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A Review of Complementary
and Alternative Medicine Practices
Among Cancer Survivors
Rose M. Bell, MSN, ARNP-c, OCN
About 4 of 10 adults in the United States use some type of complementary or alternative medicine (CAM) therapy, with the
rate being higher among patients with serious illnesses, such as cancer. The purpose of this article is to provide oncology
nurses with an understanding of the use of CAMs in cancer survivorship. By understanding the characteristics of typical
users, the reasons for their use, and ethnic- and gender-related considerations, nurses can identify patients in this population and safely guide their use of CAM throughout survivorship. The literature provides a foundation to identify survivor
needs and issues as they relate to CAM use. Nurses can play a critical role in the assessment and education of CAM use
within survivor programs, with the ultimate goal being increased overall well-being and survival.

he National Institutes of Health ([NIH], 2007) reported that 38% of adults in the United States used
some type of complementary or alternative medicine
(CAM) therapy, with a significant increase noted
from 20022007, particularly for head or chest colds.
Americans use CAM for a variety of reasons, including treatment
for diseases and medical conditions such as musculoskeletal
pain. Studies have reported higher rates of use among patients
with serious illnesses, including cancer (Miller et al., 2008; Saxe
et al., 2008). Several specific therapies had marked increases as
well, including deep breathing exercises, meditation, massage
therapy, and yoga (NIH, 2007).
The National Coalition for Cancer Survivorship ([NCCS],
2006) defined a cancer survivor as an individual from the time of
a cancer diagnosis through the remaining years of his or her life.
About one in three Americans will be diagnosed with cancer,
with almost 12 million cancer survivors currently living in the
United States (National Cancer Institute, 2009).
Cancer survivorship has more than tripled to 10 million since
the 1970s, thanks in part to advances in detection and treatment
(Institute of Medicine [IOM], 2005a). With increased survivorship, significant changes emerge in the healthcare needs of patients and their families as they learn to develop a new normal
in living with a cancer diagnosis.
Survivorship is becoming an increasingly important oncology
issue, particularly to those who have completed their cancer
treatment. Survivors who complete their treatment often move
from an orderly system into a non system (IOM, 2005b, p. 1)
that provides the survivor with little understanding, direction,
or planning to assist them along their survivorship continuum.
This transition can leave the cancer survivor with multiple is-

At a Glance
F Understanding the characteristics of complementary and
alternative medicine (CAM) use in cancer survivors is essential
to providing education and counseling.
F Care of the survivor should include identification and assessment of CAM for each individual.
F Cancer survivors are interested in information and self-care
strategies. Nurses should understand assessment and counseling in these therapies.

sues and many unmet needs. Needs identification within the

various survival stages and recognition of these stages is vital
to the development of future education and treatment of the
survivor population (McCaughan & Thompson, 2000). Survivorship care begins with the identification of these issues, starting
with the first stage after treatment, and is the cornerstone in
building personalized care plans. The goals of these care plans
include successful self-management and promotion of healthy
behaviors.
This article is intended to provide the oncology nurse with
an understanding of the use of CAMs in cancer survivorship. By

Rose M. Bell, MSN, ARNP-c, OCN, is an oncology nurse practitioner

at Northwest Medical Specialties in Federal Way, WA. (First submission
May 2009. Revision submitted September 2009. Accepted for publication
September 20, 2009.)
Digital Object Identifier:10.1188/10.CJON.365-370

Clinical Journal of Oncology Nursing Volume 14, Number 3 Complementary and Alternative Medicine Use in Survivors

