Use of Complementary/Alternative Medical Therapies by Oncology Patients in India

R Kaul, P Shukla, BK Mohanti

Introduction

It has been assumed that approximately 70% of cancer patients in India use complementary or alternative medicine (CAM), with or without conventional medical therapy, at least once during the course of their disease. A summary of 26 surveys conducted across 13 countries estimated the prevalence of the use of CAM at approximately 31.4% (range, 7.0 to 64.0%).¹ A trial reported that 28.1% of patients with breast cancer (n = 480) initiated the use of CAM within 12 months of conventional treatment, although its use was associated with greater psychosocial distress.² In 1991, the Office of Alternative Medicine at the National Institutes of Health (USA) funded 30 pilot studies among support groups at various centres to design a trial to assess the impact of CAM compared with that of imagery/relaxation on immune function and quality of life. The University of Texas Center for Alternative Medicine (UT-CAM) was established in 1995. The primary aim of the centre was to evaluate the efficacy and biopharmacological action of herbal therapies in cancer treatment and prevention. Establishment of a network for CAM practitioners and researchers to improve CAM skills and knowledge worldwide was one of the main objectives of the centre.

The aim of our study was to measure the prevalence of CAM therapy among patients with cancer who were attending the radiotherapy outpatients department and other cancer clinics at the Institute of Rotary Cancer Hospital, All India Institute of Medical Sciences in New Delhi, India.

Materials and Methods

This prospective trial enrolled 450 patients attending the radiotherapy outpatients department and other cancer clinics from January 2000 to May 2000 to assess the prevalence of use of CAM by patients with cancer. The eligibility criteria included:

• diagnosis of cancer
• younger than 85 years
• cooperative patient
• family available for verbal interview

The methods used for evaluation of the use of CAM included a questionnaire of current therapy and use of CAM, styled for the Indian populace and a verbal interview with the patients and their families.

Results

With the help of an interview with the patients and their families and a questionnaire modified to take into account illiteracy among the population, it was found that 270 of 450 patients (60%) had selected various alternative therapies during or at the end of treatment schedules. The 270 patients using CAM had a variety of cancers at presentation (table 1). The patients were prescribed CAM by a variety of practitioners, some of whom were educated and some with no medical knowledge (table 2). The largest group prescribing CAM in India constitutes the quacks, who carry self-acquired knowledge of medical skills. 50% of the patients had no knowledge of the use, efficacy, or side effects of CAM. They had some knowledge from people in their neighbourhood or advertisements, but had no reliable source of information, except for those who attended ayurvedic or homeopathic clinics. At the hospital, patients were offered treatment according to departmental protocols depending on the tumour stage, histology, performance status, and general condition (table 3).

Table 1. Cancer diagnosis at presentation in patients who adopted complementary or alternative medicine.

Diagnosis Number of patients     Breast 33     Cervix 60     Head and neck 70     Lung 28     Bone 15     Soft tissue sarcoma 12     Brain 14     Lymphoma 6     Colon 5     Anus 4     Rectum 2     Uterus 4     Stomach 2     Gall bladder 3     Liver metastases 4     Neck metastases, unknown primary 8     Total 270

Table 2. Complementary or alternative medicine prescribers.

Number of patients (%)   Prescriber   Quacks 71   (26.3)   Homeopathic practitioners 50   (18.5)   Ayurvedic doctors 50   (18.5)   Registered medical professionals (non-allopathic) 30   (11.1)   Sadhu/Muni (Ascetic) 27   (10.0)   Non-professional worker 12   (4.4)   Health worker in periphery 20   (7.4)   Babas in mosques/temples 10   (3.7)

Table 3. Prescribed treatment in hospital.

Number of patients (%)   Treatment   Radiotherapy 70   (25.9)   Curative 55     Palliative 15     Chemotherapy 40   (14.8)   Curative 30     Palliative 10     Combined radiotherapy and chemotherapy 140   (51.8)   Symptomatic therapy only (prognosis explained) 20   (7.4)

Table 4. Types of alternative or complementary therapy used in the study.

Number of patients   Therapy   Herbal therapy 20       Biological therapy 10       Ginseng 8       Ayurvedic drugs 110       Homeopathic drugs 60       Aromatherapy/naturopathy 18       Gem therapy 8       Colour therapy 5       Hydrotherapy 5       Yoga/Reiki 26

Table 5. Subjective feelings of patients after complementary or alternative therapy.

