Complementary therapies refer to a group of diverse medical practices and products that are not presently considered part of conventional medicine.1 When used with conventional treatments, limited research suggests that many complementary therapies may be beneficial to women with breast cancer by helping to manage symptoms and improve quality of life. On the other hand, some complementary therapies can interact negatively with conventional cancer treatments or pose risks in and of themselves. Informed guidance and supervision from the patient's medical team are crucial for assuring safe and appropriate use.
Complementary vs. Alternative
Alternative therapy is used in place
of conventional medicine whereas
complementary therapy is used together with
conventional medicine, with the intent of
complementing conventional treatments.
While the term complementary therapy is often used interchangeably with alternative therapy, there is a meaningful distinction. Alternative therapy is used in place of conventional medicine whereas complementary therapy is used together with conventional medicine, with the intent of complementing conventional treatments.1 2 Alternative therapies are not effective treatments for patients with cancer.1 3 The preferred practice of integrative medicine combines the best of complementary and conventional traditions with the full knowledge and involvement of the patient's medical team. Integrative approaches have become widely used, and the field of integrative oncology has grown immensely.2 4 The boundaries between conventional and complementary medicine change with time. Some therapies once thought to be alternative or complementary, such as guided imagery and relaxation therapies, for instance, are now regularly used for the management of cancer pain and are considered by some to be mainstream components of care.5
Because of increased patient demand and the potential benefits that certain complementary therapies may have for cancer patients, many leading medical centers offer integrative treatment programs which combine conventional treatments (such as radiation and chemotherapy) with certain complementary therapies (such as acupuncture, massage, herbs, hypnosis, and aromatherapy, among others).2 6 For patients, these programs allow for the safe use of complementary therapies under the direction of an informed medical team. For health professionals, integrative programs promote ongoing professional growth in a setting where complementary and conventional treatments can be examined together.
Use of Complementary
and Alternative Medicine (CAM) in the U.S.
Most recent findings of CAM use by the U.S. public derive from the 2007 National Health Interview Survey (NHIS) conducted by the National Center for Health Statistics. Results showed nearly 4 out of 10 U.S. adults using some form of CAM during the previous twelve months.7 Other studies have found that among cancer patients, up to 90% used complementary or alternative therapies as one part of their therapy.3 The most frequently used complementary health approaches by American adults include natural products, such as dietary supplements, followed by mind and body practices such as deep breathing, meditation, chiropractic and osteopathic manipulation, massage, yoga, progressive relaxation, and guided imagery.2
Cultural background strongly influences beliefs about health and illness. Patients from some ethnic groups may believe, for instance, that cancer is always a fatal disease, leading them to immediately turn to alternative therapies falsely guaranteeing cures.8 Other patients may believe that their cancer is a spiritual illness or that it is a punishment for past sins, leading them to eschew conventional treatments.9 Still others may expect that complementary or alternative therapies will be automatically integrated into their treatment plan. Given that 1 in 4 Americans identifies as an ethnic minority, consideration of a patient’s cultural background is vitally important.
Unfortunately, studies have shown that patients are reluctant to discuss their use of CAM with their health care providers and that oncologists are not well-informed about these therapies.1 3 Given that some CAM therapies may interfere with or impede conventional treatment, this lack of communication can create a dangerous situation for the patient. The Society for Integrative Oncology strongly recommends that health care providers ask directly about the use of complementary and alternative therapies during the initial evaluation of cancer patients. By creating an open and trusting environment in which to discuss all treatment possibilities, patients are less likely to pursue potentially dangerous alternative therapies and to adhere to their practitioners’ recommendations.4
Types of CAM
In contrast to conventional medicine, CAM takes a holistic approach to health and illness by seeking to address the physical, mental, emotional, and spiritual needs of the whole person. As such, treatment programs are often highly individualized, utilizing various types of practices and products drawn from one of two major categories as outlined by the National Center for Complementary and Alternative Medicine.
