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CA Cancer J Clin 1999;49:353-361
Barrie R. Cassileth, PhD
Abstract
"Complementary and alternative" therapies are actually a vast collection of
disparate, unrelated regimens and products, ranging from adjunctive modalities that
effectively enhance quality of life and promising antitumor herbal remedies now under
investigation, to bogus therapies that claim to cure cancer and that harm not only
directly, but also indirectly by encouraging patients to avoid or postpone effective
cancer care.
Complementary therapies such as music and massage, herbal teas to aid digestion and
relieve nausea, yoga, tai chi, meditation, and the many other well-documented techniques
that relieve stress and enhance well-being should be made available to patients to augment
and ease the experience of cancer treatment and recovery. Many time-tested herbal and
diet-based remedies are now being studied for their abilities to induce or extend
remission without toxicity.
At the same time, lack of government regulatory authority leaves consumers at the mercy
of those who promote unproved remedies, scores of which line grocery store and pharmacy
shelves. Many of these over-the-counter products contain harmful ingredients. Herb-drug
interactions, only some of which are documented, occur with frequency and are sufficiently
problematic to require that patients stop taking herbal remedies prior to surgery (to
prevent interactions with anesthetics and anticoagulant effects); before radiation (due to
potential for increased photosensitivity); and during courses of chemotherapy (to prevent
product-drug interactions). Moreover, both good information and misinformation that appear
in printed materials and on the Internet appeal to better educated consumers, who are, in
fact, the most likely to try complementary and alternative methods. (CA Cancer J Clin
1999;49:362-375.)
Introduction
An advantage of the currently popular phrase, "complementary and alternative"
medicine (CAM), is that it highlights important distinctions between the two words.
Alternatives may be seen as literally "other therapies"—they are promoted to
treat cancer and are used instead of mainstream therapy. Complementary or adjunctive
therapies, in contrast, are used for symptom management and to enhance quality of life
along with mainstream care.
Support for this distinction comes both from a major study in the recent medical
literature, which showed that all but 2% of those using unconventional remedies did so to
complement, rather than replace, mainstream care,1 and from the National
Institutes of Health, which changed the name of its Office of Alternative Medicine (OAM)
to the Center for Complementary and Alternative Medicine.
This distinction, however, is not universally applied. Especially in the US,
"CAM," "alternative," and "complementary" are often used
interchangeably to describe a host of disparate activities and products. These terms are
used occasionally to include self-care, routine private responses to aches and pains,
efforts to maintain fitness, and lifestyle activities, as well as unconventionaltherapies.
"Complementary" and "alternative" may also include nutritional cancer
"cures," energy healing, and other unproved and sometimes harmful methods, as
well as spiritual care and other support services that have been in mainstream use for
decades.
Alternative Therapies
Alternative therapies are promoted or used as independent treatments in place of
surgery, chemotherapy, or radiation. Typically invasive and biologically active,
alternative regimens are unproved, expensive, and potentially harmful. They may cause harm
directly through biologic activity, or indirectly, when patients postpone mainstream
therapies. Examples of alternative therapies in cancer medicine include the metabolic
therapies available in Tijuana, Mexico; shark cartilage; high-dose vitamins; and other
products and remedies sold over-the-counter in the US and elsewhere.
Although research evidence is scanty, it appears that approximately 8% to 10% of cancer
patients with diagnoses confirmed by tissue biopsy eschew mainstream therapy and
immediately seek alternative care.2 The vast majority of individuals who
seek CAM, however, use complementary rather than alternative therapies. Almost all studies
to date of cancer patients and of the general public show that those who seek CAM
therapies tend to be female, better educated, of higher socioeconomic status, and younger
than those who do not.
