Traditional, complementary, and alternative medicine in cancer care: Challenges and opportunities

Abstract

Cancer treatment and care remain challenging in countries with limited resources, often leading to delays in accessing essential medical services [1Ginsburg O. Bray F. Coleman M.P. et al.The global burden of women’s cancers: a grand challenge in global health.The Lancet. 2017; 389: 847-860Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar]. In such circumstances, many patients and their families turn to Traditional, Complementary, and Alternative Medicine (TCAM), either as a standalone approach or in conjunction with standard treatments. Their hope is to enhance disease outcomes and mitigate the complications associated with medical interventions [2Zaid H, Silbermann M, Amash A, Gincel D, Abdel-Sattar E, Sarikahya NB. Medicinal plants and natural active compounds for cancer chemoprevention/chemotherapy. Hindawi; 2017.Google Scholar]. The World Health Organization (WHO) defines TCAM as a reservoir of knowledge, skills, and practices rooted in the theories, beliefs, and traditional experiences of diverse cultures. These practices are employed for the purpose of preserving health, preventing, diagnosing, ameliorating, or treating physical and mental illnesses [3World Health Organization. WHO traditional medicine strategy 2014–2023. 2013. Geneva: World Health Organization. 2015;Google Scholar]. Over the last few decades, there has been a notable surge in the utilization of TCAM among cancer patients. The prevalence of TCAM usage in cancer survivors exhibits significant variability, ranging from 16.5% in Italy to a staggering 93.4% in China [4Kasprzycka K. Kurzawa M. Kucharz M. et al.Complementary and Alternative Medicine Use in Hospitalized Cancer Patients—Study from Silesia, Poland.International Journal of Environmental Research and Public Health. 2022; 19: 1600Crossref PubMed Scopus (6) Google Scholar,5Keene M.R. Heslop I.M. Sabesan S.S. Glass B.D. Complementary and alternative medicine use in cancer: A systematic review.Complementary therapies in clinical practice. 2019; 35: 33-47Crossref PubMed Scopus (0) Google Scholar]. The prevalence of TCAM can be attributed to several factors: the multitude of unmet patient needs [6Wang T. Molassiotis A. Chung B.P.M. Tan J.Y. Unmet care needs of advanced cancer patients and their informal caregivers: a systematic review.BMC Palliat Care. Jul 23 2018; 17: 96https://doi.org/10.1186/s12904-018-0346-9Crossref PubMed Scopus (312) Google Scholar], rising costs of conventional treatments, their ineffectiveness, and associated complications, as well as the public's perception that traditional and natural remedies are safer and more cost-effective [7Farahani A.S. Salmani N. Khoshnazar T.A.S.K. et al.The perspective of cancer patients on the use of complementary medicine.International Journal of Cancer Management. 2019; 12Google Scholar]. Despite the numerous advantages, many of these treatments carry the potential for serious side effects, drug interactions, and are associated with various challenges. The decision to incorporate TCAM into cancer care is a complex one, influenced by various factors, including attitudes and beliefs [8Bauml J.M. Chokshi S. Schapira M.M. et al.Do attitudes and beliefs regarding complementary and alternative medicine impact its use among patients with cancer? A cross-sectional survey.Cancer. Jul 15 2015; 121: 2431-2438https://doi.org/10.1002/cncr.29173Crossref PubMed Scopus (62) Google Scholar], gender [9Chao M.T. Wade C.M. Socioeconomic factors and women's use of complementary and alternative medicine in four racial/ethnic groups.Ethnicity & disease. Winter. 2008; 18: 65-71PubMed Google Scholar], disease status [10Pirri C. Integrating complementary and conventional medicine. 2011:31-39.Google Scholar], social and economic status [9Chao M.T. Wade C.M. Socioeconomic factors and women's use of complementary and alternative medicine in four racial/ethnic groups.Ethnicity & disease. Winter. 2008; 18: 65-71PubMed Google Scholar], and cultural contexts [11Rassouli M, Farahan AS, Mojen LK, Ashrafizadeh H. The Impact of Culture and Beliefs on Cancer Care. Global Perspectives in Cancer Care: Religion, Spirituality, and Cultural Diversity in Health and Healing. 