A Cancer diagnosis is often a serious and life changing event that affects both individuals and their families. Every year over one million Americans are diagnosed with Cancer and Cancer is currently the second leading cause of death in the United States ¹.

Cancer is a term that refers to a group of over 100 diseases in which abnormal cells divide without control ². Cancer cells begin to grow out of control and then invade nearby tissues and spread into other parts of the body through the bloodstream and the lymph system. Individuals diagnosed with cancer often seek out every possible method of combating the disease. Of all the possible treatment options, Complementary and Alternative Medicine is one of the most misunderstood and polarizing options.

Although commonly grouped into one category of treatment options, Complementary and Alternative Medicine refers to two distinct categories:

• Complementary Medicine – any health care systems, practices, and products not presently considered to be part of conventional medicine that are used together with a conventional medicine program ^{3, 4, 5}.
• Alternative Medicine – any health care systems, practices, and products not presently considered to be part of conventional medicine that are used in place of a conventional medicine program ^{3, 5}.

Complementary medicine is fairly common throughout the United States with an estimated 36% of Americans regularly using some form of non-conventional medicine in conjunction with their conventional medical treatments (this number climbs to 62% if prayer for health related issues is included) ^3,4. Massage therapy, guided imagery, exercise, and sound therapy for children which were all once considered non-conventional have become used in many large hospitals as pain management and stress reducing treatments ⁵. In regards to alternative medicine, very few individuals truly practice only alternative methods for all of their medical needs ⁵.

Another term that is often used in public discussion and marketing materials is “Integrative Medicine”. Integrative medicine refers to a patient centered medical approach in which the primary goal is the wellness and healing of a patient ⁵. To accomplish this physicians combine facets of conventional, complementary, and alternative medicine into a patient specific approach.

Regardless of the definition or approach chosen, two key facts about Complementary and Alternative Medicine remain true:
1. The use of Complementary, Alternative, and Integrative medicine is growing rapidly. Over 20% of American health care facilities offer some form of CAM treatment (yoga, massage, nutrition, etc.). This number has doubled within the past ten years ⁶.
2. No Complementary health practice has been clinically proven to cure cancer. However, some complementary approaches may help people manage cancer symptoms or treatment side effects and improve their quality of life ^{6, 7}.

In a 2008 study, researchers examined the demographics of cancer patients who had used CAM in order to try and understand the United States’ complementary and alternative medicine picture. The results are summarized as:

• Women are more likely than men to use some form of CAM ⁸.
  • The reasons for this are not fully understood. One potential explanation may be that women in the United States tend to pay more attention to their health (healthier behaviors and have more frequent physician visits) than men ⁸.
• Higher income individuals are more likely than lower income individuals to use some form of CAM ⁸.
  • Potential explanations for this may include higher out of pocket costs for CAM treatment options, and increased access to the internet and other research resources.
• Higher educated individuals are more likely than individuals with less education to use some form of CAM ⁸.
  • Higher education and higher income are positively correlated – increased access to, and the ability to, use the internet to positively research complementary treatment options may be a possible explanation for this finding⁸.
• Younger cancer patients (21-48) are more likely to use at least one form of CAM than older patients ⁸.
  • The reasons for this are not fully understood. One potential explanation is that, when surveyed, older adults have a stronger belief in conventional medicine than younger patients.
• Racially, non-Hispanic whites were the most likely to use at least one form of CAM during their cancer treatment ⁸.
  • Non-Hispanic whites were the most likely to use any form of CAM during their cancer treatment, however this varies racially when examining a specific type of CAM. For example:
    • African Americans were more likely to use both spiritual/faith-based and non-spiritual/faith based mind and body CAMs than non-Hispanic whites⁸.

The reasons for which an individual may choose to seek out Complementary and Alternative medicine for their cancer treatment varies. When surveyed, the most common responses by both cancer patients and cancer survivors as to why they chose to use some form of CAM were to:

• Help cope with the side effects of conventional cancer treatments (nausea, pain, fatigue, etc.) ^{8, 9}.
• Comfort themselves and ease the worries of cancer treatment and cancer related stress ^{8, 9}.
• Feel that they are doing something more to help with their own care ^{8, 9}.
• Help “cure” their cancer (or the patient has alternative beliefs about disease and health and prefers alternative therapies) ⁹.

The numerous forms of Complementary and Alternative Medicine can best be categorized into four general categories ¹⁰:
1) Mind-Body Practices
2) Biologically Based Practices
3) Manipulative and Body-Based Practices
4) Whole Alternative Medical Systems

This group of complementary treatment options are based on the belief that an individual’s mind is able to affect their body. Listed below are seven of the most commonly discussed Mind-Body complementary medicine therapies.

Meditation:
Meditation can be defined as a practice of concentrated focus upon a sound, object, visualization, the breath, movement, or attention itself in order to increase awareness of the present moment, reduce stress, promote relaxation, and enhance personal and spiritual growth ¹³. Meditation has been practiced for thousands of years and nearly every major religious and spiritual tradition has references of some sort of meditative practice. Despite its original religious rooting, meditation is a secular practice and not exclusively associated with any modern religion.

In regards to Cancer therapy, Meditation has had some of the most positive clinical results of all Complementary and Alternative therapies. In a recent 2014 systematic review of randomized controlled trials on the use of integrative therapies during breast cancer treatment, Meditation received an “A” evidenced based practice recommendation as being effective in helping Breast Cancer patients manage anxiety, stress, insomnia, mood disturbances, and depressive symptoms ^{3, 11, 12}. Meditation has been found to positively improve cancer patient’s quality of life ¹³.

