by Angela M. Johnson Board-certified Diplomate of Oriental Medicine, Cancer Integrative Medicine Program, Rush University Medical Center. Medically reviewed by Dr. C.H. Weaver M.D. Medical Editor 1/2021
There has recently been a level of growing optimism within the cancer community as reports have shown a decline in deaths from cancer. This steady decline is thought to be due in part to improvements in cancer prevention, early detection, and treatment. While these trends are truly encouraging, those living with the disease still bear a heavy burden—mentally, spiritually, and physically. Even though cancer treatments like chemotherapy and radiation often have a positive impact on survival, they can be accompanied by an array of distressing side effects, such as fatigue, depression, nausea, vomiting, disturbed sleep, and anxiety—all of which can detract from one’s quality of life.
Many patients, finding their lives disrupted by the side effects they are experiencing, have been increasingly searching beyond the standard protocol for relief. “Given the induction of side effects of conventional medicine, as well as the perceived ineffectiveness of conventional medicine at preventing or relieving these side effects, patients often seek help outside the traditional Western medical model through what is defined as complementary and alternative medicine (CAM) for aid in alleviating side effects and increasing quality of life.”
Complementary Medicine and Integrative Oncology
According to the American Cancer Society, complementary medicine (CM) is defined as a therapy that is used in addition to traditional cancer treatment. (2) CM approaches include art therapy, acupuncture, massage, mind/body approaches (such as breathing, relaxation, and visualization), music therapy, and yoga. Complementary medicine is not the same as alternative medicine, which denotes therapies used instead of mainstream medicine (such as using herbs instead of chemotherapy). The distinction between the two is important because using therapies as an alternative to mainstream medicine often poses serious problems for both the oncologist and the person with cancer, and alternative medicine is therefore not recommended.
As the practice of complementary medicine has become more widespread in the oncology community, another term that has evolved recently is integrative oncology—a specialty within the broad area of integrative medicine in which effective CM modalities are used in conjunction with mainstream cancer treatments in an attempt to alleviate distress and reduce the side effects of cancer treatment.3 But according to James Gordon, MD, clinical professor at Georgetown Medical School and founder and director of the Center for Mind-Body Medicine, the idea of integrative medicine should not be limited to oncology: “All medicine should be integrative,” he says, because it is “something that focuses on the whole person.” Dr. Gordon believes that the Western medical community “needs to see that complementary medicine is not just a little acupuncture and a little nutrition—it’s a way of looking at medicine and healthcare” where the patient is placed in the center of care.
Complementary Medicine for People Living with Cancer
Although CM has only recently gained more attention in the Western healthcare community, patients in the United States have actually been interested in these approaches for some time. According to Dr. Gordon, the move toward integrative medicine gained momentum in the 1960s, when people began “to experience the limitations of the medical care they received and began to look to these and other traditions and practices to help them with their healthcare problems.”(4) As a result of this new awareness, people began exploring options within CM that were viewed as being less toxic and more congruent with their own beliefs. “These people were not turning their backs on conventional medicine,” says Dr. Gordon, “but they were painfully aware of its limitations and side effects and therefore were exploring approaches that would complement this medicine.” (4)
Currently, studies suggest that between 7 and 54 percent of people living with cancer are electing to incorporate CM into their traditional cancer care.5 Studies also reveal that individuals incorporate CM into their cancer care because it provides them an opportunity to take an active role in their own care. According to Edgar Staren, MD, senior vice president for clinical affairs and chief medical officer at Cancer Treatment Centers of America, this participatory role is critical. “Patients want to have a voice in their own care,” he says, and they “often do better when they’re involved.” As a surgical oncologist and cancer survivor himself, Dr. Staren has seen firsthand the part that complementary medicine can play in a patient’s care, and he is very supportive of the practice: “I know it plays an important role,” he says.
In fact, research supports Dr. Staren’s observation that “patients who are involved in their own care and who take an active role in their treatment feel better, and—in some but not all studies—recover better.”(6) Other reasons given for patients’ use of CM include many hopes for improvement (5,7)
- Boosting the immune system
- Relieving pain
- Controlling side effects related to disease or treatment
- Doing everything possible to regain health
- Developing a sense of hopefulness
- Gaining more control in the decision-making process
- Engaging one’s psychological resources
- Utilization of less toxic treatments
Complementary Medicine in Cancer Symptom Management: What’s the Evidence?
