Integrative Medicine Versus Alternative Medicine: Why It's Important to Know the Difference

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People often do not make a distinction between the terms integrative medicine and alternative medicine. Below is the mission statement of the Society for Integrative Oncology:

The Society for Integrative Oncology (SIO) is a non-profit, multi-disciplinary organization of professionals dedicated to studying and facilitating cancer treatment and the recovery process through the use of integrated complementary therapeutic options. Such options include natural and botanical products, nutrition, acupuncture, massage, mind-body therapies, and other complementary modalities. Our mission is to educate oncology professionals, patients, caregivers, and relevant others about the scientific validity, clinical benefits, toxicities, and limitations of state-of-the-art integrative therapies. SIO provides a forum for presentation, discussion, and peer review of evidence-based research in the discipline. We advocate for responsible public policy and the highest standards of practice in integrative medicine through appropriate training and the certification of health care professionals.

You will note that the word "alternative" is not contained in the mission statement because the SIO is not a proponent of alternative therapies in lieu of conventional evidenced-based medicine. This is also true of most academic organizations including MD Anderson, Memorial Sloan-Kettering Cancer Center, Dana-Farber Cancer Institute, University of California, San Francisco, and others.

Supporters of integrative medicine never advocate withholding proven interventions. As a matter of course, they embrace only the utilization of viable evidence-based treatments. We are wholly committed to quality research in the area of integrative cancer therapies.         

While additional research is needed in the area of integrative oncology, there is nonetheless a sizeable and growing body of well-designed, high-quality science that clearly supports specific interventions as evidence-based ( Locating well-conducted randomized trials of integrative therapies in oncology is not a difficult matter.  

As funding for this area of research is relatively new and not supported by big pharma, many of the trials are small Phase II studies and lack appropriate control groups (often just usual care). As more positive Phase I and II trials are completed, we will start to see the larger, necessary, better-controlled Phase II and III trials to know the true benefits of some of these treatments.  

One of the other challenges of research in this area is that with the exception of the natural product clinical trials, it is difficult to develop studies using the gold standard double-blind, placebo-controlled design. However, even using single-blind designs, it is possible to at least determine if the patients remained blinded to group assignment and assess patients' baseline treatment expectations. This can help to account for placebo effects. 

Often, in double-blind, placebo-controlled trials of conventional medicine patients are clearly "unblinded" when they experience negative drug effects and adverse events that are not experienced with the placebo treatment. Typically, it is unheard of to assess if patients remained blinded throughout a trial of conventional medicine. This unblinding is rarely questioned or even reported.

It is uncommon to find scientists or practitioners who support evidence-based medicine unsupportive of well-designed clinical trials. However, this can sometimes still happen in designing, conducting and publishing integrative oncology clinical trials. Scientific observation should never be trumped by a personal belief. In fact, substituting one's own belief instead of supporting rigorous research and scientific observation is similar to what alternative medicine practitioners advocate -- deliver or withhold treatments without evidence to support that action.  

If we simply followed people's predictions and beliefs then the field of medicine would not be where it is today, as many medical discoveries went against what was commonly believed and/or predicted. A good historical example of this is the story of Dr. Ignaz Semmelweis who documented that washing hands with chlorinated lime solution prior to delivering a baby dramatically decreased the rate of puerperal fever. The germ theory of disease had not been developed at the time and Dr. Semmelweis was largely ignored, rejected or ridiculed.

Another good example in oncology is the late Dr. Judah Folkman, who discovered angiogenesis and pioneered anti-angiogenic treatments. He also was initially dismissed and ridiculed by the medical community due to his ideas, which are now, of course, widely accepted.   

As the majority of cancer patients use some form of complementary and even alternative medicine, it is the medical establishment's responsibility to provide proper medical advice in this area. Good research is what is needed to determine what is beneficial and what is not beneficial to provide practitioners and patients the information they need to make informed decisions about medical care.  

sio_2010_conference.jpgThe field of integrative oncology continues its ascent as medicine shifts toward a more personalized care model. Delivering many common and accepted modalities such as diet, exercise and stress management using a patient-centered, comprehensive approach is what distinguishes integrative medicine from reductionist and fragmented models of care. As more and more cancer survivors proactively participate in a patient-centered wellness approach, integrative oncology practitioners will continue to grow in numbers to meet this demand.  

We invite all interested oncology professionals to join us for the 7th International Conference for the Society of Integrative Oncology at the New York Academy of Medicine, Nov. 11-13.


"As a matter of course, they embrace only the utilization of viable evidence-based treatments"

I'm trying to resolve the contradiction between this statement and the SIO's "strong recommendation" for energy therapy such as Reiki.

Reiki is not a "viable evidence based treatment". While it is very good that Dr. Cohen encourages patients to continue to receive evidence-based medicine, I think it is wrong to encourage non-evidence-based medicine.

Some of what SIO wants to integrate is science. Some of what SIO wants to integrate is pseudo-science. I am disappointed to see respectable medical establishments officially encouraging pseudo-science. I fully support research. The topic here is not research, but rather clinical care.

