Surveys of complementary and alternative medicine: Part II. Use of alternative and complementary cancer therapies.

The second part of this series on surveys of complementary and alternative medicine (CAM) in the United States provides a "point-of-information" summary of the studies on patients with cancer and their use of CAM therapies. Surveys of patients with cancer were the precursors of the recent wave of studies on CAM prevalence and use. Three tables summarize the findings from a total of 18 surveys categorized by Childhood Cancer, Adult Cancer, and Breast Cancer studies.     

Participant-centered analysis in complementary and alternative medicine comparative trials

Participant-centered analysis involves applying the customary methods of statistical decision making at the level of the individual research participant. Consequently, each individual is declared a responder who benefited, a nonresponder, or possibly a responder who was harmed, using intensively collected data that were specific to that individual. There are several implications of the participant-centered approach. More data actually relevant to the important outcome need to be collected on individuals. The study results can be summarized in a simple table of responders/nonresponders by treatment group, and probabilities of true response can be estimated. The actual nature of the data collected and the statistical models used to analyze them drop into the background. Finally, production of individual-level decisions permits standard statistical approaches to be applied to the issue of which modality should be recommended for which person, instead of focusing on average effects and which modality should be recommended for everyone.     

Evidence-based research in complementary and alternative medicine I: history

Contemporary Western medicine has witnessed a fragmentation of our conceptualization of the medical endeavor into 'traditional medicine' and 'non-traditional medicine'. The former is meant to refer to the Western medical tradition, the latter encompasses both 'complementary' and 'alternative' medical practices. Complementary medicine complements conventional medical treatments, and alternative modes of medical interventions are meant to replace traditional Western medicine. Evidence-based research must be directed at establishing the best available evidence in complementary and alternative medicine. This paper is the first of a set of four 'lectures' that reviews the process of evidence-based research, and discusses its implications and applications for the early decades of the 21st century. The purpose of this paper is to introduce the series by examining some of the historical and philosophical foundations of this research endeavor.     

Surveys of complementary and alternative medicine: Part V. Use of alternative and complementary therapies for psychiatric and neurologic diseases

Surveys of general complementary and alternative medicine (CAM) use have suggested an association with high levels of depression and anxiety. This raises the question of whether anxious or depressed people seek CAM, or whether there are underlying factors associated with long-term chronic illness. There is no clear indication from four surveys of psychiatric patients. These are summarized and presented. A separate table summarizes three studies of patients with neurologic diseases, two of patients with multiple sclerosis, and one of a mixed patient population. More studies are amassing in specific disease areas, although it is difficult to detect clear trends because of methodological and terminological incompatibilities.     

Biomedical orthodoxy and complementary and alternative medicine: Ethical challenges of integrating medical cultures

This paper examines biomedicine's contemporary overture to complementary and alternative medicine (CAM) in the move toward an integrated medical system. The paper argues that a major challenge of our increasingly integrating medical culture is raising commensurate personnel to grapple with the changing ethical landscape, especially with regard to understanding the methodologies and philosophies of CAM's therapeutic paradigms. Such personnel is required to tackle realistically the critical ethical challenge of our amalgamating medical system, namely an acceptable framework for evaluating the efficacy of CAM's plural therapeutic paradigms.     

Research on complementary and alternative medicine using randomized controlled trials

In 1998, the National Institutes of Health (NIH) formed the National Center for Complementary and Alternative Medicine (NCCAM) from what had formerly been the Office of Alternative Medicine. This presentation opens with a brief discussion on the history of the NIH and the development of CAM at the NIH before moving on to the work of the NCCAM. The NCCAM is moving toward an integration of CAM therapies into conventional medicine, when there is evidence for the value of CAM. One of twenty-five institutes or centers at the NIH, the NCCAM looks at evidence-based medicine and public health. In this context, "public health" means educating the public about its health. The NCCAM supports training to conduct research and plays an important role in disseminating information to the public and to health providers about what works and what is safe. This evolves into the concept of evidence-based medical and public-health practices, that is, making decisions on the basis of evidence from scientifically rigorous studies that are sufficiently large to provide a confident estimate of biologically and medically important benefits and risks. In the hierarchy of generating scientific evidence, randomized controlled trials are considered the "gold standard." The NCCAM entertains proposals for studies that come spontaneously from investigators, or, upon identifying an existing need that is not being met by the investigative community, the NCCAM can initiate a request for proposals. Every proposal is subjected to a rigorous application and review process. Another possible step in the assessment of the evidence from clinical trials is to do a systematic analysis of several studies to bring together all the information that is available. Systematic reviews of smaller studies that individually might have an insufficient sample size can assist in making treatment decisions, but, importantly, they can lead the NCCAM in the development of future, definitive studies. Training to conduct research is especially important to CAM. This presentation outlines several approaches the NCCAM has to training (see http://nccam.nih.gov).     

