Complementary and Alternative Medicine (CAM) in urology

For those who are entrenched in modern medicine, it may be difficult to think of alternative medicine and urology as being practised together. Nevertheless, the use of complementary and alternative medicine to treat many different diseases is on the rise in many countries, including Western nations.

The United States has seen an increase in complementary and alternative medicine (CAM) usage from 33.8% in 1990 to 42.1% in 1997 which has remained stable over the last decade. This appears to be similar to the European countries as reported by the Swiss Health Survey in 2007 and 2012. The user profile in Switzerland was comparable to other countries, such as Germany, United Kingdom, United States and Australia.

In their surveys in 2002 and 2007, the National Center for Complementary and Alternative Medicine (NCCAM) reported that 30% to 75% of patients suffering from cancer globally use CAM therapies that include biological, herbal, and dietary-based approaches. This report stated that about 60% of men with prostate cancer utilize some of these CAM treatments. In the US alone, 83 million adults spent over $50 billion per year on CAM, which accounts for over 11% of the total out-of-pocket expenditure on health care.The NCCAM has grouped CAM into five major domains. These include:

• Alternative medical systems, such as homeopathy, traditional Chinese medicine, and Ayurveda.
• Mind-body interventions, such as meditation, prayer and mental healing.
• Biological-based therapy, such as vitamins, minerals, amino acids, herbal and special diets.
• Manipulative and body-based methods, such as chiropractic manipulation and massage.
• Energy-based therapies, such as biofeedback therapy, Qi Gong, Reiki and therapeutic touch.

In 1999, the American Urological Association (AUA) established a ‘Committee on CAM’ with Dr. William Fair, known as the ‘Father of CAM in Urology,’ as the first chairman. It was his own experience with cancer that led him to incorporate complementary techniques as a means to complement, not replace, conventional therapies. Dr. Fair believed in using a scientific approach to these treatments and techniques and held them to the same standard as mainstream medicine.

Some of these CAM therapies for urologic diseases that have been studied are as follows:

• Phytoestrogens and isoflavones (soy products, green tea): General nutrition, fruits and vegetables. Many reports suggest that calorie restricted diets low in saturated fats but rich in fibre, carotenoids, phytoestrogens and isoflavones may reduce the incidence and improve the course of LUTS, BPH, prostatitis and even prostate cancer. This type of diet can be seen in the Asian populations versus the Western populations, which may explain the lower incidence of prostate diseases observed there.
• Phytotherapeutic preparations (saw palmetto, African plum tree bark, South African star grass root, pumpkin seeds): Plant extracts are commonly prescribed as the first choice of therapy in many European countries and are increasingly used in the US. They are usually less expensive and regarded as ‘natural’ products. The STEP (Saw-palmetto Treatment for Enlarged Prostate) and CAMUS (Complementary and Alternative Medicine for Urological Symptoms) trials failed to indicate statistical significance; however, some clinicians point out some design flaws in these studies.
• Selenium, vitamin E, carotenoids, and zinc: Results from a double-blind trial of dietary selenium on non-melanoma skin cancer in high-risk individuals, showed a statistically significant lower incidence (63%) of prostate cancer than those receiving placebo. The role of vitamin E came from a result of a Finnish study in 1998 on men who smoked to evaluate whether either vitamin E and/or beta-carotene supplements could prevent lung cancer. There was a surprising result showing a 32% reduction in incidence and a 41% decrease in mortality from prostate cancer in the study subjects.
• Ginseng for Erectile Dysfunction (ED): Ginseng and erectile functioning are presently being looked at in a large Cochrane Review. Supplements have been used for centuries; however placebo controlled studies have shown placebo responses of 25-41%.
• Cranberry juice and Urinary Tract Infections: The Cochrane renal group conducted a systematic review and concluded overall results indicate that, compared to placebo, cranberry juice and tablets may reduce the risk of developing symptomatic UTIs in sexually active women.
• Red wine consumption and prostate cancer: The agent responsible for the effect of reduction of cancer is supposed to be the polyphenol resveratrol, a naturally occurring plant antibiotic found in grape skins and red wine. The effects include antioxidant activity, immunomodulation, growth-inhibiting activity, anti-androgenic, anti-inflammatory and inhibition of angiogenesis.

In addition to these biological based therapies, mind-body methods have also been studied in the urology patient:

• Acupuncture: ‘Qi’ or ‘life energy’ flows through meridians that connect the body organs. Interruption in this flow is thought to produce disease state. Some acupuncture points coincide with ‘trigger points’ which are anatomic sites of enriched innervation. Biophysiologic and imaging studies indicate that acupuncture triggers the release of neurotransmitters and other endogenous substances. Studies have found a 50-70% reduction of treatment-associated hot flashes in men with prostate cancer.
• Mind-body therapies: The role of mediation in health care has been subjected to study in the West for at least three decades. Its value in the management of chronic pain, hypertension, and symptoms associated with heart disease and cancer is well documented.
• Yoga: An exercise regime with a 5,000-year history. For patients with urinary incontinence, cystocele, rectocele, vaginal and uterine prolapse, chronic orchitis and interstitial cystitis, the practice of yoga postures can be beneficial. Yoga can increase a patients’ self-awareness of muscles.
• Music therapy: Patients undergoing TURP showed a reduction in blood pressure and anxiety with music therapy.
• Biofeedback: This technique requires equipment such as electromyography, thermal biofeedback or electroencephalography. Studies have shown a hastened recovery of urinary control and  eduction in severity of urinary incontinence.
• Physical activity: In a cross-sectional study of 111 prostate cancer patients treated with external beam radiotherapy, physical activity significantly improved sexual function. In a systematic review of 11 studies involving over 43,000 men detected an association between vigorous physical activity and reduced risk of BPH and LUTS.

The number of patients using CAM therapies is ever increasing world-wide. As practitioners in urology, we should avail ourselves of information, both scientific as well as that which has not been demonstrated by evidence, in this growing field. Understanding the compositions, actions and potential side effects of these therapies to complement our conventional treatments can only benefit in the healing of our patients.

Nora Love-Retinger, MS, RN, CURN, OCN, Memorial Sloan Kettering Cancer Center, Dept. of Nursing, New York (USA), loven@mskcc.org