Use of alternative medicine by patients. with cancer in a rural area of Switzerland alternative medicine. In the literature, the terms alternative medicine, …
Original article
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Use of alternative medicine by patients with cancer in a rural area of Switzerland
Fleur van der Weg, Rolf A Streuli Department of Medicine, SRO-Hospital Langenthal, Switzerland
Summary
Background: Many cancer patients use alternative therapies in addition to conventional treatment In a survey among such patients, we assessed the prevalence of and the motivation for alternative therapy use in a rural area of Switzerland Methods: From 1st February to 30th November 2001, we interviewed 108 patients treated in the oncology outpatient clinic of the Langenthal District General Hospital, Switzerland, using a structured questionnaire 77 of the patients were female 49 of the patients ie, 64 of the female patients suffered from breast cancer Results: 42 39 of all patients had used an alternative therapy in addition to conventional treatment at least once Mistletoe preparations
were by far the most popular with a prevalence of 74 Homeopathy 24 and cancer diets 12 were used less often 79 of the patients seeking help from alternative treatment informed their treating oncologist and/or medical practitioner accordingly 57 of the doctors encouraged their patients to continue the alternative treatment, none discouraged the patient to do so The main reasons for the use of alternative therapy were: the desire to feel more hopeful 83; to do as much as possible myself to cure the disease 83; and to harness mental energy 62 Only 19 of the patients hoped to be cured of cancer by alternative therapy Conclusions: The motivation to seek help from alternative treatment is not based on a distrust of conventional care Maintaining hope and taking an active role in self-care are the main stimuli for using alternative medicine Key words: alternative medicine; cancer; oncology; Switzerland
Introduction
Alternative therapies are very popular among patients suffering from cancer
and many patients use them in addition to conventional cancer treatment In a systematic review of 21 studies from 13 countries, Ernst and Cassileth [1] found a mean prevalence of 314 range 7 to 64 for patients using alternative treatments Earlier studies carried out in urban areas of Switzerland showed a prevalence of between 25 and 52 [24], while more recent surveys done in the USA found prevalence rates of as high as 80 [5, 6] Against this background, we investigated the prevalence and the types of alternative therapy used by cancer patients in a rural area of Switzerland The main focus of our study was the underlying motivation of the patients We know that alternative practitioners are often described as being more caring, taking more time and listening better to their patients [79] For this reason, we also looked at the question of whether users of alternative therapies have a greater need than non-users to discuss with their physician health-related quality-of-life issues, such as
emotional concerns, social functioning and relations towards their partner and family This might be a reason for seeking help from alternative treatment It was not the purpose of this study to investigate the effects of various alternative therapies on survival or quality of life
No financial support declared
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Patients and methods
From 1st February to 30th November 2001, all patients referred to the oncology outpatient clinic of the District General Hospital, Langenthal, Switzerland, were asked to participate in this study Exclusion criteria were an age below 18 years and an inability to understand the German language To allow them time to become acquainted with the new hospital environment, patients were not recruited at their first clinic visit All patients were interviewed by the same physician FvdW, for approximately 30 minutes each, using a structured questionnaire All data thus acquired
were kept strictly anonymous Questionnaire The questionnaire had a multiple-choice structure designed to assess demographic characteristics, questions on lifestyle, health consciousness, the disease itself, and experiences with conventional cancer treatment Questions relating to the subjective conception of a correlation between the origin of the disease and lifestyle issues were formulated according to Berger et al [10], and those on the subjective conception of conventional cancer treatment according to Obrist et al [4] The questionnaire devised by Detmar et al [11] was used to ask patients about their preferences in disclosing personal information including psychosocial issues to their doctor A list of recognised alternative therapies was compiled, based on a brochure issued by the Swiss Cancer League [12], as well as the publications of Richardson et al [5] and Morant et al [3] This included the following categories: herbal medicine; traditional and folk remedies; diet and
nutrition; relaxation methods; manual healing methods and spiritual healing methods We did not include purely psychotherapeutic or religious activities, such as prayer Patients were asked about their reasons for using alternative therapies with questions formulated as in the above-mentioned studies [3, 5] Definition of alternative medicine In the literature, the terms alternative medicine, complementary medicine and unproven, unconventional methods are often used interchangeably However, Ernst et al [13] gave a definition of complementary medicine which closely suits our view of the subject: Complementary medicine is diagnosis, treatment and/or prevention, which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine Statistical methods Most statistical analyses were performed with respect to the user variable A patient was defined as a user if he or she indicated that any
