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The Prevalence of Complementary/Alternative Medicine in Cancer


A Systematic Review

Edzard Ernst, M.D., Ph.D. Barrie R. Cassileth, Ph.D.2


1

Department of Complementary Medicine, Postgraduate Medical School, University of Exeter, Exeter, United Kingdom. Department of Medicine (Oncology), University of North Carolina, Chapel Hill, North Carolina.

BACKGROUND. Complementary/alternative cancer treatments are believed to be prevalent. However, reliable prevalence rates do not exist. The aim of this review was to summarize the existing data on this topic. METHODS. A series of computerized literature searches was performed to locate all published studies documenting the prevalence of complementary and/or alternative therapy (CAM) use among patients with cancer. RESULTS. A total of 26 surveys from 13 countries, including 4 studies of pediatric patients, was retrieved. The use of CAM therapies in adult populations ranged from 7 64%. The average prevalence across all adult studies was 31.4%. CONCLUSIONS. This large degree of variability most likely is due to different understandings of complementary/alternative medicine on the part of both investigators and patients. It is likely that the results of the current study reect the primarily adjunctive use of CAM treatments. Future studies should use a standardized protocol to determine the true prevalence of these therapies more closely. Cancer 1998;83:777 82. 1998 American Cancer Society.

KEYWORDS: alternative medicine, complementary therapies, cancer, prevalence, adjunctive therapy.

Address for reprints: Edzard Ernst, M.D., Ph.D., Department of Complementary Medicine, Postgraduate Medical School, University of Exeter, 25 Victoria Park Road, Exeter EX2 4NT, UK. Received December 5, 1997; revision received February 10, 1998; accepted February 19, 1998. 1998 American Cancer Society

omplementary/alternative medicine (CAM) is used by 25%-50% of the general population of industrialized nations.13 It has been described as diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine,4 a denition recently adopted by the Cochrane Field in Complementary Medicine. Some alternative therapies are promoted not to complement mainstream medicine, but to substitute for it. These products and regimens, unproved and deemed unpromising by oncologists, typically are invasive and costly. The reasons for CAMs present popularity most certainly are complex.5 They are related to the social and cultural context.6 In cases of severe illness, the hope to leave no stone unturned is a powerful motivator.5 This renders cancer patients prime candidates for CAM use.6,7 There is evidence to suggest that oncologists, although often unfamiliar with CAM, may take a less negative view of CAM use today than they did previously.8 This systematic review attempted to summarize the published data on CAM use in oncology. Secondary aims were to detect national differences and trends when possible.

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TABLE 1 Key Data from All Investigations Included


Authors (year of publication) Faw et al.9 (1977) Sample (country) 69 pediatric cancer patients or parents (U.S.) 151 consecutive outpatients with cancer (Finland) Families of 106 pediatric cancer patients (U.S.) 183 outpatients with various cancers (Austria) 304 inpatients with cancer and 356 patients of CAM practitioners (U.S.) 315 patients with metastatic tumors (U.S.) 101 consecutive patients with cancer (Germany) Method Interview and questionnaire Personal interviews type of treatments Prevalence Comment 25% had received recommendations to try CAM 38% of users had condence in CAM Accuracy of toxic effects poor

Laetrile, folk remedies, healing 9% had tried some form of CAM Herbs, vitamins, diet 56% of female and 30% of male patients had used CAM 16% of children had used CAM 59% had tried some form of CAM 54% of patients receiving conventional therapy used CAM in addition 7% had tried some form of CAM 32% had used or were using CAM

Arkko et al.10 (1980)

Pendergras et al.11 (1981)

Interviews

Fereberger et al.12 (1983)

Questionnaire

Knowledge/use of laetrile and seven other alternatives determined Mainly herbal remedies

Survey only published an abstract

Cassileth et al.13 (1984)

Personal interviews

Metabolic treatments, diets, megavitamins, imagery, spiritual healing, immune stimulants Laetrile, vitamins diets

40% of patients had abandoned conventional therapy for CAM. Costs were often considerable

Eidinger et al.14 (1984)

Interview

70% would try CAM if available

Obrist et al.15 (1986)

Interview

Beetroot juice, vitamins, Iscador, herbs, lactic acid, homeopathic medications Diets, vitamins, herbs, laetrile

Clinical Oncology Group16 463 outpatients with (1987) cancer (New Zealand) Beaufort et al.17 (1988) 295 put-patients with gynecologic cancers (Austria) 494 outpatients (Switzerland) 300 consecutive cancer outpatients (Switzerland)

Personal interview

37% had sought advice regarding CAM 51% had used CAM since diagnosis

Questionnaire

Herbs, diets vitamins

Berger et al.18 (1989)

Questionnaire (33% response rate) Questionnaire (53% response rate)

Morant et al.19 (1991)

Diet, anthroposophic rememdies, vitamins detoxication Herbs, healing homoeopathy diets