Prevalence of CAM Therapies
CAM use by cancer patients is widespread in North America and around the world. A
recent systematic review of relevant published data3 located 26 surveys
of cancer patients from 13 countries, including five from the US. The average prevalence
of CAM use across all studies was 31%. The most commonly used therapies included dietary
treatments, herbs, homeopathy, hypnotherapy, imagery/visualization, meditation,
megavitamins, relaxation, and spiritual healing. Current surveys substantiate these
findings.4-6
All but one of the US surveys obtained information about specific therapies. Patients
used Laetrile, metabolic therapies, diets, spiritual healing, megavitamins, imagery, and
"immune system stimulants."3 In 1997, additional studies
uncovered CAM prevalence rates of 50% in a survey of 113 family practice patients7
and 42% in a sample of 1,500 adults.8 An earlier telephone survey of a
representative national sample of 1,539 adults found that one-third had used CAM,9
whereas a 1999 survey of more than 24,000 individuals found only 8% use of CAM, with or
without mainstream care.1
These broad and discrepant findings regarding CAM use may be attributed primarily to
varying understanding and definitions of CAM. Often, surveys do not define CAM or define
it extremely broadly, resulting in the inclusion of lifestyle activities such as weight
loss efforts and mainstream support activities such as group counseling.
Herbal Remedies
Homeopathy, acupuncture, and folk remedies were used by a maximum of only 2% of
respondents in all studies. One of the1997 surveys9 of adults in the US
found that 3% of respondents had used herbal medicine. In contrast, a general survey of
individuals with health insurance conducted that same year revealed the most common CAM
therapy to be herbal remedies, used by 17% of respondents.8 Moreover,
the 1999 survey of 24,000 adults found greater than 20% use of herbal remedies.1
This growth in use of herbal remedies is not surprising given the enormous increases in
sales of such products that have occurred in recent years. Herb sales in drugstores and
food stores increased 35% from 1993 to 1994, totaling $106.7 million for the year;10
this figure would be greater if health food stores, catalog, and Internet sales were
added.
The passage in 1994 of legislation allowing herbal medicines and other "food
supplements" to be sold over the counter in the US without FDA review no doubt
profoundly encouraged use of these products. It is estimated that sales of dietary
supplements have doubled since passage of that 1994 law.
CAM Use Among Pediatric Cancer Patients
Surveys in Australia and Finland,5 British Columbia,6
and the Netherlands11 indicate substantial interest in CAM, especially
in more recent years, with 40% to 50% of pediatric oncology patients in those countries
receiving alternative or complementary therapies.
Only one study of CAM use among pediatric oncology patients in the US was published
during the past 10 years.12 The authors found that 65% of 81 cancer
patients used CAM, compared with 51% of 80 control-group children undergoing routine
check- ups. Prayer, exercise, and spiritual healing accounted for more than 96% of CAM
used. Excluded from this sample by definition, however, were pediatric patients taken to
alternative treatment clinics in the US, Mexico, or elsewhere.
Distinguishing Legitimate Research from Product Promotion
The quality and accuracy of information about CAM that is available to the public vary
widely. Many Web sites and publications that appear to be objective actually are sponsored
by commercial enterprises that promote and sell their own products.
It is often difficult for patients to distinguish between reputable sources of
information and those with vested interests that might promote ineffective methods. Some
materials and books are written by medical doctors and appear to present legitimate
information. The M.D.'s Journal, for example, a quarterly, 61-page publication sent
unsolicited to the general public has included articles such as, "M.D. Cures Terminal
Cancer" and "How to Make Yourself Almost Immune to Breast Cancer." The
impact of these articles is reinforced by accompanying photographs of an apparently
kindly, white-coated doctor, complete with stethoscope. These articles are actually
advertisements, however, for "free reports" that accompany a $79.90 subscription
to a periodical.13 Unfortunately, this is not an uncommon approach to
product promotion.
CAM and Mainstream Medicine
Bolstered by proponent efforts and media exposure, according to CAM critics, or by
public interest, according to CAM advocates, CAM has entered mainstream medicine with
unprecedented rapidity. The OAM was established at the National Institutes of Health by
Congressional mandate in 1992, its stated purpose to investigate unconventional medical
practices.14 The OAM now supports 10 CAM Research Centers. Most,
including the Center for Alternative Medicine Research in Cancer at the University of
Texas Health Science Center in Houston,15 are based at major
universities. The relevant NIH institute shares support of basic science with the OAM, as
well as the clinical research within its purview. In October 1998, apparently in
recognition of the significant distinctions between complementary and alternative
modalities, Congress renamed the OAM as the National Center for Complementary and
Alternative Medicine, appropriating $50 million for its support.
