This paper examines the benefits of complementary therapies, as supported by research evidence, in patients with breast cancer. Complementary therapies are those therapies and approaches used alongside medical treatment for breast cancer to support the patient on their cancer journey. It should be added that an integrated approach to cancer care includes the best of the orthodox medical treatments and the best evidence-based, supportive complementary modalities.

The benefits of complementary therapies to help with the side effects of conventional breast cancer treatment are examined in the following areas: pain and surgery, chemotherapy, radiotherapy, hormonal treatments, and psychoemotional and survival issues. Potential interactions between nonprescription medicines and cancer treatments and cost-effectiveness is also touched upon.

Although it is recognized in many of these areas larger and more rigorous trials must be performed, this paper hopes to give some indication of areas in which further research is warranted.

Pain, particularly postoperatively, may be ameliorated with complementary therapies. Reiki has been found to be helpful in pain control (1 to 4 days) in cancer patients 1, whereas acupuncture increases pain relief and improves arm movement after surgery 2. Massage and acupuncture can help to decrease pain and depressive mood 3, and ear acupuncture decreases pain intensity 4. Hypnotic-type methods involving relaxation, suggestion and imagery, as well as support groups and healing touch, have some impact on cancer pain 56, and hypnosis decreases pain intensity, unpleasantness, discomfort, nausea, fatigue and emotional upset after surgery for breast cancer 7.

Chemotherapy's unpleasant short-term and long-term side-effects may be ameliorated by using complementary therapies. Nausea and vomiting is eased by stimulation to the P6 point using acupuncture 8 and acupressure when self-administered 9, but not as well by wrist bands applied to that point 1011. Pain, mood disturbance and fatigue were improved by massage and healing touch 12, whereas reflexology lessened anxiety regarding chemotherapy 13.

Group relaxation with guided imagery reduced fatigue and improved sleep difficulties, whereas cognitive behavioural group intervention reduced external health locus of control 14. Anthroposophic mistletoe extracts can improve quality of life and reduce side-effects of chemotherapy 15. Mucositis can be lessened by slippery elm, but this is only supported by case study evidence and traditional use.

There is some evidence that complementary therapies can help with the side-effects of radiotherapy. Fatigue can be reduced and sleep improved by relaxation and guided imagery, whereas cognitive behavioural group intervention helped reduce external health locus of control 14. Anthroposophic mistletoe extracts can also improve quality of life and reduce side-effects from radiotherapy 15. Herbal skin gels such as aloe vera warrant further study, because mixed findings have been reported regarding their benefit in helping to protect and heal skin following radiotherapy 1617.

Homeopathic remedies of X-ray and belladona aided skin recovery beyond placebo after completion of radiotherapy 18. A variety of homeopathy remedies were found to be helpful in managing skin itching 19.

Patients with menopausal symptoms from the use of hormonal treatments often turn to complementary therapies for help with side-effects. Hot flushes can be relieved by acupuncture 20 and electro-acupuncture 21. Psychological well being improved alongside vasomotor symptoms for women treated with applied relaxation or electro-acupunture 20. Improvements in the quality of sleep were reported with participation in an 8-week mindfulness-based stress reduction programme 22.

Psychoemotional and social support is recognized as being important to recovery from breast cancer. In addition to recognized psychological interventions, complementary therapies and meditation interventions can be useful.

Hypnosis reduces emotional upset in breast surgery patients 7. Aromatherapy and massage can offer short-term benefits in terms of psychological well being and anxiety, depression, relaxation, sleep, body image and possibly physical symptoms 232425. Reflexology can provide some psychological and physical support, as well as decreasing anxiety and pain 1326. There is a review of reflexology's role in symptom relief in progress.

The 8-week mindfulness-based stress reduction programme has been shown to help with mood state, stress and cortisol levels in cancer outpatients 2728.

It is clear that significant numbers of patients with cancer, including those with breast cancer, are using nonprescription drugs such as herbal medicines to support them, but many do not tell their doctors 29. From a meta-analysis conducted by Weiger and coworkers 30, 28% of American cancer patients were at risk for detrimental interactions between chemotherapy and herbal/vitamin therapy. Review articles have specifically examined interactions between herbal medicines and prescription drugs 31 but only one in relation to anticancer agents 32. This review examined herbs with the potential to modulate significantly the activity of drug-metabolizing enzymes, notably cytochrome P450 isozymes. These include garlic, ginkgo, echinacea, ginseng, St John's wort and kava. All of these products participate in potential pharmokinetic interactions with anticancer drugs.

The evidence for use of antioxidants during chemotherapy and radiotherapy is confusing and unclear, and awaits suitable trials 33. In the absence of this evidence, patients should be advised to refrain from high intake of antioxidants, for example vitamins C and E, beyond the recommended daily allowance while they are receiving these treatments.

There is a case for well qualified and experienced complementary therapists, including medical herbalists and nutritional experts, who are knowledgeable about potential interactions to be working in integrated breast cancer care, using the model such as that of the UK-registered charity Breast Cancer Haven, which offers support, information and complementary therapies. More worrying is the fact that health food shop employees are recommending herbal preparations to women with breast cancer with insufficient knowledge of potential interactions. It is a challenge for allopathic and complementary practitioners to establish which of these many potential interactions are clinically relevant 29. It is recommended that oncologists be familiar with potential interactions between cancer treatments and nonprescription drugs, and to enquire actively regarding any nonprescription medications that their patients may be taking.

Only one US cost-effectiveness study in complementary therapies used in breast cancer currently exists 7, showing that the benefits of hypnotherapy in breast surgery patients included reduced institutional costs (procedures, medications and staff). There is an urgent need for more research here.

The majority of complementary therapies commonly used by breast cancer patients are both beneficial and safe when they are offered by well qualified and experienced professionals in an integrated way with ongoing cancer treatment. Complementary therapies can help to reduce the distress of symptoms and side-effects associated with breast cancer and its treatments, as well as the psychoemotional aspects of coping with this traumatic experience.

Areas in which particular vigilance is needed on the part of both medical staff and complementary therapists is the area of ingested medicines, such as herbal medicines and antioxidants. Patients seeking complementary therapies where there is no evidence to suggest any positive benefit should be informed of this fact and dissuaded from their use.

There is an urgent need to prioritize high-quality research into complementary therapies in breast cancer care because patients will continue to pursue these avenues for support. Cost-effectiveness analyses should be included.

The remit of the National Cancer Research Institute's Complementary Therapies Clinical Studies Development Group is to build a portfolio of high-quality research studies into complementary therapies in cancer.

All breast care health professionals must be aware of research evidence in the area of complementary breast cancer care, and should ensure that this information is available to patients.

Provision of these therapies should always be of the highest professional standard and offered in an integrated manner, using well developed, existing models.