Natural or Biologically Based Products include herbal medicines (also called botanicals), vitamins, minerals, and other natural products, such as probiotics. Dietary supplements are a subset of this category. According to the 2007 National Health Interview Survey (NHIS), the ten most commonly used products within this CAM category are fish oil/omega 3, glucosamine, echinacea, flaxseed oil, ginseng, combination herb pills, ginkgo biloba, chondroitin, garlic supplements, and coenzyme Q-10.2 7
Mind and Body Practices include a diverse group of techniques, many of which ranked among the top 10 CAM practices used by adults in the 2007 NHIS; namely, deep-breathing exercises, meditation, yoga, progressive relaxation, and guided imagery.2 3 10
- Acupuncture stimulates specific points on the body by inserting thin needles through the skin.
- Massage therapy includes many different techniques in which the practitioner manually manipulates the soft tissues of the body.
- Meditation techniques include focused breathing or repetition of words to calm the mind and focus attention. Mindfulness and transcendental meditation are two examples.
- Movement therapies include Eastern and Western movement based approaches such as the Feldenkrais method, Alexander technique, Pilates, Rolfing Structural Integration, and Trager psychophysical integration.
- Relaxation techniques include breathing exercises, guided imagery, and progressive muscle relaxation. They are intended to produce the body’s natural relaxation response.
- Spinal manipulation is utilized by chiropractors, osteopathic physicians, naturopathic physicians, physical therapists, and some medical doctors. Health care providers use their hands or a device to apply a controlled force to a joint of the spine.
- Tai Chi and qi gong are forms of traditional Chinese medicine that combine physical postures or movements with breathing techniques and meditation.
- Healing touch is based on the belief that the body has energy fields that can be used for healing. Practitioners use their hands to manipulate these fields and promote health.
- Hypnotherapy induces a state of relaxed attention in which the patient concentrates on a certain feeling, idea, or suggestion to help with healing.
These two broad categories capture most complementary health approaches. Other approaches include the world-wide practices of traditional healers who use methods based on indigenous theories, beliefs, and experiences handed down from generation to generation. A shaman is an example of a traditional healer, as is the Native American medicine man. Whole medical systems are built upon complete systems of theory and practice that have evolved apart from conventional medicine. Some are ancient systems, such as traditional Chinese medicine and Ayurvedic medicine from India. Others, including homeopathy and naturopathy, are more modern, having developed within the past few centuries.
Safety and Efficacy
Conventional cancer treatments have been rigorously studied for their safety and efficacy through high-quality scientific research. In contrast, only a relatively small proportion of CAM therapies have been well-researched. As a result, questions about safety and efficacy remain unanswered.
The Society for Integrative Oncology has issued evidence-based clinical practice guidelines for health care providers to consider in the care of their cancer patients.4 These guidelines include information about the benefits and potential harms of complementary health approaches and emphasize that health care providers should communicate routinely with their patients about CAM.
“All patients with cancer should receive guidance about the advantages and limitations of complementary therapies in an open, evidence-based, and patient-centered manner by a qualified professional. Patients should be fully informed of the treatment approach, the nature of the specific therapies, potential risk/benefits, and realistic expectations.”4
At present, no complementary health approach has been shown to be effective in curing cancer or causing it to go into remission.