Negative complications resulting directly from mediation are extremely rare. A sense of panic and mood disturbances have been reported in patients who had preexisting mental disorders ¹³. Meditation often involves sitting either on the floor, on a pillow, in a chair, or lying down. Patients with skeletal issues or other bodily injuries have reported discomfort in specific positions.

Meditation is often taught in small group classes (either within the health care facility or through a community program) with the most popular meditative practice style taught being Mindfulness Based Stress Reduction (MBSR) ¹³. MBSR is often practicing sitting or standing in a single location for a period of time and often involved a patient focusing on sound, objects, visualization, attention or breath. Movement based meditative practices such as Tai Chi often take place in a group setting outdoors or in a space which allows for freedom of movement. Once patients have learned the general principles of any meditative practice, it is possible to continue to practice individually at home or in a health care facility.

Yoga
Yoga is one of the oldest recorded mind-body practices in existence. The word Yoga is derived from an ancient Sanskrit word meaning “Union” ¹⁴. Originating in ancient India over 5,000 years ago, yoga has evolved into something of a cultural phenomenon in the United States.

Yoga is defined by Merriam-Webster as a system of exercises for mental and physical health ¹⁵. This “system of exercises” typically includes precise postures, breathing exercises, and meditation. Although there are over 100 different styles of yoga currently practiced in the United States, the essential goal of yoga is to achieve pure awareness without mental distractions. To accomplish this, Hatha yoga (the most common form of yoga) teaches self-control, guided movements, breath control, and attention, and meditation ¹⁴.

Hundreds of clinical trials have examined the significance of yoga in the clinical setting. In regards to cancer therapy, yoga has been found to positively affect cancer patient’s moods, reduce feelings of depression, and help to reduce stress and anxiety ¹⁴. For fatigued patients, it has been found to be a positive form of exercise. Yoga has also been found to help cancer patients of all ages improve flexibility and balance and can help manage lower back pain ¹⁴.

The majority of yoga practices involve some form of movement. As such, it is advisable for patients to consult their health care teams prior to beginning any sort of program ^{14, 16}. Injuries due to overstretching, falls, and overexertion have been reported. Pregnant women should avoid postures involving heavy twisting ^{14, 16}. Some yoga disciplines may practice within a heated room. As such, dehydrated, sick or pregnant patients should consult their health care teams prior to partaking in any hot yoga practice ¹⁶.

Spirituality/Religion
National surveys have concluded that over 90% of American Adults believe in the idea of a God and that over 70% of surveyed individuals identified religion as an important life influence ^{8, 17}. Religion can be viewed as a specific set of beliefs and practices associated with a recognized religion or denomination. Spirituality is generally recognized as encompassing experiential aspects, whether related to engaging in religious practices or to acknowledging a general sense of peace and connectedness.

The role of religion and spirituality in health care has been examined through hundreds of studies. In regards to cancer therapy, the results have been mixed. Prayer, attending religious service, participating in a religious community, or practicing gratitude have been shown to positively affect the way that advanced cancer patients cope with terminal illness ^{17, 18}. Overall spiritual-well-being was shown to positively affect cancer patient’s reports of depression and mood disturbances ¹⁸.

A large 2006 study examined the effect of receiving prayer from others in the recovery of heart patients. Groups of patients were told that they were to receive prayer – one group did, one group was told that they would but did not, and one group was not told and did not. The results of the experiment did not show any statistically relevant reduction of medical complications or improved outcomes as the result of receiving prayer ¹⁸.

Incorporating spirituality into conventional care can be difficult for many providers. For many health care professionals, especially in situations in which the provider and the patient have different religious beliefs, this can be very uncomfortable personally ¹⁷. Large health care facilities often have onsite chaplains and spiritual advisors who may be able to help provide spiritual or religious interventions and aid as necessary.

Imagery

Imagery is a form of mental exercise in which the patient imagines sights, sounds, or other sensations in order to create a purposeful daydream ¹⁹. Imagery has been used in medical practice for centuries ⁸. 13 th century Tibetan monks recorded the use of mental imagery to picture the treatment of diseases ¹⁹.

Imagery can involve practices such as imagining yourself in a peaceful scene of your choosing and visualizing every aspect and sensation of the scene. Athletes have traditionally used goal-oriented imagery in order to visualize a desired outcome ¹⁹.

The use of imagery as a form of “self-hypnosis” has been found to be clinically effective in reducing anxiety and stress in patients receiving conventional cancer treatment ^{3, 19}. Clinical trials involving breast cancer patients found that patients who performed imagery related practices prior to surgery or radiation treatment were less anxious about the procedures ^{3, 19}. Overall, imagery is effective in helping to manage specific side effects of chemotherapy and is generally very safe (as well as inexpensive) for cancer patients.

Music Therapy
Music therapy is the use of music by health care professionals to promote healing and improve a patient’s quality of life ^{20, 21}. Music therapy is practiced within a health care facility by trained music therapists. Music therapy typically includes listening to music, making music, writing new music, singing, and discussing music ²⁰. It can be either in a group setting or on a one-on-one basis.

Music has been used as healing method for thousands of years. There is documentation of Native Americans and ancient Greeks using music to heal specific ailments ²⁰. Today there are thousands of certified music therapists working within the United States health care system and music therapy is covered by a variety of large insurance programs.