2022;215Google Scholar]. The proliferation of unverified anecdotes and false claims associated with TCAM can easily lead vulnerable individuals to make ill-advised decisions and potentially result in drug interactions [12Jones E. Nissen L. McCarthy A. Steadman K. Windsor C. Exploring the Use of Complementary and Alternative Medicine in Cancer Patients.Integrative Cancer Therapies. 2019; 18 (2019/01/01)1534735419846986https://doi.org/10.1177/1534735419846986Crossref Scopus (35) Google Scholar]. Approximately half of cancer patients combine TCAM with conventional cancer treatments without informing their healthcare providers, which constitutes one of the most significant challenges in this field [13Berretta M. Montella L. Integrative medicine in the cancer setting: a new challenge for physicians and patients.WCRJ. 2022; 9e2405Google Scholar]. Evidence indicates that concurrent use of TCAM and anticancer medications may lead to severe side effects and a reduced quality of life in cancer patients [14Block K.I. Significance of natural product interactions in oncology.Integrative Cancer Therapies. 2013; 12: 4-6Crossref PubMed Scopus (3) Google Scholar]. Despite the common belief that herbs, being natural products, are inherently devoid of side effects and safe [15World Health Organization. National policy on traditional medicine and regulation of herbal medicines: Report of a WHO global survey. World Health Organization; 2005.Google Scholar], TCAM is not universally free from risks, and its purported advantages such as cost-effectiveness, increased life expectancy, and enhanced quality of life have yet to be conclusively substantiated [16Hoppe C. Buntzel J. VON WEIKERSTHAL L.F. et al.Usage of complementary and alternative methods, lifestyle, and psychological variables in cancer care.in vivo. 2023; 37: 106-114Crossref PubMed Scopus (2) Google Scholar]. Numerous studies have identified side effects associated with TCAM, either independently or when used in conjunction with allopathic medicines. Some of the most prevalent side effects include gastrointestinal issues (such as nausea, vomiting, diarrhea, and abdominal pain), followed by symptoms like dizziness, headaches, and fatigue [17Duru C.B. Uwakwe K.A. Chinomnso N.C. et al.Socio-demographic determinants of herbal medicine use in pregnancy among Nigerian women attending clinics in a tertiary Hospital in Imo State, south-east, Nigeria.Am J Med Stud. 2016; 4: 1-10Google Scholar,18Laelago T. Yohannes T. Lemango F. Prevalence of herbal medicine use and associated factors among pregnant women attending antenatal care at public health facilities in Hossana Town, Southern Ethiopia: facility based cross sectional study.Archives of Public Health. 2016; 74: 1-8Crossref PubMed Google Scholar]. An additional hurdle in the utilization of TCAM is the limited availability of services, often restricted to a handful of centers and innovative delivery methods. Consequently, if patients question the quality of services, they may find it challenging to seek alternative treatments elsewhere. As TCAM gains popularity among cancer patients, certain countries have witnessed the introduction of evidence-based TCAM counseling and treatments, including herbal remedies, in many leading cancer centers [19Ben-Arye E. Samuels N. Goldstein L.H. et al.Potential risks associated with traditional herbal medicine use in cancer care: A study of Middle Eastern oncology health care professionals.Cancer. 2016; 122: 598-610https://doi.org/10.1002/cncr.29796Crossref PubMed Scopus (84) Google Scholar]. Nonetheless, only a few of these centers have fully integrated these services into their conventional oncology settings as part of standard care [20Almog L. Lev E. Schiff E. Linn S. Ben-Arye E. Bridging cross-cultural gaps: monitoring herbal use during chemotherapy in patients referred to integrative medicine consultation in Israel.Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. Oct 2014; 22: 2793-2804https://doi.org/10.1007/s00520-014-2261-9Crossref PubMed Scopus (8) Google Scholar]. Non-disclosure of TCAM usage represents another challenge, often stemming from a communication gap between physicians and patients. Patients' beliefs and narratives are frequently dismissed as superstitions, and during routine medical interviews, physicians seldom inquire about TCAM usage [21Pingoy D. CAM Use at the Cancer Institute.Philippine J Intern Med. 2004; 42: 159-171Google Scholar]. Many patients opt to keep their TCAM usage concealed due to apprehension of judgment or disapproval from their healthcare providers [22Galvez-Tan JZ. Health in the hands of the people. Book of Readings on Primary Health Care. 2013:1.Google Scholar]. As referral systems have not been universally established in various countries, cancer patients may feel abandoned and, in many instances, perceive TCAM as a safer, more accessible, and cost-effective choice, leading them to choose this alternative [23Johnson S.B. Park H.S. Gross C.P. James B.Y. Complementary medicine, refusal of conventional cancer therapy, and survival among patients with curable cancers.JAMA oncology. 2018; 4: 1375-1381Crossref PubMed Scopus (0) Google Scholar]. Other factors contributing to non-disclosure include the fear of blame and stigmatization by caregivers, caregivers failing to inquire about TCAM use from the patients [24Hill J. Mills C. Li Q. Smith J.S. Prevalence of traditional, complementary, and alternative medicine use by cancer patients in low income and lower-middle income countries.Global public health. 2019; 14: 418-430Crossref PubMed Scopus (25) Google Scholar], a lack of structured TCAM training within healthcare systems of different countries [25Mwaka A.D. Tusabe G. Garimoi C.O. Vohra S. Ibingira C. Integration of traditional and complementary medicine into medical school curricula: a survey among medical students in Makerere University, Uganda.BMJ open. 2019; 9e030316Crossref PubMed Scopus (4) Google Scholar], healthcare specialists' limited understanding of TCAM mechanisms and herb-drug interactions, and a dearth of expertise and comprehensive knowledge of medicinal plants among many oncology care providers [26Trimborn A. Senf B. Muenstedt K. et al.Attitude of employees of a university clinic to complementary and alternative medicine in oncology.Annals of oncology : official journal of the European Society for Medical Oncology. Oct 2013; 24: 2641-2645https://doi.org/10.1093/annonc/mdt299Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar]. Consequently, numerous patients seek advice from family members, friends, or non-traditional healthcare practitioners [27Ucan O. Pehlivan S. Ovayolu N. Sevinc A. Camci C. The use of complementary therapies in cancer patients: a questionnaire-based descriptive survey from southeastern Turkey.American journal of clinical oncology. Dec 2008; 31: 589-594https://doi.org/10.1097/COC.0b013e31817700ccCrossref PubMed Scopus (20) Google Scholar]. Engaging in discussions with patients regarding TCAM usage can assist them in making informed decisions and minimizing potential side effects when using these therapies concurrently with conventional cancer medications [28Mwaka AD, Abbo C, Kinengyere AA. Traditional and complementary medicine use among adult cancer patients undergoing conventional treatment in Sub-Saharan Africa: a scoping review on the use, safety and risks. Cancer management and research. 2020:3699-3712.Google Scholar]. Physicians should therefore be well-informed about TCAM-induced side effects or interactions, recognize the associated risks, and advise patients against indiscriminate TCAM usage. Furthermore, patients should be encouraged to disclose their TCAM usage to their healthcare providers [29Werneke U. Earl J. Seydel C. Horn O. Crichton P. Fannon D. Potential health risks of complementary alternative medicines in cancer patients.British journal of cancer. Jan 26 2004; 90: 408-413https://doi.org/10.1038/sj.bjc.6601560Crossref PubMed Scopus (192) Google Scholar]. A significant challenge within TCAM is the absence of treatment protocols, standardization, and policy guidelines. Some TCAM methods concentrate on physical aspects of care, while others emphasize spiritual and mental aspects [30Ikram R.R.R. Abd Ghani M.K. Abdullah N. An analysis of application of health informatics in Traditional Medicine: A review of four Traditional Medicine Systems.International journal of medical informatics. 2015; 84: 988-996Crossref PubMed Google Scholar]. Despite TCAM's implementation in over 100 countries worldwide, as per the WHO Traditional Medicine Strategy 2014–2023 [31World Health Organization. WHO traditional medicine strategy: 2014-2023. World Health Organization; 2013.Google Scholar], the lack of treatment standards has hindered its progress and had a detrimental impact [32Lai T-Y, Tseng Y-T, Lee C-N. Physician and Consumer Acceptance of the Traditional Chinese Medicine Clinical Practice Support Sustem (TCMCPSS). 