Complementary and Alternative Approaches

Barrie R. Cassileth

Gary Deng

A vast collection of disparate approaches, from unproven cancer cures to soothing, adjunctive regimens, is subsumed under the single umbrella term Complementary and Alternative Medicine, known commonly by the acronym “CAM.” Although they are typically discussed in the aggregate, it is clinically and conceptually necessary to distinguish between the two categories because they comprise profoundly different modalities.

Alternative therapies may generally be perceived literally as such; they are promoted as cancer treatments and sometimes as cancer cures, and are often sold for use instead of mainstream therapy. By definition, alternative therapies are unproven. If they were backed by solid data, they would not be “alternative.” Rather, they would be found in every oncology program and used as viable treatments. Alternative regimens, which are typically invasive and biologically active, are usually very expensive and potentially harmful. They may harm directly through physiologic activity, or indirectly when patients postpone receipt of mainstream care. Late-stage patients are especially vulnerable to these therapies, as they often promise cure of even advanced disease.

Complementary therapies, in contrast, are used for symptom management and to enhance well-being. They serve as adjuncts to mainstream care; promoted not as cancer cures, but as means of enhancing patients’ quality of life. Complementary therapies are supportive, palliative care in every respect. They address body, mind, and spirit, aiming to control pain and other symptoms and to optimize quality of life for patients and families. This definition is essentially identical to that proposed by the World Health Organization for palliative care (1).

In CAM, therefore, we must work with two poles of a continuum. Patients need the knowledge and support to forego the siren calls to seek metabolic therapies in Tijuana; to buy shark cartilage; to self-treat with high-dose vitamins and other products sold over the counter or delivered intravenously in alternative clinics; and to seek remission of disease through self-proclaimed healers, electromagnetic cures, and many other products and approaches.

At the same time, patients need access to the comfort of supportive complementary modalities. These therapies are becoming increasingly available not only directly to patients on a private basis, but also in hospitals, clinics, and homes as part of symptom control and the general effort to ease the physical, psychosocial, and spiritual distresses associated with cancer and especially with end-stage disease.

This chapter addresses the state of CAM in the larger health care system, and reviews the alternative therapies that are so widely and temptingly available to patients and families. Physicians and other caregivers need to know about these pervasive alternatives. Helpful complementary therapies are reviewed as the conclusion to this chapter.

Impact of Complementary and Alternative Medicine on the Health Care System

The acceptance of unconventional therapies, along with the advent of managed care, advances in biotechnology, and other significant medical and societal events, marked health care in the 1990s and were among the significant changes that occurred during that time. The popularity of CAM has affected every component of the health care system and all specialties of medicine, including palliative oncologic care. It has left its mark on the thinking and practice of physicians and other health professionals, and broadened patients’ involvement and influence in their own care.

Unconventional cancer medicine today, no longer a collection of covert practices (2), is highly visible, and information about it is widely available to the general public thanks to the advent of the Internet. It is a multibillion dollar business in the United States, and of equivalent impact and importance throughout the developed world.

Internationally, as well as in North America, the use of CAM for cancer is widespread. A systematic review (3) located 26 surveys of patients with cancer from 13 countries, including 5 from the United States. The average prevalence of CAM use across all studies was 31%. Therapies most commonly adopted around the world included dietary treatments, herbs, homeopathy, hypnotherapy, imagery or visualization, meditation, megavitamins, relaxation, and spiritual healing. All, but one of the US surveys, obtained information about specific therapies employed. Patients used Laetrile, metabolic therapies, diets, spiritual healing, megavitamins, imagery, and “immune system stimulants” (3). Across samples, the prevalence of CAM use in the United States ranged from 7 to 50%.

A recent report presented the most comprehensive and reliable findings to date on Americans’ use of CAM in general. The National Center for Health Statistics 2002 National Health Interview Survey involved 31,044 adults and found that 75% used some form of CAM (4). When prayer specifically for health reasons was excluded, the percentage was 50%. As found in virtually all previous surveys, CAM use was most common among women, better educated people,
those hospitalized in the previous year and former smokers, indicating a more health conscious segment of the population.

