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Patients Use Complementary and Alternative Medicine
More Frequently
 Cecile
A. Lengacher, RN, PhD
Bradenton, FL
clengach@hsc.usf.edu
Mary P.
Bennett, DNSc, RN
Terre Haute, IN
nubenne@befac.indstate.edu
Women
are the highest users of complementary and alternative medicine (CAM), and
breast cancer is the leading form of cancer and the second leading cause
of cancer death among American women. The number of people living with
cancer is estimated to double from 2000 to 2050 (Simmonds, 2003). Having
breast cancer is a highly stressful experience from the time of diagnosis,
through surgery, and during adjuvant treatment (Epping-Jordan et al.,
1999). Overall, women with breast cancer have been identified as
consistent users of CAM (Boon et al., 2000; Lengacher et al., 2002;
Sparber et al., 2000).
Defining Complementary and
Alternative Medicine
CAM therapies are distinctly different.
Complementary therapies are methods or therapies used to enhance
mainstream medicine and improve quality of life (e.g., symptom management)
(Cassileth, 1999; Ernst & Cassileth, 1998). On the other hand,
alternative therapies are literally any other therapy that is used as a
substitute for mainstream or conventional medicine; these therapies can
include any unproven therapy that promotes cure or symptom management
(Cassileth). Often, cancer medicine claims that alternative therapies are
superior to traditional cancer treatments such as surgery, chemotherapy,
and radiation.
The distinction between the two groups of therapies
is evident in the renaming of the National Institutes of Health, Office of
Alternative Medicine, to the National Center for Complementary and
Alternative Medicine (NCCAM). NCCAM better defines CAM as practices that
are not presently considered to be an integral part of conventional
medicine and has categorized them into biologically based mind-body
interventions, manipulative and body-based methods, alternative medical
systems, and energy therapies (Richardson, 2001). “Integrative health
care” has emerged as a new term used to describe a synthesis or blend of
both alternative and complementary and conventional care (Milton, 1998).
Trends in Complementary and Alternative Medicine
Use
Although healthcare professionals and practitioners of
conventional medicine have justifiably criticized most CAM therapies for
the relative lack of peer-reviewed, scientifically conducted research, use
of CAM therapies has increased to such an extent that medical science can
no longer ignore their benefits and hazards (Hennekens, Buring, &
Peto, 1994; Office of Technology Assessment, 1990). Reported use of
alternative therapies increased in the general population from 33.8% in
1990 to 42.1% in 1997 (Eisenberg et al., 1998). In addition, 25%–50% of
the general population in industrialized nations use CAM therapies (Ernst,
1995; Fisher & Ward, 1994; Gray, Tan, Pronk, & O’Connor, 2002;
MacLennan, Wilson, & Taylor, 1996). When surveying members of a
managed care organization, 42% reported using at least one CAM therapy
(Gray et al.).
Although use of CAM in patients with cancer and
patients without cancer is estimated to be as high as 45%–64%, the role of
CAM in the care of patients has little scientific support (Lengacher et
al., 2002; Risberg, Lund, Wist, Kaasa, & Wilsgaard, 1998). Up to 64%
of individuals use CAM in addition to their prescribed cancer treatments
(Ernst & Cassileth, 1998).
The reasons for increasing use of
CAM are very complex; however, increased consumer demand for more choice
and control and increased availability and variety of types of therapies
are factors (Begbie, Kerestes, & Bell, 1996). Ten percent of Americans
have seen a CAM practitioner for one or more of four particular
therapies—chiropractic, relaxation techniques, therapeutic massage, or
acupuncture—to augment traditional medical treatments (Paramore, 1997).
Various factors have caused this increased demand such as frustration with
high-tech depersonalized medicine and discontent with side effects of
traditional medicine (Shirreffs, 1996).
Clients turn to
complementary medicine because they value practitioners who treat the
whole individual and believe that this gives them some control over their
health (Vincent & Furnham, 1996). Consumers turn to complementary
therapies when traditional therapies do not diminish their symptoms or
suffering (Furnham & Rawlinson, 1996), if no cure is offered by
traditional medicine (Fawcett, Sidney, Hanson, & Riley-Lawless, 1994),
or if hope is lacking about a medical cure, which becomes a primary
motivation for use (Ernst, Willoughby, & Weihmayer, 1995).