365

understanding the characteristics of typical users, the reasons

for their use, ethnic- and gender-related considerations, and
implications for care, nurses can identify and educate survivors
in their use of CAM.
The National Center for Complementary and Alternative Medicine ([NCCAM], 2009) identified complementary and alternative
therapies within four domains (see Figure 1). Although definitions of CAM vary, in general, complementary therapy is the use
of CAM along with conventional therapy; alternative therapies
are methods that are used in place of conventional therapy; and
integrative therapy is a total integrative approach to cancer
care, including both conventional and complementary therapies
(NCCAM, 2009).
The use of complementary and alternative therapies in cancer
survivors is underreported (Gansler, Chiewkwei, Crammer, &
Smith, 2008; Saxe et al., 2008), with as many as 81% of survivors
having used vitamin or mineral supplements. Although use of
the more common CAMs by cancer survivors was comparable to
the general population, Gansler et al. (2008) noted an increase in
other forms of CAM. Deng, Cassileth, and Yeung (2004) suggested
that CAM users are seeking a holistic approach to their care and
see CAM as a natural way to take responsibility and control of
their health and promote an increased quality of life (Frenkel,
Ben-Arye, Baldwin, & Sierpina, 2005; Saxe et al., 2008).
Increased CAM use was reported in short- and long-term survivors (Gansler et al., 2008). Use and types of therapies differ
according to cancer sites (Velicer & Ulrich, 2008). Survivors of
melanoma and kidney cancers were reported as least likely to use
CAM, whereas survivors of breast, ovarian, non-Hodgkin lymphoma, and brain or central nervous system cancers were reportedly
most likely to use CAM (Gansler et al., 2008; Richardson, Sanders,
Palmer, Greisinger, & Singletary, 2000). Stage of disease also influenced CAM use, with increases noted in advanced-stage disease
(Gansler et al., 2008). In addition, CAM use can be affected by
geography, with higher use reported in California (Goldstein et
al., 2005). Goldstein et al. (2005) hypothesized that the reason
for this may be the social milieu that exists in California, where
the population leads a culturally creative lifestyle (Goldstein
et al., 2005, p. 565). Additional commonalities identified in the

Biologically Based
Herbs, vitamins, omega 3, fish oil, and shark cartilage
Energy Therapies
Qi gong, Reiki, therapeutic touch, and biomagnetics (i.e., pulse fields,
alternating current, and magnetics)
Manipulative and Body-Based Practices
Chiropractic services, osteopathic manipulation, and massage
Mind-Body Medicine
Meditation, prayer, mental healing, creative therapies (i.e., art, music,
or dance), and yoga
Whole Medical Systems
Homeopathy, naturopathy, traditional Chinese medicine, and ayurveda

Figure 1. Domains of Complementary

and Alternative Medicine Practices
Note. Based on information from National Center for Complementary
and Alternative Medicine, 2009.
366

survivors who use CAM included better education, a focus on

health, and a general use of more mainstream medical services
(Deng et al., 2004, p. 419).
Ethnic considerations in CAM use also have been identified.
The interpretation of ailments as well as differences in beliefs
about ailments contribute to anomalies in use (Gansler et al.,
2008, p. 1054). In general, high CAM rates were reported in
poor, older adult, and ethnic minority populations (Goldstein
et al., 2005), populations that are reportedly under-represented
in research studies. CAM use may be directly related to income
status, with higher use associated with higher income (Goldstein
et al., 2005). According to Gansler et al. (2008), biologically based
practices (i.e., vitamins and herbs) were more common in Hispanics and other ethnic minority groups. However, Goldstein et al.
(2005) contradicted that report by saying that Latino use of CAM
was lowest in every category with the exception of prayer. Spiritual and religious practices, as well as mind-body therapies, were
more commonly reported in African Americans (Gansler et al.,
2008). Gender differences in CAM use also exist, with women exceeding men in every use category. The narrowest gap between
the sexes is in the use of biologically-based therapies (odds ratio =
0.719) (Gansler et al., 2008). Additionally, therapies that include
an emotional or tactile component are more appealing and more
likely to be accepted by women than men (Gansler et al., 2008).
Some reasons for increased use in women include more personal
focus on health, more frequent provider visits, a greater sense
of control of self, and a greater need to use adjunctive therapies
(Gansler et al., 2008). For a review of the literature, see Table 1.

