Meditations of an oncology geek

Acupuncture: Theatrical Placebo?

with 2 comments

24 June 2013

I recently came across something I rarely see in the medical literature: a review systematically dismissing a popular treatment for cancer. Actually, it’s not a cancer treatment per se, but something marketed to many cancer patients who are desperate for any form of pain relief.

Pain is a big deal. For my readers that are currently in good health, please recall the deep, jarring feeling of a broken bone, root canal, or worst headache. The type of pain that makes even the most simple tasks difficult. The type of pain eloquently portrayed by Edvard Much in his 1893 painting “The Scream”

For cancer patients, the pain can be unrelenting. It comes from various aspects of the disease, but for an example please envision a tree root slowly growing over time that cracks the solid concrete of a sidewalk. This is what metastases to the bone can do to cancer patients: literally break their bones from the inside out. Patients I’ve talked to describe it as utterly unrelenting. Although we and other groups are working to stop this process in the first place, one cannot look past the critical role played by pain medication for dramatically improving the condition of those currently battling the disease.

The late 19th and 20th century saw a revolution in pain treatment brought on by a combination of discovery, medical chemistry, and rigid application of the scientific method. Namely, clinical trials with control arms to asses, on average, how well treatments work for many people compared to those that receive no therapy, but are under the impression of receiving therapy, like a sugar pill instead of an experimental pain medication. These experiments (clinical trials) give a good proxy to predict how well a therapy will work for an individual. Through this process it’s possible to determine how well a therapy works, in what circumstances it works, and asses side effects.

In this respect, acupuncture has failed miserably. In an article “Acupuncture is Theatrical Placebo” in the journal Anesthesia and Analgesia, Dr. David Colquhoun and Dr. Steven Novella survey almost 3,000 clinical trials evaluating the efficacy of acupuncture. It’s a relatively short read and I highly recommend giving it a look if you or anyone you know has even the remotest inkling to use acupuncture to treat chronic pain.

I will use a few illustrative quotes nontheless:

“Large multicenter clinical trials conducted in Germany (references 7–10) and the United States (reference 11) consistently revealed that verum (or true) acupuncture and sham acupuncture treatments are no different in decreasing pain levels across multiple chronic pain disorders: migraine, tension headache, low back pain, and osteoarthritis of the knee.”

This point here deserves special attention. What would be a proper placebo control for acupuncture? Surely just about anyone would notice is someone pushed needles into their skin. The best controlled studies tested “proper” acupuncture, where the needles were inserted to key regions associated with traditional chinese medicine, and “sham” acupuncture, where needles were inserted to regions slightly off, or wholly off target. The patient would likely not be able to tell the difference, and would be under the impression of receiving “proper” treatment under both conditions. Under these conditions, both “sham” and “proper” acupuncture are equally consistently ineffective at combating chronic pain.

“The best controlled studies show a clear pattern, with acupuncture the outcome does not depend on needle location or even needle insertion. Since these variables are those that define acupuncture, the only sensible conclusion is that acupuncture does not work. Everything else is the expected noise of clinical trials, and this noise seems particularly high with acupuncture research. The most parsimonious conclusion is that with acupuncture there is no signal, only noise.”

Again, I was initially attracted to this article because of its no-nonsense title and tone. But even I was shocked at the magnitude of clinical trials that had been performed on acupuncture (roughly 3000) and the number of resounding “successes” (few) and the frequency of blatant internal bias and conflict of interest in the positive trials (frequent).

I recognize that the absence of disease is not health, and there is real value to improving the lives of cancer patients beyond medicine. For this reason I think that counseling, meditation, massage, and even acupuncture could have their place (if one likes the idea of having needles stuck into them. To each their own…) Even if it doesn’t help a patient live longer, there is no reason why one cannot take action to make their lives better.

That said, acupuncture is not medicine. Not for the pain of cancer. Even if we were to believe the few positive trials and discount the sea of failures, acupuncture would be the equivalent of using a garden hose to fight a house fire. Morphine and other opiates have gone through rigorous clinical trials very favorably and are currently used as first-line pain treatment. They are by no means perfect, but they are some of the best that we have at the moment. For those unfortunate souls that have pain too great for our current best pain killers, acupuncture is at best a distraction and at worst a monetary drain on already stretched families of those fighting cancer.

My last comment before signing off today is one of caution: beware of “alternative,” “hollistic,” or “complementary” medicine. These are terms used for medicine that has not, or can not be shown to work in controlled clinical trials. I.e. when subjected to actual processes of science. The authors’ tones were slightly more stern than mine:

“The argument that acupuncture is somehow more holistic, or more patient-centered, than medicine seems to us to be a red herring. All good doctors are empathetic and patient-centered. The idea that empathy is restricted to those who practice unscientific medicine seems both condescending to doctors, and it verges on an admission that empathy is all that alternative treatments have to offer.”

I will also note that “holistic medicine” or “alternative medicine” that is tested with clinical trials and shown to work repeatedly is usually referred to as “medicine.” “Medicine” that has been accepted without clinical trials (like radical masectomy or bleeding leeches) that is then subjected to clinical trials, and fails, is not considered “medicine” any longer.

Ryon

Written by Ryon

June 24th, 2013 at 3:07 pm

Posted in Science Blog

2 Responses to 'Acupuncture: Theatrical Placebo?'

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  1. My mom has Waldenstrom’s. Basically it’s blood cancer. I will grant you that this is not typically a fast moving disease, but for years, her markers were going up despite going through various types of therapies… MEDICAL therapies.

    Two years ago she started going to a holistic doctor and within a few months her blood markers for IGM and Viscosity not only stopped moving forward, but actually dropped. A year and a half later, the disease is all but stopped in its tracks.

    I respect much that science has to offer and realize and understand the need for medicines etc. But, just as you have petitioned your reader to use caution when considering “holistic” therapies, I want to caution you, a scientist, to not to close your mind to the possibility that there are alternative therapies and holistic approaches that can and do work.

    Beyond that Ryon, remember that the human spirit and mind are amazing organisms and that hope is more powerful than any drug that man or science has ever created.

    I’ll leave you with that.

    Josh Soto

    24 Jun 13 at 3:41 pm

  2. I am so glad to hear your mom’s condition is improving! But, how do you know it was the “holistic” “doctor” and not some other factor? There are many instances in the literature of spontaneous regressions of even advanced, aggressive tumors; among modern clinical trials, a rule of thumb I’ve heard mentioned several times is that a 5% response rate in the placebo group is considered normal.

    Science tests “holistic” therapies all the time. Some of them actually work, like aspirin, or the precursor of taxol. Many of them do not work. And many remain to be tested. What therapies did the holistic “doctor” use? If they work so well, he should publish his techniques in a scientific journal so the rest of the oncology community can use them too.

    Along the lines of hope and well-wishes physically affecting the outcomes of patients, I would like to direct you to perhaps the largest, bet controlled study in that realm, the Great Prayer Experiment: http://www.sciencedirect.com/science/article/pii/S0002870305006496

    Ryon

    2 Oct 13 at 1:35 pm

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