Cancer Care: Conventional, Complementary, Alternative?

ON THE COVER:   Barbara MacDonald, ND, LAc

ON THE COVER: Barbara MacDonald, ND, LAc


by Barbara MacDonald, ND, LAc

Dr. Barbara MacDonald has twenty-years-experience as a licensed naturopathic physician working in the field of complementary cancer care. She treats patients using a combination of naturopathic medicine, acupuncture, CranioSacral therapy and Qi Gong describing herself as comfortable in both conventional, research-based sciences and the most esoteric healing arts. She practices in Camden, Maine and is the author of The Breast Cancer Companion: A Complementary Care Manual (3rd ed. 2016)


       
Dr. MacDonald was invited to share how she counsels cancer patients faced with the dilemma of choosing to combine or replace conventional treatment with natural medicine. These are her opinions, to date, and are not intended as medical advice. She is open to learning from those with different experiences even if they kindly disagree with her. "By having integrity with oneself, we make choices that are aligned with our higher purpose.

Putting Things in Context

In 2017, there were approximately 1.7 million Americans diagnosed with cancer.(1)  In the last decade, it is estimated that between 40-90% of them utilized some form of complementary alternative medicine (CAM).(2-4)  This is a significant increase from the 1990s when it was estimated that only 18% of cancer patients used CAM.(5)  The term CAM is broad and includes many therapies (massage, acupuncture, etc.), natural products (vitamins, minerals, herbs, nutraceuticals) and practices (meditation, yoga, etc.) that are either added to conventional treatment (complementary or integrative) or done in lieu of them (alternative). Some cancer patients use CAM during treatment but most afterward.(6
       
One concern about relying on research studies is that one person's CAM is doing breathing exercises while another's is following a comprehensive integrative protocol. The category of CAM that represents the greatest number of users was those who reported having taken "natural products and herbs." Even though 17% of cancer patients used this type of CAM,(7) those who simply took echinacea to prevent a cold were lumped in with those who had comprehensive integrative treatment plan prescribed by a licensed CAM healthcare provider. Because the term CAM is so broad, the reliance on research studies to determine its success and failures is flawed. Not all CAM is the same.
       
There is a decent body of evidence regarding the safety of herbal and nutraceutical medicines and their interactions with surgery, chemotherapy, radiotherapy and oral medication. I feel confident that licensed naturopathic physicians and many of our medical colleagues trained in functional medicine are versed in guiding patients to avoid things that are unsafe and encourage them to complement their allopathic treatments with natural therapies that often improve their experience and maybe their outcomes. This is very different than patients taking products they read about online without sufficient training to know how to determine quality, safety, or optimal dosing.
       
What is less known is if natural medicine can replace some or all conventional medical treatment for cancer. Our patients, especially those who are 'naturally minded,' rightly ask us if we can offer them a natural-only cure. I know some holistic practitioners who, I'll call traditional, perhaps even radical and certainly the most risk-tolerant among us, comfortably answer that question with a yes. I, and most of the naturopathic oncology colleagues I consulted for this article, rarely do. I generally discourage the alternative-medicine-only option around 85% of the time. 
       
Only recently have outcome studies compared the use of alternative medicines to allopathic. In a case-control, retrospective study published in August 2017, in the Journal of the National Cancer Institute, it was found that those who did alternative-treatment-methods-only were more than twice as likely to die compared to those who chose conventional treatments.(8)  Conducted at Yale University School of Medicine, 281 cases were identified where patients with colon, breast, prostate and colorectal cancers responded that they had chosen "other-unproven cancer treatments" instead of allopathic medicine. Their outcomes were compared to those with similar cancers, stages, etc. In one article about this study the authors stated, "Overall, 78% of people having conventional treatment for cancer survived at least five years, compared to only 55% of people having alternative treatment alone. The difference was biggest for breast cancer, where people who chose alternative therapies were more than five times as likely to die within five years as those who chose conventional treatments."(9)  This is concerning. Yet again, the study doesn't discern between those who had a comprehensive, practitioner-prescribed treatment plan from those who directed their own care. The patients could have taken one capsule of curcumin or they could have engaged in a long-term, individualized, holistic approach including diet, fitness, meditation, acupuncture, hyperbaric, intravenous medicine, herbal therapy, etc. Not all CAM is the same and well-designed alternative medicine studies are non-existent.
       