Clinical evidence has shown music therapy to be effective on a short-term basis in reducing anxiety, severity of pain, stress, and the severity of nausea in patients undergoing chemotherapy ^{8, 20} . On a long term basis, music therapy does not appear to reduce pain, fatigue or depression in patients receiving long term chemotherapy ²⁰.

Although music therapy is safe for widespread use, it is important to note that musical interventions by untrained personnel can have ineffective or adverse effects. Studies have shown that untrained personnel can cause increased anxiety and stress through poorly executed musical interventions ²⁰.

Hypnosis
Hypnosis is a state of restful alertness in which an individual uses deeply focused concentration ²² . When under a state of hypnosis the individual is often relatively unaware, but not completely blind, to their surroundings ²³. Hypnosis in a health care setting is typically performed by a trained hypnotherapist, psychiatrist, or psychologist and involves a variety of hypnotic techniques.

Hypnosis has been found to be clinically effective at reducing (or eliminating) certain phobias in patients ^{22, 23}. In regards to cancer patients receiving chemotherapy, hypnosis has been found to be most effective at reducing anticipatory nausea and vomiting ²³. Hypnosis can be a helpful complementary therapy when used in conjunction with conventional cancer treatments.

Hypnosis is generally considered safe, however mood disturbances and emotional responses to hypnosis have been reported in patients ²³. Patients with preexisting mental illness should not be hypnotized without the approval of their physician.

Aromatherapy and Essential Oils
Aromatherapy is the use of fragrant natural substances (in most cases essential oils) to alter a patient’s mood or quality of life ²⁴. Aromatherapy is usually performed by a trained aroma therapist and can be incorporated as part of massage or bath. Typically, an essential oil is applied to boiling water and the steam is then inhaled ^{24, 25}. Essential oil mixtures, salves, or lotions can also be applied directly to the skin by aroma therapists.

Clinical trials into the efficacy of aroma therapy are in their infancy. As such, there is very little concrete evidence into the ability for aroma therapy to help manage the symptoms of cancer patients in any way ²⁴. Small studies have reported minor benefits in reducing stress, anxiety and possibly nausea in patients undergoing cancer treatment ^{26, 27}.

Although aromatherapy is generally considered to be safe, many essential oils are toxic if ingested. External use only is recommended. Other potential negative issues are skin irritation, allergic reactions, and eye irritation ²⁶. Pregnant or nursing women should check with their physician prior to practicing any form of aromatherapy ²⁷.

This group of complementary medicine refers to biologic therapies and interventions that are not yet accepted in main stream medicine. Listed below are four of the most commonly practiced biological based practices.

High Dose Vitamin C Infusions
Vitamin C, also called L-ascorbic acid or ascorbate, is a key nutrient that humans must get from food or other sources since it is not naturally produced within the human body ^{28, 29, 30}. High Dose Vitamin C infusions normally involve an infusion of approximately 1.5 grams of Vitamin C per kilogram mixed with sterile water ²⁹. Intravenous administration allows for significantly higher levels of Vitamin C absorption in the bloodstream when compared to vitamin c taken by mouth ²⁹.

Vitamin C has been touted in public media as a “cancer killer”, however the current clinical evidence surrounding vitamin C infusions is mixed ^{29, 30}. Vitamin C infusions were shown to improve the quality of life for breast cancer patients receiving chemotherapy. Symptoms such as nausea, fatigue, appetite loss, and pain were reduced with regular administration ^{28, 29}. Several animal based studies have shown promising results of blocked tumor growth and an increased effectiveness of certain chemotherapy drugs. Although there are a number of large clinical trials currently underway, past clinical trials have shown several potential issues and drug interactions. These include:

• Patients with acute myeloid leukemia, refractory metastatic colorectal cancer, or metastatic melanoma developed serious negative side effects and their disease progression got worse when treated with Vitamin C ²⁹.
• Patients with a history of kidney disorders should be cautious about attempting a Vitamin C treatment ^{29, 30}. Kidney failure was reported at an increased rate.
  • Patients with a history of developing kidney stones should not be treated with Vitamin C.
• Patients with G-6-PD deficiency should not be treated with Vitamin C due to a risk of hemolysis ²⁹.
• Patients with hemochromatosis should not be treated with Vitamin C. High doses of vitamin C seem to make iron more easily absorbable in the body ²⁹.
• Patients currently taking Bortezomib should avoid Vitamin C therapy until further evidence is available ²⁹ . Several animal studies showed evidence of Vitamin C reducing the effectiveness of Bortezomib treatment.
• Dehydroascorbic acid, a specific form of Vitamin C, should be avoided until further evidence is available ²⁹ . In several separate animal tests Dehydroascorbic acid was shown to reduce the effectiveness of a variety of Chemotherapy drugs ²⁹.

Although further clinical evidence will be needed in order to fully illustrate the cancer fighting capabilities of Vitamin C therapy, Vitamin C infusion therapy has been proven to be an effective complementary treatment to most forms of chemotherapy and radiation therapy²⁹. It has been proven to reduce several of the negative side effects associated with aggressive conventional cancer care and can therefore improve cancer patient’s quality of life.

Cannabis and Cannabinoids
Cannabis (commonly referred to as marijuana) consists of the dried leaves and the flowering tops of the cannabis sativa or cannabis indica plant. Cannabis contains active chemicals called cannabinoids that cause drug-like effects throughout the body. The main active cannabinoid in marijuana is delta-9-tetrahydrocannabinol (THC) ³¹.

Cannabis has been used for medical purposes by a variety of cultures around the world for thousands of years. Currently, the possession of cannabis is illegal in most of the United States ³². Several states have enacted laws to legalize its specific medical use.

