Background: The use of complementary and alternative therapies by children with cancer is common. Up to 84% of children have used complementary therapies along with conventional medical treatment for cancer. Methods: We reviewed the PubMed and CINAHL databases for studies published between 1994 and 2004 on the use of complementary and alternative therapies by children with cancer and reports from any publication year through 2004 of clinical trials involving complementary and alternative therapies for children with cancer. Results: Fourteen studies were retrieved reporting the results of survey or interview data collected from parents on children’s use of complementary and alternative therapies during or after childhood cancer. Across studies, the use of such therapies ranged from 31% to 84%. Common reasons for using complementary and alternative therapies were to do everything possible for their child, to help with symptom management, and to boost the immune system. Many parents indicated they also hoped to treat or cure the cancer. In most cases, the child’s treating physician had not been informed of the child’s use of complementary and alternative therapies. Conclusions: Use of complementary therapies by children with cancer is common, although methodological variations limit the ability to compare results across studies. Treating physicians often do not know the child is using complementary therapies in addition to medical treatments. The scientific evidence is limited regarding the effects and mechanisms of action of complementary or alternative therapies, but research is being conducted on these topics

Research reports through the year 2004 were complied from PubMed, the database provided by the National Library of Medicine, and from CINAHL (Cumulative Index of Nursing and Allied Health Literature). Research reports are summarized using the organizational framework for five domains of complementary and alternative therapies delineated by the National Institutes of Health National Center for Complementary and Alternative Medicine. These five domains include biologically based complementary therapies, manipulative and body-based therapies, mind-body interventions, alternative medical systems, and energy therapies. Specific search terms employed within each domain are presented in the section on clinical trials. Data on the Use of Complementary and Alternative Medicine Sawyer et al1 administered questionnaires to parents of 48 Australian children 4 to 16 years of age who were diagnosed with cancer (excluding brain tumors). Parents were asked to describe “any dietary supplements or alternative therapies used by the children” since the time of diagnosis. Parents indicated approximately one half (46%) of the children had used at least one such therapy since diagnosis. The most commonly used therapies included imagery, hypnotherapy, relaxation, diets, and multivitamins. Spiritualism, faith healing, meditation, megavitamins, chiropractic, and homeopathy were also used. Most parents (56%) viewed the therapies as harmless and thus did not disclose the use of complementary therapies to the child’s treating physician. Friedman et al2 collected parental reports from a convenience sample on the use of alternative therapies, specifically, practices that were not prescribed by a physician or not considered a proven medical treatment.

 They interviewed 81 parents of pediatric cancer patients and 80 parents of a control group of children attending routine checkups or noncancer acute care in the southeastern United States. Interviewers provided the study definition of alternative therapy to parents and offered clarification in response to questions. Parents indicated that 65% of the children treated for cancer and 51% of the noncancer patients had used alternative therapy, most often prayer. Excluding prayer, the two groups of children appeared more similar, with 45% of the cancer group and 42% of the control group using alternative therapies. Among the parents of children with cancer, the most frequently cited reasons for using alternative therapies were faith in the healing powers of prayer (21%) and supplementation of conventional medicine (7%). Only 2 parents of children with cancer and 3 parents of children in the control group indicated that dissatisfaction with conventional medicine contributed to providing alternative therapy to their children. The parents who discussed the use of alternative therapies with their child’s physician were most often parents of a child with cancer (53% vs 22% of parents in the control group), those with higher income (59%), and those who were white (47%). Mottonen and Uhari3 prospectively studied the use of biologically based products such as micronutrients and unconventional drugs taken internally by children in Finland (n = 15, mean age 7.3, range 4.3 to 12.6 years) with acute lymphoblastic leukemia (ALL) in the remission stage, most of whom had reached the continuation phase of therapy. They then randomly selected healthy children (n = 26) matched for age, sex, and socioeconomic status.

