In most industrialized countries, cancer ranks as the foremost cause of mortality in adults, and since 1982 Taiwan has been no exception (1). Cancer is a malignant growth that has failed normal regulation by the body, and modern medicine still has many limitations in trying to combat and eradicate the problem. With a recorded history dating back more than 5000 years, there has been a wealth of documented therapeutic medicinal resources available to the Chinese patient (2) and once a diagnosis as overwhelming as cancer is pronounced, patients willingly explore all therapeutic modalities available. Age-old Chinese medicine is now in a renaissance, or has been rediscovered to fill part of the void, yet mostly in an unscientific and unregulated mode.
Ancient Chinese medicine does not accurately define the entity of a malignant neoplasm. Instead, accumulated medical knowledge stems from observation of a set of phenomena, and then through `logical' deduction and trial and error, therapeutic solutions emerge, and selected remedies may subsequently become documented and ubiquitously used. In Taiwan, prospective candidates can be board certified as Chinese Medical Practitioners and practice medicine. Unfortunately there is still infrequent pathologic (histologic) diagnosis, and objective criteria for evaluation of treatment response and an absence of toxicity documentation. The public is often led to believe that traditional medicine is more gentle than conventional western medicines, so that toxicity is milder or even absent (2).
The Committee on Unproven Methods of Cancer Treatment of the American Cancer Society is concerned with methods of both diagnosis and therapy which are promoted for general use in any form of cancer related management. On the basis of careful review by scientists and/or clinicians, these are deemed notproven or recommended for current use (3). In this study, `alternative medicines' refers to medication other than the conventional western medicines prescribed in hospital by a qualified western medical practitioner; however, emphasis and distinction must be made between traditional Chinese medicine which has been employed by traditional Chinese practitioners for many years with proven efficacy, and `medication' of uncertain composition and uncertain efficacy.
In Taiwan, the public is constantly bombarded by anecdotal reports of `cancer cure' in the media, or `miracle remedies' which have passed down as family heirlooms. A remedy advocated by a person with a PhD or a pseudo-intellectual is most persuasive, and family and friends often cloud logic and science with pure good intention in channeling the patient into alternative medical therapy. It is also very important to realize that traditional Chinese medicines emphasize the incorporation of many herbal elements in the prescription. These are supposed to enhance a patient's defences and build up the body's immunity and inner strength, without direct tumoricidal effects (2), a line of logic that is very persuasive to a cancer patient who has undergone conventional chemotherapy/radiation therapy/surgery, and experienced its side effects and toxicities.
The aim of this study was to try and offer a more lucid picture of the current status of alternative medication use in cancer patients whilst undergoing conventional treatment in Taiwan, analyze the background fabric for undertaking such treatment and compare the trends in other societies.
Between January and August 1995, a cross sectional study of 100 consecutive cancer patients attending a cancer clinical trial referral unit was conducted. All patients had extensive and advanced disease. All patients undergoing treatment at the center have to sign informed consent for treatment administered, and that is preceded by a detailed explanation of the patient's disease, treatment course, and prognosis. However, this is no guarantee that the patient fully understands the full implications of his/her disease. Consecutive patients were approached for the interview; there were no refusals, and after verbal informed consent, the patients were personally interviewed by their own oncology research nurses, who had been assigned to take care of them for at least one month. The interview required approximatedly one hour to complete. The patients had been explicitly informed that this information would be kept confidential and anonymous, and would in no way jeopardize their treatment at the cancer center. Patients were interviewed a minimum of one month post diagnosis, and had undergone chemotherapy or radiotherapy at least once in their disease course.
The questionnaire consisted of three main parts. The first was basic demographic data, including age, diagnosis, performance status, ethnic background, religious affiliation, and educational level. The second concerned the use of traditional medication: whether there had been any use of such treatment and, if so, the type, duration, cost, source of information and source of medicinal treatment. The third part attempted to analyze the psychology, motivation and reasons for attempting such therapy, their understanding of the logic behind such treatment, and whether there had been any subjective benefit, subjective quality of life gain, and very importantly, the reasons for discontinuation of treatment. Objective tumor response measurements and toxicities incurred from conventional therapy were still attributed to and evaluated for conventional therapy. Data were analyzed by [chi]2 or Student's t test. A P value of <0.05 was considered statistically significant.
Table 1
Usage of traditional medication can be seen in relationship to demographic data in Table 1. Overall, 64% of our cancer center patients admitted to using alternative chinese medications at some time after the diagnosis of cancer. Diagnoses of our patients included gastric, lung, breast and colon cancers, hepatoma, lymphoma, melanoma, gynecologic cancers etc. In seeking out alternative treatment, it would seem that only the >70 years age group were significantly less zealous (P = 0.043); women tended to be slightly more enthusiastic (P = 0.323). After finding out that conventional therapy often plays only a palliative role in advanced cancer, individuals of all educational levels often elected to adopt a `take charge, do it yourself' attitude. Religion was no deterrent for seeking out alternative treatment. Sixty-six per cent of patients actually undertook alternative treatment concurrently with the infusion of chemotherapeutic agents, often encouraged by the person (frequently a lay person) who supplied them with the drug informing them that the prescription was supposed to potentiate efficacy or ameliorate toxicity of conventional therapy. It was surprising that only 10% of patients obtained their prescription after consultation with a qualified Chinese medical practitioner, relegating 90% of alternative medications consumed to the ranks of uncertain and questionable therapy. Only 30% of the prescriptions were obtained from a licensed vendor of chinese herbs (see Table 2).
