Although viewed with scepticism by the medical and scientific community, complementary and alternative medicine (CAM) is being used by about 50% of Australians.
Integrative medicine is a holistic approach to cancer care, with some CAM of proven effectiveness being used as adjuvants to conventional medical treatments. However, there is little evidence of a systematic process of evaluation or dialogue between mainstream cancer medicine and CAM providers in Australia. Collaboration, guidance and support for relevant research in this area are needed.
The key elements of a process of furthering integrative medicine include improving knowledge about CAM; addressing uncertainties about CAM efficacy and safety; improving communication about CAM between medical practitioners and patients, and between medical practitioners and CAM practitioners; introducing regulatory frameworks and credentialing of CAM practitioners; and addressing ethical issues.
No longer a collection of covert practices, unconventional cancer medicine today is highly visible, and information about it is widely available to the general public. It is a multi-billion-dollar business in the United States and of equivalent impact and importance throughout the developed world.1
Complementary and alternative medicine (CAM) is a diverse group of medical and health care systems, practices and products, not presently considered part of conventional medicine.2 While the word complementary implies use in conjunction with standard medical treatments, alternative suggests use instead of standard treatments. In different circumstances, the same therapy could be used as complementary or alternative therapy.
In Australia, serial population-based surveys indicate that about half the population uses non-medically prescribed medicines and more than 20% visit CAM practitioners.3,4 Expenditure on CAM ($1.86 billion in 2004)4 represents about four times the public contribution to the Pharmaceutical Benefits Scheme.3
Cancer patients are frequent users of CAM: between 9% and 91% of patients diagnosed with cancer in the United States use some form of CAM after diagnosis.5 The large range in use is partly related to different classifications of CAM, frustrating attempts to compare the prevalence of different therapies.1,6 An Australian study found that 22% of cancer patients used CAM,7 a finding corroborated by a recent survey in New South Wales.8
Cancer patients use CAM for many reasons: for symptomatic relief;9 to improve their quality of life; because of concerns about the toxicity of conventional therapies;10,11 because CAM is congruent with their values and beliefs;11 or because they believe CAM can fight cancer, or boost their immune system.12
The emergence of CAM at the forefront of consumer health-seeking behaviour has significant medical, ethical and economic implications, and impacts on the public health mandate of protecting, promoting and restoring people’s health. The prevalence of and reasons for CAM use are well documented in the Australian medical literature, but the public health implications have received far less scrutiny.
Some CAM of proven effectiveness is being used as an adjuvant to conventional medical treatments in a holistic approach to cancer care termed integrative medicine,1 although the level of integration and the quality of services offered vary in different countries and among individual cancer centres. In Australia, integration has been slow to gather momentum, with a recent Senate inquiry13 capturing the views of the diverse stakeholders involved: conventional practitioners largely opposed it on the grounds of lack of evidence for effectiveness and safety, while consumer groups and CAM practitioners perceived that alternative cancer therapies were deliberately suppressed, as they challenged the prevailing cancer treatment paradigm.13 Here, we identify some issues to focus this debate.
Although ineffective in curing cancer, some CAM can be helpful in controlling cancer symptoms and enhancing quality of life. Reviews of the effectiveness of CAM in palliative care for patients with cancer found that treatments — such as acupuncture, massage, hypnotherapy, and relaxation — showed promise, but there was insufficient evidence to recommend their widespread use.14-16
The list of agents with purported cancer-fighting properties is growing rapidly, although few have been tested in rigorous clinical trials. Awareness of risks related to the use of herbal medicines is limited, and “natural” does not necessarily correlate with “safe”. Factors that pose specific challenges include: wide variation in biological potency among herbal crops;17 possible contamination by fungi, bacteria or pesticides;18 use of incorrect plant species;19 absence of product standardisation17 (leading to possible substitution adulteration and incorrect dosing or preparation); and inappropriate labelling or advertising.20 Some herbal medicines have toxic effects (kava causes hepatotoxicity), interact with prescription drugs (St John’s wort), or cause surgical complications (garlic, ginkgo, and ginseng may enhance bleeding; ephedra causes cardiovascular instability; and ginseng causes hypoglycaemia).20,21
Surveys of Australian, Italian and Canadian oncologists’ knowledge and utilisation of CAM have identified gaps in their knowledge of non-traditional therapies.22-24 In the US, many medical schools are now offering elective courses on CAM, yet few promote critical thinking in reviewing the evidence.25
Doctors underestimate their patients’ use of CAM: a recent study found that 37% of patients receiving radiotherapy used CAM; their doctors estimated that 4% of them did.26 One study found that about half the patients using CAM do not tell their doctors,4 either because they expect them to be disinterested or express disapproval,27 or they may be unaware of possible drug–CAM interactions. This limits opportunities for patient–physician dialogue about the risks and benefits of these treatments.
