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© 2001 American Society for Clinical Oncology
Interactions Between Academic Oncology and Alternative/Complementary/Integrative Medicine: Complex But NecessaryByFrom the Cleveland Clinic Taussig Cancer Center, Department of Hematology/Medical Oncology, Lee and Jerome Burkons Research in Oncology, and Cleveland Clinic Foundation, Cleveland, OH. Address reprint requests to Maurie Markman, MD, Cleveland Clinic Taussig Cancer Center R-35, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195; email: markmam{at}ccf.org MUCH HAS BEEN written about the immense gulf between traditional/conventional medical practice and so-called alternative, complementary, or, more recently, integrative medicine.1-4 Some might state that the debate regarding a possible role for alternative/complementary medicine in standard medical practice is, at least in part, in reality about definitions. This argument suggests there is only a single form of medicine: that which is scientific and evidence-based. This definition would exclude most of what has been characterized as alternative/complementary medicine because of the essentially total absence of randomized trials, large case-control studies, or even carefully conducted phase II evaluations that might demonstrate the effectiveness (or ineffectiveness) of these strategies. Rather, personal experience and testimonials as well as long-established use (without scientifically evaluated trials) of a variety of interventions (eg, herbal medicine) are taken as sufficient evidence of benefit to justify their being considered an effective management approach. Although the medical establishment would readily acknowledge that patients may report they feel better when receiving massage, acupuncture, therapeutic touch, or even a homeopathic remedy, conventional practitioners would argue any such improvement in an individual’s sense of well-being is not a direct biologic effect of the intervention. Alternative explanations, including the well-recognized placebo effect5,6 (the existence of which has recently been questioned7), natural history of the disease process, and regression to the mean, are advanced to explain any apparent clinical benefit. Further, it has been forcefully argued that for some alternative medicine strategies, it is essentially impossible to even propose a plausible biologic hypothesis for how they could possibly produce any physiologic effect (eg, homeopathy). Yet today the academic medical world in general and the academic field of oncology in particular are in a rather remarkable position where forces in society are demanding that alternative/complementary medicine be investigated and certain interventions be incorporated into standard medical practice. What has happened to cause conventional medical practice to be challenged in this manner by those who advance theories that are so foreign to scientific medicine? Much has been written on this topic, and a variety of explanations have been put forward to explain what is, to many academic and community oncologists, a most perplexing phenomenon.1-4,8-15 However, what is increasingly certain is that individuals and groups who claim the benefits of a large number of alternative/complementary interventions in cancer management cannot be ignored. The precise percentage of cancer patients who elect some form of alternative medicine (instead of, or in addition to, conventional treatment) is unknown, but some investigators have suggested this number is substantial.4,8-15 Increasingly, patients are more open to discussing their interest in this form of treatment with their oncologists. In my own practice, where I see a large number of gynecologic cancer patients for second opinions regarding disease management, it is not an exaggeration to state that currently more than 50% of all new consultations include a request by the patient or a family member to discuss the benefits of one or more potential alternative/complementary medical interventions. But the question remains: Why should academic oncology become involved? Medicine has entered a spectacular era wherein our increased understanding of cancer biology and genetics as well as rapidly accelerating advances in biotechnology have led to the potential for truly exciting new treatments, as well as diagnostic and preventive strategies. Why should we spend the time and effort evaluating homeopathy, therapeutic touch, shark cartilage, or traditional Chinese herbs? Is this the best use of the increasingly limited resources of academic oncology? There are no simple answers to these questions, but for several reasons academic oncology has little choice but to interact with and begin to confront the world of alternative/complementary/integrative medicine (Table 1).
As noted above, patients are increasingly asking their oncologists about the value or harm associated with a variety of alternative medical interventions. Although oncologists are comfortable talking about risk versus benefit of cytotoxic chemotherapy regimens, what about those interventions advocated by the alternative medicine providers? Are they completely harmless? Do they interfere with the effectiveness of therapy? Do they increase side effects? Do they promote tumor growth? Unfortunately, objective data are sparse or nonexistent. It will never be possible to critically evaluate all (or even most) of the therapeutic approaches promoted by advocates of alternative/complementary medicine. In addition, many in the area of alternative medicine absolutely reject the notion it is possible to objectively evaluate clinical utility in a controlled clinical trial due to the fact that any benefit of such an intervention is a personal experience. Thus, it is unlikely these individuals or groups will ever be convinced a particular unconventional treatment is ineffective, regardless of the outcome of well-designed and conducted clinical trials. Therefore, it cannot be the aim of academic oncology to answer every question regarding alternative medicine, nor to convince every member of society of the ineffectiveness of certain interventions. Rather, our efforts should be directed toward those areas that will have the greatest impact on our patients, both to define possible useful therapies (eg, new agents among herbal medicines to treat malignant disease or prevent the side effects of therapy) and to alert society to totally inactive and potentially dangerous treatments and medications.16-24 REFERENCES 1. Cassileth BR, Lusk EJ, Strouse TB, et al: Contemporary unorthodox treatments in cancer medicine. Ann Intern Med 101: 105-112, 1984 2. Cassileth BR: The social implications of questionable cancer therapies. Cancer 63: 1247-1250, 1989[Medline]
3.
