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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.
Empowerment
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.
Prevention
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 hurt...it
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.
-
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.
- Carola Burroughs, "Alternative AIDS Therapies: An Historical Review,"
Gay Men's Health Crisis: Treatment Issues 7, no. 11 (Nov 1993): www.critpath.org/newsletters/ti/TI.11.txt.
- 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), www.cmbm.org.
- 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.
- David M. Eisenberg et al., "Trends In Alternative Medicine Use In The
United States, 1990-1997," JAMA 280 (11 Jan. 1998): 1569-75.
- M. Wetzel et al., "Courses Involving Complementary And Alternative
Medicine At US Medical Schools," JAMA 280, no. 9 (2 Sep 1998): 784-7.
- 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.
- The National Center for Complementary and Alternative Medicine, "The
Unconventional Timeline," (Nov 1998), altmed.od.nih.gov/nccam.
- John A. Astin, "Why Patients Use Alternative Medicine," JAMA 279
(20 May 1998): 1548-53.
- "Acupuncture Effective for Certain Medical Conditions, Panel Says,"
Complementary and Alternative Medicine Newsletter 5, no. 1 (Jan 1998):
1-2, nccam.nih.gov/nccam/ne/newsletter/1998/jan/1.htm.
- 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 www.patientcenters.com.
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