Until more recently, unconventional cancer therapies were typically underground or available outside the United States, their proponents claiming benefits beyond anything that mainstream medicine could offer. Such claims still accompany many contemporary methods, but today the field of unconventional cancer therapies, no longer underground, is crowded with openly promoted, widely available alternative products and regimens.

At the same time, harsh therapies cured increasing numbers of patients, while producing serious and often lasting side effects. The use of adjunctive complementary therapies expanded to meet cancer patients’ needs for better symptom control during treatment and as survivors. Helpful interventions such as massage therapies, relaxation and other mind-body interventions, acupuncture, music therapy, yoga, fitness programs, and so on escalated.

Because both alternative and complementary therapies developed primarily outside mainstream cancer care, they were linguistically merged as unconventional, alternative, complementary, or complementary and alternative medicine (CAM). This unfortunate linking created a confusing collection of unrelated remedies, all known by the same terms.

This chapter defines and describes the current status of complementary therapies in cancer care and distinguishes it from alternative practices. It also delineates mainstream acceptance, concerns, and regulatory issues, and discusses the implications of the health care trend represented by this growth industry. Recommended complementary therapies and potentially dangerous regimens also are listed.

The National Institutes of Health (NIH), National Center for Complementary and Alternative Medicine (NCCAM) and the National Cancer Institute (NCI) Office of Cancer Complementary and Alternative Medicine (OCCAM) support research in this area. CAM is defined by NCCAM as a group of diverse medical and health care systems, practices, and products that are not part of conventional medicine. An advantage of the phrase complementary and alternative is that it enables important distinctions between the two. Alternative therapies may be perceived literally as such; they are promoted as cancer treatments to be used instead of mainstream therapy. Complementary therapies, in contrast, are used to manage symptoms and to enhance quality of life as adjuncts to mainstream care. Increasingly, the term “integrative oncology” is applied, especially in academic settings, thus emphasizing the adjunctive utility of complementary modalities.

Alternative regimens remain big business. These are unproved or disproved bogus therapies, typically promoted as independent treatments for use instead of surgery, chemotherapy, and radiation. They are usually invasive, biologically active, expensive, and potentially harmful. Alternative regimens may harm directly through biological activity or indirectly when patients postpone receipt of mainstream care. Examples of alternative therapies include the metabolic therapies available in Tijuana, Mexico, and elsewhere; shark cartilage; high-dose vitamins and other products sold over the counter and delivered intravenously in alternative clinics; electromagnetic cures; energy healing; “dietary cures”; and many other products and regimens.

Conversely, complementary therapies are used as part of supportive care to help reduce symptoms related to cancer or cancer treatment. They do not have clinically significant effects on cancer per se. Their evidence-based benefits lie in symptom control and enhancing quality of life with noninvasive, pleasant interventions desired and appreciated by patients. They are associated with few adverse events and have substantial appeal for many cancer patients.

The popularity of complementary therapies has affected every component of the health care system and all specialties of medicine, including oncology. It left its mark on the thinking and practice of physicians and other health professionals, and, importantly, broadened patients’ involvement and influence in their own care.

We use the acronym “CAM” in the following review of related surveys because investigators have typically failed to distinguish between these two qualitatively different categories. A recent report presented the most comprehensive and reliable findings to date on Americans’ use of CAM in general. The National Center for Health Statistics’ 2002 National Health Interview Survey of 31,044 adults found that 75% used some form of CAM (1). When prayer specifically for health reasons was excluded, the percentage was 50%. As found in virtually all previous surveys, CAM use was most common among women,
better educated people, those hospitalized in the previous year, and former smokers, indicating a more health-conscious segment of the population.

In cancer patients, CAM use is highly prevalent, according to scores of surveys from North America, going back to a systematic review in 1998 (2) and before then to 1984 (3), when different terminology applied. The prevalence of CAM use ranges from 15% to more than 70%. This wide range is explained by varying or absent definitions of “complementary therapies,” “alternative medicine,” or the “CAM” umbrella term. Recent large-scale surveys from Europe (4) and Japan (5) showed similar results. Another consistent finding in cancer patient surveys is that users are typically younger, more educated, and more affluent, a function of these patients’ desires and ability to play an active role in their own care. Patients get most of their CAM information not from their physicians, but rather, for better or worse, from sources more knowledgeable about these therapies.

CAM today is very much an open and public issue, discussed widely in the media and readily found on the Internet. Magazines and television specials provide the general public with details about new therapies. The yellow pages of telephone books in most cities and towns list various types of CAM practitioners.

Information available to the public varies widely in accuracy. Many Web sites and publications that appear to be objective are actually sponsored by commercial enterprises that promote and sell the products they report. Misinformation about health issues is widespread. In 1999, the U.S. Federal Trade Commission announced that it had identified hundreds of Web sites promoting and selling phony cures for cancer and other serious ailments among the estimated 15,000 to 17,000 health-related Web sites. A Google search of “alternative cancer therapy” in February 2006 yielded 23 million Web pages, whereas the same search in 2004 produced only 8 million Web pages. It is likely that those selling bogus treatments have increased accordingly.

A survey of 295 family physicians in the Maryland-Virginia region (6) revealed that up to 90% view complementary therapies such as diet and exercise, behavioral medicine, and hypnotherapy as legitimate medical practices. The majority refers patients to nonphysicians for these therapies or provides the services themselves. Homeopathy, Native American medicine, and traditional Oriental medicine were not seen as legitimate practices.

Two hundred Canadian general practitioners held similar views, noting their patients’ particular interest in chiropractic medicine. These physicians perceive chiropractic care, hypnosis, and acupuncture for chronic pain as the most effective CAM therapies, and homeopathy and reflexology as less efficacious (7). A meta-analysis of 12 studies in Great Britain suggests that British physicians view complementary medicine as only moderately effective (8), a level of enthusiasm that contrasts with the fervent efforts of the British Royal Family to promote homeopathy and other complementary therapies, and to merge them with mainstream care.

In addition to increasing coverage of CAM services by health insurers, a final marker of mainstream interest noted here is the publication of CAM research articles in major mainstream medical journals. Articles in major journals shifted from commentaries through the 1970s expressing realistic concern about quackery, to surveys of patients’ knowledge and use of unproven methods in the 1980s, and to reports of actual research results starting primarily in the mid-1990s.

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 research on complementary therapies in recent years. In 1996 and 1997, the National Library of Medicine added many new CAM search terms to its medical subject headings and began to cover alternative medicine journals previously not reviewed for inclusion in Medline. In large part, mainstream science opposition is being replaced by emphasis on the importance of methodologically sound research, which now increasingly occurs in numerous respected institutions around the world. Integrative oncology has become an informal subspecialty of oncology and is increasingly the focus of good quality scientific research.

Health insurance programs increasingly cover CAM services and providers. More than 30 major insurers, half of them Blue Cross plans, cover more than one method. Expanding insurance coverage of complementary and alternative therapies reflects consumer demand, but it also represents managed care efforts to control costs. Most alternative practitioners typically provide an opportunity for cost savings, and food supplements are less costly than prescription pharmaceuticals if used instead of the latter. Coverage varies according to the state. Naturopathic care is covered by approximately 100 insurance companies in the United States; most are concentrated in Alaska, Connecticut, and Washington State. Acupuncture, massage therapy, and other CAM services are variably covered by insurers, and most given a physician’s prescription for that therapy. In the state of Washington, which requires the inclusion of nonmainstream practitioners in private, commercial insurance products, billings were less than 2% of overall costs for cancer patients (11).

These approaches are unproved methods promoted as literal alternatives to mainstream cancer care. Helpful complementary or adjunctive therapies are discussed separately at the end of this chapter.