Contemplating Complementary Medicine

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There is an old, familiar joke that goes something like this -

A tourist is walking through the New England countryside, trying to find his way to the nearest town. He stops a man to ask for help with directions to so-and-so. The local pauses to think about it. “Well,” he begins. “You go down this road for a bit. Then when you come to a barn, you go left. You walk through the field, and … no, wait, that’s not right.” He pauses for another moment. “What you do is this: you walk toward that hill over there, and when you come to the fence, go left. About a mile later, you’ll see a pond, where – no, wait, that’s not right.” He pauses to think about it some more, the tourist growing antsy and frustrated. Finally, the local speaks. “Well,” he says, “You can’t get there from here.”

And though I am probably going to regret poking this particular hornet’s nest, here goes. Some recent research, for this article about the alternative medicine approaches pursued by Steve Jobs following his diagnosis of a pancreatic neuroendocrine tumor, brought that joke to mind when I saw the vitriol flying around, on the one hand about so-called complementary medicine, and on the other hand, about that harsh judgment.

Complementary medicine typically refers to any approach to healthcare that a person chooses to pursue alongside modern medicine. That is, it complements the scientifically proven treatment. Complementary medicine usually includes some form of traditional Chinese medicine (or, as many refer to it, Traditional Chinese Medicine [TCM]), including acupuncture, herbal remedies, mushroom blends, and certain movement and breathing practices like Qi Gong and Tai Chi. When someone who is ill chooses to use only these approaches and no form of Western medicine, it’s usually called alternative, not complementary.

Many people are also aware that TCM has been increasingly incorporated into medical care—in cancer treatment, it’s called integrative oncology—and, albeit with less vigor than many would like, put to the test in scientific research. Scientific literature now supports the use of acupuncture as a way to reduce nausea among people receiving chemotherapy, for example.

There are many hurdles facing the use of complementary approaches in a way that modern medicine will support, but chief among them is a pervasive attitude that refers to complementary medicine as “woo” or “quackery.” And, when people who are interested in complementary medicine see it referred to thusly, the reaction that modern medicine doesn’t work and all anyone is trying to do is to get sick people to spend money on expensive drugs.

It’s difficult to subject things like dietary changes to the scientific method. It’s also questionable whether that’s the right approach. As Don Abrams, an oncologist with an extensive academic and medical background who now heads the Osher Center for Integrative Medicine at the University of San Francisco, said it during our recent interview, “The demand for placebo-controlled, randomized clinical trials is something we need when talking about cytotoxic drugs, but how dangerous could it be to eat more cruciferous vegetables and heavily pigmented fruit?” And the necessary corollary to that, “How much do we need to spend to prove it?”

Clinical trials enable researchers to compare two treatment approaches, yes, but they also enable researchers to keep patients safe from a potentially harmful new agent. When it comes to something like eating broccoli, that hardly qualifies as dangerous, but it’s also very hard to compare patients who eat more to patients who eat less as part of their overall treatment regimen.

Now that’s not to say that one should go blindly into integrating dietary changes or TCM into their medical care, but it does call up that punch-line. Can you get there from here? Can we start to think about the how’s and why’s of complementary medicine from a modern medicine standpoint? Is that the right approach? Is that valid? Is it the only approach?

One of the issues raised about TCM is that it’s based on anecdotal evidence. That’s a reasonable concern. Anecdotal evidence is subjective. The National Comprehensive Cancer Guidelines would consider it Category 3 evidence. But do you know what? Trial and error is exactly how many of the first effective combination chemotherapy regimens came about. The efficacy of methotrexate, the first curative cancer drug, was realized through the treatment of one person. A young woman was ill with choriocarcinoma was given methotrexate starting in October 1955, and by February 1956, all evidence of her disease was gone. In the days when treatment options were incredibly slim, people tried anything – giving a certain drug for five days in a row, or every other day, or whatever seemed like a good idea to try. Of course there were always clinical trials and organized research, but that wasn’t the only approach. Behind thin hospital curtains, patients with no hope were given experimental combinations of nitrogen mustard and vincristine or whatever other agents had shown promise or concrete benefit, to see what that concoction might do. And when that combination worked, making the tumor recede without killing the patient in the process, word of the success was broadcast far and wide.

All of which brings us to the issue of evidence-based medicine, and the fact that there should be ample evidence supporting the choices and recommendations made by doctors. And yet, anecdotal evidence is an inherent part of Western medicine. See this article, in the Archives of Internal Medicine, showing the extent to which decisions are made based on evidence that is not derived from a rigorous clinical trial. And this letter, from the New England Journal of Medicine, about adverse anecdote, highlights another interesting aspect. That’s not to say that the reliance on anecdotal evidence is right or wrong, but just to state the fact that it happens in conventional medical care, too.

In the earliest days of chemotherapy, many people thought that radiation and surgery were sufficient to treat cancer, and that where these interventions didn’t work, the cancer wasn’t treatable. Obviously the naysayers of that era were wrong, but it took giving the drugs to patients to show them the error of their ways. That is not to say that eventually acupuncture will be used to treat cancer. All of the doctors that I spoke with – many with one foot solidly grounded in the West and the other in the East – were very definite that tumors need to be treated with drugs, radiation, and surgery – that only these medical interventions can get at the cancer cells.

It’s also important to remember that many anticancer drugs have their origin in natural sources – not just the familiar Taxol, a synthetic compound derived from the Pacific Yew tree, but also vincristine, which comes from periwinkle (Vinca rosea), among others. The National Cancer Institute maintains an incredible collection of natural products from around the world, everything from deep sea sponges from off the coast of New Zealand to bacteria found at the top of the Andes mountains to samples of soil found in an average backyard (for their microbial value). Now of course any of those products would be studied in vitro, and then in animals, and then in people, in accordance with the clinical trials process.

But TCM and other approaches, like changes in diet and stress-reducing practices, can go a long way toward helping people heal, and we don’t know what role they might have in prevention. Yes, one shouldn’t walk naively into these practices thinking they will miraculously reverse the problem (and plenty of people are guilty of walking into a phase I clinical trial thinking that they might be the patient on whom a revolutionary compound works its unexpected miracle). But is it helpful to deliver a judgment against TCM practices because they haven’t been scrutinized in clinical trials? Can they be studied in clinical trials? Many people argue that the number of variables at play just can’t be controlled for, and that it’s impossible to isolate the exact mechanism by which dietary changes, etc. work their wonders.

Can you get there (building the evidence for complementary medicine) from here (modern medicine)? Is it possible that understanding traditional Eastern medicine requires an entirely different school of thought? Is it possible that there is some rigorous way to examine things like acupuncture and herbal teas that satisfies our need for evidence without dismissing the notion that these approaches may work according to pathways that somehow do not come under the radar of a clinical trial process?

History is littered with stories of people who were first mocked by their colleagues before being celebrated (Bose, of sound system fame, comes to mind). Simply dismissing complementary medicine as a sham is the sign of a closed mind, not a scientific one.

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