At least 75 medical schools in the US offer elective courses in CAM, as well devoting
portions of required courses to the subject.16 Nevertheless, a recent
analysis17 of the quality of such courses found that almost all present
material uncritically. In addition, numerous medical centers and cancer programs have
developed research and clinical service programs in CAM.
The publication of CAM research articles in major medical journals also marks
mainstream acceptance. The Journal of the American Medical Association, the New England
Journal of Medicine, The Lancet, the British Medical Journal, and specialty journals such
as Cancer and the Journal of Clinical Oncology have published reports of CAM research in
recent years.
Not all mainstream physicians are pleased with CAM, with current efforts to integrate
CAM into mainstream medicine, or with a separate NIH research entity for
"alternative" medicine.18-20 Vigorous opposition to CAM as
"pseudo science" based on "absurd beliefs" continues to be voiced.
CAM's deviation from basic scientific principles, implicit, for example, in homeopathy and
therapeutic touch, are decried. A 1997 letter to the US Senate Subcommittee on Public
Health and Safety signed by four Nobel Laureates and other prominent scientists deplored
the lack of critical thinking and scientific rigor in OAM-supported research.
CAM Costs and Insurance Coverage
Health insurance programs increasingly cover CAM services and providers. More than 30
major insurers, half of them Blues plans, cover more than one alternative therapeutic
method.21 Expanding insurance coverage of complementary and alternative
therapies may reflect consumer demand, but it also represents managed care efforts to
control costs.
Although full data are lacking, most alternative practitioners appear to provide
opportunities for cost savings, and food supplements are less costly than prescription
pharmaceuticals if used as substitutes. Practitioners of naturopathy, acupuncture,
chiropractic, Traditional Chinese, Native American, Ayurvedic (Indian) Medicine,
homeopathy, and other alternative therapists rely heavily on natural remedies to treat
many disorders. These alternative "natural" remedies include herbs and other
botanicals, enzymes, amino acids, vitamins and minerals, and homeopathic products.
Although formal analyses of the costs to insurers of these products are not available,
unpublished data from the Blue Cross of Washington and Alaska AlternaPath project have
been reported. Analyzing their 1994 to 1995 costs, it was determined that 39 cents of each
benefit dollar were spent on natural products.22 In 1994, the program
took in $170,000 and paid out $650,000.23 It is believed that some of
this cost overrun was due to subscribers stocking up on nutritional supplements.23
Analogous data on costs and revenues are not publicly available from American Western Life
Insurance, Oxford Health Plans, Prudential HealthCare, Blue Cross/Blue Shield of
Massachusetts, and the other carriers that provide at least some CAM coverage.
Public interest and willingness to pay out-of-pocket is evident in the 73% growth of
pharmacy sales of natural remedies and supplements from 1991 to 1995. Sales of
prescription drugs during this same period rose 31%.24
Another unanticipated cost overrun occurred when Blue Cross of Arizona was obliged
legislatively in 1983 to cover chiropractic care. It was assumed that the competition
would decrease health care costs. However, the average chiropractic case cost was $576, 8%
higher than that for surgeons and 352% higher than for general practice medical doctors.23
The cost effectiveness of chiropractic services remains a contentious and uncertain issue.25
Naturopathic care is covered by approximately 100 insurance companies in the US, with
most of these companies concentrated in Alaska, Connecticut, and Washington State.26
Acupuncture, massage therapy, and other CAM services are covered by many insurers,27
and coverage is most likely if the patient's physician has prescribed the therapy.
CAM Therapies and Practitioners
A review of currently popular therapies, many of which are unproved methods promoted as
alternatives to mainstream cancer treatment, follows. In contrast, useful complementary or
adjunctive therapies are presented in
Table 1.
Diet and Nutrition
Today's proponents of dietary cancer treatments typically extend mainstream assumptions
about the protective effects of fruits, vegetables, fiber, and avoidance of excessive
dietary fat as a potential means of reducing cancer risk, to the idea that food or
vitamins can cure cancer. Proponents of this belief make their claims in books such as The
Food Pharmacy: Dramatic New Evidence that Food is your Best Medicine, Prescription for
Nutritional Healing, and New Choices in Natural Healing.