In recent years, due to an increase in public interest, CM has been recognized as a valid approach to cancer care and has been widely utilized by many in the medical community. In 1992 the federal Alternative Medicine (OAM) was established to support research on the safety and the efficacy of various CM modalities. Six years later, with increased federal support, the OAM became the National Center for Complementary and Alternative Medicine (NCCAM). As the government’s lead agency on CM research, the NCCAM pursues its mission to study CM modalities in the context of rigorous science, to train CM researchers, and to disseminate CM information to the public and to healthcare professionals. (8)
Even though it is often difficult for researchers to identify how complementary medicine works within a Western medical framework, evidence-based studies are revealing that a variety of CM modalities are safe and effective. The following recent research findings on the management of cancer-related symptoms with CM therapies outline what we’re learning about the role of CM in cancer care today.
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Cancer-associated pain. According to the M. D. Anderson Cancer Center, approximately 30 percent of people living with cancer experience pain. (9) The cause of pain varies from person to person. Causes include the tumor, the conventional cancer treatment (chemotherapy, radiation, and surgery), and other painful conditions. Fortunately, there are several drug-free options for reducing pain. In a recent study published in Oncology, CM modalities such as mind/body approaches, acupuncture, massage, and reiki—all were found effective in reducing self-reported cancer-related pain. (10) In addition, “numerous qualitative studies have pointed to a role of music therapy in palliative cancer care.” Empiric data also suggests that music therapy alleviates anxiety associated with ongoing painful experiences. (10)
Anxiety and stress. According to the National Cancer Institute, people living with cancer experience anxiety and stress for a number of reasons: poorly controlled pain, the side effects of medications, and an inability to cope with the diagnosis or treatment. A study published in the Cancer Journal revealed that people living with cancer who receive massage experience a 19 to 32 percent reduction in feelings of anxiety. (5) Additional CM modalities considered helpful in reducing levels of cancer-related anxiety and stress include meditation, relaxation, and music therapy.11 In addition, according to the National Cancer Institute, clinical studies of the effects of acupuncture on anxiety and depression have demonstrated that “acupuncture either relieves symptoms or prevents them from becoming worse.” (12)
Fatigue. Fatigue is the most commonly reported symptom for people living with cancer. Although the condition is difficult to describe, “people with cancer may express it in different ways, such as saying they feel tired, weak, exhausted, weary, worn-out, heavy, or slow.” (13) Chronic fatigue can significantly impair one’s quality of life and may exacerbate other symptoms. According to a study conducted by Memorial Sloan-Kettering Cancer Center, massage has been found useful in reducing levels of fatigue.5 Others have reported that use of acupuncture reduced levels of fatigue in 31 percent of cancer patients who had struggled with persistent fatigue over a two-year period. (5)
Nausea and vomiting. Nausea and vomiting are two common symptoms experienced by people living with cancer. These symptoms are often most prominent in patients undergoing chemotherapy. CM modalities found effective at reducing anticipatory nausea and vomiting in adults and children with cancer include mind/body medicine approaches such as guided imagery, hypnosis, and relaxation training. The National Institutes of Health consensus study recommends acupuncture as an effective modality for chemotherapy-associated nausea and vomiting. (5)
Complementary Medicine in Cancer Symptom Management: Is It Safe?
According to the National Cancer Institute, people living with cancer should discuss their interest in and use of CM with their healthcare team. Some CM therapies “may interfere with standard treatment or may be harmful when used with conventional treatment. It is also a good idea to become informed about the therapy, including whether the results of scientific studies support the claims that are made for it.” (14)
The risks can be significantly reduced, however, when CM is performed by CM practitioners who have received specialized training and education in their respective fields and who work in conjunction with Western medical teams. In most states it is unlawful for a CM provider to practice without a proper license or national board certification. These requirements vary from state to state. To facilitate the process of finding CM practitioners with the appropriate training and education, many hospitals across the country have created integrative oncology programs or special integrative medicine centers. Although there are many benefits of working with practitioners in this type of setting, the biggest benefit is that such CM practitioners work collaboratively with other healthcare providers to provide the best in patient-centered care.
Does “Natural” Really Mean “Harmless”?
It is important to recognize that although many CM modalities are promoted as “natural” (such as natural supplements), this does not necessarily mean that they are harmless or without limitations. Always discuss with your physician your desire to begin a CM modality and be sure to find a qualified CM professional. Before you begin any new treatment, do the research. The following is some useful information about a few CM modalities that you may want to know about as you consider your options.
Supplements: yea or nay? According to Barrie Cassileth, MS, PhD, chief of Integrative Medicine Services at Memorial Sloan-Kettering Cancer Center, “most herbs and supplements as currently available are of questionable value.” (15) For this reason people living with cancer should use caution when considering the use of herbal products until they have a discussion with an oncologist knowledgeable in their use.
