Background
The use of complementary and alternative medicine is on the rise in Western society.Reference Vickers1 In general, Western healthcare practitioners express some degree of scepticism towards such remedies. Hence, complementary and alternative medicine receives little attention in most medical school and post-graduate educational curricula, despite recommendations that healthcare professionals should improve their knowledge of such treatments.Reference Taylor and Blackwell2 Clinicians' reluctance to appreciate the value some patients place on such therapies can sometimes lead to patient non-compliance with conventional therapies, which may result in inadequate, inappropriate and/or delayed treatment. Furthermore, older patients may be taking multiple drugs, and the interactions between such drugs and complementary and alternative substances is not usually well understood.Reference Shakeel, Trinidade and Ah-See3
We present the case of a patient who chose complementary and alternative medicine as the preferred treatment for his cancer, against our recommendations, with tragic consequences.
Case report
A 54-year-old Caucasian man presented to our department with a painful ulcer on the right lateral margin of the anterior tongue. He was from a low socioeconomic background, living alone, with no particular profession at the time of presentation, and he claimed to be a spiritual healer.
Histopathological analysis confirmed that the lesion was a squamous cell carcinoma, with tumour-node-metastasis staging of T1 N0 M0.
The patient underwent surgical resection of the primary tumour, with tumour-free margins.
Because there was no neck node involvement, no adjuvant treatment was recommended by the head and neck multidisciplinary team. The patient himself had been somewhat reluctant to undergo resection of the primary tumour, and was not keen on any further treatment to the neck.
The patient was kept under regular review. Unfortunately, recurrence was identified six months after the initial surgical resection. The recurrent tumour was staged as T2 N0 M0. The patient was advised of the various treatment options. It was felt that the best option would be a combination of surgery followed by post-operative radiotherapy, because of the recurrent nature of the cancer and the possibility of subclinical neck disease.
The patient agreed to undergo partial glossectomy. Histopathological examination of the resected specimen confirmed complete resection with clear margins.
The patient had previously agreed to undergo post-operative radiotherapy as part of the treatment plan, as at stage II and higher we do not treat a node-negative neck surgically but instead treat both the primary site and the neck with post-operative radiotherapy.
However, he failed to keep his appointments for radiotherapy. When contacted, he advised the team that he had instead chosen to undergo spiritual healing, and that he was confident that this would be curative. Of course, we advised him against this course of action. There did not appear to be any previous instances of spiritual healing being of any benefit to the patient, his family or friends.
The patient was counselled by the multidisciplinary oncology team, including the oncologist, surgeon, clinical oncology nurse specialist, speech therapist and dietician. He declined formal psychiatric assessment. He was advised that the chances of recurrence were higher without adjuvant radiotherapy. Throughout the discussion, the patient's stated preference remained spiritual healing as the mainstay of treatment. He agreed to surgical resection in an effort to relieve the local pain, but once again refused to undergo post-operative radiotherapy or neck dissection, and continued with spiritual healing.
We were unable to convince the patient to undergo further treatment. He persisted with spiritual healing, and eventually died of advanced cancer.
Discussion
This case highlights the importance that some patients place on complementary and alternative medicine in spite of life-threatening disease processes. A systematic review of usage in 13 countries found that 31 per cent of cancer patients used some form of complementary or alternative medicine.Reference Ernst and Cassileth4 If healthcare professionals can better understand why patients seek cures from complementary and alternative medicine, this may help them to better support and educate patients with advanced cancer.Reference Trinkaus, Burman, Barmala, Rodin, Jones and Lo5
Patients who use complementary and alternative medicine come from surprisingly varied backgrounds. However, previous research by our group found that users of complementary and alternative medicine tended to be married women over the age of 60 years, many of whom had attained university-level education.Reference Shakeel, Trinidade and Ah-See3
Current evidence supports the role of some complementary and alternative therapies in some aspects of cancer management, such as the use of hypnosis, guided imagery and relaxation techniques for the control of pain and anxiety during cancer treatment.Reference Carlson and Bultz6 Evidence from randomised, controlled trials also supports the use of yoga for improving sleep, mood and quality of life. Creative therapies, such as those involving the visual arts, dance and music, may help cancer patients express their feelings and cope with the demands of their disease.Reference Carlson and Bultz6
However, in other areas, such as the use of complementary and alternative medicine in cancer-related fatigue, there is still a paucity of robust evidence.Reference Sood, Barton, Bauer and Loprinzi7 To date, there is poor evidence to support complementary and alternative medicines as full alternatives to conventional therapies in the treatment of cancer.
The media has played a large role in raising general awareness of complementary and alternative medicine, arguably increasing patients' tendency to question conventional therapies. Mercurio et al. conducted a quantitative and qualitative analysis of targeted Australian newspaper articles published between 1998 and 2007.Reference Mercurio and Eliott8 They found that, while the articles conveyed mixed messages regarding the role of complementary and alternative medicine in the treatment of cancer, some articles supported the use of complementary and alternative medicine as a legitimate tool to assist biomedical approaches, and even as a cure. Other articles depicted complementary and alternative therapies as normal and essential forms of treatment. Often, the argument in favour of complementary and alternative medicine was patients' dissatisfaction with conventional therapies, either due to lack of effectiveness or side effects.
Such findings have implications for biomedical practitioners attempting to respect patients' wishes regarding choice of treatment. If healthcare professionals are well informed about complementary and alternative medicine, they are in a better position to foster a collaborative relationship with patients and to help them make informed choices.Reference Frenkel, Ben-Arye and Cohen9 It is often possible to combine complementary and alternative therapies with conventional treatment, particularly for non-life-threatening conditions.
• Complementary and alternative medicine is rising in popularity in the Western world
• Some patients prefer complementary and alternative medicine over conventional therapies
• The presented patient, a firm believer in spiritual healing, refused potentially curative post-operative radiotherapy for oral cavity carcinoma, and died of advanced disease
Finally, the presented case highlights a lack of responsibility on the part of complementary and alternative medicine practitioners who do not communicate their advice to conventional medical practitioners. Current UK legislation does not require complementary and alternative therapies to undergo the same rigorous clinical testing process as conventional therapies, before being approved for clinical practice. Consequently, complementary and alternative medicine practitioners have been accused of practicing opinion-based medicine, as opposed to evidence-based medicine.Reference Jose, Bhalla, Sharma, Hota, Sivaprasad and Pandhi10, 11 Recent attempts to improve the research base of complementary and alternative medicine interventions, including objective evaluation via randomised, controlled trials, may help to address these issues.Reference Harlan12, Reference Saks13
Conclusion
The use of complementary and alternative medicine is widespread, and it behoves the healthcare professional to recognise its significance to some patients. Clinicians would do well to be better informed on this subject, in order to participate in relevant clinical decisions from a more knowledgeable position. This is especially pertinent in the field of oncology, where patient's treatment choices may have a serious negative effect on survival. Healthcare professionals' recognition and acceptance of complementary and alternative medicine as indeed having a potential complementary role is necessary in order to avoid (or minimise) harm to patients.
