Complementary and Alternative Medicine Module

Introduction

Complementary and alternative medicine (CAM) includes health care systems, practices, and products that may or may not be considered to be part of conventional medicine. (The term conventional medicines refer to that practiced by qualified medical practitioners, registered nurses and allied health professionals, such as psychologists, social workers, and physical therapists). 

Complementary and alternative therapies are not new phenomena but certainly they are increasing in popularity.  This trend of investigating and using unconventional cancer treatments can raise complex ethical and practical questions for the general practitioner. 

This module is therefore not about promoting alternative medicines of questionable benefit but accepting that women have a choice.  There is, however, evidence showing the benefits of many complementary therapies used in addition to conventional treatment. 1, 2

Most women who have a good relationship with their doctor will want to discuss the various treatment approaches available to them, and may initiate the discussion about complementary and/or alternative healing practices. However, there will always be women who will not disclose their use of complementary and alternative treatments unless directly asked by their doctor.  In contrast, there will be women who need greater support and assistance that may benefit by the GP taking the initiative and raising the issue of complementary treatments available locally.

The tasks facing the GP are:

What is complementary and alternative therapy/medicine?

Complementary therapy is often used in addition to conventional medicine. The focus on this type of treatment is on enhancing psychological and physical well being in order to cope and adapt to the changes associated with the cancer diagnosis and subsequent treatment.  Complementary treatments are often referred to as supportive therapies and many are offered by the mainstream medical community.  Examples include (but not limited to):

Alternative treatments are used mostly in place of conventional medicine.  These treatments aim to reduce the tumor growth.  Treatments are promoted as having the ability to slow, halt and even cure the spread of cancer.  The evidence in most cases is scientifically unproven and relies on anecdote.  Some treatments are accessed through naturopaths, homeopaths, psychic healers etc. Some of the treatments are more controversial and unconventional than others. Examples include (but not limited to):

	Conventional Treatment	Complementary Therapy	Alternative Therapy
Examples	Surgery Radiation Chemotherapy	Mediation/Relaxation Spiritual approaches Psychotherapy Nutrition Stress Management	Homeotherapy Naturopathy Megavitamins Shark’s Cartilage Mystic Healing
Conceptual Framework	Medical model Biological and molecular approach to cancer	Holistic approach Unity of mind, body and spirit	Diverse theoretical concepts including the belief that: cure and healing requires purifying the body and/or strengthening its resources; power of mind over body
Perceived Benefits	Survival rates Evidence based Trust in the medical profession	Greater quality of life Improved sense of well-being Symptom management Research shows the benefits of social support, relaxation and spiritual practices 3,4	Sense of regaining control Hope
Potential Negative Effects	Side effects of treatment can result in: short and long term toxicities; permanent changes to the body; sexual dysfunction; etc.	Sense of failure if the cancer is not controlled or cured, potentially resulting in heightened anxiety or depression. Cost	Unproven /unknown Some may be toxic or harmful. Potential drug/herbal interactions causing harm Some demonstrated to be fraudulent Cost

Adapted from Doan B Interventions: Alternative and Complementary Therapies p 818

Are complementary and alternative medicines (CAM) widely used?

Studies both here and overseas have consistently shown that from 10%- 60% of cancer patients use some complementary and/or alternative treatment. Women are significantly more likely to use complementary and alternative products than men.  Typically those better educated with a higher income are more likely to embark on CAT often with the support of a medical practitioner. 5,6,7

A large study of CAT use in patients with different types of cancer published in the July 2000 issue of the Journal o f Clinical Oncology, found that 69 percent of 453 cancer patients had used at least one CAT therapy as part of their cancer treatment.

The motivation to use complementary and alternative therapies varies widely, from disillusionment with the conventional medical system through to wanting to please others who strongly pressure the cancer patient to explore all options.  According to the study by Begbie et all.8 (summarised in the Clinical Practice guidelines for the management of women with epithelial ovarian cancer 9 ) the main reasons for using complementary and alternative therapies were:

The therapies often used by those using CAT were:

Seventy five percent of people use more than one type of therapy.  The more radical alternative treatments are often considered when conventional medicine has not worked or the side effects from the conventional treatments are so severe that treatment has had to cease.

Safety Issues

Obviously, there are safety issues that need to be taken into account in the use of some complementary and alternative therapies. Some CAMs can interfere with the effectiveness of conventional cancer treatment whilst others can be highly dangerous if embarked upon. 
Specific safety issues to consider when contemplating CAM include:

Whilst the general practitioner does have the responsibility to inform a woman about any known potential safety concerns, the challenge is to do so in a supportive and caring manner so the relationship between the general practitioner and the woman is not placed in any jeopardy.  The provision of ongoing supportive care by the general practitioner to the woman diagnosed with cancer will therefore require,

Issues to Consider

Risk/benefit analysis

I’m wondering what you are hoping for with this treatment?

Professional responsibility

I can understand that your hoping that this treatment will be effective but have you considered the possibility of a bad reaction?

Ethical responsibility

I’m aware of the additional financial pressures placed on yourself and the family since your diagnosis.  Can you afford this treatment?

Supportive ongoing care

I understand that your hoping this treatment will reduce your fatigue and give you more energy. Can I suggest that you identify those things you want to recommence doing as a way of knowing if the treatment is working or not. Does 6 weeks sound like a reasonable timeframe to you to review the treatments effectiveness? Let’s meet again then to discuss how it’s going. You mentioned that the main reason you are pursuing this treatment is to reduce the opiates you’re currently taking in order to feel less dopey and more involved.  What is it you wish you could do? When I see you again in a couple of weeks let’s assess if the pain is being successfully managed and you are able to become more involved in the family activities again.

Professional boundaries

NSW Medical Board – complementary health care policy
www.medeserv.com.au/nswmb/publication/Complemenatry_healthcare.cfm

Further information and links

Australia

Canada

United States

Highly recommended are the resources available at the Memorial Sloan-Kettering Cancer Center Integrative Medicine Web site, particularly the section called Herbs, Botanicals & Other Products.

National Cancer Institute www.cancer.gov and http://www.nci.nih.gov/

References

Proposed Tasks

Personal Issues to consider:

Professional Issues to consider: