Complementary Therapies in Palliative Cancer Care

Edzard Ernst, M.D., Ph.D.

Department of Complementary Medicine, School ofPostgraduate Medicine and Health Sciences, Uni-versity of Exeter, Exeter, United Kingdom.

Address for reprints: Edzard Ernst, M.D., Ph.D.RCP (Edin), Department of Complementary Medi-cine, School of Postgraduate Medicine and HealthSciences, University of Exeter, 25 Victoria ParkRoad, Exeter EX2 4NT UK; Fax: (011) 44-(0)1392-424989; E-mail: E.Ernst@ex.ac.uk

Received July 10, 2000; revised January 10 andFebruary 21, 2001; accepted February 22, 2001.

BACKGROUND. Complementary medicine has become an important aspect of pal-

liative cancer care. This overview is primarily aimed at providing guidance to

clinicians regarding some commonly used complementary therapies.

METHODS. Several complementary therapies were identified as particularly rele-

vant to palliative cancer care. Exemplary studies and, where available, systematic

reviews are discussed.

RESULTS. Promising results exist for some treatments, e.g. acupuncture, enzyme

therapy, homeopathy, hypnotherapy, and relaxation techniques. Unfortunately,

the author finds that the evidence is not compelling for any of these therapies.

CONCLUSION. These results point to some potential for complementary medicine in

palliative care. They also demonstrate an urgent need for more rigorous research

into the value (or otherwise) of such treatments in palliative and supportive cancer

care. Cancer 2001;91:2181–5. © 2001 American Cancer Society.

KEYWORDS: complementary medicine, alternative medicine, cancer, palliative care.

Complementary medicine (CM) has been defined as “diagnosis,treatment and/or prevention which complements mainstream

medicine by contributing to a common whole, by satisfying a demandnot met by orthodoxy or by diversifying the conceptual frameworks ofmedicine”1 — a definition that recently has been adopted by the“Cochrane Field” working in this area. Although this definition couldbe criticized for being too broad, it does form the basis for differen-tiating CM from alternative medicine (see below).

CM has become an important aspect of palliative and supportivecancer care. A recent postal questionnaire survey, for instance, sug-gested that 70% of all departments of oncology in Britain routinelyemploy at least one form of CM in the palliative cancer care setting.2

Acupuncture, aromatherapy, enzyme therapy, homeopathy, hypno-therapy, massage, reflexology, relaxation techniques, and spiritualhealing are frequently used forms of treatment.3,4 This overview isaimed at providing some guidance to clinicians and at identifyingpromising areas of future investigation for researchers of CM.

DISCUSSIONCare versus Cure and Complementary versus AlternativeIt seems important to differentiate between alternative cancer “cures”and complementary cancer care. There is not a single alternative(rather than mainstream) intervention that has been demonstrated toconstitute an effective cure for cancer.3,4 It seems, therefore, highlyunethical (albeit prevalent) to promote alternative medicine in thisway. First, this can misguide patients to give up effective conventionaltreatments and thus potentially hasten their deaths.5 Second, it canraise false hopes, which will lead to cruel disappointments for vul-nerable patients and their families. Third, it could financially exploit

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people who may choose to invest their savings in anytreatment that promises to delay death. Disturbingly,there are many instances where this scenario is notjust a theoretical possibility but a harsh reality.6

What Are the Aims and Characteristics of CM inPalliative Care?CM in palliative cancer care aims at providing comfortto and increasing the quality of life of patients whootherwise may despair.7 More precisely, the interre-lated goals of complementary cancer care can be sum-marized as follows: promote relaxation, reduce stressand anxiety, relieve pain and other symptoms, reduceadverse effects of conventional cancer therapies, andimprove sleep. Each of these may contribute to theenhancement of well-being and the quality of life.

There is no well-defined theoretical framework ofCM in palliative cancer care. Recurring themes can,however, be identified. These relate to the holisticnature of CM, to individualized, patient-centered,treatment plans, to the absence of serious adverseeffects, to the emphasis on improving the health ofcancer patients instead of treating the disease alone,and to a recognition of the importance of the mind–body connection.8,9 Critics of CM are keen to point outthat these themes are by no means unique to CM butare hallmarks of any palliative and supportive care ofhigh quality.4,10 Thus the dividing line between com-plementary and mainstream palliative care is nebu-lous. For the purpose of this article, CM is used prag-matically as a term to describe those therapies listedabove.

Do We Require Evidence in a Palliative Care Setting?The above-named aims of CM are essentially hypoth-eses, which require adequate scientific testing. How-ever, enthusiasts of CM repeatedly have arguedagainst this strategy saying that complementary ther-apies do not necessarily need scientific or clinical val-idation because, if patients say that they feel better forit, then this is justification for providing it whether ornot their perception is backed up by research.11 Yeteven the fact that patients reproducibly feel betterafter receiving one form of CM or another cannot besimply assumed but has to be demonstrated ade-quately. The adoption of CM by cancer patients alsomay have detrimental effects. For instance, womenwho have tried CM after surgery for breast cancer havereported a worsening of their quality of life.12

To demonstrate that clinical effects are not achance occurrence, it seems inevitable to conductclinical trials. In medicine (and therefore also in pal-liative care), we have a responsibility not only to ourpatients of today, but also to the ones of tomorrow. To

ameliorate the well-being and quality of life of futurecancer patients, it is necessary to investigate whether(and how) our palliative care of today can be improvedand to test which treatment is reproducibly superiorto another. The only way to achieve this is by conduct-ing adequate scientific investigations.

