Bernstein and Grasso’s manuscript joins a growing body of literature documenting the extent of the use of complementary and alternative medicine (CAM) by cancer patients. Their data provide an indication of the proportion of cancer patients using CAM, as well as the most prevalent approaches, in a private, nonprofit hospital in South Florida. This information will enable health-care professionals in this institution to better understand their cancer patient population and to provide cancer care that reflects the reality of CAM use. As such, this report complements research projects that have examined similar questions in national and population-based samples. Because all hospitals have distinct patient populations, it is important that health-care organizations examine the behavior and preferences of their own members.Study Limitations
There are, however, a number of limitations to this study. For example, its small sample size lacks the statistical power to detect possible effects of interest, which may account for the somewhat inconsistent statements in the report about whether educational level was or was not associated with CAM use. The small sample size also precluded investigation of possible ethnic differences in CAM use. The use of culturally based CAM approaches (such as traditional medicine) is a particularly interesting possibility in this multiethnic population. The response rate (apparently 100 out of 150 patients approached agreed to participate) suggests possible biases in the sample, and the heterogeneous respondents (in terms of, for example, time since diagnosis, cancer site, and inpatient vs outpatient status) make it difficult to know how the findings can be generalized.
While these concerns affect its merit as a research study, this report’s larger value is for professionals in the institution where the study was conducted. The next step is to use these data in the context of patient care. I would like to suggest some specific ways that providers can build on these findingsthat CAM use is widespread in their patient populationin their interactions with cancer patients.Determining Why Patients Use CAM
First, health-care providers need to question cancer patients specifically about their use of CAM therapiesnot wait for the patient to initiate this discussion. Providers need to maintain a nonevaluative reaction to the patient’s response, no matter how "far out" the behavior may seem. Obtaining complete information about what patients are doing is the first step in evaluating their potential risks and benefits and developing appropriate recommendations. Eisenberg has provided helpful guidelines for discussing and monitoring the use of CAM by patients.
Cancer care providers need to understand why patients have made the decision to use CAM remedies. For example, patients may be searching for hope, making sure all avenues are being explored, looking for individuals who will spend time and talk to them, and/or are trying to take an active role in decision-making about their own care. It is possible that patients’ motivations in seeking CAM stem from their perceptions of the limitations of the health-care system, and providers can address these concerns. Similarly, understanding patients’ perspectives about how CAM therapies workfor example, that such remedies are "natural," work through "cleansing," "purification," and "strengthening the immune system"may enable health-care providers to better explain the mechanisms of action of cancer therapies and/or why the claims of some CAM therapies are dubious.Potential Hazards and Benefits
Providers need to keep abreast of new developments concerning the potential hazards and benefits of CAM therapies. The reality is that, at present, there simply are no scientific data with which to determine the efficacy of the majority of CAM therapies for cancer patients, because most of these approaches have not been subjected to rigorous scientific examination. Indeed, "educated decisions" about CAM use are currently based on an incomplete knowledge base. Counseling patients about CAM herbal products should include a discussion of efficacy, cost, possible toxicities, drug interactions, bioavailability of active ingredients, and dosage, as well as the acknowledgement that some of this information is not currently available. Patients need to make decisions about CAM use based on personal preferences as much as on scientific evidence.
Research interest in CAM has intensified in recent years, and there is a considerable amount of ongoing research. Much more information should become available in the next few years. CAM research advances are apt to be reported on the following websites: http://nccam.nih.gov (National Center for Complementary and Alternative Medicine); www.cancernet.nci.nih.gov (National Cancer Institute’s CancerNet); www.cancer.org (American Cancer Society); www.quackwatch.com (Quackwatch).Other Advisors
Finally, health-care providers need to acknowledge that they are not the only "experts" providing guidance to patient decision-making. For example, health food store revenues have increased greatly in recent years. We examined the advice given by all Oahu health food stores to individuals seeking guidance about breast cancer care and found that almost all stores (90%) offered suggestions for specific supplements, with shark cartilage the most frequently recommended. We proposed that health food stores are among the sources providing seriously considered information and suggestions about CAM approaches to cancer patients. Bernstein and Grasso’s suggestion that pharmacists need to participate in future CAM educational efforts needs to be broadened to include individuals such as health store personnel.
The appropriate use of CAM remedies requires the involvement of a wide group, including patients, families, physicians, allied health personnel (eg, pharmacists), and others in the community (eg, health food store personnel). Such efforts should be initiated at the local level, appropriate to the specific population and resources. Bernstein and Grasso have taken an initial step for their community, which may serve as a model for health-care organizations elsewhere.