The role of traditional, complementary, and alternative medicine in cancer care in the Philippines

Around 40% of patients with cancer in some Western countries (1) to over 80% of patients in some Asian countries (2) use traditional, complementary, and alternative medicine (TCAM). Its increasing popularity has sustained global efforts to integrate TCAM into national healthcare systems, and integrative oncology—the use of TCAM alongside conventional cancer therapies—is a field born from this movement. Integrative oncology, however, remains elusive for most patients in low- and middle-income countries (LMICs), where many seek TCAM despite concerns about regulation, safety, and financial toxicity (3). Given this steady patronage amongst patients with cancer, there is a need to examine socio-cultural drivers of TCAM use vis-à-vis the landscape of health systems in LMICs. We write from the Philippines, a lower-middle income country in Southeast Asia, where cancer is the fourth leading cause of death (4) and where TCAM remains popular among patients and families dealing with cancer.

As in other resource-challenged LMICs, Filipino patients with cancer face geographic obstacles to healthcare, unaffordable conventional therapies, and underdeveloped palliative and survivorship care (2,5). These barriers, compounded by low socioeconomic status and poor health literacy, drive patients to seek alternative forms of treatment, such as TCAM. However, structural and health system barriers are only contributory drivers of TCAM usage. Deeply ingrained historical and sociocultural influences heavily impact health attitudes and behaviors among Filipinos and, in particular, the role of TCAM in cancer care in the Philippines.

As a nation with a strong agrarian profile, many traditional theories of illness causation in the Philippines revolve around balance and harmony of humans with the natural environment, as well as mystical and supernatural forces (6). These theories are still embedded in modern-day Filipino beliefs, hence commonly held conceptualizations of healing necessitate herbal concoctions, prayers, and rituals, which the TCAM paradigm often provides (2,7). Positive regard for these natural remedies and their perceived benefits is reflected in the cultural association of the terms “herbal” and “natural” with safety and effectiveness.

TCAM’s credibility is also rooted in ancient spiritual and herbal medicine, especially among isolated rural communities (6,7). “Babaylans” or feminist healers (8), who held considerable sociopolitical influence as spiritual mediators, preserved healing traditions in their communities that remain highly accepted to this day. Despite the Philippines’ adoption of biomedicine, TCAM practitioners and indigenous healers have retained the same trust, respect, and power in their respective localities. They deliver individualized care at little to no cost (9), prescribing natural remedies from the immediate environment. Their culturally-sensitive and accessible approach adds to their popularity and practicality, especially among older women and resource-challenged patients in remote areas (10).

For Filipino patients with cancer, TCAM bestows autonomy over one’s health, providing active coping mechanisms for managing emotional and spiritual burdens (10,11). Prayers, vitamins, and herbal preparations are used for the purposes of stabilizing the present condition, boosting the immune system, improving quality of life, and managing the side effects of conventional therapies (10). The Philippines first legally recognized the value of TCAM in 1997 with the Traditional and Alternative Medicine Act (TAMA Law), which regulates its practice, research, and related medicines. However, despite two decades of legislation, progress towards integrative healthcare remains sluggish, partly from the deep-seated divide between biomedical and TCAM practice.

Philippine medical training subscribes to the biomedical model (6,7); therefore, lay beliefs central to patient narratives are easily dismissed as superstitious. Physicians rarely ask about TCAM use during routine health interviews (10), contributing to gaps in patient-physician communication, and many patients, fearing physician judgment or disapproval, withhold information regarding TCAM use. Fundamental differences in philosophies (2), alongside varying degrees of practitioner open-mindedness, widen the chasm between TCAM and biomedical practice. Little is known about formal communication channels between TCAM practitioners and conventional physicians, but referral systems in the country in general have yet to be developed. Without mechanisms in place, compounded by personal prejudices, it is less likely that patient management is coordinated and unified, especially with an existing distinct delineation between these two practices (7). Patients with cancer are then left to navigate the two systems without guidance. It is common for patients to opt for TCAM (12), deeming it safer, more accessible, and more affordable.

