The Nadis or energy lines as shown in ancient Indian Sanscrit.
Integrating Complementary and Alternative Therapies and medicine into mainstream cancer care:
Which way forward?
Monica C Robotin. Andrew G Penman. MJA2006; 185(7): 377-379
Author details Monica C Robotin, FRACS, MBA, Medical Director,
Senior Lecturer Andrew G Penman, MACP, MPH, CEO
Is integration of C.A.M. with mainstream medicine desirable?
— Efficacy and safety of C.A.M. for cancer patients
— Physicians’ attitudes to C.A.M. and awareness of its use
— Research into C.A.M.
— Regulatory framework for C.A.M. and C.A.M. practitioners
— Ethical, equity and consumer issues
— Which way forward?
— Competing interests
Although viewed with scepticism by the medical and scientific community, complementary and alternative medicine (C.A.M.) in its entirety is being used by about 50% of Australians.
‘Integrative medicine’ is a holistic approach to cancer care, with some C.A.M. of proven effectiveness being used as adjuvants to conventional medical treatments.
However, there is little evidence of a systematic
process of evaluation or dialogue between mainstream cancer medicine and C.A.M. providers exists in Australia.
Collaboration, guidance and support for relevant research in this area is needed.
The key elements of a process
of furthering integrative medicine include improving knowledge about C.A.M.;
- addressing uncertainties about all C.A.M. efficacy and safety;
- improving communication about C.A.M. between medical practitioners and patients,
between medical practitioners and C.A.M. practitioners;
- introducing regulatory frameworks and credentialing of C.A.M. practitioners;
- and addressing ethical issues.
What is C.A.M.;
No longer considered as a collection of covert practices and unconventional cancer medicine, C.A.M. today
is highly visible and information about it is widely available to the general public. It is a multi-billion-dollar business in the United States and of equivalent impact and importance throughout the developed world.
and alternative medicine (C.A.M.) is a diverse group of medical and health care systems, practices and products, not presently considered part of the conventional medicine scheme.
While the word complementary implies use in conjunction with
standard medical treatments, alternative suggests use instead of standard treatments. In different circumstances, the same therapy could be used as complementary and or alternative therapy.
In Australia, serial population-based surveys indicate
that about half the population uses non-medically prescribed alternative medicines and more than 20% visit C.A.M. practitioners.
Expenditure on C.A.M. ($1.86 billion in 2004) represents about four times the public contribution to the
Pharmaceutical Benefits Scheme.
Cancer patients are frequent users of C.A.M.: between 9% and 91% of patients diagnosed with cancer in the United States use some form of C.A.M. after diagnosis.
The large range of use is partly
related to different classifications of C.A.M., frustrating attempts to compare the prevalence of different therapies.
An Australian study found that 22% of cancer patients used C.A.M., a finding corroborated by a recent survey in New South
Cancer patients use varieties of C.A.M for many reasons: for symptomatic relief; to improve their quality of life; because of concerns about the toxicity of conventional therapies; because C.A.M. is congruent with their values and beliefs;
or because they believe C.A.M. can fight cancer, or boost their immune system.
The emergence of C.A.M. at the forefront of consumer health-seeking behaviour has significant medical, ethical and economic implications, and impacts on the public
health mandate of protecting, promoting and restoring people’s health.
The prevalence of and reasons for C.A.M. use are well documented in the Australian medical literature, but the public health implications have received far less scrutiny.
Is integration of C.A.M with mainstream medicine desirable?
Some C.A.M of proven effectiveness is being used as an adjuvant
to conventional medical treatments in a holistic energy approach to cancer care programs termed integrative medicine, this approach is avilable in Western Australia, and is promated by SolarisCare although the level of integration and the quality of services
offered vary in different countries and among individual cancer centres.
In Australia, integration has been slow to gather momentum, with a 2005 Australian Senate inquiry capturing the views of the diverse stakeholders involved: conventional
practitioners largely opposed it on the grounds of lack of evidence for effectiveness and safety, while consumer groups and C.A.M. practitioners perceived that Complementary and or Alternative Cancer Therapies were deliberately suppressed, as they challenged
the prevailing cancer treatment paradigm.