Table 2Details of usage of alternative medicines in 64 patients
In spite of their decision to receive alternative treatment, no patient was able to give a scientific rationale or expectation for alternative medication taken. Most gained information of such treatment by word of mouth (79%), reflecting a very limited source of information, a situation also obvious in other societies (4). Fifty per cent of the treatment was obtained through direct marketing. Most agreed to attempt it feeling that it was better than nothing; some were encouraged to think that it would potentiate conventional treatment without increasing toxicity, some felt that it might palliate symptoms of cancer without curing it, and others felt it might build up their inner strength which had been severely ravaged by cancer and harmful conventional treatment.
At best, our patients were only able to describe the physical form of treatment that they had received, e.g. little black pills, herbs, liquid concoctions (including China number one) etc. In just over 50% of patients, treatment was endured for less than three months, but 25% of patients took it for 12 months or longer. Most patients (65%) felt that they experienced no obvious subjective benefit from alternate medication (see Table 3), but that may have been related to their level of expectation, and this was the most common reason for stopping treatment. No patient reported on any side effects from such treatment, and attributed all side effects to conventional treatment. Seventy per cent of patients spent US$40-2000/month for alternative medicines, 17% received their treatment as a gift, and just under 5% spent >US$2000/month.
Table 3Reasons and subjective response to alternative medicine use in 64 Chinese cancer patients
In an antiestablishment and anti-intellectual climate, compounded by the fear of cancer and death, and anger directed at the current standard medical establishment for its inefficiency in curing cancer, the intellectual (yet non expert) often attempts to resolve the `cancer dilemma'. Ancient chinese medicine has been repackaged in modern scientific jargon, formulations often renamed `scientifically formulated chinese herbs', advocated to generally `strengthen immunity' and `ameliorate toxicity', making it more appealing and acceptable to modern man, and ultimately offer infinite hope and the promise of a potential miracle behind a veil of immense uncertainty.
In the USA, 13% of patients from one cancer center admitted in personal interviews to using alternative therapy (5), and a nation-wide survey identified 9% of cancer patients as using alternative treatments (4); the six most common alternative therapies, in descending order of frequencies are metabolic therapy, diet treatments, megavitamins, mental imagery, spiritual/faith healing, and immune therapy, the rationale being to correct all previous unhealthy living habits, optimally adjust nutrition, improve mental attitude, and entrust one's fate to a higher power (5). In the United Kingdom, a postal screening questionnaire of cancer patients identified 16% as having tried alternative therapy (6), the most popular alternative treatment modalities in order being: healing, relaxation, visualization, diet, homeopathy, vitamins, and herbalism (6,7). Most patients use these alternative therapies in the hope of adjusting body homeostasis to better combat cancer, hoping for improvement rather than cure (6).
In Taiwan, the expectation for improvement or cure is probably much higher. This is partly attributable to the overwhelming aura of religious, mythological and quasi-truthful cures of illnesses documented over 5000 years of recorded history. The variety of medicinal choices is wide, so that patients would tend to spend less time on adjusting body homeostasis, preferring a `solid formulation' that has the potential of decimating the cancer cells or building up the body. The trend is thus towards taking herbs /pills /chemicals /tonics parenterally, and there is a lesser tendency to participate in religious healing or homeostasis-adjusting treatment protocols. The focus in this study is thus on alternative medications rather than alternative therapies in general.
Analyzing data from affluent/industrialized countries, it would seem that patients belonging to economically productive age groups, the affluent and better educated persons have a greater tendency to choose alternative therapy as an adjunct to conventional therapy, hoping with superior intelligence and luck to improve upon currently established standard treatment. This is in contrast to very limited data from developing countries, where it would be the less sophisticated and more economically compromised patient who would opt for alternative treatment (8,9,10). Alternative therapy is not cheap; in the USA, the amount spent on alternative treatment is estimated to reach billions of US dollars/year (1,12,13). The logic advocated for alternative therapy to work is often simplistic and easy for the medically unsophisticated person to understand and imbibe as `truth'. Patients and family become very gullible once cancer has been diagnosed, and fall easy prey to proponents of alternative treatments who are willling to compassionately spend time with the patient (13). It is alarming that, when considering alternative chinese medications, patients seldom consult professional board-certified chinese medical practitioners; instead, they frequently relinquish their fate and welfare to the goodwill or mischief of family and friends.
