Affiliation of author: Office of Cancer Complementary and Alternative Medicine, Office of the Deputy Director of Extramural Science, National Cancer Institute, Bethesda, MD.
Correspondence to: Jeffrey D. White, M.D., National Institutes of Health, Executive Plaza North, Rm. 102, Bethesda, MD 20892 (e-mail: ncioccam-r{at}mail.nih.gov).
There is an increasing acceptance of complementary and alternative medicine as a field of importance to the general public and to the medical practice and research communities. This acceptance is reflected in many forms, from an increase in lay print and electronic publications to the growing numbers of academic conferences and peer-reviewed journals for practitioners and scientists focusing on the topic. The Office of Alternative Medicine of the National Institutes of Health (NIH), Bethesda, MD, was established in 1992 and was converted to the National Center for Complementary and Alternative Medicine in 1999. In 2000, the White House Commission on Complementary and Alternative Medicine Policy was established to make recommendations about research, credentialing of practitioners, access to therapies, and third-party reimbursement. James S. Gordon, the chairman of this commission and one of the authors of Comprehensive Cancer Care: Integrating Alternative, Complementary and Conventional Therapies, has been an important figure in virtually all aspects of this growth.
Gordon, a psychiatrist formerly at the National Institute of Mental Health, NIH, is now the director of the Center for MindBody Medicine, a nonprofit educational organization in Washington, DC. He has been the organizing force behind a series of three annual conferences entitled "Comprehensive Cancer Care." This book extracts some of the information discussed at these conferences, interpreting and extrapolating it and addressing the result predominantly to cancer patients rather than to health-care practitioners or researchers. In the introduction, the authors state, "We present the most authoritative information about complementary approaches that offer maximal benefits and may be safely integrated into every persons cancer care."
In the second chapter, entitled "Facts for Life," the authors give a clear explanation of what cancer is, which, despite small inaccuracies (e.g., ". . . cancer cells do not undergo apoptosis . . ."), should be helpful to many patients. Subsequent chapters provide useful information on understanding terms, interpreting data, and the evolution of cancer therapies and clinical trials.
The writing is very good throughout. Perhaps the books greatest strength lies in its many stories of real patients. The process of learning about their disease and treatment options, their interactions with family, the effect of their diagnosis on relationships, and their interactions with conventional, alternative, and complementary health-care providers are all very well presented. The reader is given a vivid sense of the internal struggles of a newly diagnosed cancer patient, especially the search for self-help information and the negative effects of physicians not being capable and/or interested in helping the patient with that search.
The authors advise patients to actively gather and review information with a qualified health-care professional. This approach poses a challenge to conventional medical practitioners to become knowledgeable about these therapies and to find ways to address the patient inquiries that will result. Many cancer patients would welcome open-minded and informative discussions about complementary and alternative medicine; consequently, caring physicians should try to meet this challenge.
Bringing together different world views and practice communities, which is the goal of the integrative or "comprehensive" medicine concept, is a difficult balancing act, particularly since the topic is so large and inhomogeneous. However, when certain generalities are made about complementary and alternative medicine modalities (e.g., p. xviii"They nourish the bodys reparative processes, increase its ability to destroy cancer cells, and decrease the tumor burden."), they seem grandiose, unrealistic, and unlikely to be supported by meaningful data. Specific evidence is needed to develop an appropriate perspective of the potential value of each of the many approaches to complementary and alternative medicine.
Despite advocating an evidence-based approach, the authors are inconsistent in adhering to their own advice. The section on shark cartilage in chapter 8 is perhaps the best example of this. It is a very selective presentation of data that would lead the uninformed reader to a serious misunderstanding about the state of evidence for a clinically relevant anticancer activity of shark cartilage. The authors mention that the so-called "Cuban study," discussed on the news magazine 60 Minutes in 1994, has never been published but then go on to describe the data without explaining who performed the study or what product was used. They also fail to mention the phase II trial by Miller et al. in the November 1998 issue of the Journal of Clinical Oncology, which failed to show any partial or complete remissions. The median time to disease progression in that study was 7 weeks. These are serious omissions, particularly in a book whose major readership will likely be cancer patients trying to make decisions about whether or not to use these products.
Similar omissions are evident in chapter 9, where the herbal supplement PC-SPES is discussed and described as a "non-toxic treatment . . .," whereas all four of the published trials of PC-SPES have described its estrogenic effects, with toxic effects ranging from breast tenderness and impotence to venous thromboses. Many individuals already believe that natural products, such as herbs, are not toxic. When there is real documentation of such toxic effects, it needs to be presented accurately.
The authors probably overstate the level of evidence for the benefit of mindbody approaches, but in general they provide a more balanced presentation of these therapies than of many of the biologic therapies. For example, in chapter 11, the authors greatly misrepresent the problems other researchers had in attempting to critically evaluate Stanislav Burzynskis antineoplaston therapy. They give a detailed presentation of Dr. Burzynskis data but ignore the negative study by Buckner et al. in the February 1999 issue of the Mayo Clinic Proceedings.
Patients and health-care providers will seek background and advice on complementary and alternative medicine from various sources. Both groups need to understand the issues involved in assessing complementary and alternative medicine therapies, what their options are, and what the level of evidence is for these therapies. This book will meet some of those needs; however, in important ways, it falls short of being either comprehensive or balanced.
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