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A Review of Complementary and Alternative Medicine Practices Among Cancer Survivors Rose M. Bell, MSN, ARNP-c, OCN® About 4 of 10 adults in the United States use some type of complementary or alternative medicine (CAM) therapy, with the rate being higher among patients with serious illnesses, such as cancer. The purpose of this article is to provide oncology nurses with an understanding of the use of CAMs in cancer survivorship. By understanding the characteristics of typical users, the reasons for their use, and ethnic- and gender-related considerations, nurses can identify patients in this population and safely guide their use of CAM throughout survivorship. The literature provides a foundation to identify survivor needs and issues as they relate to CAM use. Nurses can play a critical role in the assessment and education of CAM use within survivor programs, with the ultimate goal being increased overall well-being and survival.

T

he National Institutes of Health ([NIH], 2007) reported that 38% of adults in the United States used some type of complementary or alternative medicine (CAM) therapy, with a significant increase noted from 2002–2007, particularly for head or chest colds. Americans use CAM for a variety of reasons, including treatment for diseases and medical conditions such as musculoskeletal pain. Studies have reported higher rates of use among patients with serious illnesses, including cancer (Miller et al., 2008; Saxe et al., 2008). Several specific therapies had marked increases as well, including deep breathing exercises, meditation, massage therapy, and yoga (NIH, 2007). The National Coalition for Cancer Survivorship ([NCCS], 2006) defined a cancer survivor as an individual from the time of a cancer diagnosis through the remaining years of his or her life. About one in three Americans will be diagnosed with cancer, with almost 12 million cancer survivors currently living in the United States (National Cancer Institute, 2009). Cancer survivorship has more than tripled to 10 million since the 1970s, thanks in part to advances in detection and treatment (Institute of Medicine [IOM], 2005a). With increased survivorship, significant changes emerge in the healthcare needs of patients and their families as they learn to develop a “new normal” in living with a cancer diagnosis. Survivorship is becoming an increasingly important oncology issue, particularly to those who have completed their cancer treatment. Survivors who complete their treatment often move “from an orderly system into a non system” (IOM, 2005b, p. 1) that provides the survivor with little understanding, direction, or planning to assist them along their survivorship continuum. This transition can leave the cancer survivor with multiple is-

At a Glance F Understanding the characteristics of complementary and alternative medicine (CAM) use in cancer survivors is essential to providing education and counseling. F Care of the survivor should include identification and assessment of CAM for each individual. F Cancer survivors are interested in information and self-care strategies. Nurses should understand assessment and counseling in these therapies.

sues and many unmet needs. Needs identification within the various survival stages and recognition of these stages is vital to the development of future education and treatment of the survivor population (McCaughan & Thompson, 2000). Survivorship care begins with the identification of these issues, starting with the first stage after treatment, and is the cornerstone in building personalized care plans. The goals of these care plans include successful self-management and promotion of healthy behaviors. This article is intended to provide the oncology nurse with an understanding of the use of CAMs in cancer survivorship. By

Rose M. Bell, MSN, ARNP-c, OCN®, is an oncology nurse practitioner at Northwest Medical Specialties in Federal Way, WA. (First submission May 2009. Revision submitted September 2009. Accepted for publication September 20, 2009.) Digital Object Identifier:10.1188/10.CJON.365-370

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understanding the characteristics of typical users, the reasons for their use, ethnic- and gender-related considerations, and implications for care, nurses can identify and educate survivors in their use of CAM. The National Center for Complementary and Alternative Medicine ([NCCAM], 2009) identified complementary and alternative therapies within four domains (see Figure 1). Although definitions of CAM vary, in general, complementary therapy is the use of CAM along with conventional therapy; alternative therapies are methods that are used in place of conventional therapy; and integrative therapy is a total integrative approach to cancer care, including both conventional and complementary therapies (NCCAM, 2009). The use of complementary and alternative therapies in cancer survivors is underreported (Gansler, Chiewkwei, Crammer, & Smith, 2008; Saxe et al., 2008), with as many as 81% of survivors having used vitamin or mineral supplements. Although use of the more common CAMs by cancer survivors was comparable to the general population, Gansler et al. (2008) noted an increase in other forms of CAM. Deng, Cassileth, and Yeung (2004) suggested that CAM users are seeking a holistic approach to their care and see CAM as a natural way to take responsibility and control of their health and promote an increased quality of life (Frenkel, Ben-Arye, Baldwin, & Sierpina, 2005; Saxe et al., 2008). Increased CAM use was reported in short- and long-term survivors (Gansler et al., 2008). Use and types of therapies differ according to cancer sites (Velicer & Ulrich, 2008). Survivors of melanoma and kidney cancers were reported as least likely to use CAM, whereas survivors of breast, ovarian, non-Hodgkin lymphoma, and brain or central nervous system cancers were reportedly most likely to use CAM (Gansler et al., 2008; Richardson, Sanders, Palmer, Greisinger, & Singletary, 2000). Stage of disease also influenced CAM use, with increases noted in advanced-stage disease (Gansler et al., 2008). In addition, CAM use can be affected by geography, with higher use reported in California (Goldstein et al., 2005). Goldstein et al. (2005) hypothesized that the reason for this may be the “social milieu” that exists in California, where the population leads a “culturally creative lifestyle” (Goldstein et al., 2005, p. 565). Additional commonalities identified in the

