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Overview

Complementary and alternative medicine (CAM) refers to any treatment/therapy not recognized or implemented in conventional medical care. These may include, but are not limited to: energy therapy (Reiki, chakra balance), body-mind intervention (meditation, hypnosis, yoga, imagery, etc.), spiritual healing (prayer, ayurvada, etc.), supplements (mega-vitamins, super fruits, etc.), minerals, diet and exercise, acupuncture, herbs and teas, chiropractic, massage, and homeopathy. These treatments are largely sought after by cancer patients as an integrative therapy as a result of the side effects of radiation and chemotherapy, but they are also used as alternative treatments. The majority of cancer patients have used some sort of CAM therapy. Despite the widespread use of CAM among cancer patients, the bulk of conventional care practitioners have not changed their approaches to cancer treatment.

Complementary and alternative medicine (CAM) has remained largely marginalized within the medical care system in America. The reasons for this are lack of education about CAM therapies in the medical community and lack of access to those therapies. There is also an issue of high out-of-pocket cost and lack of information about the safety and effectiveness of such treatment methods. Patients are looking at CAM as a form of self-care and a way to take back control over their health and wellness. Many find CAM therapies to be restorative to their psyche and spirit, which may in turn benefit their health and increase their lifespan. Debate over the effectiveness of CAM therapies is ongoing because there have not been many studies done on their effects.

This subject is important to me because I, like many others, have been personally affected by the death of a loved one from cancer. I am not using this platform to persuade anyone that CAM therapies work or to discredit their effectiveness. I am aware of the conspiracy theories out there, such as how the body must remain alkaline in order to kill cancer cells. I am not here to discuss these theories. However, I am trying to better understand the dialog between patients and medical providers on the subject of complementary and alternative treatment methods. Some questions that I hope to answer through my research this past semester are: (1) what determines whether a person uses CAM? (2) How prevalent is CAM use among cancer patients? (3) Why don’t patients talk to their doctors about CAM? (4) How can we develop better communication between physicians and patients about CAM therapies?

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Complementary/alternative medicine in chronic illness as informed self-care decision making

“In explaining their reasoning processes related to CAM use, the participants revealed the logic they used in terms of reconciling the presumed contradictions between conventional and CAM approaches to care, gaining sophistication in interpreting information, taking on an increasing responsibility for their own role in disease management, reframing the outcome measures by which they would evaluate the efficacy and value of any therapeutic strategy, and creating the conditions under which CAM practices could be integrated to the extent possible with their conventional medical management” (Thorne et al. 2002).

“The business of self-care management for a chronic illness seems inevitably to challenge the individuals involved to make sense of the dynamic interrelationships between mind and body, between logic and instinct, between conforming to a societal expectation of appropriate sick role behavior and trying to live as well as is possible under the circumstances. Thus it is perhaps not surprising that persons living with chronic disease commonly balance conventional and CAM approaches as a pragmatic approach to self-care management” (Thorne et al. 2002).

“If our collective intent is to assist persons with chronic diseases to live as well as is possible within the constraints of their conditions, then a reasoned and realistic approach to integrating CAM and conventional medicine seems necessary. Because chronic illnesses are, by very definition, those conditions for which biomedicine has not found a cure, the role of CAM in ameliorating symptoms, promoting health and enhancing healing seems particularly relevant” (Thorne et al. 2002).

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“Breast Cancer Survivors’ Perception of Complementary/Alternative Medicine (CAM): Making the Decision to Use or Not to Use”

The article provides insight into the decision-making process with respect to complementary and alternative medicine (CAM). The authors studied breast cancer survivors’ perceptions of CAM and why or why not they decided to seek CAM treatment methods.

 “Thoughts that influenced their decision to use CAM were: the longing to enhance chances of survival, reaction to bad experiences with conventional medicine, attempts to be proactive and prevent further illness, and the belief that they had nothing to lose” (Boon et al. 1999). The authors ultimately found that the majority of survivors were simply “hedging their bets” by using both CAM and conventional medicine, as oppose to a reaction to a negative experience with conventional practices or a deep philosophical belief in the holistic paradigm (Boon et al. 1999).

Barriers included: high cost, limited access, and the large amounts of time required to complete the therapy. They found that individualized treatment protocols empowered some patients because they were a vital part of their treatment planning. However, other patients found that there was a greater risk involved in being a part of the process because of their personal lack of professional expertise. They emphasized the need for guidance and the lack preparedness of practitioners to discuss CAM therapies and products. Some practitioners openly discouraged the use of CAM therapies. The main reason that survivors ultimately chose not to use CAM was the lack of “meaningful information regarding safety and efficacy” (Boon et al. 1999).  

