Published: Thursday, May 03, 2007

The experience of breast cancer can be a time of great confusion and anxiety. From the moment of finding a suspicious lump, through the diagnostic interval, months of treatment, and reintegrating back into one’s “new life” and beyond, a plethora of decisions must be made that require women to carefully consider risks and benefits and “fit” with their beliefs and values. The use of complementary and alternative medicine (CAM) has also been described by women with breast cancer as adding to the demands of decision making throughout the cancer journey. ^{2, 24}

Content in this section was developed by Tracy Truant, Regional Professional Practice/ Academic Leader Nursing, BC Cancer Agency with assistance from Dr. Lynda Balneaves, Assistant Professor, UBC School of Nursing.

1. Definition of complementary and alternative medicine (CAM)
2. Role of the nurse in CAM decision making
3. The five domains of CAM
4. Prevalence and patterns of CAM use
5. Uses of CAM
6. Why women with breast cancer use CAM
7. Common goals of CAM use in the breast cancer population
8. Who to talk to about CAM and breast cancer
9. Getting information about CAM and breast cancer
10. Barriers to CAM use
11. Information needs about use of CAM
12. Making decisions about using CAM therapies
13. Role of family and significant others in CAM decision making
14. Assisting patients to search for and evaluate information on CAM
15. Key questions to ask when evaluating CAM
16. Considerations when making CAM decisions
17. CAM and cancer information resources

1. Definition of complementary and alternative medicine (CAM)

Complementary therapies can be defined as “A group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine." ¹⁹

Conventional medicine is defined as “medicine practiced by holders of MD [medical doctor] or DO [doctor of osteopathy] degrees and by their allied health professionals, such as registered nurses, physical therapists, and psychologists”. Complementary therapies (CTs) are used in combination with conventional medicine; alternative therapies are used instead of conventional medicine. The term integrative medicine is becoming more popular, denoting the combination of conventional medicine and complementary therapies that have a strong scientific base for use and safety.²⁰

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2. Role of the nurse in CAM decision making

Existing nursing policy on nursing and CAM use:

• Canadian Nurses Association (Complementary Therapies: Finding the Right Balance, CNA 1999) www.cna-aiic.ca/CNA/documents/pdf/publications/ComplementaryTherapies_July1999_e.pdf
• College of Registered Nurses in BC (CRNBC) – Practice Standard for Registered Nurses and Nurse Practitioners: Complementary and Alternative Health Care (2006) www.crnbc.ca/downloads/437.pdf
• Oncology Nursing Society (ONS) Position Statement on Complementary and Alternative Medicine (United States) - http://www.ons.org/publications/positions/ComplementaryTherapies.shtml

Q. What is the role of the nurse in supporting CAM decision making?

A. (Based on CNA (1999) and CRNBC (2006) Standards for Practice):

Nursing’s role is to assess the patient for CAM use, and provide support for the safe integration of CAM use into his or her conventional cancer treatment plan. To accomplish this role, it is critical to open dialogue with patients to make discussion about CAM safe for him or her. In addition, nurses and other health care professionals must get educated about CAM use. A variety of CAM resources are outlined at the end of this section.

Every nurse considering involvement in CAM therapy, to whatever extent, should carefully consider each of the following responsibilities:

• Advocacy
  • Ask about CAM use
  • Understand patients’ reasons for use/ goals of CAM therapy
  • Respect patients’ right to use CAM
  • Communicate, collaborate and consult with interprofessional team regarding CAM use
  • Evaluate own personal and professional beliefs regarding use of CAM and recognize how these values can affect the care of patients seeking or using these therapies
• Provide evidence-based information
  • Patients have the right to timely, impartial, evidence based information to make informed decisions about any intervention, including CAM
  • Nurses have an obligation to assist patients to fully understand their health problem, and to assist them to receive the evidence-based information and support they need to make fully informed decisions about CAM therapies
• Competence
  • Must have the knowledge and skill to support CAM decision making
  • Able to assess for and support CAM/conventional treatment decision making
  • Able to critique all sources of information for credibility (from lay literature to peer reviewed research)
  • When recommending a CAM therapy, must:
    • know the indications, contraindication, possible risks, anticipated outcomes, and interactions with conventional therapy;
    • use the nursing process to assess, plan, intervene and evaluate CAM use; and
    • document information about patient use and outcomes of CAM
• Authority
  • Must keep within the scope of nursing practice
• Regulation
  • Employer position statements and guidelines on CAM use must be considered.
  • Examples at the BC Cancer Agency:
    • Unconventional Cancer Therapies
    • Natural Health Products and Cancer Therapy (PDF)

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3. The Five Domains of CAM

The National Centre for Complementary and Alternative Medicine categorizes CAM into five domains²⁰: alternative medical systems, mind-body interventions, biologically based therapies, manipulative and body based methods, and energy therapies. More information on specific CAM therapies can be obtained by clicking on the therapy or via the websites listed at the end of this document.

1. Alternative Medical Systems

Alternative medical systems are built upon complete systems of theory and practice. Often, these systems have evolved apart from and earlier than the conventional medical approach used in the United States. Examples of alternative medical systems that have developed in Western cultures include homeopathic medicine and naturopathic medicine. Examples of systems that have developed in non-Western cultures include traditional Chinese medicine and Ayurveda.

2. Mind-Body Interventions

Mind-body medicine uses a variety of techniques designed to enhance the mind's capacity to affect bodily function and symptoms. Some techniques that were considered CAM in the past have become mainstream (for example, patient support groups and cognitive-behavioural therapy). Other mind-body techniques are still considered CAM, including meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, or dance.

3. Biologically Based Therapies

Biologically based therapies in CAM use substances found in nature, such as herbs, foods, and vitamins. Some examples include dietary supplements,³ herbal products, and the use of other so-called natural but as yet scientifically unproven therapies (for example, using shark cartilage to treat cancer).

4. Manipulative and Body-Based Methods

Manipulative and body-based methods in CAM are based on manipulation and/or movement of one or more parts of the body. Some examples include chiropractic or osteopathic manipulation, and massage.

5. Energy Therapies

Energy therapies involve the use of energy fields. They are of two types:

Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. The existence of such fields has not yet been scientifically proven. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Examples include qi gong, Reiki, and Therapeutic Touch.

Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields.

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4. Prevalence and patterns of CAM use

The most frequently used CAM therapies in the general cancer population include prayer, natural products, deep breathing, meditation, chiropractic, yoga, and massage.³ Researchers have reported that 50%-83% of patients with cancer use CAM therapies.⁴

The prevalence of complementary therapy use in the breast cancer population has been quoted between 66-81%.^{5,6,9,13,14,19} Most frequently reported CAM therapies in the breast cancer population in North America include:

• meditation and relaxation;
• spiritual and faith healing;
• herbal remedies/ natural health products;
• diet and nutritional supplements;
• massage; and
• acupuncture.^2,6,16,18

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5. Use of CAM

Most common in:

• Women
• 35-54 years
• Income > 60,000
• Higher educational levels
• Chronically ill

6. Why women with breast cancer use CAM

• Health beliefs
• Perception of CAM as “natural”
• Acculturation/ family values
• Prior experience
• Dissatisfaction with conventional care
• Scepticism of biomedicine
• Availability and popularity of CAM
• Desperation - end of life care ¹⁷

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7. Common goals of CAM use in the breast cancer population

• Manage/ minimize side effects of conventional treatment
• Manage/ minimize symptoms
• Promote feelings of well being; quality of life
• Enhance immune system
• Enhance efficacy of conventional treatment
• Promote a sense of control
• Augment hope^2,6,16,18