Despite its popularity, there has been limited research into CAM. Some of the challenges for CAM research relate to methodological issues, as individualised patient treatment (a cornerstone of the CAM philosophy) makes many CAM practitioners reluctant to adopt randomised controlled trial methodologies. There are also difficulties with recruitment for trials, identifying appropriate outcome measures, and finding appropriate placebos.28 Establishing research collaborations is also a problem,29 with few clinicians being supportive of CAM research.6 Added to this are differing research priorities, difficulties in securing research funding, and a reluctance of ethics committees to endorse research on products or procedures lacking formal safety testing.
In Australia, complementary medicines are regulated under the Therapeutic Goods Act 1989 (Cwlth), administered by the Therapeutic Goods Administration. Most complementary medicines are categorised as “listed” rather than “registered” products. They are therefore required to meet safety and quality of manufacture standards, rather than the rigorous quality, safety and efficacy evaluations required of registered products.30 The Expert Committee on Complementary Medicines in the Health System identified a need to improve the quality of adverse reaction reporting in complementary medicine to raise awareness of treatment interactions.30
Under the Australian Constitution, the power to regulate the health professions is the prerogative of state and territory governments. Regulation of CAM practitioners takes the form of statutory regulation or self-regulation. A nationally agreed process, in place since 1995, stipulates that occupational regulation is required only if the majority of the jurisdiction agree to it and certain criteria are met, one of which is a potential for causing harm.30 The Expert Committee30 recommended that all jurisdictions would need to develop more effective self-regulation for CAM professions, with some CAM practitioner groups receiving federal government support to explore implementation options.
Educational standards are extremely variable among Australian CAM practitioners, and consumers and health care professionals lack reliable methods of identifying suitably qualified practitioners.30 Acquiring and updating information on CAM should be part of undergraduate vocational and continuing medical education, but significant barriers remain in putting this into practice.30
Issues with significant ethical and legal ramifications include: identifying and reporting potential CAM–drug interactions;31 the use of CAM in children; determining acceptable levels of knowledge of CAM treatments for medical practitioners; and defining professional duty with regard to (i) patient information about CAM risks and benefits, (ii) when and how to refer patients to qualified CAM practitioners, and (iii) how to remain involved in a patient’s care.32,33 Practitioners also need to consider equity issues, as the sometimes significant costs of CAM treatments are borne largely by patients.
An important aspect of CAM is safeguarding consumer choices. Patients most commonly receive information on CAM from family and friends, the media,12 from books, and increasingly from the Internet.6 Using the Internet to gather information about CAM can empower individuals and give them greater opportunities to become active participants in their care, but separating reputable sources of information from those selling “bogus cures” challenges consumers’ ability to make informed decisions.34
The move of CAM from the “invisible mainstream” into the open signals a difference in perception between what patients expect of conventional medical practitioners and what practitioners themselves believe they are providing. Integrating CAM therapies into mainstream cancer care is contingent upon CAM meeting safety and efficacy standards and on the development of effective collaborations among relevant stakeholders. Some steps that could facilitate program planning and implementation are given in the Box. An integrated model needs to be built around a tailored CAM research agenda, a mentoring program for CAM researchers, and the development of evidence-based practice models.35 A combined research and clinical program of integrative medicine, as commonly practised in North America,1 could foster dialogue between CAM and conventional treatment providers, and create new opportunities for collaborations to both explore the potential of novel treatments and facilitate their rigorous evaluation.5
The medical and public health communities need to become more involved in this dialogue: CAM is not a passing fad and, in view of its enormous popularity, the potential for harm, and the lack of effective mechanisms to safeguard consumer choices, it is time for clinicians and public health practitioners to learn more about “the other side”.
