777
The Prevalence of Complementary/Alternative
Medicine in Cancer
A Systematic Review
Edzard Ernst, M.D., Ph.D.
Barrie R. Cassileth, Ph.D.2
1
Department of Complementary Medicine, Post-
graduate Medical School, University of Exeter, Ex-
eter, United Kingdom.
2
Department of Medicine (Oncology), University of
North Carolina, Chapel Hill, North Carolina.
Address for reprints: Edzard Ernst, M.D., Ph.D.,
Department of Complementary Medicine, Post-
graduate Medical School, University of Exeter, 25
Victoria Park Road, Exeter EX2 4NT, UK.
Received December 5, 1997; revision received
February 10, 1998; accepted February 19, 1998.
© 1998 American Cancer Society
BACKGROUND. Complementary/alternative cancer treatments are believed to be
prevalent. However, reliable prevalence rates do not exist. The aim of this review
was to summarize the existing data on this topic.
METHODS. A series of computerized literature searches was performed to locate all
published studies documenting the prevalence of complementary and/or alterna-
tive therapy (CAM) use among patients with cancer.
RESULTS. A total of 26 surveys from 13 countries, including 4 studies of pediatric
patients, was retrieved. The use of CAM therapies in adult populations ranged from
7– 64%. The average prevalence across all adult studies was 31.4%.
CONCLUSIONS. This large degree of variability most likely is due to different un-
derstandings of “complementary/alternative medicine” on the part of both inves-
tigators and patients. It is likely that the results of the current study reflect the
primarily adjunctive use of CAM treatments. Future studies should use a standard-
ized protocol to determine the true prevalence of these therapies more closely.
Cancer 1998;83:777– 82. © 1998 American Cancer Society.
KEYWORDS: alternative medicine, complementary therapies, cancer, prevalence,
adjunctive therapy.
C omplementary/alternative medicine (CAM) is used by 25%-50% of
the general population of industrialized nations.1–3 It has been
described as “diagnosis, treatment and/or prevention which comple-
ments mainstream medicine by contributing to a common whole, by
satisfying a demand not met by orthodoxy or by diversifying the
conceptual frameworks of medicine,”4 a definition recently adopted
by the Cochrane Field in Complementary Medicine. Some “alterna-
tive” therapies are promoted not to complement mainstream medi-
cine, but to substitute for it. These products and regimens, unproved
and deemed unpromising by oncologists, typically are invasive and
costly.
The reasons for CAM’s present popularity most certainly are
complex.5 They are related to the social and cultural context.6 In cases
of severe illness, the hope to “leave no stone unturned” is a powerful
motivator.5 This renders cancer patients prime candidates for CAM
use.6,7 There is evidence to suggest that oncologists, although often
unfamiliar with CAM, may take a less negative view of CAM use today
than they did previously.8
This systematic review attempted to summarize the published
data on CAM use in oncology. Secondary aims were to detect national
differences and trends when possible.
 10970142, 1998, 4, Downloaded from https://acsjournals.onlinelibrary.wiley.com/doi/10.1002/(SICI)1097-0142(19980815)83:4<777::AID-CNCR22>3.0.CO;2-O, Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
778 CANCER August 15, 1998 / Volume 83 / Number 4

TABLE 1
Key Data from All Investigations Included

Authors (year of
publication) Sample (country) Method type of treatments Prevalence Comment