8. Who to talk to about CAM

“I had an intern… somebody who was studying to be an oncologist… And I said something about my naturopath, and he said, ‘Well, you know that I don’t believe in that.” And I said, “Well, you know what, I don’t give a reef what you think!” So now there was no opening to talk about it, and how I wish someone had said to me, “Well, you know, there are other things you can do too along with what we are doing…” - Woman with breast cancer

Up to 50% of clients do not inform health care professionals (HCPs) about their CAM use and this raises concerns about informed CAM decision making in the context of conventional cancer treatment.^{23, 25}

Reasons for not disclosing include:

• Embarrassed
• Worried about HCP’s reaction
• HCP didn't ask or seem interested
• Did not see it as being relevant
• Belief that HCP would not be informed or helpful about CAM

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9. Getting information about CAM

• 57.6% family/ friends
• 37.4% magazines/ books
• 22.6% health food store
• 22.2% physician
• 5.4% nurse²

Oncology nurses may be caring for patients without knowledge of concurrent CAM use. Routine assessment of CAM use and close monitoring of patients using CAM therapies have the potential to enhance patient safety and promote integrative care.¹⁶

10. Barriers to CAM use

• Cost
• Being overwhelmed with information
• Lack of accessible, relevant information
• Novice ability to critique information/ credibility of sources of information/ credibility of CAM practitioners
• Relationship with health care provider - e.g. having conversations about CAM “shut down” by health care professionals
• Fatigue and other conventional treatment side effects limiting ability to search for and locate credible CAM information and practitioners
• Not having enough time to investigate CAM prior making other treatment decisions ^6,18

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11. Information needs about the use of CAM

Searching for, locating, synthesizing and evaluating information are key activities in preparation for making CAM decisions. Nurses can play a key role in addressing information needs to support the CAM decision making process.

• Timing of CAM use within the conventional cancer treatment trajectory
• Potential interactions of natural health products with conventional cancer treatments
• The known risks and benefits of CAM
• Therapy outcomes and side effects
• Which CAM therapies would be beneficial for them as an individual
• Credible sources of information about CAM and CAM health care providers
• The majority of people simply requested "more information, please!" ¹

"I started, right away, looking at alternatives. Immediately. I read everything and people kept sending me stuff and I started reading things and I walked into the health food store and I remember saying to the manager, “Can you help me out? I’ve just been diagnosed with cancer and I need help.”
- Woman with breast cancer

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12. Making decisions about using CAM therapies

CAM decision making for women with breast cancer is not a static process. From the time of diagnosis, through treatment, survivorship and beyond, women with breast cancer constantly make decisions and re-evaluate their CAM use at key points.^2,10,24 It is important for nurses caring for patients with breast cancer to understand this dynamic process, to most effectively support these patients’ CAM decision making.

Emerging evidence from qualitative studies involving women with early stage (I-II) breast cancer indicate that there are three general styles of how CAM decisions are made in conjunction with conventional cancer treatment: Stepwise, Combined, and Integrated.¹

• Stepwise: At each step of the conventional treatment trajectory, an attempt to integrate CAM treatments is made with a high level of decisional conflict
• Combined: Conventional treatment decisions are the primary focus of decision making, with CAM treatments added in where perceived gaps exist and with minimal conflict
• Integrative: Conventional and CAM treatment decisions are a part of one continuum of care and treatment decisions are made in an integrated manner

A number of key characteristics differentiate among the three styles, providing nurses with direction for assessment and care. These key characteristics are described in Table 1.

Table 1. Key Characteristics of the three CAM decision making styles of women with early stage breast cancer:

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13. Role of the family and significant others in CAM decision making

The social context of CAM decision making is beginning to receive attention in the research literature. CAM decisions may provide an opportunity for family and significant others to be involved in treatment decisions and “do something” for their loved one following diagnosis. Table 2 describes types of involvement and various roles family and significant others may play to support their loved ones’ CAM decision making and use.²¹ Understanding the types of involvement and roles will allow nurses to assist patients and their significant others to negotiate mutually acceptable roles in the CAM decision making process.