 Daily diary data collected for 2 years indicated that children with ALL took micronutrients and vitamins much more often than did children in the control group. Forty percent of children with ALL compared to 7.7% of the control group had taken biologically based products, including preparations of multivitamins, trace elements, fluoride tablets, and other minerals. Four children with ALL took a mixture of trace elements, 3 took shark liver tablets, and 1 took oil of evening primrose. Grootenhuis et al4 conducted semistructured interviews and administered questionnaires to children and parents to assess the use of “alternative treatment” by 84 children 8 to 18 years of age with a cancer history. Among these 84 children, 43 were in first continuous remission and 41 had relapsed or had a second malignancy. Overall, nearly one third (31%) of children used one or more alternative therapy, with relapsed patients using these more often (46%) than patients who were in remission (16%). No other medical characteristic (eg, number of hospitalizations, time since diagnosis) predicted use vs nonuse of alternative therapy. Homeopathy and macrobiotic diet were among the most often used therapies (used by 15 children). Massage, applied kinesiology, and light therapy were in the next most commonly used group of therapies (used by 9 children). Psychic healing,imagery healing,and faith healing were in the third most commonly used group (used by 6 children), while diets claiming to prevent cancer were used by 2 children. One child in the remission group and 7 in the relapsed group used more than one kind of alternative therapy. The investigators concluded that the prospect for survival was the strongest predictor for using one or more alternative therapies.

 Fernandez and colleagues5 conducted a retrospective cohort questionnaire survey of parents of 583 children who were diagnosed with cancer between 1989 and 1995 in British Columbia and who were referred to tertiary care. Definitions of alternative and complementary therapies were included in the introductory letter to parents. Alternative therapies were defined as “remedies that are used by individuals for cancer and other aspects of health that are characterized by a lack of scientific testing and lack of recognition of effectiveness by conventional medicine.” Complementary therapies were defined as “those used in addition to conventional medicine to improve the well-being of the child and relieve symptoms.” A total of 366 parents participated in the survey. Results indicated that 156 children (42.6%) had used complementary or alternative therapies,with herbal teas,plant extracts,relaxation/imagery strategies, vitamins, massage, diets, and therapeutic touch among the most frequently employed therapies. Most (68%) began using them while still on their initial medical treatment. Among children who relapsed or died,60% used complementary or alternative therapies. Most parents believed the therapies were beneficial (49%) or very beneficial (20%) to their child’s quality of life. No parent ascribed serious adverse effects to the complementary or alternative therapies, although 8 parents described mild adverse effects (eg, unpleasant taste, diarrhea, pain). Factors associated with the use of complementary or alternative therapies included their prior use, a positive attitude toward the therapies, information on them from family, friends, or alternative caregivers, high risk of death at diagnosis, and advanced education of at least 1 parent. 

Most parents indicated that they initiated the use of complementary and alternative therapies in order to do everything possible for their child (n = 126) or to “boost” the immune system (n = 117). Additional goals were to cure the cancer (n = 60),to give “softer”treatment (n = 57), to slow the progression of the cancer (n = 52), to use a more holistic approach (n = 50), and to use psychologic forces (n = 45). Therapies were most often used in conjunction with conventional medical treatment; however, 8 parents of children with a poor-prognosis disease reported using alternative therapies in place of recommended conventional medical treatments. More than half of the parents (55%) did not believe the oncologist was aware of their child’s use of complementary or alternative therapies. Reasons for not using them included lack of knowledge about complementary and alternative therapies and concerns about their potential interference with medical treatment. Yeh et al6 conducted semistructured, individual, indepth interviews with parents of 63 pediatric oncology patients at least 2 months postdiagnosis in Taiwan about their child’s use of “alternative therapy” such as non-Western therapies including traditional Chinese medicine, Eastern spiritual practices, and folk remedies in conjunction with Western conventional oncology medicine. Seventythree percent of the children had used at least one nonWestern therapy. The most commonly reported remedies were packaged liquids or powders purported to be high in nutritional value and capable of limiting side effects, increasing immune function, and improving prognosis (48%).