Faw et al.9 (1977) 69 pediatric cancer Interview and Laetrile, folk remedies, healing 9% had tried some 25% had received
patients or parents questionnaire form of CAM recommendations to try CAM
(U.S.)
Arkko et al.10 (1980) 151 consecutive Personal interviews Herbs, vitamins, diet 56% of female and 30% 38% of users had confidence in
outpatients with of male patients had CAM
cancer (Finland) used CAM
Pendergras et al.11 (1981) Families of 106 pediatric Interviews Knowledge/use of laetrile and 16% of children had Accuracy of toxic effects poor
cancer patients (U.S.) seven other alternatives used CAM
determined
Fereberger et al.12 (1983) 183 outpatients with Questionnaire Mainly herbal remedies 59% had tried some Survey only published an abstract
various cancers form of CAM
(Austria)
Cassileth et al.13 (1984) 304 inpatients with Personal interviews Metabolic treatments, diets, 54% of patients 40% of patients had abandoned
cancer and 356 megavitamins, imagery, receiving conventional therapy for CAM.
patients of CAM spiritual healing, immune conventional Costs were often considerable
practitioners (U.S.) stimulants therapy used CAM
in addition
Eidinger et al.14 (1984) 315 patients with Interview Laetrile, vitamins diets 7% had tried some 70% would try CAM if available
metastatic tumors form of CAM
(U.S.)
Obrist et al.15 (1986) 101 consecutive patients Interview Beetroot juice, vitamins, 32% had used or were More men than women used;
with cancer Iscador, herbs, lactic acid, using CAM Iscador known by physicians;
(Germany) homeopathic medications other methods known in only
25% of cases
Clinical Oncology Group16 463 outpatients with Personal interview Diets, vitamins, herbs, laetrile 37% had sought advice Compliance with CAM advice was
(1987) cancer (New Zealand) regarding CAM only 19%, costs for CAM often
were high
Beaufort et al.17 (1988) 295 put-patients with Questionnaire Herbs, diets vitamins 51% had used CAM CAM mostly used in addition to
gynecologic cancers since diagnosis conventional treatments and
(Austria) mostly judged as effective (by
patients)
Berger et al.18 (1989) 494 outpatients Questionnaire (33% Diet, anthroposophic 71 patients were using main reason (in 87%): to build up
(Switzerland) response rate) rememdies, vitamins CAM resistance
‘‘detoxification’’
Morant et al.19 (1991) 300 consecutive cancer Questionnaire (53% Herbs, healing homoeopathy 52% had used CAM Younger patients were more likely
outpatients response rate) diets to use CAM. Most frequent
(Switzerland) reason was to do everything
possible to regain health
Lerner et al.20 (1992) 2743 cancer patients Telephone Not specified 9% had used at least 1 In 73% of the cases CAM use
(representative of all interview type of CAM in their recommended by physician. 6%
cancer patients) (U.S.) lifetime experienced adverse effects of
CAM, costs often were high
Burke and Sikora21 (1993) 100 new consecutive Structured personal Counseling, meditation, 32% had used some 66% would have accepted CAM if
patients with various interview relaxation, visualization, form of CAM offered by the hospital
cancers (U.K.) healing
Damkier et al.22 (1994) 769 outpatients with Questionnaire (97% Coenzyme Q10 45% used CAM CAM use in women more frequent
cancer (Denmark) response rate) than in men
Downer et al.23 (1994) 600 unselected oncology Postal Healing, relaxation, 16% had used CAM 82% of patients were (very)
patients (U.K.) questionnaire visualization, diets, satisfied with CAM; adverse
and personal homoeopathy effects of diets were reported
interview (n 5
48)
Sawyer et al.24 (1994) 48 children with cancer Questionnaire filled Imagery, hypnotherapy, 46% had used at least 1 Less than 50% of parents had
(Australia) in by parent relaxation, diets, type of CAM since discussed CAM use with
multivitamins diagnosis physician
(continued)
 10970142, 1998, 4, Downloaded from https://acsjournals.onlinelibrary.wiley.com/doi/10.1002/(SICI)1097-0142(19980815)83:4<777::AID-CNCR22>3.0.CO;2-O, Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Alternative Medicine and Cancer/Ernst and Cassileth 779

TABLE 1 (continued)

Authors (year of
publication) Sample (country) Method type of treatments Prevalence Comment