Cannabinoids have been identified as clinically effective complementary treatments for the control of nausea and vomiting in cancer patients ³¹. Dronabinol and Nabilone (both synthetic derivatives of delta-9-THC) are approved by the United States Food and Drug Administration for the treatment of Cancer therapy associated nausea and vomiting ^{31, 32}.

• In numerous studies, both Dronabinol and Nabilone were found to be more effective than conventional antiemetics (prochlorperazine, metoclopramide, chlorpromazine, thiethylperazine, haloperidol, domperidone, and alizapride) ³¹.
• Dronabinol was found to be statistically significant in increasing appetite and calorie intake in HIV patients, however when tested against megestrol acetate in cancer patients it was found to be as effective but not statistically superior ³¹. Synthetic cannabinoids do have a variety of potential side effects and issues ^{31, 32}:
• Patients may experience drowsiness, abrupt mood changes, or a sense of high that some find uncomfortable.
• Hallucinations have been reported by patients taking Nabilone.
• Sleepiness
• Dry Mouth
• Trouble concentrating and focusing on detailed tasks. Patients should be supervised and should not operate a vehicle or other heavy machinery while taking cannabinoids.
• Women who are pregnant or nursing should not use cannabinoids in any form.

Although synthetic cannabinoids have proven clinically effective for managing nausea and vomiting in cancer patients, the majority of marketing and media coverage focuses on inhaled cannabis. Cannabis has proven difficult for clinical researches to study based on the variability in THC levels of specific strains and crops of cannabis and the current national legal situation ³¹. Cannabis is typically either smoked, inhaled (with the use of a vaporizer), or consumed orally (through a tea or some sort of food) ³².

Inhaled cannabis has proven to be effective at reducing cancer patient’s symptoms of anxiety and stress ³¹. Small studies involving healthy patients (patients who did not have cancer) found cannabis to positively increase appetite and increase calorie consumption³². Further studies are necessary in order to clinically recommend Cannabis use for treating cancer related anorexia. In another small study, advanced cancer patients who inhaled cannabis while receiving sustained-release morphine has a significantly lower mean pain score over a 5 day period ³¹. Again, further clinical trials are necessary before this can be recommended as an evidence based practice. Noteworthy potential side effects and issues of inhaled cannabis include ³²:

• Sleepiness
• Improved mood
• A sense of well-being and relaxation
• Reduced anxiety
• Paranoia has been reported in certain cases
• Patients with a history of mood disorders have experienced rapid mood swings
• Difficulty concentrating, reduced response times, and confusion
• Changes in the perception of time and space
• Chemosensory changes involving sound, taste, feel, and smell.
• Low Blood Pressure
• Heart Palpitations
• Women who are pregnant or nursing should not use marijuana in any form. Studies have associated cannabis use while pregnant or nursing to an increase in stillbirths, and an increase in childhood developmental issues ³².
• Although marijuana smoke contains many of the same carcinogens as tobacco smoke, studies linking marijuana smoke with cancer development have been inconclusive ³¹.
• Marijuana overdoses in children have resulted in hospitalization. Marijuana overdoses in pets have resulted in severe issues and dog and cat deaths ^{31, 32}.

In conclusion, cannabis and cannabinoids have been found to be clinically effective in certain roles however further evidence is needed in order to support many of the popular usage claims. The classification of Marijuana as a Class I controlled substance by the United States Drug Enforcement Administration imposes many difficulties on both researchers and patients seeking this form of complementary therapy.

Nutrition, Special Diets, and Vitamin Supplements
One third of all cancer related deaths are linked to issues in diet and physical exercise ³³. With that in mind there is a huge amount of public discussion about vitamin supplements and current surveys estimate that over 50% of US adults currently take some form of regular vitamin supplement ³⁴.

In regards to cancer prevention or symptom management, the simple answer is that a vitamin (or supplement) a day is not guaranteed to keep the cancer away. Clinical studies involving everything ranging from Vitamin D, Selenium, Lycopene, Ginger, Omega-3 Oils, Coffee, Multivitamins, Soy, Antioxidants, Shark Cartilage, and even Green Tea have not found any statistically significant results among large populations involving cancer prevention or reduction ^35-38. Simply taking a popularly suggested supplement regularly will not replace the positive effects of life long exercise and proper diet. For more information regarding the American Cancer Society’s dietary guidelines please refer to the link listed below:

http://www.cancer.org/healthy/eathealthygetactive/acsguidelinesonnutritionphysicalactivityforca
ncerprevention/acs-guidelines-on-nutrition-and-physical-activity-for-cancer-prevention-summary

The forms of complementary and alternative medicine in this category focus on the structures and systems of the human body (tissues, muscles, bones, skin, circulatory system, etc.). Listed below is the current evidence for two of the most common manipulative and body-based practices for cancer patients.

Massage
Massage involves the rubbing or kneading of a patient’s muscles and tissues in order to promote relaxation. There are dozens of different massage styles and massage provided in a health care setting is practiced by licensed and trained practitioners. Currently, massage is one of the most common forms of complementary and alternative medicine offered in American health care facilities ^{25, 39}. In a recent survey of Cancer clinics, over 50% offered some form of massage therapy ^{39. 40}.

The use of massage for relaxation, sports, and war injuries dates back to ancient cultures from the Arabian Peninsula and southern Asia ³⁹. In regards to cancer therapy, the current evidence is conflicting. Despite many practitioner’s claims that regular massage therapy can reduce or prevent cancer, there is no clinical evidence to support this fact ³⁹. However, in terms of symptom management there is positive clinical evidence that massage therapy may help improve cancer patient’s moods, decrease stress, and improve a patient’s overall quality of life ^{8, 39}.

