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Complementary and Alternative Medicine

ABSTRACT: It is important for cancer patients to make full use of the most effective, scientifically validated therapies for treating their cancer. However, complementary and alternative (CAM) therapies may also be helpful for specific purposes. This article defines complementary and alternative therapies, differentiates between the two, discusses some historical aspects of both CAM and mainstream medicine, discusses the limits of proof in both, identifies reasons patients turn to CAM therapies as well as concerns about CAM, and closes on a note of cautious optimism.

Complementary and alternative medicine (CAM) includes a range of approaches for preventing and treating illness, including diet and exercise programs, herbs, chiropractic treatment, and the healing power of the mind, among others.

Defining CAM therapies

Complementary and alternative therapies are defined and grouped in a somewhat confusing variety of ways. This confusion can lead to misunderstandings about what exactly is being discussed or compared.

In his landmark study on the frequency and distribution of alternative therapy use in the United States,1 Dr. David Eisenberg defined alternative therapies as "medical interventions not taught widely at United States medical schools or generally available at United States hospitals." But, therapies that qualified in his 1993 study may not qualify under that definition today, as more medical schools and hospitals add some of these therapies to their programs.

The National Library of Medicine Medical Subject Heading (MESH) defines alternative medicine as "an unrelated group of unorthodox practices, often with explanatory systems that do not follow conventional biomedical explanations." In a 1993 article on alternative AIDS therapies, Carola Burroughs defines "alternative" as a "catch-all phrase" used for "various treatments which simply have not been accepted by the medical establishment."2 Terms like unconventional or unorthodox make a political distinction. Distinctions like modern medicine, versus traditional or folk medicine denote cultural variations and imply a superior level of advancement. Unproven is another often-used distinction. However, there are standard medical treatments used today that have gained their acceptance through history of use, rather than formal clinical testing. Drugs tested and approved for one use can be prescribed off-label for a new use when preliminary outcomes look hopeful and the physician feels the situation warrants the risk. Although not yet thoroughly tested and proven for that use, off-label uses are common in clinical practice.

Here, when we refer to alternative or complementary therapies, we mean nonstandard forms of treatment--therapies not formally accepted as standard clinical practice. However, experimental therapies currently in clinical trials are not included in this category. They are viewed here as pre-standard therapies in the process of crossing over into acceptance as standard treatments.

Distinguishing complementary from alternative therapies

Complementary therapies are used in addition to standard therapy with the hope of reducing side effects, enhancing the outcome of standard treatment, or improving the quality of life. For example, acupuncture can be used to reduce nausea during chemotherapy, guided imagery can be used to reduce the physical and emotional stress of treatment, or yoga can be used to increase flexibility after surgery. While nutrition and exercise may not be listed as standard treatment for a particular condition, most physicians encourage complementary lifestyle changes that will improve the patient's general health and quality of life.

Often, the term alternative is used to indicate both complementary and alternative practices. However, therapy is technically only truly alternative if the patient chooses to use it in place of the standard recommended treatment.

Taking a new look at complementary and alternative therapies

Contemporary fads often color what we see as progressive and modern treatment. We can look back at the popularity of the healing water spas in the early 1800s or the patent medicine cure-alls of the 1880s and 1890s. The words scientific and modern were commonly used to market these forms of treatment and many treatments looked on as useless or even dangerous today were endorsed by respected physicians of those periods. On the other hand, some popular therapies dismissed by the medical community as unsubstantiated in the past, upon closer examination have been shown to be effective. Dr. William Fair, former head of urology at Memorial Sloan-Kettering says:

When I was in medical school, acupuncture was thought to be really hocus-pocus. We now know (especially in the area of oncology) that nausea and vomiting can be very effectively controlled by acupuncture.3

Since Dr. Eisenberg's 1993 study showing the widespread use of alternative therapies was published in the New England Journal of Medicine, medical professionals have begun to take a closer look at nonstandard therapies. Dr. Eisenberg found that 34 percent of the people he surveyed had used at least one unconventional therapy to treat a serious or bothersome condition in the past year. In fact, their visits to unconventional care practitioners exceeded visits to primary care physicians that year.4 A 1997 follow-up study showed the use of non-conventional therapies had increased to 42.1 percent and total out-of-pocket expenditures had more than doubled.5

