The use of complementary and alternative medicine remains controversial, as it has arisen largely from systems that are apart from conventional medicine. However, complementary and alternative medicine is in widespread use in the community and this mandates that medical workers be educated. In particular, its potential interaction with prescribed medicines need to be discussed with patients. Complementary and alternative medicine is most often used to complement conventional therapy rather than as an alternative to it, and most often are directed at symptom relief. Some therapies have become mainstream, such as psychological therapies, and these have been demonstrated to improve quality of life. Other complementary and alternative medicines have been the subject of research. For example, ginger, acupuncture and hypnosis have all been shown to be effective in trials of their use with chemotherapy induced emesis. Studies of prayer, however, highlight the methodological challenges of researching complementary and alternative medicine. Patients’ perceptions of complementary and alternative medicines are firmly divided into those who use them as part of a holistic approach and those who reject them, usually on the basis that they are not curative. Little work has been done on the complex interactions with family over the use of complementary and alternative medicine, which can either be divisive or improve cohesion. Finally, the attempts to practise integrative medicine are analysed as a model for the way forward for patient centred care.
Human cultures have been using botanical products for medicinal purposes since the dawn of civilisation, as with the herbal knowledge of early civilisations subsequently extending to Europe and the Middle East. Of the estimated 300,000 higher plants available today, approximately 1% are used as foods and 10-15% have a documented medical use, although few of them have withstood the scrutiny of pharmacological evaluation. In the developing world plants remain the primary sources of medicine, with more than 60% of the world’s population relying on traditional medicine for their health care needs. Botanical products are used in various forms: the entire plant (or parts of it), as herbal materials (plant oils, juices or resins); or as herbal preparations (where purified or extracted compounds are mixed with other ingredients to make pills, powders, or topical preparations). While orthodox medicine uses drugs generally as single chemical entities, traditional medicine commonly uses plants as mixtures. The complexity of these mixtures poses significant challenges to the identification of active compounds and to ensuring the consistency of formulation and quality control of these preparations. This review examines some of today’s uses of botanical products in Indigenous cultures, traditional medical systems, as complementary medicine and as sources of new drugs.
While the evidence behind effectiveness of complementary therapies is increasing, patients’ interest in complementary care is frequently driven by factors other than evidence of efficacy alone and reflects a desire for a different model of care and a different relationship with a health care provider. Patients who seek complementary care tend to be different demographically to those who do not and are more likely female, younger, more highly educated and earning a higher income. Seekers of complementary therapies are more likely to suffer from depression and have poorer physical quality of life. There are multiple barriers to access to complementary care, both provider and patient related. These relate to the insufficient awareness by providers regarding the evidence behind specific therapies or their interactions with conventional care, as well as the expectations placed upon conventional care providers regarding what their role might be. Little is known about how much information patients expect conventional health professionals to provide and there is little agreement on how much would be considered reasonable by the providers themselves. Greater collaboration and communication between complementary and conventional care providers would assist, not only in overcoming the barriers of access, but also building the body of evidence on the potential efficacy of complementary interventions in cancer.
Considering the prevalence of complementary and alternative medicine in the community and the growing evidence base, health practitioners (and patients) need to develop informed and balanced attitudes, skills and knowledge that are going to assist in making safe and beneficial decisions regarding the use of complementary and alternative medicine. Education regarding complementary and alternative medicine use generally, and for cancer in particular, has tended to be tokenistic and piecemeal at best or, at worst, totally absent or misinformed. Complementary and alternative medicine content is often marginalised rather than being seen as an integral part of the core knowledge and skills that a well-rounded and informed health practitioner requires. This is problematic for a number of reasons, including that the practitioner is less aware of which therapies are potentially useful or harmful and is therefore less able to help patients make informed and safe decisions regarding this aspect of their healthcare. It also potentially impedes the therapeutic relationship and communication between therapist and patient, especially if a patient has a disposition towards complementary and alternative medicine. This paper will review some of the background issues regarding education about complementary and alternative medicine and make suggestions about what should be minimal knowledge and competency for a health practitioner. At a minimum this content should include teaching on the common complementary and alternative medicine modalities, ethics, the economics of complementary and alternative medicine, evidence, safety and risks including interactions, clinical applications, clinical skills in history taking and communication around complementary and alternative medicine, and how to find and assess further information. Rather than being taught as a separate discipline, complementary and alternative medicine is best integrated into the wider curriculum and healthcare delivery based upon integrative medicine principles.
