Integrating complementary and conventional medicine
Faculty of Health Sciences (Psychology), Murdoch University, Western Australia.
Complementary and alternative medicine, for reasons varying from a desire to control symptoms and prevent and treat cancer to high accessibility, has assumed significant importance in cancer treatment and care for many patients. An estimated 14% to 65% of Australian adult cancer patients use complementary and alternative medicine (compared with up to 80% to 91% in Europe and the US). Cancer patients who use complementary and alternative medicine are typically female, younger, more educated and of higher socioeconomic status. Moreover, 33% to 77% of patients do not disclose complementary and alternative medicine use to their physicians. Particular complementary and alternative medicine (eg. herbal medicines, nutritional supplements) have drawn steadfast opposition from clinicians, primarily because they remain unproven in clinical trials. However, some complementary therapies (eg. relaxation, massage) used as adjuncts to conventional medical treatments have proven beneficial in reducing disease or treatment symptoms and improving quality of life and psychological functioning in high quality cancer clinical trials. Nevertheless, cancer patients problematically perceive complementary and alternative medicine as more 'natural’ and safer than conventional treatments. Indeed, there is evidence of harm. Herbal medicine, nutritional supplements and other natural therapies, for instance, may pose direct safety risks because of their potential adverse effects or interactions with conventional anti-cancer treatments and other medications. Consequently, some complementary therapies should not be used under any circumstances irrespective of potential benefit (eg. St John’s wort), while others may be beneficial when cancer patients are not undergoing conventional treatments and have no other contraindications. Complementary and alternative medicine may also cause indirect harm (eg. resultant delays in conventional treatment potentially compromise treatment outcomes, quality of life and survival). It is therefore imperative that those involved in the medical care of cancer patients are equipped with the skills and knowledge to help patients appropriately evaluate complementary and alternative therapies. Additionally, due to the safety risks involved, clinicians are strongly encouraged to routinely ask patients about complementary and alternative medicine use. In conclusion, whether termed integrative cancer care or complementary medicine, health professionals in Australia should strongly consider offering evidence-based complementary therapies (or at least safe forms of them) alongside conventional treatments through their own cancer services. Conceivably, this will influence patients to continue with mainstream care and help them avoid any potential harm that may occur with autonomous complementary and alternative medicine use. In this way, optimal holistic care will be ensured for cancer patients by clinicians providing conventional oncology treatment and care.
Complementary and alternative medicine (CAM) continues to evoke fierce debate and divergent views within the medical community. It remains an attractive and commonly used treatment option for many cancer patients regardless of whether their clinicians like it or believe in it. Consequently, it divides health professionals providing conventional cancer care and CAM practitioners offering unconventional care.
The US National Centre for Complementary and Alternative Medicine (NCCAM) defines CAM as ‘a group of diverse medical and health care systems, practices and products that are not presently considered part of conventional medicine’.1 Complementary and alternative therapies must be distinguished, however complementary therapies are adjuncts to conventional medical treatment that are increasingly perceived as an important part of supportive care;2,3 they are often used for symptom management and to enhance quality of life and overall patient care.4 Alternative therapies, in contrast, are clinically unproven and are used instead of conventional treatments.2 They can be particularly damaging to cancer patients, as delay or outright refusal of conventional treatment often compromises their likelihood of cure or remission.5 More recently, the term ‘integrative oncology’ has emerged and involves a standard of care for cancer patients that utilises safe, evidence-based complementary therapies in conjunction with conventional anti-cancer treatments via a multidisciplinary approach designed to evaluate and treat the whole person rather than the disease per se.6
In the most recent population surveys in 2005/06, an estimated 67% of Australians used CAM,7 which was at least equivalent to prescription drug use,7,8 and represented out-of-pocket spending of $4.1 billion, with as many visits being made to CAM practitioners as medical practitioners (approximately 68 million each).9 In adult cancer patients, a systematic review of 21 studies worldwide reported an average prevalence of CAM use of 31% (range: 7-64%).10 Other studies report even higher prevalence depending on CAM definitions used and cancer populations studied (eg. up to 91% of US patients reported CAM use including prayer and exercise).11,12 In Australia, CAM use by cancer patients has varied widely from 14% to 65%.13,14
