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© 1999 American Society for Clinical Oncology
Complementary and Alternative Cancer MedicineFrom the Memorial Sloan-Kettering Cancer Center, New York, NY. Address reprint requests to Barrie R. Cassileth, PhD, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021; email cassileth{at}mskcc.org COMPLEMENTARY AND alternative therapies today include a large assortment of unrelated modalities, ranging from unproved or disproved cancer "cures" to helpful adjunctive regimens. These dissimilar therapies often are known by the same terms: complementary medicine, alternative medicine, or complementary and alternative medicine (CAM). Using the same words for vastly different remedies may result in dismissing or accepting them all. Such cases of mistaken understanding can have unfortunate clinical implications. In my opinion, a distinction between "alternative" and "complementary" is essential. Alternatives may be perceived literally as such; they include any unproved therapy that is promoted as a cancer treatment or cure or promoted as a treatment to be used instead of mainstream oncology care. Complementary therapies, in contrast, are used as adjuncts to mainstream cancer medicine for symptom management and to enhance quality of life. The importance of this useful distinction was validated by the National Institutes of Health (NIH) nomenclature shift (the Office of Alternative Medicine was renamed the Center for Complementary and Alternative Medicine) and by results of a recent survey, the largest ever conducted to determine public use of unconventional therapies.1 The survey found that all but 2% of those who used unconventional therapies did so to complement rather than replace mainstream treatment. In cancer medicine, alternative therapies are claimed to be superior to surgery, chemotherapy, and radiation. Typically invasive and biologically active, alternative regimens are, by definition, unproved. They are also potentially harmful, either directly through biologic activity or indirectly when patients postpone mainstream care. Examples of alternative therapies in cancer medicine include the metabolic therapies that are available in Tijuana, Mexico, and elsewhere, shark cartilage, high-dose vitamins and other products that are sold over the counter and delivered intravenously in alternative clinics, electromagnetic cures, and many other products and regimens. Although research evidence is scanty,2 approximately 8% to 10% of cancer patients seek alternative care after tissue-biopsy diagnosis. The great majority of cancer patients who use CAM pursue complementary therapies, not alternative therapies. Specific complementary and alternative therapies are reviewed below. THE IMPACT OF CAM ON THE HEALTH CARE SYSTEM With the advent of managed care and advances in biotechnology, the entry of unconventional therapies into dominant medical arenas had a marked impact on health care in the 1990s and was among the significant changes of that decade. The popularity of alternative and complementary medicine has affected every component of the health care system and all specialties of medicine, including oncology. It has influenced the thinking and practice of physicians and other health professionals and broadened patients' involvement and influence in their own care. Unconventional cancer medicine today, unlike the covert practices of prior decades, is highly visible and widely available to the general public. It is a multibillion dollar business in the United States and has equivalent impact and importance throughout the developed world. THE PREVALENCE OF COMPLEMENTARY AND ALTERNATIVE CANCER THERAPIES Internationally as well as in North America, the use of CAM for cancer is widespread. A systematic review3 located 26 surveys of cancer patients from 13 countries. Five were conducted in the United States. The average prevalence across all studies was 31%. Therapies most commonly used around the world included dietary treatments, herbs, homeopathy, hypnotherapy, imagery or visualization, meditation, megavitamins, relaxation, and spiritual healing. New investigations substantiate these results.4-6 In the United States surveys, patients used Laetrile, metabolic therapies, diets, spiritual healing, megavitamins, imagery, and "immune system stimulants."3 The prevalence of CAM use in the United States ranged from 7% to 50%. Additional surveys involving members of the United States general public (not cancer patients) uncovered prevalence rates of one third in a representative sample of 1,539 adults as reported in 1993.7 In 1997, prevalence rates of 50% of 113 family practice patients8 and 42% of 1,500 members of the general public9 were reported. A 1998 study found that 42% of 2,055 people surveyed used CAM.10 The previously noted 1999 survey of more than 24,000 individuals found that 8% of the study population used CAM with or without mainstream care.1 Prevalence rates from all CAM studies internationally