Some complementary therapies used to manage cancer symptoms and treat side effects are safe, effective, and evidence-based:
- Acupuncture and hypnotherapy have both been found to be effective therapies to manage treatment-related nausea and vomiting and may also be helpful in reducing pain. Extra precautions should be taken with acupuncture needles to ensure sterility and avoid infection. 1 3 4
- Massage therapy may help relieve pain, nausea, anxiety, and depression. Massage should not include the use of deep or intense pressure without the health care provider’s approval and should avoid sites near cancer lesions, enlarged lymph nodes, radiation sites, medical devices, or anatomic distortions. 1 3 4
- Mindfulness-based stress reduction, which is a type of meditation training, has been shown to relieve anxiety, stress, fatigue, and general mood and sleep disturbances, particularly in early stage breast cancer patients.1 4
- Yoga may improve anxiety, depression, distress, and stress. It may also lessen fatigue. Because yoga involves physical activity, the health care provider’s approval should be granted.1
- Some natural products can help alleviate cancer symptoms or treatment side effects, but the use of these products must be carefully considered. Ginger, for instance, may help control chemotherapy-related nausea but can also have anti-coagulant effects, leading to complications in surgery. 1 3
Additional complementary methods that are potentially helpful when used together with standard medical treatment are biofeedback, relaxation therapies, aromatherapy, music therapy, art therapy, and tai chi.6
Potentially harmful therapies for cancer patients include:5
- herbs and supplements that may interfere with chemotherapy, such as black cohosh, echinacea, garlic, ginkgo biloba, ginseng, green tea, grape seed, kava kava, milk thistle, St. John’s wort, soy, and valerian
- dietary supplements and herbs that have potentially negative, even dangerous, effects on their own, such as St. John’s wort, ephedra alkaloids, kava kava, echinacea, saw palmetto, ginseng, ginkgo biloba, green tea, hydrazine sulfate, shark cartilage, laetrile, and antineoplastons
An additional concern about the use of CAM is that patients relying on these therapies may delay or reject the use of conventional treatment, leading to disease progression and greater rates of mortality.3
For detailed information on herbs and supplements, including information about dosing, interactions, and safety, visit Medline Plus, a service of the U.S. National Library of Medicine and National Institutes of Health. Herbs at a Glance, on the NCCAM website, provides a series of fact sheets with basic information, including uses and potential side effects. Additionally, consumers and healthcare providers can find information about dietary supplements on the FDA website. This agency can also be contacted to report general complaints or concerns about dietary supplements by calling FDA at 1-800-FDA-1088 or online. For detailed information about the broader list of CAM approaches, see NCCAM's Health Topics A-Z.
NCCAM is the federal government's lead agency for the scientific study of complementary and alternative medicine. This agency was established in 1999 with a mission to “define, through rigorous scientific investigation, the usefulness and safety of complementary and alternative medicine interventions and their roles in improving health and health care." The Resources for Health Care Providers section of NCCAM's website offers evidence-based tools, including clinical guidelines and printable fact sheets, to help clinicians prepare for discussions of CAM approaches with their patients. The NCCAM Time to Talk campaign also provides tips for patients about discussing their use of CAM with their physicians. For information about open clinical trials seeking patients, visit NCCAM's open studies listing at ClinicalTrials.gov.
Finding a Provider
Assuming that a patient's choice of CAM is medically appropriate, her primary care provider can assist with the process of finding a qualified CAM practitioner. Provider involvement will help ensure coordinated care and increase the chances of a positive outcome.
NCCAM suggests calls to local hospitals or medical schools for a list of area CAM practitioners. Contacting representative professional organizations is also recommended for inquiring about standards of practice, training needed, and whether or not licensing or certification by an approving state authority is required. If licensing laws do not apply for a particular CAM therapy, patients should ask about a practitioner's length of training and experience. Additional guidance for finding a qualified CAM provider can be found on the NCCAM website (see Selecting a Complementary and Alternative Medicine Practitioner).
Once a potential CAM provider has been found, the National Cancer Institute recommends the following sets of questions:10
General questions for the CAM practitioner:
- What types of CAM do you practice?
- What are your training and qualifications?
- Do you see other patients with my type of cancer?
- Will you work with my doctor?
Questions about the therapy for the CAM practitioner:
- How can this help me?
- Do you know of studies that prove it helps?
- What are the risks and side effects?
- Will this interfere with my cancer treatment?
- How long will I be on the therapy?
- What will it cost?
- Do you have information that I can read about it?
- Are there any reasons why I should not use it?
Questions for a patient to ask herself:
- Do I feel comfortable with this person?
- Do I like how the office looks and feels?
- Do I like the staff?
- Does this person support standard cancer treatments?
- How far am I willing to travel for treatment?
- Is it easy to get an appointment?
- Are the hours good for me?
- Will insurance cover the cost of CAM?
Many health systems, universities, and cancer centers in California now have departments devoted to integrative medicine. Patients in San Diego, for example, can receive free complementary therapy services at the San Diego Cancer Research Institute through the UCSD San Diego Cancer Center Integrative Medicine Program. Integrative medicine programs are also offered a UC Irvine, UCSF and UCLA as well as at cancer centers across California.
