Complementary Therapies in the Health Care System - Essay Example

Complementary Therapy Introduction Worldwide, only 10% to 30% of healthcare is provided by conventional, western, biomedical practitioners. The remainder is delivered either through folk beliefs or alternative traditions. [1]Complementary and alternative medicine (CAM) has become more popular in the United States over the past few decades. With this increasing popularity of CAM, it is important that practitioners become with area of medical practice for all diagnoses. [2]More than one in four U.S. hospitals now offers alternative and complementary therapies, such as acupuncture, homeopathy, and massage therapy. [3] According to the National Center for Complementary and Alternative Medicine (NCCAM), CAM is defined as "a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine". [4] The list of modalities included in this definition continually changes as practices are integrated into Western conventional medicine. They also identify 5 concepts, or domains, of CAM: [2] .Manipulative and body-based systems (chiropractic, osteopathic, and massage) .Mind-body medicine (meditation, prayer, art, music, and dance) .Biological-based systems (herbs, vitamins, and "natural" products) .Energy therapies (biofield, touch, Qigong, and bioelectromagnetic) .Alternative medical systems (homeopathy, naturopathy, traditional Chinese medicine (TCM), and Ayurveda). Complementary medicine suggests treatments in conjunction with Western medicine, for example, aromatherapy can be used to lessen patients discomfort after surgery, and eucalyptus can complement antihistamines for allergic rhinitis. Alternative therapies suggest replacements for western medicine, for example, when a special diet is used for cancer patients instead of chemotherapy, radiation, or surgery. [2] Integrative medicine combines conventional Western medical therapies and CAM, for which there is some high-quality substantiated evidence for safety and efficacy. A very popular form of integrative medicine is seen in immune enhancement products, such as vitamins A, B6, C, zinc, Echinacea, and eucalyptus oil. [2] Herbal and Integrative nutritional Therapies in cancer Cassileth (2001) initially observed that only 8% to 10% of patients with biopsy-diagnosed malignancy use alternative treatments. [6] However, the growth in the nutritional supplement industry indicates that there is a significant rise in the use of complementary/integrative nutritional therapies (CINTs) for disease treatment as well as for prevention in general. [7]CINTs are being sought by 30% to 80%of cancer patients during cancer treatment and for prevention. The most frequent users are those with breast cancer (80% to 85%)[8][9],pediatric cancers(46%)[10],prostatic cancer(27% to 43%)[11][12],and head and neck cancer(25%)[13]. A study reported by Kao and Devine (2000) observed that 37% of prostate cancer patients were using complementary nutritional modalities concurrently with radiation treatment. These ongoing studies indicate that complementary medicine use is much more prevalent among cancer patients than has been previously believed. Although patients, institutions, media, and healthcare professionals have considerable interest in CINTs for cancer treatment and prevention, little is known about the efficacy, safety, and potential interactions of these therapies with conventional treatments.[14] A range of adverse interactions with prescription drugs may occur.[15] Benefits from complementary/integrative therapies Some biologics and micronutrients have been identified as having the potential to prevent induction and inhibit the development of preinvasive and invasive neoplasia and its progression. Increasing evidence from animal research, observational human studies, and a few clinical trials suggests that some nutrients may indeed help prevent certain cancers or assist in cancer therapy The concept of cancer preventing using nutrients is based on evidence from human epidemulogy, clinical trials, and studies of animal carcinogenesis models for cancer-inhibiting potential of these nutrients and non-nutrients derived from foods. Basic research has identified nutrients as agents that are carcinogen-blocking, are antioxidant/anti-inflammatory, and are capable of inhibiting mutagenesis and hyperproliferation, as well as those that induce apoptosis.[16] More than 40 diet-derived agents and agent combinations have been identified and are currently being evaluated clinically as chemopreventive agents for major cancer targets, including breast, prostate, colon, and lung cancers. Some of the most promising nutrients identified as chemopreventive agents include soy isoflavones, green and black tea polyphenols, curcumin, lycopene, indole-3-carbinol, vitamins D and E, selenium, and calcium. [17]Conclusive evidence can be obtained only from well-characterized agents tested in suitable cohorts and using the same rigor used to evaluate pharmaceutical agents and also using reliable intermediate biomarkers of cancer for evaluating their efficacy. [16] Certain types of cancer appear to rely heavily on hormonal influences. These include