Obviously the research methodology of such in-vestigations has to be suited to the research questionthat is being asked. If we want to know whether or notthe apparent effects of a given intervention are caus-ally related to a given outcome, or whether or not theyare in any way preferable to those of another treat-ment, the best available (which is not to say flawless)method to date is the randomized clinical trial(RCT).13 This statement, however, does not invalidateother research methodologies, which may be suited toother research questions.

What is the Evidence?This is not the place to provide a comprehensive ac-count of all research ever conducted in this area. In-stead, the following will briefly discuss exemplarystudies and (where available) systematic reviews ofRCTs relating to the above-named complementarytreatments. The aims are to provide some guidance toclinicians, to help identify areas of potentially fruitfulresearch for investigators, and to stimulate discussionabout CM in palliative care. Brief explanations regard-ing all treatments discussed are provided in Table 1.

AcupunctureSystematic reviews suggest that acupuncture allevi-ates dental14 and low back pain.15 Although these twoindications seem largely irrelevant for cancer care atfirst sight, they may serve as specific examples ofneuropathic pain management in general. Thus, onemight postulate that acupuncture also could relieveneuropathic pain in cancer patients. In a Phase IIstudy, 183 cancer patients were treated with acupunc-ture and 47% experienced less pain subsequently.16

Such results are encouraging but require confirmationthrough rigorous RCTs.

According to several systematic reviews of RCTson this topic, acupuncture also is effective in reducingnausea and vomiting of various causes.17 A recent RCTsuggested that simple finger acupressure at the P6acupuncture point can reduce nausea and vomiting inoncology outpatients.18 Thus, acupuncture or acu-pressure could offer practical, safe, and inexpensiveways of reducing nausea and vomiting after conven-tional cancer therapy. Rigorous trials that test the rel-ative effectiveness of acupuncture compared withconventional antiemetic treatments for cancer pa-tients should be initiated now.

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AromatherapyIn spite of its popularity, very few trials of aroma-therapy have been published to date.19 Those that areavailable lend some, albeit not compelling, support tothis approach in reducing anxiety.20,21 A recent RCTincluded 103 cancer patients who regularly receivedeither aromatherapy with a carrier oil (placebo) orwith the oil of Roman chamomile for 2 weeks.22 Bothgroups experienced an improvement in quality of life.The effect was, however, significantly greater in theexperimental group compared with the placebogroup.

Enzyme therapyOral proteolytic enzymes have been promoted, partic-ularly in Europe, for relief of symptoms associatedwith cancer. A recent systematic review located 7 pro-spective clinical trials that included 692 cancer pa-tients.23 These collective data imply that enzyme ther-apy may be a helpful therapeutic option for reducingthe adverse effects of cancer therapies, thus improvingquality of life. Enzyme therapy seems to be tolerated

well. The authors of the review stress that the mech-anism of action is as yet unknown. Moreover, theexisting studies are burdened with serious method-ologic flaws. More and better research, therefore,seems to be warranted.

HomeopathyHomeopaths usually do not adopt the diagnostic cri-teria of conventional medicine but claim to treat thewhole person. Several clinical trials suggested thathomeopathy also may benefit patients suffering fromcancer. For instance, a recent double-blind RCT in-cluded 66 women undergoing radiotherapy afterbreast cancer surgery. In addition to conventionaltreatment, they received either a homeopathic mix-ture (belladonna 7 CH, X-ray 15 CH, i.e. two homeo-pathic remedies in high dilutions) or a placebo dailyfor 8 weeks. The results suggested that the homeo-pathic mixture was superior to placebo in minimizingthe dermatologic adverse effects of radiotherapy.24

One weakness of this study is that the outcome wasquantified using a custom-made, nonvalidated scoreof dermatologic signs such as edema, hyperpigmenta-tion, temperature, and erythema. The question ofwhether homeopathy has a place in palliative cancercare is open at present.

HypnotherapySeveral clinical trials suggested that hypnotherapy canbe useful in palliative cancer care.25 For instance, 20cancer patients who were receiving chemotherapywere randomly assigned to either hypnotherapy or nosuch treatment in addition to standard care.26 Theresults showed that hypnotherapy was associated withless nausea and vomiting and less need for antiemeticmedication. Similarly, hypnotherapy has been shownin RCTs to reduce cancer-induced pain and cancertherapy-associated pain.29 A recent review summa-rized all published clinical trials of hypnotherapy.28 Itconcluded that there is encouraging, but not compel-ling, evidence to suggest that hypnotherapy is helpfulfor controlling anxiety and pain as well as nausea andvomiting in cancer patients.