The chapter on cancer in a popular tome, Alternative Medicine, for example, criticizes
chemotherapy, radiation, and surgery as "highly invasive... and may shorten the
patient's life." It recommends instead that therapy address the entire body and
employ a "non-toxic approach... incorporating treatments that rely on
biopharmaceutical, immune enhancement, metabolic, nutritional, and herbal, non-toxic
methods."28
The Macrobiotic Diet
Although a relatively recent creation, the macrobiotic diet is rooted in the ancient
yin-yang principle of balance. Yin and yang, the concept of opposite forces on which
Traditional Chinese Medicine is based, is believed to describe all components of life and
the universe. In macrobiotics, this worldview of balance is embodied in the diet,
including the selection, preparation, and consumption of food.29
No diet has been shown to cure cancer. Nevertheless, the macrobiotic diet as currently
constructed is similar to recent USDA recommendations for healthful eating. The
macrobiotic diet derives 50% to 60% of its calories from whole grains, 25% to 30% from
vegetables, and the remainder from beans, seaweed, and soups. The diet avoids meat, dairy,
certain vegetables and processed foods, and promotes soybean consumption. Soups made with
miso, a product of soybean fermentation, represent an important component of the
macrobiotic diet.
Genistein, a substance found in soybeans, may contribute to reduced incidence of breast
cancer.30 There is no evidence, however, that the macrobiotic diet is
beneficial for patients already diagnosed with cancer. Moreover, some versions of this
diet are nutritionally deficient, and can cause weight loss in patients with cancer.
Megavitamin Therapy
Some patients and alternative practitioners believe that large dosages of
vitamins—typically hundreds of pills a day—or intravenous infusions of high-dose vitamin
C, can cure disease. There is no evidence that megavitamin or orthomolecular therapy is
effective in treating any disorder.
Mind-Body Techniques
The notion that we can influence health with our minds is an extremely appealing
concept for many Americans. It affirms the power of the individual, a basic value of
American culture. Some mind-body interventions have moved from the category of
alternative, unconventional therapies into mainstream medicine. Good documentation exists,
for example, for the effectiveness of meditation, biofeedback, and yoga in stress
reduction and the control of specific physiologic reactions.31,32
Some proponents argue that patients can use mental attributes and mind-body work to
prevent or cure cancer. This belief is attractive because it ascribes to patients almost
complete control over the course of their illnesses.33 Studies
suggesting that mental factors or prayer influence the course of cancer are widely
publicized despite the fact that they may involve small numbers of patients or remain
unreplicated. There is no credible evidence that the course of cancer can be altered
through mental efforts.
Bernie Siegel, MD, former surgical oncologist and author of Love, Medicine, and
Miracles34 and other best sellers, is a popular proponent of the active
link between the mind and cancer. Siegel developed the concept of "exceptional cancer
patients" (E-CaP), where patients are encouraged to maintain positive attitudes and
to assume responsibility for their own health. They are asked to consider why they might
"need" their cancer. The premise is that cancer results from unhealthy emotional
patterns, correction of which can cure cancer or prolong remission.
A study coauthored by Siegel, however, found no difference in length of survival for
E-CaP versus non-E-CaP patients, where both patient groups completed standard mainstream
therapy for breast cancer.35 Because the results were negative, failing
to confirm more than 12 years of unsubstantiated claims, the article did not receive much
media exposure and did not much affect the belief systems of mind-body proponents.
Studies suggesting that mental factors or prayer influence the course of cancer
continue to be widely publicized, despite serious methodologic or statistical flaws. For
example, a 1989 Lancet report suggested that women with breast cancer who attended weekly
support group sessions had double the survival rates of women who did not attend.36
Prospective versions of this study have failed, however, to replicate those 1989 results.
Attending to the psychosocial needs of cancer patients is a fundamental component of
good cancer care. However, the idea that patients can influence the course of their
disease through mental or emotional work is not substantiated and can evoke feelings of
guilt and inadequacy when disease continues to advance despite patients' best spiritual or
mental efforts.33
Bioelectromagnetics
Bioelectromagnetics is the study of interactions between living organisms and their
electromagnetic fields. According to proponents, magnetic fields penetrate the body and
heal damaged tissues, including cancers.28 No peer-reviewed publications
could be located for any clinical cancer-related claims regarding bioelectromagnetics.
