Integrative and complementary medicine among cancer patients: At what price?
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Available online at www.sciencedirect.com European Journal of Integrative Medicine 3 (2011) e139–e141 Opinion article Integrative and complementary medicine among cancer patients: At what price? Aminah Jatoi Department of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Received 18 November 2010; received in revised form 6 June 2011; accepted 6 June 2011 Abstract Cancer patients frequently utilize integrative and complementary approaches. Indeed, patients are paying as much as $34 billion a year out-of- pocket for such approaches in the United States. This review discusses whether such therapies are ever cost-effective, provides some data on how much money individual patients appear to be spending, and suggests general guidelines on how healthcare providers may want to broach such issues with cancer patients. © 2011 Published by Elsevier GmbH. Keywords: Cost; Integrative medicine; Cancer Approximately $34 billion are spent each year on integrative and complementary medicine in the United States [1]. Reporting on 2007 data from the United States, Nahin and others provided a breakdown of this figure. These investigators found that the costs of the healthcare practitioner account for $11.9 billion [1]. An additional $14.8 billion are used by patients for the acquisition of non-vitamin and non-mineral natural products. Classes in yoga, tai chi, and qigong account for $4.1 billion, and homeopathic practices account for $2.9 billion. Relaxation techniques account for another $0.2 billion. Finally, self-care that utilizes integrative and complementary approaches accounts for the remaining $22 billion. Who is paying for all these interventions? The forgoing data refer only to out-of-pocket costs from both cancer and non-cancer patients and were obtained by means of surveys of non-pediatric patients. These data make the point that inte- grative and complementary therapies, such as those described above, can be expensive and that patients themselves are often covering the costs. The fact that patients themselves are willing to pay out-of- pocket for integrative and complementary approaches – many of which lack substantive proof of efficacy – underscores the need to probe further into the cost effectiveness of such integrative and complementary approaches. Thus, this review discusses the E-mail address: [email protected] following two questions. Are there any data to indicate that inte- grative and complementary medicine can be worth the cost for cancer patients? How should we as healthcare providers counsel cancer patients about the issue of cost? Is integrative and complementary medicine worth the cost? The National Center for Complementary and Alternative Medicine defines the above approaches as follows: “a group of diverse medical and health care systems, practices, and prod- ucts that are not presently considered to be part of conventional medicine”. A major challenge in determining whether such inter- ventions are worth the cost rests upon a dearth of data that allow us to determine the efficacy or the comparative efficacy of such approaches. A recent review by Ernst attempted to categorize such interventions based on cost and also based on perceived efficacy with respect to more standard interventions [2]. This investigator from the United Kingdom discussed acupuncture for nausea and vomiting, massage for anxiety, aroma therapy for the general palliation of cancer symptoms, as well as several other interventions. He concluded that the cost of integrative and complementary approaches varied markedly from one approach to another but that often times the efficacy of the conventional approaches was greater. This review draws two important points. First, in the absence of direct comparative data, such as phase III studies, this approach is the best that one can do. It helps patients and health- care providers face this issue of cost even in the absence of more conclusive and rigorous data. Second, this review forces 1876-3820/$ – see front matter © 2011 Published by Elsevier GmbH. doi:10.1016/j.eujim.2011.06.005
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Available online at www.sciencedirect.com
European Journal of Integrative Medicine 3 (2011) e139–e141
Opinion article
Integrative and complementary medicine among cancer patients:At what price?
Aminah JatoiDepartment of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
Received 18 November 2010; received in revised form 6 June 2011; accepted 6 June 2011
bstract
Cancer patients frequently utilize integrative and complementary approaches. Indeed, patients are paying as much as $34 billion a year out-of-
ocket for such approaches in the United States. This review discusses whether such therapies are ever cost-effective, provides some data on howuch money individual patients appear to be spending, and suggests general guidelines on how healthcare providers may want to broach suchssues with cancer patients.2011 Published by Elsevier GmbH.
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eywords: Cost; Integrative medicine; Cancer
Approximately $34 billion are spent each year on integrativend complementary medicine in the United States [1]. Reportingn 2007 data from the United States, Nahin and others provided areakdown of this figure. These investigators found that the costsf the healthcare practitioner account for $11.9 billion [1]. Andditional $14.8 billion are used by patients for the acquisition ofon-vitamin and non-mineral natural products. Classes in yoga,ai chi, and qigong account for $4.1 billion, and homeopathicractices account for $2.9 billion. Relaxation techniques accountor another $0.2 billion. Finally, self-care that utilizes integrativend complementary approaches accounts for the remaining $22illion.