van der Zouwe et al.25
(1994)
Risberg et al.26 (1995)
Risberg et al.27 (1995)
Begbie et al.28 (1996)
Jirillo et al.29 (1996)
Liu et al.30 (1997)
Möttönen and Uhari31
(1997)
Sollner et al.32 (1997)
Rasky (unpublished data)
(1997)
Risberg et al.33 (1998)
949 patients with various Face to face ‘‘Alternative treatments’’ 9.4% were current users Young, highly educated patients in
forms of cancer from interview and (not specified) palliative care were likely users;
several outpatient questionnaire the majority hoped alternative
departments (Holland) therapies would slow disease
progression
642 patients with various Questionnaire Healing, homoeopathy, 20% were current users, 40% of users had used alternative
cancers from various reflexology, herbs, vitamins, healing was the most treatments prior to their cancer
centers (Norway) diets, Nitter therapy, Iscador prevalent (12%) diagnosis
and other (not specified)
therapies
252 patients with various Questionnaire Healing, homoeopathy, herbs, 20% used at least one Patients without cancer held a more
forms of cancer from diets, reflexology, Nitter treatment, 2% used positive view on the benefits of
inpatient and therapy (specifically named), combinations, healing alternative treatments than
outpatient departments plus any other alternative was the most cancer patients
(Norway) therapy the patient listed prevalent (9.0%)
507 outpatients with Questionnaire (66% Diets, psychologic methods 22% had used CAM Average annual cost of $530 was
cancer (Australia) response rate) perceived as value for money.
40% did not discuss CAM use
with their physician
563 questionnaires Anonymous surveys Any unconventional cancer 17% of respondents in Results were similar in Italy and
distributed to cancer treatment each country used Argentina. 20–38% of alternative
patients in Italy; 400 in alternative methods treatments were proposed by
Argentina physicians
100 consecutive patients Questionnaire Chinese medication 64% took such Prevalence higher in females, many
with advanced cancer medications hoped for a miracle cure;
(Taiwan) information on CAM rarely came
from physicians, costs normally
were moderate
15 children with acute Patient diaries ‘‘alternative medicines’’ (not 40% of the patients used The investigation included a age-
lymphoblastic specified) alternative treatments matched, noncancer control
leukemia from one group, 8% of whom used
pediatric department alternative treatments
(Finland)
215 patients with Questionnaire Any unconventional cancer 14% of patients used Alternative therapies used in
melanoma (Austria) therapy alternative therapies supplementary fashion
154 patients attending an Questionnaire 74 different unconventional 62% had used CAM, 33% Young patients and married
oncology clinic methods mistletoe, 20% Bach patients used CAM more
(Austria) flower, remedies, 20% frequently
homoeopathy
252 patients (as in initial Questionnaire with Healing, homoeopathy, Prevalence increased In only follow-up study to date, 5-
survey). Reduction in follow-ups after reflexology, herbs, vitamins, during follow-up: 26% year survival was notinfluenced
sample size over time 4, 12, 24, and 60 diets, injection therapies at 4 months, 24% at by CAM use
(110 after 60 months) months and (e.g., Nitter, Iscador), plus 12 months, 18% at 24
(Norway) telephone any other alternative therapy months, and 27% at
interview after the patient listed 60 months; women
last question- used CAM more
naire frequently than men

CAM: complementary/alternative medicine.

METHODS scanned for further relevant contributions. Inclusion

The following databases were searched from their in-
ception through January 1998 for articles on cancer
and CAM: MEDLINE, Embase, and CISCOM (a data-
base specializing in the “grey” literature of CAM). The
authors’ own extensive files also were consulted. The
bibliographies of all articles thus retrieved were
in this review required original data relating to the
prevalence of CAM in samples of patients with cancer.
There were no restrictions regarding the language of
the articles. All articles were read in full and data were
extracted in a standardized, predefined fashion (Table
1). We have not reviewed the original data behind the