vary from less than 10% to more than 50%. This broad range, with its apparent discrepancies, is attributable to variable understandings and definitions of CAM. Often CAM is not defined in surveys, or it is defined so broadly as to include lifestyle activities such as weight loss efforts, exercise, church attendance, and support activities (such as group counseling), which results in overblown figures for CAM use. Herbal medicines were used by 3% of respondents. In contrast, the 1997 general public survey revealed the most common CAM therapies to be herbal remedies, used by 17% of respondents, and chiropractic, used by 16% of those surveyed.9 The 1994 legislation allowing herbal medicines and other food supplements to be sold over the counter without review by the United States Food and Drug Administration (FDA) has profoundly influenced public behavior. This is evident in the increased use of herbal remedies from 3% in 19917 to 17% in 19979 to more than 20% in 1999.1 It is estimated that sales of dietary supplements have more than doubled since passage of the 1994 law. Expanding insurance coverage of chiropractic care during this same time period may account for similar growth in its utilization. Homeopathy, acupuncture, folk remedies, and the like were used by a maximum of only 2% of respondents in the studies noted above. Virtually all studies conducted to date of cancer patients and of the general public internationally show that those who use CAM tend to be female, better educated, of higher socioeconomic status, and younger than those who do not. They tend to be more health conscious and use more mainstream medical services than do people who do not use CAM. It seems that CAM use by cancer patients has increased in recent years,3,11 which probably reflects increases in over-the-counter remedies and broader availability of complementary therapies in mainstream cancer programs. It is important to note that patients who receive alternative cancer therapies exclusively are not reflected in CAM surveys, because, with one exception,2 all such surveys were conducted in mainstream clinics or hospitals. PUBLIC ACCESS TO CAM INFORMATION Information about CAM varies widely in its accuracy. Many web sites and publications that seem to be objective actually are sponsored by commercial enterprises that promote and sell the products they report. Misinformation about health issues abounds. In 1999, the United States Federal Trade Commission (FTC) announced that it had identified hundreds of web sites selling bogus cures for cancer and other serious illnesses among the estimated total of approximately 17,000 health-related web sites.12 It is all but impossible for most patients to distinguish between reputable sources of information and those backed by vested interests. Some promotional materials and books are written by medical doctors and seem to present legitimate information. NIH AND MEDICAL ESTABLISHMENT ACTIVITY In addition to its acceptance by the public, CAM also has infiltrated mainstream medicine in an unprecedented fashion. An Office of Alternative Medicine (OAM) was established at the NIH by congressional mandate in 1992; its stated purpose was to investigate unconventional medical practices.13 In 1998, Congress elevated the OAM to the National Center for Complementary and Alternative Medicine (CCAM) and increased its funding to $50 million. CCAM now supports 10 CAM Research Centers. Most, including the Center for Alternative Medicine Research in Cancer at the University of Texas Health Science Center in Houston, TX,14 are university-based. Research is funded cooperatively by the relevant NIH institute and CCAM. Mainstream interest in CAM is displayed also in the emergence and growth of medical school courses that cover complementary and alternative medicine. Elective courses in CAM were taught in 75 medical schools in the United States in 1997,15 and the number seems to have increased since that time.16 In addition, numerous hospitals, medical centers, and cancer centers have developed research and clinical service programs in CAM. These programs differ by departmental base, types of clients served (inpatients, outpatients, community), access (physician or self-referral), administrative staff (physician, nurse, CAM expert), and services provided. Services range from mind-body sessions only, to massage and exercise, to the provision of herbs and food supplements, to remedies that are even more removed from mainstream care, such as colonic irrigation and homeopathy. Some clinical CAM programs are repackaged support services that were previously offered as spiritual care, counseling, art therapy, nutritional guidance, and so on. A final marker of mainstream interest to be noted here is the publication of research articles about CAM in major mainstream medical journals. The Journal of the American Medical Association, the New England Journal of Medicine, The Lancet, the British Medical Journal, and specialty journals such as the