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© 2000 American Society for Clinical Oncology
Discussing Complementary Therapies With Cancer Patients: What Should We Be Talking About?Dana-Farber Cancer Institute, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA THE USE OF COMPLEMENTARY and alternative medicine (CAM) has become the norm for many cancer patients. Large surveys published in this issue of the Journal of Clinical Oncology demonstrate that at least two thirds of all cancer patients are engaged in some form of complementary or alternative health practices. What does this mean, and what should oncologists do about it? As published in the current issue of the Journal of Clinical Oncology, Richardson et al1 at the M.D. Anderson Cancer Center conducted cross-sectional prevalence surveys on the use of CAM among patients in their clinics. Eighty-three percent of patients from across a spectrum of malignancies and disease stages acknowledged use of complementary health practices, including 69% who were using some method besides spirituality or psychotherapy. On average, patients using CAM were found to use four to five different therapies. Expectations for CAM were quite high: patients expected CAM to improve their quality of life, alleviate symptoms, prolong life, cure their disease, and boost their immune system. Patients with incurable disease particularly valued CAM for its medicinal potential. Among the reasons cited for use of CAM, patients included hopefulness, the lack of toxicity, and a desire to have more control over their medical care. The related study in this issue by Boon et al2 was a population-based cross-sectional prevalence survey of use of CAM among women in Ontario, Canada, who had previously been diagnosed with breast cancer. In this cohort, the prevalence rate for CAM practices was 67%, and again, patients typically employed a large number of methods. Patients identified their desire to "boost the immune system," enhance their quality of life, gain control over their life, prevent or treat their cancer, and treat side effects of cancer therapy as the principal reasons for using CAM. Patients credited their conventional practitioners with truthfulness and technical knowledge. By contrast, they particularly valued their CAM providers for providing emotional support and listening. Unfortunately, neither set of surveys captured extensive data on conventional medical treatments or conducted formal evaluations of health-related quality of life among study participants. For any given patient, it is not possible to know when CAM use began, why specific CAM modalities were chosen, or whether CAM interest influenced standard medical treatment choices. Both reports, however, offer important insights into the role of CAM in the lives of cancer patients. CAM use is affected by a variety of demographic, social, clinical, and personal factors. As has been widely documented and confirmed by both Richardson et al1 and Boon et al,2 education, wealth, sex, and age all strongly influence prevalence rates for CAM utilization. Over the past decade, there has been a steady increase in the prevalence of CAM among the general population and among cancer patients.3,4 The reasons for this increase include public interest in natural or holistic therapies, the creation of a marketplace for CAM products and practitioners, the easing of labeling regulations on dietary supplements, the dissemination of CAM information through mass media and the Internet, an expanding health consciousness in American society, social acceptance of nonstandard medical practices, and disillusionment with the way conventional health care is delivered.5,6 In addition, the definition of CAM has been broadened to include dietary and lifestyle behaviors as well as personal philosophies or religious sentiments that were not formerly considered part of unorthodox or alternative medicine, back when those phrases implied the exclusive use of unproven medicinal therapeutics such as laetrile.7 Despite the sense that CAM use is becoming more widespread, oncologists may be surprised to find just how common this practice is, because we tend to not ask about it. A recent study prospectively evaluated the prevalence of CAM use among patients receiving radiation therapy.8 Routine history taking and physical examination, including questions about medications, disclosed that 5% of patients were taking some form of CAM. However, subsequent directed questioning specifically seeking use of CAM disclosed that an additional 40% of patients were engaged in some form of complementary health practice. This small study suggests that clinicians will miss 80% to 90% of all CAM utilization if they do not directly inquire about such practices. Oncologists are not unique in this regard; in a survey of arthritis patients, the most common reason patients cited for not telling their rheumatologists about CAM was that the physician did not ask.9 The findings published by Richardson et al1 and Boon et al2 further document the communication gap that separates patient practices from physician awareness. Substantially fewer than one half of the patients fully reported their CAM practices to physicians. As yet, there have been no data to suggest that people who use CAM eschew conventional medicine. Partly, this reflects methodologic biases inherent to most studies of CAM. Most research, as in the instance of the report by Richardson et al1 at M.D. Anderson, has been conducted within the walls of traditional clinical facilities, where one expects patients to receive standard medical treatments. In population-based studies, such as reported by Boon et al,2 documentation of traditional treatments is quite difficult. Nonetheless, there is little reason to believe that patients are choosing CAM instead of standard oncologic care. In a study of treatment choices among women with early-stage breast cancer, there were no differences between conventional medical treatments chosen by women who either did or did not use CAM.10 Similarly, studies of the population at large have demonstrated that people who use CAM are avid consumers of traditional health care,11 perhaps even receiving more conventional care than nonusers of CAM, despite having equivalent health status.12 The great majority of patients using CAM probably do so in conjunction with standard cancer therapies, and not to the exclusion of oncologic treatments that physicians endorse. These practices are most aptly described as complementary, and not alternative. A concern is that these adjunctive practices might pose risks to patients. There