In 1997, I graduated with a four-year doctoral degree in naturopathic medicine and, in 2003, a master's degree in classical Chinese medicine. I then had the privilege of practicing for thirteen years, mentored by women's natural health expert Dr. Tori Hudson and Chinese herbalist Dr. Menge Kou. In the early years, I believed that by eating well, taking natural medicines and addressing mental, emotional, and energetic imbalances, one could cure their cancer. I believed in the theory that our body, restored to balance, would recognize unhealthy mutations and direct the immune system to do what it knows to do – stop cancer cells from replicating and bring them back from the 'dark side' to being productive members of the community of cells working toward the greater good within each of us.
       
I still believe this in theory. I was raised by a now-retired osteopathic physician, who instilled in me a belief in the healing power of our inner physician. Through my own failures and those of my most respected colleagues, I have learned that theory isn't enough. The practice of knowing which combination of natural therapeutics, lifestyle changes, and mental-emotional shifts to recommend for each person's unique situation, at a pace to turn the tides of cancer has, so far, been like using a sailboat to chase a speed boat. I have met individuals who had all the factors in alignment to achieve this. Unfortunately, they are not the norm. They are the miracles. I say this not to squelch the faith of those who believe that natural-only can work. I realize that, for some, it will, and I have the deepest respect for patient choice. I and my dedicated colleagues have, however, attended too many funerals held in honor of beloved patients who were clinging to the faith that the natural-only option would save them while denying potentially life-prolonging conventional medical treatments. Therapies that might have given the natural options more time to work. On the other hand, patients have suffered, and some have died due to side effects from unnecessary surgeries and drug treatments. It is all about timing and balance.
       
I am however, very confident in the use of well-designed complementary or integrative approaches that pair the best of both worlds. These would include properly timed, natural medicines used in therapeutic dosages along with individually chosen diet therapies, mental-emotional healing, stress management, and energetic balancing to work in tandem toward a cure with carefully chosen and safely dosed conventional allopathic procedures and medicines. The success at facilitating remission is especially high, in my observations, under the care of our medical colleagues who use methods that reach beyond what is possible in our country today. In Europe, some oncologists are individualizing treatments using a host of conventional and natural methods combined. They are, however, not yet approved by the FDA to be used in this country.
       
After all these years, I am not confident in the success rates among those who forgo all forms of conventional medicine. What I feel deflated by is that we do not yet have reproduceable natural treatment protocols to offer as an alternative to conventional medical treatment. This is due, in part, to the limitations placed on medical and naturopathic physicians in our county. We don't have a body of research that proves our methods work, nor do we know when to use which form of natural medicine. Reading about those who claim to have better success than the MD-only options, I react with a blend of healthy skepticism and hope. I realize I may be scorned by my own people here: colleagues who may have a patient or perhaps several, who, under their care, found a cure or extension of life with a natural-only approach. I pray that you succeed, but to date, this is where I believe we are. Without repeatable and trainable methods, we are left to advise patients to find the balance between conventional and natural. Perhaps the burgeoning science of immunotherapy is what we've been waiting for – using the healing power of our own immune system with help from sophisticated science, and yes, the capitalist-driven machine of conventional medicine, to bring about a much-needed cure for cancer that works with our body's wisdom. I could get on board with that. But, then again, I was raised by folks who believe in unicorns and won't give up looking for the natural-only holistic approach that works.
       
I am proud of the state of my profession's offerings in complementary treatment during conventional cancer therapies. I strongly recommend that patients seek this form of care and wish patients had more access to holistic care at their cancer clinics. But, while we are getting closer every year to the alternative, natural-only options that we desperately want to provide, I encourage patients to think carefully before embarking on that journey.

While waiting too long may be a risk, only in dire cases can a recently diagnosed person not wait a few weeks to feel ‘right’ about their treatment decisions.

Decision Making 

If you are among those recently diagnosed with cancer, your thoughts and feelings, questions and concerns, your left brain, your right, your logic and your intuition all matter. While this will affect those who love you, it is your experience, no one else's. You get to call the shots even if it might not feel that way.
       
The rest of this article is intended to help you navigate cancer treatment decisions if you are considering the addition of natural medicine along with conventional medical treatment or instead of it. That defines the difference between complementary (a.k.a. integrative) vs. alternative medicine. Even though you are likely mentally and emotionally overwhelmed by your recent diagnosis and conventional treatment options, the goal is to feel confident about the forms of natural medicines their dosage, timing and sources you choose. 
       