Journal of Clinical Oncology and Cancer have published reports of CAM research in recent years. In 1996 and 1997, the National Library of Medicine added many new CAM search terms to its medical subject headings and began to cover alternative medicine journals that were previously not reviewed for inclusion in MEDLINE. Not everyone is happy about CAM. The professional oncology community is hardly unanimous in its approval, and many mainstream scientists are displeased with the integration of CAM into mainstream medicine and are particularly unhappy about the existence of a separate NIH research entity for alternative medicine.17-19 Vigorous opposition to parts of CAM as "pseudo science" based on "absurd beliefs" has been voiced. The deviation from basic scientific principles, which is implicit in homeopathy and therapeutic touch, for example, is decried. The very existence of CCAM as an entity apart from existing NIH research institutes, many claim, supports a separate, inferior level of research and an antiscience bias. Alternative medicine is a quintessential example of the sociopolitical force behind medical change. That force continues in congressional efforts to ensure broad availability of CAM. In 1999, hearings were held by the House of Representatives Committee on Government Reform to improve availability of CAM to women with breast and gynecologic cancers.20 The committee expressed special concern about policies of the United States Health Care Financing Administration, Medicare, and Medicaid, and other federal institutions. INSURANCE COVERAGE AND OUT-OF-POCKET PAYMENT Health insurance programs increasingly cover CAM services and providers.21 More than 30 major insurers, one half of them Blue Cross plans, cover more than one alternative method.22 Increased coverage of complementary and alternative therapies reflects managed care efforts to control costs as well as consumer demand.23 However, public willingness to pay out-of-pocket is evident in the 73% growth of pharmacy sales of natural remedies and supplements from 1991 to 1995; prescription drug sales during this same period increased by 31%.24 POPULAR CAM CANCER THERAPIES Currently favored unproved cancer therapies, or treatments that are promoted as actual alternatives to mainstream cancer care, are noted briefly here. Although there is no evidence that these treatments impede the progression of malignant diseases, they remain popular and are used by large numbers of patients. (Helpful complementary/adjunctive therapies are listed in the Appendix.)
Diet and Nutrition Cures The macrobiotic diet ranks among the more enduring and still popular dietary "treatments" for cancer. Developed in the 1930s by George Ohsawa, a Japanese philosopher, the macrobiotic diet was an effort to integrate traditional Asian medicine, Christian teachings, and aspects of Western medicine.25 Macrobiotic concepts of human physiology and disease and of diagnosing disease with iridology and similar techniques are fanciful and incorrect. Moreover, versions of this diet are nutritionally deficient and can cause weight loss in cancer patients. Some patients and alternative practitioners believe that large doses of vitamins, such as 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,26,27 but megavitamin and orthomolecular therapy—the latter adds minerals and other nutrients—remain popular among cancer patients. There is no evidence that megavitamin or orthomolecular therapy is effective in treating any disorder. Metabolic therapies continue to draw patients from North America to the many clinics in Tijuana, Mexico, that specialize in practitioner-specific combinations of diet plus vitamins, minerals, enzymes, and "detoxification." These therapies are based on the belief that toxic products of cancer cells accumulate in the liver, leading to liver failure and death. The Gerson regimen, for example, counteracts such liver damage with a low-salt and high-potassium diet, coffee enemas, and consumption of a gallon of fruit and vegetable juice daily.28 Detoxification is thought to be necessary for the body to heal itself. Cancer and other illnesses are seen as symptoms of the accumulation of toxins. This nonphysiologic concept originated in ancient Egyptian, Ayurvedic, and other early efforts to understand illness and death, which were believed to be caused by the putrefaction of food in the colon. Decay and purging were major themes in early cultures' therapeutic regimens. Neither the toxins nor the benefit of eliminating them has been documented. Modern drinkable cleansing formulas, which are said to detoxify and rejuvenate the body, are also available in health food stores, books, and on the Internet. A mixture of liquid clay, psyllium seed husks, and fruit juice, for example, is said to remove harmful food chemicals and air pollutants.29 These products are major laxatives, potentially dangerous when taken on a regular basis as recommended by promoters, and of special concern for cancer patients.