By 1998, a survey of US medical schools showed that 64 percent offered some coursework in complementary and alternative medicine.6 Another group of surveys conducted between 1982 and 1995 showed that 43 percent of the physicians interviewed made referrals for acupuncture, 40 percent for chiropractic, and 21 percent for massage therapy. The authors concluded:

This review suggests that large numbers of physicians are either referring to or practicing some of the more prominent and well-known forms of CAM (complementary and alternative medicine) and that many physicians believe that these therapies are useful or efficacious.7
Clinics offering the combination of standard and complementary medicine, sometimes referred to as integrative medicine, are opening up in association with major medical centers.

Traditional medicine: The foundation of modern medicine

The World Health Organization (WHO) estimates that 80 percent of the people in most developing countries rely on traditional medicine for their basic healthcare. The World Health Organization defines traditional medicine as healing traditions that existed before the arrival of modern medicine--traditions handed down from generation to generation. The use of traditional medicine remains high even among people in developed countries. Herbal preparations account for 30 percent to 50 percent of the medicinal consumption in China. Japan is estimated to have the highest per capita use of herbal medicine in the world. Interest in the use of traditional medicine is on the increase in European countries and in the United States.

Some medical traditions are very old. According to the National Center for Complementary and Alternative Medicine's Unconventional Timeline8, herbalism can be traced back 200,000 years, as the oldest known form of medical treatment. Spiritual healing and shamanism date back 20,000 years, acupuncture 2,000 years, and homeopathy 200 years.

Some drug companies send ethnobotanist plant hunters to interview traditional healers and search the rain forests for sources of new commercial medicines. Pharmacognocists study plant samples and microbes to isolate active ingredients that hold promise as future pharmaceuticals. Medical chemists study the relationship of chemical structure to biological activity in the hope of synthesizing drugs from these natural products and to learn how they work to protect us from or treat our diseases

Traditional use of plants by indigenous people has provided the source of some of our most valued and respected modern medicines. African folklore led researchers at Eli Lilly to the discovery of the Madagascar periwinkle, which was developed into vinblastine and vincristine for the treatment of childhood leukemia and Hodgkin's disease. Aspirin comes from white willow bark and morphine from the opium poppy, both used by the ancient Greeks. Even the smallpox vaccine has its roots in medical folk belief. Edward Jenner developed the vaccine after a milkmaid told him that local farmers believed that a mild case of cowpox made them immune to smallpox.

The limits of scientific proof

As mentioned earlier, not all accepted standard methods of treatment have been subjected to the rigorous scientific scrutiny required for the initial marketing of a new drug. Estrogen for example is approved for eliminating symptoms of menopause and reducing the risk of osteoporosis. Estrogen has also been studied and promoted for lowering the risks of heart disease and Alzheimer's, but these are not uses for which estrogen is officially approved. Various studies showing associations with reductions in risk have led to the promotion of these potential benefits as reasons for using estrogen replacement therapy. They are not listed as proven uses in FDA-approved insert information, yet the use of estrogen is often recommended by doctors to reduce those risks.

Even proven standard treatments have a risk of unexpected side effects, drug interactions, and long-term complications. Drugs such as diethylstilbestrol (DES), thalidomide, and fen-phen were approved as standard treatment options, and then later withdrawn from the market for re-evaluation after significant complications developed as the result of their use.

A former biologist who is being treated for cancer explains how she evaluates both standard and nonstandard treatments:

I know how to read scientific literature, but the most important thing for me when, deciding on a treatment, traditional or alternative, is the simple notion that "you can never know for sure." If someone recommends something to me as a sure thing, I immediately become suspicious. Even with treatments that have been thoroughly studied, there is always at least one question that the researchers have forgotten to ask.

The economics of product development

The research process is slow and expensive. According to the Pharmaceutical Research Manufacturers of America (PhRMA), the cost of moving a new drug through the development process in the United States averages $500 million. While a drug patent gives a company exclusive rights for twenty years to develop and market a new drug, development and approval take up about twelve to fifteen of those years. That leaves a short period of exclusivity for a drug manufacturer to recoup the cost of development. Only about 1 out of every 5,000 drugs tested in US pharmaceutical labs survives the development process to reach the marketplace.