Here, we identify some issues to focus this debate.
Efficacy and safety of C.A.M. for cancer patients
Although the use of C.A.M. is yet to proved
as being ineffective in curing cancer, some C.A.M. in particular, Energy Therapies can be helpful in controlling cancer symptoms and enhancing quality of life.
Reviews of the effectiveness of C.A.M. in palliative care for patients
with cancer found that treatments — such as acupuncture, massage, hypnotherapy, meditation, relaxation and Energy therapies including
Reiki— showed promise, but in the eyes of the individual conventional medicine practitoners there was insufficient evidence to recommend their widespread use.
The list of agents with purported cancer-fighting
properties is growing rapidly, although few have been tested in rigorous clinical trials. Awareness of risks related to the use of herbal medicines is limited, and “natural” does not necessarily correlate with “safe”.
that pose specific alternative challenges include: wide variation in biological potency among herbal crops; possible contamination by fungi, bacteria or pesticides; use of incorrect plant species; absence of product standardisation (leading to possible substitution
adulteration and incorrect dosing or preparation); and inappropriate labeling or advertising.
Some herbal medicines have toxic effects (kava causes hepatotoxicity), interact with prescription drugs (St John’swort), or cause surgical
complications (garlic, ginkgo, and ginseng may enhance bleeding; ephedra causes cardiovascular instability; and ginseng causes hypoglycaemia).
Physicians’ attitudes to C.A.M. and awareness of its use
Surveys of Australian, Italian and Canadian oncologists’ knowledge and utilisation of C.A.M. have identified gaps in their knowledge of non-traditional therapies. In the US, many medical schools are now offering elective courses on C.A.M.,
yet few promote critical thinking in reviewing the evidence.
Doctors underestimate their patients’ use of C.A.M.: a recent study found that 37% of patients receiving radiotherapy used C.A.M.; (their
doctors estimated that 4% of them did). One study found that about half the patients using C.A.M. do not tell their doctors, either because they expect them to be disinterested or express disapproval, or they may be unaware of possible drug–C.A.M.
interactions. This limits opportunities for patient–physician dialogue about the risks and benefits of these treatments.
Research into C.A.M.
Despite its apperant popularity,
there has been limited research into all aspects of C.A.M. Some of the challenges for C.A.M. research relate to methodological issues, as individualised patient treatment (a cornerstone of the C.A.M .philosophy) makes many C.A.M. practitioners reluctant to
adopt randomised controlled trial methodologies. There are also difficulties with recruitment for trials, identifying appropriate outcome measures, and finding appropriate placebos.
Establishing research collaborations is also a problem,
with few clinicians being supportive of C.A.M. research. Added to this are differing research priorities, difficulties in securing research funding, and a reluctance of ethics committees to endorse research on products or procedures lacking formal safety testing.
Regulatory framework for C.A.M. and C.A.M. practitioners
In Australia, Alternative Medicines are regulated under the Therapeutic Goods Act 1989 (Cwlth), administered by the
Therapeutic Goods Administration. Most Alternative medicines are categorised as “listed” rather than “registered”
products. They are therefore required to meet safety and quality of manufacture standards, rather than the rigorous quality, safety and efficacy evaluations required of registered products. The Expert Committee on (Complementary Medicines, C.M. ) in the Health
System identified a need to improve the quality of adverse reaction reporting in Alternative Medicine to raise awareness of treatment interactions.
Under the Australian Constitution, the power to regulate the health professions is the
prerogative of state and territory governments. Regulation of C.A.M practitioners takes the form of statutory regulation or self-regulation. A nationally agreed process, in place since 1995, stipulates that occupational regulation is required only if the majority
of the jurisdiction agree to it and certain criteria are met, one of which is a potential for causing harm.
The Expert Committee recommended that all jurisdictions would need to develop more effective self-regulation for C.A.M. professions,
with some C.A.M. practitioner groups receiving federal government support to explore implementation options.