Practitioners of complementary medicine are seen as being more
sympathetic, using better communication skills, and being more sensitive
to emotions (Furnham & Rawlinson). In addition, users of complementary
medicine have been found to be more educated, and complementary medicine
is congruent with their philosophy of life and health (Astin, 1998).
Increased use could be a reflection, in part, of a higher number of
insurers and managed care organizations that offer CAM programs and
benefits (Pelletier, Marie, & Krasner, 1997). Integrated medicine,
which combines traditional medicine with complementary therapies, is
projected to be the future of health care (Shirreffs,
1996).
Complementary and Alternative Medicine in
Oncology
Various approaches have been used to investigate CAM
therapy use among patients with cancer; however, prior studies are limited
by a number of factors. Early studies, while providing some information on
the use of alternative therapy, frequently were biased by focusing on what
the researchers termed “unorthodox, unconventional, or questionable”
cancer cures and did not adequately document participants’ use of
complementary therapies to improve well-being and quality of life
(Cassileth, Lusk, Strouse, & Bodenheimer, 1984). Many of these early
studies considered a therapy orthodox if it was used to improve mental
well-being, decrease pain, or improve quality of life but treated the
same therapy as unorthodox if the intent was to improve the physical
well-being of the person with cancer (Lerner & Remen, 1985).
In an early study that utilized a self-developed interview to
determine the prevalence of unorthodox cancer therapies among a sample of
Americans with cancer, 43% used conventional therapy alone, 8% used
unorthodox therapy alone, and 49% used a combination of conventional
therapy and unorthodox treatment (Cassileth & Chapman, 1996). The most
popular unorthodox treatments were metabolic therapy (42%), diet therapy
(35%), megavitamin therapy (24%), imagery (24%), spiritual and faith
healing (19%), and immune therapy (i.e., injecting various substances to
boost immune function) (15%). Most participants used more than one type of
unorthodox therapy combined with conventional medical treatment (Cassileth
& Chapman).
Similarly, in a study of 100 patients with cancer, 63%
reported using at least one CAM and 57% used CAM before and after
diagnosis; 18% who did not use CAM before diagnosis did so after
diagnosis, and 12% used CAM before diagnosis but did not afterward
(Sparber et al., 2000). The most frequently used therapies after diagnosis
were relaxation (26%), imagery (21%), exercise (16%), lifestyle and diet
therapies (24%), spiritual health (36%), and high-dose vitamins or
antioxidants (22%). Women reported using more therapies than men, and
reasons for use included treatment-related medical conditions such as
depression, anxiety, and insomnia. Patients reported that they used CAM to
cope with stress and their disease. Women with high levels of education
were more frequent users. This study did not examine use of CAM over time
but asked patients to report on prior use. The study also had a limited
sample (N = 100), of which 24 were patients with breast cancer. Although
this study described use of CAM in breast cancer, the interview was
retrospective in nature, rather than prospective throughout diagnosis, and
the sample sizes within each diagnostic category were small.
Based
on a review of 26 studies of the prevalence of CAM use in Western
developed countries, use ranged from 7%–64% and the average prevalence
across all studies was 31% (Ernst & Cassileth, 1998). The most
commonly used therapies were dietary treatments, herbs, homeopathy,
hypnotherapy, imagery or visualization, meditation, megavitamins,
relaxation, and spiritual healing (Ernst & Cassileth). However, some
of these estimates may be low because patients may be reluctant to report
use of unconventional therapies. Most studies have been conducted in
mainstream cancer programs; therefore, patients who forgo conventional
treatment are not included. Unconventional alternative therapy methods
tend to appeal to patients with advanced stages of cancer primarily to
improve their quality and length of life (Miller, Anderson, Stark,
Granick, & Richardson, 1998).
In their review, Sparber and
Wootton (2001) identified 19 studies related to use of complementary or
alternative cancer therapies for childhood cancer, adult cancer, and
breast cancer. They identified that CAM treatments still are alternatives
to conventional treatments, but the extent of use is unclear from the data
present in the studies. The authors reported that use of lifestyle and
self-healing therapies increased at a rate that was compatible with
conventional treatments.
