In the United States, complementary and alternative medicine (CAM) is defined by the National Center for Complementary and Alternative Medicine (NCCAM) as a group of diverse medical and health care systems, practices, and products that are not normally considered to be part of conventional medicine. NCCAM classifies CAM therapies into four broad categories: natural products, mind and body medicine, manipulative and body-based practices, and other CAM practices (see Table 28.1).

CAM includes nonconventional modalities that may or may not have high-quality evidence or financial incentives to support their intended use in the conventional medicine setting. Alternative medicine is when a patient makes use of a CAM modality for which there is no evidence for its efficacy in place of conventional medicine. Complementary medicine is when a patient makes use of a CAM modality for which there may or may not be evidence for its efficacy in combination with conventional medicine.

Integrative medicine, or complementary and integrative medicine (CIM), is becoming more prevalent in medical settings. Integrative medicine describes a philosophy of practice using an evidence-based approach to merge conventional and nonconventional therapies. The Consortium of Academic Health Centers for Integrative Medicine has defined this 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” (Consortium of Academic Health Centers for Integrative Medicine 2009). Integrative medicine uses an interdisciplinary approach to evaluate the risks and benefits of individual therapies. Practitioners of all disciplines should be aware of all treatment options and openly communicate with each other. The opportunity exits to optimize outcomes through a coordinated, comprehensive treatment plan. Throughout this chapter, we will use the term CIM in favor of CAM or other terms.

The World Health Organization estimates that up to 80% of people in developing countries rely on nonconventional traditional medicines for primary health care. People in more developed countries also seek out complementary medicine and practices. A 1997 survey of adults in the United States showed that CIM use (excluding self-prayer) varied from 32% to 54%. A 2007 survey by the US Centers for Disease Control and Prevention showed that 38% of adults had used CIM therapies during the past 12 months (Barnes et al. 2008).

Among patients with cancer and cancer survivors, the use of CIM is higher than in the general population. An estimated 40–69% of patients with cancer in the United States use CIM therapies (Navo et al. 2004; Richardson et al. 2000). A survey of five clinics within a United States comprehensive cancer care center found that CIM therapies (excluding psychotherapy and spiritual practices) were used by 68.7% of patients (Richardson et al. 2000). In a survey of cancer survivors, 43.3% reported using CIM in the past year. Patients with breast cancer use CIM more often than patients with other types of cancer; the overall prevalence of CIM use among patients with cancer ranges from 17% to 87%, with a mean of 45%. This range of prevalence reflects differences in patient populations studied.

In most cases, people who use CIM are not disappointed or dissatisfied with conventional medicine. Patients with cancer use CIM to reduce side effects (such as organ injury), to improve quality of life, to protect and stimulate immunity, or to prevent second primary cancers or recurrences. Whether or not patients use CIM therapies to treat cancer or its effects, they may use CIM to treat other chronic conditions such as arthritis, heart disease, diabetes, and chronic pain.

Research indicates that neither adult nor pediatric patients with cancer receive sufficient information or discuss CIM therapies with physicians, pharmacists, nurses, or CIM practitioners. Most patients do not bring up the topic of CIM because no one asks; thus, patients may believe it is unimportant. It is estimated that 38–60% of patients with cancer use complementary medicines without informing their health care team (Navo et al 2004; Richardson et al. 2000). This lack of discussion is of concern because biologically based therapies (such as herbs) may interact with cancer treatments. Patients are commonly unaware of differences between medicines approved by the US Food and Drug Administration and supplements defined by the Dietary Supplement Health and Education Act of 1994. Supplements defined under this legislation are exempt from the same scrutiny that the US Food and Drug Administration imposes on medications; these supplements are not intended to treat, prevent, or cure diseases. The common belief among patients that “natural” means safe needs to be addressed with education. Some herbs and supplements have been associated with drug interactions (Ulbricht et al. 2008), increased cancer risk, and organ injury. These concerns are addressed later in this chapter.

Existing research suggests that most patients with cancer desire communication with their doctors about CIM (Verhoef et al. 1999). To provide optimal patient care, oncologists must be willing and able to discuss all therapeutic approaches, including CIM, with their patients. It is the health care professional’s responsibility to ask patients about their use of complementary medicines. The discussion should ideally take place before the patient starts using a complementary treatment—whether it is a nutritional supplement, mind-body therapy, or other CIM approach.

A number of strategies can be used to address CIM use during a health care encounter. One approach is to include the topic of CIM as part of a new patient assessment. For example, when asking about medications, physicians should inquire about herb and supplement use. Physicians may consider having the patients bring in the actual bottles of herbs and supplements for evaluation. When asking about a patient’s medical history, physicians may ask if the patient has visited with naturopathic or chiropractic practitioners. If the issue of CIM arises, clinicians need to develop an empathic communication strategy. The strategy needs to balance clinical objectivity with creation of a therapeutic alliance, benefitting both patient and health care provider. Patients need reliable information on CIM from reliable resources, with adequate time to discuss this information with their oncologists. Table 28.2 provides a list of websites useful for health care professionals seeking information on CIM therapies.

CIM therapies have the potential to lead to adverse outcomes (Palmer et al. 2003). With adequate precautions, yoga, massage, or acupuncture can be used safely during treatment and throughout survivorship. Herbs and supplements, however, should be considered more similar to prescription medications and therefore may be useful but can also lead to harm. The pathways by which biologically based CIM therapies may lead to negative clinical outcomes include metabolic interactions, treatment interactions, organ toxicity, cancer promotion, and lack of quality control standards.