At the first consultation after a diagnosis of cancer is made, patients should be clearly informed of their disease, treatment options, and prognosis, and be invited to discuss alternative treatment they are considering and to document alternative treatments taken. This documentation should form part of the hospital records. Patients should be urged to broaden their information base by obtaining information from more reputable organizations (government or private), be logically dissuaded from unnecessary alternative medications, and be encouraged to receive known and effective recognized therapy without delay.
Analyzing the motivation behind receiving alternative therapy, future education should be directed at a few key points. At first attendance in a doctor's clinic, patients should be encouraged not to delay known and effective conventional treatment for alternative treatment of unproven integrity, encouraged to inform medical staff of any alternative treatment they are undertaking, and at least be dissuaded from taking any other drugs/pills/herbs/concoctions during conventional treatment courses to avoid potential pharmacokinetic interactions. Medical staff should remain open minded, and be wary in documenting any unusual toxicity or excessively severe known toxicity in patients undergoing conventional chemotherapy and admitting to taking other treatment. Randomized phase III trials incorporating alternative treatment options will be the only way to determine whether that treatment is of any benefit to the patient. For example, in the phase III randomized trial incorporating hydrazine sulfate (14-17) in colorectal and non-small cell lung cancer patients, hydrazine not only failed the efficacy test but also resulted in more toxicity, with adverse influences on quality of life and survival. A randomized study (18) found no difference in survival between two matched groups of cancer patients with extensive disease, one group receiving only conventional therapy, the other receiving alternative therapy in addition. Moreover, the conventionally treated group scored better on quality of life assessments. However, the commitment posed by randomized trials in terms of cost, time and personnel (doctor, nurse and patient) involvement is so great that they cannot be easily undertaken. The use of alternative treatment modalities by patients will remain a ubiquitous global problem and possible complicating factor in the treatment of cancer patients, and one which all involved physicians should be aware of.
In conclusion, chinese cancer patients willingly, randomly, and non-selectively undertake alternative medications, with very little or no understanding of the type of medication they have received, its possible effects, side effects or projected treatment duration; and yet considerable financial expense and uncertain pharmacological consequences can be incurred.
Japanese Journal of Clinical Oncology
Pages
Introduction
Subjects and Methods
Results
Discussion
References
Parameters
No. on alternative
treatment/total (%)P value
Sex
0.323
Male
38/66
(57.6)
Female
26/34
(76.0)
Age (in yrs)
0.043
<30
2/3
(66.7)
31-40
9/12
(75.0)
41-50
14/16
(87.5)
51-60
13/18
(72.2)
61-70
20/35
(57.1)
>71
6/16
(37.6)
Religious affiliation
0.08
None
23/40
(55.8)
Buddhist
37/51
(57.5)
Christian
4/9
(44.4)
Educational level
0.062
<= Primary school
20/36
(55.6)
Junior high
12/16
(75)
High school
12/33
(36.4)
>= College/university
9/15
(60)
Alternative medicines
Number of patients
(%)
Timing in relationship to chemotherapy
Pre chemotherapy only
15
(23.4)
Overlapping chemotherapy
43
(67.2)
Post chemotherapy only
6
(9.4)
Traditional medications in use
Pills (small black pills) + powdered prescription
5
(7.8)
Ling Chi +/- herbs
39
(60.9)
Pharmaceutical concoctions (bottled in vials)
4
(6.3)
Combinations of the above
16
(25.0)
Duration of use
<3 months
32
(50.0)
3-6months
10
(15.6)
7-12 months
6
(9.4)
>12 months
16
(25.0)
Cost per month
<US$40
4
(6.3)
US$40-200
20
(31.2)
US$201-400
11
(17.2)
US$401-2000
15
(23.4)
>US$2001
3
(4.7)
Cost unknown/gift
11
(17.2)
Source of Information
Physician
0
(0)
Family/friends/other patients
48
(75.0)
Media
2
(3.2)
Chinese med. practioner
7
(10.9)
Others
1
(1.5)
More than one source
6
(9.4)
Source of Medication
Chinese medical clinic (with licensed practitioner)
20
(31.2)
Herb shop
10
(15.6)
Direct marketing/gift
30
(46.9)
More than one source
4
(6.3)
No. of patients
(%)
Subjective evaluation
Subjective improvement
22
(34.4)
No change
42
(65.6)
Motivation for usage
Treat cancer
9
(14.1)
Palliate symptoms
4
(6.3)
Increase strength
7
(10.9)
`Try it for the heck of it'
32
(50.0)
Mixed reasons
12
(18.7)
Reasons for discontinuation
Continued usage
20
(31.2)
Ineffective/useless
18
(28.1)
Discontinuation pre C/T
7
(10.9)
Progressive disease
6
(9.4)
Side effects from treatment
3
(4.7)
Exorbitant cost
4
(6.3)
Others
6
(9.4)
References
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Copyright© Japanese Journal of Clinical Oncology, 1997.
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