Who is paying for all these interventions? The forgoingata refer only to out-of-pocket costs from both cancer andon-cancer patients and were obtained by means of surveysf non-pediatric patients. These data make the point that inte-rative and complementary therapies, such as those describedbove, can be expensive and that patients themselves are oftenovering the costs.
The fact that patients themselves are willing to pay out-of-ocket for integrative and complementary approaches – many of
hich lack substantive proof of efficacy – underscores the needo probe further into the cost effectiveness of such integrativend complementary approaches. Thus, this review discusses the
E-mail address: [email protected]
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876-3820/$ – see front matter © 2011 Published by Elsevier GmbH.oi:10.1016/j.eujim.2011.06.005
ollowing two questions. Are there any data to indicate that inte-rative and complementary medicine can be worth the cost forancer patients? How should we as healthcare providers counselancer patients about the issue of cost?
Is integrative and complementary medicine worth the cost?he National Center for Complementary and Alternativeedicine defines the above approaches as follows: “a group
f diverse medical and health care systems, practices, and prod-cts that are not presently considered to be part of conventionaledicine”. A major challenge in determining whether such inter-
entions are worth the cost rests upon a dearth of data that allows to determine the efficacy or the comparative efficacy of suchpproaches. A recent review by Ernst attempted to categorizeuch interventions based on cost and also based on perceivedfficacy with respect to more standard interventions [2]. Thisnvestigator from the United Kingdom discussed acupunctureor nausea and vomiting, massage for anxiety, aroma therapyor the general palliation of cancer symptoms, as well as severalther interventions. He concluded that the cost of integrative andomplementary approaches varied markedly from one approacho another but that often times the efficacy of the conventionalpproaches was greater.
This review draws two important points. First, in the absence
f direct comparative data, such as phase III studies, thispproach is the best that one can do. It helps patients and health-are providers face this issue of cost even in the absence ofore conclusive and rigorous data. Second, this review forces
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140 A. Jatoi / European Journal of Int
ne to consider the true role of these integrative and comple-entary approaches. Although it appears that efficacy might be
tronger at times with the use of conventional therapy, thereonetheless appears to be a role for integrative and complemen-ary approaches. These approaches may provide a supplementaldvantage when combined with conventional therapy, therebympowering patients to make their own treatment decisionshile, at the same time, giving them an extra advantage towards
chieving more favorable clinical outcomes. Thus, when exam-ning whether integrative and complementary approaches areorth the cost, conclusions may not always be black and white.Have any studies probed into whether integrative and com-
lementary approaches might spare patients from utilizingonventional approaches and thereby cut back on overall costs?o our knowledge, a few studies have done so, and not allave suggested cost savings. However, two studies suggesthat integrative and complementary approaches might saveosts. Herman and others concluded [3], “CAM therapies maye considered cost-effective for migraine, neck pain, stressanagement. . .”. Similarly, Lind and others concluded [4],
Among insured patients with back pain, fibromyalgia, andenopause symptoms, patients who use CAM providers have
ower insurance expenditures”.For example, Lind and others investigated insurance claims
ata within the State of Washington between 2000 and 2003.hese investigators performed a patient-matched case controltudy to better examine expenditures. They observed that usersf integrative and complementary medicine were paying $1219nnually for outpatient expenditures, in contrast to $1502 byon-users. Additionally, inpatient expenditures were $765 and1178, respectively. Other expenditures included $1184 and1473, respectively. Notably, $630 was spent specifically onntegrative and complementary approaches. Although similarata have not been captured among cancer patients, the findingsrom Lund and others demonstrate a potential shift in medicalare utilization from conventional to integrative and comple-entary approaches with the use of the latter resulting in overall
ower healthcare costs. In other words, if a patient has backain and utilizes an integrative and complementary approachhat alleviates the pain, it becomes unlikely that that patient willubsequently require an MRI to assess his back pain. This abilityo circumvent an MRI results in lower healthcare costs. Again, tour knowledge, such observations have not been reported amongancer patients, but the concept of shifting and saving costs inhis manner seems plausible in medicine in general. It becomesnclear, however, whether such shifts benefit the patient whoay at times be paying for integrative and complementary ther-
py out-of-pocket expenses or a third party payor who mightave been paying only for the MRI scan that was not obtained.