Reasons for Use

Survivors identified many reasons for using CAM, and indicated that locus of control may be one important factor
(Gansler et al., 2008). Survivors responses positively correlated with the use of CAM as a means of stress and recurrence
reduction and enhancement of wellness and quality of life
(Buettner et al., 2006; Greenlee, White, Patterson, & Kristal,
2004; Saxe et al., 2008), with the belief that CAM therapies
are nontoxic (Richardson et al., 2000). Additionally, for those
with advanced disease, CAM use was believed to be associated
with prolongation of life (Richardson et al., 2000), the desire to
remain hopeful (Richardson et al., 2000; Verhoef, Balneaves,
Boon, & Vroegindewey, 2005), or to provide cure (Richardson
et al., 2000).
In cancer survivors, CAM was reportedly used primarily for
treatment for ailments other than the cancer diagnosis (Goldstein, Lee, Ballard-Barbash, & Brown, 2008). The National
Center for Health Statistics reported that cancer survivors were
more likely to die from noncancer causes, and that they are
more likely to have at least one functional limitation. As a result,
the negative impact on quality of life or function from chronic
health issues (Goldstein et al., 2008; Saxe et al., 2008), as well
as the short- and long-term cancer-related medical issues or
symptoms (Carpenter, Ganz, & Bernstein, 2008; Greenlee et al.,
2004; Miller et al., 2008; Wesa, Gubili, & Cassileth, 2008), were
identified as initiating factors for using CAM by cancer survivors.
The use of chemotherapy during treatment also was associated
with an increased CAM prevalence (Mao et al., 2008).

June 2010 Volume 14, Number 3 Clinical Journal of Oncology Nursing

Table 1. Review of Complementary Therapies Research in Cancer Survivors

Article

Study

Most popular Therapies

Comments

Highest Population use

Buettner et
al., 2006

Identified the prevalence

and correlation with
complementary and
alternative therapy use
in 2,022 nurse breast
cancer survivors

Relaxation or imagery, massage, high-dose vitamins, and

herbs

Patients with poor QOL used energy

healing CAMs; patients with better
QOL were among those practicing
yoga. Chemotherapy was associated
with relaxation or imagery, and radiotherapy was associated with high-dose
vitamins.
For patients with comorbidities, pulmonary disease was associated with massage and high-dose vitamins, rheumatoid arthritis was associated with yoga
and energy healing, and thyroid disease
was associated with high-dose vitamins
and relaxation.

Younger, educated, and

higher income survivors.
CAM users had worse QOL
scores than nonusers.

Carpenter
et al., 2008

Explored the use of complementary and alternative therapies in 371

breast cancer survivors
10 years after diagnosis

Echinecea (29%), herbal tea

(21%), ginko biloba (19%),
ginseng (13%), and Saint
Johns wort (13%)

Postdiagnosis medical conditions and

lower mental functioning were strongly
associated with CAM usage.

Younger survivors

Gansler et
al., 2008

Examined the prevalence

of complementary therapy use in 4,139 cancer
survivors from 1024
months after diagnosis

Prayer or spiritual practices

(61%), relaxation (44%), faith
or spiritual healing (42%),
nutritional supplements or
vitamins (40%), and meditation (15%)

Least popular practices reported were

acupuncture or acupressure (1.2%), biofeedback (1%), and hypnosis (0.4%).

Young Caucasian women

with high income and high
education. Highest use was
seen in younger survivors.

Goldstein
et al., 2008

Explored the use and

benefits of CAM among
1,844 Californians with
cancer

Two or more dietary supplements (87%), prayer (58%),

other provider (58%), chiropractor (45%), and special diet
(41%)

Least popular practices reported were

other provider (16%), three or more
other providers (12%), or unconventional
cancer therapies (4%).

