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CAM has existed since time immemorial in Mauritius. The presence of CAM practitioners all round the island, as well as their long years of experience, provide indications about the dependence of Mauritians on CAM and the lengthy existence of CAM in Mauritius. Although different types of CAM are not officially recognised and registered in our country, cultural, traditional, and religious beliefs encourage their use to treat or manage various diseases. A wide range of CAM can be found in Mauritius, with varying degree of popularity.
The majority of CAM practitioners were found in urban areas; however rural regions were not excluded. Greater business opportunities and contact with a higher number of people might explain why CAM practitioners were more concentrated in the capital city and towns than in rural areas. Although many CAM providers such as herbalists, TCM practitioners, ayurvedic practitioners, and naturopaths, have inherited knowledge from previous generations, most of them have professionalised their knowledge by following courses and/or training sessions leading to the award of certificates (Table 3.1.). Working experience of CAM practitioners ranged from 2 to 24 years, with a mean of 11.3 years (Table 3.2.).
However, while a significant positive correlation was found between age group and working experience, no significant correlation was found between working experience and availability of treatment to cancer patients (Table 3.4.).
Nutritional medicine was by far the most common type of CAM encountered in Mauritius, given the large number of pharmacies found in the island. Meditation, ayurvedic medicine, naturopathy, TCM, herbal medicine, acupuncture, and others, followed (Fig 3.3.). Thus, CAMs available in Mauritius were both of local and foreign origin. 78.2% of CAM providers were assisted in their daily duties by staffs. In most cases, the staffs were qualified or given proper training by the CAM practitioners themselves (Fig 3.6.).
4.2. CAM IN THE MANAGEMENT OF CANCER IN MAURITIUS
Whilst it is yet impossible to cure cancer, CAM has a lot to offer to cancer patients in terms of managing the disease and its symptoms. The majority (82.1%) of CAM practitioners interviewed declared that they could offer services to cancer patients to manage the disease (Fig 3.7.). However, central to the notion that CAM plays an important role in the cancer care setting was the awareness that CAM is complementary to, and should therefore be used in conjunction with conventional treatment rather than as stand-alone therapies (Fig 3.8.). Thus, CAM providers do not replace conventional providers but instead are combined into overall care. This is in line with almost all studies that have been published regarding CAM use by cancer patients, where CAM has been promoted for its role in palliative and supportive care in oncology (Ernst, 2009; Fox et al. 2012).
Although they offered different therapies, CAM practitioners valued the use of the therapies in alleviating symptoms and side effects of chemotherapy and radiotherapy, allowing quicker recovery of the patients (Fig 3.11.). The ways in which the therapies helped cancer patients varied with the type of CAM offered, however the three most common ways were to reduce stress and anxiety, to alleviate symptoms of conventional treatment, and to boost the immune system (Fig 3.9.). Reasons why patients took recourse to CAM were studied in a survey involving CAM use among breast cancer patients in USA. Similar findings were obtained, i.e. patients used CAM as a means to reduce stress and anxiety, as well as to boost the immune system (Shen et al. 2002). Psychological support was also one of the most frequently cited reasons why CAM practitioners recommended the use of CAM therapies to cancer patients. Therapies such as meditation, yoga, and reiki served to provide moral and emotional support. Thus, emphasis is laid on addressing the patients' physical needs (symptom management), without bypassing their psychological needs. Moreover, according to CAM practitioners, the majority of their cancer patients sought CAM therapies so as to have better control over the disease and its treatment, and also to improve their overall quality of life (Fig 3.12.). This is in line with Shen et al.'s findings (2002), where "increasing quality of life through a feeling of control and empowerment" was discussed to be one of the major health benefits of CAM. Ernst (2012) also argued that most patients who used CAM were not dissatisfied with conventional medicine, but rather CAM treatments allowed them to take control, feel better and decrease uncomfortable symptoms like pain, fatigue, and nausea.