Cancer patients may make the decision to use CAM upon diagnosis, during conventional treatment, in response to disease progression or recurrence, or during remission/survivorship. Cancer patients who use CAM are typically female, younger, more educated and of higher socioeconomic status.2,15,16,17-19 There are many reasons why cancer patients use CAM (Table 1), including: cancer cure or prolongation of life;20-29 relief from cancer symptoms and conventional treatment side-effects;19,27,30,31 to assist conventional treatments;21,25 boosting immunological function or energy;16,19,27,30 enhancing physical, emotional and spiritual wellbeing;15,16,32,33 and maintaining a sense of control or hope.16,19,20-22,24,25,32,34 Finally, research indicates that 33% to 77% of patients do not disclose CAM use to their physicians,45 including 40% of cancer patients in one Australian study.20
Cancer physicians’ concerns and attitudes regarding CAM
Collectively, there is a lack of scientific evidence for the efficacy of CAM in oncology.10,46-48 Certainly, no CAM has proven effective in reliably curing or suppressing any form of cancer.6 A useful distinction however, is that between cancer cure and cancer care.49 Some CAMs (eg. mind/body techniques such as relaxation, acupuncture, massage) have proven relatively effective and safe in relieving disease/treatment symptoms and enhancing quality of life/psychosocial functioning and, thus, are important in caring for patients throughout the cancer experience.4,6,50-53 Other CAMs (eg. herbs, nutritional supplements, antioxidants) however, have drawn steadfast opposition from oncologists, primarily because they: remain unproven in clinical trials; possess greater health risks due to adverse interactions with prescribed cancer treatments or medications (eg. CAM-drug interactions, surgical complications such as bleeding); and may delay or reduce the efficacy of conventional treatments and, subsequently, compromise the likelihood of cure/remission and shorten survival time (Table 2).54
Efficacy and safety of CAM
In one population survey, 75% of people agreed that combining conventional medical treatment and CAM was preferable to using either alone.56 Problematically however, CAM is often perceived by cancer patients as being more ‘natural’ and, by association, safer than conventional treatments35 CAMs can directly harm patients via toxic or allergic reactions to their use alone, interactions with chemotherapy agents and prescribed medications, or contaminants in their manufacturing or from the environment (eg. heavy metals, pesticides, bacteria, fungi).52,54 Some herbs, nutritional supplements and other botanical agents: have toxic and potentially life-threatening effects (eg. kava, comfrey and black cohosh may cause hepatotoxicity);57,58 interact with chemotherapy and prescription drugs (eg. St John’s wort may result in serotonin syndrome when taken with antidepressants, and reduce the efficacy of chemotherapy involving irinotecan and imatinib);54,58 or cause complications during surgery (eg. garlic, ginkgo biloba and ginseng may increase bleeding) and radiotherapy (see Table 3 for a summary of direct harm that may result from CAM use).54,59,60
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Table 3: Safety of complementary and alternative medicine: direct harm resulting from CAM use by cancer patients.
CAM may also cause indirect harm to patients (Table 4). Resultant delays in conventional treatment potentially compromise treatment outcomes, quality of life and survival.61,62 Financial or emotional burden (eg. prolonged denial), or the squandering of precious, limited time that some patients have left also constitute indirect harm. Finally, patients may fall victim to harm as a result of the unsafe practices of CAM practitioners with inadequate training or competence, often owing to the absence of self-regulatory bodies and unsatisfactory government legislation protecting health consumers. Moreover, harm may be exacerbated by: regulatory deficiencies in monitoring the biological potency of herbal crops or use of the correct plant species (causing wide variation in therapeutic efficacy); product standardisation in terms of purity and dosage (resulting in possible substitution/adulteration and incorrect dosing or preparation); and product labelling or advertising.63
Despite the long history of most CAM, rigorous scientific research evaluating their efficacy and safety is a recent phenomenon. A diverse range of CAM is utilised by cancer patients in Australia and elsewhere, and the heterogeneity of these techniques appear to be reflected in their reported efficacy also.6,52,60,66-68 Some show considerable promise and in years to come may be integrated into everyday clinical practice, while others are ineffective and, worse still, directly harmful. Subsequently, there is a sizable gap between the use of some popular CAM and the evidence to support that use.