If a remedy is already in use, or has been described in the scientific literature, it cannot be patented. Many CAM treatments, derived from age-old remedies, cannot be patented, so they are not cost-effective products for drug companies to pursue. In response to this dilemma, the National Center for Complementary and Alternative Medicine has begun to provide funding for the study of promising CAM treatments that don't offer the promise of high monetary profit that patent exclusivity provides.

Cultural variations in standard treatment

Some standard practices in the healing systems of China or India are considered alternative practices in the US. Standard therapy varies from country to country. In her book, Medicine & Culture: Varieties of Treatment in the United States, England, West Germany, and France, Lynn Payer observes that the French prefer gentler forms of medical therapies. Their standard treatments use lower drug doses and less invasive techniques than those recommended in the United States. West German doctors are more likely to prescribe mud baths, walks in the forest, or herbal medicine. The British emphasize relieving discomfort and are more skeptical about the expectation of cure.

Considering an alternative or complementary therapy

The question often raised in response to Dr. Eisenberg's studies is: why are patients going outside mainstream medicine for treatment and prevention?

In a 1998 Journal of the American Medical Association article, John Astin, PhD, reported on a survey at the Stanford Center for Research in Disease which asked that same question.9 His results showed that those who use alternatives do so "largely because they find these healthcare alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life."

Astin found the level of an individual's education to be the top predictor. Of those respondents with a high school education or less, 31 percent used alternatives in comparison to 50 percent of the respondents with a graduate degree. Astin also found that as a person's health status declined, his alternative usage went up. Specific health issues like back problems, chronic pain, anxiety, and urinary tract problems also increased the likelihood of usage.

One might consider nonstandard treatments for a range of reasons:

  • Physical and emotional comfort
  • Empowerment
  • Ease of access
  • Simpler, less invasive approach
  • Quality of life
  • Treatment of chronic conditions
  • Prevention
  • Hope of survival

Physical and emotional comfort

Alternative practitioners tend to pay more attention to a patient's physical comfort. Soft music, lowered lights, and warm blankets provide a soothing atmosphere. Patients generally feel that alternative care practitioners spend more time with them. Treatments are more likely to involve touch and feel more nurturing. Even if the process is not as efficient or effective, the experience is more appealing.

Modern medicine relies on test results. When medical tests are used to evaluate health or progress in treatment, a patient's sense of well-being becomes dependent on the results of the test. Being sent home with a negative test result feels like a personal failure. Sometimes in the face of a lot of bad news, patients need a break from the responsibility of evaluation and decision-making especially when there are no obvious answers or clear-cut treatment choices. One woman explains:

I find that when I'm overwhelmed with medical decision-making and frightening possibilities, I need to indulge in things that soothe my mind and emotions--that get me centered again.
A relaxing massage or an herbal tea may help restore a patient's sense of well-being.


After being diagnosed with an acute disease, patients may feel their lives revolve around doctor visits and treatment schedules with little time to pause and reflect about how they feel and what they want to do. Taking time out to consider and/or use non-standard complementary or alternative treatments gives them the feeling that they are more active participants in the development of their treatment plans.

Ease of access

The use of alternative therapies, vitamins and supplements does not require prescriptions or approval. They are explained in simple terms and patients can purchase or practice them without a prescription. Access is easy. Initial costs are generally lower, particularly compared to the costs of medications and treatments for acute diseases.

Simpler, less invasive approaches

Standard therapy may be aggressive and have damaging side effects. The long-term safety of newer treatments is not known. Positive outcomes are not guaranteed. Some patients may want to try simpler approaches first.

In this example a man tried an alternative approach to relieve his back pain and avoid the need for back surgery:

I have painful deteriorating disks in my back. In lieu of an operation, I decided to try proliferative therapy. It is a therapy developed in New Zealand where glucose is injected into the ligaments parallel to the disks to strengthen the tissue around the disks and give lateral support to my back. It doesn't do anything to the disks but the tissue around it is healed and strengthened so it gives support to the disks.

It worked. I've had similar injections on a shoulder injury and in my knee. Using these treatments I was able to avoid rotator cuff surgery on my shoulder and arthroscopic surgery for my knee.