2014:321-327.Google Scholar]. Additionally, contradictory findings and potential herbal-drug interactions have impeded the establishment of universally accepted guidelines. Consequently, healthcare professionals often recommend abstaining from herbal products entirely during active anti-cancer treatments, a stance deemed by some as lacking principles [33Sparreboom A. Cox M.C. Acharya M.R. Figg W.D. Herbal remedies in the United States: potential adverse interactions with anticancer agents.Journal of clinical oncology : official journal of the American Society of Clinical Oncology. Jun 15 2004; 22: 2489-2503https://doi.org/10.1200/jco.2004.08.182Crossref PubMed Scopus (0) Google Scholar]. However, this perspective may not be well-received by patients, their families, or society and may disrupt the physician-patient relationship [34Hardy M.L. Dietary supplement use in cancer care: help or harm.Hematology/oncology clinics of North America. Aug 2008; 22 (vii): 581-617https://doi.org/10.1016/j.hoc.2008.04.012Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar]. Furthermore, it may be considered an unethical approach that disregards patient autonomy [35Ben-Arye E. Attias S. Tadmor T. Schiff E. Herbs in hemato-oncological care: an evidence-based review of data on efficacy, safety, and drug interactions.Leukemia & lymphoma. Aug 2010; 51: 1414-1423https://doi.org/10.3109/10428194.2010.487622Crossref PubMed Scopus (24) Google Scholar]. Although specific TCAM regulations and directives have been instituted in some countries to streamline the procedures, there remains a need for the development and approval of further regulations regarding the authorities responsible for addressing related complaints and how non-specialists practicing TCAM are to be treated [36Taghipour A. Bahrami Taghanaki H. Hosienzade H. Noras M. Ethical and legal challenges in complementary and alternative medicine. Review.Iranian Journal of Medical Ethics and History of Medicine. 2016; 9: 23-31Google Scholar]. Challenges related to TCAM studies represent another significant obstacle. All TCAM treatment approaches share common features, including the use of complex interventions such as herbal remedies, individualized diagnosis and treatment, emphasis on the body's inherent healing capacity, and treating patients holistically, considering their physical and mental characteristics. Validating the effectiveness of TCAM methods requires the conduct of scientific research and the generation of sound evidence using appropriate methodologies. However, in many instances, conducting clinical trials poses considerable challenges. TCAM is not seamlessly integrated into the mainstream healthcare system, and the expenses associated with its treatments are added to the overall research costs. Comparing conventional treatments with TCAM methods often yields incomparable results, as many patient responses, particularly those related to spiritual changes following these treatments, are challenging to quantify. Ethical dilemmas in clinical trials, as well as issues with randomization and blinding methods, alongside the absence of long-term patient follow-ups, present additional hurdles [37Yang Y. Tian K. Bai G. et al.Health technology assessment in traditional Chinese medicine in China: current status, opportunities, and challenges.Global Health Journal. 2019; 3 (2019/12/01/): 89-93https://doi.org/10.1016/j.glohj.2019.11.002Crossref Scopus (13) Google Scholar]. Uncertainty regarding research costs in TCAM medicine, challenges within research centers, the lack of support and incentive packages for traditional medicine research in certain countries, and the abundance of keywords linked to TCAM represent further research challenges in this field [38Kenu A. Kenu E. Bandoh D.A. Aikins M. Factors that promote and sustain the use of traditional, complementary and integrative medicine services at LEKMA hospital, an complementary medicine and Jan PubMed Scopus (3) Google Scholar]. In numerous countries, herbal medicines and related products are to the without undergoing safety or is a lack of regulations methods and quality Herbal products, and from and to easily the M.M. Tan issues on used herbal products, herbal medicines and in the of Association of of Scholar]. Some herbal products on the may be of quality and efficacy, yet they are often without the of potential risks associated with their use C. Integration of traditional and complementary medicine in to evidence-based clinical practice. Scholar]. Challenges in this include the popularity of natural remedies for herbal products as anticancer remedies a lack of and beliefs to M. complementary and alternative medicine in the conventional treatment of cancer patients: analysis of a clinical of medical and of medicine. 