Table 2. Significant other’s (SO's) involvement and roles in cancer patient’s CAM decisions:

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14. Assisting patients to search for and evaluate information on CAM

Supporting patients to search for and evaluate CAM therapies is one of the key nursing responsibilities when assisting patients to make safe, informed and confident decisions about CAM in the context of conventional treatment. The following section describes important tips for consumers of CAM, which nurses may teach to patients to support their decision making process.

Locating credible sources of information:

• Consider goals, funding, reputation of organization providing information
  • Recognized academic/ health care institution?
  • Non-profit (government/ peer-reviewed funding)
• Look for information based on randomized clinical trials or population-based studies
• Systematic reviews
• Avoid information from marketing sources (e.g. product websites), lay periodicals (e.g. Common Ground)

Web-based resources:

• Both credible and non-scientific resources available – caution needed!
• Best examples include (links to websites listed at end of document):
  • National Center for Complementary and Alternative Medicine (NCCAM)
  • Health Canada’s Natural Health Product Directorate
  • Cancer Source
  • CAMline
  • Natural Medicines Comprehensive Database
  • Institutional websites - BC Cancer Agency
  • PubMed – has CAM search engine

Books:

• Those published by scientific publishers (e.g. Mosby, Sage, Elsevier) or professional organizations (e.g. NCIC, ACS)
• Avoid those based only on patient testimonials

Health care professionals:

• Both conventional and complementary care providers
• Especially helpful related to biologically-based therapies are pharmacists, nutritionists and herbalists
• Recognize that all health care professionals come with their own biases based on the paradigm in which they were educated and trained
• Many health care professionals lack adequate education about CAM
• Find someone open to listening and consulting about CAM

People living with cancer:

• Have often conducted extensive searches on CAM
• Can share stories, experiences, and resources

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15. Key questions to ask when evaluating CAM

• What is the goal of the therapy?
  • Beware of therapies that claim to “cure”
  • Goals may be physiological, emotional, and spiritual.
• What is a “safe” dose?
  • Too much of a good thing
• What are the risks/ benefits?
  • Need to balance and also consider what is unknown
• What are the costs associated with using this therapy?
  • Financial costs?
  • Emotional costs?
  • Time costs?
• How will therapy interact with other treatments?

Be an informed consumer:

• Making Decisions About Using CAM
• How to Select a CAM Practitioner
• Consumer Financial Issues in CAM
• 10 Things To Know About Evaluating Medical Resources on the Web ²⁰

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16. Considerations when making CAM decisions

• Respect your own attitudes and beliefs about cancer, conventional treatments, and CAM therapies
• Consider how you prefer to make decisions about treatments. What is your decision-making “style”? Use the resources that are available to you, including family members, friends, fellow cancer survivors as well as health care providers
• Understand that there are many available CAM therapies and providers
• Take your time researching your options and choosing therapies that match your beliefs and values
• Recognize that CAM is a rapidly expanding area of research. Stay current and informed^15,20

17. CAM and cancer information resources

Web-Based Resources

The following are comprehensive websites that include summaries of CAM therapies, and state of science reviews. Research databases are also included to provide access to peer-reviewed studies on complementary therapies.

Canada:

• Canadian Health Network (CHN) - a national, non-profit, bilingual health information service. Provides general health information as well as nutritional and CAM information. http://www.canadian-health-network.ca/
• CAMline - an evidence-based website on CAM resulting from the collaboration of conventional and CAM organizations. New therapy summaries are added frequently. http://www.camline.ca
• Réseau PROTEUS: Portail santé de médecine intégrée/ Passport Sante - A French language searchable database comprised of summaries of select CAM therapies. Is currently being translated into English. http://www.passeportsante.net/fr/Accueil/Accueil/Accueil.aspx

International:

• Memorial-Sloan Kettering Cancer Centre (US) - An easy-to-search database for clinicians and patients of many different natural health products. Provides mechanism of action, contraindications, and evidence based on current research. http://www.mskcc.org/mskcc/html/11570.cfm
• National Center for Complementary and Alternative Medicine (NCCAM) (US) - a department within the National Institutes of Health (NIH), a prominent public health agency in the United States. http://nccam.nih.gov/
• ClinicalTrials.gov (US) - A database of clinical trials developed and maintained by the US National Institutes of Health. Includes some CAM trials. http://www.clinicaltrials.gov/
• Office of Cancer Complementary and Alternative Medicine (OCCAM) (US) - OCCAM is a department of the US National Cancer Institute (NCI) that is devoted to CAM research. http://www3.cancer.gov/occam
• CAM on PubMed (US) - A part of the PubMed Medline database. Allows user to search for peer-reviewed, research articles on CAM. http://www.nlm.nih.gov/nccam/camonpubmed.html
• HerbMed (US) - A database that provides access to the scientific data underlying the use of herbs for health. Requires membership ($). http://www.herbmed.org/
• Natural Standard (US) - provides high quality, evidence-based information about CAM. More than 50 academic institutions contribute. Requires membership ($). http://www.naturalstandard.com/
• Natural Medicines Comprehensive Database - Is often considered the “gold standard” for natural health product information and uses recent research to discuss mechanism of action, safety, effectiveness, and contraindications. Requires membership ($). http://www.naturaldatabase.com/(1gv4203f0otkvwvpyfhvgf55)/home.aspx?li=1&st=2&cs=&s=ND
• Information on Dietary Supplements (IBIDS) Database - provides access to international, published literature on CAM. http://dietary-supplements.info.nih.gov/Health_Information/IBIDS.aspx
• Complementary and Alternative Medicine Evidence Online (CAMEOL) database - part of the UK Research Council for Complementary Medicine. This database reviews research evidence of effectiveness of a number of specific therapies including those used in the context of cancer. http://www.rccm.org.uk/

Books on CAM and Cancer

• Decker, Georgia M. (1999). Introduction to Complementary and Alternative Therapies. Oncology Nursing Society.
• Ernst, Edzard, Eisenberg, David et al. (2001). The Desktop Guide to Complementary & Alternative Medicine: An Evidence-Based Approach. Elsevier.
• Kelner, Merrijoy & Wellman, Beverly. (2000). Complementary and Alternative Medicine: A Primer. Routledge.
• Natural Standards. (2005). Natural Standard Herb and Supplement Reference  - Evidence-Based Clinical Reviews. Mosby.
• Rosenthal, David S. (2000). American Cancer Society's Guide to Complementary and Alternative Cancer Methods. American Cancer Society.