Prevalence rates from all CAM studies conducted in the United States and internationally vary from less than 10% to more than 70%. This broad range with its apparent discrepancies is attributable primarily to variable understandings and definitions of CAM. Surveys often do not define CAM, or more typically, define it extremely broadly, resulting in the inclusion of lifestyle activities such as weight loss efforts, exercise, church attendance, and support activities such as group counseling, thus resulting in bloated figures for CAM use. Moreover, few studies distinguish between the use of alternative therapies (in lieu of mainstream cancer treatment) versus adjunctive use of complementary modalities.

Although research evidence is scanty (2), it appears that approximately 8–10% of patients diagnosed with tissue-biopsy cancer eschew mainstream therapy and immediately seek alternative care. Most CAM users, however, seek complementary, not alternative, therapies for cancer-related problems.

In 1994, legislation was passed allowing herbal medicines and other “food supplements” to be sold over the counter without U.S. Food and Drug Administration (FDA) review. This resulted in an estimated doubling of dietary supplement sales in the following 6 years. According to National Nutritional Food Association, annual sale of dietary supplements reached $19.8 billion in 2003, among them $4.2 billion in herbs. Although the sale of most supplements increases each year, the sale of herbs declined by 3% in 2002 and 1.8% in 2003 (5). The decline is presumed due to unrealistically high public expectations, media reports about safety concerns and questionable effectiveness, and public confusion about the vast array of products.

Despite the drop in sales of herbal remedies, CAM use by patients with cancer has grown in recent years (3); a secondary analysis of close to 3000 patients with cancer estimates a 64% increase after 1987 (6). It is likely that this reflects expanded variety of over-the-counter remedies and broader availability of complementary therapies in mainstream cancer programs and centers.

Complementary and Alternative Medicine Use Among Pediatric Patients with Cancer

The use of CAM methods among pediatric patients with cancer represents a special and understudied issue. Surveys in Australia and Finland, in British Columbia, and in the Netherlands indicate substantial interest in CAM, especially in more recent years, with 40–50% of pediatric patients with cancer in those countries receiving alternative or complementary therapies (3).

Few studies of CAM use among US pediatric patients with cancer have been published in the past 10 years. A 1998 article reported that 65% of 81 US patients with cancer used CAM, whereas 51% of 80 control-group children receiving routine checkups did so. Of particular interest is the type of CAM received. Prayer, exercise, and spiritual healing accounted for more than 96% of CAM used. Excluded from this sample by definition, however, were the pediatric patients brought for alternative treatment to clinics in the United States, Mexico, Germany, or elsewhere. Patients who received only alternative cancer therapies did not appear in CAM surveys, because all but one such survey was conducted in mainstream clinics or hospitals.

Public Access to Information

CAM today is very much an open and public issue, discussed widely in the media and readily found on the Internet. Magazines and television specials provide the general public with details about new CAM therapies. The yellow pages of telephone books in most cities and towns typically list various types of CAM practitioners. Information available to the public varies widely in accuracy. Many Web sites and publications that appear to be objective actually are sponsored by commercial enterprises that promote and sell the products they report. Misinformation about health issues is widespread. In 1999, the U.S. Federal Trade Commission (FTC) announced that it had identified hundreds of Web sites promoting and selling phony cures for cancer and other serious ailments among the estimated 15,000–17,000 health-related Web sites. Because today there are approximately 874,000,000 such sites, it is likely that those selling bogus treatments have increased accordingly.

Recognition by Mainstream Journals and Physicians

A survey of 295 family physicians in the Maryland-Virginia region (7) revealed that up to 90% view complementary therapies such as diet and exercise, behavioral medicine, and hypnotherapy as legitimate medical practices. A majority refers patients to nonphysicians for these therapies or provides the services themselves. Homeopathy, Native American medicine, and traditional Oriental medicine were not seen as legitimate practices.

Two hundred Canadian general practitioners held similar views, noting their patients’ interest especially in chiropractic. These physicians perceive chiropractic care, hypnosis, and acupuncture for chronic pain as the most effective CAM therapies, and homeopathy and reflexology as less efficacious (8). A meta-analysis of 12 studies in Great Britain suggests that British physicians view complementary medicine as only moderately effective (9), a level of enthusiasm that contrasts with the fervent efforts of the British Royal Family to promote homeopathy and other complementary therapies, and to merge them with mainstream care.