How should we as healthcare providers counsel canceratients about the issue of cost? Clearly, the availability of fundsredicts whether or not patients will use integrative and com-lementary therapies. Wolsko and others conducted a random
ousehold telephone survey of 2055 United States adults andbserved that individuals who had full insurance coverage whichncluded coverage of integrative and complementary approachesere almost 5 times more likely to utilize such integrative andC
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omplementary approaches [5]. Along similar lines, Wyatt andthers examined breast cancer patients – sometimes as manys 80% of these patients are utilizing integrative and comple-entary approaches; and these investigators focused specifically
n 222 patients with early stage disease [6]. Wyatt and othersbserved a trend to suggest employment – or having a steadyncome – was positively predictive of whether integrative andomplementary approaches would be used by a patient. Thisbservation about availability of funds has important conse-uences. Although occasionally patients are able to receive somer partial insurance coverage to enable them to utilize such inte-rative and complementary approaches, often times patients aren fact paying out of pocket – and, although they might be ableo afford such therapies early on – the continued use of suchnterventions might take a toll on one’s ability to keep paying.
Previously, our group undertook a patient simulation exer-ise that was designed to investigate how much cancer patientsre paying for nutrition-based integrative and complementarypproaches [7]. We focused on utilizing the internet becauseany of these approaches are accessed and purchased on-line.dditionally, because many patients are reluctant to admit theirse of integrative and complementary approaches to their health-are providers, we thought a patient simulation exercise woulde of value by circumventing this reluctance. Looking at a vari-ty of such agents, our group observed that the cost of thesepproaches ranged from $4.33 to $263 per month. When oneonsiders that patients often use more than one type of integra-ive and complementary approach, these costs can ultimately beuite substantial for a particular patient.
How should we as healthcare providers help patients deal withuch costs? First, it seems important not to ignore this issue, buto acknowledge to patients and families at the outset that the costssociated with these interventions can be substantial for someatients. Admittedly, talking about money matters with a patients sometimes viewed as a taboo topic, but when one considers theatient- and family-related hardship that can be invoked by suchosts, these discussions are warranted. Secondly, recognitionf the cultural aspects of some integrative and complementarypproaches is important. For some patients, the use of a non-onventional therapy is a foregone conclusion and very muchn keeping with their cultural heritage. This cultural sensitivityan be of great importance during discussions with patients andheir families. Thirdly, it is important to discuss cost and efficacyogether. If there are absolutely no data to suggest that a costlyntegrative and complementary approach carries efficacy or ifhere are data to show that it does not, then it would be importanto discuss with the patient that he may be spending money onn intervention that may not provide benefit. Finally, sometimesamily members want to do everything they can for a lovedne, and yet they simply cannot afford a particular integrativend complementary approach. Such circumstances can generateotable guilt. Talking about this issue and bringing this situationnto the open can help patients and families better cope.
onflict of interest
The author has no conflict of interest.
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eferences
1] Nahin RY, Barnes PM, Stussman BJ, Bloom B. Costs of complementary andalternative medicine and frequency of visits to CAM practitioners: UnitedStates 2007. In: National Health Statistics Report. 2009.
2] Ernst E. Complementary and alternative medicine: what the NHS should befunding? Br J Gen Pract 2008 [March].
3] Herman PM, Craig BM, Caspi O. Is complementary and alternative
medicine cost-effective? A systematic review. BMC Complement AlternMed 2005;5:11.4] Lind BK, Lafferty WE, Tyree PT, et al. Comparison of health care expendi-tures among insured users and nonusers of complementary and alternative
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medicine in Washington State: a cost minimization analysis. J Altern Com-plement Med 2010;16:411–7.
5] Wolsko PM, Eisenberg DM, Davis RB, et al. Insurance coverage, medicalconditions, and visits to alternative medicine providers. Results of a nationalsurvey. Arch Intern Med 2002;162:281–7.
6] Wyatt G, Sikorskii A, Willis CE, An HS. Complementary and alternativemedicine use, spending, and quality of life in early stage breast cancer. Nurs
7] Alsawaf MA, Jatoi A. Shopping for nutrition-based complementary andalternative medicine on the internet: how much money might cancer patientsbe spending online? J Cancer Educ 2007;22:174–6.
