Alternative therapy (AT), also known as complementary, nonallopathic, unconventional, holistic, or natural therapy, refers to healing practices that have become increasingly popular with the general public, but are not widely accepted by the medical profession. Examples of AT techniques include therapeutic massage, acupuncture, imagery, energy healing, prayer, and use of medicinal herbs. According to 1990 data, the number of visits to practitioners of AT was greater than the number of visits to all primary care physicians nationwide.¹ Reasons patients use AT include a belief that it will cure or help a condition not treatable by conventional medicine, dissatisfaction with allopathic medicine, and a desire to use more natural methods of healing.

It is estimated that Americans spend >$10 billion a year on unproven cancer remedies.² AT is thought to be used more frequently in patients with cancer than in patients with minor illnesses.² According to Fletcher³, between 20% and 50% of cancer patients use or consider using AT. Although much research has been conducted on its use by adults with cancer, only two previous studies have focused on its use by children with cancer and their families. In the first, Faw et al⁴ in 1977 investigated use of AT among families of 69 children with cancer at M D Anderson Cancer Center and reported a rate of 9% using, and an additional 6% having considered using, AT. A more recent (1994) Australian study by Sawyer⁵ reported that 46% of the 48 children and families studied had used at least one AT. Less than half the parents had informed their physician about it.

Neither of the two previous investigations included a control group of noncancer patients for comparison. Using a cross-sectional prevalence survey design, our study included a control group of children without cancer attending a continuity care clinic for acute care and routine check-ups. We hypothesized that the families of children with cancer use more AT than those of children without. We describe the AT techniques used in our study population, the reasons for its use, and the frequency with which AT was discussed with the patient's physician.

MATERIALS AND METHODS

Subjects

Measures

The questionnaire also asked whether parents used AT to treat their own medical conditions. Parents of the control patients were asked whether they would use AT if their child had a curable or incurable form of cancer. In addition to multiple choice and yes/no questions, parents were encouraged to answer open-ended items concerning comments about AT and about this study. Before completion, parents had an opportunity to discuss the questionnaire.

Statistical Analysis

RESULTS

Diagnosis

Table 1. Patient Visit Type [View Table]

Demographic Factors

Table 2. Sociodemographic Characteristics [View Table]

AT Practices

Table 3. Distribution of AT Used by Cancer Patient Group and Control Group [View Table]

Reasons for AT Use and Sources of Information

Table 4. Reasons for Use of AT [View Table]

Table 5. Among Patients Using AT, Sources From Which Parents Received Information About AT [View Table]

Communication With Physician

Table 6. Among Patients Using AT, Number of Parents Who Discussed Using AT With Physician [View Table]

Table 7. Among Patients Using AT, Number of Parents Who Discussed Using AT [View Table]

Other Factors

DISCUSSION

The definition of AT is controversial. The word alternative is misleading, implying a therapy used instead of or in place of conventional therapies. It may also carry a pejorative tone, implying a therapy inferior to conventional treatment. Many AT techniques may be considered part of standard medical therapy. For example, relaxation techniques, imagery, and self-hypnosis are frequently taught by oncology personnel to assist children with painful procedures. Although some of these therapies are used in our hospital, it is interesting to note that massage therapy and relaxation techniques were used more often in our control group than in our cancer group. Many parents questioned the inclusion of prayer as an AT. We included it when it was being used specifically to treat illness, because few physicians prescribe prayer or consider it part of standard therapy. Religion and spirituality are not consistently addressed in medical school curricula, and even may be considered inappropriate teaching subjects.⁶ However, physicians are beginning to recognize the role of spirituality and prayer in the healing practices of their patients, as indicated by conferences sponsored by the National Institutes of Health.^7,8

In this study, we investigated use of AT as an adjunct to conventional therapies. By definition, none of our subjects had refused standard medical treatment, although we did no formal compliance assessment. We defined AT as any practice not prescribed by a physician or not considered a proven medical treatment. Different definitions of AT may explain different results across studies. Although we excluded over-the-counter medications, we did not limit our definition to specific AT techniques, as may have been the case in previous studies. We found that children attending a general pediatric clinic were using AT much more often (51%) than those in a 1994 Canadian study (11%)⁹ that defined AT as being provided by a practitioner, thus excluding home remedies, prayer and exercise, and other commonly used therapies. After excluding the latter from our analysis, however, 39% of our patients still were using AT, which remains a rate higher than that in the Canadian study.