Mind-Body Techniques Some argue that patients can use mental attributes and mind-body work to prevent or cure cancer. Although they may involve small numbers of patients or remain unreplicated, research suggesting that psychologic factors or therapies influence cancer are widely publicized.33 Prospective versions of this study have failed to replicate the 1989 results.34 Bernie Siegel, MD, former surgical oncologist and best-selling author, is a proponent of the idea that attitudes, assumption of responsibility for one's own health, and understanding why patients "need" their cancers can help correct unhealthy emotional patterns, thereby affecting cancer remission or cure. A study coauthored by Siegel, however, found no difference in length of survival for his support group patients versus controls, where patients in both groups had completed standard mainstream therapy for breast cancer.35 Attending to the psychologic health of cancer patients 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.30
Traditional Chinese Medicine In addition to acupuncture and acupressure, traditional Chinese medicine also includes a full herbal pharmacopoeia with remedies for cancer and most other illnesses.39 Chinese herbal teas and relaxation techniques are soothing to many patients with cancer, who use them as complementary therapies (see Appendix). The potential anticancer benefits of Chinese green tea and other herbal remedies are under investigation.40-42
Pharmacologic and Biologic Treatments Interest in shark cartilage as a cancer therapy began in 1992 with a book by I. William Lane, PhD, entitled Sharks Don't Get Cancer. Advocates base their support of shark cartilage on its supposed antiangiogenic properties,45 but shark cartilage protein molecules are too large to be absorbed by the gut and are excreted. A recent phase I-II trial of shark cartilage found no clinical benefit.46 Cancell is said to return cancer cells to a "primitive state" from which they are rendered inert. FDA laboratory studies, which showed Cancell to be composed of common chemicals including nitric acid, sodium sulfite, potassium hydroxide, sulfuric acid, and catechol, found no basis for proponent claims of Cancell's effectiveness against cancer.47
Manual Healing Methods One of the most popular manual healing methods is therapeutic touch (TT), which, despite its name, involves no direct contact. Instead, healers move their hands a few inches above a patient's body and sweep away "blockages" to the patient's energy field. Although a study in the Journal of the American Medical Association showed that experienced TT practitioners could not detect the investigator's "energy field,"51 and despite scientists' rejection of its fundamental premises, TT is taught in North American nursing schools and is widely practiced by nurses in North America and other countries.52 Related therapies involve use of an individual's special energy gifts. Healing of this type has remained popular over the centuries in less developed areas of the world53,54 and has become increasingly popular in the United States. Healers in many areas of the United States claim to have the ability to cure people of cancer.55 Many patients are sufficiently convinced of healers' abilities that they decline to have tumors removed surgically.
Herbal Remedies for Cancer Pau d'arco tea, an old Incan remedy for cancer and other illnesses, is made from the bark of an indigenous South American evergreen tree. Its active ingredient, lapachol, displayed antitumor activity in animal studies conducted in the 1970s. However, it does not seem to affect human malignancies. Nonetheless, pau d'arco tea is sold as a cancer remedy in health food stores, through mail order, and on the Internet. Asian herbal remedies show greater promise. Several mushroom-derived compounds are approved for use as cancer treatments in Japan. PC-SPES (PC for prostate cancer; SPES is Latin for "hope"), which is a combination of eight herbs, all but two from traditional Chinese medicine, reduced prostate-specific antigen levels in men with advanced prostate cancer.56 Its mechanism of action may relate to its phytoestrogen effects. A study developed by researchers at the University of California at San Francisco Breast Cancer Center involves patients from that institution and from the Memorial Sloan-Kettering Cancer Center. Women with advanced metastatic breast cancer who are receiving a Tibetan herbal formula are being studied for clinical outcome, including survival. Historic herbal cancer remedies, when pretested to ensure purity and consistency of product and when studied carefully, may produce potentially useful and nontoxic cancer treatments. The difficulty is that they are rarely tested for purity, examined for consistency, or studied carefully. They are, nonetheless, in common use. Herb sales in drugstores and food stores increased 35% from 1993 to 1994, totaling $106.7 million for the year.57