In addition to increasing coverage of CAM services by health insurers, a final marker of mainstream interest noted here is the publication of CAM research articles in major mainstream medical journals. Articles about CAM in major journals shifted from commentaries through the 1970s expressing realistic concern about quackery, to surveys of patients’ knowledge and use of unproven methods in the 1980s, to reports of actual research results starting primarily in the mid-1990s.

The Journal of the American Medical Association, the New England Journal of Medicine, the Lancet, the British Medical Journal, and specialty journals such as Cancer and the Journal of Clinical Oncology have published reports of CAM research in recent years. In 1996–1997, the National Library of Medicine added many new CAM search terms to its medical subject headings, and began to cover alternative medicine journals previously not reviewed for inclusion in Medline. In large part, mainstream science opposition is being replaced by emphasis on the importance of methodologically sound research, which now increasingly occurs in numerous respectable institutions around the world.

Complementary and Alternative Medicine Therapies and Practitioners

While recognizing overlap, the National Center for Complementary and Alternative Medicine (NCCAM) groups CAM therapies into four domains: biologically based practices;
mind–body medicine; manipulative and body-based practices; and energy medicine. In addition, whole medical systems cut across all domains. Traditional Chinese medicine, for example, includes biologically active botanicals, mind–body practices, manipulative techniques, and acupuncture. Therapies commonly sought by patients with cancer are discussed in the following sections. Many of these approaches are unproven methods promoted as alternatives to mainstream cancer treatment. Helpful complementary or adjunctive therapies are discussed separately at the end of this chapter.

Diet and Nutrition

Advocates of dietary cancer treatments typically extend mainstream assumptions about the protective effects of fruits, vegetables, fiber, and avoidance of excessive dietary fat in reducing cancer risk, to the idea that food or vitamins can cure cancer. Proponents of this belief make their claims in books with titles such as The Food Pharmacy: Dramatic New Evidence that Food is your Best Medicine, Prescription for Nutritional Healing, and New Choices in Natural Healing.

The macrobiotic diet is a persistently popular example of such dietary approaches. As currently constructed, it is similar to recent U.S. Department of Agriculture dietary pyramid recommendations for healthful eating, except that the macrobiotic diet omits dairy products and meat. This diet derives 50–60% of its calories from whole grains, 25–30% from vegetables, and the remainder from beans, seaweed, and soups. All animal meat and certain vegetables and processed foods are to be avoided, and soybean consumption is promoted. Despite claims in publications and Web sites, there is no evidence that this or any other diet can cure cancer.

Metabolic Therapies and Detoxification

Metabolic therapies continue to draw patients from North America to the many clinics in Tijuana, Mexico. These therapies involve practitioner-specific combinations of diet plus vitamins, minerals, enzymes, and “detoxification.” One of the best known sites for metabolic therapy is the Gerson clinic, where treatment is based on the belief that toxic products of cancer cells accumulate in the liver, leading to liver failure and death. The Gerson treatment aims to counteract liver damage with a low-salt, high-potassium diet, coffee enemas, and a gallon of fruit and vegetable juice daily (10). The clinic’s use of liquefied raw calf liver injections was suspended in 1997 following sepsis in a number of patients.

Other Tijuana clinics and practitioners provide their own versions of metabolic therapy, each applying an individualized dietary and “detoxification” regimen. Additional components of treatment are included according to practitioners’ preferences. Metabolic regimens are based on belief in the importance of “detoxification,” which is thought necessary for the body to heal itself. Practitioners view cancer and other illnesses as symptoms of the accumulation of toxins. This is a nonphysiologic but venerable concept that originated in ancient Egyptian, Ayurvedic, and other early efforts to understand illness and death, both of which were believed caused by the putrefaction of food in the colon. Decay and purging were major themes in early cultures’ therapeutic regimens. Neither the existence of toxins nor the benefit of colonic cleansing has been documented.

Modern variations on the older approach to internal cleansing are drinkable cleansing formulas, said to detoxify and rejuvenate the body. Many variations are available in health food stores, books, and on the Internet. A shake of liquid clay, psyllium seed husks, and fruit juice, for example, is said to remove harmful food chemicals and air pollutants. These products tend to function as major laxatives, potentially dangerous when taken over days or weeks or on a regular basis as recommended by promoters, and of special concern for patients with cancer.

