Complementary & Alternative Medicine

Cancer is a term for diseases in which abnormal cells divide without control. Cancer cells can invade nearby tissues and spread to other parts of the body through the bloodstream and the lymph system, however, improvements in screening, detection, treatment, and care have increased the number of cancer survivors, and experts expect the number of survivors to continue to increase in the coming years.

Complementary and alternative medicine (CAM) is the term for medical products and practices that are not part of standard medical care, which is based on scientific evidences from research studies, but rather used, alongside mainstream cancer care.

Complementary health approaches are a group of diverse medical and health care systems, practices, and products whose origins come from outside of mainstream medicine. They include such products and practices as herbal supplements, other dietary supplements, meditation, spinal manipulation, and acupuncture. Some complementary approaches are not meant to replace, but rather, as adjuncts to mainstream cancer care. They are supportive measures that control symptoms, enhance well being, and contribute to overall patient care.

The same careful scientific evaluation that is used to assess conventional therapies should be used to evaluate complementary approaches, for some complementary approaches plans that may help patients cope with disease, are beginning to find a place in cancer treatment, not as cures, but as additions to treatment symptoms and alleviate side effects or improve a patient’s sense of well-being ( 1 ) .

Alternative therapies, on the other hand, are healing techniques and beliefs that have developed over time and include homeopathy, naturopathy, and traditional Chinese medicine, and are promoted for use instead of mainstream treatment.

Being diagnosed with cancer and undergoing treatment is a frightening, exhausting, and demanding experience. CAM appeals to many patients with cancer because these treatments often offer a chance to take control, feel better, and decrease uncomfortable symptoms, such as pain, fatigue, and nausea.

Over time, some complementary therapies are proven safe and effective. These become integrated into mainstream care, producing integrative oncology, a synthesis of the best of mainstream cancer treatment and rational, data based, and adjunctive complementary therapies. Such integration is evolving, hence, ‘the term “integrative medicine” is fast replacing that of complementary and alternative medicine, or CAM’ (2). The very term applied to the program at the Memorial Sloan-Kettering Cancer Center (Integrative Medicine Service) and similar titles applied to related programs in North America, the United Kingdom, and Europe, suggest that complementary therapies are being brought into mainstream medicine, including cancer care. Integration varies from country to country, as does the quality of therapies offered. Centers for integrative medicine are being established in many academic medical centers (3, 4).

The interest in therapies outside of mainstream oncology care is not limited geographically or among particular segments of the population. In countries in which modern medicine predominates, 40–50% of patients with cancer use CAM therapies outside the mainstream ( 5 ). Among cancer survivors in the US, up to 40% used complementary or alternative therapies during the period following their treatment.

By various accounts, from less than 10% to more than 60% of cancer patients have used CAM (6). The Datamonitor 2002 Survey in USA, indicated that 80% of cancer patients used an alternative or complementary modality (7). Some other data indicate that the likelihood of using complementary approaches varies with the type of cancer and with factors such as sex, age, and ethnicity. The results of surveys from 18 countries show that use of complementary approaches by people who had been diagnosed with cancer was more common in North America than in Australia/New Zealand or Europe and that use had increased since the 1970s and especially since 2000.

Well-designed comparative studies include a placebo treatment, (Placebo, is an inactive medication or treatment) as well as a “real” treatment, so that the two may be compared. For example, a CAM treatment that claims to improve symptoms of nausea in 50 percent of patients is of little benefit if the placebo treatment also improves symptoms in 50 percent of patients. The placebo effect is not well understood but has a strong influence on the results of any research study, whether in conventional or complementary medicine.

Among the complementary health system are the following:

• Acupuncture, which involves inserting thin metal needles into the skin at specific points on the body. It causes little to no pain. Electrical stimulation is sometimes applied to the acupuncture needle. There have been numerous studies of acupuncture’s efficacy in reducing nausea, pain, dry mouth after radiation treatment for head and neck cancer, and hot flashes, and results have been mixed (8). Acupuncture with electrical stimulation has been found to be useful in treating nausea and vomiting from chemotherapy
  some trials suggest that acupuncture can reduce cancer pain, although a review of multiple trials showed it to be of no benefit.
  In one trial, the use of acupuncture significantly reduced mouth pain and the sensation of dry mouth in a group of patients undergoing radiation therapy for head and neck cancer.
• Mind – body techniques — Mind-body techniques include practices such as hypnosis, guided imagery, meditation, yoga, biofeedback, and prayer (9). These techniques may be useful before or during painful or stress-inducing medical procedures, chemotherapy, or radiation treatment to control anxiety, pain, or nausea and vomiting. Patients of any age can learn mind-body techniques. The 2007 National Health Interview Survey showed that four in ten adults (38.3% of adults; 83 million individuals) and one in nine children less than 18 years of age (11.8% of children; 8.5 million individuals) in the US used dietary supplements and various mind–body therapy techniques.
• Homeopathy is based on the belief that a disease can be cured by a very low dose of substance that creates similar symptoms in a healthy person. These ideas are known as ‘like cures like’ an the ‘law of the minimum dose’, this conflicts with fundamental concepts of physics and chemistry and there is no good evidence from reviews of research to support its use (10)
• Hypnosis is a state of altered consciousness that allows you to focus away from your pain, anxiety, or nausea. You are not sleeping while hypnotized but are actually in a state of heightened imagination, similar to daydreaming. An expert can hypnotize an individual, or you can learn self-hypnosis techniques. Hypnosis is safe and has few side effects.
• It is not clear how or if hypnosis is helpful, although studies have suggested that it may be useful for controlling pain and nausea/vomiting in various settings and may reduce vomiting that can develop before starting chemotherapy (called anticipatory emesis).
  One study examined the benefit of hypnosis before surgery for breast cancer. They found that women who had a 15-minute hypnosis session before surgery had less pain, nausea, and fatigue after surgery, and they required significantly less time in the operating room compared with women who were not hypnotized. It is not clear whether some of these benefits represent placebo effects.
  Hypnosis may also be useful in children for preventing anxiety and pain from difficult procedures, such as lumbar puncture (spinal tap) or bone.
• Visual or guided imagery — Visual or guided imagery is a technique that encourages the patient to relax by focusing on calming thoughts or experiences. You sit or lie in a comfortable position while imagining a pleasant experience, such as relaxing on the beach. In one study, women receiving chemotherapy for newly diagnosed breast cancer had a better quality of life if they used relaxation training and guided imagery, as compared with a group that had chemotherapy alone (2).
• Spirituality — A majority of individuals have religious beliefs, and many people rely on their religion or spirituality in difficult times, such as during treatments for cancer. Researchers found that spirituality, when combined with conventional medicine, was an important component in the healing process and was of benefit not only to the patient but also to caregivers and healthcare professionals.
  Some, but not all, studies have shown that religious involvement and spirituality are associated with better health outcomes, including longer life, improved coping skills, better health in general, and lower rates of anxiety, depression, and suicide (11).
• Energy therapies — Energy therapies involve using assumed energy fields to heal and maintain wellness. Believers in energy medicine describe disruptions in the energy field as a cause for illness and teach that balancing energy can aid in healing. It is difficult to study the effectiveness of energy medicine due to the intangible nature of the body’s “energy. “Reiki is a form of energy medicine and has been evaluated in several clinical trials for treatment of anxiety and improvement of well-being in cancer patients. Some, but not all, trials showed positive results, although the studies showing benefit were not well designed, and it is difficult to distinguish the true benefit from placebo effect. Alternative cancer treatments (ACTs), however, are usually promoted as replacements to conventional cancer treatments. Cancer patients may seek them out in the hope of a cure. Some ACTs require the patient to receive treatment at their clinics, often located outside the United States. In many cases, reliable clinical trials have found these treatments ineffective or unsafe, and the US Food and Drug Administration (FDA) has not given approval for these treatments inside the United States.
• Dietary ACTs — Good nutrition is important for cancer patients. However, none of the dietary ACTs are proven to prolong life or cure cancer. In addition, some alternative cancer diet treatments are costly and potentially harmful.
• Gerson regimen — The Gerson regimen requires an organic, vegetarian diet and includes a strict schedule for ingesting juice made from fruits and vegetables. In addition, patients are given a number of vitamin supplements. No clinical study has proven this regimen’s efficacy. It is not recommended and may be expensive and harmful (13)
• Macrobiotic diets — Macrobiotic diets are low-fat, vegetarian diets that include large amounts of complex carbohydrates. One report found that one-third of cancer patients who followed a macrobiotic diet lost weight, which resulted in other problems. This was likely due to several factors, including the expense or inaccessibility of some of the required foods, time spent preparing the meals, and the restrictive, sometimes unpleasant, nature of the diet. Macrobiotic diets are not recommended for people with cancer.
• Selected vegetables — Selected vegetables (SV), also called Sun’s Soup, is a blended, boiled, and freeze-dried product that claims to have immune-stimulatory and anticancer properties. Two small studies have been conducted in patients with late-stage non-small cell lung cancer, both of which found that patients who received the supplement had an improved survival. Patients in both studies received conventional medical treatments, as well as the SV mix. However, the studies were small and had weaknesses in study design; further studies are needed before the treatment can be considered safe and effective.
• Herbal medicine — Combinations of herbs (also called botanicals) are often promoted as ACTs. Herbal medicines may come in the form of a powder, liquid, or pill. Examples of herbal treatments include essiac, ginseng, green tea, Flor Essence tea, mistletoe, PC-SPES (a mixture of herbs marketed for prostate cancer, now recalled due to an increased risk of blood clots), sho-saik-to, and St. John’s wort .
  None of these herbals have been proven to cure or improve cancer in reliable clinical studies; some can cause dangerous side effects. In addition, some herbal products (particularly St. John’s wort) can interact with conventional cancer treatments, making conventional treatments less effective (14).
  
