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BREAST CANCER REVIEW

Complementary Therapies

Introduction

Complementary therapies refer to a diverse group of medical practices and products that are not presently considered a part of conventional medicine. Used as a supplement to 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

While complementary therapy is often mentioned together with alternative therapy, there is a meaningful distinction between the two terms. Alternative therapy is used in place of conventional medicine whereas complementary therapy is used as a supplement, with the intent of complementing conventional treatments.¹ For minor health issues, some alternative therapies may not pose risks. However, in the case of breast cancer or other serious illness, a reliance on alternative therapy in place of conventional medicine is considered by most health professionals as unwise. The preferred approach combines the best of both traditions with the full knowledge and involvement of the patient's medical team. For women with breast cancer, certain complementary approaches can be used to support the efforts of conventional medicine before, during and after treatment by helping to manage symptoms and improve quality of life.

In recognition of the potential benefits 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, aromatherapy, among others. For patients, these programs allow for the safe use of unconventional therapies under the direction of an informed medical team. For health professionals, integrative programs promote ongoing professional growth in a setting where unconventional and conventional treatments can be examined together. The recent growth of integrative programs in the U.S. is partly attributed to the sheer popularity of use among consumers.²

Use of Complementary and Alternative Medicine (CAM) in the U.S.

According to the National Center for Alternative and Complementary Medicine (NCCAM), the U.S. public spent an estimated $36 to $47 billion on CAM therapies in 1997. Of this, between $12 and $20 billion was paid out-of-pocket for the services of CAM practitioners, more than the public paid out-of-pocket for all hospitalizations and about half of what it paid for all out-of-pocket physician services during that same year. Five billion dollars of out-of-pocket spending was on herbal products.³

More recent findings about CAM use derive from the 2002 edition of the National Health Interview Survey, conducted by the National Center for Health Statistics (NCHS).⁴ According to this survey, 36% of U.S. adults use some form of CAM. When megavitamin therapy and prayer used specifically for health reasons were included in the definition, the percentage rose to 62%. Of the survey respondents that reported using CAM, over a quarter indicated that a conventional medical professional suggested trying CAM. Over half believed that CAM would improve their health when used in combination with conventional medical treatments.

As the use of CAM gains popularity among U.S. health consumers, it is in the best interest of patients for their practitioners of conventional medicine to keep an open mind while evaluating these different approaches. The danger of doing otherwise is that the patient interested in unconventional treatment may seek help elsewhere at the exclusion of essential medical care. Similarly, if a patient feels uncomfortable disclosing her use of CAM to her doctor, the risk of treatment interference from certain herbs or dietary supplements is increased. Healthcare providers are encouraged to ask patients about their use of CAM, and to share with them their medical opinions through open and respectful dialogue.  

Types of CAM

In contrast to conventional medicine, the orientation of CAM is holistic: it seeks 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 the five major CAM types. These types, also called domains, are briefly described as follows:

Whole Medical Systems are built upon complete systems of theory and practice that have evolved independent of conventional medicine used in the U.S. Major Eastern whole medical systems include traditional Chinese medicine (TCM) and Ayurvedic medicine, from India. Major Western whole medical systems include homeopathy and naturopathy. Other systems have been developed by Native American, African, Middle Eastern, Tibetan, and Central and South American cultures.

Mind-Body Interventions use a wide variety of techniques designed to enhance the mind's ability to affect the body's function and symptoms. Examples include such various approaches as meditation, hypnosis, biofeedback, yoga, guided imagery, breathing techniques, and prayer. Therapies that use creative outlets such as art, music or dance are also included within this domain. Some mind-body techniques previously considered CAM have become adopted into the mainstream, such as patient support groups and cognitive-behavioral therapy.

Biologically Based Therapies make use of substances found in nature, such as botanicals, animal-derived extracts, vitamins, minerals, fatty and amino acids, proteins, prebiotics and probiotics, whole diets, and functional foods. Dietary supplements are a subset of this type of CAM.

Manipulative and Body-Based Methods are therapies that work with one or more parts of the body. Some examples in this heterogeneous group include chiropractic and osteopathic manipulation, massage therapy, Tui Na, reflexology, rolfing, Bowen technique, Trager bodywork, Alexander technique, Feldenkrais method, and many others. Some derive from ancient systems of medicine while others were developed within the last 150 years (e.g., chiropractic and osteopathic manipulation).

Energy Therapies are based on a core belief in the existence of a universal life force, or subtle energy, that resides in and around the body.  There are of two main types of energy therapies, known as veritable (which can be measured) and, putative (which have yet to be measured). Bioelectromagnetic-based therapy (a veritable form) involves the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields. Biofield therapy (putative form) is intended to affect energy fields that purportedly surround and penetrate the body. Examples include qi gong, Reiki, Therapeutic Touch, and intercessory prayer, in which a person intercedes through prayer on behalf of another.  

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 therapies currently considered CAM have been well-researched. As a result, many key questions about safety and efficacy remain unanswered.

Therapies such as acupuncture, biofeedback, and meditation are generally considered safe and effective for helping cancer patients relieve pain, ease side effects, and enhance their quality of life. Additional complementary methods that the American Cancer Society  (ACS) list as potentially helpful for some people, when used along with standard medical treatment, are aromatherapy, yoga, tai chi, music therapy, art therapy, prayer and spirituality.⁵ Other therapies, however, including certain herbs and dietary supplements, can cause harm by interfering with conventional treatments. For example, ginkgo biloba, garlic, vitamin E, and ginger when taken alone can help to prevent abnormal blood clotting but, if taken with chemotherapy, there may be abnormal bleeding. Likewise, some types of supplements may dangerously interact with anesthesia for patients having surgery, or cause skin reactions for patients being treated with radiation therapy.⁶ Some dietary supplements and herbs can also have negative, even dangerous, effects on their own, as may certain body manipulation techniques. While limited research suggests that many types of complementary therapies may be beneficial to women with breast cancer when used in a supportive role, informed guidance and supervision from the patient's primary care provider are crucial for assuring safe and appropriate use.