72.4% of treatments/therapies offered by CAM practitioners had no side effect whatsoever on the patients (Fig 3.10.). Orally ingested CAMs such as herbal medicine, naturopathic remedies, ayurvedic remedies, Traditional Chinese Medicine remedies, and some nutritional supplements, were among the 27.6% which involved the possibility of adverse events. Allergic reactions, nausea, drop in blood pressure are examples of adverse events associated with these types of CAM. Although many forms of CAM are associated with no or minimal risk to patients, it is not true for all such therapies (Smith et al. 1999). Herbal remedies may produce serious adverse reactions if not properly prepared and consumed (Markman, 2002). Quality control of preparations can be a major concern. Concerns include variability in biological potency of different crops, the very realistic likelihood of contamination (e.g. fungus, bacteria), and the use of incorrect plant species. Green tea, commonly known for its antioxidant property, has been indicated in cancers such as prostate cancer. However, although research has shown that green tea can cause insomnia, emesis, diarrhea, and also confusion among patients, none of its adverse effects has been described by the participants. Green tea also has the potential to cause liver damage, to interact with prescription drugs to alter their therapeutic efficacy, and to cause harm when combined with other highly popular herbal remedies (Schonthal, 2011). Thus, as mentioned by most herbalists and other traditional medicine practitioners, for any remedy, the dose and the treatment regimen have to be properly followed so as to prevent any type of adverse event. Other types of CAM such as acupuncture, chiropractic, massage therapy, aromatherapy, yoga, tai chi, reiki, etc, are generally considered quite safe. However, the practice has to be properly carried out. Considering acupuncture, hygiene practices have to be properly followed. Transmission of infectious organisms through needle insertion, broken, forgotten, or misapplied needles, can cause further complications in cancer patients.
Surprisingly, only 51.6% of CAM practitioners advertised their services (Fig 3.13.). Contact cards and pamphlets were the most common ways which they used to inform the public about their services. Those who did not have any means of advertising their services relied on the goodwill of satisfied patients to spread their name amongst other patients and the public at large.
4.3. PROFESSIONALLY ORGANISED ALTERNATIVE THERAPIES
Professional organised alternative therapies are quite common in Mauritius. However, not all of them have been actively involved in the management of cancer or cancer symptoms in our country. According to CAM practitioners, their potential has not yet been fully exploited due to various reasons. Lack of regulation of CAM in Mauritius, lack of awareness of the patients, as well as lack of recognition of medical practitioners for the benefits of CAM, are reasons which might account for such negligence of the potential benefits of these types of therapies in the management of cancer in Mauritius.
Over the recent years, acupuncture has been widely used by cancer patients to manage cancer symptoms (O'Regan and Filshie, 2010). However, in Mauritius, acupuncture practitioners are not actively involved with cancer patients. Most of them believed that acupuncture could not offer anything to cancer patients, whether to manage the disease or the symptoms. In contrast, human studies carried out in China showed that acupuncture helped in boosting the immune system to a great extent. Acupuncture treatment enhanced platelet count and prevented leukocyte decrease after radiation therapy or chemotherapy; increased interleukin-2 (IL-2) level and natural killer (NK) cell activity. Thus, the anticancer effect of acupuncture was suggested to be mediated via the mechanism of immunomodulation (NCI, 2013).
The intensity of cancer-related pain could be decreased with acupuncture, according to one of the participants (Table 3.5.). Practicing at a private clinic in Les Mariannes, Congomah, the practitioner claimed that acupuncture could be carried out to relieve pain, anxiety, and chemotherapy-related sickness by stimulating certain points in the patient's body, depending on his needs. While the acupuncture points vary with the patient's needs and the type of cancer, almost all meridians are involved since "Qi" flows within all the meridians. Both manual and electro-acupuncture are used at the clinic. Research has shown that electro-acupuncture might reduce immunologic damage caused by chemotherapy, thus it could be used as the auxiliary therapy for patients undergoing chemotherapy (Ye et al. 2007).
Bioresonance and auricular acupuncture are also practiced at the private clinic (Table 3.6.). Bioresonance uses electromagnetic (EM) waves which help to detect changes in cell morphology. Acupuncture is then used to reset EM changes which occur, thereby restoring normal condition. On the other hand, auricular acupuncture helps in decreasing pain intensity. One study, conducted to investigate the efficacy of auricular acupuncture in decreasing pain intensity, concluded that statistically significant difference in pain intensity was observed in treatment group and placebo group, with less pain in treatment group (Alimi et al. 2003).
Unlike in other countries where chiropractic was found to be useful in managing cancer symptoms such as pain and stress (ACS, 2011), chiropractic manipulation was not considered appropriate for cancer patients in Mauritius. Chiropractic practitioners showed much reluctance to handle cancer patients. The main reason accounting for such disinclination was the fear that manipulative or adjustment therapies might further upset the patient's nervous system and general health. Moreover, most of the chiropractic practitioners were more involved in sports therapy and spinal injuries than in managing diseases.
