The Physician as a Scientist and a Healer

By David S. Rosenthal, MD

2009-07-01

Dr. Rosenthal is Medical Director, Leonard P. Zakim Center for Integrative Therapies at Dana-Farber Cancer Institute, Henry K. Oliver Professor of Hygiene, Harvard University, and Professor of Medicine, Harvard Medical School.

Dr. Rosenthal consults for Genzyme and receives research funding from NIH/NCCAM.

What happened to the time when a physician, hematologist or otherwise, was a researcher, clinician, teacher, and healer? As medical practice has become more complex, have we become too focused on treating disease and not the whole person? Have we incorporated both qualitative research, such as quality-of-life and survivorship findings, and quantitative research, such as tumor models, into standard care? To achieve the goal of best managing patients’ symptoms, it seems important to address both quantitative and qualitative measures.

Recently, it has been reported that there are some who would like to “defund” the National Institutes of Health’s (NIH) National Center for Complementary and Alternative Medicine (NCCAM)1 and also, perhaps, close the Office of Cancer Complementary and Alternative Medicine (OCCAM) within the National Cancer Institute. Currently, these two entities fund about $244 million of NIH’s total $300 million allotment for integrative therapies or CAM research. Given that the total NIH budget is more than $29 billion, this allocation represents just over 1 percent of the budget. These critics also would like to prohibit the 0.3 percent of the NIH stimulus funds from going to NCCAM, on the basis that this money is being taken away from “scientific approaches.” Their criticism stems from the observation that the results of a small number of studies funded to date have been inconclusive, while other studies have produced negative results, leading to a premature pronouncement that there is a better use for those funds elsewhere.

Terminology, such as the often cited use of “alternative medicine” versus “complementary” or “integrative” medicine, is one of the challenges for leaders in the field of complementary/integrative therapy research. Many of these leaders have worked in conventional medical disciplines and have contributed to that body of research before embarking on research in the emerging field of integrative medicine.

In the United States, hematology and oncology patients frequently use CAM therapies, not as “alternatives” to conventional therapy, but instead, in combination with conventional care to assist with controlling symptoms, to improve quality of life, to increase tolerance of the symptoms of disease and/or the side effects of the therapy, and to rehabilitate after curative therapies.2 Most Americans visit CAM practitioners more frequently than they visit physicians, and they often do not share their CAM practices with their primary physicians.3 The use of biologicals and herbs is widespread in the hematology/oncology community, and the importance of studying potential drug interactions (either positive or negative) of these therapies with conventional chemotherapy cannot be overemphasized. Given the extensive use patients make of these modalities and the modest scientific study into their utilities, the call to abandon further scientific inquiry is puzzling.

The Society of Integrative Oncology (SIO) was founded in 2003 as a “forum for presentation, discussion, and peer review of evidence-based research and treatment modalities in the discipline known as integrative medicine.” This international association has established recommendations regarding the use of CAM. The first two recommendations are most important. First, all patients with cancer should be asked specifically about their use of CAM, and, second, all patients with cancer should receive guidance about the advantages and limitations of complementary therapies in an open evidence-based and patient-centered manner by a qualified professional. The Institute of Medicine (IOM) and the Bravewell Collaborative hosted a “Summit on Integrative Medicine and the Health of the Public” in February 2009. Dr. Ralph Snyderman, chair of the Summit Planning Committee and chancellor emeritus of Duke University, described that the purpose of the summit was to “explore how science and a patient-centered, prospective integrated approach to care can make a positive difference.”

Integrative medicine emphasizes the patient–physician therapeutic relationship. It neither rejects conventional medicine nor accepts alternative therapies. The principles of integrative hematology/oncology optimally combine the best of all available therapies, the combination of evidence-based complementary therapies, and the best evidence-based conventional therapies for each patient, while strengthening the patient–physician relationship.

It is a weakness of CAM research to date that it has been more focused on survey information and small trials. It has been debated whether the same criteria used for drug clinical trials should be applied to acupuncture, massage, music therapy, etc. and how best to address controlling for the placebo effect. It stands to reason that the same general scientific principles should apply to research endeavors in either a conventional biomedical or complementary medicine realm (e.g., standardization of product in pre-clinical studies and adherence to randomization, masking, adequate reporting, etc.) for clinical studies. Reproducibility is important to studies across the full spectrum. Problems with adequate funding, resources, recruitment, and retention of study subjects are common to many research studies; however, the effects are magnified when opportunities for scientific inquiry are scarcer, as in CAM research. There is a need for novel research designs and approaches in both biomedical and CAM research. Some methodological issues still need to be solved, such as for acupuncture, which is a procedure, not a drug delivery equivalent. CAM studies have also been criticized for their infrequent demonstration of efficacy; however, a recent article regarding investigational drugs in phase III clinical trials in oncology indicated that only 5 percent reached the market.4

At the upcoming 2009 ASH Annual Meeting in December, Drs. Volker Diehl and Kara Kelly, two outstanding clinicians and investigators in adult and pediatric hematology/oncology, respectively, will discuss the role and importance of integrating complementary medicine into hematology care. Dr. Diehl, whose research on Hodgkin lymphoma is well known, will discuss the importance of dealing with life after treatment, and Dr. Kelly, known for her work on childhood leukemia, will discuss nutrition and the role of antioxidants. It is imperative that we continue to increase research funding in all sectors of hematology and medical oncology: the conventional basic, molecular, and clinical as well as the integrative therapies. We need to find novel research protocols that take advantage of all evidence-based therapies to treat disease and improve patients’ quality of life.

  1. Brown, David. “Critics Object to ‘Pseudoscience’ Center.” The Washington Post. 17 Mar. 2009: HE01.

  2. Richardson MA, Sanders T, Palmer JL et al. Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol. 2000;18:2505-14.

  3. Eisenberg DM, Kessler RC, Van Rompay MI et al. Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey. Ann Intern Med. 2001;135:344-51.

  4. Adjei AA, Christian M, Ivy P. Novel designs and end points for phase II clinical trials. Clin Cancer Res. 2009;15:1866-72.

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