Biologically Based Herbs, vitamins, omega 3, fish oil, and shark cartilage Energy Therapies Qi gong, Reiki, therapeutic touch, and biomagnetics (i.e., pulse fields, alternating current, and magnetics) Manipulative and Body-Based Practices Chiropractic services, osteopathic manipulation, and massage Mind-Body Medicine Meditation, prayer, mental healing, creative therapies (i.e., art, music, or dance), and yoga Whole Medical Systems Homeopathy, naturopathy, traditional Chinese medicine, and ayurveda

Figure 1. Domains of Complementary and Alternative Medicine Practices Note. Based on information from National Center for Complementary and Alternative Medicine, 2009. 366

survivors who use CAM included “better education, a focus on health, and a general use of more mainstream medical services” (Deng et al., 2004, p. 419). Ethnic considerations in CAM use also have been identified. The “interpretation of ailments as well as differences in beliefs about ailments contribute to anomalies in use” (Gansler et al., 2008, p. 1054). In general, high CAM rates were reported in poor, older adult, and ethnic minority populations (Goldstein et al., 2005), populations that are reportedly under-represented in research studies. CAM use may be directly related to income status, with higher use associated with higher income (Goldstein et al., 2005). According to Gansler et al. (2008), biologically based practices (i.e., vitamins and herbs) were more common in Hispanics and other ethnic minority groups. However, Goldstein et al. (2005) contradicted that report by saying that Latino use of CAM was lowest in every category with the exception of prayer. Spiritual and religious practices, as well as mind-body therapies, were more commonly reported in African Americans (Gansler et al., 2008). Gender differences in CAM use also exist, with women exceeding men in every use category. The narrowest gap between the sexes is in the use of biologically-based therapies (odds ratio = 0.719) (Gansler et al., 2008). Additionally, therapies that include an emotional or tactile component are more appealing and more likely to be accepted by women than men (Gansler et al., 2008). Some reasons for increased use in women include more personal focus on health, more frequent provider visits, a greater sense of control of self, and a greater need to use adjunctive therapies (Gansler et al., 2008). For a review of the literature, see Table 1.

Reasons for Use Survivors identified many reasons for using CAM, and indicated that “locus of control” may be one important factor (Gansler et al., 2008). Survivors’ responses positively correlated with the use of CAM as a means of stress and recurrence reduction and enhancement of wellness and quality of life (Buettner et al., 2006; Greenlee, White, Patterson, & Kristal, 2004; Saxe et al., 2008), with the belief that CAM therapies are nontoxic (Richardson et al., 2000). Additionally, for those with advanced disease, CAM use was believed to be associated with prolongation of life (Richardson et al., 2000), the desire to remain hopeful (Richardson et al., 2000; Verhoef, Balneaves, Boon, & Vroegindewey, 2005), or to provide cure (Richardson et al., 2000). In cancer survivors, CAM was reportedly used primarily for treatment for ailments other than the cancer diagnosis (Goldstein, Lee, Ballard-Barbash, & Brown, 2008). The National Center for Health Statistics reported that cancer survivors were more likely to die from noncancer causes, and that they are more likely to have at least one functional limitation. As a result, the negative impact on quality of life or function from chronic health issues (Goldstein et al., 2008; Saxe et al., 2008), as well as the short- and long-term cancer-related medical issues or symptoms (Carpenter, Ganz, & Bernstein, 2008; Greenlee et al., 2004; Miller et al., 2008; Wesa, Gubili, & Cassileth, 2008), were identified as initiating factors for using CAM by cancer survivors. The use of chemotherapy during treatment also was associated with an increased CAM prevalence (Mao et al., 2008).