Megavitamin and Orthomolecular Therapy

Some patients and alternative practitioners believe that large dosages of vitamins—typically hundreds of pills a day—or intravenous infusions of high-dose vitamin C can cure disease. In 1968, Nobel Laureate Linus Pauling coined the term orthomolecular to describe the treatment of disease with large quantities of nutrients. His claims that massive doses of vitamin C could cure cancer were disproved in clinical trials (11), but megavitamin and orthomolecular therapy—the latter adds minerals and other nutrients—remain popular among patients with cancer. There is no evidence that megavitamin or orthomolecular therapy is effective in treating any disorder.

Mind–Body Techniques

The potential to influence health with our minds is an extremely appealing concept in the United States. It affirms the power of the individual, a belief intrinsic to U.S. culture. Some mind–body interventions have moved from the category of alternative, unconventional therapies into mainstream complementary or supportive care. Good documentation exists, for example, for the effectiveness of meditation, biofeedback, and yoga in stress reduction and the control of some physiologic reactions (12).

The argument that patients can use mental attributes or mind–body work to cure cancer is not tenable (13, 14). Attending to the psychological health of patients with cancer is a fundamental component of good cancer care. Support groups, good doctor–patient relationships, and the emotional and instrumental help of family and friends are vital. However, the idea that patients can influence the course of their disease through mental or emotional work is not substantiated and can evoke feelings of guilt and inadequacy when disease continues to advance despite patients’ best spiritual or mental efforts (15).

Bioelectromagnetics

Bioelectromagnetics is the study of interactions between living organisms and their electromagnetic fields. According to proponents, magnetic fields penetrate the body and heal damaged tissues, including cancers. No peer-reviewed publications could be located for this work, or for any clinical cancer-related claims regarding bioelectromagnetics. Despite the lack of data and the patent absurdity of these claims, proponents continue to sell electromagnetic therapy as a cure for cancer and other major illnesses.

Electromagnetic therapy and the related group of energy therapies, discussed in the section Manual Healing Methods, illustrate a striking difference between previous and currently popular alternative practices. Whereas many earlier alternatives reflected concepts important to scientific study of the time, many of today’s popular alternatives are mystical and explicitly contrary to contemporary scientific and medical thought. It is as though the new millennium encouraged deeper adoption of explanatory notions applied in millennia past.

Alternative Medical Systems

This category includes ancient systems of healing typically based on concepts of human physiology that differ from
those accepted by modern western science. Two of the most popular healing systems are traditional Chinese medicine and India’s Ayurvedic medicine, popularized by best-selling author Deepak Chopra, MD (16).

“Ayurveda” comes from the Sanskrit words “ayur” (life) and “veda” (knowledge). Ayurveda’s ancient healing techniques are based on the classification of people into one of three predominant body types. There are specific remedies for disease, and regimens to promote health, for each body type. This medical system has a strong mind–body component, stressing the need to keep consciousness in balance. It uses techniques such as yoga and meditation to do so. Ayurveda also emphasizes regular detoxification and cleansing through all bodily orifices.

Traditional Chinese medicine explains the body in terms of its relationship to the environment and the cosmos. Concepts of human physiology and disease are interwoven with geographic features of ancient China and with the forces of nature. Chi, the life force said to run through all of nature, flows in the human body through vertical energy channels known as meridians.

The 12 main meridians are believed to be dotted with acupoints. Each acupoint corresponds to a specific body organ or system, so that needling (acupuncture) or pressing an acupoint (acupressure) can redress the life-force imbalance causing the problem in that particular organ. To determine the source of the blockage, the practitioner relies on pulse diagnosis, a technique applied by doctors of traditional Chinese medicine today as it was millennia ago. It involves concentration on several body pulses by the practitioner for approximately 45 minutes.

Although the very existence of chi or a “vital energy force” remains unproven, acupuncture has been shown to induce measurable neurophysiologic change. It also helps reduce certain symptoms experienced by patients with cancer. Tai chi, a gentle exercise technique with a mind–body component to foster the smooth flow of Chi, is useful in preventing falls among the frail or elderly (17). Traditional Chinese medicine also includes a full herbal pharmacopoeia with remedies for most ailments, including cancer (18). The potential anticancer and immunomodulatory benefits of many Chinese herbs and other botanicals are under investigation in the United States and elsewhere.

Only gold members can continue reading. Log In or Register to continue