There were also differences in types of AT practices in our study compared with others. The Canadian patients were more likely to use homeopathy, naturopathy, and acupuncture,⁹ and the Australians hypnotherapy, mental imagery, and relaxation.⁵ Our patients used prayer, massage, spiritual healing, and relaxation most often and acupuncture or homeopathy rarely. Whereas spiritual healing was often used by our cancer group, they were used by only a small percentage of Australian patients. These differences may be attributable to cultural or ethnic factors, and might be investigated further by cross-cultural surveys.

Prayer was used by many in both our groups, but significantly more in the cancer group. The ordeal of having a child with cancer may lead parents to embrace formal or informal spiritual practice for comfort and strength. Prayer as therapy has been studied widely, and the evidence is mixed. Marwick⁷ reviewed 115 articles on prayer and health outcome: 37 showed a positive effect, 47 a negative effect, and 31 showed neither. King and Bushwick⁶ found that many patients wished their physicians would ask about their spiritual lives. According to their results, 48% expressed they would like their physician to pray with them, and 42% believed that a physician should ask patients about spiritual experiences.⁶

These findings suggest that many Americans use prayer and faith healing as a therapeutic adjunct. Discussions of spiritual practices may improve well-being and compliance. In a much reported study, Byrd¹⁰ conducted a randomized, double-blind study of 393 patients, in which patients on the University of California, San Francisco, coronary care unit were prayed for by various religious groups who had only their first name and a brief description of their condition.¹⁰ The test patients and families did not know they were being prayed for. Fewer patients in the prayed-for group died, and significantly fewer developed pulmonary edema, received antibiotics, or needed intubation. The researchers concluded that the prayed-for group endured less suffering. Although this study has been criticized for its design, it shows the important role that prayer may play in illness.⁸

Given the high frequency of AT use, physicians should make a habit of asking their patients about it. Several studies have shown that parents fear telling their doctors that they are practicing AT. Although such discussions may seem difficult, Spigelblatt emphasizes an approach that may help physicians open communication lines.⁹ She suggests that 1) physicians inquire regularly about AT; 2) such inquiry be made in a nonjudgmental manner; and 3) the physician be knowledgeable about the implications of AT use. This means developing a working knowledge of a rapidly growing literature. Patients may have misperceptions about AT that the physician can clarify; doctors should also be prepared for patients to present literature and ask for advice.

About half of 120 US medical schools now include course work on AT and other integrative health approaches, thus new physicians will have a greater knowledge of this major trend in self-care by the public. Pediatricians need to realize that many children and their families are practicing AT, and that such use is not limited to life-challenging illnesses such as cancer. As its use continues to rise, only through scientific research and effective communication can care givers serve their patients optimally.

Downer found that patients using AT were significantly more anxious than those using only conventional therapy.¹¹ Patients may turn to AT out of anxious or hopeless feelings, perhaps from an unfavorable prognosis. Fletcher believes imparting hope is a professional responsibility of physicians,³ because pessimism may lead patients to seek AT out of a false sense of hope in its efficacy.^3,11 This does not imply that physicians need be deceptive and so undermine trust in situations involving unfavorable prognoses. Parents in our study did not turn to AT because of dissatisfaction with conventional medicine, but rather because of beliefs in its efficacy. As with Sawyer's Australian study⁵ and Downer's English study,¹¹ parents felt a strong urge to help their children in ways unique to them to counter their own feelings of helplessness.

A potential limitation of our study is that the control patients did not have serious illnesses. Future studies should consider matching cancer and control groups more closely in terms of illness severity and chronicity, perhaps comparing cancer with cystic fibrosis, diabetes, or transplant patients. Cross-cultural studies of patients with similar cancer diagnoses and treatment modalities are also needed. Studies should also compare patients who seek AT practitioners with those who self-administer AT.

Another limitation of our study was that it was cross-sectional. Large-scale longitudinal prospective studies would reflect changes in the use of AT as a function of changes in the patient's status. Our study also did not evaluate compliance or outcomes. Differences in both compliance and illness outcome among AT users and non-AT users are of obvious importance.