Major changes during the intervening
decade include reporting of greater discrimination between questionable
and reputable alternatives with an increased openness in the use of CAM
and acceptance by society and the medical profession (Cassileth &
Chapman, 1996). In one study, 75% of surveyed patients with cancer stated
that they would like to ask their physician for a referral to a CAM
provider (Coss, McGrath, & Caggiano, 1998). Most physicians perceive
themselves as unfamiliar with available alternative cancer therapies and
reported that the main source of their information is their patients and
the lay press (Bourgeault, 1996). Physician attitudes and
reactions to use are influenced by the efficacy or inefficacy of standard
treatments and the invasiveness of the alternative therapy rather than by
the efficacy of the alternative therapy used (Bourgeault). Evidence also
suggests that oncologists’ reactions toward CAM may be less negative than
previously noted (Bourgeault).
Reliable prospective data are
lacking regarding which complementary therapies may be effective and which
interventions are used most often, either individually or in combination,
by patients with cancer. Few longitudinal studies have been completed;
however, the use and types of CAM do change over time (Risberg et al.,
1998; Verhoef, Hagen, Pelletier, & Forsyth, 1999). Major methodologic
shortcomings have included inconsistent definitions of CAM, lack of
distinction between therapies used in an adjunctive mode and those applied
toward cure exclusive of mainstream treatment, and selection bias.
Information is unavailable about CAM use and individuals admitted to
clinical trials, as well as types of cancer and CAM use. Researchers have
noted that standardized questions are needed to generate more comparable
data (Ernst & Cassileth, 1998). Future research needs to focus on
identifying beneficial therapies that can be used as adjuncts to cancer
treatment, such as relieving symptoms of cancer or controlling treatment
side effects (Office of Technology Assessment, 1990).
The efficacy
and safety data based on standard clinical trials are significantly
lacking as well as minimal published information in mainstream biomedical
literature (Owen & Fang, 2003). Although studies have examined the
efficacy of use of complementary therapies in patients with cancer in
North America and Europe, information is unavailable about the symptom
control and the symptom experience of patients with cancer who use CAM
therapies. Symptom management traditionally has focused on use of medical
treatment (i.e., medications for relief of symptoms). CAM typically seems
to be used for symptom management for a range of adverse effects resulting
from radiation, chemotherapy, hormones, steroids, and other biologic
responses.
Symptom control is a greater concern as aggressive
treatments become more common and are applied to a broader range of
patients (Simonton & Sherman, 1998). Sometimes the adverse side
effects from treatment are harder on patients than the disease itself and
can lead patients to discontinue or reduce the prescribed treatment
(Burish & Jenkins, 1992). To maintain a higher quality of life when
traditional medicine has failed to relieve symptoms, patients turn to CAM
therapies.
In a current study of 105 women diagnosed with breast
cancer, Lengacher (2004) found that patients used all multiple CAM
therapies to reduce physical symptoms and side effects. The highest
frequency of use was for traditional ethnic medicines (70% for
chiropractic), followed by stress-reducing techniques (51% for relaxation
techniques) and use of diet and nutritional supplements (50% for health
foods). The most frequently used CAM category to reduce psychological
distress was stress-reducing techniques (80% for counseling), and the
least used category was diet and nutritional supplements (30% for herbs,
such as ginkgo), with traditional ethnic medicine used often. Results
showed that CAM therapies were used to gain a feeling of control over
treatment, with the most frequently used category “use of diet and
nutritional supplements” to the least used category “use of
stress-reducing techniques.” The category of traditional ethnic medicine
often was used. Results showed that education and chemotherapy treatment
predicted use of CAM therapies.
Summary
Although several studies on the use of
complementary therapies in patients with cancer have been carried out in
North America and Europe, reliable information is lacking about the types
of therapies being used, how patients are referred to these therapies, the
reasons for choosing or implementing specific therapies, and whether some
patients use CAM in a manner that may compromise the effectiveness of
conventional treatment modalities. Reasons for use of CAM are poorly
understood. Review of studies indicates the following shortcomings:
Inconsistent definitions of CAM vary internationally, and broad
definitions result in the inclusion of lifestyle activities; therapies
used in complementary mode compared to those applied toward cure exclusive
of mainstream treatment are not distinguished; and selection can be
biased. The literature has not reported on CAM use among individuals
admitted to clinical trials along with their types of cancer and CAM use.
Standardized questions are needed to generate more comparable data, and
research should focus on identifying beneficial therapies that can be used
as adjuncts to cancer treatment (Ernst & Cassileth, 1998; Office of
Technology Assessment, 1990).
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Jo
Ann C. Owen, BSN, RN 
Pat
Snowden Dittig, RN, MSN, CRNP
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