TCAM is meant to be utilized for supportive and palliative care. However, Filipinos underserved by the current healthcare system are left to rely on it as a primary form of treatment despite its limitations, in the absence of accessible and affordable conventional cancer therapies. It must also be acknowledged that choosing treatment with TCAM exclusively may lead to the delay or outright refusal of conventional therapies altogether, especially when discussions on TCAM use are not handled satisfactorily by their physicians. In the interest of protecting patient safety and achieving optimal treatment outcomes, it is necessary for healthcare providers to initiate the conversation on TCAM, explore patient beliefs and core values, and integrate TCAM usage in patient counseling (13).

Without appropriate guidance, patients with cancer are the most vulnerable from the current divide between TCAM and biomedicine. Businesses capitalize on the popularity of natural remedies for profit and exploit patients by marketing herbal products with anti-cancer claims despite lacking scientific evidence, especially since Filipinos may not understand Food and Drug Administration (FDA) labels that are rarely translated into their native language (14,15). Additionally, traditionally used herbal products, herbal medicines, and herbal supplements lack finer categorization and regulation, and unregistered products can easily penetrate the market (15). With inadequate patient education and less stringent safety evaluations compared to conventional medicines, adverse side effects experienced by patients taking herbal preparations are often unrecognized or assumed to be part of the medicine’s healing action, and remain unreported (16). Some plants commonly used in traditional Chinese medicine induce or inhibit the cytochrome P450 enzyme system, particularly CYP3A4, which may lead to either decreased effectiveness of some chemotherapeutic drugs or increase in their side effects and toxicity (17).

These existing concerns on safety and regulation have led proponents of biomedicine to prematurely dismiss TCAM, instead of viewing it as a valuable asset to cancer care, particularly in supportive and palliative care. The fixation on the “negative” in TCAM research fails to address the deeper roots of the problem, such as poor health literacy, lack of training and regulation, shortcomings in patient-physician communication, and insufficient social, financial, and structural safety nets. It also disregards the motivations behind continued patronage for the service, including affordability, cultural belief systems, satisfaction from prior experience, and discontent with the current health system.

In the context of cancer, integrative oncology in the Philippines is a vision currently unattainable for the majority. The recently passed National Integrated Cancer Control Act presents an opportunity to champion comprehensive cancer care for all Filipinos, but this requires recognizing the potential of TCAM to improve health service delivery. We enjoin its council to build on the achievements of the TAMA Law by mainstreaming more herbal medicine into clinical practice through larger investments in research and development, and regulating the market to ensure patients with cancer are using quality, safe, and effective products (15).

The TCAM-biomedicine gap must be bridged to protect patients made vulnerable by existing health inequities. Health leaders must include TCAM practitioners in policy making to initiate systemic reforms and provide institutional safety nets spanning the cancer care continuum. There is an urgent need to break existing barriers in cancer care, beginning with establishing regional integrated cancer centers, improving service delivery to remote areas, expanding national health insurance to include evidence-informed TCAM modalities, and strengthening the national cancer referral network. We also stress the role and agency of medical communities in actively promoting the recognition of TCAM as a part of the formal medical system by crafting more inclusive medical curricula. Furthermore, the academe can deepen understanding of TCAM in the medical field by facilitating research on its role for patients with cancer, including its palliative and psychosociocultural value. Lastly, engaging patients in genuine dialogue and recognizing them as partners will lay the foundation for cohesive, culturally-sensitive, and patient-centered cancer care.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Chinese Clinical Oncology. The article has undergone external peer review.