An increasing proportion of the population use complementary and alternative medicine including herbal medicine. This use is frequently undertaken in addition to their prescribed treatments, often without their physician’s knowledge. For many types of complementary and alternative medicine, this concomitant use of treatments is without significant risk of adverse effects. However, for systemically administered complementary and alternative medicine, such as herbal medicine, there are significant risks of adverse drug interactions between herbal medicine and conventional treatments, which may result in either increased drug toxicity or therapeutic failure. It is clear that certain combinations of herbal medicine and conventional medicine carry significant risks of reduced efficacy or adverse effects and the combinations are contraindicated. For instance, in vivo studies have shown that concomitant use of St John’s wort with therapeutic agents that are metabolised by the enzyme CYP3A4 has the potential to cause therapeutic failure. In cancer treatments there is also potential for pharmacodynamic interactions between herbal medicine and anti-cancer agents. For example, patients with oestrogen receptor positive breast cancers should be advised to avoid administration of phyto-oestrogen containing herbal preparations. Physicians should be proactive in obtaining a complete medication history, including herbal medicine use, in all their patients receiving cancer chemotherapy, in order to advise them appropriately with a view to making informed decisions about their treatment.
Complementary and alternative medicine encompasses a vast array of interventions aimed at improving the health of individuals. A large proportion of people use complementary and alternative medicine after a diagnosis of cancer and there is a need to understand these interventions, their efficacy and interaction with conventional medical treatments. The quality and rigour of complementary and alternative medicine research has been frequently criticised. Some deficiencies in reporting of complementary and alternative medicine research can be addressed by improved research design. Further improvements are possible through the use of frameworks for evaluation of complex or whole systems that clearly document the complementary and alternative medicine intervention, placing it in the context of treatment delivery and the philosophical assumptions underpinning the intervention. These frameworks provide guidance as to the staged and systematic development of complementary and alternative medicine interventions. Using these frameworks to document the complementary and alternative medicine intervention development supports the inclusion of the philosophical concepts at the core of the intervention. Doing so is likely to assist in the development of a shared language between complementary and alternative medicine researchers and evidence-based practitioners.
The definition of complementary and alternative medicine is broad and evolving. We question whether it should encompass ‘prayer’ when prayer can be directed at improving health, the mechanism is unexplained and the practice based on personal beliefs. A review of studies on prayer for the alleviation of ill-health by the Cochrane collaboration suggested results remain equivocal. A local randomised blinded study of intercessory prayer in patients with cancer showed a significant improvement in assessments of spiritual and emotional wellbeing, despite small effects. Most studies of prayer use as a complementary and alternative medicine are from the United States where religious affiliation is reportedly high. Classifying prayer within complementary and alternative medicine domains varies by culture but is usually combined with mind/body therapies (ie. meditation), distorting patterns of use. Importantly, complementary and alternative medicine use is not commonly raised with patients’ physicians despite such discussions having been shown to enhance communication. Physicians who describe themselves as ‘spiritual’, as opposed to ‘religious’, appear more likely to accept complementary and alternative medicine. Including prayer as a complementary and alternative medicine raises difficulties in definition and measurement, but its widespread societal use suggests it should be acknowledged. Physicians should ask their patients about complementary and alternative medicine use as it may actually improve the acceptance and adoption of conventional treatment.
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.
Families of patients with cancer shape and share in the many and difficult decisions faced following diagnosis, with significant involvement in decisions regarding complementary and alternative medicine. Such decisions may be particularly difficult due to conflicting opinions regarding complementary and alternative medicine and relative lack of medical guidance. Family may act as information seekers, advocates and/or role models, either prompting, enabling or discouraging use by the patient. Complementary and alternative medicine use within a family may promote familial cohesion and functioning, or increase familial distress and conflict. Where outcomes are poor, the ability of the family to care for themselves and the patient may be compromised, adding to the burden of cancer within the community. Some complementary and alternative medicine may offer benefits to family members themselves, either with or without patient use. Evidence is lacking, however, regarding the effect of differences in the experiences or perceptions of complementary and alternative medicine use by individuals in different familial relationships to the patient, or in differences associated with gender, socio-economic or geographical status, ethnic or cultural background, or non-traditional family structure. Morever, little is known about how families negotiate decisions about complementary and alternative medicine, nor of the long-term consequences of these decisions upon family well-being and functioning. Such knowledge would enable clinicians to better advise patients and their families on treatment choices following a cancer diagnosis.
Patients’ perceptions of complementary and alternative medicine are not well studied. This review highlights attitudes towards complementary and alternative medicine, particularly for cancer patients. In general, the longer the time since a cancer diagnosis, the more likely it is that someone may use complementary and alternative medicine. In addition, women of a younger age with a higher education are more likely to use complementary and alternative medicine. Most commonly, complementary and alternative medicine is used to treat a range of physical and emotional problems relating to cancer, and only rarely as a means to cure the cancer itself. Dietary supplements, dietary changes and meditation are the most commonly used therapies. Many people perceive that these – and other complementary and alternative medicines – are beneficial for both physical and emotional reasons. However, not all people gain their desired outcomes from using complementary and alternative medicine. There are few reports of negative effects, but these are factors in some people not using or ceasing complementary and alternative medicine. Others do not use complementary and alternative medicines because of disbelief or due to concerns about complementary and alternative medicine benefits or safety. Doctors are not always consulted about complementary and alternative medicine use, but many people hope their doctors are supportive of it.