Younger, described their

race as other, were more
educated, and were diagnosed at least three years
prior to the interview

Greenlee
et al., 2004

Explored the use and

types of supplements in
10,857 cancer survivors
in comparison to 64,226
cancer-free controls

Cranberry pills for bladder cancer, zinc with ovarian cancer,

saw palmetto and soy with
prostate cancer, melatonin
with cervical cancer, vitamin
D with thyroid cancer, vitamin
A for colon cancer, vitamin E,
calcium, and multivitamin for
breast cancer

No difference in use between cancer survivors and the control group (similar use)

Women with specific cancer types

Lawsin et
al., 2007

Examined demographic,
medical, and psychosocial correlates to complementary and alternative
therapy in 191 colorectal
cancer survivors

Home remedies (37%), chiropractic care (35%), counseling

or support groups (30%),
relaxation or stress reduction
(28%), and massage (27%)

Poor perceived support correlated to

chiropractic care, intrusive thoughts
correlated to counseling, and poor QOL
correlated to herbal remedies and homeopathic and aromatherapies.

Younger women with

poorer perceived QOL and
more intrusive thoughts

Mao et al.,
2008

Investigated the relationship of unmet needs

to the use of complementary and alternative
therapy in 2,585 cancer
survivors 3.54 years
after diagnosis

Vitamins (36%), herbs or

natural products (30%), deep
breathing (30%), meditation
(24%), massage (17%)

Received info on CAM from family or

friends (50%), doctor or nurse (31%),
other sources (e.g., Internet, print media,
social organizations) (20%), or other
patients with cancer (13%)

Younger, married Caucasians who are less likely

to live in an urban setting
and have lung or colorectal
cancer

Richardson
et al., 2000

Examined the use of

CAM in 453 patients
with cancer

Spiritual practices (81%), CAM

overall excluding spiritual or
psychotherapy (69%), vitamins
or herbs (63%), movement or
physical therapies (59%)

Combined CAM with conventional therapy spiritual practices (91%), CAM overall
(88%), mind or body (76%), vitamins or
herbs (77%), and CAM overall excluding
spiritual or psychotherapy (75%)

Younger, indigent women

with some college who
were postsurgical

CAMcomplementary and alternative medicine; QOLquality of life

Clinical Journal of Oncology Nursing Volume 14, Number 3 Complementary and Alternative Medicine Use in Survivors

367

The rising cost of health care (Saxe et al., 2008), coupled with
multiple unmet needs, equates to multiple CAM uses (Mao et al.,
2008). These unmet needs were identified by Mao et al. (2008)
as emotional, physical, nutritional, financial, informational,
treatment- and employment-related, and daily living activities. Other reasons included an identified dissatisfaction with
conventional care (Richardson et al., 2000; Saxe et al., 2008),
fragmentation of care into survivorship, lack of empathy and
support, or if a survivors subsequent needs were unfulfilled
(Mao et al., 2008). In addition, Carpenter et al. (2008) identified decreased emotional function and multiple medical issues
in very long-term breast cancer survivors who used CAM. The
potential for recurrence and high levels of worry (Mao et al.,
2008) and distress (Lawsin et al., 2007) also were reported
with increased use. Finally, the use of herbal supplements were
reportedly used to reduce the side effects of treatment and to
boost immune function (Buettner et al., 2006; Deng et al., 2004;
Lawsin et al., 2007; Richardson et al., 2000; Saxe et al., 2008).