4.3.3. Herbal medicine
Several plants have been shown to be effective in managing cancer and cancer symptoms. Mauritian herbalists also recommend the use of plants to cancer patients. These include Triticum aestivum (wheatgrass), Trichodesma zeylanicum (herbe tourterelle), Aloe vera, Moringa oleifera, and a polyherbal formulation consisting of Ayapana triplinervis, Cynara scolymus (Artichaut), and Illicium verum (Star anise) (Table 3.7.). However, wheatgrass was the most common plant recommended against cancer.
Wheat grass (Triticum aestivum) refers to the young grass of a common wheat plant which belongs to the gramineae family. It has shown potential anti-inflammatory, antioxidant and anti-ageing properties (Arya et al. 2011). Mauritian herbalists encourage the use of wheatgrass in cancer patients mostly due to its haemoglobin-increasing effect. Similarly, a study conducted in a cancer centre in India proposed wheatgrass juice as an effective alternative of blood transfusion in terminally ill cancer patients. It has been shown that its high chlorophyll content is useful in building the blood, restoring balance in the body, removing toxic metals from the cells, nourishing the liver & kidneys and restoring vitality (Dey et al. 2006). The plant is grown in Mauritius itself, and it is believed that if the harvest is done when the moon is black, the concentration of the active ingredient is higher. The dried leaves or grains are used, and is usually formulated as a juice (Table 3.7.). Moreover, formulated wheatgrass tablets are available in pharmacies and ayurvedic stores.
Homeopathic remedies were not recommended in the management of cancer or cancer symptoms. According to one of the participants, "Homeopathic remedies take long to show its effects, and most of the times, cancer patients are so desperate to find a "cure" for their disease that they prefer conventional medicine to traditional medicine." While some homeopathic remedies which can manage cancer symptoms are available in India and can be imported upon demand from patients, no such demand is registered in Mauritius.
4.4. COMPLEMENTARY THERAPIES
Complementary therapies are widely available in Mauritius. Cancer patients usually make use of these therapies to complement conventional medicine. Most of the therapies in this category allow patients to have a feeling of "control" over the disease and its treatment.
Aromatherapy is commonly used by cancer patients to relieve stress, anxiety, and depression, according to the participants (Table 3.9.). Lavender oil and peppermint oil were the most common essential oils used by the aromatherapists interviewed. Lavender (Lavandula angustifolia) has a long history of medicinal use and is asserted to possess anxiolytic, sedative and calming properties (Perry et al. 2012). Direct inhalation of a mixture of peppermint oil and ginger oil for 30 minutes, usually after chemotherapy or radiotherapy sessions, was reported to be effective in reducing nausea and vomiting in cancer patients. These findings are in line with studies carried out to assess the use of aromatherapy by cancer patients, where although no statistically valid results were obtained to confirm the efficacy of essential oils in the management of cancer, their effectiveness in managing anxiety was observed in treatment groups compared to placebo groups (Kyle, 2006). However, the essential oils used in the studies are not similar to what has been reported by the participants. While frankincense oil and lemongrass oil have been reported to have anticancer properties (Frank et al. 2009; Sharma et al. 2009), none of these have been mentioned by the participants.
4.4.2. Massage therapy
Stress, anxiety, and fatigue are symptoms which can be managed by massage therapy, according to the massage therapists interviewed. Relaxation techniques such as massage involving the head, neck, and shoulders allow patients to feel better, but cannot treat the cancer (Table 3.10.). Sagar et al. (2007) also concluded that therapeutic massage for cancer patients allowed symptom control and enhanced overall quality of life, without treating cancer. 3 or more sessions per week are usually required, depending on the patients' needs. Few massage therapists declared not offering any service to cancer patients, with fear of upsetting their metabolism. This is in contrast with studies done, where massage therapy was used to help relieve constipation in cancer patients by stimulating bowel motion (Lai et al. 2011).
Reflexology, although now gaining popularity among Mauritians, does not offer much to cancer patients. Only one of the reflexologists interviewed declared that nausea which normally occurs during or after chemotherapy could be managed with reflexology (Table 3.10). In contrast, other studies although not claiming to treat cancer concluded that reflexology could be used to manage anxiety and pain in cancer patients (Stephenson et al. 2000).