Quality of life

Patients may think of alternatives as a way to boost their immune systems during and after harsh treatments like chemotherapy or to help alleviate the side effects. Acupuncture, for example, has been shown to significantly reduce the amount of drugs needed for pain and to reduce the duration of stays in treatment facilities.10

Alternative practices and therapies sometimes offer healing even when they don't offer cure. One woman uses meditation techniques during treatment:

My husband and I learned transcendental meditation about twenty-five years ago. It's a big help in learning to focus as well as for relaxing when the nurse is trying to find that elusive vein for the fifth time in ten minutes.

Treatment of chronic conditions

Both Eisenberg and Astin's surveys showed that alternative therapies are most often used for chronic conditions. Eisenberg found that 36 percent of the people in his study sought treatments for back pain, 28 percent for anxiety, 27 percent for headaches, and 26 percent for chronic pain. These were the three top reasons for using alternative therapies. (Cancer accounted for less than 3 percent.) Patients who suffer from a condition that standard medicine has not been able to treat successfully may be more willing to look at nonstandard options.


Both alternative and prescription treatments advertise protection as a hedge on genetic susceptibilities to the diseases that killed our parents and grandparents. Healthy women are given hormone replacement therapy to reduce risk of heart disease and osteoporosis even when they have no current symptoms of either. Blood pressure and cholesterol medications are given to reduce the risk of strokes and heart attacks.

For those who would prefer not to take prescription drugs for prevention, lifestyle changes and other non-prescription approaches such as vitamins, herbs, and food supplements may present an appealing alternative.

Hope of survival

Survival is a strong motivating force. When scientific medicine runs short of tools to stem the progress of the disease, patients feel like they are on their own. Many cancer patients know this scenario well, as this woman relates:
My 25-year marriage to a scientist has certainly had an influence on my critical thinking tendencies (which were pretty strong to begin with). But in January, something very different happened when an MRI showed indisputable metastases in my bones. The quest for the right treatment takes on a new personality, a new urgency, when the goal is saving my life (and our life together). Now this PhD scientist, who makes his living being a skeptic, an analyst, an experimenter, is willing to look into anything on the continuum from far-out to tried-and-true approaches.

But notice that I said "look into" not "try." We still want some evidence, beyond the anecdotal, that there might be some efficacy in a particular therapy or practice.

The value of hope should not be underestimated. Sometimes all a treatment really has to offer is hope, but that's a lot as this woman explains:
I've looked at all my medical options and none of them hold much promise. My oncologist agrees. I heard about a Qi Gong healer. Since I started going to her, it's the first time I have felt hopeful.

Lack of scientific studies

HMOs often request scientific proof of effectiveness before they will cover an alternative or complementary treatment. This forces medical organizations to limit their range of treatment recommendations to those that are standardized or evidence-based.

The demand for written proof puts CAM therapies at an even greater disadvantage. Many of them are based on observation, but have not yet been formally studied in clinical trials. As previously mentioned, clinical trials can be extremely expensive and difficult to finance unless a chance of profit on a disease with millions of patients can be predicted.

We need reliable information on expected outcomes and side effects of non-standard therapies as well as an honest evaluation of what aspects need further study--the same quality of information as we expect to be given for standard treatment regimens.

Treatment delays

Doctors who work with life-threatening disease often talk about working with patients who refuse standard treatment in favor of alternative therapy. Then, when the patient returns for help, it is sometimes after their disease has progressed to a point where standard therapy can no longer provide hope for a cure or even disease management. At the same time, doctors are keenly aware of the limitations they face. They currently do not have enough tools available to treat or to save some of their patients.

Practitioner licensing

Efforts are being made to standardize licensing within the various practices. Acupuncturists, Chinese medicine practitioners, and chiropractors, for example, all have some form of licensing. Chiropractors are the best organized, with licensure in every state. Acupuncturists are licensed in two-thirds of the states and in Washington, DC. Some therapeutic practices may have association guidelines but no formal licensing requirements. There may be more than one type of license within a specific therapeutic community. Licensing requirements also vary from state to state.

