Complementary therapies
No longer a collection of covert practices, complementary therapies today are highly visible, and information about them is widely available to the general public. Their use is increasing in Australia with many people with cancer using complementary therapies on a regular basis.
by Professor Stephen J. Clarke
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Medicine, whether conventional or complementary, is the science or art of restoring or preserving health and treating disease. Early last century, scientific medicine emerged as the dominant model for health care in the West. Despite the success of scientific medicine, many people have continued to seek treatment outside conventional medicine. 1
Complementary therapies are a diverse group of treatments, varying from non-invasive treatments such as massage, music therapy and meditation through to systemic treatments such as Chinese herbal medicines, vitamins and nutritional support. A principal emphasis of complementary therapies is provision of supportive care that can improve wellbeing and maintain quality of life for people with cancer. Their use is increasing in Australia with many people with cancer using complementary therapies on a regular basis. Health professionals are increasingly seeing some of these therapies as useful, particularly their potential for dealing with side effects of treatments and the emotional wellbeing of patients. Some hospitals are offering some of these therapies as part of the care pathway for people being treated for cancer.
Cancer in Australia is conventionally treated by surgery, radiotherapy, chemotherapy and palliative care or a combination of these. When people are diagnosed with cancer, they may continue or start to use complementary therapies either during or after their cancer treatment, often without the knowledge of health professionals.
More and more people are focused not only on ridding their body of cancer but in maintaining emotional, physical and psychological wellbeing.
Many people facing a cancer diagnosis want to take a more holistic approach to their recovery than conventional treatments offer. More and more people are focused not only on ridding their body of cancer but in maintaining emotional, physical and psychological wellbeing.
In Australia, the use of complementary therapies is widespread. A 1993 survey by MacLennan et al 2 found that in the previous year, close to half of all respondents (48.5 per cent) had used at least one ‘alternative’ medicine. In 2000 a similar survey found the overall use of complementary therapies had increased to 52.1 per cent. 3 In just seven years the Australian health consumer expenditure on complementary medicines and therapies had more than doubled from approximately $1 billion in 1993 to an estimated $2.3 billion in 2000. Yet there is still little scientific evidence to support many of the claimed beneficial effects of complementary therapies.
Reasons for use
Why do people turn to these therapies? A variety of reasons have been proposed for the use of CAM (complementary and alternative medicine). A recent systematic review found the most common reasons were: a perceived beneficial response from CAM (38%); a desire for control (17%); a last resort after failure of conventional treatment (10%); and finding hope (10%). 4 Studies from overseas suggest that chronic symptoms and the real or perceived side effects of conventional treatments also influence decision making. 5 Complementary therapists tend to view their patient’s disease and its effects on the whole body rather than from a specialised clinical view or within the time pressured environment of primary care. 6 How popular a complementary therapy is should not be confused with its value. The popularity of complementary therapies may simply reflect the supposed limitations of conventional treatments. CAM are more commonly used by women, young people and those from a higher socioeconomic status, however the latter issue may be due to the costs associated with many types of CAM and a lack of reimbursement for the costs incurred.
Research into CAM
In the past 20 years there has been substantial research on the effectiveness of complementary therapies; however, there is still insufficient evidence to support many CAM treatments. By March 2004 the Cochrane Collaboration had 145 completed reviews of randomised controlled trials of complementary and alternative therapies: a third showed a positive or possibly positive effect, although more than half found insufficient evidence to make any judgments in regard to efficacy. 7 While this suggests evidence for the effectiveness of some complementary therapies, further research is required.
There is still a significant lack of research dealing with many complementary therapies.
Conventional cancer treatments are relatively new and have been through rigorous testing to determine their safety and effectiveness, whereas many complementary therapies are derived from traditional methods and may have been used for hundreds or thousands of years. Their effectiveness has been based on trial and error and knowledge about their use has been passed down through the generations, often by word of mouth. Traditional therapists don’t always know how or why a remedy works, but they use it because of a longstanding belief that it is effective.
There is still a significant lack of research dealing with many complementary therapies. While much research is being undertaken, a cohesive and coordinated approach is required to ensure consumers receive independent information about therapies and high quality products and services. The National Institute of Complementary Medicine (NICM) has been established in Australia and is attempting to encourage and coordinate research into complementary medicines nationally. Disease specific interest groups, including cancer, are being established to develop priorities for research endeavours. Funding for research will be provided both by NICM and the NHMRC (National Health and Medical Research Council).
Benefit & risks
An important premise of cancer treatment is the respect for patient choice in meeting their medical needs. However, it is important to advise patients about the realistic expectations of benefit and risk in using complementary therapies.
It is important to advise patients about the realistic expectations of benefit and risk in using complementary therapies.
Each therapy poses a different risk to a cancer patient. Of major concern to the traditional cancer specialists is the issue of whether the complementary therapies might adversely affect their conventional cancer treatments, such as chemotherapy. This is particularly the case with systemically administered CAM including vitamins and herbal medicines. For example, vitamin C makes urine acidic and may impair the renal excretion of cancer drugs such as methotrexate, which crystallises in acidic fluids. This can lead to renal impairment and increased toxicity from methotrexate to the bowel and bone marrow, which can produce severe infection, morbidity and mortality. Furthermore, it has been shown that herbal remedies such as the anti-depressant St. John’s Wort may induce cytochrome P450 3A and the drug transporter P-glycoprotein. These interactions have the potential to reduce the effectiveness of a number of cytotoxic anti-cancer drugs. It is possible that other herbal remedies have similar effects; however, the potential for many herbs to interact with conventional systemic therapies is unknown. This situation mandates more research in this area, but also highlights the importance of communication between patients and doctors about their use of CAM. There is evidence that patients will not inform their doctors about CAM use if they perceive the doctors will react negatively.