Massage: helpful or harmful? Another common concern voiced by the cancer community is that massage may promote the spread of cancer. At this time there is no evidence to indicate that massage promotes tumor metastasis,16 but “it is prudent to avoid massage directly over known tumors or even predictable metastasis sites without known disease.”16 People living with cancer are also advised to avoid massage if they have bony metastases or are prone to fractures, and extreme care must be taken “to avoid further injury to tissues damaged by surgery or radiation therapy.”(16)
Acupuncture: when and where? When performed by trained and licensed practitioners, acupuncture is another CM modality found safe and effective for people living with cancer. According to the National Institutes of Health Consensus Development Conference Statement, “the overall frequency of acupuncture-related adverse events is extremely low, and prospective studies have indicated that even minor adverse events are rare.”16 Although rare, the most common side effects of treatment include minor bleeding or bruising at the needle site. Most often individuals find acupuncture extremely relaxing and many fall asleep during the treatment. In general, acupuncture, manipulative therapies, and deep tissue massage are not indicated in patients with thrombocytopenia, bleeding disorders, or aplasia.5 Acupuncture is also not recommended for patients who are neutropenic and those with severe coagulopathy. (17)
Communicating with Your Oncologist
Several studies in the medical literature indicate that only a small proportion of people discuss with their physicians their interest in or use of complementary therapies. According to Dr. Staren, this is particularly true for people living with cancer: “As many as 80 percent of the patients incorporating CM into their care are not talking about it with their healthcare teams, but it’s critical that doctors know.” Not only does the oncologist need to know which CM modalities the patient is using, to ensure that there are no conflicts in the care being provided, but the patient also benefits from the doctor’s support and guidance. “People need support in [selecting CM modalities],” says Dr. Staren, “because it can be overwhelming without it. Therefore it’s important to find oncology professionals who are at least willing to discuss it.” Fortunately, Dr. Staren says, today more and more physicians are likely to be open to CM and its benefits; if they are completely opposed, he says, “patients should question whether that’s the right physician for them.”
CAM and Cancer Care
With the myriad of CAM therapies available, it is often difficult and overwhelming to determine which, if any, may be appropriate. Because of the potential for interaction between CAM therapies and conventional medical treatments, it is extremely important for a patient to consult with their oncologist and other attendant health care professionals about CAM therapies they currently use or are considering using. While information regarding interactions is limited, it is crucial that the information available be utilized. For example, some data suggest that certain CAM therapies may interfere with specific chemotherapy agents or cause dangerous side effects when used concurrently.
Another benefit of discussing CAM therapies with one’s conventional medical provider is that it promotes a health care team approach in which appropriate information may be shared for optimal treatment. In China, for example, a cancer patient often has an oncologist and an acupuncturist working together. This structure assists health care providers in developing comprehensive treatment plans.
As a patient interested in CAM therapies, several steps can taken to make informed decisions. First, research CAM therapies. Make sure that health claims are supported by scientific studies, recognizing that results in laboratory or animal studies often do not translate to the same benefits in humans. Also look for evidence that the CAM therapy is safe. An oncologist or other health care professional may be able to help interpret these scientific studies.Most medical doctors have not received training in CAM and therefore do not offer CAM treatments. However, a physician or other health professionals may be able to recommend a CAM practitioner. Sometimes local hospitals, medical schools, or area clinics maintain a list of local CAM practitioners and may offer recommendations. It may also be helpful to contact a professional organization or regulatory agency regarding the type of CAM therapy in question.When considering a prospective practitioner, it is important to understand his or her qualifications and the CAM therapy itself. To this end, the following questions may be helpful during an initial consultation:
- What are the training requirements and credentials for this type of CAM therapy?
- Does the treatment intend to promote wellness, manage symptoms and/or treat cancer?
- Have any scientific studies been published on this CAM therapy in peer-reviewed medical journals?
- Do patients with similar illnesses commonly use this CAM therapy? Can the practitioner provide references of patients for whom the treatments have proven successful?
- How does one know whether the treatment is working? What are indications of benefit?
- Can the CAM therapy be used concurrently with conventional medical treatments? Does it increase the efficacy of the conventional treatment? Are they any known contraindications?
- What are the potential side effects? How safe is the treatment?
- What does the treatment consist of? How long does a treatment session last? How often is it required?
- How much does treatment cost? Do insurance companies usually cover these costs?
- Is the practitioner willing to communicate with other health care providers, particularly conventional physicians and oncologists, regarding the CAM therapy?
Use care when choosing a CAM practitioner. Patients should be comfortable with any CAM therapy they choose to undergo and the practitioner they select. They should be equally at ease in discontinuing treatment if they choose to or in not using any CAM therapy at all. The ultimate decision about health care strategies lay in the hands of the person most affected: the patient.
Ultimately, integrating CM with conventional medicine can be an empowering process for many patients. Studies suggest that a variety of CM modalities are safe and effective and can be useful in helping people living with cancer achieve more comfort mentally, spiritually, and physically. It is imperative, however, that patients work in cooperation with their oncologists and receive the guidance of qualified CM practitioners.