Responding to recent publicity on the use of complementary and alternative medicine (CAM) in cancer care.
A short news story published in the Times on 20th July entitled “Cancer deaths higher among users of alternative therapies1”, contained potentially confusing and misleading information about the use of complementary medicine (CM) among people with curable cancers and possible effects on survival.
The article was based on a research paper published online in JAMA Oncology, the day before, by researchers from Yale School of Medicine: “Complementary Medicine, Refusal of Conventional Cancer Therapy, and Survival Among Patients with Curable Cancers2″.
The main conclusions of the Yale researchers were that:
- The people who they identified as using complementary medicine (CM) were more likely to go on to refuse further conventional treatment than people not identified as using CM.
- People in their study who declined further conventional treatment had poorer survival outcomes than those who continued with conventional treatment.
- There was no difference in survival between people who were using CM alongside ongoing conventional treatment and those who were having conventional treatment alone.
The need to distinguish between complementary and alternative medicine.
We believe The Times article was misleading because it used the terms Complementary Medicine (which is used alongside conventional medicine) and Alternative Medicine (which is used instead of conventional medicine) interchangeably. The title implied that it was the use of the Complementary or Alternative Medicine (CAM) treatments themselves that was responsible for the increased deaths, rather than the refusal of conventional treatment, as the Yale researchers had concluded.
In addition, the Yale article was also misleading because of the way the Yale researchers identified CMs users. Their findings differ greatly from what is already known from existing published data on the prevalence of use of complementary medicine among people with cancer.
Even though the research methods and the numbers may be flawed, the Yale researchers have highlighted a very important point: that some people with cancer feel they have to choose between using conventional and complementary treatment, or are unable to tolerate the side effects of conventional treatment so choose to discontinue conventional treatment and pursue an Alternative Medicine treatment pathway.
Promoting Integrative Approaches
An Integrative Oncology approach would appear to be potentially the most useful solution. Supporting people to use safe, effective, evidence-based complementary therapies in an integrative way, alongside their conventional treatment, to help them to tolerate the full courses offered, thereby increasing their survival chances, and addressing their holistic needs and importantly increasing their quality of life.
The Bristol Whole Life Approach promotes an Integrative Approach to cancer through free lifestyle and complementary therapies designed to work safely alongside any conventional cancer treatment. The aim is to help people get the best from both evidence-based complementary and conventional approaches so that they do not feel that they have to choose between the two, to maximise the effectiveness of any treatment they receive while minimising the likelihood of harm or adverse interactions and the severity of any conventional treatment-related side-effects. Evaluation of people using Penny Brohn UK services shows improvement in their cancer related concerns and their overall wellbeing8.
This article was prepared by Dr Catherine Zollman, Fellow in Integrative Medicine (University of Arizona); Medical Director, Penny Brohn UK; Macmillan GP, Bristol and Rev Dr Victor Barley, Trustee and Medical Advisor to Penny Brohn, retired Consultant Oncologist and former Lead Clinician of Avon, Somerset and Wiltshire Cancer Services Network.
More about the Yale study
The Yale researchers identified CMs users by looking back through the clinical records of a group of patients on the US National Cancer Database and identifying those where Complementary Medicine was mentioned in their clinical records (in other words they did not ask the patients about their use of CM, but only looked at historic hospital records).
Of the 1,901,815 records they examined, they found only 258 where CM was documented in the clinical records. This gives an estimated prevalence of CM use of 0.01% in the cancer population, whereas several published patient surveys have documented CM use as between 49% and 83% of the cancer population (depending on how CM is defined), with most using CM to increase quality of life and wellbeing3,4,5,6, and reduce side effects of treatment. Less than half of those using CM informed their clinicians about their CM use7. This enormous difference in CM use prevalence estimation is likely to reflect a significant problem with the Yale researchers’ methods and the applicability of their findings to a wider CM-using population.
Indeed, the authors themselves mention this in their discussion of the study limitations: “[Our analysis is limited by its retrospective and observational nature. The use of CM was likely under-ascertained given patients’ hesitancy to report its use to clinicians and for database registrars to code this use reliably.] [In addition, it is possible that clinicians were more likely to document the use of CM when patients were using noteworthy therapies that may have resulted in a refusal of CCT]2”. In other words, the group of patients identified by the Yale researchers were likely to be a small, atypical group of people using some highly controversial and questionable CM modalities, which resulted in their clinicians being sufficiently concerned to document this in the clinical records, and which probably also led to them being more likely to turn down conventional treatment and pursue a more “alternative” treatment path.
- Cancer deaths higher among users of alternative therapies Kat Lay, Health Correspondent, The Times, July 19, 2018
- Complementary Medicine, Refusal of Conventional Cancer Therapy, and Survival Among Patients With Curable Cancers, Skyler B. Johnson, Henry S. Park, Cary P. Gross, and James B. Yu, JAMA Oncol. published online 2019 (doi:10.1001/jamaoncol.2018.2487).
- Use of Complementary Therapies for Cancer Symptom Management: Results of the 2007 National Health Interview Survey, Joel G. Anderson, Ann Gill Taylor, J Altern Complement Med. 2012 Mar; 18(3): 235–241
- Complementary medicine use by the Australian population: a critical mixed studies systematic review of utilisation, perceptions and factors associated with use Rebecca Reid, Amie Steel, Jon Wardle, Andrea Trubody, Jon Adams, BMC Complement Altern Med. 2016; 16: 176. Published online 2016 Jun 11
- Use of complementary and alternative medical therapies (CAM) by patients attending a regional comprehensive cancer care centre. Wilkinson, J. & Stevens, M. Journal of Complementary and Integrative Medicine, 2014 11(2), pp. 139-145.
- Decision-making about complementary and alternative medicine by cancer patients: integrative literature review Laura Weeks, Lynda G Balneaves, Charlotte Paterson, Marja Verhoef Open Med. 2014; 8(2): e54–e66. Published online 2014 Apr 15.
- Cancersurvivors’ disclosure of complementary health approaches to physicians: the role of patient-centered communication.Sohl SJ1, Borowski LA, Kent EE, Smith AW, Oakley-Girvan I, Rothman RL, Arora NK. Cancer. 2015 Mar 15;121(6):900-7. doi: 10.1002/cncr.29138. Epub 2014 Nov 11.
- Using a Whole Person Approach to Support People With Cancer: A Longitudinal, Mixed-Methods Service Evaluation, Marie J. Polley, Rachel Jolliffe, Emily Boxell, Catherine Zollman, Sarah Jackson, Helen SeersIntegrative Cancer Therapies, 2016 Vol 15, (4), pp. 435 – 445 https://doi.org/10.1177/1534735416632060