Raja yoga meditation was found to be most popular in Mauritius, with 6 major centres around the island (Table 3.11.). Stress, anxiety, and despair are three common symptoms that can be effectively managed with meditation. Raja yoga meditation is a self initiated technique in which healing takes place as a result of activation of health promoting physiological and biochemical processes (Patel, n.d.). Transcendental meditation and prayerful meditation are other types of meditation which can manage stress, anxiety, and despair. The centres offer a 7-days course to the patients, who then continue on their own or in the centres. While leydon et al. (2012) have proposed that mindfulness meditation helps in managing fatigue and anxiety in cancer patients, no such finding was obtained in Mauritius.
4.4.5. Nutritional supplements
Proper diet is an essential part of cancer treatment which helps patients stay strong and improve their overall quality of life (ACS, 2013). Feroglobin and Health Aid Co-enzyme Q10 are the most commonly recommended supplements available in local pharmacies (Table 3.12.). While feroglobin and other iron-increasing supplements are indicated in anaemic patients, Health Aid Co-enzyme Q10 improves energy production in cells and acts as antioxidant (UMMC, 2011). The body has developed antioxidant defenses to protect against free radicalâ€induced damage. Although it has been hypothesised that the antioxidant vitamins E and C and coenzyme Q10 are potentially involved in these antioxidant defenses, preventing the formation of free radicals alone does not cure diseases such as cancer (Shekelle et al. 2003). Propolis has also been indicated as an effective supplement which can manage cancer. Research is ongoing to investigate the effect of propolis on cancer, with results showing that it may be efficient in healing cancer sores, mostly in nose and throat cancer (MedlinePlus, 2012). Human studies have revealed that pancreatic cancer patients consuming liquid propolis for 12 months showed no growth in the number or size of the tumours; many of the tumours had shrunk or disappeared (Maruta, 2012).
Liquid supplements such as Fortimel, Ensure, and Lifegain, are indicated for cancer patients when oral intake of food is insufficient and/or when there is a lack of appetite. These supplements are usually packed with important vitamins, minerals, proteins, carbohydrates and fats (Wood-Moen, 2011).
A weak negative correlation (r= -0.063) was found between percentage by which the supplements have been cited by pharmacists/dispensers and the cost of the treatment per month; however it was found to be insignificant since p>0.05 (Table 3.13.). Thus, considering that percentage of citation reflects the availability of the supplements, the cost of treatment was not a determining factor for the availability of the supplements.
4.4.6. Tai chi (TC)
As a complementary therapy, TC has been recommended to combat stress and anxiety in cancer patients. According to the participants, TC is a form of "meditation in motion" where emphasis is laid upon harmonising "Qi" and maintaining good physical, mental and spiritual health, while mastering breathing techniques. TC also helps cancer patients to sleep better and find inner peace. TC movements are independent of the type of cancer (Table 3.14.). While several studies discussed the use of TC among breast cancer patients (Mustian et al. 2008; Lee et al, 2010), no association between breast cancer and TC was reported by the participants.
Bhakti yoga is the type of yoga commonly encountered in Mauritius. It involves eradication of evil thoughts and concentration on divine thoughts, thereby increasing spirituality among those who practice it. Bhakti yoga has been recommended for cancer patients, however the patients are taught very light movements and relaxation techniques by the masters. This complementary therapy can be practiced daily to fight stress, anxiety and despair felt by cancer patients (Table 3.14.). Along the lines of scientific research (Cancer Research UK, 2009), although none of the masters claimed that they could cure or prevent cancer through yoga, an improvement in the quality of life of the patients was deemed to be possible.
Reiki is also a form of complementary therapy which can be used by cancer patients to manage stress and anxiety. According to reiki masters, reiki can help retard the progress of the cancer is the patient is still in the first stage of the disease (Table 3.14.). The light hand placement technique is used on the body in order to align the chakras (vital points in body) and channel positive energy in patients. Similar to yoga, although there is no scientific basis, studies have found that reiki can lower stress, promote relaxation and alleviate some types of pain (Cancer Research UK, 2009).
4.5. ALTERNATIVE DISCIPLINES
Ayurvedic medicine, naturopathy, and TCM are disciplines which are of great importance in Mauritius. Ayurvedic medicine and TCM are much valued in different cultures in the country. Interestingly, they offer a wide range of products to cancer patients.