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References

1. Balneaves, LG, Davison, BJ, Verhoef, M, Kelly, M, & Truant, T (2006). Choices in healing: Complementary and Alternative Medicine and Breast Cancer. Interactive poster presentation at the Reasons for Hope Conference, Montreal, QE. Funded by CBCRA.
2. Balneaves, LG, Kristjansen, LJ, & Tataryn, D. (1999). Beyond convention: Describing complementary therapy use by women living with breast cancer. Patient Education and Counselling, 38, 143-153.
3. Barnes, P.M., Powell-Griner, E., McFann, K., & Nahin, R.L. (2004). Complementary and alternative medicine use among adults: United States, 2002. Advance Data, 27, 1-19.
4. Basch, E., & Ulbricht, C. (2004). Prevalence of CAM use among U.S. cancer patients: An update [Editorial]. Journal of Cancer Integrative Medicine, 2(1), 13-14.
5. Bennett, M., & Lengacher, C. (1999). The use of complementary therapies in a rural cancer population. Oncology Nursing Forum, 26, 1287-1294.
6. Boon, H., Stewart, M., Kennard, M.A., Gray, R., Sawka, C., Brown, J.B., McWilliam, C., Gavin, A., Baron, R.A., Aaron, D., Haines-Kamka, T. (2000). Use of complementary/alternative Medicine by breast cancer survivors in Ontario: Prevalence and perceptions. Journal of Clinical Oncology, 18(13), 2515-2521.
7. British Columbia Cancer Agency (2006). Unconventional therapies. Retrieved June 14 from http://bccancer.bc.ca/PPI/UnconventionalTherapies
8. British Columbia Cancer Agency (2006). Natural health products and cancer. Retrieved June 14 http://bccancer.bc.ca/PPI/UnconventionalTherapies
9. Burstein HJ, Gelber, S Guandagnoli E, et al., (1999). The use of alternative medicine by women with early-stage breast cancer. N Engl J Med, 340, 1733-1759.
10. Canales, MK & Geller, BM (2003). Surviving breast cancer: The role of complementary therapies. Family & Community Health, 26(1), 11-24.
11. College of Registered Nurses of British Columbia (2006). Practice Standard: Complementary and Alternative Health Care. Vancouver, BC: author
12. De Lemos, et al. (2004). Advising cancer patients on Natural Health Products – A structured approach. Annals of Psychotherapy, 38.
13. Eisenberg, DM, Davis, RB, Ettner, SL et al , (1998). Trends in alternative medicine use in the United States, 1009-1997: Results of a follow up national survey. JAMA 280, 1569-1575.
14. Eisenberg, DM, Kessler, RC, Foster, C, et al. (1993). Unconventional medicine use in the United States: Prevalence, costs, and patterns of use. N Engl J Med 328, 246-252.
15. Kaegi, E (1998). A patient’s guide to choosing unconventional therapies. CMAJ, 158, 1161-1165.
16. Lee, M, Lin, S, Wrensch, M, Adler, S, & Eisenberg, D. (2000). Alternative therapies used by women with breast cancer in four ethnic populations. Journal of the National Cancer Institute, 9, 42-47.
17. Lengacher, CA, Bennett, MP, Kip, KE, Gonzalez, L, Jacobsen, P, Cox, CE, (2006). Relief of symptoms, side effects, and psychological distress through use of complementary and alternative medicine in women with breast cancer. Oncology Nursing Forum, 33(1), 97-104.
18. Lengacher, CA, Bennett, MP, Kip, KE, Keller, R, LaVance, M, Smith, L &, Cox, CE, (2002). Frequency of use of complementary and alternative medicine in women with breast cancer. Oncology Nursing Forum, 29(10), 1445-1452.
19. Lerner IJ, & Kennedy, BJ (1992). The prevalence of questionable methods of cancer treatment in the United States. CA Cancer J Clin 42, 181-191.
20. National Centre for Complementary and Alternative Medicine (2001). What is complementary and alternative medicine? Retrieved June 13, 2006 from http://nccam.nih.gov/health/whatiscam.
21. Ohlen, J, Balneaves, LG, Bottorff, JL, & Brazier, AS (2006). The influence of significant others in complementary and alternative medicine decisions by cancer patients. Social Science & Medicine, (in press)
22. Oncology Nursing Society (2002). The use of complementary and alternative therapies in cancer care [Position Statement]. Retrieved June 14, 2006, from http://www.ons.org/publications/positions/ComplementaryTherapies.shtml
23. Robinson, A., & McGrail, M.R. (2004). Disclosure of CAM use to medical practitioners: A review of qualitative and quantitative studies. Complementary Therapies in Medicine, 12, 90-98.
24. Truant, T & Bottorff, J, (1999). Decision making related to complementary therapies: A process of regaining control. Patient Education and Counselling, 38, 131-142.
25. Verhoef, M.J., Balneaves, L.G., Boon, H.S., & Vroegindewey, A. (2005). Reasons for and characteristics associated with complementary and alternative medicine use among adult cancer patients: A systematic review. Integrative Cancer Therapies, 4, 274-286.

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