Educational standards are extremely variable among Australian C.A.M. practitioners, and consumers and health care professionals lack
reliable methods of identifying suitably qualified practitioners. Acquiring and updating information on C.A.M. should be part of undergraduate vocational and continuing medical education, but significant barriers remain in putting this into practice.
Ethical, equity and consumer issues
Issues with significant ethical and legal ramifications include:
Identifying and reporting potential C.A.M. ( Alternative ) drug interactions;the
use of C.A.M. in children;
determining acceptable levels of knowledge of C.A.M. treatments for medical practitioners; and
defining professional duty with regard to patient information about C.A.M. risks and benefits,when and
how to refer patients to qualified C.A.M. practitioners, and how to remain involved in a patient’s care.
Practitioners also need to consider equity issues, as the sometimes significant costs of C.A.M. treatments are borne largely by
An important aspect of C.A.M. is safeguarding consumer choices. Patients most commonly receive information on C.A.M. from family and friends, the media, from books, and increasingly from the Internet. Using the Internet to gather
information about C.A.M. can empower individuals and give them greater opportunities to become active participants in their care, but separating reputable sources of information from those selling “bogus cures” challenges consumers’ ability
to make informed decisions.
Which way forward?
The move of C.A.M. from the “invisible mainstream” into the open, signals
a difference in perception between what patients expect of conventional medical practitioners and what practitioners themselves believe they are providing.
Integrating C.A.M therapies into mainstream cancer care is contingent upon C.A.M.
meeting safety and efficacy standards and on the development of effective collaborations among relevant stakeholders. An integrated model needs to be built around a tailored C.A.M. research agenda, a mentoring program for C.A.M. researchers, and the development
of evidence-based practice models.
A combined research and clinical program of integrative medicine, as is starting to practiced in North America, could foster dialogue between C.A.M. and conventional treatment providers, and create new opportunities
for collaborations to both explore the potential of novel treatments and facilitate their rigorous evaluation.
The medical and public health communities need to become more involved in this dialogue: C.A.M. is not a passing fad and, in view
of its enormous popularity, the potential for harm, and the lack of effective mechanisms to safeguard consumer choices, it is time for clinicians and public health practitioners to learn more about “the other side”.
ways of advancing the process of integrating C.A.M. into mainstream cancer care
* Developing integrative services: logistical aspects
* Consult stakeholders to define scope, objectives and outcomes
* Form collaborative group to include “C.A.M. champions”
Agree on models and implementation options
* Identify possible pilot sites for integrated C.A.M. delivery, informed by
local interests and available expertise
* Define scope of C.A.M. in pilot sites and expected outcomes
* Facilitating information transfer and meeting educational objectives
* Assess options and requirements for educational programs
Define target audiences (eg, medical undergraduates, oncology trainees, clinicians, general practitioners, nurses, community service centres.
* Provide reviewed and regularly updated information for consumers
* Develop communications and continuing
medical education modules on CAM
* Supporting C.A.M. research
* Identify interested research groups and establish common goals
* Define research priorities
* Provide training in research methodology for interested C.A.M. researchers
* Establish research collaborations, depending on interests and available expertise
* Consider including operational research in all new projects
* Support research on public health questions related to C.A.M.
* Supporting the development of
regulatory aspects related to integrative medicine
* Collaborate with statutory bodies to define options for C.A.M. registration
* Assist the process of developing credentialing policies
* Define practice standards for C.A.M. treatments suitable for integration
Define procedures around obtaining informed consent and risk management
* Establish pharmacy policies relating to Alternative
products such as dietary supplements and herbal remedies
* Establish policies on granting of clinical privileges and practice
* Stipulate malpractice liability arrangements
* Assist the translation of C.A.M. therapies into standardised diagnostic and treatment codes and define clear practice standards
* Establishing working relationships with other groups and individuals
* Clarify the role played by C.A.M. practitioners in health care provision
* Develop an agreed ethical
base for C.A.M. practice
* Agree on referral guidelines and systems
* Reach agreements on C.A.M. practitioners’ working relationships with conventional practitioners