Issue 5 / 25 February 2013

REGARDLESS of whether doctors like it or believe in it, complementary and alternative medicine is used by more than half of all Australians each year.

Uptake among chronically ill patients is often greater, with up to 65% of Australian cancer patients using complementary and alternative medicine (CAM) to complement standard treatments rather than as an alternative to conventional treatments.

What’s worrying, though, is that many patients do not talk about their CAM use with doctors — only one-third of primary care patients consult their GP and as few as 20% of cancer patients discuss it with their specialists.

There are many stumbling blocks for patients in talking about CAM with doctors. They range from the very real prospect of receiving a negative or indifferent response, to doctors simply not asking about CAM, through to the worrying belief of many patients that CAM is entirely “natural” and safe alongside conventional treatment.

Doctors need to nurture an environment where patients can talk about their use of CAM without fear of disapproval, if for no reason other than the prospect that their use may cause serious drug interactions with conventional treatments or adverse side-effects on their own.

A recent systematic review that I carried out sheds more light on the safety risks of CAM use to cancer patients.

The safety and efficacy of over 50 individual complementary and alternative therapies were evaluated across more than 300 meta-analytic and systematic reviews. Weighing up risk versus benefit, the top 10 therapies that cancer patients should be discouraged from using are St John’s wort, laetrile/amygdalin/vitamin B17, kava, ginkgo biloba (EGb 761), lingzhi/reishi mushroom, green tea, ginseng, black cohosh, shark cartilage and garlic.

Generally, botanical agents pose the greatest risk of harm to cancer patients. In particular, their use as unproven alternative therapies (eg, laetrile/amygdalin) in place of conventional medicine should be strongly discouraged.

Some herbal medicines, dietary supplements and other “natural” therapies have toxic and potentially life-threatening effects (eg, laetrile/amygdalin can cause cyanide poisoning and death; kava and black cohosh may cause liver problems). Others interact with chemotherapy and prescription drugs (eg, St John’s wort potentially interacts with 70%–80% of all prescription medicines, and reduces the efficacy of some chemotherapy drugs). Some cause complications during radiotherapy and surgery (eg, garlic, ginkgo biloba and ginseng may increase bleeding).

That said, we shouldn’t tar all CAM interventions with the same brush as there is substantial evidence to support the safe and effective use of some interventions. Clinical trials have shown that some therapies, when used in support of conventional treatments, are beneficial in reducing symptoms or emotional distress and improving the quality of life of cancer patients.

Weighing up risk versus benefit once again, the top 10 most effective and safe therapies from my review for people with cancer are relaxation techniques, support groups led by health professionals, physical activity programs, music therapy, meditation (including mindfulness), acupuncture, massage, omega-3 fatty acids, yoga and ginger (combined with prescription antiemetics).

Generally, mind–body and manipulative/body-based therapies have the greatest potential for benefit among cancer patients. Relaxation techniques, for example, are the most effective non-pharmacological approach for the relief and prevention of depression and anxiety in patients undergoing cancer treatment.

Relaxation can also reduce nausea/vomiting, cancer-related pain and fatigue and, in respiratory cancer patients, breathing difficulties. Physical activity programs involving aerobic or resistance exercise can also be particularly beneficial for physical/emotional wellbeing and fatigue, even in metastatic cancer patients.

Patients may seek guidance about CAM therapies and medical practitioners are in the prime position to provide this. Therefore, doctors ought to be educated about CAM.

Medical schools and hospitals should integrate teaching about CAM into medical training. Doctors need to become familiar with websites and online databases that provide information about the wide range of therapies available. The Cancer Council Australia and Australasian Integrative Medicine Association are good starting points.

Cancer specialists should consider offering access to safe and effective complementary therapies (or at least safe forms of them) alongside conventional treatments through their own cancer services.

As long as complementary therapies used by cancer patients are safe and under medical supervision, where is the harm? Hippocrates once said: “As to diseases, make a habit of two things — to help, or at least, to do no harm.”

When patients don’t feel that they can talk about CAM with their doctors for fear of disapproval and doctors don’t routinely take the time to ask, is that likely to help or harm the patient with cancer? It’s certainly a question every doctor should ponder.

Carlo Pirri is a research psychologist/consultant and PhD candidate based at Murdoch University, Perth. He is a working party member of the Complementary and Integrated Therapies Interest Group established by the Clinical Oncological Society of Australia.

Posted 25 February 2013

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15 thoughts on “Carlo Pirri: Embracing CAM

  1. Dr Ken Harvey says:

    The NPS reviewed good sources of information about CAM and their recommendations are available at:

  2. M Busby says:

    I agree, but …
    it is the same old phrase… doctors “should consider offering access to safe and effective complimentary therapies” as if doctors are somehow holding out on offering these amazing treatments.
    I don’t think any of us have a problem with offering them if they are in fact “safe and effective”. Once they are shown to be “safe and effective”, however,they are no longer “complimentary or alternative”. Then they become “medicine”.
    There really ought to be no “alternative and complimentary medicine” industry. Either we use treatments proven to work (medicine) or we are honest and tell the patient that they can use something lacking in rigorous evidence but thought to be effective. There is no room for “professions” that peddle unproven treatments (with nonsense explanations for how it could possibly work) but make very definite claims about their efficacy.
    AHPRA should really be acting as a “healthcare honesty” regulator instead of registering bogus health professions alongside legitimate professions.