Implications for Oncology Nurses

To provide quality care to the cancer survivor, oncology
nurses should understand the characteristics and reasons for
CAM use and examine personal views and beliefs regarding
CAM. Once personal biases and beliefs have been identified,
the nurse can explore reasons for looking into the use of these
therapies with the patient. Nurses should approach CAM with a
non-judgmental attitude (Saxe et al., 2008) to avoid non-reporting of CAM use by the patient. Saxe et al. (2008) and Frenkel et
al. (2005) reported that patients often do not report the use of
CAM primarily because of the healthcare providers negative
attitudes or limited knowledge regarding their use. Additionally, the patient or survivor may choose only to disclose one of
multiple CAM therapies that they are using (Saxe et al., 2008).
Robinson and McGrail (2004) reported that disclosure rates of
CAM use ranged from 23%90%. Chen, Bernard, and Cottrell
(1999) demonstrated lower reporting to physicians who did not
practice some form of CAM (67%) versus those who did (90%).
Disclosure remains important to consider because patients who
are seeing CAM providers and subsequently engaging in CAM
treatments in addition to conventional care may cause interruption in their treatment and potential harm to themselves (Saxe et
al., 2008). Cultural sensitivity also is essential for understanding
CAM use. Cultural beliefs are important in the acceptance of, or
mistrust with, conventional health care. This can lead to subsequent rejection of Western health care (Mao et al., 2008).
Nursing assessment should focus on psychological processes
of the patient (Gansler et al., 2008), including fear, quality of life,
and spiritual values, as well as feelings of hope, optimism, and
personal control (Richardson et al., 2000) (see Table 2).
An evaluation of common characteristics may assist the provider in identification of increased use. An example of this is
that supplement use has been reported to be associated with
survivors with increased exercise and dietary changes that included increased fruit and vegetable intake (Gunther, Patterson,
Kristal, Stratton, & White, 2004; Miller et al., 2008).
Preliminary assessment also should include factors such as
financial concerns related to care, cancer type, stage, prognosis,
368

and end-of-life issues, because diagnoses such as breast cancer

are associated with increased CAM use in conjunction with conventional treatment (Deng et al., 2004; Mao et al., 2008). Nurses
need to possess a good understanding of the survivors motivation surrounding the use of CAM. Addressing unmet needs,
side-effect management, and conducting an evaluation of the
patients understanding of safety in these therapies is imperative
in future survivor care. Because CAM use is more likely related
to symptom treatment, such as pain, fatigue, and hot flashes
(Mao et al., 2008), a thorough focus on side-effect management
also is an essential component of survivorship.

Table 2. Complementary and Alternative Medicine

(CAM) Assessment and Intervention
Assessment

Intervention

Cancer treatment plan

Research-based education, dispel

myths, and provide the evidence for
CAM

Cancer type and stage

Research-based education, symptom

management, and address psychological issues

Chronic health issues and

troubling side effects, such as
pain, fatigue, and hot flashes

Symptom management and address

psychological issues

Cultural and community CAM

use and beliefs

Research-based education, dispel

myths, and provide the evidence for
CAM

Disease prognosis

Research-based education, symptom

management, and address psychological issues

Fear, hope, optimism, and

spiritual values

Address psychological issues, evaluate and address psychosocial issues,

and provide research-based education

Financial concerns

Evaluate and address psychosocial

issues

Interests

Explore the reasons for interest,

discuss the CAM plan, and provide
research-based education

Likes and dislikes

Research-based education, dispel

myths, and provide the evidence for
CAM

Motivation for use

Explore the reasons for interest, discuss the CAM plan, education, and
symptom management

Patients knowledge of CAM

Dispel myths and provide the evidence for CAM interests

Personal control

Exercise recommendations, diet recommendations, and education

Prior therapies used

Research-based education, dispel

myths, and provide the evidence for
CAM

Quality of life

Symptom management and address

psychological issues

June 2010 Volume 14, Number 3 Clinical Journal of Oncology Nursing

Once the initial assessment is conducted, the nurse should then

evaluate the use of prior therapies, likes and dislikes, what has
worked and failed in the past, and how decisions are made. This
assessment also should include longstanding community, cultural,
and family beliefs as they may strongly influence the decision for
use and type of CAM used (Frenkel et al., 2005). Including those
engaged in patients care as caretakers also is important.