Future research in CAM and establishing research priorities
Relatively little CAM research has been performed in Australia. Unfortunately, research gaps are the rule rather than the exception in the CAM area. Disincentives to CAM research are not purely financial, but also involve a lack of qualified investigators among CAM practitioners and methodological and ethical difficulties unique to conducting CAM clinical trials. Furthermore, until recently Australia had no national research body to encourage and prioritise CAM research, or co-ordinate collaborative research between CAM and conventional medical practitioners (compared with US NCCAM, UK National Cancer Research Institute, European Commission). A formal collaborative approach to establish common research goals was initiated in 2007 by the creation of the Australian National Institute of Complementary Medicine (NICM) and the inclusion of complementary medicine in the overall health and medical research strategic plan of the National Health and Medical Research Council.69 The mission of the NICM is to increase complementary medicine research and investment across Australia, effectively linking complementary medicine researchers and practitioners with the broader research community, industry and other stakeholders to provide strategic focus and foster excellence in research.69,70
Ultimately, the NICM’s primary objective is to translate complementary medicine research evidence (safety, quality, efficacy, cost effectiveness) into clinical practice and relevant policy. To this end, the NICM has established three collaborative research centres: (1) traditional chinese medicine; (2) natural medicines; and (3) neurocognition, and nutraceuticals and herbal medicine, which have secured approximately $8 million in research funding from government, universities and other collaborative partners.70 Emphasis is currently focused on areas of high disease burden, where preliminary evidence is strong and demonstrates likelihood of positive impact. Cancer is one of those areas and integrative oncology research has been initiated as a result of a partnership between the NICM and National Breast Cancer Foundation.70 Importantly, this research falls into two high priority areas for cancer patients: (1) complementary therapies in the management of disease symptoms and side-effects of conventional anti-cancer treatments and; (2) adverse effects of CAM-drug interactions during conventional treatments (ie. drug toxicity, therapeutic failure).70 Other high priority areas that need to be addressed however, include: (3) quality control and labelling of herbal medicines, nutritional supplements and other natural products, and quality control of practitioner-administered CAMs; (4) the role of nutrition and other forms of CAM in cancer prevention, as well as the potential role they serve in cancer survivorship and prevention of recurrence; and (5) the mechanisms of action underpinning beneficial complementary therapies.
Integrative cancer care in Australia today
Most medical schools offer CAM-based courses and/or training in the US and Europe (91% of US medical schools for the graduating class of 2009, up from 26% in 2001),71 and many hospitals there offer integrative therapies for patients.72 However, relatively little has been accomplished to make evidence-based complementary therapies available to (cancer) patients in Australian hospitals, despite growing demand. A few notable exceptions exist, though.
The SolarisCare Foundation Cancer Support Centre was established in 2001 at Sir Charles Gairdner Hospital in Perth, Western Australia. Complementary therapy and supportive care services offered by SolarisCare include psychological and group support, relaxation/meditation, several types of massage therapy and other manipulative and body-based practices, touch therapies and education/information, but purposely exclude therapies that involve ingesting substances (eg. nutritional supplements).73 Initially met with considerable opposition from some medical practitioners,74 more than 25,000 free sessions have been provided to over 1800 cancer patients and their carers statewide by a team of over 100 qualified/trained volunteers.75 SolarisCare has recently expanded its free and paid services to the privately run St John of God Hospital, Subiaco and to rural cancer patients and their carers in Bunbury and other regional centres in Western Australia. Of interest, however, is that 85% of individuals using their services have been women, and 55% have reported a diagnosis of breast cancer.74,75
The Peter MacCallum Cancer Centre, Australia’s only dedicated cancer hospital, in Melbourne, Victoria, provides complementary therapy and supportive care services to patients and their families in the form of psychological support, different types of massage therapy, relaxation/meditation, stress management and education/information, with some emphasis on music therapy.76 Also, under construction is the Olivia Newton-John Cancer and Wellness Centre, which is based at Austin Hospital in Heidelberg, Victoria. The centre’s ‘wellness’ therapies and support services will complement the centre’s mainstream medical care and treatment, and collaborative research into new anti-cancer treatments with the US Ludwig Institute for Cancer Research.77
Integrating complementary medicine into mainstream cancer care
Integrative cancer care or oncology is a patient-centred approach that nurtures the physical, emotional and spiritual well-being of cancer patients by integrating safe, evidence-based complementary therapies with conventional anticancer treatments. It uses a multidisciplinary approach that assesses and treats the patient as a whole rather than addressing their disease alone. Complementary therapies used by cancer patients are diverse in their origin, premise, practice, efficacy and safety. In Australia, CAMs may be categorised by the Therapeutic Goods Administration (TGA) as registered or listed products. Registered products are prescribed or non-prescribed medications which meet Australian standards of quality, safety and efficacy. Listed products are low risk items that are not routinely evaluated with respect to a manufacturer’s claims before marketing, but are subject to a random audit after listing.78 Listed products consist almost entirely of CAMs, which implies that they are produced according to appropriate standards for quality and safety, but guarantees nothing in regard to their efficacy. Cancer patients and other members of the public are mostly unaware of such distinctions and may believe that a complementary (or alternative) medicine listed by the TGA has been assessed as both effective and safe and approved for use by the Federal Government. Additionally, many complementary therapies have long histories as components of ancient traditional medical practices, but have only been subjected to rigorous scientific investigation in the last 10-20 years. More research is required to evaluate or confirm the efficacy and safety of many of these therapies.