So, how do you find confidence in your plan when you are new at this and the stakes are high? Finding answers to the following questions, may help you organize your thoughts.

  • First, how much time do you have to make an informed decision?

  • Second, what choices do you have?

  • Third, if you choose a complementary or alternative path, where will you get the expertise you need to guide you?

  • Fourth, if you choose a complementary path, what type of natural medicine is best for you?

  • Fifth, if you are leaning toward an alternative path, what should you be thinking about?

  • Lastly, how can you comfortably work within the conventional medical system even if you choose CAM?

How Much Time Do I Have Before I Have to Do Something?

After a diagnosis of cancer, the conventional treatment 'system' efficiently whisks patients into a well-meaning river of action that requires that you trust, not in yourself, but in the experience of others. For many, this may be your first time having to use conventional medicine. Patients are often paddled along by supportive loved-ones who fear losing them. Many patients, however, especially those who think of themselves as 'natural,' are compelled to swim against the establishment current as fast as they can or at least tread water a while.
       
I advise you to take your time making your treatment choices. While waiting too long may be a risk, only in dire cases can a recently diagnosed person not wait a few weeks to feel 'right' about their treatment decisions. If you are not sure, ask the surgeon or oncologist, "how many days or weeks do you think I have to safely make an informed decision about your recommendations?" With that in mind, the next step is to organize the decisions that must be made now, and the ones that can wait a while. As the Tao de Jing advises: there are times to move forward, times to pause, and times to retreat.
       
How do you know how much time you have to pause or retreat and try natural methods? This depends on the type of cancer, stage, location, how aggressive it is, and how successful conventional treatments are at leading to remission or cure. These criteria are also the same ones that may lead you to choose the amount of conventional medicine you find necessary. An oncologist can help you answer these questions and give you some insight into what you are facing. Often the surgeon is the first person you will meet, however. You are encouraged to consider speaking to an oncologist (doctor who specializes in cancer) before deciding on surgery, if there is time to do so. This conversation is especially important these days as new forms of cancer treatment and clinical trials may offer pre-surgical options that were not available even a few years ago. Don't be afraid to ask for a second opinion from a surgeon or oncologist at an unaffiliated hospital too.
       
To get the most out of your oncology visit, you may want to ask the difficult questions such as:

  • How common is this form of cancer?

  • Is my situation quite typical of those with this form of cancer or are there factors that make my situation unique?

  • How aggressive is this form of cancer?

  • Help me understand what stage it is.

  • If untreated, will the tumor soon inhibit organ function?

  • What are the five- and ten-year survival rates for people who have been studied with this specific type of cancer using your suggested treatment method?

  • If I did no conventional treatment at all, how long do you think I'd have to live?

  • If I only do part of what you recommend, how does that affect long-term survival outcomes?

  • Be honest, if you were me, and you were in my exact shoes, would you do the treatment that you are recommending to me?

  • If you were discussing my case with other physicians, what would you describe as my biggest challenge?

Knowing what's next is also dependent on knowing yourself. Are you a person who needs to list all the pro's and con's? Are you one to listen to your gut? Do you usually play it safe and do what doctors recommend? Do you run screaming at the thought of doing anything an allopathic doctor recommends? Think about how you have successfully thought your way through other challenging decisions and start there. Also, be honest with yourself about when your blinders might be on. Don't confuse wishful or magical thinking for truly discerned inner wisdom.
       
In some cases, having a conventional treatment now, while debating the other decisions, is necessary. A few examples include a) there is a narrow window of time that surgery is an option b) a tumor is invading an essential organ that can't function without its removal c) starting chemotherapy before other treatments is advised to shrink a large tumor d) the cancer is so aggressive and rapidly replicating that no form of natural medicine could possibly outpace it.
       
For example, if a patient has been told that they have an aggressive cancer (for example small-cell lung cancer) that has been diagnosed after a biopsy, and it is currently operable, my advice would be to have the surgery ASAP and then consider natural options later because they are lucky to have found it at an operable stage. However, if a person was diagnosed with a common small, stage I breast cancer which has good outcomes with conventional treatment, but she is riddled with anxiety having never even taken antibiotics in her life, perhaps she can pause for a week while gathering information. 
       