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Table 1. Review of Complementary Therapies Research in Cancer Survivors Article

Study

Most popular Therapies

Comments

Highest Population use

Buettner et al., 2006

Identified the prevalence and correlation with complementary and alternative therapy use in 2,022 nurse breast cancer survivors

Relaxation or imagery, massage, high-dose vitamins, and herbs

Patients with poor QOL used energy healing CAMs; patients with better QOL were among those practicing yoga. Chemotherapy was associated with relaxation or imagery, and radiotherapy was associated with high-dose vitamins. For patients with comorbidities, pulmonary disease was associated with massage and high-dose vitamins, rheumatoid arthritis was associated with yoga and energy healing, and thyroid disease was associated with high-dose vitamins and relaxation.

Younger, educated, and higher income survivors. CAM users had worse QOL scores than nonusers.

Carpenter et al., 2008

Explored the use of complementary and alternative therapies in 371 breast cancer survivors 10 years after diagnosis

Echinecea (29%), herbal tea (21%), ginko biloba (19%), ginseng (13%), and Saint John’s wort (13%)

Postdiagnosis medical conditions and lower mental functioning were strongly associated with CAM usage.

Younger survivors

Gansler et al., 2008

Examined the prevalence of complementary therapy use in 4,139 cancer survivors from 10–24 months after diagnosis

Prayer or spiritual practices (61%), relaxation (44%), faith or spiritual healing (42%), nutritional supplements or vitamins (40%), and meditation (15%)

Least popular practices reported were acupuncture or acupressure (1.2%), biofeedback (1%), and hypnosis (0.4%).

Young Caucasian women with high income and high education. Highest use was seen in younger survivors.

Goldstein et al., 2008

Explored the use and benefits of CAM among 1,844 Californians with cancer

Two or more dietary supplements (87%), prayer (58%), other provider (58%), chiropractor (45%), and special diet (41%)

Least popular practices reported were other provider (16%), three or more other providers (12%), or unconventional cancer therapies (4%).

Younger, described their race as “other,” were more educated, and were diagnosed at least three years prior to the interview

Greenlee et al., 2004

Explored the use and types of supplements in 10,857 cancer survivors in comparison to 64,226 cancer-free controls

Cranberry pills for bladder cancer, zinc with ovarian cancer, saw palmetto and soy with prostate cancer, melatonin with cervical cancer, vitamin D with thyroid cancer, vitamin A for colon cancer, vitamin E, calcium, and multivitamin for breast cancer

No difference in use between cancer survivors and the control group (similar use)

Women with specific cancer types

Lawsin et al., 2007

Examined demographic, medical, and psychosocial correlates to complementary and alternative therapy in 191 colorectal cancer survivors

Home remedies (37%), chiropractic care (35%), counseling or support groups (30%), relaxation or stress reduction (28%), and massage (27%)

Poor perceived support correlated to chiropractic care, intrusive thoughts correlated to counseling, and poor QOL correlated to herbal remedies and homeopathic and aromatherapies.

Younger women with poorer perceived QOL and more intrusive thoughts

Mao et al., 2008

Investigated the relationship of unmet needs to the use of complementary and alternative therapy in 2,585 cancer survivors 3.5–4 years after diagnosis

Vitamins (36%), herbs or natural products (30%), deep breathing (30%), meditation (24%), massage (17%)

Received info on CAM from family or friends (50%), doctor or nurse (31%), other sources (e.g., Internet, print media, social organizations) (20%), or other patients with cancer (13%)

Younger, married Caucasians who are less likely to live in an urban setting and have lung or colorectal cancer

Richardson et al., 2000

Examined the use of CAM in 453 patients with cancer

Spiritual practices (81%), CAM overall excluding spiritual or psychotherapy (69%), vitamins or herbs (63%), movement or physical therapies (59%)

Combined CAM with conventional therapy spiritual practices (91%), CAM overall (88%), mind or body (76%), vitamins or herbs (77%), and CAM overall excluding spiritual or psychotherapy (75%)