  3. Sue Ieraci says:

    M Busby is spot on! “Safe and effective” = medicine. Save but not effective = scam. Not-safe and not-effective = dangerous.

  4. Urban Sundvall says:

    I certainly see evidence in my practice that many of my clients are hesitant to discuss these issues with their primary health practitioner. As a Therapist I have many tools in my toolbox apart from the Psychological interventions of Psychotherapy. Hypnosis being one of those tools. Although acceptance certainly has increased for the mind/ body connection, many G.P.’s and Specialists are failing to communicate this to their patients and thereby missing out on the collaboration with these patients and their chosen adjunct healthcare provider. Most of us within these fields do welcome the ability to collaborate in a way that both helps and protects our patients/clients.
    I also think it is important for us to ensure that we provide the primary with written information of the work we do for their files.

  5. Dr Ken Harvey says:

    The NHMRC is currently reviewing the evidence for the effectiveness of certain “natural therapies” such as massage, aromatherapy, homeopathy, naturopathy, western herbalism and nutrition.
    The findings of this review will inform the government’s Natural Therapy Review Advisory Committee.
    The aim is to ensure that taxpayer funds that are paid through the rebate to subsidise natural therapies are underpinned by a credible evidence base that demonstrates their clinical efficacy, cost effectiveness and safety and quality.

  6. Dr Mick Vagg says:

    The oft-quoted figure of “half of all Australians” is highly misleading. This is only reached by including such commonplaces as multivitamins and ‘relaxation therapies’.

    The idea of ‘Integrative Medicine’ is offensive to those who value the scientific method, as it implies that holding all treatments to the same standards and rejecting the use of those which aren’t up to scratch is somehow the wrong way to do medicine.

    In my opinion, medical students should be taught how to educate patients about health frauds and misleading advertising rather than just trying to be politically correct.

  7. Trevor says:

    When I go and see my doctor I expect him to apply evidence based medicine. Given that there is so much for a general practitioner to already know, when do they get the time to learn about that which lacks evidence? Perhaps there is an educative role for assisting GPs to learn what scams are out there and how to best deal with them.

  8. Sue Ieraci says:

    I do agree that doctors should be aware of therapies that ARE shown to be beneficial. The author lists: “the top 10 most effective and safe therapies from my review for people with cancer are relaxation techniques, support groups led by health professionals, physical activity programs, music therapy, meditation (including mindfulness), acupuncture, massage, omega-3 fatty acids, yoga and ginger (combined with prescription antiemetics).” I don’t think most people would classify relaxation, health-professional-led support groups, physical activity, meditation, massage or yoga as “CAM” – they are techniques that encourage wellness, not “therapies”. Of the remaining ones, can the author state what the evidence is for acupuncture, omega3’s or ginger in cancer? If these therapies are shown to be effective, then they should be classified as therapy, not “CAM”.

  9. Poit says:

    I think it would be better if CAM was renamed Supplementary, Complimentary and Alternative Medicine (SCAM). This would be a more realistic acronym.

  10. Tweedie says:

    I have always found it difficult to advise patients to use or avoid CAM, not because of disrespect but because I just don’t know enough about it. If you dismiss CAM simply because there is no evidence to support its efficacy, then you can say there’s no evidence that the patient SHOULD take the medicine, but you don’t quite have the authority to say that the patient SHOULDN’T take the medicine. I could say that CAMs are potentially unsafe, but I cannot support my claim with a solid knowledge base of their interactions and side effects. I end up saying that I don’t know enough about CAM to advise the patient either way, but then come across as being disinterested and unhelpful. If we are serious about advocating safe use or avoidance of CAM, we will need to be better educated about how it is thought to work and any evidence for or against it.

  11. Anonymous says:

    If doctors were trained and expected to raise the alarm and warn their patients when discussion turns to questionable treatments (re safety, side-effects and effectiveness), would that apply to ‘traditional’ treatments (interventions and drugs) as well?
    If “the idea of ‘Integrative Medicine’ is offensive to those who value the scientific method”, we really have a problem, and medical professionals have developed a …misplaced sensitivity. Maybe it is treatable.

  12. Julian says:

    “SCAM” therapies. Loving it. Hope you don’t mind if I use it.

    Julian Fidge

  13. Kalori says:

    I agree with Tweedie. Time and again as a patient, I have asked GPs and specialists about alternative medications and I just get a blank look. Millions of Chinese take Dan Shen, millions of Indians take Arjuna Terminalia, but no one seems to know how they interact with standard heart medications, or with each other. Integrated medicine training that incorporated all of them would be ideal. BUT it would add years to medical training. Also there would need to be a lot of integrative research done, and who would finance that?
    I hope someone has the answers.

  14. Peter McLaren says:

    The dangers of consuming green tea? Please elaborate.

  15. Dr Ken Harvey says:

    There are a number of resources available to check out potential CAM – conventional drug interactions including those recommended by the NPS (see my page 1 post above). Others include: and

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