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.
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 al2 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.
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.
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