are theoretical reasons for thinking that some vitamin or herbal supplements might biochemically interfere with chemotherapy or radiation treatments,13 adversely alter treatment compliance,14 or cause side effects such as hepatic injury.15 Although there are only limited data on the safety of most herbal products, there is little clinical evidence to suggest that many of them either cause harm or interact unfavorably with regular medications. Further, these concerns apply principally to CAM that are ingested or injected. Many common CAM modalities (chiropractic, spirituality, meditation, body/mind therapies, and so on) are probably much less likely to have side effects. There is also little evidence that CAM practices work in a medical sense. A comprehensive literature search of CAM for breast cancer disclosed a lack of "documentation of the efficacy of popular unconventional therapies or ideas about other ways to improve... survival or disease-free survival."16 For other cancers, the number of substantial clinical reports is so limited as to preclude an analysis. In the studies by Richardson et al1 and Boon et al,2 most patients taking CAM held the notion that it would help their immune system. There are no convincing data that any CAM practice "boosts" the immune system, as defined by clinically important end points. Why are cancer patients using CAM? The reports published in the Journal of Clinical Oncology are notable, because investigators have finally asked patients that question. The answers are very honest and compelling: whereas some patients may believe they are directly treating their malignancy, most cancer patients try CAM to make themselves feel better, to give themselves more control of their health, and to sustain hope. Among patients at M.D. Anderson, 73% of patients were using CAM in order to feel hopeful, 77% wanted CAM to improve their quality of life, 44% wanted relief of symptoms, and 44% wanted greater control in the decision-making process for their medical care.1 More than one half of breast cancer patients in Ontario who were using CAM cited an increase in quality of life as a major reason, 38% sought control over their life, and 21% wanted relief from side effects of standard therapies.2 Other research studies support the idea that impaired quality of life and patient symptoms drive the utilization of CAM. Greater psychosocial distress, impaired health-related quality of life, and greater numbers and intensity of somatic symptoms were all associated with new use of CAM after diagnosis of early-stage breast cancer.10 Among patients with brain tumors, use of CAM was associated with cancer-related impaired physical well-being and functioning,17 and among arthritis patients, pain control was the most common reason cited for use of CAM.9 Given the prevalence of CAM practice among cancer patients, oncologists need to grapple with the implications for our patients and ourselves. An interpretation of the reports of Richardson et al 1 and Boon et al2 is that cancer patients have many legitimate needs and concerns that they are trying to meet through complementary health practices. Although cancer patients include treating their tumors and their therapy-related side effects among their reasons for using CAM, the role of CAM extends far beyond the purported medicinal value of any CAM, and in fact, may have little to do with whether or not CAM works as a traditional medicine. Patients are seeking relief of physical, emotional, and existential discomfort. As pointed out in the survey by Boon et al,2 our patients have great confidence in the technical and therapeutic knowledge held by oncologists. However, cancer patients will often pursue active engagement in their health care and seek solace and comfort for their afflictions through the extramural medical realm of complementary and alternative therapy. The suggestion that CAM use is often not about cancer treatment but about feeling better and about having greater control over one’s destiny argues that the most important thing to do about CAM is to talk about it. Oncologists need to "ask the unasked question"18 and probe directly and specifically for use of alternative therapies or participation in other complementary health-related behaviors. We should expect that the answer will be yes, and the follow-up question is why. We need to understand what patients are expecting and seeking from CAM and how they chose their particular practices. This requires sensitivity to the cultural, social, and ethnic diversity among our patients. One study compared the CAM choices of breast cancer patients drawn from four different ethnic groups.19 The overall prevalence rate for CAM was essentially the same for whites, African-Americans, Latinos, and Chinese. However, the particular types of CAM pursued by each ethnic group differed greatly. Next, we need to assess patients carefully for symptoms of physical discomfort or emotional distress. Cancer patients merit optimal treatment for pain, anxiety or mood disorders, sleep disturbance, and other symptoms. Screening for impaired quality of life can be a difficult task within the confines of brief clinical encounters, and better tools are needed. Discussions originating from patient use of CAM represent an opportunity to forge a stronger relationship with our patients by listening carefully to their concerns about health and illness in the broadest context. This does not mean we need to endorse CAM for our patients. Most patients will be gratified for the chance to have a frank and honest discussion about what they are thinking and doing when not in the doctor’s office. Physicians can acknowledge the lack of safety and efficacy data for most CAM without sacrificing the appropriately high standards of evidence in oncology. Oncologists can offer patients greater empowerment and choice within health care by encouraging them to participate more directly in the traditional clinical decision-making process. In sum, the interest in CAM is an understandable expression of the hopes, concerns, and symptoms experienced by cancer patients. Such interest poses a challenge to oncologists: a challenge not to our scientific credentials or clinical intentions, but a challenge to be better doctors—to treat the disease and the patient. The use of complementary health-related practices is an opportunity to discuss the meanings that lie behind these practices, to share further in the experience of illness and well-being, and to focus clinicians on the genuine needs of cancer patients that neither surgery nor radiation nor chemotherapy can satisfy. REFERENCES
1.