breast, prostate, endometrial, and overian cancers. Breast, endometrial, and overian cancers are under the control of estrogen, and to a lesser extent, progesterone. Prostate cancer relies on testosterone as a driving force in its growth and development. However not all breast, endometrial, overian, and prostate cancers are under hormonal control. [18] Many herbs and other natural products possess intrinsic hormonal properties, functioning similarly to mammalian hormones and conventional cancer therapies. CINTs with hormonal properties used in patients with cancer: [19] Hormonal Mechanism CINTS Phytoestrogens Ginseng(Asian) Estrogenic, isoflavones Soy Antiestrogenic Saw palmetto(Seronoa replens) Estrogenic Alfalfa(Medicago sativa) Estrogenic Ginseng(American, Siberian, Asian) Estrogenic, phytoestrogens, antiestrogenic Flaxseed(not flaxseed oil) Estrogenic, progestogenic Chasteberry(Vitex agnus-castus) Estrogenic Dong quai Estrogenic, estrogen constituents Hops(humulus lupulus) Estrogenic, estrogen constituents, antiestrogenic Licorice(Glycyrrhiza glabra) Progestogenic Oregano (Oregano spp.) Estrogenic, isoflavones Red clover(Trifolium praatense) ُEstrogenic, androgenic Dehydroepiandrosterone(DHEA) Estrogenic(controversial) Black cohosh(Cimcifuga racemosa) Phytoesrogens in breast, endometrial, and overian cancer Phytoestrogens are diphenol compounds that comprise one of the greatest groups of natural hormonal supplements consumed today. [20] These agents are categorized according to their chemical structures, with isoflavones, lignans, couumestans, and resocryclic acid lactones comprising the four major classes. Isoflavones are the most abundant compounds in commonly consumed foods, with 230 types identified. The most important natural sources of phytoestrogens include soybeans, clover, alfalfa sprouts, and oilseeds (e.g. flaxseeds). Components of these plants vary with geographic location, soil type, year, and environmental conditions of growth. [18] Processing also influences the amount and form of isoflavones in soy products. [18] The estrogen activity of phytoestrogen was first observed in Australian ewes. It was found that some animals suffered reproductive disorders, resulting in permanent infertility after eating red clover. Genistein and daidzein, constituents of red clover, were later identified as agents most likely to have caused this effect in the animals. [18] Many other mechanisms of biological activity have been demonstrated with various phytoestrogens. Genistein, for example, has both proliferative and anti-proliferative effects, depending on the concentrations studied. At low concentrations, genistein stimulates the growth of breast cancer cells; at high concentrations, growth inhibition is observed.[18] A small retrospective study conducted in China to evaluate soy food intake during childhood and adolescence found an inverse association with adult breast cancer risk.[18] Epidemulogic evidence seems to support the notion that increased consumption of phytoestrogens decreases the risk of endometrial cancer.[18] No data regarding the effects of phyto estrogens on ovaries or overian cancer could be found, making it difficult to ascertain the risks associated with phytoestrogen supplementation in overian cancer.[18] Phytoestrogens in prostate cancer Phytoestrogen supplementation is extremely controversial for the treatment of prostate cancer yet may prove to be more beneficial than for patients with breast, endometrial, or overian cancer. Epidemiologic and laboratory evidence seems to support the idea that phytoestrogens are protective against prostate cancer. Asian men have been shown to have a decreased incidence of prostate cancer, which is believed to be a result of a diet high in phytoestrogens. [18] In the other hand Urban and colleagues failed to find any effect on prostate specific antigen (PSA), which is tumor marker, in men with baseline elevations in PSA who were undergoing supplementation with a soy protein beverage. This was a small study and does not eliminate the potential for beneficial effects on the prostate by similar phytoestrogenic compounds. [18] A study using a mouse xenograft model for prostate cancer incorporated increasing concentrations of soy protein into the animals diet to determine the effects on prostate tumor growth. Diets with highest concentrations of phytoestrogens were associated with tumor growth inhibition, while diets containing lower levels of pytoestrogens were associated with reduced tumor growth compared with diets without supplementation. This growth inhibition was associated with apoptotic mechanisms and decreased angigenesis. [18] Complementary therapy in pediatric cancer The use of CAM therapies by children with cancer is common. Up to 84% of children have used complementary therapies along with conventional medical treatment for cancer. [21] Sawyer et al administered questionnaire to parents of 48 Australian children 4 to 16 years of age who were diagnosed with cancer (excluding brain tumors). Parent was asked to describe any dietary supplements or alternative therapies used by children since the time of diagnosis. Parents indicated approximately one half (46%) of the children had used at least one such therapy since diagnosis. The most commonly used therapies included imagery, hypnotherapy, relaxation, diets, and multivitamins. Most parents (56%) viewed the therapies as harmless and thus did not disclose the use of CAM therapies to the childs treating physician. [10] Parents intended purpose in choosing to provide their children with CAM therapies included doing everything that they could for their child to contribute to their health, help with symptom management, improve the immune system, and have a direct anticancer effect including hopes of curing the cancer. Only 3 of 15 studies reviewed, cited dissatisfaction with conventional medicine as one of the main reasons for use of complementary therapies. Nearly all studies reported CAM therapy use in conjunction with medical treatment for cancer.[10] There were exceptions, however, 9 families substituted alternative therapies for conventional treatments, most often when there was poor prognosis.[22] Complementary therapy use needs to be addressed with each family. The importance of accurate estimation of use lies in safety (including toxicities associated with ingested products as well as their interactions with medical regimens used in cancer treatment) and in the interpersonal implications of communication in the patient-health-care provider relationship. In addition to protecting patients from harmful therapies, parents also deserve to be provided with unbiased, evidence-based information on potentially helpful complementary therapies that they may safely incorporate into their childs care. [21] The use of dietary supplements that affect the immune system is also a concern for patients with cancer. Patients with malignancies often use CAM with intention of enhancing the immune system. In a survey of 453 cancer patients with various solid and hematologic malignancies, 83% of the patients had used at least one type of CAM.[23] The majority of CAM users expected the therapy to boost their immune system(71%) and improve their quality of life(76%)[18] Commonly used dietary supplements for immunomodulatory effects, [19, 24, 25] Reported immunomodulatory effect/s Dietary supplement Increases phagocytosis, lymphocyte activity, TNF-a, IL-1, and IFN-beta-2(b) Echinacea(Echinacea purpurea) Monocyte activation, TNF-ainduction(b) North American ginseng(panax quinquefolius) Increases NK cell activity,(b,c) decreases TNF-a,© increases lymphocyte proliferation(b) and total leukocytes(d) Asian Korean ginseng(panax ginseng) Increases lymphocyte proliferation,(b) inhibits TNF-a(b) Milk thistle(silybum marianum) Increases T-cell proliferation,(b), IL-2,(c) TNF-a(b) andIFN-y(c) Garlic (allium sativum) Decreases lymphocyte proliferation and IL-2(b) Ginger(Zingiber officinale) Increases IL-2 and IL-2-induced lymphocytosis, monocyte activation(b) Melatonin(N-acetyl-5-methoxytryptamine) Increases lymphocyte proliferation(b) Dong quai(Angelica sinensis) Increases IgG, IgM, leukocytes, and neutr(d) Coriolus mushroom Coriolus versicolor (a)TNF=tumor necrosis factor; IL = interleukin; IFN = interferon; Nk =natural killer; Ig = immunoglobulin. (b) In vitro data. (c) Animal data. (d) Human data. Supplements with known or theoretical drug interaction Research has revealed substantial interactions between many prescription medications and the consumption of grape-fruit juice. The effects of St. Johns wort on CYP isoenzymes have also been well-defined through observations and detailed research. These interactions are typically reported involving a prescription medication, but supplement-supplement interactions are also possible and much more difficult to identify. [18] Side effects and adverse interactions of some supplements: [16] Echinacea may counteract immune-suppressant drugs. Taken over time may suppress immunity. Dandelion (Taraxacum officinale): Potassium-rich compounds have a diuretic effect that may enhance activity of diuretic medicines. Flaxseed (Linum usitatissimum): High fiber content. Taken concurrently with drugs or food, may bind lipids, nutrients and some drugs, reducing absorption. Licorice (Glycyrrhiza glabra) may impair action of drugsthat cause potassium loss. It may enhance action of corticosteroids. It may counteract effectiveness of drugs used to treat hypertension. Hawthorn (Cratageus oxyacantha, Cratageus monogyna) contains flavinoids that may enhance action of cardiac glycosides and ease their side effects. Oak bark (Quercus Alba, Quercus rubrum) and Raspberry leaves (Rubus idaeus) are rich in tannin which may reduce absorption of cationic minerals, e.g. calcium, and some drugs. Valerian (Valeriana officinalis) may enhance the effects of sedatives and hypnotic drugs. Saw palmetto (Seronoa ripens, Saba seriate): Prostate cancer patients taking saw palmetto might experience false low readings on the PSA test. Clinicians should be informed when patients are taking this herb. Healthcare professionals need to develop a great awareness of the CAM therapies used by their patients during therapy, and they should examine the potential inter actions that these therapies may have with indicated cancer treatments. Practitioners