Contemplating Complementary Medicine

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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14 Responses to Contemplating Complementary Medicine

  1. Simba says:

    Why would the challenges posed in research on complementary practices (say, reflexology) be greater than that posed in research on non-complementary practices (say, foot massage)?

    The fact is that when looking at a lot of complementary practices, it’s not that the research is particularly hard to do, it’s that there’s no interest in doing it properly in a lot of disciplines- acupuncture is well researched (and placebo acupuncture often works just as well), but the quality of a lot of the research for other complementary treatments is appalling.

    Anectdote is an important starting point, but that’s all it is- a starting point. The powers of deduction and experimentation that led to water being given for cholera also led to blood-letting to balance the humors, or ‘purging’ for pretty much everything. Traditional medicines have been tested and proved or otherwise before under current practices of science-based medicine, so it wouldn’t require “an entirely different school of thought”. Most of the concepts aren’t much different from traditional western medicine practices- the Irish used moxibustion, for example, and cupping. If it works when tested, people will try to figure out how and why it works, and the explanations will be tested and heard.

  2. Joel Peterson says:

    Anecdotal evidence can be used to “prove” the claims of anyone, from faith healers to witch doctors to snake oil salesmen. Wherever there are believers, there will be supporting anecdotes. While anecdotes may be used for forming hypotheses, scientific questions need to be answered with stronger evidence.

    The evidence for alternative medicine is almost entirely lacking. Acupuncture has been shown to have value for relief of pain and nausea, but it is no more effective than sham acupuncture, which uses the wrong acupuncture points and inserts the needles to the wrong depth, or not at all. This strongly suggests that the pain-killing effects of acupuncture are a type of placebo effect.

    If future evidence strongly supports what now seems like a highly improbable idea, like hopping on one foot to cure cancer, then so be it. Reality is whatever it is and scientists would then have to figure out why it worked. But if someone pushed hopping as a cure for cancer and offered no reasonable justification then they would deserve all the ridicule they got.

    Yes, many thinkers who were ahead of their time were mocked, but for every great thinker who was mocked there were thousands of raving cranks. Accepting alternative medicine without adequate supporting evidence is not open-mindedness, it is gullibility.

  3. Rob says:

    “The evidence for alternative medicine is almost entirely lacking. ”

    Have you recently completed a meta-analysis of all alternative medicine’s efficacy or is this statement just anecdotal?
    There is very strong evidence for health benefits for a wide variety of herbal extracts (ginkgo biloba, saw palmetto, hawthorn, valerian, garlic, and ginger are some of the common ones) and, in other cases, the evidence is lacking. Please don’t commit the intellectual mistake of equating lack of evidence with lack of efficacy though. In most cases, there simply isn’t the financial ability or incentive to bring products through the expensive and laborious phases of clinical trials for something that cannot be patented.

  4. In the vast majority of cases, the lack of evidence is for the lack of efficacy. The more research that is conducted, the more of these CAM treatments are found to be ineffective. Pharmacognosy is the science of studying the medicinal effects of plants and researchers use the scientific method to determine the efficacy os these plants.

    Don’t underestimate the financial incentives such as Borion to avoid research that would impact their bottom line. Borion is is the world’s largest manufacturer of homoeopathic treatments.

  5. Joel Peterson says:

    “Have you recently completed a meta-analysis of all alternative medicine’s efficacy or is this statement just anecdotal?”

    You’re comparing apples to oranges. If there are a finite number of cases to consider you can just look at them without a meta-study. There are a finite number of commonly used forms of alternative medicine and, yes, evidence is almost entirely lacking; in many cases there is strong contradictory evidence

    What does work in alternative medicine?

    You brought up herbalism where there is some real evidence of benefit. (Aspirin, as we all know, is modified form of a chemical discovered in willow bark.) But even here, when one reads further, the evidence for specific herbs is often unclear and contradictory. For example, see this article about ginko biloba. When herbs do work they are like any other drug – they need to be taken in sufficient quantity to be useful while avoiding an overdose. Without testing we don’t know what these amounts are. Also the potency can vary from one individual plant to another, making dosing difficult. It is usually much better to develop from the herb some inexpensive generic drug for which the potency is known, like aspirin.

    Chiropractic seems to have benefit for short-term relief of back pain, but not for anything else.

    Eating your vegetables and exercising is recommended by everyone and really isn’t alternative medicine although some people seem to think it is.

    What ideas in alternative medicine have little supporting evidence or even strongly contradictory evidence?

    Pretty much everything else: TCM, homeopathy, Gerson therapy, and therapeutic touch just for starters. It also applies to many of the things people in the alternative medicine community worry about, such as cell phones causing cancer and vaccines causing autism, etc.

    “Please don’t commit the intellectual mistake of equating lack of evidence with lack of efficacy though.”

    It would be an intellectual mistake to say that because there is a lack of evidence that an idea is utterly impossible and should not be considered. But modern science is built on the idea of the null hypothesis which says that new ideas should be considered false until tested. Most random ideas without any supporting evidence are false. If future testing shows some form of alternative medicine to be useful – GREAT! Until then such ideas need to be treated as false. Just because a lot of people believe in an idea doesn’t make it any more scientific. Before the rise of clinically-controlled tests bloodletting was widely believed – and complete nonsense.

    On what basis do I make my previous claims? When it comes to health, or any technical issue, we must be very careful where we get our information. First check reputable science magazines, respected scientists, large universities, etc. (Even Wikipedia is usually pretty good.) Then check to see if there is a general agreement. You will find little in these sources to support the claims of alternative medicine. They could all be wrong of course, but the scientific community brought us the modern technical age. They have a pretty good track record for getting things right.