14: PubMed Scopus (0) Google Scholar]. that in many countries, TCAM independently from healthcare it often monitoring by the safety mechanisms and systems established within the and legal [15World Health Organization. National policy on traditional medicine and regulation of herbal medicines: Report of a WHO global survey. World Health Organization; 2005.Google Scholar]. medicine has the field of traditional medicine its in many countries and has in is only natural with the in traditional medicine among the centers traditional medicine services should a more in disease and treatment, by an enhanced of and the challenges associated with the use and of traditional medicine into the healthcare system, it is to the of these be In various worldwide, particularly in and countries, TCAM as a of healthcare Health Organization. of Traditional Medicine and Medicine: A Scholar]. many this medical approach is in their and constitutes a of healthcare Health Organization. on the of Traditional Medicine in Primary Health Scholar]. In certain instances, it may be the or healthcare in and N. Smith L. Health in and the of the Traditional healthcare in of Health Management. Scopus Google Scholar]. The of the of including the of traditional medicine in the of health for A. of on health Scholar]. numerous and have been established to the of traditional medicine into healthcare as a to Health Integrating traditional and complementary medicine with healthcare systems for health in and the & 2019; PubMed Scopus Google Scholar]. The of TCAM within healthcare systems has as a and S. et for of health care policy in from the perspective of and of integrative medicine. 2017; PubMed Google Scholar]. The World Health Organization (WHO) of and healthcare In the integrative TCAM is and into aspects of healthcare as in countries like the of and The healthcare TCAM as an of medical it may not be fully integrated into aspects of healthcare and following this approach include and in the healthcare system, certain TCAM methods are accepted [31World Health Organization. WHO traditional medicine strategy: 2014-2023. World Health Organization; 2013.Google S. E. and of traditional medicine in A of Research 2010; Scholar]. on training in the field of TCAM represents one of the most significant TCAM is on the global with the World Health Organization (WHO) it due to WHO training is in countries worldwide, while countries have instituted training to in complementary medicine and medical Health Organization. WHO global on traditional and complementary medicine World Health Organization; Scholar]. In this is the establishment of medical research centers, and new health Additionally, the of the Traditional and Complementary Medicine has been established within the of in conjunction with and medical centers within the of complementary medicine, or not S. A. with in the of A of Complementary and Alternative Medicine of and Research in Google Scholar]. Integrative as a and a centers on the health of cancer patients. approaches to conventional treatments such as treatments, and The is to principles and for complementary medicine interventions that are and for patients, healthcare and at The integrative oncology for patient care and oncology Aug 2008; PubMed Google Scholar]. TCAM complementary methods that have the potential to enhance quality of their and or mitigate side effects, it is integrated with conventional cancer The challenges associated with TCAM usage in cancer care should not of conventional medicine to TCAM as a in cancer care, particularly within the of and In many instances, the of these services are including their cost-effectiveness, with cultural belief patient with and with the current healthcare on opportunities, it is to these challenges and the

Topics & Concepts