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We must let patients know we are on their side and make every effort to ascertain and deliver what it is they seek from treatment
MJA 1996; 165: 536
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In this issue of the Journal, Begbie and colleagues show once again the continued attraction of alternative medicine or unproved remedies. In many developed countries, a large proportion of the general public (nearly half over 12 months, according to a recent survey in South Australia 1 ) attend alternative practitioners, use unconventional therapies, or both. It seems not to matter whether the country has a universal health scheme or not; the public is prepared to spend large sums on alternative treatment, as shown in studies from both the United States 2 and the United Kingdom. 3 Several of the surveys have shown that among users of alternative practitioners and alternative remedies there is a bias towards younger, fitter people, towards women and towards the better educated.
However, it is not just the healthy who turn to alternatives. As the paper by Begbie and colleagues, and others, 4 shows, among cancer patients the use of alternative therapy is widespread. Why is this so and what can the medical profession learn from this?
Some of the attractions of alternative treatments for cancer are perhaps self-evident. When faced with an illness incurable by medical science, patients and their families understandably turn to those who claim that their remedies are effective, "natural" and harmless. Thus, alternative therapies abound not only for cancer but also for conditions such as multiple sclerosis and rheumatoid arthritis. These therapies do, however, come and go. Where now is copper ointment for rheumatoid arthritis? Where now is ozone treatment for HIV? For cancer, where now Krebiozen (a treatment popular in the 1950s), Milan Brych's secret remedy (of the 1970s) and Laetrile (from the 1980s)? Although these have gone, others have replaced them. In Australia, the most popular currently are diets, and psychological measures such as relaxation and meditation. As quoted by Begbie et al., there are "no unproven treatments for universally curable diseases". 5 It might also be relevant that there are few unproven treatments for conditions that can be more readily understood than cancer, such as pneumonia, bone fractures and venous thrombosis. When medical science has an effective treatment, even if it's not a cure, the alternative industry has little to offer.
An important message is that the profession should use its available treatments to best advantage. The current trend to "evidence-based medicine" will strengthen our hand, and guide doctors to the most effective treatments. For example, the publications on early breast cancer distributed by the National Breast Cancer Centre 6,7 should provide an effective answer to many patients' questions and may limit their need to seek help from the un qualified. Patients may not necessarily seek a "cure" -- effective symptom relief, using modern palliative care, may fulfil the needs of many.
It is also important for medical practitioners to gain patients' confidence so that they do not feel inhibited about discussing alternative treatments. The discussion may reveal that the patient feels pressured into trying some alleged cure by a well-meaning, but ill-informed, friend or relative. Straightforward scientific information about the lack of evidence of the "remedy" in question may be all that the patient is seeking. If the doctor is unfamiliar with the particular treatment, a Cancer Council will provide the information needed.
The discussion may reveal that what patients really seek is something that may be as readily available through orthodox channels as the unorthodox. All of the State and Territory Cancer Councils run their own support and self-help groups, or can refer patients to those organised by approved organisations and institutions. Meditation, social support and a sympathetic ear can also be found, if not through the Cancer Councils, then the oncology department of the local hospital should be able to point patients in the appropriate direction.
Should we be concerned? That so many patients seek "alternatives" not only indicates certain failings in the services provided by the profession, it actually exposes patients to potential harm. 8-10 Many so-called cancer diets are nutritionally inadequate, the costs may be substantial and "natural" does not necessarily equate to "harmless". Some natural substances that are far from harmless include snake venom, strychnine, toadstools, potato leaves and tobacco. Laetrile and comfrey, previously recommended for the treatment of cancer, carry their own dangers. Some allegedly natural herbal medications conceal their real ingredients. 11 There is also the danger that patients may forgo proven effective treatments for cancer, and their only chance of cure. None of this discussion denies the many shortcomings of orthodox medicine nor the potential dangers of our own prescriptions. Nor does it lessen the need for the scientific study of folk remedies in the hope of finding new effective "natural" treatments to follow, for example, aspirin (from willow bark) or paclitaxel (from the Pacific yew tree).
It is important for the public to know that we are on their side. With treatments for cancer, cure is the aim whenever possible, but always and above all else the aims are comfort and relief of suffering. The medical profession must ensure that a wide range of treatments and support services is available to cancer patients. Their needs can best be met by a doctor-patient partnership, by free discussion, and by use of measures of proven effectiveness.
Raymond M Lowenthal
Director of Medical Oncology, Royal Hobart Hospital, TAS
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