Presenting the alternative: cancer and complementary and alternative medicine in the Canadian print media

Goals of work Cancer patients repeatedly identify the mass media as a primary information source to support their decisions to use complementary and alternative medicine (CAM). Accordingly, the objectives of this research are to describe: (1) what has been reported in the Canadian print media regarding CAM treatment for cancer between January 1, 1990 and December 31, 2005; (2) how that information was represented; and (3) trends in reporting frequency and reporting characteristics. Materials and methods Content analysis of all articles published in four Canadian newspapers and five magazines that discussed CAM treatment for cancer. Main results 915 articles were identified: 760 newspaper articles and 155 magazine articles. The CAM therapies most commonly described in media reports were: natural health products, CAM therapies in general, special diets, spirituality, and meditation. CAM therapies were most often described in a positive fashion, and CAM use was most often described as a potential cure for cancer. The majority of articles did not present information on the risks, benefits, and costs of CAM use and few provided a recommendation to speak with a health care provider before use. Conclusions The results correspond with the commercial interests of media outlets, as coverage appears to be focused around entertainment rather than information provision. The media play a role in introducing a range of treatment options to cancer patients that may not be discussed by conventional health care providers; however, the information provided in media articles appears insufficient to assist patients with informed decision-making.     

Communicating facts and knowledge in cancer complementary and alternative medicine

OBJECTIVES: To review written resources disclosing reliable facts and knowledge in cancer complementary and alternative medicine (CAM). DATA SOURCES: Conventional and biomedical and complementary and alternative medicine journals, electronic media, full text databases, electronic resources, and newsletters. CONCLUSION: Sources of CAM information are numerous. The inherent quality of this information fluctuates. High-quality sources of cancer CAM information are available and accessible for health care providers. IMPLICATIONS FOR NURSING PRACTICE: As the use of CAM therapies becomes more commonplace in consumer health care, it is critical that health care providers are cognizant of available sources of high-quality CAM facts and knowledge and possess the ability to discuss this information with colleagues and consumers in the scientific and lay communities.     

Surveys of complementary and alternative medicine: part I. General trends and demographic groups

Data from the surveys of the Harvard team, led by David Eisenberg, M.D., are frequently used as a summary first paragraph introduction to the status of complementary and alternative medicine (CAM) in the United States. However, there is now a substantial body of literature on various facets of CAM use. Six national surveys to date are briefly discussed and summarized in a table. Some surveys have been conducted at a regional level. Three are summarized but there are too few data yet to draw any conclusions. Eighteen more exploratory surveys of specific subpopulations are presented to help draw a clearer picture of income, ethnic, and age groups. The search strategy is provided. The changing terminology in the field, the development of the CAM survey, and some common shortcomings are also addressed.     

n-of-1 randomized controlled trials: an opportunity for complementary and alternative medicine evaluation

Complementary and alternative medicine (CAM) practice has traditionally relied on expert opinion and case examples to evaluate the outcome of a particular therapeutic treatment. Such trials are subject to bias, leading to the formation of erroneous conclusions about the effectiveness of most treatments. This paper reviews the feasibility of n-of-1 trials to better evaluate the clinical and statistical significance of CAM therapies. In particular: (1) problems arising from the use of standard therapeutic trials; (2) the n-of-1 trial and data analysis; (3) clinical use and advantages of the n-of-1 trial in conventional medicine; (4) potential clinical uses of the n-of-1 trial in CAM; (5) preliminary guidelines for the use of the n-of-1 trial in CAM; (6) constraints on the use of the n-of-1 trial in CAM; and (7) ethical issues in the conduct of the n-of-1 trial.     

Physicians and complementary and alternative medicine cancer therapies in Greece: a survey

OBJECTIVES: To assess the prevalence of complementary and alternative medicine (CAM) cancer therapies and attitudes toward them in a nonrandom sample of physicians in Greece. SUBJECTS: Four hundred and ninety-four (494) physicians from private practices and hospitals in the Athens area were approached to complete a questionnaire on perceived cancer etiology, self-reported knowledge, and attitudes about CAM therapies used by cancer patients. Two hundred and thirty-six (236) (47.8%) questionnaires were returned. RESULTS: Greek physicians are most familiar with homoeopathy (58.5%), diets (58.1%), antioxidants (vitamin C) (55.9%), and acupuncture (47.9%). Perceived rates of patients using CAM are low. Predominantly, physicians shared concepts of carcinogenesis accepted by conventional biomedicine. Only physicians who considered disorders of cellular metabolism or in the flow of body energy to be relevant believed that homoeopathy could be an adequate CAM therapy. CONCLUSIONS: Greek physicians in our sample displayed little interest in CAM. However, media and Internet coverage may generate a greater demand for these methods in the future in Greece and physicians will thus need to be better informed.     