Lastly, and most challenging, perhaps, is the person told that they have six months to live with metastatic cancer. Some might choose to fight with all forms of medicine, others to pause a while to decide and some to do nothing and enjoy the time they have without enduring side effects of treatment in what is likely their last months of life. In that case, it is more about how you make decisions because whether natural or conventional or a mix, no one can promise a cure, but some find one.

What Are My Choices? 

The next step is formulating the right questions, which means knowing your options.

  • Should I follow the conventionally advised course of treatment only? (A: Conventional Medical Only Option)

  • Should I follow only part of it? (B: Individualized Medical Option)

  • Should I follow part or all of it and add natural medicine to it? (C: Conventional and Complementary Medicine Option = Integrative Option)

  • Should I do the course of advised medical treatment and then try to prevent recurrence with natural medicine? (D: Conventional Then Natural Medicine Option)

  • Should I forgo conventional advice and do only natural medicine? (E: Alternative Medicine Option)

If you choose C, D, or E, then there are even more questions to answer. If I do any natural therapies, which ones do I choose? Do I stay local or travel to a comprehensive integrative cancer clinic or a natural only one in the US or abroad? Do I work with a licensed naturopathic oncologist, licensed ND with cancer treatment experience, a holistic DO/MD, other natural practitioner or create my own treatment plan from my online reading?
       
As you are likely gathering from this long list of important questions, you could spend years trying to figure these things out. Chances are you are mentally and emotionally doe-eyed by now and are feeling pressured by others and are rightly confused and overwhelmed. While you may have more time than you were led to believe to make treatment decisions, don't let your need to have all the answers right now get in your way of taking one wise action step.

Who Are Reliable Experts in Complementary and Alternative Medicine?

Without a licensed naturopathic physician in most oncology clinics, it is up to the individual to find a well-trained, licensed, natural medicine provider with extensive cancer care experience whose practice philosophy is up your alley. My recommendation is to choose a licensed naturopathic physician/doctor (ND). Unlike unlicensed naturopaths with an online certificate, a licensed ND is trained in four-year graduate level naturopathic medical schools. We are primary care physicians in many states and specialists in others and are not licensed in some. Licensed NDs are uniquely trained in both conventional science-based medicine and the art and science of healing by treating the whole person, using the healing power of nature and avoiding the obstacles to a cure. We all must pass national basic science and clinical licensing exams that include competency in pharmaceutical and naturopathic medicines. In many states, we have DEA licenses and full prescriptive rights like MDs and DOs where even intravenous vitamins and botanicals are administered. In other states the drug formulary is limited or nonexistent. Most are members of the Oncology Association of Naturopathic Physicians (OncAnp.org). 
       
A licensed naturopath who focuses their practice in oncology is not bound by a standard of care like medical oncologists are. There are no protocols that we must follow. This is great for individualized care, but it also puts the onus on patients to discern which ND is the best fit for them.
       
Just like you might consider getting more than one medical oncologist or surgeon opinion, I recommend that you interview a few licensed NDs before choosing one to guide you. Some of us are more classical in our approach and use 'nature-cure' methods while others use a more science-based approach or both. Many offer a free 15-minute meet-and-greet visit to see if you are compatible. Good questions to ask would be how much of your practice is oncology? How long have you practiced? What forms of natural medicine do you most often use? What are your opinions about complementary vs. alternative medicine? What are your opinions about conventional allopathic treatments? How do you avoid giving things that might negatively interact with conventional therapies?
       
Some licensed naturopathic physicians have taken a special board exam to become a fellow of the American Board of Naturopathic Oncology (FABNO). They are referred to as naturopathic oncologists. Many have or do work at Cancer Treatment Centers of America where they learn expertise in complementary oncology limited to natural medicines that can be proven with peer-reviewed studies. They are the perfect choice for a person who prefers an evidence-based approach. You can find a list of FABNO's at http://fabno.org/membership.html.
       
There are osteopathic and medical doctors with training in complementary cancer care who learned from integrative or functional medicine courses. Some have cancer clinics that offer simply relaxation techniques. Others direct comprehensive clinics offering everything from intravenous vitamins to hyperthermia and hyperbaric medicine. To my knowledge, there is no national certification for allopathic doctors in CAM therapies. Many allopathic physicians practicing integrative oncology are members of the Society for Integrative Oncology (SIO at integrativeonc.org.)
       