Table 3. Research Evidence for Complementary

and Alternative Medicine (CAM) Use in Cancer
Survivors
CAM Type

Potential Benefits

Acupressure

Chemotherapy-related nausea and vomiting

Acupuncture

Possible use for radiation-induced xerostomia, evidence for hot flashes, fatigue, and
shortness of breath

Aromatic oil

Enhances effects of the massage

Biofeedback

Muscle strengthening in urinary and fecal

incontinence and constipation, as well as
insomnia

Diet (dietary considerations such as a low-fat

plant-based diet)

Cancer risk reduction and decreased comorbidities

Electroacupuncture

Ameliorated nausea and vomiting

Exercise (weight reduction)

Cancer risk reduction and decreased comorbidities

Massage

Anxiety and lymphedema, relaxation, decreased pain, and improved sleep

Opportunity to Educate
Two studies have reported a cancer diagnosis or the completion
of treatment as a catalyst to stimulate increased health behaviors,
including diet and exercise (Andrykowski, Beacham, Schmidt, &
Harper, 2006), resulting in the teachable moment (Andrykowski et al., 2006; Wahnefried, Aziz, Rowland, & Pinto, 2005) for
the survivor. Trask et al. (2005) reported that cancer screening
rates in survivors were higher than individuals without a cancer
diagnosis, and that the screening varied by type of screening.
The importance of educating the survivor on a follow-up plan
becomes yet another teachable moment. However, despite the
possible educational impact, the opportunity is frequently missed
by healthcare providers. Data demonstrate that only 20% of oncologists currently provide CAM education when the patient was
present for follow-up (Wahnefried et al., 2005).
By understanding the increased motivation for health in the
cancer survivor, the healthcare team can begin to build a survivorship plan with a focus on wellness and the incorporation
of responsible CAM use. This plan should include symptom
management, diet, exercise, and psychological and psychosocial care. Education begins with the nurses familiarization
of CAM therapies and supplements to provide advice and assist the patient with decisions regarding therapies (see Table
3). Education should be conducted with an emphasis on the
scientific and research studies that are currently available on
CAMs because the popular sources of information often can be
inaccurate and sometimes dangerous (Frenkel et al., 2005, p.
290). The nurse or patient can begin by exploring NCCAM and
its comprehensive Web site (http://nccam.nih.gov) intended for
both the medical professional as well as patients or survivors,
as well as the American Cancer Society (www.cancer.org/doc
root/ETO/ETO_5.asp) and the National Cancer Institute (www
.cancer.gov). The sites contain current and credible information
on many CAM therapies.

Conclusion
The current body of literature on survivorship and CAM provides a foundation for the identification of survivor needs and
issues as they relate to CAM use. Survivors want individualized,
concrete information on how cancer therapy will affect their
daily lives. The literature reports that patients also desire selfcare strategies to manage this impact on their lives and families
(Skalla, Bakitas, Furstenberg, Ahles, & Henderson, 2004). If
patients are to maximize coping, their needs must be met (McCaughan & Thompson, 2000). Nurses can play a critical role in
the assessment and education on the use of CAM within survivor
programs by becoming aware of CAM use in these patients with
the ultimate goal of increased overall well-being and survival.

CAM with good evidence, such as art therapy, acupuncture, and hypnosis, often are unused.
Note. Based on information from American Cancer Society, 2008; Blom
& Lundeberg, 2000; Deng et al., 2004; Filshie et al., 1996; Monti & Yang,
2005; Wesa et al., 2008.
a

The author takes full responsibility for the content of

the article. The author did not receive honoraria for this
work. The content of this article has been reviewed by
independent peer reviewers to ensure that it is balanced,
objective, and free from commercial bias. No financial
relationships relevant to the content of this article have
been disclosed by the author, planners, independent peer
reviewers, or editorial staff.
Author Contact: Rose M. Bell, MSN, ARNP-c, OCN, can be reached at
rosebl3@aol.com, with copy to editor at CJONEditor@ons.org.

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June 2010 Volume 14, Number 3 Clinical Journal of Oncology Nursing