HIV: effectiveness of complementary and alternative medicine

Outcome studies examining the efficacy of CAM among people living with HIV-AIDS are often conducted among small sample sizes with very little follow-up data or time points. Generalizability of many of the study findings is further limited by participant attrition. It is difficult to conduct clinical studies on chronically ill patients without participants dropping out, typically because the study demands coupled with their illness become too burdensome. Several studies have been conducted that include control groups, double-blind designs, and randomization. These scientifically sound studies have demonstrated promising results that strongly indicate a need for further research with larger samples in a prospective research design so that safety and efficacy can be determined over time. Many of the studies with small sample sizes reported trends, but did not find statistical significance. Increasing sample sizes in future studies is necessary to evaluate the scientific merit of these trends. Moreover, researchers need to evaluate the clinical and statistical significance in CAM use. The psychologic benefits of taking CAM should not be underestimated. For the purposes of this article, the authors did not include psychologic outcomes; however, there is evidence suggesting that decreasing depression can decrease HIV-related somatic complaints [69]. Studies need also to examine the effectiveness of CAM on psychologic outcomes and physical outcomes. This article and the authors' own research (Gore-Felton C et al, unpublished data) have revealed a high prevalence of alternative supplement use in conjunction with HIV medication, indicating an urgent need to understand the health benefits and the health risks of alternative supplements among patients with HIV and AIDS. Patients and physicians need more empirically based research to examine the toxicities, interactions, and health benefits of CAM. Many patients do not report the use of CAM to their physicians and very few physicians record treatments in the clinical record [70]. This will likely change as CAM becomes more widely recognized as a legitimate medical intervention; however, controlled outcome studies among large, diverse samples of people living with HIV-AIDS are needed. Health care providers need to assess the use of herbal and alternative therapy practices by their patients. Some patients may not be aware that they are taking a supplement or plant-based herb. Furthermore, some patients may believe that they are using something innocuous and even healthy simply because it came from a health food store. Understanding the contraindications of alternative therapies is necessary to prevent deleterious outcomes and to facilitate the safe and efficacious use of CAM in the management of HIV disease and related symptoms. As the epidemic in the United States continues to rise among women and minority populations, clinical research trials must include ethnically diverse patient populations that are gender balanced. Current available studies indicate that many CAM interventions may improve the quality of life of people living with HIV-AIDS; however, further studies using longitudinal, controlled designs are needed to accurately assess the safety of such interventions.     

Ethnic differences in complementary and alternative medicine use among cancer patients

OBJECTIVES: This study estimated the prevalence of complementary and alternative medicine (CAM) use and its relation to quality of life (QOL) among cancer patients from diverse ethnic backgrounds. Given the ethnically diverse population in Hawaii, we hypothesized that CAM use may be related to the ancestry and the cultural heritage of cancer patients. DESIGN AND SETTING: Participants for this mail survey were identified through the Hawaii Tumor Registry, a state-wide population-based cancer registry. SUBJECTS: Patients with invasive cancer diagnosed 1995-1996. Of the 2,452 questionnaires received, 1,168 (47.6%) were returned. OUTCOME MEASURES: Prevalence of CAM use and QOL measures. RESULTS: One in four respondents reported at least one CAM therapy since cancer diagnosis. CAM use was highest among Filipino and Caucasian patients, intermediate for Native Hawaiians and Chinese, and significantly lower among Japanese. Some ethnic preferences for CAM followed ethnic folk medicine traditions, e.g., herbal medicines by Chinese, Hawaiian healing by Native Hawaiians, and religious healing or prayer by Filipinos. CAM users reported lower emotional functioning scores, higher symptom scores, and more financial difficulties than nonusers. CONCLUSIONS: This study detected ethnic differences in CAM use, in particular a low use among Japanese patients, and supports the importance of cultural factors in determining the frequency and type of CAM therapies chosen. Consideration of patients' cultural heritage may facilitate communication between physicians and patients about CAM with the goal to achieve optimal cancer care.