Herbal Medicine The potential for herb-drug interaction is sufficiently strong that patients on chemotherapy should not simultaneously use herbal remedies. Similar cautions are necessary for patients who undergo radiation therapy, as some herbs photosensitize the skin and cause severe reactions. Before surgery, herbal remedies should be discontinued because some herbs produce dangerous blood pressure swings and other unwanted interactions with anesthetics.59 Herbs such as feverfew, garlic, ginger, and ginkgo have anticoagulant effects and should be avoided by patients on warfarin, heparin, aspirin, and related agents. The risk of herb-drug interactions seems to be greatest for patients with kidney or liver problems. Regulatory and safety issues remain serious concerns so long as governmental agencies are precluded from assessing the safety and efficacy of dietary supplements. These supplements, which include vitamins and minerals, homeopathic remedies, herbal treatments, antioxidants, and other over-the-counter products, are commonly purchased by cancer patients as well as by the public generally. According to the Nutrition Business Journal, 1998 sales of supplements sold over the Internet alone reached $40 million, an increase from $12 million in 1997. The Nutrition Business Journal estimates that sales of food supplements will reach $160 million in 1999 and $500 million in 2001. Many complementary (adjunctive) therapies are well studied. Most alternatives (unproved therapies) are not. Overall, CAM today represents a medical, social, and economic phenomenon that cannot be ignored and that remains in need of proper research. Some CAM proponents argue that research is unnecessary to determine the effectiveness of alternative therapies for cancer; others claim that CAM therapies are too individualized to study with usual scientific methods. In fact, there is no unconventional therapy that cannot be properly evaluated.60-62 CAM therapies require standard, scientific research. The most difficult problem may lie in the ability of science, the public, and the true believers to accept the results of rigorous inquiries, no matter what they reveal. APPENDIX: For Patients: Complementary Therapies to Smooth the Way During Cancer Treatment and Recovery62
Anxiety and Stress Aromatherapy: Put a few drops of essential oil of rosemary, lavender, or camomile (available in health food stores and pharmacies) in the bath, or light a scented candle while relaxing. The fragrance is luxurious and calming. Meditation and other relaxation techniques: These are opportunities for mini emotional vacations. Close your eyes and see yourself in a pleasant, peaceful place. Breathe deeply and slowly. Or lie down, eyes closed. Start at the toes and gradually move up the body as you consciously relax each body part. Your body and mind will relax accordingly. Music therapy: Music has important physiologic as well as emotional benefits. It calms, distracts, and soothes at a very fundamental level of being. Therapeutic massage: Visit a licensed, certified massage therapist who is experienced with people undergoing cancer therapy, or arrange for that person to visit you. Or have a friend or family member gently massage your neck and shoulders, hands and feet. Weekly therapeutic massages will keep you feeling well. Patients with lymphatic cancers should avoid touch massage. Valerian: Make a tea from 1 to 2 teaspoons of the dried root from this herb. You may prefer capsules because the tea doesn't have a pleasant odor (health food stores and pharmacies have both). It is safe and nonaddictive, and it effectively reduces anxiety and brings about sleep. Yoga: Take a class, rent a videotape, borrow a book, and practice postures along with deep breathing techniques. Anyone can do yoga, even while bedridden. It is said to bring mind, body, and spirit together in a peaceful union. Regardless of the way in which it works, yoga relaxes.
Backache or Muscle Ache Hydrotherapy: A warm bath or Jacuzzi should help relieve muscle aches. Massage: Try a professional massage by a licensed, certified massage therapist or a careful muscle massage by a friend or relative. Patients with lymphatic cancers should avoid touch massage. Willow tea: The bark of the willow tree contains salicin, the active ingredient in aspirin. (Avoid this herb if aspirin causes upset stomach or if your doctor told you to use an aspirin substitute.)
Colds and Influenza (Flu) Echinacea: Take this herb when you feel a cold coming on, and you may reduce its duration. It also relieves symptoms. Echinacea works as a tea or capsule. Avoid if you have allergies to ragweed, daisy, or sunflower. Eucalyptus or peppermint oil: Place in a steam vaporizer and inhale. Ginger: Make a large cup of tea with 2 tablespoons of shaved ginger and boiling water. It's an effective way to relieve cold symptoms, and it tastes good too. Add some chopped ginger to this or any other tea for its special benefits as an expectorant and cough suppressant. Iceland moss and plantain: Tea from these herbs soothes sore throats and helps calm colds and flu. Watercress tea: Tea made with watercress or fresh watercress helps treat cough and running nose. Zinc lozenges: Studies show they may reduce the duration of a cold or flu.