must first identify patients who are vulnerable and then support these patients to make informed, safe, and appropriate choices. To identify patients using unconventional treatments concurrently with conventional ones, they should be specially questioned about their use of complementary therapy. This clinical screening allows evaluation of patient supplement intake against known and potential adverse interactions with the cancer therapy protocol being implemented. It is needed to provide not only the best conventional care, but also the best information and guidance for patients who are using CAM therapies. [16] Physicians attitude towards CAM therapies vary among countries, suggesting that the distinction between alternative and conventional medicine is not always clear-cut and that many therapies previously considered fringe have become more accepted and used. [26] Studies in many Western countries indicate that physician interest in the use of CAM therapies appears substantial, but scientific evidence does not appear to be the basis for their interest.[27] In the United States a survey of primary care physician in the Chrsapeake Bay area found physicians to not only open to using or referring patients for complementary therapies but also interested in receiving training in many complementary therapies.[28] Winslow L, et al, concluded that education about CAM modalities is a significant unmet need among Denver physicians, and education may help alleviate the discomfort physicians have when answering patients questions about CAM. Physicians who use CAM treatments themselves are much more likely to recommend CAM for their patients than physicians who do not. [29] Practitioners of CAM are seeking recognition, more training and high quality education. They need more support from the government to give priorities for research in the field of CAM therapies which is a public demand. Di Stefano V concluded that the increasing professionalism of complementary medicine is now an established reality. It has been strongly driven by the movement of educational programs into university environments, and by government registration of particular modalities. It is also supported by the existing bona fide professional associations representing the interests of complementary medicine practitioners. [30] As of the year 2000, 25 countries reported having a national traditional medicine (TM) policy. Such a policy provides a sound basis for defining the role of TM in national health care delivery, insuring the necessary regulatory and legal mechanisms are created for promoting and maintaining good practice, that is equitable, and that the authenticity safety and efficacy of therapies are assured.[31] Many developed countries (including Australia) are now finding that TM issues concerning safety, and quality, licensing of practitioners and standards of training, and priorities for research, can best be tackled within the framework of a national TM policy. [31] The World Health Organization outlined bases for making CAM therapies an essential part of health care system: 1. Establish registration and licensing of providers 2. Establish national regulation and registration of herbal medicines. 3. Establish safety monitoring of herbal medicines and other CAM therapies. 4. Provide selective support for clinical research into use of CAM for treating countrys common health problems. 5. Develop national standards and technical guidelines and methodology, for evaluating safety, efficacy, and quality of CAM. 6. Develop national pharmacopoeia and monographs of medicinal plants. [31] Government actions regarding CAM therapies - Identify safe and effective CAM therapies and products by developing training guidelines for commonly used CAM therapies. - Support research regarding CAM - Recognize role of CAM providers in providing health care by strengthening and increasing organization of CAM providers. - Optimize and upgrade the skills of CAM providers. - Protect herbal medicine knowledge through recording and preservation. - Cultivate and conserve medicinal plants to ensure their sustainable use. - Make reliable information on proper use of CAM therapies and products available for consumers. - Improve communication between health care providers and their patients concerning use of CAM. Associations Concerning Herbal Medicines * Victorian Herbalists Association * National Herbalists Association of Australia Summary Looking to the literature and findings, many people are using and seeking CAM therapies alongside with conventional medicine for treating and prevention of cancer. Healthcare professionals need to develop more awareness of CAM therapies used by their patients during therapy, and they should examine the potential interactions that these therapies may have with indicated biomedical cancer treatments. Practitioners must first identify patients who are candidate and then support them to make informed, safe, and appropriate choices. Public and governmental efforts should be done to support research concerning CAM therapies, and to support practitioners by helping them to get higher levels of education. Recognition of practitioners and CAM therapy is important for the required development of making them as a part of the healthcare system. The increasing popularity of CAM increases the urgency for research into safety and efficacy of these modalities. References 1.Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States: Prevalence, cost, and patterns of use. N Eng J Med. 1993; 328: 246-252. 2. Solomon HR. Complementary and alternative medicine: Advances on allergy, asthma, and immunology. American College of Allergy, Asthma, and Immunology. 2006 Annual Meeting. http://www.medscape.com/viewarticle/549780 3. Ananth S. "Health Forum 2005 Complementary and Alternative Medicine Survey of Hospitals". American Hospital Association. News release. July 19, 2006. 4. What is complementary and alternative medicine. National Center for Complementary and Alternative Medicine (NCCAM). http://nccam.nih.gov/health/whatiscam/ 5. Blanc PD, Chen H, Katz PP, et al. Complementary and alternative medicine practices among adults with asthma and rhinitis: relation to physical health status in prospective follow up. Chest Meeting Abstracts. 2006; 130: 164S-165S. 6. Cassileth BR. Physicians heal themselves! J Altern Complement Med. 2001; 7: 221. 7. Astin JA. Why patient use alternative medicine: results of a national study. JAMA. 1998; 279: 1548-1553. 8. Newman V, Rock CL, Faerber S, et al. Dietary supplement use by women at risk for breast cancer recurrence. The womens healthy eating and living study group. J Am Diet Assoc. 1998; 98: 285-292. 9. Morris KT, Johnson N, Homer L, et al. A comparison of complementary therapy use between breast cancer patients and patients with other primary tumor sites. Am J Surg. 2000; 179: 407-411. 10. Sawyer MG, Gannoni AF, Toogood IR, et al. The use of alternative therapies by children with cancer. Med J Aust. 1994; 160: 320-322. 11. Lippert MC, McClain R, Boyd JC, et al. Alternative medicine use in patients with localized prostate carcinoma treated with curative intent. Cancer. 1999; 86: 2642-2648. 12. Burstein HJ, Gelber S, Guadagnoli E, et al. Use of alternative medicine by women with early-stage breast cancer. N Engl J Med. 1999; 340: 1733-1739. 13. Warrick PD, Irish JC, Morningstar M, et al. Use of alternative medicine among patients with head and neck cancer. Arch Otolaryngol Head Neck Surg. 1999; 125: 573-579. 14. Kao GD, Devine P. Use of complementary health practices by prostate carcinoma patients undergoing radiation therapy. Cancer. 2000; 88: 615-719. 15. Kessler RC, Davis RB, Foster DF, et al. Long term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med. 2001; 135: 262-268. 16. Nagi BK, Hopkins K, Allen K, et al. Use of complementary/integrative nutritional therapies during cancer treatment: Implications in clinical practice. Cancer Control. 2002; 9(3): 236-243. 17. Kumar B, Besterman-Dahan K. Nutrients in chemoprevention of prostate cancer: current and future prospects. Cancer Control. 1999; 6: 580-586. 18. Michaud LB, Karpiniski JP, Jones KL, et al. Dietary supplements in patients with cancer: risks and key concepts, Part2. Am J Health-Syst Pharm. 2007; 64(5): 467-480. 19. Piscitelli SC, Burstein AH, Welden N, et al. The effect of garlic supplements on the pharmacokinetics of sauinavir. Clin Infect Dis. 2002; 34: 234238. 20. Harpham WS. Alternative therapies for curing cancer: what do patients want? What do patients need? CA Cancer J Clin. 2001; 51: 131-136. 21. Myers C, Stuber ML, Bonamer-Rheigans JI, et al. Complementary therapies and childhood cancer. Cancer Control. 2005; 12(3): 172-180. 22. Bold J, Leis A. Unconventional therapy use among children with cancer in Saskatchewan. J Pediatr Oncol Nurs. 2001; 18: 16-25. 23. Boon H, Stewart M, Kennard MA, et al. Use of complementary/alternative medicine by breast cancer survivors in Onario: Prevalence and perceptions. J Clin Oncol. 2000; 18: 22515-2521. 24. Nestel PJ, Yamashita T, Sasahara T, et al. Soy isoflavones improve systemic arterial compliance but not plasma lipids in menopausal and perimenopausal women. Arterioscler Thromb Vasc Biol. 1997; 17: 3392-3398. 25. Fanti P, Monier-Faugere MC, Geng Z, et al. The phytoestrogen genistein reduces bone loss in short-term ovariectomized rats.Osteoporos Int. 1998; 8: 274-281. 26. Berman BM, Singh B.Primary care physicians and complementary-alternative medicine: Training, attitudes, and practice patterns. J Am Board Fam Pract.1998; 11(4): 272-281. 27. Schachter L, Weingarten MA, Kahan EE. Attitudes of family physicians to nonconventional therapies. A challenge to science as the basis of therapeutics. Arch Fam Med. 1993; 2: 1268-1270. 28. Berman BM, Singh BK, Lao L, et al. Physicians attitudes toward complementary or alternative medicine: a regional survey. J Am Board Fam Pract. 1995; 8: 361-366. 29. Winslow LC, Shapiro H. Physicians want education about complementary and alternative medicine to enhance communication with their patients. Arch Intern Med. 2002: 162: 1176-1181. 30.Di Stefano V. On becoming a profession. J Aust Traditional-Medicine Soc. 2002: 8(3): 103-107. 31. Traditional Medicine-Growing Needs and Potential. World Health Organization Policy perspectives on Medicines. No.2 May 2002. Read More