.  The American Urological Association stated bluntly:

"The AUA is outraged and believes that the Task Force is doing men a great disservice by disparaging what is now the only widely available test for prostate cancer, a potentially devastating disease."

The AUA also issued press releases and launched a lobbying effort, asking their members to contact the media and Congress.  They even provided a sample letter for urologists to send to their representatives in Congress.

Unfortunately for the AUA, their responses contain a very slanted presentation of the facts.  The AUA president's response emphasizes the studies that found a benefit for PSA testing, but ignores those that found no benefit.  In addition to this cherry-picking, they make the misleading claim that the recent U.S. PLCO study found "a significant reduction of prostate cancer death rates," which it did not.  In fact, the PLCO study found a higher death rate from prostate cancer in men who received PSA testing.
And the AUA statements ignore the very serious risks of prostate surgery; essentially they are pretending the risk is zero.

Why did the urologists react so strongly?  The answer appears to be simple: money.  Urologists make a lot of money on prostate cancer treatments. The USPSTF estimated that in the first 20 years of PSA testing, 1 million additional men were treated as a result of screening.   And if the surgery is unnecessary, you don't get a refund.  

So who are you going to believe?  The Preventive Task Force report presents a thorough review, laying all the details on the table.  Their members don't make a profit from prostate surgeries.  Their report simply more credible than the knee-jerk reaction from the urologists' association.  I'll let the Task Force have the last word:

"The harms of PSA-based screening for prostate cancer include a high rate of false-positive results and accompanying negative psychological effects, high rate of complications associated with diagnostic biopsy, and—most important—a risk for overdiagnosis coupled with overtreatment. Depending on the method used, treatments for prostate cancer carry the risk for death, cardiovascular events, urinary incontinence, erectile dysfunction, and bowel dysfunction. Many of these harms are common and persistent." 

At my last checkup, my doctor asked if I wanted a PSA test.  I told him no thanks.