Alternative Medical Systems
Ancient systems of healing are based on concepts of human physiology that differ from
those accepted by Western science. Two of the most popular healing systems are Traditional
Chinese Medicine and India's Ayurvedic Medicine, popularized by best-selling author Deepak
Chopra, MD.37
Ayurveda
The term "Ayurveda" is derived from the Sanskrit words "ayur"
(life) and "veda" (knowledge). Ayurveda's ancient healing techniques are based
on the classification of people into one of three predominant body types, with specific
remedies for disease- and health-promoting regimens for each. This medical system has a
strong mind-body component, stressing the need to keep consciousness in balance and
utilizes techniques such as yoga and meditation. Ayurveda also emphasizes regular
detoxification and cleansing through all physiologic systems of elimination and orifices.
There are said to be 10 Ayurveda clinics in North America, including one hospital-based
clinic that has served 25,000 patients since 1985. The number of cancer patients who seek
care at Ayurvedic clinics and spas is not documented.
Traditional Chinese Medicine
Traditional Chinese Medicine views the body in terms of its relationship to the
environment and the cosmos. Concepts of human physiology and disease are interwoven with
geographic features of ancient China and with the forces of nature. Chi, the life force
said to run through all of nature, flows in the human body through vertical energy
channels known as meridians. The 12 main meridians, which correspond to the 12 main rivers
of ancient China, are believed to be dotted with acupoints. Each of the original 365
acupoints corresponds to a specific body organ or system, so that needle stimulation or
pressure on the accupoint can redress the life-force imbalance causing the problem in that
particular organ.
In addition to acupuncture, which has antiemetic effects for some patients,38
and acupressure, basic therapeutic tools include qi gong and tai chi to strengthen and
balance chi. Traditional Chinese Medicine also includes a full herbal pharmacopoeia with
remedies for most ailments, including cancer.39 The protective benefits
of Chinese green tea and other herbal remedies are currently being studied.40
Metabolic Therapies and Detoxification
Metabolic therapies continue to draw patients from North America to the many clinics
that offer these modalities in Tijuana, Mexico. Treatments there are based on the belief
that toxic products of cancer cells accumulate in the liver, leading to liver failure and
death. The Gerson treatment, for example, aims to counteract liver damage with a low-salt,
high-potassium diet, coffee enemas, and a gallon of fruit and vegetable juice daily. That
clinic's use of liquefied raw calf liver injections was suspended in 1997, following the
development of sepsis in a number of patients.41
Other Tijuana clinics provide their own versions of metabolic therapy, each applying an
individualized dietary and detoxification regimen, with additional components according to
practitioners' preferences.
Nicholas Gonzalez, MD, is a rare example of a US internist who practices alternative
cancer medicine. He uses a version of metabolic therapy involving a restrictive diet,
pancreatic enzymes, and coffee enemas. Following recent documentation of one-to-four-year
survivals in 11 patients with inoperable pancreatic cancer,42 the
National Cancer Institute is now supporting a randomized phase III clinical trial of the
Gonzalez regimen at New York Presbyterian Hospital in New York City.
Metabolic regimens are based on belief in the importance of detoxification, which is
thought necessary for the body to heal itself. Practitioners view cancer and other
illnesses as symptoms of the accumulation of toxins. Nevertheless, neither the presence of
toxins nor the benefit of eliminating them has been documented.
Detoxification with high colonics involves infusion into the colon of 20 or more
gallons of water containing herbs, coffee, enzymes, or other substances believed useful by
the practitioner. The use of high colonics, a central component of current Ayurvedic
Medicine and other present-day alternative practices, is available independently from
colonic practitioners and storefront walk-in colonic clinics in some cities as a purported
means of maintaining health. Despite their popularity, high colonics have no known
benefits and have been associated with serious clinical problems.41,43
Pharmacologic and Biologic Treatments
Antineoplastons
Antineoplastons represent probably the best known and most popular alternative
pharmacologic therapy for cancer today. Developed by Stanislaw Burzynski MD, PhD,
antineoplaston therapy is available in his clinic in Houston, Texas44
for $15,000 to $30,000 per year.
Preliminary data from the Burzynski Institute were recently criticized by respected
mainstream researchers as uninterpretable; moreover, antineoplaston therapy was
characterized as useless and toxic.45, 46 Nevertheless, Burzynski and
his patients continue antineoplaston therapy and speak out in favor of its efficacy,
disclaiming all critiques.