• Other supplements — A number of dietary supplements have been advertised as being useful ACTs. These include coenzyme Q10, hydrazine, melatonin, shark cartilage, shiitake mushroom extract, and thymus extract. No supplement has proven reliable as either an alternative or complement to conventional cancer treatment.

References:

• Weiger WA, Smith M, Boon H et al. Advising patients who seek complementary and alternative medical therapies for cancer. Ann Intern Med 2002;137:889–903.
• Adams J, Sibbritt DW, Easthope G et al. The profile of women who consult alternative health practitioners in Australia. Med J Aust 2003;179:297–300.
• Abbott RB, Hui KK, Hays RD. Medical student attitudes toward complementary, alternative and integrative medicine. Evid Based Complement Alternat Med. 2011;985243.
• Barton, D. Integrative medicine: not just garnish. ONCOLOGY Nurse Ed. 26 (2012).
• Chrystal K, Allan S, Forgeson G et al. The use of complementary/alternative medicine by cancer patients in a New Zealand regional cancer treatment centre. NZ Med J 2003;116:U29.
• Lee MM, Chang JS, Jacobs B et al. Complementary and alternative medicine use among men with prostate cancer in 4 ethnic populations. Am J Public Health 2002;92:1606–1609.
• Eisenberg DM, Davis RB, Ettner SL et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA 1998;280:1569–1575.
• NIH Consensus Conference. Acupuncture. JAMA 1998; 280:1518.
• Montgomery GH, Bovbjerg DH, Schnur JB, et al. A randomized clinical trial of a brief hypnosis intervention to control side effects in breast surgery patients. J Natl Cancer Inst 2007; 99:1304.
• U.S. Food and Drug Administration. Homeopathy: real medicine or empty promises. http://www.fda.gov/fdac/features/096_home.html, accessed 09/29/03.
• Walker LG, Walker MB, Ogston K, et al. Psychological, clinical and pathological effects of relaxation training and guided imagery during primary chemotherapy. Br J Cancer 1999; 80:262.
• Rummans TA, Clark MM, Sloan JA, et al. Impacting quality of life for patients with advanced cancer with a structured multidisciplinary intervention: a randomized controlled trial. J Clin Oncol 2006; 24:635.
• Memorial Sloan-Kettering Cancer Center. Information resource: About herbs, botanicals and other products. http://www.mskcc.org/abuotherbs, accessed 09/29/03.
• Hildenbrand GL, Hildenbrand LC, Bradford K et al. Five-year survival rates of melanoma patients treated by diet therapy after the manner of Gerson: a retrospective review. Altern Ther Health Med 1995;1:29–37.

written by Dr Khalida Mousawy MB, ChB, Ph.D