CAM Information on the Internet
Enter the terms "complementary and alternative medicine" into the Google search box and the result will yield over 9.1 million listings. Many of these web pages provide valuable and valid information. Some, however, do not. Knowing how to tell the difference is essential when seeking information about unconventional therapies.
The U.S. Food and Drug Administration (FDA) has prepared a quick summary checklist of the most important questions to ask:11
- Can you easily see who sponsors the website?
- Is the sponsor a government agency, a medical school, or a reliable health-related organization, or is it related to one of these?
- Is there contact information?
- Can you tell when the information was written?
- Is your privacy protected?
- Does the website make claims that seem too good to be true? Are quick, miraculous cures promised?
More information can be found by reading the entire FDA posting, How To Evaluate Health Information on the Internet or from NCCAM's Evaluating Web-Based Health Resources.
In addition to these, quackwatch.org is "concerned about health-related frauds, myths, fads, fallacies, and misconduct." Founded by a medical doctor and maintained by a worldwide network of volunteers and expert advisors, quackwatch.org is an indispensable resource for helping providers and their patients assess the reliability of websites proffering CAM information.
Finally, providers can recommend that their patients look for the HONcode seal on health and medical web sites. Health On the Net Foundation (HON) is a non-governmental organization dedicated to guiding "the growing community of healthcare consumers and providers on the World Wide Web to sound, reliable medical information and expertise." The HONcode seal appearing on health-related websites identifies compliance with a set of basic ethical standards.
National Center for Complementary and Alternative Medicine. (2013, May). Get the facts. Cancer and complementary health approaches. Retrieved from: http://nccam.nih.gov/health/cancer/camcancer.htm
2National Center for Complementary and Alternative Medicine. (2013, May). CAM basics. Complementary, alternative, or integrative health: what’s in a name? Retrieved from: http://nccam.nih.gov/sites/nccam.nih.gov/files/CAM_Basics_What_Are_CAIHA.pdf
3Ernst, E. (2013, July3). Complementary and alternative therapies for cancer. Retrieved from the Up to Date website: http://www.uptodate.com/contents/complementary-and-alternative-therapies-for-cancer
4Deng, G. E., Frenkel, M., Cohen, L., Cassileth, B. R., Abrams, D. I., Capodice, J. L.,...Sagar, S. (2009). Evidence-based clinical practice guidelines for integrative oncology: complementary therapies and botanicals. Journal of the Society of Integrative Oncology, 7(3), 85-120.
5Strada, E. A., & Portenoy, R. K. (2013, July 1). Psychological, rehabilitative, and integrative therapies for cancer pain. Retrieved from the Up to Date website: http://www.uptodate.com/contents/psychological-rehabilitative-and-integrative-therapies-for-cancer-pain
6American Cancer Society. (2012, March 8). Complementary and alternative methods for cancer management. Retrieved from: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternative Medicine/complementary-and-alternative-medicine-landing
7Barnes, P. M., Bloom, B., & Nahin, R. L. (2008, December 10). Complementary and alternative medicine use among adults and children: United States, 2007. National Health Statistics Reports; no 12. Hyattsville, MD: National Center for Health Statistics.
8Daher, M. (2012). Cultural beliefs and values in cancer patients. Annals of Oncology, 23(Suppl 3), 66-69. doi: 10.1093/annonc/mds091
9Colon, Y. (2007, September/October). Ethnic diversity and cultural competency in cancer care. Oncology Issues. Retrieved from the Association of Community Cancer Centers website: http://www.acccancer.org/oncology_issues/articles/sepoc07/colon.pdf
10National Cancer Institute. (2005). Thinking About Complementary and Alternative Medicine. (NIH Publication No. 04-5541). Retrieved from: http://www.cancer.gov/publications/patient-education/367NCINewV2.pdf.
11U.S. Food and Drug Administration. (2013, September 25). How to evaluate health information on the internet, December 2005. Retrieved from: http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/
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Last updated: January 6, 2014
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