From the perspective of the public, the effectiveness of this treatment remains
unclear. Although antineoplaston therapy is unproved, many patients report anecdotal
success. And chemically, 80% of antineoplastons consist of phenylacetate, a metabolite of
phenylalanine that is being studied for potential anticancer activity by researchers at
the NCI and elsewhere.47
Shark Cartilage
Advocates of shark cartilage as a cancer therapy point to its putative antiangiogenic
properties. However, shark cartilage protein molecules are too large to be absorbed by the
gut and would be destroyed if absorbed. Shark cartilage decomposes into inert ingredients
and is excreted. A recent phase I-II trial of shark cartilage found no clinical benefit.48
The dwindling commercial success of shark cartilage as a cancer therapy has led to its
promotion for a different medical condition. Full-page color ads in alternative medicine
journals read, "The most important joint decision you'll ever make. Your patients can
now fight aging bone conditions. The secret is shark cartilage." Because the ads
avoid specific claims that the therapy can cure an ailment, they fall within the
guidelines of the 1994 Food Supplement Act. Thus, despite the lack of safety or efficacy
data, the ads are permitted. In this way, shark cartilage as a putative but waning cancer
remedy regains momentum and economic potential.
Cancell
Another well-known biologic remedy, Cancell, appears to be especially popular in
Florida and the Midwestern US. Proponents claim that it returns cancer cells to a
"primitive state" from which they can be digested and rendered inert. FDA
laboratory studies, which showed Cancell to be composed of common chemicals, including
nitric acid, sodium sulfite, potassium hydroxide, sulfuric acid, and catechol, found no
basis for proponent claims of Cancell's effectiveness against cancer.49
Manual Healing Methods
Manual healing includes a variety of touch and manipulation techniques.
Massage
Hands-on massage is a useful adjunctive technique for cancer patients and others for
its stress-reducing benefits.
Chiropractic
The benefit of chiropractic treatment for low back pain was supported by an NIH
consensus conference,50 but the value of chiropractic is disputed by
mainstream physicians.20 Some cancer patients seek chiropractic
treatment for cancer, although there is no evidence whatsoever that this approach is
beneficial.
Therapeutic Touch
One of the most popular manual healing methods is therapeutic touch, which, despite its
name, involves no direct contact between therapist and client. In therapeutic touch,
healers move their hands a few inches above a patient's body and sweep away
"blockages" that are believed to obstruct the patient's energy field. A study
reported in the Journal of the American Medical Association showed that experienced
practitioners of therapeutic touch were unable to detect the investigator's "energy
field."51 Despite the lack of documented effects on any disease,
and notwithstanding mainstream scientists' unwillingness to accept its fundamental
premises, therapeutic touch is taught in North American nursing schools and widely
practiced by nurses in the US and other countries.52 Debates between
skeptics and believers in therapeutic touch enliven numerous Web sites.53
Herbal Remedies for Cancer
Herbal remedies typically are part of traditional and folk healing methods with long
histories of use. Anticancer effects are claimed for many herbal remedies, but only a few
have gained substantial popularity as alternative cancer therapies.
Essiac
Essiac is one of the most popular herbal cancer alternatives in North America. It was
popularized by a Canadian nurse, Rene Caisse (Essiac is Caisse spelled backwards), but was
developed initially by a Native Canadian healer. It is comprised of four herbs: Burdock,
Turkey rhubarb, sorrel, and slippery elm. Researchers at the NCI and elsewhere have not
found Essiac to have any anticancer effect. Illegal in Canada, Essiac is widely available
in US pharmacies and health food stores.
Iscador
Iscador, a derivative of mistletoe, is a popular cancer remedy in Europe, where it is
available in many mainstream cancer clinics. Although European governments have funded
studies of iscador's effectiveness against cancer, definitive data have not emerged.
Pau d'arco Tea
Pau d'arco tea is said to be an old Inca Indian remedy for many illnesses, including
cancer. Made from the bark of an indigenous South American evergreen tree, its active
ingredient, lapachol, has been isolated. Although lapachol showed antitumor activity in
animal studies conducted in the 1970s, it does not appear to affect human malignancies. It
does, however, induce nausea and vomiting. Despite the absence of efficacy, pau d'arco tea
is sold as a cancer remedy in health food stores, by mail, and on the Internet.