As stated previously, high quality cancer clinical trials indicate that some complementary therapies, used as adjuncts to conventional medical treatments, are beneficial in reducing disease or treatment symptoms and improving quality of life and psychological functioning.6,52,60,66-68 There is evidence of potential harm also (Tables 3 and 4). Herbal medicines, nutritional supplements and other natural therapies may pose direct safety risks because of their potential adverse effects or interactions with conventional anti-cancer treatments (chemotherapy, radiotherapy, surgery, hormonal therapies) and other medications. Some should not be used under any circumstances irrespective of potential benefit (eg. St John’s wort), while others may be beneficial when cancer patients are not undergoing these treatments and have no other contraindications.
It is imperative that those involved in the medical care of cancer patients are equipped with the skills and knowledge to help patients appropriately evaluate CAM, in order to receive benefit while avoiding harm. Unfortunately, most physicians have limited knowledge of the safety and efficacy of specific complementary and alternative therapies and have not had any formal training in the CAM area.79-82 Furthermore, few oncology health professionals feel comfortable discussing CAM, and are concerned that they cannot effectively communicate with patients or have the skills to help them maintain hope.35,83-85 Surveys indicate that clinicians desire greater access to evidence-based CAM information, to improve the quality of their care, and to enhance communication with patients.86,87 Due to safety risks associated with CAM, clinicians are strongly encouraged to routinely ask patients about complementary and alternative therapy use.
Several recommended approaches for discussing CAM with cancer patients have been published,88-95 including a set of communication guidelines.96 These approaches and guidelines to effective communication generally involve: (1) eliciting the patient’s perspective of his or her illness; (2) being open-minded/non-judgmental and respectful in regard to cultural and linguistic diversity and different belief systems; (3) asking patients questions about CAM use at critical points in their cancer experience; (4) actively listening to patients and responding to their emotional state in exploring the details of CAM use or motivations to use it; (5) discussing relevant concerns while respecting the patient’s beliefs and emphasising that ‘natural’ does not necessarily equate with safety in explaining known safety risks; (6) providing patients with balanced, evidence-based information and advice about specific complementary and alternative therapies; and (7) providing close clinical follow-up and psychological support of patients using CAM, even if they choose therapies which their clinician disagrees with.
Complementary therapies or CAMs, as they are commonly referred to by patients and clinicians, are much sought after by Australian cancer patients as a means of coping with the physical and emotional impact of their disease and/or treatment. Irrespective of whether doctors like them or believe in them, patients will use them. If health professionals are to provide cancer patients with the best care and advice possible, then they cannot ignore this sign of the times.
Whether termed integrative cancer care or complementary medicine, cancer physicians in Australia should strongly consider offering evidence-based complementary therapies (or at least safe forms of them) alongside conventional treatments through their own cancer services.74 Conceivably, this will influence patients to continue with mainstream care and help them avoid any potential harm that may occur with autonomous CAM use. In this way, optimal holistic care will be ensured for cancer patients by clinicians providing conventional oncology treatment and care.
I would like to thank Professor Ian Olver (Guest Editor), Professor Peter Drummond and Mr Paul Katris for their comments on an early draft of this paper.
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