Dr. Wein addresses two issues: the terminology of unproven methods, and patients’ reasons for using them. He prefers to use a previously popular term, “unproven therapies,” to those in common use today, although his term fails to account for the complementary or adjunctive therapies used by the vast majority of cancer patients who try complementary and alternative medicine. The suggestion that we adopt a different label is consistent with the ever-evolving terminology that characterizes this area of cancer care.
Labeling Issues
Terms applied to questionable cancer therapies have changed dramatically over the decades. Reflecting varying degrees of disapproval, the labels applied historically have included “unorthodox,” “unconventional,” “questionable,” “unproven,” and the American Cancer Society’s 1914 reproach—“quackery.”
More recently, however, the term “complementary” came into use in Europe and elsewhere, while “alternative” prevailed initially in the United States, leading, for example, to the National Institutes of Health (NIH) “Office of Alternative Medicine,” which opened in 1992. Since that time, the European and North American terminology has merged, so that today’s most commonly used label is “complementary and alternative medicine,” as in the new NIH “Center for Complementary and Alternative Medicine.” The American Cancer Society (ACS) changed the name of its “Questionable Methods” Committee to “Complementary and Alternative Methods” a few years ago.
Alternative vs Complementary Therapies
This language reflects the status of the field internationally. It also enables important distinctions to be made between complementary and alternative remedies. Alternative therapies often are promoted for use instead of mainstream care, whereas complementary therapies are used for symptom management and as adjuncts to mainstream care, to enhance quality of life. This distinction was validated by the NIH and ACS shifts in nomenclature and by the results of the largest survey of public use of unconventional therapies.[1] All but 2% of those surveyed who used such remedies did so to complement, rather than replace, mainstream care.
Although research evidence is scant,[2] it appears that approximately 8% to 10% of tissue-biopsy–diagnosed cancer patients refuse mainstream therapy and immediately seek alternative care. The vast majority of complementary and alternative medicine users seek complementary, not alternative, therapies for cancer.
A glaring flaw in Dr. Wein’s taxonomic effort appears in his proposed reasons for patients’ use of unproven therapies—explanations that he categorizes as “fundamental mechanisms” and “practical factors.” The latter category includes symptom relief. Remedies applied for symptom relief are not consistent with his definition of unproven remedies as cure-oriented and lacking data.
Furthermore, most complementary therapies used for pain and other symptom control are often well supported by data. There are, for example, numerous articles in the medical literature describing the physiologic and psychological benefits of massage therapy, acupuncture, music and art therapies, tai chi, meditation, yoga, relaxation therapies, and so on. Complementary therapies represent an extension of what we used to call “supportive care” in oncology. Moreover, the NIH, including the National Cancer Institute, is now backing several studies designed to evaluate complementary as well as alternative or unproven therapies.
Nevertheless, the terminology of complementary and unproven medicine will continue to evolve, and may even revert to past labels such as “unproven.” Of greater import is the second aspect of the article, Dr. Wein’s speculation about what he terms the “fundamental motives” behind patients’ attraction to unproven methods.
Reaction to the Diagnosis
“It is my contention,” he says, “that the use of unproven therapies is a mechanism to deal with the fear of death—in particular, where associated with cancer.” Although reaction to a diagnosis of cancer is culture-bound to some degree, “fear of death with an ensuing psychological need to repress this fear” is not the most accurate description of the reaction of most North Americans. More typically, fear is followed by efforts to deal with the problem, and those efforts most often take the form of seeking recommended mainstream treatment.
Dr. Wein points to fears of death and of nonexistence, loneliness, the unknown, pain, loss of control, and emptiness as the “fundamental” reasons for use of unproven therapies by cancer patients. But surely we all recognize these fears as virtually universal reactions to the diagnosis itself, following which most patients elect to receive mainstream care. Thus, it is equally logical to explain patients’ willingness to undergo surgery, chemotherapy, and radiation therapy as a reaction to such fears.
In addition, there is the fact that only about 55% of patients are cured of cancer in the United States; in other countries, the percentage is lower, and internationally it is 15%.[3] If, as Dr. Wein states, conventional physicians see patients as deluded when they rely on unproven therapies to alter the course of cancer, what label should we attach to people who believe that mainstream oncologic care can alter the course of pancreatic and some other cancers?
Oncology Care: Imperfect
The popularity of alternative medicine may be a biting criticism of mainstream medicine, but it is often and equally an opportunity for patients to participate in their own care; to exert some control over their lives and well-being. We skate on very thin ice when we criticize or attach psychiatric labels to patients who seek unproven methods. Oncology care too often remains imperfect. Dr. Wein cites Cassileth as noting that there are few questionable methods for curable illnesses. The questionable methods in cancer medicine will disappear when we discover a universal cure for malignant disease.
Meanwhile, let us continue to attack the magic and mysticism, recognize that many—possibly a majority—of alternative practitioners are physicians, educate patients about the pros and cons of popular therapies, and encourage the use of adjunctive complementary techniques to ease the physical and emotional burden of both cancer and its mainstream treatments.
A 52-year-old man presented with an erythematous lesion in the axilla of unknown duration. Surgical excision was performed. What is your diagnosis?