Small studies involving cancer patients undergoing treatment for lymphedema found that a special form of massage therapy (Manual Lymph Drainage) can be a beneficial part of Complex Decongestive Therapy ³⁹. Manual Lymph Drainage, when combined with skin care routines, compression clothing, and special exercises can be an effective therapy option for patients with lymphedema ³⁹. Manual Lymph Drainage is normally practiced by trained lymphedema specialists.

It is crucial that cancer patients seek out massage professionals who have experience working with clients undergoing cancer therapy. Inexperienced professionals may cause severe injuries, especially to patients who are currently undergoing chemotherapy, radiation therapy, or who are currently taking some form of blood thinner (Warfarin) ^{39, 40}.

Acupuncture
Acupuncture is defined as the stimulation of specific points on the body (acupuncture points) through needling, cupping, warming, moxibustion (burning/warming an herb above a specific point), or acupressure (massage at a specific point) ⁴².

The origins of acupuncture can be traced back 4,000 years to ancient China ^{41, 42}. Acupuncture is a form of the Traditional Chinese Medicine system and has been in practice within the United States for nearly 200 years. However, it was not until the 1970’s, when United States and Chinese diplomatic ties were resumed, that acupuncture began to spread outside of small traditional Chinese immigrant communities. In 1996, the United States Food and Drug administration recognized the traditional acupuncture needle as an official medical device ⁴².

There is a wide variety of clinical studies investigating acupuncture in relation to cancer therapy. Although there is no statistically significant evidence regarding cancer prevention or reduction, several studies have found Acupuncture to be an effective therapy in regards to symptom management ⁴¹. In a small study, Acupuncture was found to be as effective at reducing vomiting symptoms related to chemotherapy and radiation as the placebo drug ⁴². Acupuncture has also been found to be effective at reducing stress and improving muscular range of movement in cancer patients ⁴².

When practiced by a trained professional, traditional acupuncture is considered safe for most patients. In the United States sterile one-time-use needles are required by law and the risk of infection is relatively low ^{41, 42} . Cancer patients who may be traveling to Asia in search of Acupuncture treatments should be cautious. Standards, cleanliness, and licensing vary per country and the risk of potential infection is higher.

Whole alternative medical systems are often referred to as Eastern Medicine, Asian Medicine, Non-Traditional Medicine, or Alternative Medicine. These medical systems contain complex therapies and approaches and are often practiced by specially trained practitioners. Although the usage of these entire systems are generally low in the United States, individual components of these systems are quite popular. Listed below are four of the most common Whole Alternative Medical Systems.

Ayurvedic Medicine
Ayurvedic Medicine, or Ayurveda, is an ancient Indian medical system which focuses on maintaining or reestablishing harmony between the mind, body, and forces of nature ^43-45. Ayurvedic medical practices are well integrated within the Indian National Health Care System and it is estimated that over 80% of the Indian population uses some form of Ayurvedic medicine ⁴⁵. The term Ayurveda consists of the Sanskrit words Ayur (life) and veday (Knowledge or science) ⁴⁵ . Ayurvedic practitioners diagnose patients through careful observation of the nine doors: both eyes, both ears, both nostrils, mouth, genitalia, and anus ⁴⁵. They also observe the patient’s pulse, lungs, and personal history and work to balance a patient’s dosha (a person’s physical, emotional, and spiritual characteristics as well as his or her daily habits and lifestyle) with their external environment ^{44, 45}.

Patient care involves a wide variety of practices such as: changes in lifestyle, Ayurvedic medicines, cleansing or detoxifying, massage, exercise, yoga, and meditation ^{43, 45}. As a whole, there are few western studies into the effectiveness of the Ayurvedic medicine system in the treatment of cancer. As such, there is no clinical evidence supporting claims that Ayurvedic medicine alone is able to treat cancer or minimize the spread of cancer ⁴⁵. However, certain facets of Ayurvedic medicine (yoga, proper diet, and meditation) have been proven to be clinically effective in managing cancer treatment related symptoms ^{43 - 45}.

There are several health concerns involved with Ayurvedic medicine. Firstly, a 2008 study of Ayurvedic medicines found that of 193 commonly sold online remedies 20% of the herbal mixtures contained lead, mercury, and/or arsenic levels above the United States’ maximum daily intake levels ^{43, 45, 46}. There have been few reported poisonings related to Ayurvedic medicine, however this is still of concern for cancer patients. Another crucial issue is that currently no states license Ayurvedic practitioners ⁴⁵. As such, there is very little standardized regulation in the United States. NAMA (National Ayurvedic Medical Association) has begun to require 500 training hours prior to individual practice and is currently working to standardize specialty areas and facility requirements ⁴⁵.

Chinese Medicine

Traditional Chinese Medicine is a complex alternative medical system that involves an extensive variety of herbal medicine, forms of acupuncture, Tui Na (Chinese Therapeutic Massage), Tai Chi, Qi Gong (similar to Tai Chi), and dietary changes ⁴⁷. Traditional Chinese Medicine (TCM) originated in ancient China and has spread to nearly every continent. Today, over 40 states license TCM practitioners and there are at least 50 TCM colleges in the United States ^{47, 48}. It is estimated that over 1.5 million patients visit TCM practitioners each year in the United States.