Asian Remedies
Asian herbal remedies show greater promise. Several mushroom-derived compounds are
approved for use as cancer treatments in Japan, and PC-SPES, a combination of eight herbs
primarily from Traditional Chinese Medicine, reduced prostate specific antigen levels in
men with advanced prostate cancer.54
A formula of 19 vegetables from Traditional Chinese Medicine believed to have antitumor
activity was added to the diets of 12 patients with stages III and IV non-small cell lung
cancer. The median survival of control patients was four months versus 15.5 months for
those receiving the formula. The completely nontoxic vegetable brew significantly, and
positively, affected quality and quantity of life.55
Women with advanced metastatic breast cancer receiving a Tibetan herbal formula are now
being studied for extended survival at the University of California, San Francisco and
Memorial Sloan-Kettering Cancer Center in New York City.
These studies suggest that some herbal cancer remedies, tested to ensure purity and
consistency, and carefully evaluated, may represent potentially useful, nontoxic cancer
treatments. The difficulty with time-honored herbal remedies is that they are rarely
tested for purity, examined for consistency, or studied carefully. They are, nonetheless,
in common use.
Herbal Medicine Alert
Cancer patients also occasionally or regularly use over-the-counter herbal products in
addition to or instead of those promoted specifically as cancer treatments. It is
therefore important to recognize those that are toxic or that interact with other
medications
(Table 2).
Because the FDA does not examine herbal remedies for safety and effectiveness, few
products have been formally tested for side effects or quality control. Nevertheless,
information is beginning to emerge on the basis of public experience with over-the-counter
supplements.
Recent reports in the literature describe severe liver and kidney damage from some
herbal remedies (Table 2).
These reports underscore the fact that "natural" products, contrary to
apparent consumer belief, are not necessarily safe or harmless.56, 57
Indeed, herbs are natural drugs in diluted form. They may contain hundreds of different
chemicals, most of which have not been assessed for safety and efficacy. Effects of such
"natural" drugs are not always predictable.
The potential for herb-drug interaction is sufficiently problematic that patients on
chemotherapy should be cautioned to stop using herbal remedies during treatment. Similar
advisories are necessary for patients receiving radiation, as some herbs photosensitize
the skin and cause severe reactions. Patients scheduled for surgery should also
discontinue "natural" remedies, because some herbs produce dangerous blood
pressure swings and other unwanted interactions with anesthetics, as well as multiply the
blood thinning effects of medications such as coumadin. The risk of herb-drug interactions
appears to be greatest for patients with kidney or liver problems.
Conclusions
Although store shelves contain harmful and worthless products, they also offer a range
of remedies that can safely provide relief from a variety of ailments. The challenge is to
avoid contaminated products and those that may interact with prescription pharmaceuticals.
Dietitians and pharmacists, as well as reputable books and Web sites
(Table 3)
can offer helpful guidance.
Recently, two journals—The Scientific Review of Alternative Medicine,
http://www.hcrc.org/sram; and FACT (Focus on Alternative and Complementary Therapies),
www.fact@exeter.ac.com—have been launched to cover scientific reports of CAM.
Distinguishing reliable journals and articles from useless ones is particularly
important with regard to CAM. Some CAM proponents argue that research is not necessary to
determine the effectiveness of alternative therapies for cancer; others claim that it is
not possible to evaluate CAM, because the therapies are too subtle or too individualized
to study with usual scientific methods.
In fact, there is no therapy that cannot be properly evaluated. Several CAM-interested
researchers have called for mandated, rigorous, scientific CAM evaluation, and have
outlined guidelines for implementation.58,59 The notion that proper
evaluation is unnecessary or impossible for CAM is held by a minority of CAM proponents.
The widely accepted view as articulated in the work of the Cochrane Collaboration on CAM,
as well as in recently launched scientific publications, is that CAM therapies require and
deserve standard, scientifically accepted research methodologies.
Dr. Cassileth is Chief of the Integrative Medicine Service at Memorial Sloan-Kettering
Cancer Center in New York City, NY.
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