High Pre Valance of Complementary and Alternative Medicine Use Among Cancer Patients, Implications...

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High Prevalence of Complementary andAlternative Medicine Use Among Cancer Patients:Implications for Research and Clinical CareBarrie R. Cassileth and Andrew J. Vickers, Integrative Medicine Service, Memorial Sloan-Kettering Cancer Center,New York, NY

In this issue, Hyodo et al1 report that herbs and other

dietary supplements are used by substantial numbers of

cancer patients in Japan44.6% of 3,100 patients, as op-

posed to 25.5% of 361 noncancer (benign tumor) patients

surveyed. These data are consistent with results from

numerous prior surveys on complementary and alterna-

tive medicine (CAM) use in oncology. A 1998 systematic

review examined 26 surveys of cancer patients from 13

countries and reported an average prevalence of 31%,

with rates ranging up to 64%.2 Subsequent studies report

even higher prevalence, depending on the definition of

CAM used.3,4 Reports of prevalence often are exagger-ated because surveyors include many aspects of life, such

as spirituality, attention to diet, and routine self-care,

that from our perspective are not complementary thera-

pies. Nonetheless, use of complementary therapies by

cancer patients is substantial.

Virtually all studies conducted internationally, such as

that reported here, indicate that people who seek comple-

mentary therapies are better educated, of higher socioeco-

nomic status, and more likely to be female and younger

than those who do not. Data from Hyodo et al1 show that

herbs and supplements, which are directed primarily at

cancer control, are used much more commonly in Japanthan are the symptom management complementary thera-

pies more typically sought in North America. This differ-

ence is also of interest because, despite some promising

agents, most herbs and other supplements as currently

available are of questionable value,5-7 whereas substantial

evidence from randomized trials supports the use of com-

plementary therapies for symptom control in patients with

cancer, including acupuncture,8,9 massage,10 music thera-

py,11 and relaxation techniques.12

In the survey by Hyodo et al,1 more than 96% of pa-

tients used Chinese herbs, mushrooms, shark cartilage, vi-

tamins, and soon (Table3 ofHyodoet al 1). Not mentioned

in this article, however, are Japans Kampo products, which

are based on traditional Chinese herbal formulas. Kampo

botanicals are produced at a pharmaceutical grade, avail-

able in pharmacies by prescription, and commonly pre-

scribed by physiciansin Japan.This survey excluded Kampo

products, explicitly definingCAM as remedies used without

the approval of relevant government authorities and not

covered by health insurance. Many Kampo products,

conversely, are approved by the Japanese governmentand are covered by health insurance. Essentially, they are

high-quality, standardized, government-regulated ver-

sions of herbal medicines, which in the West are termed

dietary supplements.

In North America, however, dietary supplements do

not meet the same standards as do the government-

regulated Kampo products in Japan. Ours are poorly stan-

dardized, often contaminated, usually not evidence based,

and unregulated, and may be dangerous in the oncology

setting. Herbs and other supplements are not required to

meet standards of safety,efficacy, and consistency, and their

use has important implications for clinical care. The con-tinuing availability of such products in the United States

results in large part from the 1994 Dietary Supplement and

Health Education Act, which created a protective new cat-

egory for the approximately 20,000 vitamins, minerals,

herbs, and other agents sold as supplements before October

1994. Spurred by supplement industry lobbying, the act

protects supplements from government scrutiny and man-

dates that the US Food and Drug Administration prove

harm before distribution of a product can be regulated.

JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L

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2590Journal of Clinical Oncology, Vol 23, No 12 (April 20), 2005: pp 2590-2592DOI: 10.1200/JCO.2005.11.922

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Problems with highly publicized products such as

ephedrine, which was associated with serious toxicities, andPC-SPES, an herbal compound used for prostate cancer,

which was found to be contaminated with pharmaceuti-cals,13 are perhaps the best-known consequences of such

limited regulation. This is doubly unfortunate becauseephedra is a valuable herb from which pseudoephedrine

(Sudafed) is derived. Similarly, PC-SPES was found to becontaminated with diethylstilbestrol, as well as a tranquil-

izer and anti-inflammatory drugs. It was forced off themarket despite showing efficacy in clinical trials.14

Perhaps of greatest concern, it is now clear that herbsand other supplements may interfere with conventional

oncologic management via metabolic interaction15 or byantioxidant-related protection of tumor cells from oxida-

tive damage.16,17 Accordingly, patients in our institutionare advised to avoid the use of herbs and of supplements

greater than the recommended daily allowance during andfor a week before radiotherapy and chemotherapy.

Medicinal mushrooms, the most commonly usedproduct in the survey by Hyodo et al,1 are popular world-wide, and are commonly prescribed in Japan. Moreover,

data from controlled clinical trials suggest that they mayvery well be beneficial.18-20 For example, a randomized trial

of 462 colorectal cancer patients receiving curative resec-tion compared adjuvant chemotherapy (mitomycin and

fluorouracil) alone to chemotherapy plus PSK, an extractfrom the fungus Coriolus versicolor. Both disease-free and

overall survival were significantly higher in the PSKgroup (3-year survival probabilities of 77% v 68% and

86% v79%).20

Many researchers, predominantly in the United States,are working on these issues. We now know that medicinalmushrooms contain a class of polysaccharides known as

beta-glucans (-glucans), and that these promote antitu-mor immunity related to antibody-Fc interactions by acti-

vating complement receptor 3.21 This suggests that

-glucans might act synergistically with therapeutic anti-

bodies such as trastuzumab or rituximab, an effect alreadydemonstrated in the mouse model.22 Different -glucan

products have been compared in laboratory studies to selectan agent for clinical study,23 and phase I clinical trials cur-

rently are underway to define dosing. Investigators alsohave begun to understand the putative immune-enhancing

effects of medicinal mushrooms in terms of their effects ongrowth and differentiation of bone marrow cells.23

The use of the term complementary and alternativemedicine by Hyodo et al1 raises the issue of language. Their

survey respondents were not using alternative therapies,given that patients were recruited from mainstream cancer

clinics. Similarly, only a minority were using the sort ofcomplementary therapies, such as massage or acupuncture,

available at U.S. cancer centers.We have proposed the termintegrative oncology,24 a synthesis of the best of cancer

treatment and evidence-based, supportive complementary

modalities that effectively relieve many of the physical andemotional symptoms that cancer patients experience.25

Centers such as Memorial Sloan-Kettering, Dana-Farber, University of California at several sites, M.D.

Anderson, and many more now have programs that clini-cally integrate conventional and complementary medicine.

They also conduct research on complementary therapiesand on herbs and other supplements. By bringing these

issues into mainstream practice and researchrejectinguseless treatments, offering those of proven value, and sys-

tematically developing those that show promisewe canemulate Japans regulatory efforts and ensure that the phe-

nomenon described by Hyodo et al,1 common in the West-ern worldas well, becomes a force for the greater well-being

of cancer patients.

Authors Disclosures of Potential

Conflicts of Interest

The authors indicated no potential conflicts of interest.

2005 by American Society of Clinical Oncology

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Editorial

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Cassileth and Vickers

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