Traditional Chinese Medicine is based on the idea that the human body is a smaller version of the larger surrounding universe and that a balance must be maintained between yin and yang (two opposing forces) ⁴⁷. Harmony between these forces supports health–imbalance between these opposing yet complementary forces creates illness ⁴⁷.

Clinical studies involving the effectiveness of TCM in treating serious disease have been non-conclusive and did not produce statistically significant results. Western researches are worried that the large scale studies recently performed in China may not be representative of the actual study results. Recent reports have shown that Chinese researchers have purposefully withhold negative results and have published only the studies showing positive outcomes ⁴⁹.

Regardless of the evidence concerning TCM as a whole medical system, individual facets of TCM such as Acupuncture and movement based meditation (Tai Chi and Qi Gong) have been found to help cancer patients manage particular cancer therapy related symptoms^{47, 48}. Most United States TCM practitioners do not make claims that TCM can cure cancer; in fact, many promote their services as complementary (rather than as an alternative) to traditional medical care ⁴⁸.

There are several safety related concerns for Traditional Chinese Medicine:

• TCM herbal medications are not regulated by the FDA and are considered to be dietary supplements. It is possible that specific herbs or mixtures could interact with traditional medication and cause negative side effects.
  • The Chinese plant (Ma Huang), commonly known as ephedra, has been linked to serious complications, especially in patients with heart issues ⁴⁷. Ephedra has been prohibited from sale in the US as a weight loss supplement but is still available in many traditional TCM herbal medications.
  • There have been reports internationally of heavy metal contamination of mass produced TCM herbal medications ^{47, 48}. Care should be taken whenever considering a TCM herbal medicine.
• The same warnings listed earlier concerning acupuncture and movement based meditation apply.

Homeopathy
Homeopathy is an alternative medical system that originated in Germany 200 years ago. Homeopathy is perhaps one of the most controversial and polarizing alternative medical systems in the world. It is based on two key viewpoints:

• The Law Of Similars – the idea that a substance that causes an illness can cure that illness if given in small enough quantities ^{50, 51}.
• The Law of Infinitesimals – The idea that the more diluted a substance becomes the more powerful it becomes ^{50, 51}.

Homeopathy is controversial because the two views listed above directly oppose the foundations of modern chemistry, physics, and pharmacology. There is currently no scientifically sound way in which researchers are able to justify the idea that a remedy containing little to no active ingredients should have any effect greater than the placebo remedy ^50-53. Further, many treatments are personalized to the patient and as such there are few standardized treatment options available for comprehensive study ⁵⁰.

Other than anecdotal references and patient testimonials, there have been no clinical studies showing homeopathy to be effective at treating any specific ailment ^{50, 51}. Homeopathy has not been clinical proven to help to manage any cancer related symptom ⁵⁰.

Despite the comprehensive lack of international clinical results, Homeopathy has continued to grow worldwide and it is estimated that 3.9 million US adults used some form of Homeopathic remedy within the past year ⁵⁰ . The out of pocket costs for Homeopathic medicine are estimated at $2.9 Billion ⁵¹ . Licensing of Homeopathic medicine varies from state to state and Arizona, Connecticut, and Nevada are the only states who have a standing Homeopathic licensing board for doctors ^{50, 51}.

There are several safety related concerns for Homeopathic Medicine:

• Most Homeopathic medicines are considered safe due to the low amount of concentration in the specific solution. However, there is a potential for drug interactions when taken as a complementary form of medicine ⁵¹.
• Homeopathic providers have recently begun to promote the usage of “nosodes” or “homeopathic immunizations” as substitutes to conventional immunizations. There is no clinical evidence suggesting that these alternate immunizations are effective in any way at preventing disease ⁵⁰. The Centers for Disease Control (CDC) and the National Center for Complementary and Alternative Medicine (NCCAM) support the national policy of conventional childhood immunizations ^{50, 51}.
• Certain homeopathic drugs, when independently tested, have been found to contain none of the stated active ingredients ⁵² . This is either due to unscrupulous providers or due to an ingredient concentration so minimal that it is not able to register as a present ingredient.

Naturopathic Medicine
Naturopathic Medicine, or Naturopathy, is a European alternative health care system with origins in the late 19 th century. Naturopathy focuses on the healing power of nature and on treating the entire person ⁵⁴ . Treatment options typically include nutrition counseling, vitamins, herbal remedies, therapeutic massage, exercise, and lifestyle coaching ^{54, 55}.

There are few studies examining naturopathy as a comprehensive practice ⁵⁴. Individual components of naturopathy such as regular exercise, therapeutic massage, and healthy diet have been found to be individually effective at managing particular symptoms and preventing disease ^{54, 55}. However, as a whole alternative medical practice there is currently no large scale clinical evidence supporting claims that naturopathy can cure specific diseases or ailments ⁵⁴.

In the United States there are three general categories of naturopathic providers: Naturopathic Physicians, Traditional Naturopaths, and other health care providers who incorporate naturopathic practices ⁵⁵ . Licensing requirements vary per state and any patients interested in working with a naturopathic provider should research their specific qualifications.

Specific safety related concerns are:

• Certain Naturopathic providers have recently begun to promote the usage of nontraditional remedies as substitutes to conventional immunizations. There is no evidence suggesting that these alternate forms of immunization are effective in any way at preventing disease ^{54, 55}. The Centers for Disease Control (CDC) and the National Center for Complementary and Alternative Medicine (NCCAM) support the national policy of conventional childhood immunizations ^{54, 55}.
• Naturopathic providers may be licensed in a specific state to prescribe drugs. As such it is crucial for patients to coordinate care between each of their providers in order to avoid potential drug interactions ^{54, 55}.