Younger, indigent women with some college who were postsurgical

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The rising cost of health care (Saxe et al., 2008), coupled with multiple unmet needs, equates to multiple CAM uses (Mao et al., 2008). These unmet needs were identified by Mao et al. (2008) as emotional, physical, nutritional, financial, informational, treatment- and employment-related, and daily living activities. Other reasons included an identified dissatisfaction with conventional care (Richardson et al., 2000; Saxe et al., 2008), fragmentation of care into survivorship, lack of empathy and support, or if a survivor’s subsequent needs were unfulfilled (Mao et al., 2008). In addition, Carpenter et al. (2008) identified decreased emotional function and multiple medical issues in very long-term breast cancer survivors who used CAM. The potential for recurrence and high levels of worry (Mao et al., 2008) and distress (Lawsin et al., 2007) also were reported with increased use. Finally, the use of herbal supplements were reportedly used to reduce the side effects of treatment and to boost immune function (Buettner et al., 2006; Deng et al., 2004; Lawsin et al., 2007; Richardson et al., 2000; Saxe et al., 2008).

Implications for Oncology Nurses To provide quality care to the cancer survivor, oncology nurses should understand the characteristics and reasons for CAM use and examine personal views and beliefs regarding CAM. Once personal biases and beliefs have been identified, the nurse can explore reasons for looking into the use of these therapies with the patient. Nurses should approach CAM with a non-judgmental attitude (Saxe et al., 2008) to avoid non-reporting of CAM use by the patient. Saxe et al. (2008) and Frenkel et al. (2005) reported that patients often do not report the use of CAM primarily because of the healthcare provider’s negative attitudes or limited knowledge regarding their use. Additionally, the patient or survivor may choose only to disclose one of multiple CAM therapies that they are using (Saxe et al., 2008). Robinson and McGrail (2004) reported that disclosure rates of CAM use ranged from 23%–90%. Chen, Bernard, and Cottrell (1999) demonstrated lower reporting to physicians who did not practice some form of CAM (67%) versus those who did (90%). Disclosure remains important to consider because patients who are seeing CAM providers and subsequently engaging in CAM treatments in addition to conventional care may cause interruption in their treatment and potential harm to themselves (Saxe et al., 2008). Cultural sensitivity also is essential for understanding CAM use. Cultural beliefs are important in the acceptance of, or mistrust with, conventional health care. This can lead to subsequent rejection of Western health care (Mao et al., 2008). Nursing assessment should focus on psychological processes of the patient (Gansler et al., 2008), including fear, quality of life, and spiritual values, as well as feelings of hope, optimism, and personal control (Richardson et al., 2000) (see Table 2). An evaluation of common characteristics may assist the provider in identification of increased use. An example of this is that supplement use has been reported to be associated with survivors with increased exercise and dietary changes that included increased fruit and vegetable intake (Gunther, Patterson, Kristal, Stratton, & White, 2004; Miller et al., 2008). Preliminary assessment also should include factors such as financial concerns related to care, cancer type, stage, prognosis, 368

and end-of-life issues, because diagnoses such as breast cancer are associated with increased CAM use in conjunction with conventional treatment (Deng et al., 2004; Mao et al., 2008). Nurses need to possess a good understanding of the survivor’s motivation surrounding the use of CAM. Addressing unmet needs, side-effect management, and conducting an evaluation of the patient’s understanding of safety in these therapies is imperative in future survivor care. Because CAM use is more likely related to symptom treatment, such as pain, fatigue, and hot flashes (Mao et al., 2008), a thorough focus on side-effect management also is an essential component of survivorship.

Table 2. Complementary and Alternative Medicine (CAM) Assessment and Intervention Assessment

Intervention

Cancer treatment plan

Research-based education, dispel myths, and provide the evidence for CAM

Cancer type and stage

Research-based education, symptom management, and address psychological issues

Chronic health issues and troubling side effects, such as pain, fatigue, and hot flashes

Symptom management and address psychological issues

Cultural and community CAM use and beliefs

Research-based education, dispel myths, and provide the evidence for CAM

Disease prognosis

Research-based education, symptom management, and address psychological issues

Fear, hope, optimism, and spiritual values

Address psychological issues, evaluate and address psychosocial issues, and provide research-based education

Financial concerns

Evaluate and address psychosocial issues

Interests

Explore the reasons for interest, discuss the CAM plan, and provide research-based education