4.5.1. Ayurvedic medicine
Aloe vera, noni, amla, triphala, wheatgrass, drumstick, and giloy (Tinospora cordifolia) are examples of ayurvedic products which have been recommended for cancer patients (Table 3.15.). They are highly involved in boosting the immune system and detoxifying the body. However, the most interesting finding of this study concerning ayurveda is a product called "Maharishi Amrit Kalash" (MAK). Generally, MAK enhances immunity and prevents free radical generation by inducing the body to produce more superoxide dismutase (SOD). This mechanism has been proposed to explain how MAK can prevent cancer and promote regression of tumours (Maharishi ayurveda, 2007). A study carried out to investigate the cancer-inhibiting effect of MAK in vitro and in vivo revealed that a MAK-supplemented diet hinders liver carcinogenesis in urethane-treated mice. The prevention of excessive oxidative damage and the up-regulation of connexin expression are two of the possible effects of MAK (Penza et al. 2007). MAK is recommended to cancer patients who seek ayurvedic remedies for duration of 3 to 6 months.
Similar to ayurvedic medicine, Aloe vera and wheatgrass are recommended by naturopaths due to their detoxifying and antioxidant nature respectively. Beta-16 consists of multiple vitamins and minerals which improves general health of patients (Table 3.16). The main finding in this section is a mixture of medicinal mushrooms Coriolus versicolor and Ganoderma lucidum which is believed to relieve cancer-related pain. It has been widely discussed that mushroom constituents may inhibit promotion or progression phases by exercising direct cytotoxicity against tumour cells, interfering with angiogenesis, or upregulating other non-immune tumour suppressive mechanisms (Khatun et al. 2011). The protein-bound polysaccharides (polysaccharopeptides) produced by C. versicolorÂ are highly effective immunopotentiators used to complement chemotherapy and radiotherapy of cancers (Cui et al. 2003). A flow cytometry analysis on cell cycle and apoptotic cell death of human leukemia Molt 4 cells indicated that the anticancer mechanism of polysaccharopeptides from C. versicolor is related to its ability to induce S-phase cell arrest and apoptosis (Lee et al. 2006).
G. lucidum, also known as lingzhi or reishi, has demonstrated anticancer activity in numerous experiments with cancer cells (Sliva, 2003; Khatun et al. 2011; Martinez-Montemayor et al. 2011). In ancient China, the dried powder of G. lucidum is used as cancer chemotherapy agent. Biologically active polysaccharides isolated from G. lucidum are mainly in the form of Î²-D-glucans. These were found to prevent oncogenesis, and tumour metastasis indirectly via the activation of immune response through the stimulation of natural killer cells, T-cells, B-cells, and macrophage-dependent immune system responses (Sliva, 2003). G. lucidum was also found to be a potent anti-invasion agent that prevents tumor spheroid formation with the potential to inhibit the spread of inflammatory breast cancer (Martinez-Montemayor et al. 2011).
Thus, C. versicolor and G. lucidum are natural products with a sound scientific basis used in the management of cancer. However, no studies relating to the use of these products as mixtures were found. Also, published studies pertaining to the effect of these mushrooms in alleviating cancer pain were not found.
4.5.3. Traditional Chinese medicine (TCM)
Medicinal mushrooms such as G. lucidum and shiitake mushroom are widely used in TCM. Teas such as green tea and white tea are also recommended to cancer patients due to their antioxidant properties. Wolfberries are consumed widely due to its cancer-preventive effects (Table 3.18.).
A decoction of Scutellaria barbata and Agkistrodon acutus snake venom was suggested by TCM practitioners to be effective in inducting apoptosis in cancer cells (Table 3.18.). It has been shown that extracts of S. barbata have growth inhibitory effects on several human cancers, the major mechanisms being cell apoptosis and cytotoxic effects. Treatment of lung cancer, digestive system cancers, and breast cancer by S. barbata extracts has been reported (Yin et al. 2004). Snake venoms are recognised as useful sources of bioactive substances having a wide range of pharmacological activities. Snake venom L-amino acid oxidase (LAAO) induces platelet aggregation and cytotoxicity in various cancer cell lines (Sheeja et al. 2011). From Agkistrodon acutus snake venom, a cytotoxic protein called ACTX-8 was isolated, and found to induce apoptosis in Hela cervical cancer cells. The mitochondrial pathway played an important role in the ACTX-8-induced apoptosis, which was regulated by Bcl-2 family members (Zhang et al. 2007).
Ongoing research is validating the use of such products in the management of cancer. However, it should be noted that these products are not easily available in Mauritius due to lack of regulation of TCM. Their importation from China, especially the snake venom, is difficult, and requires a medical practitioner's prescription. Thus, TCM practitioners prefer to offer natural products such as teas, shiitake mushroom, and G. lucidum to cancer patients.