Constipation Plantago seed: Also called psyllium seed, this is an effective herbal laxative. Take it with plenty of water. Pureed rhubarb: Flavored with apple juice, lemon, and honey, pureed rhubarb is a delicious way to solve the problem. Water and fiber: Water (six to eight glasses a day) and fiber (fruit, bran cereal, prunes) consumed regularly should keep this problem away, and regular exercise is also helpful. Depression Hypericum: Also known as St. John's wort, hypericum is a common herb that blooms around the time of St. John's birthday, hence its name. It is a proven antidepressant for mild or moderate problems. It probably does not work as well for more serious depression, which requires pharmaceuticals, but that issue is under study. Capsules are readily available over the counter. St. John's wort has few if any side effects. Do not take with any prescription medication for depression. Licorice: Black licorice contains monoamine oxidase inhibitors. These are the same antidepressant chemicals found in prescription pharmaceutical products such as phenelzine and tranylcypromine. Licorice is powerful medicine. As with any monoamine oxidase inhibitor, avoid smoked foods and aged cheeses, alcohol, narcotics, and cold and allergy remedies, and do not take it if you are on any prescription medication for depression or if you have an adrenal disorder. Add some to an herbal tea that has its own antidepressant properties, such as tea made with ginger, purslane, or rosemary. Light therapy: These are bright-light boxes that are placed at eye level on a desk or table. Light boxes are made specifically to reduce depression, and they are especially effective in northern parts of the world where sunlight is rare or during winter months in the northern hemisphere. Light boxes are used in mainstream medicine and recommended by psychiatrists to treat seasonal affective disorder. Meditation and yoga: These are very helpful for depression as well as anxiety (see Anxiety and Stress). Tai chi: This gentle exercise program is practiced daily by millions of older Chinese. Follow the slow motions, which typically mimic animal movements, as displayed in books, videos, and classes. Research shows that tai chi not only lifts depressed mood, but that it also improves bodily balance, reduces falls, and increases physical strength. Diarrhea Relieve diarrhea with agrimony or peppermint tea; applesauce or cooked carrots; dried blackberry, blueberry, or raspberry leaves; dried blueberry fruit; or up to two teaspoons of pulverized seeds from the herb fenugreek. Headache Acupressure: Press the acupoint between your eyebrows or in the hollows at the base of the skull on both sides of the spine. Evening primrose tea: sunflower seeds, garlic, and onion relieve headaches, too. Feverfew: Make tea (steep six to eight leaves in boiling water; avoid further boiling because it will break down the active chemicals) or take capsules of fresh or freeze-dried leaf. Add bay leaves to feverfew tea to increase effectiveness against headaches, including migraines. Progressive relaxation or massage: See Anxiety and Stress. Heartburn Herb teas: Especially ginger, camomile, and licorice. Salad items: Including lettuce, onion, garlic, and olives. Walnuts, in addition to fennel or anise tea, also help. Indigestion Peppermint or chamomile tea. Nausea Acupressure: Press inside of wrist with fingers of other hand. (See Anxiety and Stress). Cinnamon or peppermint tea. Ginger: Use tea, capsules, or candy. Add fresh shaved gingerroot to boiled water to make tea, or add sugar and gelatin to the boiled ginger water and let it cool. Cut into cubes and eat as candy. Ginger ale or cookies, if made with real ginger and not flavoring, work too. Chronic Pain Acupuncture: Consult the yellow pages in your local telephone directory for a licensed, accredited acupuncture doctor. Properly trained acupuncturists use disposable stainless steel needles and do a virtually painless job. Biofeedback: This requires equipment and a trained biofeedback therapist. Check the telephone book. Many pain clinics and pain management experts in hospitals use biofeedback or can make referrals. Useful herbs: External capsicum (see Backache or Muscle Ache), sunflower seeds (eat them or grind them with some oil or water and apply to skin), willow bark ("natural aspirin") tea (avoid if you have been instructed to not take aspirin), mountain mint leaf tea (apply the cooked leaves to the skin). Hypnotherapy: Some people can eliminate chronic pain, or reduce it substantially, with hypnosis. Pain clinics, the telephone book, and your nurse or doctor are good referral sources for certified hypnotherapists. Massage: See Anxiety and Stress. Sleep Problems Relax in a warm bath scented with lavender oil, drink lemon balm herb tea, or try massage or meditation. Make tea of fresh or dried passionflower herbs, valerian root, or chamomile. REFERENCES
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Copyright © 1999 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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