A study published in the Journal of Clinical Oncology this week has concluded that acupuncture can decrease cancer related fatigue in breast cancer patients. However concluding something and finding something are two separate beasts.
In this study, 227 breast cancer patients were treated with acupuncture alongside the usual care they receive, 75 patients did not receive acupuncture but continued to receive their normal care. In order to asses fatigue levels, anxiety, depression and quality of life, established 20 point scales determined by questionnaires were performed and the results show that on average the acupuncture patients improved on all assessments compared to the non-acupuncture group.
That sounds promising doesn’t it? Surely the only thing you might conclude from this study is that acupuncture can reduce fatigue in breast cancer patients? Well not exactly no; what we can conclude from these results is that acupuncture might reduce fatigue in breast cancer patients and here’s why.
Clinical science is a funny old thing, this is mostly because human beings are a fairly odd sort with complicated psychology and what some may call intelligence. This means that studying the effects of health care interventions is a lot different from studying say physics. The laws of physics are immutable and constant, if you were to drop a ball with the exact same weight and dimensions from the same height with the same force and the exact same environmental conditions, the ball would take exactly the same amount of time to hit the ground, every time. Humans though, not so much.
How do you feel right now? It seems like an easy question but I’m willing to bet that you had to think quite hard about it, chances are if I asked you tomorrow you might not give me the same response, even though little will have changed. This is because human emotions and perception is affected by the experiences and expectations you gain from your existence. This is what makes clinical trials quite tricky, if you are told that you are getting a treatment, you might expect to get better, then when you are asked if you feel better you think that you do, because it’s what you expect. This is called the placebo effect.
So let’s get back to why the conclusion from this study is not congruent with the results they obtained. The author described this study as a “Pragmatic Study”, what this means is that is a real world study. Usually a pragmatic study is used to make an observation and then form a hypothesis. In order to reach a conclusion you must do a controlled trial that accounts for all the variables that are reasonable to control. Concluding that an effect exists from a pragmatic study is just plain poor science.
In the study there were two groups, one that did not receive acupuncture and a group that did. As stated earlier the group that received acupuncture improved on all measured levels of wellbeing by a small amount, which might suggest that acupuncture is useful as a treatment, however that is all you can surmise from those results, it might be useful. This is because the study did not control for the other variables that might account for these results.
Let’s talk about blinding, this is a tool used by scientists to remove variables such as the placebo effect. Blinding means that the patients do not know whether they are receiving the treatment or not. This is important because if the patient doesn’t receive a treatment but still reports an improvement the effect can’t be due to the treatment, but more likely because they expected to improve. If the effect from the treatment group isn’t stronger than the placebo group, it is safe to assume that the treatment is no more effective than no treatment at all.
What this trial needed then was a third group, this group would have received a placebo type of treatment, this involves using fake needles that retract rather like a stage knife, or the acupuncture is done in none-acupuncture points (although this makes the assumption acupuncture must be done on certain points on the body and isn’t just the process of inserting the needles) my preference would be the fake needles because these don’t actually pierce the skin. Importantly the subjects would not know whether they were receiving “real” acupuncture or the placebo acupuncture.
If the results of this trial had then shown that the real acupuncture group had a bigger effect than both the non-treatment and placebo acupuncture group, that would have been more interesting and the conclusion that acupuncture is effective rather than might be effective is much more valid.
At the least this trial should have included a group that received another form of alternative treatment such as massage or aroma therapy. While this still doesn’t allow us to make firm conclusions about the effectiveness of acupuncture it would at least indicate whether the effect was specific to acupuncture or not.
The fact is that a non-blinded, non-placebo controlled study is almost worthless to our understanding of whether something works or not. For the author of this study to make such a definitive conclusion shows a poor lack of knowledge about the scientific method and at worst an agenda to promote acupuncture. That this article was published in a reputable journal is all the more disappointing.