71 patients were using CAM 52% had used CAM

More men than women used; Iscador known by physicians; other methods known in only 25% of cases Compliance with CAM advice was only 19%, costs for CAM often were high CAM mostly used in addition to conventional treatments and mostly judged as effective (by patients) main reason (in 87%): to build up resistance Younger patients were more likely to use CAM. Most frequent reason was to do everything possible to regain health In 73% of the cases CAM use recommended by physician. 6% experienced adverse effects of CAM, costs often were high 66% would have accepted CAM if offered by the hospital CAM use in women more frequent than in men 82% of patients were (very) satised with CAM; adverse effects of diets were reported

Lerner et al.20 (1992)

2743 cancer patients Telephone (representative of all interview cancer patients) (U.S.) 100 new consecutive patients with various cancers (U.K.) 769 outpatients with cancer (Denmark) 600 unselected oncology patients (U.K.) Structured personal interview Questionnaire (97% response rate) Postal questionnaire and personal interview (n 48) Questionnaire lled in by parent

Not specied

9% had used at least 1 type of CAM in their lifetime 32% had used some form of CAM 45% used CAM 16% had used CAM

Burke and Sikora21 (1993)

Damkier et al.22 (1994) Downer et al.23 (1994)

Counseling, meditation, relaxation, visualization, healing Coenzyme Q10 Healing, relaxation, visualization, diets, homoeopathy

Sawyer et al.24 (1994)

48 children with cancer (Australia)

Imagery, hypnotherapy, relaxation, diets, multivitamins

46% had used at least 1 Less than 50% of parents had type of CAM since discussed CAM use with diagnosis physician (continued)

Alternative Medicine and Cancer/Ernst and Cassileth TABLE 1 (continued)


Authors (year of publication) van der Zouwe et al.25 (1994) Sample (country) Method type of treatments Alternative treatments (not specied) Prevalence 9.4% were current users Comment

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949 patients with various Face to face forms of cancer from interview and several outpatient questionnaire departments (Holland) 642 patients with various Questionnaire cancers from various centers (Norway)

Risberg et al.26 (1995)

Risberg et al.27 (1995)

Begbie et al.28 (1996)

Jirillo et al.29 (1996)

Liu et al.30 (1997)

Mo tto nen and Uhari31 (1997)

Sollner et al.32 (1997) Rasky (unpublished data) (1997)

Risberg et al.33 (1998)

Healing, homoeopathy, 20% were current users, reexology, herbs, vitamins, healing was the most diets, Nitter therapy, Iscador prevalent (12%) and other (not specied) therapies 252 patients with various Questionnaire Healing, homoeopathy, herbs, 20% used at least one Patients without cancer held a more forms of cancer from diets, reexology, Nitter treatment, 2% used positive view on the benets of inpatient and therapy (specically named), combinations, healing alternative treatments than outpatient departments plus any other alternative was the most cancer patients (Norway) therapy the patient listed prevalent (9.0%) 507 outpatients with Questionnaire (66% Diets, psychologic methods 22% had used CAM Average annual cost of $530 was cancer (Australia) response rate) perceived as value for money. 40% did not discuss CAM use with their physician 563 questionnaires Anonymous surveys Any unconventional cancer 17% of respondents in Results were similar in Italy and distributed to cancer treatment each country used Argentina. 2038% of alternative patients in Italy; 400 in alternative methods treatments were proposed by Argentina physicians 100 consecutive patients Questionnaire Chinese medication 64% took such Prevalence higher in females, many with advanced cancer medications hoped for a miracle cure; (Taiwan) information on CAM rarely came from physicians, costs normally were moderate 15 children with acute Patient diaries alternative medicines (not 40% of the patients used The investigation included a agelymphoblastic specied) alternative treatments matched, noncancer control leukemia from one group, 8% of whom used pediatric department alternative treatments (Finland) 215 patients with Questionnaire Any unconventional cancer 14% of patients used Alternative therapies used in melanoma (Austria) therapy alternative therapies supplementary fashion 154 patients attending an Questionnaire 74 different unconventional 62% had used CAM, 33% Young patients and married oncology clinic methods mistletoe, 20% Bach patients used CAM more (Austria) ower, remedies, 20% frequently homoeopathy 252 patients (as in initial Questionnaire with Healing, homoeopathy, Prevalence increased In only follow-up study to date, 5survey). Reduction in follow-ups after reexology, herbs, vitamins, during follow-up: 26% year survival was notinuenced sample size over time 4, 12, 24, and 60 diets, injection therapies at 4 months, 24% at by CAM use (110 after 60 months) months and (e.g., Nitter, Iscador), plus 12 months, 18% at 24 (Norway) telephone any other alternative therapy months, and 27% at interview after the patient listed 60 months; women last questionused CAM more naire frequently than men

Young, highly educated patients in palliative care were likely users; the majority hoped alternative therapies would slow disease progression 40% of users had used alternative treatments prior to their cancer diagnosis

CAM: complementary/alternative medicine.

METHODS
The following databases were searched from their inception through January 1998 for articles on cancer and CAM: MEDLINE, Embase, and CISCOM (a database specializing in the grey literature of CAM). The authors own extensive les also were consulted. The bibliographies of all articles thus retrieved were

scanned for further relevant contributions. Inclusion in this review required original data relating to the prevalence of CAM in samples of patients with cancer. There were no restrictions regarding the language of the articles. All articles were read in full and data were extracted in a standardized, predened fashion (Table 1). We have not reviewed the original data behind the

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studies listed here. We have in all cases accepted the original authors representations as true and evidence-based.

