By Paul Anderson, NMD
This post originally appeared on Emerson Ecologics
Reference: Johnson SB, Park HS, Gross CP, Yu JB. Use of Alternative Medicine for Cancer and Its Impact on Survival [Brief Communication]. J Natl Cancer Inst (2018) 110(1): djx145. doi: 10.1093/jnci/djx145
The “Headlines” generated by this one tiny paper are quite imposing, and in some cases plainly misleading:
“Cancer Patients Who Turn To Alternative Medicine Are 2.5 Times More Likely To Die”
“Alternative Medicine Alone as a Cancer Treatment linked to Lower Survival”
“You are more than twice as likely to die from your cancer if you choose alternative medicine. If you have breast or colorectal cancer, you’re more than five times as likely to die.”
“Cancer is way more likely to kill you if you rely on ‘natural’ therapies – Chemotherapy is brutal, but crucial.”
“Choosing alternative cancer therapy doubles risk of death, study says.”
Regardless of the potential validity of this research recently released by Johnson, et.al, these extrapolative headlines making the rounds on social and traditional media outlets are confusing to patients and families of those with cancer — but also misleading.
There are at least three areas to consider when looking at the original publication as one assesses its veracity in regard to all the public claims being made based on it. First, one should assess the paper itself, second, the definitions used to make the claims, and third the other data which may bring a more comprehensive and accurate overview of the topic.
The paper is a “Brief Communication” rather than a full research article. There is nothing inherently wrong with a brief communication, but often they are used to disseminate some critical data that just “has to get to the community” before a full analysis can be made. They are also used when a group sees “headline-grabbing” potential in some preliminary data, which in my opinion, is the point of this. It is of note that they disclosed: “The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the results herein.”
So, what does the paper assert? From the Abstract:
There is limited available information on patterns of utilization and efficacy of alternative medicine (AM) for patients with cancer. We identified 281 patients with nonmetastatic breast, prostate, lung, or colorectal cancer who chose AM, administered as sole anticancer treatment among patients who did not receive conventional cancer treatment (CCT), defined as chemotherapy, radiotherapy, surgery, and/or hormone therapy… AM use was independently associated with greater risk of death compared with CCT overall … Although rare, AM utilization for curable cancer without any CCT is associated with greater risk of death.
Definitions of CCT and AM.
Conventional Cancer Treatment (CCT) is well defined above. Alternative Medicine (AM) is referred to based on the data identifier they used to derive the “AM” group, but where did that come from and what does it mean? For this one must consult the American College of Surgeons “National Cancer Database.” If one reads far enough (page 197) the identifier of Alternative Medicine is explained as “Code-6: Other Unproven; Cancer treatments administered by nonmedical personnel”. This means AM (the ‘therapies’ leading to a two or more fold increase in cancer-related death (over CCT) are therapies administered by non-medical or medically trained persons. Additionally (and I have been involved in such research coding as a clinical researcher) this code is literally a “junk drawer” code which has very low specificity. This could mean I refused CCT and asked my non-medical neighbor for advice, my barber or just read that eating more peaches could cure my colon cancer on a food blog.
Just to underscore the sloppiness of this as the “comparator” I could easily do the same data search and prove (and get headlines) “patients with sepsis are more likely to die using Alternative Medicine than standard of care interventions…”
The other slippery detail, which is not brought out until the end, is that they do eventually make a distinction between “AM” in the ACS definition and “complementary and integrative” medicine. From the final portion of the paper:
“It is important to note that complementary and integrative medicine are not the same as AM as defined in our study.”.
“Whereas complementary and integrative medicine incorporate a wide range of therapies that complement conventional medicine, AM is an unproven therapy that was given in place of conventional treatment.”
Abrams and Weil write:
Integrative medicine is healing-oriented medicine that takes account of the whole person, including all aspects of lifestyle. It emphasizes the therapeutic relationship between practitioner and patient, is informed by evidence, and makes use of all appropriate therapies. In contrast, alternative therapies are used instead of conventional interventions, often without evidence of effectiveness.
So to be brief, none of the group with lower survival would qualify if being treated by a medically trained or supervised provider.