 Spiritual practices such as worshipping in Buddhist temples or consulting a shaman were also frequently used (41%). Folk medicine and herbal remedies were used by 28% of children, and practitioners of traditional Chinese medicine had treated 19% of children. Reasons for use of non-Western therapies included, in order of frequency, reducing pain, shortening the therapeutic cycle, limiting side effects, increasing the child’s internal strength, improving the child’s ability to cope with unpleasant medical events, and curing the disease. Use of non-Western approaches was not predicted by education or the family’s social status. Ten parents disclosed the use of non-Western therapies. Those who did not (77%) cited their concern that such disclosure might imperil relationships with their child’s medical providers. Kelly et al7 administered a questionnaire in a face-toface interview or by telephone interview to parents of 75 cancer patients 3 months to 26 years of age who were at least 3 months postdiagnosis and receiving conventional medical care for cancer or follow-up for conventional medical care at an urban academic hospital in the northeastern United States. Fourteen of the patients themselves, ranging in age from 10 to 26 years, were also interviewed. Results indicated that 84% of patients had used one or more “unconventional therapies,” defined as “an agent or practice initiated since diagnosis that was not part of the standard care of the child with cancer.” Most often these therapies were changes in diet, nutritional supplements, herbal remedies, and mind-body approaches, especially prayer.

 Use was not predicted by cancer diagnosis, race, ethnicity, socioeconomic status, or education. The most common intended purpose for using unconventional therapies was to improve the general health of the child (29%). Relaxation was also frequently mentioned (14%), particularly for mind-body therapies and touch therapies. Additional intended goals for use included detoxification (13%), improvement in immune function (8%), tumor reduction (8%), improvement in appetite/digestion (7%), wound healing (5%), decrease of nausea (4%),prevention of recurrence (2%),and pain control (2%). Fifty-five of the patients were enrolled in clinical protocols for primary treatment, of whom 85% were concurrently using unconventional therapies including several ingested products with potential biologic activity that could potentially interact with chemotherapy. Of the various unconventional therapies used, half were reported to the treating physician. Bold and Leis8 conducted a cross-sectional survey and telephone interviews of 44 parents of children 14 years of age or younger when diagnosed with cancer within a 2- year period in Saskatchewan, Canada. The investigators defined unconventional therapies as “those therapies other than medical treatments that are considered standard … that pediatric cancer patients received specifically for their cancer and/or associated symptoms of conditions, regardless of the type of provider (eg, alternative practitioner, health food store operator, health professional).” The interview asked for information on the use of “other treatments, therapies, and health practices” as a measure of unconventional therapy. Results showed that 16 families (36%) had used or were using some form of unconventional medicine to complement the child’s care. 

One family reported substituting unconventional treatment for medical treatment, although they continued to have the child medically monitored. Twenty-one percent had considered using unconventional treatment but were not currently. Forty-three percent had not used or considered use of unconventional therapy, mostly because of progress in current regimen and confidence in the medical system. Herbal remedies had the highest usage (47%), with Essiac being the most common remedy. Reflexology, aromatherapy, color therapy, and massage therapy comprised the next most highly used group of therapies (19%). Relaxation and musical techniques and traditional/ethnomedicine (including acupuncture and aboriginal healing) both had usage rates of 13%. Shark cartilage (categorized as a pharmacologic/biological) was used by 9%. The most frequently mentioned expectations given by parents for using unconventional therapies were to fight or stop cancer, to boost the immune system, to shrink the tumor, to improve general health, to help with side effects of medical treatment, and to cope with emotional effects of having cancer. Parents who expressed some dissatisfaction with their child’s medical experience, such as delays in diagnosis and treatment and concerns about adequate information, were more likely to provide unconventional therapy to the child. Unlike the majority of studies in which parents indicate that most physicians are unaware of the child’s use of unconventional therapies, in this sample 72% of the physicians knew about the use of unconventional therapy either because the parents initiated a discussion about it or because the therapy (eg, relaxation training or acupuncture) was provided by the physician or an allied health professional.