  6. Joel Peterson says:

    The correct link for ginko biloba is <a href="http://www.cnn.com/2009/HEALTH/12/29/ginkgo.biloba.brain/index.html"here.

  7. Simba says:

    “In most cases, there simply isn’t the financial ability or incentive to bring products through the expensive and laborious phases of clinical trials for something that cannot be patented.”
    There are institutions devoted to researching complementary and alternative medicine.

    Provided it’s new and innovative you can patent it- if you come up with a new way of extracting a drug from a plant, that’s new and innovative.

    The major pharmaceutical companies also tend to do a lot of work on plants, to try and develop new drugs from them. Just because it comes from a plant doesn’t mean you can’t make a profit from it- quite the contrary, drug developers are turning to plants as a way to find new chemicals which might hold promise. Think theobromine, theophylline, turbocurarine, taxol, pilocarpine, quinine for some of the more obvious examples.

  8. bcpmoon says:

    I am so tired of these strawmen…
    Every scientist involved in drug discovery will happily acknowledge the very important role that case studies and natural compounds play. Really.
    But case studies are not enough. Even if I were seriously ill, I would like to know if the probably toxic compound (and boy are natural substances toxic) my doctor wants me to swallow will help me beforehand. How did the second person to get methodrexate feel? As a guinea pig? Also, how many substances were blindly tested before and after that one hit?
    Also, natural substances. The same people who accuse scientists of not looking at nature are complaining about bioimperialism. How is that possible? Either nature gets ignored or exploited, but choose one.
    The scientific method (in my opinion) is nothing more than an attempt to avoid fooling yourself with wishful thinking. It is not difficult. It starts with the question: Is it real? Only then comes the: Why? How? I do not need to know how TCM works before I know that it does work. But here all alternative treatments fail: The closer you look, the smaller the effect. In the end, its placebo. But again, there is nothing wrong with that.

  9. Personally, I am disappointed to see a post like this on PLoS blogs.

  10. Rob says:

    It’s comical how polarized this whole topic usually is. People usually have a dogmatic mindset toward the whole topic and lump vastly disparate areas under an umbrella of “alternative medicine” and then cite CNN articles as proof it’s all bunk. That’s about as far as people dig usually because they have already decided it’s all hokum. I think each area of “alternative medicine” should be looked at individually and assessed separately. I completely agree reputable information sources are key. It’s an area that has a vast amount of misinformation, often disseminated and repeated ad nauseum by our mainstream media. Here is a more recent meta analysis on benefits of ginkgo biloba in dementia: http://www.biomedcentral.com/1471-2318/10/14
    I can assure you, if you actually approach the topic open minded and actually take the time to do your own research and digging, that there is a vast amount of credible research to support use of herbal extracts, probiotics, omega-3 fatty acids, and other supplements. Other areas of “alternative medicine” may be completely worthless. I’m in Canada myself, and Health Canada regulates herbs and supplements with an NPN (Natural Product Number) license and approved health claim. This involves analysing the body of supportive research available, and has resulted in thousands of products being removed from the market because clinical trials don’t exist, or because the ones that do are not of good quality, but it has also resulted in strengthened claims for the ones that do have good quality evidence. People who dismiss all complementary medicines like this in a kneejerk reaction have their heads in the sand and their reaction is based on prejudicial beliefs rather than science in my opinion.

  11. bcpmoon says:

    I want to return to some points, sorry, but it worries me that these thing pop up on this site, because they show a deep misunderstandind of central concepts:
    Take for example:

    “..how dangerous could it be to eat more cruciferous vegetables and heavily pigmented fruit?”

    Yes indeed. How dangerous could it be? The starting point of science is not to take things for granted, to question the “self-evident”.

    And when that combination worked, …, word of the success was broadcast far and wide.

    Anecdotes are not data. And here we have the origin story of snake oil: One success story, broadcast far and wide. How do you know that this was not (horribile dictu) chance? Especially with something so unique like cancer? You cannot know this without trials, a case can only be a starting point. More worryingly in the article is the implicit assumption that because one wonder drug
    was found this way, all of these things on the market are justified (laetrile,…).

    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.

    Yes, but this is seen as an error, not as a virtue. This “you too” approach does not speak for “Alternative”.

    Is it possible that understanding traditional Eastern medicine requires an entirely different school of thought?

    Sorry, but invoking “other ways of knowing” are a sure sign of woo. Perhaps unintentional here, but still. It is a shorthand for wishful thinking. It always comes up when the hypotheses brought up to explain TCM, homeopathy,… are shown to be false, as if that would change anything. I am not interested in explanations how something works, as long it is not shown that it works at all! For example, it has been shown that acupuncture works – correction: it has been shown that sticking needles in your body works, regardless if you use the “2000 year old tradition”, involving meridians, chi, whatever or just stick them somewhere. So: Acupuncture has been in fact disproven, i.e. the philosophical system has been shown to be wrong. But not the sticking-needles-in-your-body thing.
    One last thing: The “Galileo gambit” in the last paragraph is also not a good sign…
    “Yes they laughed at Bose – but they also laughed at Bozo the Clown”.

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  14. Carrie says:

    While I agree with Don Abrams that eating more vegetables probably being safe and may be very beneficial, there are a lot of alternative and complementary medicines/therapies that are not so benign. It is difficult to test some of these therapies, but safety should be tested first and foremost. For example, Natural Standard gives ephedra an evidence grade of A for effectiveness (meaning good scientific evidence) for its use in weight loss; however, there are well documented and potentially deadly side effects (22 reported deaths) associated with its use. I’m not saying that alternative medications aren’t beneficial because a lot of people have been helped. I’m more concerned with folks jumping in without looking into any of the safety information because its ‘natural’ or ‘traditional’.