Likes and dislikes

Research-based education, dispel myths, and provide the evidence for CAM

Motivation for use

Explore the reasons for interest, discuss the CAM plan, education, and symptom management

Patient’s knowledge of CAM

Dispel myths and provide the evidence for CAM interests

Personal control

Exercise recommendations, diet recommendations, and education

Prior therapies used

Research-based education, dispel myths, and provide the evidence for CAM

Quality of life

Symptom management and address psychological issues

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Once the initial assessment is conducted, the nurse should then evaluate the use of prior therapies, likes and dislikes, what has worked and failed in the past, and how decisions are made. This assessment also should include longstanding community, cultural, and family beliefs as they may strongly influence the decision for use and type of CAM used (Frenkel et al., 2005). Including those engaged in patients’ care as caretakers also is important.

Table 3. Research Evidence for Complementary and Alternative Medicine (CAM) Use in Cancer Survivors CAM Type

Potential Benefits

Acupressure

Chemotherapy-related nausea and vomiting

Acupuncture

Possible use for radiation-induced xerostomia, evidence for hot flashes, fatigue, and shortness of breath

Aromatic oil

Enhances effects of the massage

Biofeedback

Muscle strengthening in urinary and fecal incontinence and constipation, as well as insomnia

Diet (dietary considerations such as a low-fat plant-based diet)

Cancer risk reduction and decreased comorbidities

Electroacupuncture

Ameliorated nausea and vomiting

Exercise (weight reduction)

Cancer risk reduction and decreased comorbidities

Massage

Anxiety and lymphedema, relaxation, decreased pain, and improved sleep

a

Opportunity to Educate Two studies have reported a cancer diagnosis or the completion of treatment as a catalyst to stimulate increased health behaviors, including diet and exercise (Andrykowski, Beacham, Schmidt, & Harper, 2006), resulting in the “teachable moment” (Andrykowski et al., 2006; Wahnefried, Aziz, Rowland, & Pinto, 2005) for the survivor. Trask et al. (2005) reported that cancer screening rates in survivors were higher than individuals without a cancer diagnosis, and that the screening varied by type of screening. The importance of educating the survivor on a follow-up plan becomes yet another teachable moment. However, despite the possible educational impact, the opportunity is frequently missed by healthcare providers. Data demonstrate that only 20% of oncologists currently provide CAM education when the patient was present for follow-up (Wahnefried et al., 2005). By understanding the increased motivation for health in the cancer survivor, the healthcare team can begin to build a survivorship plan with a focus on wellness and the incorporation of responsible CAM use. This plan should include symptom management, diet, exercise, and psychological and psychosocial care. Education begins with the nurse’s familiarization of CAM therapies and supplements to provide advice and assist the patient with decisions regarding therapies (see Table 3). Education should be conducted with an emphasis on the scientific and research studies that are currently available on CAMs because the popular sources of information often can be “inaccurate and sometimes dangerous” (Frenkel et al., 2005, p. 290). The nurse or patient can begin by exploring NCCAM and its comprehensive Web site (http://nccam.nih.gov) intended for both the medical professional as well as patients or survivors, as well as the American Cancer Society (www.cancer.org/doc root/ETO/ETO_5.asp) and the National Cancer Institute (www .cancer.gov). The sites contain current and credible information on many CAM therapies.

Conclusion The current body of literature on survivorship and CAM provides a foundation for the identification of survivor needs and issues as they relate to CAM use. Survivors want individualized, concrete information on how cancer therapy will affect their daily lives. The literature reports that patients also desire selfcare strategies to manage this impact on their lives and families (Skalla, Bakitas, Furstenberg, Ahles, & Henderson, 2004). If patients are to maximize coping, their needs must be met (McCaughan & Thompson, 2000). Nurses can play a critical role in the assessment and education on the use of CAM within survivor programs by becoming aware of CAM use in these patients with the ultimate goal of increased overall well-being and survival.

CAM with good evidence, such as art therapy, acupuncture, and hypnosis, often are unused. Note. Based on information from American Cancer Society, 2008; Blom & Lundeberg, 2000; Deng et al., 2004; Filshie et al., 1996; Monti & Yang, 2005; Wesa et al., 2008. a

The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the author, planners, independent peer reviewers, or editorial staff. Author Contact: Rose M. Bell, MSN, ARNP-c, OCN®, can be reached at [email protected], with copy to editor at [email protected].

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