Complementary and Alternative medicine is a diverse world in which cancer patients can easily become lost. As health care providers, it is our responsibility to help present CAM options as objectively and comprehensively as possible for interested patients. Further, we should strive to create facilities and processes that encourage the discussion of complementary options and create an environment in which the patient feels safe and comfortable enough to discuss their interests.

As evidenced above, certain CAM options are clinically effective solutions for improving a cancer patient’s quality of life and helping them manage specific solutions. It is important to remember that the word “natural” does not necessarily mean safe and that the “history and longtime use” of a practice does not automatically justify its safety. Health care providers should consider each of the treatment options available, as well as the current evidence available, in order to create an effective health care plan for a patient.

(1) National Cancer Institute. (2011). SEER Stat Fact Sheets: All Cancer Sites. Retrieved from:http://seer.cancer.gov/statfacts/html/all.html
(2) National Cancer Institute. (2014). What Is Cancer? Retrieved from:http://www.cancer.gov/cancertopics/cancerlibrary/what-is-cancer
(3) Deng, Gary, Frenkel, Moshe, Cohen, Lorenzo, and et. al. (2009). Evidence Based Clinical Practice Guidelines for Integrative Oncology: Complementary Therapies and Botanicals. Journal of the Society for Integrative Oncology. 2009 7(3) pg85-120. Retrieved online at: http://jncimono.oxfordjournals.org/content/2014/50/346.full.pdf#page=1&view=FitH
(4) National Center for Complementary and Alternative Medicine. (2008). The Use of Complementary and Alternative Medicine in the United States. Retrieved from:http://nccam.nih.gov/news/camstats/2007/camsurvey_fs1.htm
(5) National Center for Complementary and Alternative Medicine. (2014). Complementary, Alternative, or Integrative: What’s in a Name? Retrieved from:http://nccam.nih.gov/health/whatiscam
(6) National Cancer Institute. (2014). Complementary and Alternative Medicine in Cancer Treatment: Questions and Answers about Complementary and Alternative Medicine. Retrieved from: http://www.cancer.gov/cancertopics/pdq/cam/cam-cancer-treatment/patient/page2
(7) National Center for Complementary and Alternative Medicine. (2013). Cancer and Complementary Health Approaches. Retrieved from: http://nccam.nih.gov/health/cancer/camcancer.htm
(8) Gansler, T., Kaw, C., Crammer, C. and Smith, T. (2008), A population-based study of prevalence of complementary methods use by cancer survivors. Cancer, 113: 1048–1057. doi: 10.1002/cncr.23659
(9) The American Cancer Society. (2014).What are Complementary and Alternative Methods? Retrieved from:
http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicin
e/complementaryandalternativemethodsandcancer/complementary-and-alternative-methods-and-
cancer-what-are-cam
(10) National Cancer Institute. Complementary and Alternative Medicine: What is Complementary and Alternative Medicine? Retrieved from: http://www.cancer.gov/cancertopics/cam
(11) Witek-Janusek L, Albuquerque K, Chroniak KR, et al: Effect of mindfulness based stress reduction on immune function, quality of life and coping in women newly diagnosed with early stage breast cancer. Brain Behav Immun 22(6):969–981, 2008.

(12) Matchim Y, Armer JM: Measuring the psychological impact of mindfulness meditation on health among patients with cancer: A literature review. Oncology Nursing Forum 34(5):1059–1066, 2007.
(13) The American Cancer Society. (2008). Meditation. Retrieved from: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/mindbodyandspirit/meditation
(14) The American Cancer Society. (2008). Yoga. Retrieved from: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/mindbodyandspirit/yoga (15) Yoga. (n.d.). Retrieved December 16, 2014, from http://www.merriam-webster.com/dictionary/yoga
(16) National Center for Complementary and Alternative Medicine. (2013). Yoga: An Introduction. Retrieved from: http://nccam.nih.gov/health/yoga/introduction.htm
(17) The American Cancer Society. (2012). Spirituality and Prayer. Retrieved from: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/mindbodyandspirit/spirituality-and-prayer
(18) Conway, Jiajoyce. (2010). Integrating Spiritual Care as Part of Comprehensive Caner Treatment. Oncology Nurse Advisor. December 2010. Retrieved from: http://www.oncologynurseadvisor.com/integrating-spiritual-care-as-part-of-comprehensive-cancer-treatment/article/192686/
(19) The American Cancer Society. (2008). Imagery. Retrieved from: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/mindbodyandspirit/imagery
(20) The American Cancer Society. (2008). Music Therapy. Retrieved from: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/mindbodyandspirit/music-therapy
(21) Clark M, Isaacks-Downton G, Wells N, et al. Use of preferred music to reduce emotional distress and symptom activity during radiation therapy. J Music Therapy. 2006; 43:247-265.
(22) Montgomery GH, Bovbjerg DH, Schnur JB, David D, Goldfarb A, Weltz CR, Schechter C, Graff-Zivin J, Tatrow K, Price DD, Silverstein JH. A randomized clinical trial of a brief hypnosis intervention to control side effects in breast surgery patients. J National Cancer Inst. 2007; 99:1304-1312.
(23) The American Cancer Society. (2008). Hypnosis. Retrieved from: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/mindbodyandspirit/hypnosis
(24) The American Cancer Society. (2008). Aromatherapy. Retrieved from: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/mindbodyandspirit/aromatherapy