MassageThere is little doubt that manual massage techniquescan convey intensive and pleasant relaxation to boththe body and the mind.29 There are, however, fewstudies that have tested whether this conveys relevantbenefits to cancer patients. One small RCT with acrossover design demonstrated no significant im-provement in symptoms of cancer patients treatedwith regular back massages compared with no suchintervention.30 Because of its limited sample size, this

TABLE 1Examples of Complementary Therapies Relevant in Palliative Care

Name of therapy Brief description

Acupuncture Stimulation of acupuncture points by inserting aneedle, electrical current(electroacupuncture), heat (moxibustion),laser (laser acupuncture) or pressure(acupressure)

Aromatherapy Application of ‘essential’ oils from plants, usuallythrough gentle massage

Enzyme therapy Oral administration of proteolytic enzymesaimed at increasing well-being

Homeopathy System of medicine developed about 200 yearsago by S. Hahnemann based on the ‘like cureslike’ principle, often using extremely highdilutions

Hypnotherapy Form of cognitive information processing usingsuspension of peripheral awareness aimed atapparently involuntary changes in perception,memory, mood, and physiology

Massage Manual techniques of rubbing, stroking, tapping,or kneading the body with a view to treatingphysical or emotional conditions

Reflexology Use of manual pressure to specific areas(typically on the sole of the foot) thought tobe related to inner organs

Relaxation Eliciting a relaxation response, i.e. release ofphysical and mental tension; often includedin broader therapeutic programs

Spiritual healing Channeling of ‘healing energy’ from an externalsource (e.g. God) through the healer to thepatient with a view to enhancing health andwell-being

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study is prone to a type II error and would seem torequire an independent replication. Because of itsrather obvious clinical benefit, its popularity, and thepatient satisfaction it usually generates, massage ther-apy seems to be worthy of further study.

ReflexologyThe effectiveness of reflexology has not been testedfrequently in RCTs. The few trial data that are avail-able31 suggest that it may be helpful for stress reduc-tion. A recent RCT with a crossover design showedthat patients with breast or lung cancer improved interms of anxiety and pain when treated with reflexol-ogy.32 The sample size (n 5 23) of this study was small,and more trials are needed to define the usefulness ofthis therapy.

RelaxationThere are several RCTs that demonstrate the effective-ness of a range of relaxation techniques, includingvisualization or music therapy,33 in reducing stress34

and pain35 and in increasing quality of life36 in cancerpatients. As the results of these studies are encourag-ing, we should endeavor now to determine what typeof relaxation technique is best for what type of patientand to establish how these interventions comparewith conventional treatments.

Spiritual healingVarious forms of spiritual healing exist, for example,Reiki or Therapeutic Touch. A recent review of all 23placebo-controlled (or otherwise) RCTs showed that57% of these studies arrived at a positive conclusionconcerning the effectiveness of these interventions.37

Two trials specifically conducted with cancer patientssuggest that Therapeutic Touch lowered anxiety38 andimproved well-being39 significantly more than simplerest periods, which constituted the control interven-tions. Because these studies are burdened with con-siderable methodologic shortcomings, rigorous trialsare required to confirm or refute the value of spiritualhealing in palliative cancer care.

Other treatmentsOne might ask whether CM offers other treatmentmodalities that could be useful in reaching the above-mentioned aims of palliative care. Several herbal rem-edies are particularly worthy of consideration in thisrespect. St. Johnswort (Hypericum perforatum) is aneffective and safe treatment of mild to moderate de-pression.40 Kava (Piper methysticum) is a powerfulanxiolytic herbal medicine.41 A number of herbal rem-edies have been shown to have analgesic effects sim-ilar to nonsteroidal antiinflammatory drugs

(NSAIDs).42 The oral medication of ginger (Zingiberofficinalis) has shown promise as an antiemeticagent.43 Finally, valerian is an herbal hypnotic drugwith several RCTs to back it up.44 It must be pointedout, however, that these herbal medicines so far havenot been tested adequately in cancer patients. More-over, our knowledge of adverse effects is incomplete atpresent. Finally, herb– drug interactions have been de-scribed for all of these herbal medicines,45,46 and thisis of obvious relevance for cancer patients.

CONCLUSIONSCollectively, the above evidence implies that CM hasconsiderable potential in palliative and supportivecancer care. However, most of the evidence availableto date is preliminary. Substantiating this evidenceseems to be a relevant challenge both for the field ofpalliative medicine as well as for CM. Given the meth-odologic difficulties in conducting clinical trials in pal-liative care47 and the dire funding situation in CMresearch,48 this task doubtlessly will be difficult, timeconsuming, and expensive. Yet, as pointed out above,in the interest of the patient, there should be no shortcuts to or substitutes for rigorous clinical research.

In caring for cancer patients, physicians must fo-cus on the values of patients and their families.49

Many of the treatment modalities used in CM seem tobe appropriate in this respect. CM providers often arehighly motivated and deeply compassionate in caringfor cancer patients. We should channel this potentialwisely—not for CM promotion but for CM researchand ethical practices that benefit cancer sufferers.

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