Cautious optimism

Patients can be encouraged to sort complementary and alternative treatment options by level of risk. Low-risk options are those where, "It can't might help." Sometimes a lifestyle change can reduce reliance on medical intervention as happened to this woman:
The doctor put me on medications for high cholesterol and for high blood pressure. Recently, I went on a diet to lose weight. I've changed my eating habits so much that both my cholesterol and blood pressure are back in the normal range so I have been able to stop taking the medications.
Treatments with more potential for harm need to be monitored more closely. Some patients establish evaluation criteria with their doctor and alternative practitioners as this woman does:
Most of the alternative therapies I've tried have not been very successful for me. On the other hand, neither have the conventional ones!

I never know in advance whether or not the treatment will work for me. If I trust the doctor or friend or article that recommends the treatment, and I've assured myself that the dangers are minimal (this is often the hardest thing to find out), I just try it and see if it works for me. For example, I took Essiac tea, a concoction of fresh herbs. I took it for three months, but my disease progressed during that time.

I consider several factors in deciding whether to stop or continue a therapy. I rely on my doctor's interpretation of blood tests and scans for traditional therapies, and on my own gut feelings for both traditional and alternative therapies.

I ask myself if I can stand feeling like this for x more months, or for the rest of my life. If the treatment makes me feel too bad and the doctor feels I should continue we discuss lowering the dose or having the treatment less often.

If I'm dissatisfied with an herbal therapy or dubious about its efficacy, I consult the practitioner or experiment myself with lowering the dose, taking the drug at a different time of day, or stopping it altogether and seeing how I feel, or if the disease is progressing. I also watch my body for good or bad results as I go about my daily life.

Talking with the doctor

A 1998 JAMA article about the integration of alternative therapies into the curriculum of medical schools concluded:
Patients are increasingly seeking to identify a physician who is solidly grounded in conventional, orthodox medicine and is also knowledgeable about the value and limitations of alternative treatments.11
The boundary between "conventional orthodox" medicine and an alternative approach, however, is not as sharply defined as health consumers are encouraged to believe. Polarization sells products, and extremists on each side argue that their approach is more reasonable, logical, and safe. The bottom line is whether or not there is enough evidence to support the treatment's safety and effectiveness for treating a given condition.


  1. David M. Eisenberg et al., "Unconventional Medicine In The United States. Prevalence, Costs, And Patterns Of Use," New England Journal of Medicine 328, no. 4 (28 Jan 1993): 246-52.

  2. Carola Burroughs, "Alternative AIDS Therapies: An Historical Review," Gay Men's Health Crisis: Treatment Issues 7, no. 11 (Nov 1993):

  3. William Fair, MD, "Complementary Therapy is an Essential Part of Cancer Treatment," Center for Mind-Body Medicine's Integrating Complementary & Alternative Therapies Conference in Arlington, VA (June 12-14),

  4. David M. Eisenberg et al., "Unconventional Medicine In The United States. Prevalence, Costs, And Patterns Of Use," New England Journal of Medicine 328, no. 4 (28 Jan 1993): 246-52.

  5. David M. Eisenberg et al., "Trends In Alternative Medicine Use In The United States, 1990-1997," JAMA 280 (11 Jan. 1998): 1569-75.

  6. M. Wetzel et al., "Courses Involving Complementary And Alternative Medicine At US Medical Schools," JAMA 280, no. 9 (2 Sep 1998): 784-7.

  7. John A. Astin et al., "A Review Of The Incorporation Of Complementary And Alternative Medicine By Mainstream Physicians," Archives of Internal Medicine 158 (1998): 2303-10.

  8. The National Center for Complementary and Alternative Medicine, "The Unconventional Timeline," (Nov 1998),

  9. John A. Astin, "Why Patients Use Alternative Medicine," JAMA 279 (20 May 1998): 1548-53.

  10. "Acupuncture Effective for Certain Medical Conditions, Panel Says," Complementary and Alternative Medicine Newsletter 5, no. 1 (Jan 1998): 1-2,

  11. Miriam S. Wetzel et al., "Courses Involving Complementary And Alternative Medicine At US Medical Schools," JAMA 280, no. 9 (2 Sep 1998): 784-7.
This article was adapted from Making Informed Medical Decisions: Where to Look and How to Use What You Find by Nancy Oster, Lucy Thomas, and Darol Joseff, MD, © 2001 by Patient-Centered Guides. For more information, call (800) 998-9938 or see

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