Number of patients   Patients' feelings   Prolonged life 60       Improved strength 35       Improved quality of life 40       Improved immunity 15       Alleviated cytotoxicity of conventional therapy 20       Spiritual effect 35       Natural cure 5       Superstitious myth 60

The CAM therapies used by the patients are listed in table 4. Seventy patients stopped conventional medical therapy and chose to use only CAM. Within 2 months of therapy, 75% of these patients experienced recurrence or progression of disease, resulting in general ill health. Only 25% of patients experienced an improvement in general well being and body image, and had stable disease. However, all of the 200 patients who completed conventional medical therapy and used CAM either with the conventional therapy or afterwards had the benefit of mutual synergism of both modalities. These patients nurtured a hope for life and had better survival rates. The beliefs that led to patients choosing CAM were that this mode of therapy increases immunity, prolongs life, and cures cancer (table 5). It is clear that CAM alone does not help cancer patients to overcome this disease, especially when therapies are provided by unprofessional workers. Due to the lack of knowledge regarding the drugs given, in terms of efficacy and toxicity, patients¹ conditions often deteriorate to the extent whereby medical science can offer only palliative care. As a comparison, patients who continued with both treatment modalities experienced the benefits due to the synergism of both methods of therapy.

However, the exact mechanism of action is not known. In India, there have been no standardised treatment protocols or trials in favour of CAM therapy, although it is considered that ayurvedic and homeopathic medicine helps patients to some extent. All CAM needs methodical research, prospective trials, and proper categorisation before they can be advocated in daily clinical practice.

Discussion

The first research work on CAM was initiated at the University of Texas MD Anderson Cancer Center (MDACC) and the School of Public Health in the USA. One of the first pilot studies conducted by the MDACC evaluated CAM approaches and assessed the impact of support groups versus imagery/relaxation practices on immune function, quality of life, and coping with treatment. Subsequently, the UT-CAM was established in 1995. The main aim of this centre was to evaluate the efficacy of biopharmacological and herbal therapies for cancer treatment, establish a CAM network for collaborative research, and improve self-assessment skills of CAM researchers. The first task of UT-CAM was to assess the state of the science and establish a research agenda. UT-CAM used multiple sources to identify agents, books, and consultations in the field.³ Subsequently, more than 30 therapies were identified for review and categorised as herbal, biological, pharmacological, or integrated regimens. This systematic review entailed an exhaustive search of libraries, databases, MEDLINE, Cancerlit, and Embase. The review yielded 6000 references of which 58.8% were related to cancer alone.

A survey conducted in 8 clinics at the MDACC assessed the use of CAM.⁴ Eighty three percent of 400 patients used CAM, of whom 62% used herbal tonics and vitamins. Overall, 64.5% did not discuss CAM with providers because they were uncertain of the benefit (54.0%) or because the physician did not ask (47.6%). The popular herbal tonic, Flora essence, was used extensively by cancer patients. The patients were asked about their agenda for seeking CAM. Surprisingly the beliefs were often overlapping, 53.2% reported that the tonic offered hope, 75.8% expected it to increase immune function, 59.2% believed it prolonged life, and 48.9% believed it cured cancer.

Herbal green tea extract, mainly mistletoe lectin III polyphenol, developed by liquid chromatography at the UT-CAM, primarily affects CD8 cells. The extract reduces the frequency of telomeric association and c-anaphases and reduces Bcl2 and p53 proteins.⁵ Water-soluble extract of oleander has a similar mode of action to polyphenol. Ginseng saponin is also used extensively throughout the world. Korean red ginseng saponins modulate carcinogenic metabolism and have an impact on precancerous lesions in rat colon. Compared with other herbal or biological agents, only ginseng significantly reduced aberrant crypt foci by 25% in the low dose group (0.1 gm/kg) but not in the high dose group (1 g/kg) [p < 0.05].⁶

Emodin, ellagic acid, resveratrol, and genistein purified from plants have optimum chemopreventive activity. In vitro studies of dolastatin 10 isolated from the molecule dolabella auricularia helps to prevent telomeric association, induction of polypoidy, and cell death. This molecule has a potent antineoplastic activity.⁷ Similarly, extracts from sea cucumber, phylum echinodermata, class holothurioidea, Q10 ubiquinone, melatonin, mistletoe, and shark cartilage are widely used by patients throughout the world, having an impact on analgesic consumption, weight loss, and tumour progression. However, no data on these agents are available.⁸ Preclinical pharmacokinetic testing and developmental phase I and II studies are necessary before starting clinical trials. Research should continue towards increasing knowledge of the importance of CAM for cancer therapy. Until then, patients hoping for survival will continue to believe in these therapies although there is currently no evidence base for these practices.

Conclusion

Regardless of their level of acceptance by conventional medicine, these therapies have infiltrated every aspect of health care. For many CAM therapies, data on characterisation of the product, standard protocols, reproducibility, safety, and basic pharmacology are lacking. We believe that CAM may help patients but more systematic research is needed to elucidate their methodology and acceptance. As indicated by the research activities of UT-CAM, preclinical, pharmacokinetic testing, and developmental phase I and II studies are necessary before these therapies can be integrated into clinical practice.

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