RESULTS
Twenty-six publications were found (references 9 33 and Rasky et al., unpublished data), including 1 follow-up report of previously studied patients. The key data from these reports are summarized in Table 1. Increasing interest in CAM use among patients with cancer is reected in the geometric growth in the numbers of publications on the subject. A single article was published in the 1970s, 9 in the 1980s, and 16 between 1990 to date. Publications were based on studies conducted in 13 countries. The majority of articles came from the U. S. (ve articles) and Germany (four). Investigators in South America, Australia, New Zealand, and China also conducted studies, as did researchers in many Western European countries. The 4 articles concerning pediatric patients (from Australia, Finland, and the U. S. [2 publications]), suggest but do not show conclusively a growth in the use of alternative therapies in children from 9% in 1977 to 16% in 1981, 46% in 1994, and 40% in 1997. Data from these four studies cannot prove actual growth because the studies are not consistent in their denitions or methodology. Laetrile (l-mandelonitrile--glucuronic acid), common in the earliest pediatric studies, was replaced in later years by CAM therapies of greater contemporary interest, such as imagery, hypnotherapy, relaxation, diets, and multivitamins. Of the 21 studies involving adult cancer patients, 50% reported that up to 27% of respondents used CAM; the remaining studies found that 25% of respondents tried CAM therapies. Percentages range from a low of 7% to a high of 64%. The average percentage use across adult studies was 31.4%. Although the particular nature of CAM is not always specied, reported regimens range widely from diets and relaxation to iscador and Chinese medications. In the 1990s, the most commonly noted CAM therapies across all studies include mind-body approaches (meditation, relaxation, hypnotherapy, visualization, and other imagery techniques), reexology, dietary approaches and food supplements, Chinese medications, botanical preparations, homeopathy, and spiritual healing.

DISCUSSION
The studies reported in this article display an apparently wide range of prevalence for CAM use. This is not explained by either regional variations or increasing popularity over time. For example, the three sur-

veys published in 199730-32 and by Rasky et al. (unpublished data) yield prevalence rates ranging from 14%-64%. Two of these surveys are from the same country (reference 32 and Rasky et al.), but suggest vastly different prevalence rates. The lack of specicity and inconsistent denitions of CAM contribute signicantly to this variability. CAM often is not dened in prevalence studies or is dened so broadly as to include all treatments received outside of a hospital. Thus the inclusion of counseling, group therapy, and other activities more appropriately counted as mainstream, as well as wellness regimens, self-help efforts, home remedies, and other non-CAM activities in respondents answers distort the actual extent of CAM utilization. Although some studies uncovered for this analysis indicate that patients used CAM in an adjunctive or supplementary fashion, prevalence studies rarely differentiate between therapies used in an adjunctive mode and those applied toward cure, exclusive of mainstream treatment. With one exception,13 the studies reported here include patients seen in mainstream cancer programs only. Therefore, by denition patients who were receiving cancer care in other settings and who may have been receiving alternatives to mainstream care were not represented in these investigations. Most surveys also are open to biases. For example, selection bias can result from the choice of study sample, and high nonresponse rates and recall bias may occur in retrospective analyses. Moreover, it should be noted that physicians comments as reported by patients may be inaccurate. Discrepancies between what the patient heard or remembered and what the physician actually said may well exist. As CAM has become more widely discussed by the media and in mainstream medicine, patients are likely to feel more comfortable about reporting their use of these therapies. Thus, the apparently increased rates seen today also may reect patients willingness to talk more openly about their use of CAM. Data from pediatric surveys reviewed here suggest an increase in CAM use or reports of use during the last 20 years. Although longitudinal data by Risberg et al. might suggest such an increase in adults as well, these same data also could reect increased use of CAM by the same patients as their disease advances,33 or more open reporting by patients. Regardless, it is clear that patients with cancer in Europe, Asia, the Americas, and Australia use CAM frequently. Although Chinese medications are sought most commonly in Asia, as would be expected, remaining CAM approaches differ little from country to

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country. Given this degree of consistency as well as popularity, physicians lack of knowledge about CAM requires careful consideration.34 Critical analyses of this area should inform both the patient and the physician.35,36 In particular, future research should clarify distinctions between potentially harmful alternative cancer cures and potentially benecial complementary therapies employed as adjuncts to cancer treatment.7 Future studies might seek to apply a more standard series of questions and denitions to generate comparable data. A better understanding then could be reached regarding patients expectations, reactions, costs, discussion of CAM with their physicians, clinical outcomes, and optimal uses of complementary therapies in future cancer care. Although CAM use has been found in surveys of cancer patients around the world, its impact on cancer patients well-being has been explored only minimally.37 Despite the absence of reliable prevalence gures, we conclude that the use of CAM by cancer patients is common and widespread. Consistently dened information and data on alternative versus complementary use of unconventional regimens are needed to inform the debate regarding the potential benets or harms of such treatments.

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