780 CANCER August 15, 1998 / Volume 83 / Number 4
studies listed here. We have in all cases accepted the
original authors’ representations as true and evi-
dence-based.
RESULTS
Twenty-six publications were found (references 9 –33
and Rasky et al., unpublished data), including 1 fol-
low-up report of previously studied patients. The key
data from these reports are summarized in Table 1.
Increasing interest in CAM use among patients with
cancer is reflected in the geometric growth in the
numbers of publications on the subject. A single arti-
cle was published in the 1970s, 9 in the 1980s, and 16
between 1990 to date.
Publications were based on studies conducted in
13 countries. The majority of articles came from the
U. S. (five articles) and Germany (four). Investigators
in South America, Australia, New Zealand, and China
also conducted studies, as did researchers in many
Western European countries.
The 4 articles concerning pediatric patients (from
Australia, Finland, and the U. S. [2 publications]), sug-
gest but do not show conclusively a growth in the use
of alternative therapies in children from 9% in 1977 to
16% in 1981, 46% in 1994, and 40% in 1997. Data from
these four studies cannot prove actual growth because
the studies are not consistent in their definitions or
methodology. Laetrile (l-mandelonitrile-b-glucuronic
acid), common in the earliest pediatric studies, was
replaced in later years by CAM therapies of greater
contemporary interest, such as imagery, hypnother-
apy, relaxation, diets, and multivitamins.
Of the 21 studies involving adult cancer patients,
50% reported that up to 27% of respondents used
CAM; the remaining studies found that . 25% of re-
spondents tried CAM therapies. Percentages range
from a low of 7% to a high of 64%. The average per-
centage use across adult studies was 31.4%.
Although the particular nature of CAM is not al-
ways specified, reported regimens range widely from
diets and relaxation to iscador and Chinese medica-
tions. In the 1990s, the most commonly noted CAM
therapies across all studies include mind-body ap-
proaches (meditation, relaxation, hypnotherapy, visu-
alization, and other imagery techniques), reflexology,
dietary approaches and food supplements, Chinese
medications, botanical preparations, homeopathy,
and spiritual healing.
DISCUSSION
The studies reported in this article display an appar-
ently wide range of prevalence for CAM use. This is
not explained by either regional variations or increas-
ing popularity over time. For example, the three sur-
10970142, 1998, 4, Downloaded from https://acsjournals.onlinelibrary.wiley.com/doi/10.1002/(SICI)1097-0142(19980815)83:4<777::AID-CNCR22>3.0.CO;2-O, Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
veys published in 199730-32 and by Rasky et al. (un-
published data) yield prevalence rates ranging from
14%-64%. Two of these surveys are from the same
country (reference 32 and Rasky et al.), but suggest
vastly different prevalence rates.
The lack of specificity and inconsistent definitions
of CAM contribute significantly to this variability.
CAM often is not defined in prevalence studies or is
defined so broadly as to include all treatments re-
ceived outside of a hospital. Thus the inclusion of
counseling, group therapy, and other activities more
appropriately counted as mainstream, as well as well-
ness regimens, self-help efforts, home remedies, and
other non-CAM activities in respondents’ answers dis-
tort the actual extent of CAM utilization.
Although some studies uncovered for this analysis
indicate that patients used CAM in an adjunctive or
supplementary fashion, prevalence studies rarely dif-
ferentiate between therapies used in an adjunctive
mode and those applied toward “cure,” exclusive of
mainstream treatment. With one exception,13 the
studies reported here include patients seen in main-
stream cancer programs only. Therefore, by definition
patients who were receiving cancer care in other set-
tings and who may have been receiving alternatives to
mainstream care were not represented in these inves-
tigations.
Most surveys also are open to biases. For example,
selection bias can result from the choice of study
sample, and high nonresponse rates and recall bias
may occur in retrospective analyses. Moreover, it
should be noted that physicians’ comments as re-
ported by patients may be inaccurate. Discrepancies
between what the patient heard or remembered and
what the physician actually said may well exist.
As CAM has become more widely discussed by the
media and in mainstream medicine, patients are likely
to feel more comfortable about reporting their use of
these therapies. Thus, the apparently increased rates
seen today also may reflect patients’ willingness to talk
more openly about their use of CAM.
Data from pediatric surveys reviewed here
suggest an increase in CAM use or reports of use
during the last 20 years. Although longitudinal data
by Risberg et al. might suggest such an increase in
adults as well, these same data also could reflect
increased use of CAM by the same patients as their
disease advances,33 or more open reporting by pa-
tients.
Regardless, it is clear that patients with cancer in
Europe, Asia, the Americas, and Australia use CAM
frequently. Although Chinese medications are sought
most commonly in Asia, as would be expected, re-
maining CAM approaches differ little from country to

country. Given this degree of consistency as well as
popularity, physicians’ lack of knowledge about CAM
requires careful consideration.34
Critical analyses of this area should inform both
the patient and the physician.35,36 In particular, future
research should clarify distinctions between poten-
tially harmful alternative “cancer cures” and poten-
tially beneficial complementary therapies employed
as adjuncts to cancer treatment.7
Future studies might seek to apply a more stan-
dard series of questions and definitions to generate
comparable data. A better understanding then could
be reached regarding patients’ expectations, reactions,
costs, discussion of CAM with their physicians, clinical
outcomes, and optimal uses of complementary thera-
pies in future cancer care. Although CAM use has been
found in surveys of cancer patients around the world,
its impact on cancer patients’ well-being has been
explored only minimally.37
Despite the absence of reliable prevalence figures,
we conclude that the use of CAM by cancer patients is
common and widespread. Consistently defined infor-
mation and data on alternative versus complementary
use of unconventional regimens are needed to inform
the debate regarding the potential benefits or harms of
such treatments.
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