For comprehensive fact sheets 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.  Similar safety and efficacy issues about CAM techniques can be researched at InteliHealth, an Aetna-sponsored web site featuring content created by faculty at Harvard Medical School.

NCCAM, the federal government's lead agency for the scientific study of complementary and alternative medicine, maintains that the same scientific evaluation used to assess conventional cancer treatments should be used to assess CAM therapies. Recent NCCAM trials include studies of acupuncture (to relieve neck and shoulder pain following surgery for head or neck cancer); massage (for the treatment of cancer pain); ginger (as a treatment for nausea and vomiting caused by chemotherapy); and mistletoe extract combined with chemotherapy (for the treatment of solid tumors). Additional NCCAM trials are ongoing, some conducted in partnership with other institutes at the National Institutes of Health (NIH). For more information, visit the NCCAM Clinical Trials web page.

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. The National Library of Medicine provides a comprehensive Online directory of health organizations at DIRLINE. If licensing laws do not apply for a particular CAM therapy, asking about a practitioner's length of training and experience is basic. Additional guidance for finding a qualified CAM provider can be found in NCCAM's Online publication: Selecting a CAM Practitioner. 

Once a potential CAM provider has been found, the National Cancer Institute recommends the following sets of questions:⁷

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?

• 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?

• 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?

Evaluating CAM Information on the Internet

Enter the terms "complementary and alternative medicine" into the search feature at Google.com and it will respond with over 2 million listings. Many of these web pages provide valuable and valid information. Others, however, may not. Knowing how to tell the difference is essential when seeking information about unconventional therapies.

Patients who find CAM-related content on the Internet should be encouraged to discuss what they find with their doctors, taking special note of the information source. Who runs the site?  Who funds the site? What is its purpose? Generally, web sites sponsored by federal and state governments, along with university medical schools, are among the best for finding accurate and balanced content, but these are not the only reliable sources, nor is source the only important indicator.  Where does the information come from? How is it selected? Is the information current? These are also important questions. If a web site links to other web sites, to which does it link? The same set of questions should be applied to the web site's list of selected links. How the web site manages interactions with visitors is also key. Does it specify its terms of use and privacy policy? Does it provide a way for visitors to contact owners with problems and feedback? Does someone respond? With regard to CAM, web sites that permit Online purchasing, post patient testimonials, or claim a cure for cancer should raise red flags.

The U.S. Food and Drug Administration (FDA) has prepared a quick summary checklist of the most important questions to ask:⁸

• Can you easily see who sponsors the web site?
• 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?
• Is your privacy protected?
• Does the web site make claims that seem too good to be true? Are quick, miraculous cures promised?

More information can be found by reading the entire FDA publication, How To Evaluate Health Information on the Internet or from NCCAM's 10 Things To Know About Evaluating Medical Resources on the Web.  Moore's University of California, San Diego Cancer Center has also prepared an excellent guide for Evaluating and Interpreting Information on the Internet.

In addition to these, quackwatch.org is a nonprofit corporation "whose purpose is to combat health-related frauds, myths, fads, and fallacies." Founded and maintained by a medical doctor, with assistance from a worldwide network of volunteers and expert advisors, quackwatch.org is an indispensable resource for helping providers and their patients assess the reliability of web sites 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-profit, non-governmental organization dedicated to "promoting and guiding the deployment of useful and reliable Online medical and health information, and its appropriate and efficient use." The HONcode seal appearing on health-related Web sites identifies compliance with a set of basic ethical standards.

Notes

¹The term conventional medicine refers to medicine as practiced by health professionals with M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees, some of whom may also practice complementary medicine. Other terms for conventional medicine are orthodox, standard, allopathy, Western, regular and mainstream.

²Jaret, P. Dealing With Cancer (July 24, 2000). Retrieved Mar. 31, 2006 at:  http://www.medicinenet.com/script/main/art.asp?articlekey=50626&pf=3&page=1

³National Center for Complementary and Alternative Medicine. The Use of Complementary and Alternative Medicine in the United States (Sep., 2004). Retrieved Mar. 28, 2006 at: http://nccam.nih.gov/news/ camsurvey_fs1.htm

⁴See note 2

⁵American Cancer Society.Complementary and Alternative Methods for Cancer Management (revised, Jan. 3, 2006). Retrieved Mar. 28, 2006 at: http://www.cancer.org/docroot /ETO/ content/ETO_5_1_Introduction.asp

⁶People Living With Cancer. Spotlight on Complementary and Alternative Medicine and Cancer. Retrieved July. 13, 2006 at: http://www.plwc.org/portal/site/PLWC/ menuitem. 034b98abc 65a8f566343cc10ee37a01d/? vgnextoid=01a4565d4969a010V gnVCM100000f2730ad1RCRDsp

⁷National Cancer Institute. Thinking About Complementary and Alternative Medicine: Choose Practitioners with Care (June 8, 2005). Retrieved Mar. 31, 2006 at: http://www.cancer.gov/ cancer topics/ thinking-about-CAM/page8

⁸U.S. Food and Drug Administration. How To Evaluate Health Information on the Internet (Dec., 2005). Retrieved Apr. 1, 2006 at: http://www.fda.gov/oc/opacom/evalhealthinfo.html

Revised: December 2, 2007.

Source URL: http://qap.sdsu.edu/education/bcrl/Bcrl_complementary/bcrl_complementary_index.html

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