About two-thirds (67.0%) of the practitioners responding to the survey were male. Educational degrees held by at least 5% of the practitioners are shown in . More than half (53.2%) of the respondents held MD degrees, and about one-fifth (19.2%) held PhDs. Although 42.6% of respondents reported that they had a bachelor’s degree, this percentage is probably low since most people with MD or PhD degrees also have a bachelor’s degree.
Practitioners Holding Various Degrees (%)
Certificates or licenses relating to CAM practice held by practitioners are shown in . The most frequently held license was licensed acupuncturist (LAc), held by 18.1% of the practitioners. All of the other certificates listed on the survey were held by less than 10% of the respondents. Additional certificates were named by 41.5% of the respondents. Although the exact name of most of these other certificates varied, the areas in which three or more practitioners had certificates were naturopathy, homeopathy, acupuncture, holistic medicine, herbal medicine, and chelation.
Practitioners Holding Various Certificates or Licenses Relating to CAM Practice (%)
There were 134 respondents; 96 (72%) of the respondents were involved in the care of cancer patients. Of these 96, 27% cared for 1 to 10 cancer patients per year, 36% cared for 11 to 50, 11% cared for 51 to 100 patients, and another 25% cared for more than 100 cancer patients per year. Ninety-eight percent of the respondents reported that they provided CAM for their cancer patients and/or referred their cancer patients to other health care providers for CAM treatments.
Practitioners were asked about the location of other health care providers to whom they referred either some or all of their cancer patients for CAM treatment. Forty-four percent made referrals both within and outside their practice, and another 34% made referrals solely outside of their practice. Finally, 5.3% of the respondents did not make any referrals to other health care providers for CAM treatment (). The survey specifically addressed the question of the various modalities of CAM treatment that the practitioner either provided or referred his patients to. More specifically, for each CAM modality, it was asked whether the practitioner was either providing or referring for the purpose of improvement of quality of life or increased survival. For each CAM modality, the percentage of practitioners providing it for each purpose was similar (). For example, nutritional therapeutics was provided by 84.0% of the practitioners for the purpose of improving quality of life and by 83.0% for increasing survival; however, the types of CAM provided by the practitioners showed considerable variation. Nutritional therapeutics (84.0%) and alternative medical systems (68.1%) were prescribed most frequently. Movement and unconventional physical therapies (22.3%) and manipulative and body-based methods (27.7%) were prescribed the least frequently for improving quality of life.
Location of Other Health Care Professionals to Whom Practitioners Referred Some or All of Their Cancer Patients for CAM Treatment
Practitioners Providing and Making Referrals for Various CAM Treatment Categories for the Purposes of Improving Quality of Life and Increasing Survival (%)
A somewhat different pattern emerged for referrals. For most modalities of CAM, more practitioners made referrals for the purpose of improving quality of life than for increasing survival. At the same time, there was less variation in the distribution across the CAM modalities with respect to referrals. This included referrals for purposes of increased survival, as well as improving quality of life. The percentage of practitioners making referrals to other health practitioners for the purposes of improved quality of life ranged from 42.6% for nutritional therapeutics to 58.5% for manipulative and body-based methods, with the other CAM modalities lying within this range.
The types of CAM treatments that the practitioners provided themselves differed from the types for which they made referrals. For example, although about one-fourth of the practitioners provided manipulative or body-based methods for improving quality of life (27.7%) or increasing survival (23.4%), they were more apt to make referrals for this type of treatment, with almost three-fifths (58.5%) making referrals for improving the quality of life. On the other hand, more than four-fifths of the practitioners provided nutritional therapeutics for improving the quality of life (84.0%) and increasing survival (83.0%) and were less likely to make referrals for this type of CAM treatment.
Strength of Research Evidence
Practitioners were asked to rate the strength of the research evidence supporting the efficacy of several categories of CAM used as a cancer treatment (). Nutritional therapeutics was the only CAM category for which more than half of the respondents (53.2%) said that there was very strong or strong evidence. However, when very strong, strong, and moderate evidence responses were combined, four categories of CAM were considered to have supporting research evidence by more than half of the respondents: nutritional therapeutics (79.8%), pharmacologic and biologic treatments (73.4%), alternative medical systems and some specific components (61.7%), and mind-body interventions (58.5%).
