In Response To: Professor Cassileth's manuscript on "Alternative and Complementary Cancer Treatments," Featured in The Oncologist 1996;1:173-179.

COMMENTS FOR PROFESSOR BARRIE R. CASSILETH: I have enjoyed reading the two issues of The Oncologist I've received so far. I would like to make some comments on Dr. Cassileth's article. I'm a pediatric oncologist at the National University Hospital in Singapore. Singapore is an interesting place to study people, as ours is a multi-racial country, with 75% Chinese, 16% Malays and 7% Indians, plus a significant expatriate population (Americans, British, Australians, etc.). I've been very interested in the influence of different ethnic and social backgrounds on how our patients cope with their diseases, especially families of children with cancer. We did a survey of 20 patients and found that nine of the children are given bird's nest, nine are given ginseng, and five had been given Chinese medicinal herbs. I've been doing a bit of literature search, and found that there's some evidence that Chinese medicine may help to "boost the immune system," enhancing the ability of the patients to undergo conventional cancer therapy. However, most traditional Chinese medicine practitioners would recommend that these patients continue with their "Western treatment." I have no objection to patients availing themselves of these complementary approaches, though we do not encourage it either. We are in the unenviable situation of trying to help and give advice to our patients about things about which we know little, as there is so little hard evidence. Of all the literature I've gone through so far, I find the recent Choices in Healing by Michael Lerner (MIT Press) the most helpful. PROFESSOR CASSILETH'S RESPONSE: Dr. Quah raises a number of important issues. I share his interest in the influence of culture and ethnicity on how patients and families cope with cancer. The cultural meaning of malignant disease, in fact, has long shaped not only individual reactions, but also how societies have approached research, treatment, and communication. In the United States, for example, the word "cancer" literally was banned from public print until the mid-1920s [1], and only now are physicians beginning to discuss cancer with their patients in Russia [2]. The survey of 20 patients conducted by Dr. Quah represents a substantial portion of the literature on the subject of alternative therapy use for children with cancer. During the decade of laetrile popularity in the United States, a study at a major pediatric oncology center found that 17 of 106 patients (16%) received alternative therapy, although eight different types of alternative therapies were known by 50% of parents. That study was conducted in 1977-1978 [3]. An Australian study published in 1994 [4] found that approximately 46% of children had been given alternative treatments; like Dr. Quah's patients and those in the Australian study, they remained simultaneously under mainstream care. One suspects that by now, close to 100% of parents as well as adult patients could name at least eight different types of alternative cancer therapies. I concur with Dr. Quah's assessment of Choices in Healing. It differs strikingly from other publications about alternative cancer medicine, almost all of which are proponent books that extoll unproven or discredited methods and decry a government/pharmaceutical industry conspiracy to withhold cancer cures (read "alternative, unproven methods") from the public. A visit to the health and medicine section of any large bookstore provides an eye-opening display of books on dozens of methods promoted as cancer cures. Can Chinese medicine "boost the immune system?" Claims for the mechanisms by which alternatives of the past were said to work typically reflected mainstream science of the day. The most common claim across the variety of today's popular alternative cancer therapies is that they enhance immune function. Many herbal remedies, including those from China, are sold for this purpose in America. Several Chinese medicines, such as polysaccharide from a root used in traditional Chinese medicine, Six Flavor Tea and Golden Book Tea used in conjunction with chemotherapy and radiation therapy, and Mylabris - dried Chinese beetle - have been studied for their utility against cancer in recent years. Because studies such as these are reported almost exclusively in Chinese journals, and because they tend to be preliminary, they are not well known in other countries. Dr. Quah's own professional home, the National University of Singapore (NUS), is one of the first medical schools in Asia to use the World Wide Web to distribute health information. NUS has the major cancer databases from the United States and many other important international databases. It intends to become a global health information hub on the Internet. Hopefully this resource will help fill in some of the information gaps. But most oncologists, like Dr. Quah, indeed are faced with trying to advise patients about therapies for which there is little hard evidence. The best guiding principles at this point are to discourage remedies that promise cancer cure or are promoted for use instead of mainstream treatment, encourage non-invasive, comforting, complementary (adjunctive) therapies such as massage, green tea and qi gong, and check medical journals and newspapers for warnings such as those issued recently for Ma Huang (ephedrine), a still-common ingredient in herbal remedies widely available through catalogs and in health food stores.