Academic journal article Health Sociology Review

The Problematic Nature of Conflating Use and Advocacy in CAM Integration: Complexity and Differentiation in UK Cancer Patients' Views

Academic journal article Health Sociology Review

The Problematic Nature of Conflating Use and Advocacy in CAM Integration: Complexity and Differentiation in UK Cancer Patients' Views

Article excerpt

Introduction

Calls for the integration of complementary and alternative medicine (CAM) into cancer care are ubiquitous. The notion of 'integrative medicine' has been hotly debated in the medical literature over the last decade (e.g. Caspi et al 2000; Ernst 2005a). However, there still exists little or no consensus on what integration actually means in oncology contexts, or indeed, the most effective means of achieving 'an integrative approach' to cancer care. Much of the debate about integration in cancer care has centred on evidence production and the degree to which CAM therapies can be justified in a UK policy context espousing evidence-based practice (Ernst 2005a). Regardless of such debates, pockets of grassroots integration are becoming more evident in the UK, particularly in the context of palliative and hospice care (Broom and Tovey 2007). However, little empirical attention has been given to how attempts at integration are actually regarded by cancer patients.

The work which has been done in the area of CAM and cancer has focused on what cancer clinicians and other biomedical stakeholders think of actual or potential integration (e.g. Hewson et al 2006). As a consequence, a tendency to conflate use of CAM services with support for the process of integration into state funded services has emerged. It is regularly assumed that the majority of cancer patients' view CAM integration as prima facie good (e.g. Frenkel and Borkan 2003). However, this assumption has little empirical evidence to back it up. While high levels of personal usage amongst cancer patients (see Cassileth and Vickers 2005) may translate into widespread support for integration into public service delivery, this cannot be treated as inevitable. To date, we know little about cancer patients' views of: the benefits and limitations of integration; the relative importance of evidence in driving integration; the relationship between financial cost versus physiological (and psychological) benefit; and finally, the importance of the context of delivery (i.e. location/provider type) on experiences of integrative care.

The aim of this article is to examine empirically this assumption of cancer patients' support for CAM integration. In so doing we argue that:

1) a characterisation of unequivocal cancer patients' support for integration (even amongst those who use CAM) is an over-simplification and distortion of the situation;

2) it is inappropriate to conflate 'use' with 'advocacy';

3) patients' engagement with the idea of integration is complex and multi-layered; and

4) this complexity can be explicated by looking at key dimensions of an integrative process: evidence and risk, cost, and provider legitimacy.

Background

There has been much debate about the potential benefits and pitfalls of integrating complementary and alternative medicines into the NHS cancer services (House of Lords 2000). Although there is already sporadic integration, CAM is not provided on a systematic basis to NHS cancer patients despite substantial private usage. In May 2006 the Foundation for Integrated Medicine (2006) presented findings from a report commissioned by the Prince of Wales, arguing for greater momentum toward the integration of CAM into the NHS. This was strongly rebutted by prominent members of the British medical establishment who promptly called for any existing funding of CAM (however limited) to be discontinued (Baum 2006) in a very public denigration of CAM. Despite the more consensusdriven approach of the last decade, integration remains a contentious issue amongst practitioners and policy makers.

It is useful, for the purpose of providing a background to the results presented below, to outline some of the key issues in such debates about integration. In particular, we focus here on those related to: 1) evidence of effectiveness, 2) risk of harm, 3) cost effectiveness, and 4) provider legitimacy.

Evidence

The most prominent debate regarding CAM integration has been over evidence of effectiveness and the need to adhere to the basic tenets of evidence-based practice (EBP). …

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