Burstein HJ: Discussing complementary therapies with cancer patients: What should we be talking about? J Clin Oncol 18: 2501-2504, 2000
4.
Fernandez CV, Stutzer CA, MacWilliam L, et al: Alternative and complementary therapy use in pediatric oncology patients in British Columbia: Prevalence and reasons for use and nonuse. J Clin Oncol 16: 1279-1286, 1998 5. Roberts AH, Kewman DG, Mercier L, et al: The power of nonspecific effects in healing: Implications for psychosocial and biological treatments. Clin Psychol Rev 13: 375-391, 1993 6. Beecher HK: The powerful placebo. JAMA 159: 1602-1606, 1955
7.
Hrobjartsson A, Gotzsche PC: Is the placebo powerless? An analysis of clinical trials comparing placebo with no treatment. N Engl J Med 344: 1594-1602, 2001
8.
Risberg T, Lund E, Wist E, et al: Cancer patients’ use of nonproven therapy: A 5-year follow-up study. J Clin Oncol 16: 6-12, 1998 9. Kao GD, Devine P: Use of complementary health practices by prostate carcinoma patients undergoing radiation therapy. Cancer 88: 615-619, 2000[Medline] 10. Ernst E, Cassileth BR: The prevalence of complementary/alternative medicine in cancer: A systematic review. Cancer 83: 777-782, 1998[Medline]
11.
Paltiel O, Avitzour M, Peretz T, et al: Determinants of the use of complementary therapies by patients with cancer. J Clin Oncol 19: 2439-2448, 2001 12. Metz JM, Jones H, Devine P, et al: Cancer patients use unconventional medical therapies far more frequently than standard history and physical examination suggest. Cancer 7: 149-154, 2000
13.
Boon H, Stewart M, Kennard MA, et al: Use of complementary/alternative medicine by breast cancer survivors in Ontario: Prevalence and perceptions. J Clin Oncol 18: 2515-2521, 2000
14.
Richardson MA, Sanders T, Palmer JL, et al: Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol 18: 2505-2514, 2000
15.
Burstein HJ, Gelber S, Guadagnoli E, et al: Use of alternative medicine by women with early-stage breast cancer. N Engl J Med 340: 1733-1739, 1999
16.
Moertel CG, Ames MM, Kovach JS, et al: A pharmacologic and toxicological study of amygdalin. JAMA 245: 591-594, 1981 17. Moertel CG, Fleming TR, Rubin J, et al: A clinical trial of amygdalin (laetrile) in the treatment of human cancer. N Engl J Med 306: 201-206, 1982[Abstract] 18. Markman M: Medical complications of "alternative" cancer therapy. N Engl J Med 312: 1640-1641, 1985[Medline] 19. Creagan ET, Moertel CG, O’Fallon JR, et al: Failure of high-dose vitamin C (ascorbic acid) therapy to benefit patients with advanced cancer. N Engl J Med 301: 687-690, 1979[Abstract] 20. Miller DR, Anderson GT, Stark JJ, et al: Phase I/II trial of the safety and efficacy of shark cartilage in the treatment of advanced cancer. J Clin Oncol 16: 3649-3655, 1998[Abstract]
21.
Hainer MI, Tsai N, Komura ST, et al: Fatal hepatorenal failure associated with hydrazine sulfate. Ann Intern Med 133: 877-880, 2000
22.
Nortier JL, Martinez M-CM, Schmeiser HH, et al: Urothelial carcinoma associated with the use of a Chinese herb (aristolochia fangchi). N Engl J Med 342: 1686-1692, 2000
23.
Jacobson JS, Troxel AB, Evans J, et al: Randomized trial of black cohosh for the treatment of hot flashes among women with a history of breast cancer. J Clin Oncol 19: 2739-2745, 2001
24.
Lee SH, Oe T, Blair IA: Vitamin C–induced decomposition of lipid hydroperoxides to endogenous genotoxins. Science 292: 2083-2086, 2001
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Copyright © 2001 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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