Prevalence of Complementary and Alternative Medicine Use in Cancer Patients

The article by Bridget J. Bernstein andTeresita Grasso comes at a time when complementary and alternative medicine(CAM) is on the minds of health-care workers and the public alike. The authorsfocus their study on the aspects of CAM that are most relevant to the role ofthe clinical pharmacist. Clinical pharmacists are key sources of information forcancer patients and their families, and they greatly influence how theprescribed treatments are perceived. The US Food and Drug Administration hasidentified at least 104 deaths directly related to "natural"supplements, which further supports the importance and timeliness of this study.

It is not unusual for consumer magazines with widecirculations to cover similar stories. However, the recent coverage of CAM, asin a story published simultaneously by the New Yorker[1] and U. S. News &World Report[2] is a reflection of the importance and mass appeal ofcomplementary and alternative medicine. Interest in CAM has grown well beyondthe intense but always ephemeral attention of the mass media. The NationalLibrary of Medicine’s PubMed online database has over 220,000 references,abstracts, and full-text articles on CAM.[3]

CAM has only recently gained the somewhat sluggish andresentful attention of the premier medical institutions. Paradoxically, asmanaged care has significantly limited an individual’s choice of physiciansand settings, consumers are driving the CAM engine by stepping outside of thehealth-care system and spending their own dollars. In 1999, the US Congress’sGeneral Accounting Office estimated CAM-related consumer spending to be inexcess of $31 billion.

Language Problems

The article by Bernstein and Grasso provides a helpfulliterature review of the importance of CAM, for an intended audience of"health-care professionals, especially pharmacists." The authors citethe National Institutes of Health’s Office of Alternative Medicine definitionsof complementary and alternative medicine. The information provided by theirsurvey is also helpful but falls prey to many of the same language problemsidentified in their article. The terms "complementary" (therapy usedin addition to conventional treatments) and "alternative" (therapyused instead of conventional treatments) are used interchangeably, despite thefact that all patients in the sample were receiving medical care (leftundefined) at a South Florida Hospital.

The authors acknowledge that the sample was small (96 or 100,depending on who is actually included) and comprised primarily of whites andHispanics (91 of the 99 who responded to the race question). However, the dataare presented in a somewhat confused manner. The reader has to work hard toextract what can be valuable information. For example, the authors note,"80% of patients reported using some type of CAM; 81% tookvitamins . . ." and, "No correlation was found betweenthe use of CAM and age, gender, ethnicity, or education. However, 65% (n = 52)of college graduates and 90% (n = 72) of whites reported using vitamins, herbaltherapies, and/or relaxation techniques."

The patient questionnaire is also problematic. Complex termsare used but not defined, and it is impossible to decipher what is part ofnormal self-care (such as taking a daily multivitamin) and what is actuallybeing used with the intent of enhancing immune function or as an antineoplasticagent. Given that patients in the sample were being cared for at a hospital, theterm alternative used throughout the article and in the questionnaire shouldprobably be replaced with complementary. There is also inadequate explanation asto why prayer, for example, was excluded from the questionnaire. (Perhaps onlythose agents that most relate to the practice of clinical pharmacy were listed.)

Given the intended audience, a discussion of practicalinformation that would aid pharmacists in protecting patients from dangerouscomplementary and alternative agents would have been helpful. Also, pharmacistsshould be encouraged and taught to routinely ask patients if they are taking anyagents in addition to their prescribed medicines. Such a dialog could revealessential information for the treating health-care team. Hopefully, theinvestigators will pursue this strategy in a follow-up study.

Overall, the study is helpful in beginning to identify whichCAM therapies cancer patients are currently using. Some other areas that werealluded to but not adequately discussed follow.

Why So Many People Use CAM

As with the early hospice movement, CAM has evolved in aclosely parallel but distinctly nonintersecting orbit with that of establishedmedicine. Hospitals are now scrambling to develop credible CAM programs thatattract patients and managed-care contracts, but they have not been able tofigure out how to pay for these services. This is a significant problem forhospitals and universities confronting dwindling reimbursements, agingpopulations, and fiercer competition for educated patients with resources.Virtually all CAM programs use existing staff (who perform these services inaddition to their regular assignments), or refer to outside practitioners overwhom they have little quality control. The few CAM programs that actually dohave full-time staff are supported primarily by research grants or philanthropy.

Health-care professionals, especially physicians, expressconfusion over why CAM is so important to patients and families, given the lackof scientific support for almost all these interventions. For many patients withserious (but potentially curable) or life-threatening diseases, even anundefined vague sense of hope is much more real and meaningful than theobjective scientific "certainty" of statistics. The lack of connectionto a health-care team that has too little time to spend with them and noopportunity to see them as people, creates a sense of vulnerability and exposurethat is intolerable to many people.

Patients want to benefit from the best that science has tooffer, but they also need to feel a human connection to those on whom they feelso utterly dependent for their survival. The ability of people to pin theirhopes of healing and recovery on another human being predates the scientificmethods by many millennia. Patients who actively use CAM are, in part, yearningfor their physician to also be a shaman—to have magic beyond science. In thisrole, it is a vague evolutionary memory of an atavistic relationship now longgone from objective consciousness that controls the sense of abandonment, fear,and exposure. Perhaps this is no longer possible in any health-care system.

Conclusions

Science represents the best system for developing newknowledge and overcoming problems, but it is not an instrument for healing theseparation and sense of exposure that people feel when they become ill. Only asense of connection to other people or a higher undefined power can do that.Perhaps it is time for organized medicine to cross the schism it created whencuring a disease became the gold standard, and the messy business of caring fora person was relegated to the status of a social problem.

If the example of hospice is any clue as to how institutionswill respond to the unmet needs of patients and families, sell your biotechstocks and invest in coffee and shark cartilage.

References:

1. Specter M: The outlaw doctor. The New Yorker February 5,2001, pp 48-61.

2. Spake A: Natural hazards. US News & World Report130(6):43, 2001.

3. Reuters Health Information: Alternative medicineliterature now available on NIH’s PubMed database. February 5, 2001. Availableat: www.reutershealth.com. Accessed August 1, 2001.