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“Reasons for and Characteristics Associated with Complementary and Alternative Medicine Use among Adult Cancer Patients: A Systematic Review”

All types of cancer were included in their research. Fifty-two eligible studies were identified. These studies were conducted in 14 different countries, with 34.6 % of those studies completed in the United States. Most studies were conducted in urban areas.

“They found that the most commonly cited reasons for using CAM were: a therapeutic response to diagnosis, wanting control of their own treatment, a strong belief in complementary and alternative medicine, CAM as a last resort, and finding hope outside of conventional care” (Verhoef et al. 2005). Women and younger people were more likely to use CAM than were men and older people. Higher income was predictive of CAM use because of the out-of-pocket expenses.  Patients with more education were more likely to be cynical towards conventional medicine and more aware of CAM. Those living a traditional lifestyle due to their culture were more likely to use CAM. Breast and prostate cancer were the most commonly cited diseases associated with CAM use.

Decision aids support patients in clarifying their values about a decision by encouraging individuals to consider the desirability of benefits or attitude toward the risks when the outcome of a decision is uncertain. Decisional aids increase patient knowledge and active participation, reduce decisional conflict, and assist patients in developing realistic expectations.

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“Bridging the Gap: Decision-making Processes of Women with Breast Cancer Using Complementary and Alternative Medicine (CAM)”

The purpose of this study was to “explore the personal and social processes women with breast cancer engaged in when making decisions about complementary and alternative medicine” (Balneaves et al. 2007). The authors wanted to create a conceptual model of the treatment decision-making process for future decision support strategies.

“The resulting decision-making model was composed of four major concepts including: maximizing choices/minimizing risks, experiencing conflict, gathering and filtering information, and bridging the gap between CAM and conventional medicine” (Balneaves et al. 2007). The initial exploration of CAM therapies was influenced by various personal factors, including women’s knowledge about the potential benefits of CAM and harmful effects of conventional cancer treatments, their past experiences with CAM, their beliefs about the nature of health itself, and their desire for an active role in their healing process. Many of the women sought assistance from what they considered to be more legitimate sources, such as their physicians, CAM practitioners, and medical journals.

Many of the women observed the differences between the conventional and CAM health care systems with regards to the underlying assumptions about health, healing, and evidence. The women also described how CAM was marginalized within the conventional healthcare system and not available alongside conventional cancer treatments. “The concept of “bridging the gap” theory is the decisions made by the women based on their understanding and belief about conventional and CAM health care along with the conflict they have experienced in attempting to merge different paradigms of care” (Balneaves et al. 2007).

Women with breast cancer used one of three decision making styles to address the conflict they experienced as a result of the gap they perceived between conventional care and CAM: (1) taking it one step at a time in choosing CAM treatments, (2) playing it safe with regard to CAM decisions, and (3) bringing it all together by using both CAM and conventional care. 

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Breast Cancer patient’s experience with acupuncture.

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Advising Patients Who Seek Alternative Medical Therapies

Alternative therapies are defined as medical interventions that are neither taught widely in U.S. medical schools nor generally available in U.S. hospitals.

“In 1993, an estimated 60 million Americans used alternative medical therapies at an estimated cost of 13.7 billion dollars. The estimated number of annual visits to CAM providers exceeded the number of visits to U.S. primary care doctors. More than 70% of patients never mentioned the use of alternative therapies to their physicians” (Eisenberg 1997). This trend poses a question to physicians: how to responsibly advise patients who use or seek alternative therapies in the face of inconclusive evidence about the safety and effectiveness of these therapies?

“This unavoidable challenge is not without risk…The reality is that no case law directly answers the question, “Will I be sued if I knowingly co-manage a patient who sees an alternative therapy practitioner and experiences a bad outcome from that therapy?” (Eisenberg 1997).

Talking with patients about alternative therapies requires additional skills and time.

This article offers a step-by-step approach were medical providers and patients can proactively discuss alternative medical treatments. Three important efforts to emphasize for physicians are: patient safety, the need for documentation in the patient’s record, and the importance of shared-decision making.

Begin a conversation about alternative therapies! Leading discussion about CAM is the safest route. Examples:

“Patients with __________ (chief symptom) frequently use other kinds of therapy to find relief. For example, acupuncture, etc.

“Have you used or thought about using any of these or other therapies for your ________, or for other reasons?”

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Shared Decision Making in medical encounter

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Prevalence of Complementary and Alternative Medicine Use in Cancer Patients during Treatment

Chemotherapy and radiation therapy cause an array of traumatic side effects – fatigue, sleep disturbance, anxiety, depression, nausea, and vomiting. Cancer patients seek outside help because of the ineffectiveness of conventional medicine at relieving these side effects.

“National Center for Complementary and Alternative Medicine (NCCAM) defines CAM as ‘a group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine.’” (Yates et al. 2005).

“Average cancer patient uses between 4 and 5 CAM modalities and often does not discuss them with their oncologist” (Yates et al. 2005).

The questionnaire sent out to the 752 participants asked about different forms of CAM, including: exercise, prayer, relaxation, chiropractic, massage, imagery, spiritual healing, diets, herbal medicine, mega-vitamins, self-help groups, hypnosis, and acupuncture.

Results: “Of the patients surveyed, 91% reported using at least one form of CAM during treatment. The most widely used forms of CAM were prayer, relaxation, and exercise, respectively” (Yates et al. 2005).

“While some patients discussed CAM usage with their physicians, almost half the patients who reported using CAM did not tell their doctors about any of the CAM modalities they were utilizing. Moreover, while over half the patients revealed to their doctors at least one CAM therapy they were using, they did not necessarily discuss all of them. The lack of discussion of CAM modalities with a physician could have been the result of the following: (1) the doctor did not specifically ask, (2) the patient did not see the potential of the CAM to affect their standard cancer treatment, or (3) the patient did not perceive the therapy they were using as CAM” (Yates et al. 2005).

“Unfortunately, medical doctors, particularly oncologists, are not taught about CAM in medical school and rarely receive any training in this area as part of a residency, so meeting the needs of patients in this arena may be very challenging” (Yates et al. 2005).

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Exercise and Cancer - does it make a difference?

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Communication between Physicians and Cancer Patients about Complementary and Alternative Medicine: Exploring Patients’ Perspectives

“As many as 50-83% of cancer patients reported using at least one type of CAM therapy” (Tasaki et al. 2002)

An example of the adverse effects from lack of communication about CAM therapies:

“The mechanisms of action of chemotherapeutic agents and antioxidant nutrition supplements suggest that combining the two may increase the risk for a cancer recurrence because chemotherapeutic agents utilize reactive oxygen species as a mechanism for cytotoxicity” (Tasaki et al. 2002)

In many cases, patients perceived their physicians’ attitudes toward CAM use to be negative. Some had vague, hidden disapprovals and some had outright opposition. Some described that their doctors’ attitudes about CAM “lacked compassion.”

“In general, the lack of communication is a serious matter in the health care context because effective interpersonal communication is a necessary condition for the development of openness and trust between health care providers and clients” (Tasaki et al. 2002)

Successful communication about CAM includes:

1.      Physicians ask about and listen to the patient’s description of their CAM use

2.      Provide relevant information if interactions with prescribed cancer treatments are possible

3.      Discuss openly the possible risks and benefits

4.      Express support for their patient’s efforts to improve their condition

5.      Attempt to understand reasons for the CAM choices in case the CAM use is an indicator for unmet needs *such as psychological counseling or social support.

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Tips for Patients on Complementary and Alternative therapies. I realize this video is for prostate cancer patients, but I believe these tips can be applied to all cancers and diseases. 

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Works Cited

Balneaves, Lynda G., Truant, Tracy L. O., Kelly, Mary, Verhoef, Marja J., and Davison, B. Joyce. 2007. “Bridging the Gap: Decision-making Processes of Women with Breast Cancer Using Complementary and Alternative Medicine (CAM).” Support Care Center. 15: 973-983.

Boon, Heather, Brown, Judith B., Gavin, Alan, Kennard, Mary Ann, and Stewart, Moira. 1999. “Breast Cancer Survivors’ Perception of Complementary/Alternative Medicine (CAM): Making the Decision to Use or Not to Use.” Qualitative Health Research. 9(5): 639-653.

Eisenberg, David M. 1997. “Advising Patients Who Seek Alternative Medical Therapies.” Ann Intern Med. 127: 61-69.

Tasaki, Katsuya, Maskarinec, Gertraud, Shumay, Dianne M., Tatsumura, Yvonne, Kakai, Hisako. 2002. “Communication between Physicians and Cancer Patients about Complementary and Alternative Medicine: Exploring Patients’ Perspectives.” Psycho-Oncology. 11: 212-220.

Thorne, Sally, Paterson, Barbara, Russell, Cynthia, Schultz, Annette. 2002. “Complementary/Alternative Medicine in Chronic Illness as Informed Self-Care Decision Making. International Journal of Nursing Studies. 39: 671-683

Verhoef, Marja J., Balneaves, Lynda G., Boon, Heather S., and Vroegindewey, Annette. 2005. “Reasons for and Characteristics Associated with Complementary and Alternative Medicine Use Among Adult Cancer Patients: A Systematic Review.” Integrative Cancer Therapies. 4(4): 274-286.

Yates, Jennifer S., Mustian, Karen M., Morrow, Gary R., Gillies, Leslie J., Padmanaban, Devi, Atkins, James N., Issell, Brian, Kirshner, Jeffrey J., Colman, Lauren K. 2005. “Prevalence of Complementary and Alternative Medicine Use in Cancer Patients during Treatment.” Support Care Cancer. 13: 806-811.