Suggested ways of advancing the process of integrating CAM into mainstream cancer care
Consult stakeholders to define scope, objectives and outcomes
Form collaborative group to include “CAM champions”
Agree on models and implementation options
Identify possible pilot sites for integrated CAM delivery, informed by local interests and available expertise
Define scope of CAM in pilot sites and expected outcomes
Assess options and requirements for educational programs
Define target audiences (eg, medical undergraduates, oncology trainees, clinicians, general practitioners, nurses)
Provide reviewed and regularly updated information for consumers
Develop professional communications and professional continuing medical education modules on CAM
Identify interested research groups and establish common goals
Define research priorities
Provide training in research methodology for interested CAM researchers
Establish research collaborations, depending on interests and available expertise
Consider including operational research in all new projects
Support research on public health questions related to CAM
Collaborate with statutory bodies to define options for CAM registration
Assist the process of developing credentialing policies
Define practice standards for CAM treatments suitable for integration
Define procedures around obtaining informed consent and risk management
Establish pharmacy policies relating to products such as dietary supplements and herbal remedies
Establish policies on granting of clinical privileges and practice reimbursements
Stipulate malpractice liability arrangements
Assist the translation of CAM therapies into standardised diagnostic and treatment codes and define clear practice standards
Clarify the role played by CAM practitioners in health care provision
Develop an agreed ethical base for CAM practice
Agree on referral guidelines and systems
Reach agreements on CAM practitioners’ working relationships with conventional practitioners
- 1. Cassileth BR, Deng G, Vickers A, Yeung, SK. Integrative oncology: complementary therapies in cancer care. Hamilton, Ontario: BC Decker, 2005.
- 2. National Center for Complementary and Alternative Medicine. Get the facts. What is complementary and alternative medicine? http://nccam.nih.gov/health/whatiscam/ (accessed Sep 2006).
- 3. MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-573.
- 4. Maclennan AH, Myers SP, Taylor AW. The continuing use of complementary and alternative medicine in South Australia: costs and beliefs in 2004. Med J Aust 2006; 184: 27-31. <MJA full text>
- 5. White JD. The National Cancer Institute’s perspective and agenda for promoting awareness and research on alternative therapies for cancer. J Altern Complement Med 2002; 8: 545-550.
- 6. Ernst E. The current position of complementary/alternative medicine in cancer. Eur J Cancer 2003; 39: 2273-2277.
- 7. Begbie SD, Kerestes ZL, Bell DR. Patterns of alternative medicine use by cancer patients. Med J Aust 1996; 165: 545-548. <MJA full text>
- 8. Girgis A, Adams J, Sibbritt D. The use of complementary and alternative therapies by patients with cancer. Oncol Res 2005; 15: 281-289.
- 9. Kimby CK, Launso L, Henningsen I, Langgaard H. Choice of unconventional treatment by patients with cancer. J Altern Complement Med 2003; 9: 549-561.
- 10. Menniti-Ippolito F, Gargiulo L, Bologna E, et al. Use of unconventional medicine in Italy: a nation-wide survey. Eur J Clin Pharmacol 2002; 58: 61-64.
- 11. Singh H, Maskarinec G, Shumay DM. Understanding the motivation for conventional and complementary/alternative medicine use among men with prostate cancer. Integr Cancer Ther 2005; 4: 187-194.
- 12. Shen J, Andersen R, Albert PS, et al. Use of complementary/alternative therapies by women with advanced-stage breast cancer. BMC Complement Altern Med 2002; 2: 8.
- 13. Parliament of Australia Senate Community Affairs References Committee. The cancer journey: informing choice. Report on the inquiry into services and treatment options for persons with cancer. Canberra: Commonwealth of Australia, 2005. http://www.aph.gov.au/Senate/committee/clac_ctte/cancer/report/index.htm (accessed Aug 2006).
