Handbook of Integrative Oncology Nursing
Defining Complementary and Alternative Medicine
Throughout this handbook, the acronym CAM refers to complementary and alternative medicine therapies, and the term conventional refers to traditional or standard approaches. Conventional approaches are those that historically have broad application in Western medicine (National Center for Complementary and Alternative Medicine [NCCAM], 2009). CAM therapies also are termed integrative, integrated, or complementary when these therapies are combined with conventional approaches. The term alternative refers to a CAM therapy that is used instead of a conventional treatment. The intention with which a therapy is used best describes it. The interchangeable use of these terms can cause miscommunication and misunderstanding between patients and healthcare professionals (HCPs), as well as among HCPs (Decker & Lee, 2005). Additional terminology is explained in Appendix I.
Whorton (1999) suggested that an awareness of the historical development of CAM is essential to understand the philosophical viewpoints among practitioners through the years to the present. Prior to the 19th century, unconventional methods of disease treatment were considered folk medicine or quackery. The second generation of developing medical systems began in the late 20th century and was represented within osteopathy, chiropractic, naturopathy, and hydropathy. Simultaneously, contemporary holism emerged, focusing on treating the “whole” patient. This led to the current movement of wellness promotion (Gallin, 2002). During the 1950s, nursing curricula made a distinction between patient needs and problems from a medical diagnosis (Black & Matassarin-Jacobs, 1993).
Contemporary Complementary and Alternative Medicine Use
Consumers continued to seek CAM therapies despite the medical advances of the 1970s and 1980s. Because of increasing significant issues within the field, the Office of Alternative Medicine (OAM) was established in 1992. In 1998, OAM became NCCAM. To increase high-quality research and information about CAM use specifically within the oncology population, the National Cancer Institute (NCI) established the Office of Cancer Complementary and Alternative Medicine (OCCAM) in 1998 as well. OCCAM is responsible for NCI’s resource agenda in CAM as it related to cancer prevention, diagnosis, treatment, and symptom management. In March 2000, the White House Commission on Complementary and Alternative Medicine Policy (2002) convened to further address significant issues such as access to and delivery of CAM, research priorities, and consumer and HCP education. In 2003–2004, the Institute of Medicine (IOM) of the National Academies, a non-government agency established in 1970, sponsored seven committee meetings to investigate scientific, policy, and practice questions that arise from the increasing use of CAM. IOM guarantees unbiased, evidence-based information and advice concerning health and science policy to policy makers, HCPs, and the public (IOM, 2004).
Surveys of Complementary and Alternative Medicine Use
Early surveys of CAM use were not population or diagnosis specific (Eisenberg et al., 1993; Ernst & Cassileth, 1998). However, by the beginning of 2000, researchers had accumulated sufficient amount of publishable data regarding CAM use in the oncology population (Ashikaga, Bosompra, O’Brien, & Nelson, 2002; Nam, Fleshner, & Rakovitch, 1999; Swisher et al., 2002). When compared with non-CAM users, individuals who use CAM are more likely to be female, better educated, and have higher incomes (Ernst & Cassileth; IOM, 2004; Sparber et al., 2000). Although the quality and quantity of information about CAM use have increased, much remains to be learned about specific indications and contraindications for specific therapies when used in specific clinical situations, as well as clarification of the role and scope of HCPs in CAM. Contemporary efforts speak to this clarification within professional societies and academic settings.
Guidelines for Complementary and Alternative Medicine Use
Formalized guidelines for CAM use were not in existence until recently. Theoretically, documents of this type offer a foundation for societal, academic, consumer, and healthcare approaches to CAM use. Examples are (a) Society for Integrative Oncology’s Evidence-Based Clinical Practice Guidelines for Integrative Oncology (see Appendix II) and (b) American Cancer Society’s (ACS’s) Guidelines for Using Complementary and Alternative Methods (ACS, 2009). They lack, however, recognition and acknowledgment of the fundamental role of nursing in integrative oncology. The position statement of the American Holistic Nurses Association (AHNA) directly addresses the nurse’s role in the practice of complementary and alternative therapies (AHNA, 2008). To recognize the fundamental role of nursing in cancer care, the Oncology Nursing Society (ONS, 2008) offered its position statement, The Use of Complementary and Alternative Therapies in Cancer Care (see Appendix III).
Integrative Oncology Nursing Role
Lee (2003, 2004) offered that oncology nurses must become knowledgeable in integrative oncology given the rapidly increasing use of CAM. The model for integrative oncology nursing care begins with the nurse, the patient, and other healthcare team members and endorses three core actions: (a) distinguishing fact from fiction, (b) acknowledging misperceptions about CAM, and (c) mixing and un-mixing therapies. End points for nursing are as follows (Lee, 2004):
- Expand individual baseline knowledge regarding cancer CAM through oral and written modes with experiential learning.
- Provide high-quality patient and peer education regarding safety and efficacy of CAM therapies.
- Facilitate partnerships between patients, conventional HCPs, CAM providers, and colleagues to discuss knowledge and perspectives about cancer CAM.
- Seek proper training, demonstrate competency, and obtain necessary credentials if practicing a CAM therapy.