(25) Fellowes D, Barnes K, Wilkinson S. Aromatherapy and massage for symptom relief in patients with cancer. Cochrane Database Systematic Review. 2004; (2):CD002287.
(26) Soden K, Vincent K, Craske S, Lucas C, Ashley S. A randomized controlled trial of aromatherapy massage in a hospice setting. Palliat Med. 2004; 18:87-92.
(27) The National Cancer Institute (2012). Aromatherapy and Essential Oils: Human and Clinical Studies. Retrieved from:
http://www.cancer.gov/cancertopics/pdq/cam/aromatherapy/healthprofessional/page5
(28) The National Cancer Institute. (2013). High Dose Vitamin C: An Overview. Retrieved from: http://www.cancer.gov/cancertopics/pdq/cam/highdosevitaminc/healthprofessional
(29) The National Cancer Institute. (2013). High Dose Vitamin C: Human and Clinical Trials. Retrieved from: http://www.cancer.gov/cancertopics/pdq/cam/highdosevitaminc/healthprofessional/page5
(30) The American Cancer Society. (2013). Vitamin C. Retrieved from: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/herbsvitaminsandminerals/vitamin-c
(31) The American Cancer Society. (2014). Marijuana. Retrieved from: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/herbsvitaminsandminerals/marijuana
(32) The National Cancer Institute. (2014). Cannabis and Cannabinoids: Human and Clinical Studies. Retrieved from:
http://www.cancer.gov/cancertopics/pdq/cam/cannabis/healthprofessional/page5
(33) The American Cancer Society. (2012). ACS Guidelines on Nutrition and Physical Activity for Cancer Prevention. Retrieved from: http://www.cancer.org/healthy/eathealthygetactive/acsguidelinesonnutritionphysicalactivityforcancerprevention/acs-guidelines-on-nutrition-and-physical-activity-for-cancer-prevention-intro
(34) Stobbe, Mike. (2011). Vitamins: How Many Americans Use Them? Huffington Post: Huffpost Good News. Retrieved from: http://www.huffingtonpost.com/2011/04/13/vitamin-use_n_848777.html
(35) Albanes D. Vitamin supplements and cancer prevention: where do randomized controlled trials stand? J National Cancer Institute. 2009 Jan 7; 101(1):2-4.
(36) Lawenda BD, Kelly KM, Ladas EJ, et al: Should supplemental antioxidant administration be avoided during chemotherapy and radiation therapy? J National Cancer Institute 2008; 100:773-783.
(37) Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin C. Accessed at http://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/
(38) Patterson RE, White E, Kristal AR, Neuhouser ML, Potter JD. Vitamin supplements and cancer risk: the epidemiologic evidence. Cancer Causes Control. 1997; 8:786-802.

(39) The American Cancer Society. (2013). Massage. Retrieved From: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/manualhealingandphysicaltouch/massage
(40) National Center for Complementary and Alternative Medicine. (2012). Massage Therapy: An Introduction. Retrieved from: http://nccam.nih.gov/health/massage/massageintroduction.htm
(41) The National Cancer Institute. (2014). Acupuncture: Human and Clinical Studies. Retrieved From: http://www.cancer.gov/cancertopics/pdq/cam/acupuncture/healthprofessional/page5
(42) The American Cancer Society. (2010). Acupuncture. Retrieved From: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/manualhealingandphysicaltouch/acupuncture
(43) National Center for Complementary and Alternative Medicine. (2013). Ayurvedic Medicine: An Introduction. Retrieved from:
http://nccam.nih.gov/health/ayurveda/introduction.htm
(44) Ayurveda. (2014, December 8). In Wikipedia, The Free Encyclopedia. Retrieved 15:48, December 16, 2014, from http://en.wikipedia.org/w/index.php?title=Ayurveda&oldid=637127059
(45) The American Cancer Society. (2011). Ayurveda. Retrieved from: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/mindbodyandspirit/ayurveda
(46) Kales SN, Saper RB. Ayurvedic lead poisoning: an under-recognized, international problem. Indian Journal of Medical Science. 2009 Sep; 63 (9):379-381.
(47) National Center for Complementary and Alternative Medicine. (2013). Traditional Chinese Medicine: An Introduction. Retrieved from: http://nccam.nih.gov/health/whatiscam/chinesemed.htm
(48) The American Cancer Society. (2011). Chinese Herbal Medicine. Retrieved from: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/herbsvitaminsandminerals/chinese-herbal-medicine
(49) Wu T, Li Y, Bian Z, and et al. Randomized trials published in some Chinese journals: how many are randomized? Trials. 2009 Jul 2; 10:46.
(50) National Center for Complementary and Alternative Medicine. (2013). Homeopathy: An Introduction. Retrieved from: http://nccam.nih.gov/health/homeopathy
(51) The American Cancer Society. (2013). Homeopathy. Retrieved From: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/pharmacologicalandbiologicaltreatment/homeopathy
(52) Ernst E. Homeopathy for cancer? Current Oncology 2007 Aug; 14 (4):128-130.
(53) Ernst E. A systematic review of systematic reviews of homeopathy. British Journal of Clinical Pharmacology. 2002; 54 (6):577–582.

(54) National Center for Complementary and Alternative Medicine. (2012). Naturopathy: An Introduction. Retrieved from: http://nccam.nih.gov/health/naturopathy/naturopathyintro.htm#hed8
(56) The American Cancer Society. (2013). Naturopathic Medicine. Retrieved From: http://www.cancer.org/treatment/treatmentsandsideeffects/complementaryandalternativemedicine/mindbodyandspirit/naturopathic-medicine