Peer Review File: Available at https://cco.amegroups.com/article/view/10.21037/cco-22-91/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cco.amegroups.com/article/view/10.21037/cco-22-91/coif). AMUG serves on the advisory board of Amgen and Eli Lilly and has received honoraria for lectures from AstraZeneca, Boehringer Ingelheim, Janssen, MSD, Pfizer, Roche, Sandoz, and Unilab. JZGT has received honoraria for speaking engagements on traditional medicine, health and wellness, natural medicines, lifestyle tourism, and research resource mobilization from the University of the Philippines Manila, the University of the Philippines Diliman Tri-College Ph.D. Philippine Studies Program, the National Academy of Science and Technology (NAST), the Philippine Academy of Acupuncture, Inc. (PAAI), the Department of Science and Technology—Philippine Council for Health Research and Development (DOST-PCHRD), the International School of Sustainable Tourism, Oceana Philippines, SM Development Corporation, Menarco Development Corporation, and Impact Hub Manila. ECD is funded in part through the Cancer Center Support Grant from the National Cancer Institute (P30 CA008748). The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Cramer H, Cohen L, Dobos G, et al. Integrative oncology: best of both worlds-theoretical, practical, and research issues. Evid Based Complement Alternat Med 2013;2013:383142. [Crossref] [PubMed]
2. Mao JJ, Pillai GG, Andrade CJ, et al. Integrative oncology: Addressing the global challenges of cancer prevention and treatment. CA Cancer J Clin 2022;72:144-64. [Crossref] [PubMed]
3. Kong YC, Kimman M, Subramaniam S, et al. Out-of-pocket payments for complementary medicine following cancer and the effect on financial outcomes in middle-income countries in southeast Asia: a prospective cohort study. Lancet Glob Health 2022;10:e416-28. [Crossref] [PubMed]
4. Philippine Statistics Authority. Causes of deaths in the Philippines (preliminary): January to October 2021. Available online: https://psa.gov.ph/content/causes-deaths-philippines-preliminary-january-october-2021
5. Rondilla NAO, Rocha ICN, Roque SJR, et al. Folk medicine in the Philippines: A phenomenological study of health-seeking individuals. The International Journal of Medical Students 2020;9:25-32. [Crossref]
6. Tan ML. Revisiting usog, pasma, kulam. student edition. Manila: University of the Philippines Press, 2008.
7. Galvez Tan JZ. Health in the hands of the people. Manila: JZGalveztan Health Associates, Inc., 2013.
8. Roxas Q. Essential but not essentialized. On Politics 2021;14:87-102.
9. King RE, Sacdalan DL, Angeles RR. Herbal product and dietary supplement intake among patients at the Philippine General Hospital (PGH) medical oncology clinic: A cross-sectional survey. Ann Oncol 2018;29:ix129-38. [Crossref]
10. Pingoy NP, Macalua GP, Abas RC, et al. Complementary and alternative medicine (CAM) use among patients at the Cancer Institute (CI). Philippine Journal of Internal Medicine 2004;42:159-71.
11. Dahilig VRA, Salenga RL. Prevalence, perceptions and predictors of complementary and alternative medicine use in selected communities in the Philippines. Journal of Asian Association of Schools of Pharmacy 2012;1:16-24.
12. Johnson SB, Park HS, Gross CP, et al. Complementary medicine, refusal of conventional cancer therapy, and survival among patients with curable cancers. JAMA Oncol 2018;4:1375-81. [Crossref] [PubMed]
13. Adams KE, Cohen MH, Eisenberg D, et al. Ethical considerations of complementary and alternative medical therapies in conventional medical settings. Ann Intern Med 2002;137:660-4. [Crossref] [PubMed]
14. Ong SRK, Mier JDB, Mesina BVQ, et al. A cross-sectional triangulation analysis of the knowledge, attitudes and practices of patients from the endocrinology clinic of the Philippine General Hospital on the use of herbal dietary supplements. Acta Medica Philippina 2013;47:58-67.
15. Robles YR, Peña IG, Loquias MM, et al. Regulatory issues on traditionally used herbal products, herbal medicines and food supplements in the Philippines. Journal of Asian Association of Schools of Pharmacy 2012;1:170-9.
16. Hartigan-Go K. Developing a pharmacovigilance system in the Philippines, a country of diverse culture and strong traditional medicine background. Toxicology 2002;181-182:103-7. [Crossref] [PubMed]
17. Ashour ML, Youssef FS, Gad HA, et al. Inhibition of cytochrome P450 (CYP3A4) activity by extracts from 57 plants used in traditional Chinese medicine (TCM). Pharmacogn Mag 2017;13:300-8. [Crossref] [PubMed]