- Request and require informed consent (with witness) of patients receiving a CAM therapy.
- Ensure proper credentialing of a CAM provider prior to recommending the provider to patients.
- Establish institutional-specific standards of practice for the use of CAM therapies within specific patient populations.
- Document patient consent procedures, tolerance, and response to CAM therapy.
- Design a new program or assist in the quality maintenance of a pre-established integrative care program.
- Develop and update a working knowledge of cost issues and reimbursement of CAM in the community.
- Collaborate in the design of methodologically rigorous cancer CAM treatment and supportive care clinical trials.
- Contribute to the body of nursing knowledge in cancer CAM through publications and presentations in the United States and internationally.
The future holds opportunities for nursing to demonstrate and claim a fundamental role in integrative oncology. This begins with the expansion of nurses’ knowledge of CAM. The goal of this handbook is to promote evidence-based practice within integrative oncology nursing by synthesizing present knowledge with regard to safety, efficacy, concurrent use with conventional therapy, and long-term use across the cancer continuum.
American Cancer Society. (2009). Guidelines for using complementary and alternative methods. Retrieved August 24, 2009, from http://www.cancer.org/docroot/ETO/content/ETO_5_3x_Guidelines_For_Using_
American Holistic Nurses Association. (2008). Position on the role of nurses in the practice of complementary and alternative therapies. Retrieved August 20, 2009, from http://www.ahna.org/
Ashikaga, T., Bosompra, K., O’Brien, P., & Nelson, L. (2002). Use of complementary and alternative medicine by breast cancer patients: Prevalence, patterns and communication with physicians. Supportive Care in Cancer, 10(7), 542–548.
Black. J.M., & Matassarin-Jacobs, E. (1993). Nursing process. In J.M. Black & E. Matassarin-Jacobs (Eds.), Luckmann and Sorensen’s medical-surgical nursing: A psychophysiologic approach (4th ed., pp. 1–2). Philadelphia: W.B. Saunders.
Decker, G., & Lee, C.O. (2005). Complementary and alternative medicine (CAM) therapies. In C.H. Yarbro, M.H. Frogge, & M. Goodman (Eds.), Cancer nursing: Principles and practice (6th ed., pp. 590–620). Sudbury, MA: Jones and Bartlett.
Eisenberg, D.M., Kessler, R.C., Foster, C., Norlock, F.E., Calkins, D.R., & Delbanco, T.L. (1993). Unconventional medicine in the United States. Prevalence, costs, and patterns of use.New England Journal of Medicine, 328(4), 246–252.
Ernst, E., & Cassileth, B.R. (1998). The prevalence of complementary/alternative medicine in cancer: A systematic review. Cancer, 83(4), 777–782.
Gallin, J.I. (2002). A historical perspective on clinical research. In J.I. Gallin (Ed.), Principles and practice of clinical research (pp. 1–11). San Diego, CA: Academic Press.
Institute of Medicine of the National Academies. (2004). Use of complementary and alternative (CAM) therapies by the American public. Washington, DC: Author.
Lee, C.O. (2003, November). CAM in the 21st century in the US: Role of nursing and evidence-based practice efforts. Poster session presented at the 4thAnnual Oncology Nursing Society Institutes of Learning,Philadelphia, PA.
Lee, C.O. (2004). Clinical trials in cancer part II. Biomedical, complementary, and alternative medicine: Significant issues. Clinical Journal of Oncology Nursing, 8(6), 670–674.
Nam, R.K., Fleshner, N., & Rakovitch, E. (1999). Prevalence and patterns of the use of complementary therapies among prostate cancer patients: An epidemiological analysis. Journal of Urology, 161(5), 1521–1524.
National Center for Complementary and Alternative Medicine. (2009). What is complementary and alternative medicine? Retrieved August 26, 2009, from http://nccam.nih.gov/health/whatiscam/
Oncology Nursing Society. (2008). The use of complementary and alternative therapies in cancer care. Retrieved November 12, 2009, from http://www.ons.org/Publications/Positions/media/ons/docs/positions/alternativetherapies.pdf
Sparber, A., Bauer, L., Curt, G., Eisenberg, D., Levin, T., Parks, S., et al. (2000). Use of complementary medicine by adult patients participating in cancer clinical trials. Oncology Nursing Forum,27(4), 623–630.
Swisher, E.M., Cohn, D.E., Goff, B.A., Parham, J., Herzog, T.J., Rader, J.S., et al. (2002). Use of complementary and alternative medicine among women with gynecologic cancers. Gynecologic Oncology, 84(3), 363–367.
White House Commission on Complementary and Alternative Medicine Policy. (2002). Final report. Washington, DC: U.S. Department of Health and Human Services. Retrieved December 21, 2009, from http://govinfo.library.unt.edu/whccamp/pdfs/fr2002_document.pdf
Whorton, J.C. (1999). The history of complementary and alternative medicine. In W.B. Jonas & J.S. Levin (Eds.), Essentials of complementary and alternative medicine (pp. 16–30). Philadelphia: Lippincott Williams & Wilkins.