With the interest in complementary therapies growing around the world, many therapies are coming under scientific scrutiny to determine whether they are clinically effective and, if they are, how they actually work. A majority of cancer treatment and research is undertaken in tertiary institutions in Australia and in order to respond to both the increased use of CAM and necessity to undertake research in this area many hospitals and universities have developed units with expertise in CAM. This should assist in allaying fears about the bona fides and expertise of the CAM practitioners involved and ensures that patients receive optimal therapies.
Access to CAM
To assess the current provision of facilities for CAM use in NSW Hospitals, the NSW Government cancer control agency, the Cancer Institute NSW, conducted a Complementary Therapies Access Review in 2005 to determine those complementary therapies currently offered to people with cancer through the NSW Area Health Services.
With attitudes of doctors and administrators towards CAM changing we should shortly be able to provide Australian cancer patients with a full spectrum of evidence based cancer treatments.
The review was conducted to provide baseline data on the complementary therapies currently offered in cancer services in NSW. Thirty-six health professionals from 32 cancer services participated in the survey. Each Area Health Service in NSW and private services were included. Thirty-one of the centres provided at least one complementary therapy.
Cancer services were most likely to offer complementary therapies that were mind and body based, were non-invasive, and which helped patients cope during treatment and recovery. Ninety-one per cent of cancer services provide counselling and supportive programs and 84 per cent run support groups. Some form of relaxation or psycho-education program exists in 59 per cent of services; more than 40 per cent provide imagery or visualisation and another 31 per cent offer meditation. However, manipulative-based therapies were rarely offered, nor were herbal approaches. Diet is an important aspect of everyone’s health but is central to recovery yet only a third of services employ a dietician to ensure patient’s nutritional needs are being met and 9 per cent provided vitamin or mineral supplements or nutritional supplements. Interestingly, no services provide energy medicine therapies or traditional whole medical systems such as Chinese medicine, homeopathy and Ayurvedic medicine.
Cancer services were keen to increase the numbers and types of complementary therapies they offer and saw their main role as supporting patients in making decisions about complementary therapies.
These data clearly show that we are a long way behind the major comprehensive cancer centres in the United States, such as the Memorial Sloan Kettering Cancer Centre in New York and M.D. Anderson Cancer Centre in Texas, where patients are provided with access to both conventional cancer treatments and integrative oncology services providing a range of CAM treatments in the same setting. However, with attitudes of doctors and administrators towards CAM changing, and with the leadership of NICM and the NHMRC, we should shortly be able to provide Australian cancer patients with a full spectrum of evidence based cancer treatments.
References
- Kaptchuk TJ, Eisenberg DM: Competing medical systems in North America. Varieties of healing. 1: medical pluralism in the United States. Ann Intern Med 135:189-95, 2001.
- MacLennan A, Wilson D, Taylor A: Prevalence and cost of alternative medicine in Australia. Lancet 347:569–573, 1996.
- MacLennan A, Wilson D, Taylor A: The escalating cost and prevalence of alternative medicine. Prev Med 35:166–173, 2002.
- Verhoef M, Balneaves L, Boon H at al: Reasons for and Characteristics Associated With Complementary and Alternative Medicine Use Among Adult Cancer Patients: A Systematic Review. Integrative Cancer Therapies 4:274-286, 2005.
- Sharples FM, van Hasalen R, Fisher P: NHS patients’ perspective on complementary medicine: a survey. Complement Ther Med 11:243-8, 2003.
- Cant S, Sharma U: The nature of use demand: from patient to consumer? A new medical pleuralism? Alternative medicine, doctors, patients and the state. London: UCL Press, 1999:21-50.
- Manheimer E, Berman B, Dubnick H et al: Cochrane reviews of complementary and alternative therapies: evaluating the strength of the evidence. 2004. www.cochrane.org/colloquia/abstracts/ottawa/P-094.htm. Viewed 15 June 2009.
About the author: Professor Stephen J. Clarke
Stephen Clarke is a Medical Oncologist and Clinical Pharmacologist and is currently Professor and Head of the Discipline of Medicine at the Concord Hospital Clinical School of the University of Sydney. He obtained an MBBS from Sydney University in 1983 and then undertook specialty training in Medical Oncology, obtaining a Fellowship from the Royal Australasian College of Physicians in 1990.
Between 1991 and 1993, he was a research fellow at the Clinical Pharmacology Department of the Royal Marsden Cancer Hospital and the Drug Development Section of the Institute of Cancer Research in Sutton, Surrey, UK. This led to a PhD through the University of London on the Preclinical and Clinical Pharmacology and Toxicology of ZD1694 (raltitrexed-a novel anti-cancer compound). In 1994, Stephen returned to Australia to a Staff Specialist position at Westmead and Nepean Hospitals, but moved to the Sydney Cancer Centre located at Royal Prince Alfred and Concord Hospitals in late 1995.
Stephen is Head of the Complementary Therapies NSWOG of the Cancer Institute NSW and a member of the Scientific Advisory Committee of the NICM. He is also a core member of the Australian Drug Evaluation Committee and the Repatriation Pharmaceutical Reference Committee.