- 14. Ernst E. Complementary therapies in palliative cancer care. Cancer 2001; 91: 2181-2185.
- 15. Fellowes D, Barnes K, Wilkinson S. Aromatherapy and massage for symptom relief in patients with cancer. Cochrane Database Syst Rev 2004; (2): CD002287.
- 16. Pan CX, Morrison RS, Ness J, et al. Complementary and alternative medicine in the management of pain, dyspnea, and nausea and vomiting near the end of life. A systematic review. J Pain Symptom Manage 2000; 20: 374-387.
- 17. Glickman-Simon R. Complementary and alternative medicine (CAM): an evidence-based approach. Medscape, 2005. http://www.medscape.com/viewarticle/507242 (accessed Aug 2006).
- 18. Ko RJ. Adulterants in Asian patent medicines. N Engl J Med 1998; 339: 847.
- 19. Murch SJ, KrishnaRaj S, Saxena PK. Phytopharmaceuticals: problems, limitations, and solutions. Sci Rev Alternat Med 2000; 4: 33-37.
- 20. Drew AK, Myers SP. Safety issues in herbal medicine: implications for the health professions. Med J Aust 1997; 166: 538-541. <MJA full text>
- 21. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA 2001; 286: 208-216.
- 22. Newell S, Sanson-Fisher RW. Australian oncologists' self-reported knowledge and attitudes about non-traditional therapies used by cancer patients. Med J Aust 2000; 172: 110-113. <MJA full text>
- 23. Crocetti E, Crotti N, Montella M, Musso M. Complementary medicine and oncologists' attitudes: a survey in Italy. Tumori 1996; 82: 539-542.
- 24. Bourgeault IL. Physicians’ attitudes toward patients’ use of alternative cancer therapies. CMAJ 1996; 155: 1679-1685.
- 25. Sampson W. The need for educational reform in teaching about alternative therapies. Acad Med 2001; 76: 248-250.
- 26. Kao GD, Devine P. Use of complementary health practices by prostate carcinoma patients undergoing radiation therapy. Cancer 2000; 88: 615-619.
- 27. Richardson MA, Masse LC, Nanny K, Sanders C. Discrepant views of oncologists and cancer patients on complementary/alternative medicine. Support Care Cancer 2004; 12: 797-804.
- 28. Richardson MA, Straus SE. Complementary and alternative medicine: opportunities and challenges for cancer management and research. Semin Oncol 2002; 29: 531-545.
- 29. Lie D. Conference report: 2nd International Scientific Conference on Complementary, Alternative and Integrative Medicine Research; 2002 Apr 12-14; Boston, Mass. Medscape Family Medicine/Primary Care, 2002.
- 30. Expert Committee on Complementary Medicines in the Health System. Complementary medicines in the Australian health system. Report to the Parliamentary Secretary to the Minister for Health and Ageing. Canberra: Commonwealth of Australia, 2003. http://www.tga.gov.au/docs/html/cmreport1.htm (accessed Aug 2006).
- 31. Rosenthal DS, Dean-Clower E. Integrative medicine in hematology/oncology: benefits, ethical considerations, and controversies. Hematology Am Soc Hematol Educ Program 2005; 491-497.
- 32. Australian Medical Association. AMA position statement on complementary medicine 2002. Canberra: AMA, 2002. http://www.ama.com.au/web.nsf/doc/WEEN-6L74GC (accessed Sep 2006).
- 33. Kerridge IH, McPhee JR. Ethical and legal issues at the interface of complementary and conventional medicine. Med J Aust 2004; 181: 164-166. <MJA full text>
- 34. Lowenthal RM. Public illness: how the community recommended complementary and alternative medicine for a prominent politician with cancer. Med J Aust 2005; 183: 576-579. <MJA full text>
- 35. Giordano J, Engebretson J, Garcia MK. Challenges to complementary and alternative medical research: focal issues influencing integration into a cancer care model. Integr Cancer Ther 2005; 4: 210-218.
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