The second question is what other data show in regard to complementary and integrative medicine (CIM) in regard to oncology care? First, it is a published modality of some benefit related to palliative care in the American Society of Clinical Oncology literature. Second, two papers stated (in regard to CIM):
Overall, an initial integrative oncology consultation resulted in clinically meaningful improvements in psychosocial symptoms for patients who returned for follow-up. Greater overall impact across all symptoms was observed for those reporting a moderate to high symptom burden at initial presentation. Patients were very satisfied with the encounter at the initial consultation and at follow-up, with their top concerns being addressed to their satisfaction.” And “We have demonstrated that by providing consultations on how to bring together conventional and non-conventional treatment approaches in an evidence-based manner, we are providing a service that is valued by patients.[5,6]
It is important to note that multiple reviews of CIM exist, one being quite comprehensive and concluding: “The research literature documents a growing number of integrative oncology programs. These programs share a common vision to provide whole-person, patient-centered care, but each program is unique in terms of its structure and operational model.”
And finally are any examples of CIM in advanced cancer of a specific variety published showing positive outcomes? There are a number of such publications but this recent paper has an interesting and positive conclusion: “Our data demonstrate the importance and potential of health services research showing that IO (Integrative Oncology) treatment can be successfully implemented in the every-day care of patients suffering from advanced pancreatic cancer.”
Although not completed, data reported on at the Society of Integrative Oncology regarding our research at Bastyr Integrative Oncology Research Center also opposed the findings of the Johnson paper as well. One specific group that can be compared between our BIORC outcomes and the Johnson reported outcomes are lung cancer patients. Lung cancer in the CIM treated group at 36 months (BIORC trial) had a 63% survival and the matched non CIM using (i.e. “CCT” – standard of care only) controls  had a 15% survival at 36 months. This is in contrast to the Johnson report that lung cancer patients had a 50% survival at 36 months in the CCT group versus 25% in the AM group at the same interval.
I believe the discussion of the data above speaks for itself. As summary points I would simply say the following are true based on the Johnson paper as well as the other related data reviewed:
- Be careful to define the terms used in studies.
- Always look at the last three paragraphs of a paper for any disclaimers, qualifiers or other potentially context changing statements.
- If providing alternative, palliative, complementary, integrative or other care for cancer patients be medically trained or supervised.
- And, if looking at a traditional or online “attention grabbing” headline please look a little deeper!
This article first appeared on Dr. Anderson’s monthly review for Emerson Ecologics.
- Johnson SB, Park HS, Gross CP, Yu JB. Use of Alternative Medicine for Cancer and Its Impact on Survival [Brief Communication]. J Natl Cancer Inst (2018) 110(1): djx145. doi: 10.1093/jnci/djx145
- American College of Surgeons. National Cancer Data Base Participant Use Data File (PUF) Data Dictionary. Version: PUF 2014 – Containing cases diagnosed in 2004-2014 (page 197)
- Abrams DI, Weil AT. What’s the alternative? N Engl J Med. 2012;366(23):2232.
- Ferrell B. et.al. Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 35:96-112
- Lopez G. et.al. Integrative Oncology Outpatient Consultations: Long-Term Effects on Patient-Reported Symptoms and Quality of Life. Journal of Cancer. 2017; 8(9): 1640-1646. doi: 10.7150/jca.18875
- Lopez G. et.al. Integrative Oncology Physician Consultations at a Comprehensive Cancer Center: Analysis of Demographic, Clinical and Patient Reported Outcomes. Journal of Cancer. 2017; 8(3): 395-402. doi: 10.7150/jca.17506
- Seely DM. et.al. A systematic review of integrative oncology programs. Curr Oncol, Vol. 19, pp. e436-461; doi: http://dx.doi.org/10.3747/co.19.1182
- Axtner. Et.al. Health services research of integrative oncology in palliative care of patients with advanced pancreatic cancer. BMC Cancer (2016) 16:579. DOI 10.1186/s12885-016-2594-5
- Standish L, Anderson P, et.al. Can Integrative Oncology Extend Life in Advanced Disease? 10th International Conference of the Society for Integrative Oncology (SIO): Abstract 79. Presented October 21, 2013. Released in the report: “Integrative oncology might be helping to extend the lives of patients with advanced cancer, new research indicates.” Medscape Medical News > Conference News; Roxanne Nelson; October 25, 2013 http://www.medscape.com/viewarticle/813217.
- Cetin K, Ettinger DS, Hei YJ, O’Malley CD. Survival by histologic subtype in stage IV nonsmall cell lung cancer based on data from the Surveillance, Epidemiology and End Results Program. Clin Epidemiol. 2011;139-48