Focus on Alternative and Complementary Therapies
www.pharmpress.com/fact
Focus Alternat Complement Ther©2005 Pharmaceutical Press
Focus Altern Complement Ther 2004; 9: 183
The Prince of Wales, one of Britain’s greatest champions of CAM, once stated that ‘…if they [complementary therapies] are proved to work, they should be made more widely available’.1 Few FACT readers (or rational thinkers for that matter) would not agree with this message. Let us therefore try to analyse what it means.
‘Proved to work’ obviously cannot mean that a therapy has helped one or two patients anecdotally. Case reports can be informative but never constitute proof of efficacy. This is as true for keyhole surgery as it is for CAM. Similarly, observational studies are at best indicative of efficacy. The recent U-turn in thinking on hormone replacement therapy (HRT) is an excellent example. HRT’s alleged benefit in respect of cardiovascular disease was based largely on observational data. When evidence emerged from large controlled studies, the benefit evaporated into thin air.2 The generalisable moral from this story is that uncontrolled data can be correct but sometimes they are not. Various types of biases can distort observational findings. Thus bias needs to be minimised, and the best way to achieve this is to conduct rigorous RCTs.
‘Proved to work’ implicitly also means that the therapy in question is safe. Most forms of CAM are probably vastly safer than conventional treatments.3 This is most encouraging but sadly it is also quite beside the point. The point, I would submit, is not absolute safety but the relation between risk and benefit. In other words, establishing efficacy and safety (or vice versa) can only be steps towards the ultimate goal, namely determining whether CAM (that is a given therapy for a given condition) generates more good than harm. Once we have done this we have achieved a lot.
I hate to add confusion to an already complex matter, but ‘a lot’ is not everything. Provided that, for a given condition, more than one treatment exists, we should really find out how the CAM option compares to competing treatments. In other words we should determine the risk–benefit profile of one therapy in comparison with the other. This is possible in principle and, what is more, in some instances the CAM option may even come out on top.4
Finally, if we want to make our case truly watertight, we should also provide data on the cost of CAM or, better, the relative costs of various treatment options. In our healthcare systems, which are notoriously stretched for funds, the ultimate ‘proof’ of a treatment would be the demonstration that it saves money. This does not necessarily mean treatment A has to cost less than treatment B. Rather, it means that using CAM should save money for the system, for instance through causing fewer adverse effects, which can be expensive both from a personal and a societal point of view.
In conclusion, ‘proved to work’ is a seemingly simple concept but on close scrutiny it hides several layers of complexity. Of course, champions of CAM know that. We have to address all of these layers with the same rigour as is required of other types of medicine. Double standards are not called for because they are not helpful to anyone.