Richardson MA, Sanders T, Palmer JL, et al: Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol 18:2505-2514, 2000
2.
Boon H, Stewart M, Kennard MA, et al: The use of complementary/alternative medicine by breast cancer survivors in Ontario: Prevalence and perceptions. J Clin Oncol 18:2515-2521, 2000 3. Ernst E, Cassileth BR: The prevalence of complementary/alternative medicine in cancer. Cancer 83:777-782, 1998[Medline]
4.
Eisenberg DM, Davis RB, Ettner SL, et al: Trends in alternative medicine use in the United States, 1990–1997. JAMA 280:1569-1575, 1998
5.
Astin JA: Why patients use alternative medicine: Results of a national study. JAMA 279:1548-1553, 1998 6. Angell M, Kassirer JP: Alternative medicine: The risks of untested and unregulated remedies. N Engl J Med 229:839-841, 1998
7.
Lerner IJ, Beckhardt S: The physician and unorthodox cancer therapies. J Clin Oncol 15:401-406, 1997 8. Metz JM, Jones H, Devine P, et al: Cancer patients use unconventional medical therapies far more frequently than standard history and physical examination suggests. Proc Am Soc Clin Oncol 19:602a, 2000 (abstr 2368)
9.
Rao JK, Mihaliak K, Kroencke K, et al: Use of complementary therapies for arthritis among patients of rheumatologists. Ann Int Med 131:409-416, 1999
10.
Burstein HJ, Gelber S, Guadagnoli E, et al: Use of alternative medicine by women with early-stage breast cancer. N Engl J Med 340:1733-1739, 1999
11.
Eisenberg DM, Kessler RC, Foster C, et al: Unconventional medicine in the United State: Prevalence, costs, and patterns of use. N Engl J Med 328:246-252, 1993
12.
Druss B, Rosenheck RA: Association between use of unconventional therapies and conventional medical services. JAMA 282:651-656, 1999 13. Labriola D, Livingston R: Possible interactions between dietary antioxidants and chemotherapy. Oncology 13:1003-1012, 1999[Medline] 14. Durant JR: Alternative medicine: An attractive nuisance. J Clin Oncol 15:1-2, 1998 (editorial)
15.
Pratt DS, Kaplan MM: Evaluation of abnormal liver-enzyme results in asymptomatic patients. N Engl J Med 342:1266-1271, 2000
16.
Jacobson JS, Workman SB, Kronenberg F: Research on complementary/alternative medicine for patients with breast cancer: A review of the biomedical literature. J Clin Oncol 18:668-683, 2000
17.
Verhoef MJ, Hagen N, Pelletier G, et al: Alternative therapy use in neurologic diseases: Use in brain tumor patients. Neurology 52:617-622, 1999
18.
Eisenberg DM: Advising patients who seek alternative medical therapies. Ann Intern Med 127:61-69, 1997
19.
Lee MM, Lin SS, Wrensch MR, et al: Alternative therapies used by women with breast cancer in four ethnic populations. J Natl Cancer Inst 92:42-47, 2000 This article has been cited by other articles:
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Copyright © 2000 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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