Finally, there are cancer clinics that patients travel to for treatment. It is vital to discern sham clinics from those with well-trained oncologists who had to leave the US to provide a combination of conventional and natural treatments without waiting for FDA approval. The only resource that I am aware of when considering foreign clinics is Ralph Moss, PhD's Cancerdecisions.com. Many providers and CAM clinics around the world provide often life-saving methods. Others advertise much more than they deliver at great financial expense to people who are most vulnerable with little time to research whom to trust. So, my next piece of advice is to thoroughly consider who you will work with to guide your CAM plan.

My experience tells me that most often, if you said you’d ever be willing, and it is logical to those who know the details of your case, do the conventional medicine sooner rather than later. It is an issue of timing.

Fourth, What Type of Natural Medicine Is Best for You?

Once you have decided what conventional therapies you will or will not choose to do and you have decided to take a complementary or integrative route and found a practitioner you trust, next you need to decide which natural therapies are best for you. This is often based on your personal situation and the prescribing CAM physician. In most therapeutic settings, you will likely be offered complementary treatment plans that help you avoid side effects and optimize conventional treatments like surgery, chemotherapy, radiation, oral medications, and immunotherapy. In some cases, if the cancer you are working to heal from is aggressive or later stage, you may be adding natural therapies that have independent anti-cancer benefits.
      
CAM or integrative medicines include so many possibilities that this article cannot cover them all. A new book may shed more light on this subject, however: Outside the Box Cancer Therapies by Stengler and Anderson (Hay House Publishing, 2018). 
       
Some therapies that are reputable include combinations of botanical medicine from various traditions or standardized extracts of single plants such as curcumin, artemisinin, berberine and mushroom extracts. Vitamins, minerals, amino acids, essential fatty acids, homeopathic remedies are often included. There are treatments that holistic practitioners may offer such as acupuncture, mind-body therapies or you may be referred to classes in meditation, yoga, Qi Gong, or invited to join a fitness program for those with cancer such as the YMCA's free Livestrong program. Most practitioners will likely discuss what you eat, drink, your fitness, and stress management regimens. Some with additional training might recommend intravenous vitamins and amino acids, and a few are trained in administering IV botanicals. Low-dose medicinal cannabis may treat side effects while higher dosages, with an aim to treat cancer, need the guidance of an experienced practitioner. In addition, European therapies are coming to the United States such as mistletoe injections, hyperthermia, and hyperbaric. 
       
I encourage you to avoid doing therapies that are recommended online until you have found a practitioner with expertise to help you discriminate the ones that have merit from those that will cost you hundreds of dollars a month and do you no good at all.

What Should You Consider?

"Do I go against everything I believe about living a healthy life and do what these doctors, who don't even know me, tell me are my only choices: surgery, chemotherapy and/or radiation?" Many patients have shared this inner struggle with their naturopath. It makes sense to most of us, and it is likely how we'd feel in your shoes (and many NDs have been cancer patients as well.) You might be thinking, I'll eat even healthier, do cleansing and detoxification, take herbs and mushroom extracts, medical marijuana, cottage cheese and flax seeds. Maybe even do hyperbaric and IV-vitamins, supplements, acupuncture and herbal medicines or the other dozens of possible natural therapies.
       
How can you discern between fear of conventional treatment and your inner-wisdom that says I know this isn't right for me? Is now the time to do what feels right and forgo convention? Each situation is unique. Consider the risks and the benefits of both, what you know about yourself, perhaps get the opinions of experts in natural medicine for your personal situation and then ask yourself: "Will I ever be willing to do any form of conventional medicine?" Often patients want to try natural medicine first, saving chemotherapy or surgery if that fails. My experience tells me that most often, if you said you'd ever be willing, and it is logical to those who know the details of your case, do the conventional medicine sooner rather than later. It is an issue of timing. If you knew you'd have the perfect combination of natural factors for that sailboat to catch up to the speedboat, you'd do it. But, if you have a form of cancer that 'can't wait' to try natural-only methods, you will likely be encouraged to compromise your health-related beliefs in the short term, undergo a medical treatment you dread, and follow that up with the best of natural medicine. 
       
