The American Society of Clinical Oncology (ASCO) 2008 annual meeting in Chicago last week was a good chance to assess the integration of complementary and alternative (CAM) medicine into oncology as a whole. The world of CAM at the moment is divided into those few practitioners who use purely nutritional and/or alternative treatments, and a larger group that is trying to integrate the use of non-conventional treatments into conventional oncology, sometimes at major cancer centers. I was struck by the paltry representation of either kind of approach at the ASCO meeting.

Here is my survey of the many abstracts in the convention's Proceedings. In particular I have looked at ten representative treatments that are commonly used by practitioners in Germany and other countries where CAM flourishes (see table below). I have included not just typical CAM treatments, such as yoga, acupuncture, and exercise, but some of the more unusual applications of radiation and chemotherapy as well. While including the latter undoubtedly inflates the meager track record of ASCO on CAM, it does provide a measure of just how innovative ASCO is - or is not.

CAM TREATMENT ABSTRACTS
AT THE 2008 ASCO MEETING (CHICAGO)

What can we infer from the above table?

Clearly, we can see that CAM represents just a minuscule portion - about one fifth of one percent! - of the overall work reported at ASCO.

Now I must explain about a change this year in the way material is presented at ASCO - the introduction of a two-tier system of abstracts. All of the abstracts - many thousands of them - are still published at ASCO's Web site (www.asco.org). But by no means all of these are deemed worthy of a poster presentation at the meeting itself. Only about 11,000 abstracts are chosen for presentation as posters and included in the official book of proceedings. But many thousands others are simply listed by title alone in the book that is distributed before the meeting, although the full abstracts are included in ASCO's online searchable database.

The difference is crucial. In a poster presentation, the lead researchers can print up a huge copy of their abstract, pin it to a bulletin board in proximity to dozens of abstracts on related topics, and then discusses this work with passers-by who maybe have an interest in the topic. This "marketplace of ideas" is a vital way that scientists (especially younger or less prominent ones) can network with others who are interested in the same topic. To my mind this has always been one of the most pleasurable and useful things about ASCO. Now, however, only those abstracts that are deemed superior by leaders of the organization can be presented in poster format (much less presented in lectures or seminars). This policy was ostensibly put into place as a means of managing the burgeoning number of abstracts submitted for inclusion, but it has had the unfortunate effect of further winnowing out less acceptable and less orthodox ideas.

Pictured above: Sample ASCO Poster Click here or on image for larger view.

Look how this has worked out in the case of CAM. I selected 12 of the top topics of interest to CAM practitioners (and to many patients). Of course, I have stacked the deck in favor of ASCO by including many topics that are properly part of the cutting edge of conventional oncology, rather than of CAM per se. I used both the printed Proceedings and also the search engine at ASCO's Web site (www.asco.org). Primarily, I searched by title but sometimes I 'beat the bushes' by using collateral search terms in the body of the text. In all, I found a total of 46 relevant papers on these topics presented in any format at ASCO. Of these, 24 (52 percent) actually made it into the poster presentations. I think I was generous in my selection. For instance, under "herbs" I included a poster presentation by Amy Gross, RN, which simply mentions herb use among ovarian cancer patients. She actually has nothing positive to say about the topic. Meanwhile, the single other paper that actually mentions herb use (authored by Keith Block, MD) was relegated to the online abstracts.

The rest of the relevant papers were similarly consigned to obscurity. In other words, their authors never formally got to interact over their presentations with other interested researchers at ASCO. I know of a few cases in which researchers who had previously come to ASCO specifically for the opportunity to interact with other scientists decided not to come this year because of the new two-tier abstract policy. So, in my opinion, this new policy has definitely resulted in an even lower profile for CAM at the meeting, and particularly for US CAM researchers...and bear in mind that the picture wasn't so rosy in years gone by, either.

ASCO is an American society, at least in name (many of the participants come from foreign countries). At this quintessentially American meeting - directed by American oncologists and always held in a US venue - there was a conspicuous lack of participation by American CAM researchers. Of the 46 CAM papers that I identified above, only 17 had US-based authors. Not all of these papers, of course, were supportive of CAM use. For example, Gross's paper on hopelessness in ovarian cancer patients reached negative conclusions about the psychological value of CAM. (Ironically, this presentation won a special citation for excellence from the ASCO judges.)

Lorenzo Cohen Click here or on image for larger view.

Most of the few American CAM researchers who made it through this winnowing process presented "softer" forms of complementary medicine (such as yoga or exercise) rather than anything that was challenging to standard conventional approaches. Sometimes this was not for lack of trying. Lorenzo Cohen, PhD, is director of the integrative medicine program at the justly famous M. D. Anderson Cancer Center, Houston, TX. He shares my dismay over the state of integrative oncology at ASCO. "This year the CAM abstracts at ASCO were few and of relatively low quality compared to past years," he wrote me. "I'm not sure if this is attributable to a lack of 'quality' submissions or some other factor."

For instance, Cohen and his M. D. Anderson colleagues have done remarkable work in researching the preclinical and clinical effects of natural agents. "We did submit an abstract combining some of our new preclinical work on huachansu (toad venom) and our phase I trial results," he wrote. "It was rejected! I was quite surprised, as I have never had an abstract rejected from ASCO before. Some of the preclinical work in the past has been presented at AACR [the American Association for Cancer Research, ed.], so I thought ASCO would be the perfect place to present some new preclinical data combined with the phase I trial. But for some reason it was not [deemed] worthy."

Many readers will remember the excitement that greeted the inception of the NIH Office of Alternative Medicine (now the National Center for Complementary and Alternative Medicine) in the early 1990s. ASCO itself had a number of seminars on the topic of CAM. But in reality nothing much has changed at ASCO since CAM first burst on the scene more than a dozen years ago. It is still the scorned stepchild of oncology, constantly scrambling for crumbs from the banquet table. Meanwhile, we must remind ourselves that little or no progress has been made by orthodox oncology in extending the survival of most patients with advanced cancer. Give CAM a chance.

Scenes from ASCO 2008

For a selection of pictures taken at the 2008 meeting of ASCO please click here or to go:
http://www.flickr.com/photos/24860924@N07/sets/72157605469519033/

--Ralph W. Moss, Ph.D.