Just to be clear: I think that a treatment model that has the patient directed towards an oncologist specializing in a certain form of treatment, and getting exclusively that is not a good model.

The principle of integrating other evidence-based treatments is a great one. The problem here is that what is being said, essentially, is:
As long as the patient continues to receive the primary therapy recommended by their oncologist, we can safely lower the standard of evidence so low that we integrate what is, effectively, magic.

Reiki practitioners claim to be able to heal people at any distance, simply by looking at a picture of the patient. That is an extraordinary claim, which is unsupported by evidence. To suggest that it is a fine idea to integrate it into a reputable treatment regimen because, hey, it doesn't hurt - incredible.

I agree with Gopiballava. Further, renaming reiki "complementary," rather than "alternative," does not change its status as an unproven method.

Moreover, I object to including nutrition, exercise etc. as "complementary." While such advice from naturopaths and chirpractors, etc. may be useless, they are valid scientific topics in the hands of a real health professional.

So that there is no misunderstanding, MD Anderson does not offer Reiki, Healing Touch, Therapeutic Touch, or other forms of "energy medicine" to patients. The evidence-base does not exist for these modalities and, as such, they are not offered. Moreover, the SIO does not make a “strong recommendation” for these treatments. At our annual meeting we “allow” people to present their research on this topic, as we support research in all areas. In the SIO Clinical Practice Guidelines ( energy therapies are not endorsed per se, the evidence for and against in simply presented and the reader, whether physician or patient, can make their own decision on how to proceed clinically.

The inclusion of nutrition and dietary counseling, physical activity counseling, stress management, social support, etc. within the integrative medicine model is based on the philosophy of providing these approaches in a comprehensive fashion under the direction of a medical oncologist. This is what distinguishes integrative oncology from how these treatments are often delivered within most conventional medical systems – if they are offered at all.

Dr. Cohen,

Thank you for taking the time to respond.

I claimed that the SIO Clinical Practice Guidelines gave a strong recommendation after reading through them. It is possible that I have misunderstood.
On page 97, section 5, Energy Therapies, category 1B or 1C, both of which are listed as "strong recommendation", based on the table on page 88.

So, if all you offer is medicine (and you recognize that diet and exercise fall under that rubric), why do you call it "integrative?"

I believe in the original blog post above, and in some of my prior posts (Comprehensive Care Across the Cancer Continuum: The Role of Integrative Medicine; Integrative Medicine Will Make a Difference in Cancer Care), I tried to describe and define integrative medicine and what makes it distinct and necessary in the field of medicine today. From above: “Delivering many common and accepted modalities such as diet, exercise and stress management using a patient-centered, comprehensive approach is what distinguishes integrative medicine from reductionist and fragmented models of care”. Most physicians, clinics, and medical centers do not even offer these services, that we know are critical for prevention and optimizing clinical outcomes in cancer care. Integrative medicine is more a philosophy of medicine versus a focus on the modalities of treatment: Conventional medicine – surgery, chemotherapy, radiotherapy, etc.; Complementary medicine – making use of non-conventional modalities in combination with conventional medicine; or Alternative medicine – when a patient makes use of a non-conventional treatment modality in place of conventional medicine whether or not there is evidence for its efficacy.

The Consortium of Academic Health Centers for Integrative Medicine has defined Integrative Medicine term as “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing”. I also like this broader definition:

"Integrative medicine is an approach to care that can be easily incorporated by all medical specialties and professional disciplines, and by all health care systems… A practical strategy, integrative medicine puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person’s health. By treating the whole person, both the patient’s immediate needs as well as the effects of the long-term and complex interplay between a range of biological, behavioral, psychosocial and environmental influences are addressed. This process enhances the ability of individuals to not only get well, but most importantly, to stay well. Important elements of an integrative approach to health care include engaging the patient as an informed and empowered partner and personalizing the care to best address the individual’s unique conditions, needs and circumstances. The integrative approach emphasizes prevention, health maintenance and early intervention, and utilizes all appropriate, evidenced-based and personalized therapeutic approaches to achieve optimal health and wellbeing across one’s lifespan."

I have always said that the true success of the field of integrative medicine would be for all physicians, clinics, and medical centers to address the “full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person’s health” by providing appropriate services to meet these needs within the conventional medical model. When this happens, then a distinct field called Integrative Medicine would not need to exist. Encouragingly, medical specialties are adopting and advocating for a whole-health approach (please see the American Academy of Family Physician and the American Academy of Pediatrics to start). Integrative medicine presupposes the need for a slight change from the simplistic linear cause and effect ideas for health to the integration of multiple, synergistic modalities using more of a systems-based approach. We need to honor patients’ own belief systems and interests with respect to medical care. Patients are too complicated for the medical community to simply take a one-size-fits-all approach, and thankfully their voices are being heard.

Thank you for this clarification. Your point is well taken and worth considering. I will discuss with the SIO leadership. I expect a new version of the Guidelines will be published in 2011.

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