If you do use complementary natural medicine during conventional medical cancer treatment, it is strongly advised that you a) use a licensed naturopathic physician or other integrative doctor who has expertise in the type of CAM you are choosing b) inform your oncologist about what you are taking c) use high quality products that can provide a certificate of analysis proving that they are tested for purity and contamination d) take therapeutic doses of well-researched natural medicines instead of a smattering of a lot of things you read about online e) make sure that you and your natural practitioner are watching out for negative interactions with other medications or conditions and f) if you are using alternative methods, choose a treatment facility or practitioner that is well-vetted by an objective source such as cancerdecisions.com to avoid shams.

Summary

In conclusion, nearly 1.1 million Americans will use complementary and/or alternative medicine during or after going through conventional medical cancer treatment. We don't know how many patients choose to forgo these allopathic treatments and instead seek natural cures. The types of complementary natural medicine chosen during conventional cancer treatment vary greatly from taking a yoga class to travelling to comprehensive integrative cancer clinics in Europe or Mexico. While the body of research on the safety of complementary cancer care is growing rapidly, there are little data on success and failure rates of alternative protocols. This dearth of research leaves patients who are instinctively drawn to natural medicine to create their own plan of action with insufficient confidence in either system. Some gather all their financial resources to go abroad to be treated by those with excellent training in both conventional and alternatives. Some find the cure they were hoping for. For some, the timing, training, or resources have failed them. Those without financial resources or who are more comfortable being treated near home may seek guidance from local licensed holistic health providers with enough experience in oncology to give them great advice.
       
It is my belief that we, as practitioners of natural medicine, are obliged to counsel cancer patients in an individualized manner based on their goals, the type and stage of their cancer, the success rates of conventional therapies, and potential conventional clinical trials for which they may meet the criteria. We owe patients the truth about our current limitations, balanced with the hopes of our powerful medicines, and proper counsel to help them make an informed decision about when, how much, and what type of natural medicines create a plan that they will feel confident in. 
       
There is a time to move forward, a time to pause and a time to retreat. Knowing oneself and being educated in your choices will help you to know what is next for you. In the long run, this is your experience to direct in any way that you feel is right for you. If you aren't sure what to do next, take one step and perhaps you will discover more options than you could see before. This is an incredible time in the field of oncology. While I wish no one had cancer, I have more hope than I ever did before – in both conventional and natural treatments used hand-in-hand.

What Could Be Next?

My wish list includes a survey of natural oncology practitioners to identify who has had success and with what methods. Next, a case conference to share experiences combined with roundtable discussions. Finally, a privately or institutionally funded not-for-profit research institute to explore the possibilities of both alternative and complementary natural approaches dedicated to individualized cancer treatment and transparency.

Dr. Barb MacDonald, ND, LAc, can be reached by emailing drbarbmacdonald@yahoo.com.

References
1.     American Cancer Society online: Cancer Facts and Figures. https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2017.html. Accessed 12/29/17.
2.     Molassiotis A, et al. Complementary and alternative medicine use in breast cancer patients in Europe. Support Care Cancer. 2006;14(3):260–267. 
3.     Yates JS, et al. Prevalence of complementary and alternative medicine use in cancer patients during treatment. Support Care Cancer. 2005;13(10):806–811. 
4.     Sikorskii A, et al. Recruitment and early retention of women with advanced breast cancer in a complementary and alternative medicine trial. Evid Based Complement Alternat Med. 2011;734517.
5.     Downer SM, et al. Pursuit and practice of complementary therapies by cancer patients receiving conventional treatment. BMJ. 1994;309(6947):86–89.
6.     Perlman, A, et al. Prevalence and Correlates of Postdiagnosis Initiation of Complementary and Alternative Medicine Among Patients at a Comprehensive Cancer Center. Journal of Oncology Practice. January 2013;9(1):34-41.
7.     Barnes PM, Bloom B, Nahin R. Centers for Disease Control. Complementary and alternative medicine use among adults and children: United States, 2007. National Health Statistics Reports. 2008(12):1–24.
8.     Johnson SB, et al. Use of Alternative Medicine for Cancer and Its Impact on Survival. Journal of the National Cancer Institute. Published online August 10, 2017.
9.     PubMed Health. Behind the headlines: health news from NHS. Accessed on 3/11/18 at https://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines/news/2017-08-16-alternative-cancer-therapies-may-increase-your-risk-of-death/.