Percentage of respondents saying that there was very strong, strong, or moderate evidence supporting the efficacy of CAM categories used as a cancer treatment. (Details may not add to totals because of rounding)
The practitioners were also asked to rate the strength of the research evidence supporting the efficacy of several categories of CAM used in symptom/side-effect management. The percentages of respondents indicating that there was very strong, strong, or moderate evidence were similar to the results for the CAM as cancer treatment section. Nutritional therapeutics was the only CAM category for which more than half of the respondents (53.2%) said that there was very strong or strong evidence for use as symptom/side-effect management; however, when very strong, strong, and moderate evidence responses were combined, four categories of CAM considered to have supporting research evidence emerged: nutritional therapeutics (79.8%), alternative medical systems (66%), pharmacologic and biologic treatments (66%), and mind-body interventions (62.8%) ().
Percentages of respondents saying that there was strong, very strong, or moderate evidence supporting the efficacy of CAM categories used in symptom or side-effect management.
Practitioners were asked to rate the priority they would give to conducting research on various CAM categories used either for cancer treatments or symptom/side-effect management (). For cancer treatment, 85.1% of the practitioners gave high priority to research of nutritional therapeutics. Alternative medical systems and pharmacologic/biologic treatments were both given high priority by 69.2% of respondents. Finally, mind-body interventions were given a high priority by 52.1% of those responding. These four categories were also those for which the majority of respondents thought there was very strong, strong, or moderate evidence supporting their efficacy as cancer treatments (see ). These same categories were given high priority for research in symptom/side-effect management by the greatest percentage of practitioners (83%, 73.4%, 69.2%, and 62.8%, respectively). With regard to the categories of energy therapies, manipulative and body-based methods, and movement and unconventional physical therapies, respondents were more inclined to give research priority to symptom/side-effect management than cancer treatment.
Practitioners Giving High Priority to Research Regarding the Use of Various CAM Treatment Categories for Cancer Treatment and Symptom/Side-Effect Management (%)
Practitioners were asked to indicate the CAM categories in which they were interested for collaborative research (). More than half of the practitioners expressed an interest in nutritional therapeutics (72.4%), pharmacologic and biologic treatments (71.1%), and the alternative medical systems (60.5%). The category eliciting the least amount of interest for collaborative research was manipulative and body-based methods (18.4%).
Practitioners Indicating They Were Interested in Various CAM Categories for Collaborative Research (%)
Obstacles Related to Conducting CAM Research
All respondents who were interested in participating in cancer CAM research in the future (n = 79) were asked a series of questions about NCI’s grant application process.
The practitioners who had considered participating in CAM research projects were asked to identify the obstacles to research that they had previously encountered (). The most frequently encountered obstacle was lack of awareness of appropriate funding sources, cited by three-fourths (75.4%) of the practitioners. Furthermore, of those who encountered this obstacle, 10% felt that it was the most significant in hindering CAM research. Many practitioners (72.1%) also cited lack of access to appropriate cancer research collaborators as a hindrance to conducting CAM research, with 11.7% indicating it to be the most significant. Other obstacles mentioned by at least 50% of the respondents included difficulty in designing a CAM research study that meets grant requirements (excluding placebo-related problems) (60.7%), lack of time (59.0%), lack of institutional support (55.7%), Institutional Review Board issues/regulations (54.1%), lack of success in receiving funds for CAM research (52.5%), and Food and Drug Administration issues/regulations (50.8%). Although no single obstacle predominated as the most significant, four were cited most frequently: lack of awareness of funding sources (10%), lack of access to cancer research collaborators (11.7%), lack of time (11.7%), and lack of success in receiving funds for CAM research (11.7%).
Practitioners Who Encountered Various Obstacles in the Conduct of Cancer CAM Research Projects and Who Indicated that the Obstacle Was the Most Significant (%)
NCI BCS Program
The survey contained a description of the NCI’s BCS Program, which is a process for evaluating case report information from practitioners that involves the same rigorous scientific methods used to evaluate treatment responses with conventional medicine. The program is an opportunity for cancer CAM practitioners to share their well-documented cases, with the goal of assessing whether sufficient evidence is available for NCI-initiated prospective research. Respondents were asked if they knew about the NCI BCS Program prior to receiving the survey. Fifty-six respondents (71%) had heard about the program. Of those 56, about 48% became aware of the program through a conference presentation, 27% through OCCAM’s Web site, and 23% through a letter from the director of OCCAM. Twelve of the 56 responding practitioners had submitted cases for review. The remaining 44 practitioners had not submitted cases and cited several reasons. These included lack of time necessary to compile case study material, lack of support staff and resources to compile case study material, and lack of a program information packet. Some of the practitioners felt that the effort required to compile case studies was not worthwhile. Other reasons included lack of access to patient records and lack of cases that meet eligibility requirements.