In July 2018, the Integrator published a series of articles challenging a JAMA Oncology study and stunning headlines that those using complementary therapies in cancer treatment die quicker. The integrative oncology community condemned the paper –  though oddly falling short of calling for retraction. (In the Integrator series, I urged retraction.) After 7 months and 193,000 downloads of this story, the JAMA Oncology finally published letters from researchers in 4 nations that led an Medscape article on the reaction to quote a scientist claiming the five letters “completely destroy(ed) the pseudoscience article.” Why is it not retracted? One wonders when the integrative oncology community will demand respect.

The original JAMA Oncology article, led by Yale researchers Skyler Johnson, MD and James Yu, MD, MHS, jockeyed numbers and definitions to conclude that the use of complementary medicine in this study was associated with worse 5-year overall survival. The New York Times and others re-broadcast warnings to readers.

Six months later JAMA Oncology published the letters under a banner headline of “Methodology Flaws and Implications of a Complementary Medicine Study.” Here is information about the authors, origins and key points of the letters mostly behind pay walls.

• Canadian Linda Carlson et al of bluntly state that the study “misrepresents that CM is harmful” and that there “are 2 major methodological issues that challenge the validity of this study.” (Notably, the three writers, all leaders of the Society for Integrative Oncology leaders , did not present this as an SIO perspective.)
• While Spanish researcher Ozan Bahcivan, MSc opens with a diplomatic, congratulatory tone, the other shoe quickly drops: “the lack of clarity between CM and alternative medicine in the article … may cause confusion in the international health communities.” The problem created is global.
• A Norwegian-Danish team is “not convinced that the authors’ results support their conclusion.” They underscore the challenges it creates in “shared decision making” with patients.
• Two from Brookwood Baptist Health in Birmingham, Alabama, USA wanted to “address a glaring methodological flaw in this study, and to address the ramifications this study may have for the practice of medicine.” The study will “drive a wedge between [conventional] health care practitioners and patients interested in CM.”
• Another researcher from Spain raises ethical issues, noting that the study has 3 problems: “Two are genuinely methodological, whereas the third is more related with the ethics of research. The 3 problems severely undermine the study’s scientific rigor.” They conclude that there is “evidence of lack of objectivity on the part of the authors.”

JAMA Oncology invited the Yale team to respond. The response is dodgy. Johnson fails to have the faintest cultural appreciation that a “trained cancer expert” on which the authors apparently relied might have superlative abilities, say, in speaking English (aka conventional cancer treatment) and yet be illiterate when it comes to, say Italian (distinctions between “alternative” and “complementary”). They do not budge.

Glaring flaws. Harm to practitioner-patient relationship. Global sweep of harm.  Questionable ethics. Yet, strangely, none call for retraction. What is the bar for retraction?

The Medscape analysis of the response letters finally broaches the subject. Published as Harsh Criticism of Study Showing Complementary Medicine for Cancer Lowers Survival, the writer quotes one of the Norwegian letter writers. They finally broke the retraction barrier not in the pages of the nominally august journal but rather in a Twitter dispute with Johnson:

Sadly he believes the fatal statistical flaws of his study has been addressed by some nice-sounding comments. In fact, the only way to address the flaws is to retract the paper. My advice to them: Apologize, retract, read up on statistics and come back with proper paper later.

In the Twitter exchange, Johnson protests that his castle of statistics and assumptions was not destroyed. The integrative oncology community was also unimpressed by Johnson’s defense. I sent queries to a group I’d worked with last August and invited their response to the letters. Here retraction is the common theme. UCSF’s integrative oncologist Donald Abrams, MD, who provided a critique of the original here, responded:

“The people pointing out the deficiencies were all very consistent. The authors’ response seemed off target and non-responsive. I think retraction would be the best option personally, but I do not see that happening!”

Canadian naturopathic physician Dugald Seely, ND, FABNO, vice president of the Oncology Association of Naturopathic Physicians, bent hard toward retraction:

“The fact that [the article] will continue to be cited and cited calls for a need to retract. The critical letters and responses are excellent but they will always be considered secondary if considered at all in comparison to the original article Johnson and Lu. To retain a reputation for scientific rigor and objectivity, JAMA Oncology should force a retraction of the paper due to an invalid analysis and conclusions.”

University of Duisburg-Essen in Germany integrative medicine researcher Holger Cramer, PhD, whose letter to JAMA Oncology that was not published is referenced here, noted:

Those letters actually also quite closely mirror the arguments in our letter to JAMA. It was rejected because other letters with comparable content had been accepted – at least this was true. I totally agree that the article needs to be withdrawn or at least reworded to not falsely create the impression it was on CM in general.

Israeli integrative oncologist, Moshe Frenkel, MD, the former director of such services at MD Anderson, responded to my query merely by pointing to his initiatial affirmative evidence of the value of integrative oncology that was published in a September-October 2018 JACM Special Issue on Integrative Oncology that he co-edited.

JAMA Oncology‘s breaking of its 6-month silence on the negative reaction coincided with the publication of a guest editorial on the issues I was invited by Larry Dossey, MD and Ben Kligler, MD, MPH to write for Explore. I approached the editorial, Musings on Patient Care and Polarization after JAMA Oncology’s Erroneous Report that Complementary Medicine Kills, from a patient’s perspective, first. (The article is available in open access for a month.) I concluded again with a renewed call for retraction:

JAMA Oncology has an opportunity to declare for such a patient centered, integrative oncology future through a proactive rejection of the multiple, misleading methods and outcomes of this paper.

The discourse raises significant questions regarding failure to act. Why did the Society for Integrative Oncology not choose to weigh in with force as an organization? Why did none of these scientists call for retraction in these letters?

If the rules of academic publishing preclude calls for retractions of an article this flawed, the rules need to be changed. The organized integrative oncology community should directly knock on the doors of JAMA Oncology to urge the journal to retract. Failure to call out abuse – whether bodily harm, or of science and common sense – invites additional abuse.

Meantime, amidst parsing of appropriate academic behavior, JAMA Oncology continues to pollute the choice processes of countless human beings – both patients and practitioners – who are struggling to understand where and if complementary treatments can have value amidst the brutal assaults of routine cancer treatment.

See prior articles:

• Retraction Needed? JAMA Oncology’s Bum Science Suggests People Die Faster Using Complementary Medicine
• Interview: SIO President Lynda Balneaves on the JAMA Oncology Paper Linking Complementary Care with Early Death
• An E-Dialogue with Yale Researchers Who Say “Complementary Medicine” Hastens Death
• Follow-up: Action on Erroneous JAMA Oncology “Complementary Medicine Kills” Article

Plus: from Explore (available online for 4 weeks):

• Musings on Patient Care and Polarization after JAMA Oncology’s Erroneous Report that Complementary Medicine Kills