alternative treatment was explicitly undertaken because of the cancer Statistical significance was determined using a two-sided test with rejection levels of 5 and 10 P values for multivariate parameters Table 1 have been computed using a bootstrap chi-square test with 100000 samples Two-sided 95 confidence intervals Tables 2, 4 of user percentages have been computed using bootstrap sampling The twosided 95 confidence interval for the odds-ratio OR Tables 5, 6, 7 have also been computed using bootstrap sampling P values in Tables 5 and 6 have been computed exactly, the user percentage being described by a binomial distribution
Results
Patient characteristics During the study period, 94 new patients were referred to the clinic; 77 patients agreed to be inTable 1 Characteristics of the patient population
terviewed, 10 refused, and 7 did not answer our written request Within this time, we additionally recruited 31 patients newly referred to the gynaeP value N 66
Characteristics
no of
patients users non-users N 42 20 30 46 70 9 14 17 26 16 24 24 36 27 41 14 21 8 12 17 26 24 36 15 23 8 12 19 29
Sex
Men Women
5 12 37 88 9 21 14 33 15 36 4 10 26 62 3 7 5 12 8 19 8 19 11 26 5 12 18 43
0028
Age groups
50 years 5160 years 6170 years 71 years
0020
Type of cancer
Breast Colon and Rectum Ovarian Other
0111
Time from diagnosis
1 year 12 years 23 years 3 years
0246
users: users of alternative cancer treatment non-users: non-users of alternative cancer treatment
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Table 2 Types of alternative treatment used by patients N 42
Type of treatment Mistletoe Iscador Homeopathy Diets Bach flower remedies Music therapy and colour therapy Massage Spiritual healing, healing by laying on of hands Metals, crystals Hypnosis Acupuncture Osteopathy Biofeedback Simonton therapy
no of patients 31 10 5 4 3 3 3 3 1 1 1 1 1
738 238 119 95 71 71 71 71 24 24 24 24 24
95 CI [595857] [119381]
[24214] [24190] [00167] [00167] [00167] [00167] [0071] [0071] [0071] [0071] [0071]
The sum of the percentages exceeds 100, because many patients used more than one type of alternative treatment
Table 3 Comparison of the prevalence of using alternative cancer treatment and the types of treatment in different studies carried out in Switzerland all figures in
Present study Users among cancer patients Mistletoe Homeopathy Diets Metals, crystals Spiritual healing, healing by hands Acupuncture 39 74 24 17 7 7 2
Obrist 1986 [4] 317 21 6 6
Berger 1989 [10] 44 34 10 34 3 3 6
Morant 1991 [3] 52 156 14 12 40 12
cological oncology clinic of the same hospital, bringing the final number of participants to 108 77 of the patients were female table 1 42 39 of the 108 patients had used an alternative therapy for cancer treatment in addition to conventional therapy, at least once Women were significantly more often users of alternative therapies than men p 0028 Only 10 of the patients older
than 71 years used alternative therapies The types of malignant disease in our patients are listed in table 1 Patients with breast cancer have a significantly higher user percentage as compared to patients with other malignant diseases p 0035 The prevalence of alternative therapy use among those who had known their diagnosis for less than 1 year was lower than among the other patients, but this did not reach statistical significance Educational level and profession were similar in both groups 23 of the patients had only primary education, most 66 had completed vocational training, 9 had a college degree, and 2 had a university degree 44 of the female patients were full-time housewives, 33 were working part-time; 12 were full-time employees, 11 were self-employed or had a managerial position Of the last group, only 8 used alternative therapies, a significantly lower figure than in the other professional groups p 003 81 of the users had heard about their chosen
alternative therapy
through family or friends, 45 from other cancer patients, while 29 had read about it in books Newspapers and the internet were mentioned as information sources by only 4 and 3 patients, respectively Forms of alternative therapies Of the 42 patients who had used an alternative cancer therapy at least once, 30 71 used only one alternative treatment, 4 10 used two different types, and 8 19 three or more types The various alternative treatments used are listed in table 2 With a prevalence rate of 74 95 confidence interval [CI]: 595 to 857, mistletoe preparations Iscador were by far the most popular alternative drugs Table 3 shows the distribution of alternative methods used by our study group compared with three other investigations carried out in Switzerland Reasons for the use of alternative therapies and expectations The most common reasons for using alternative therapy at the same time as conventional treatment were the desire to feel more hopeful 83; 95 CI: 714 to 922 and to do as
much as possible myself to cure the disease 83; 95 CI: 714 to 922, as can be seen in table 4 Only 10 of the users were disappointed by conventional treatment and 10 thought that conventional treatment cannot help me any
Use of alternative medicine by patients with cancer in a rural area of Switzerland
236
833 833 619 524 429 429 429 143 95 95 95 95 CI [714929] [714-929] [476762] [381667] [286571] [286571] [286571] [48262] [24190] [24190] [24190]
Table 4 Reasons for the use of alternative therapies for cancer treatment N 42
Reasons for use I want to do as much as possible by myself I feel more hopeful I want to harness my mental energy This is a non-toxic treatment I had good experience from previous treatment Corresponds to my lifestyle Fewer side effects My disease is not curable I was disappointed by conventional treatment I got no help from conventional treatment I want to avoid chemotherapy and/or radiotherapy
no of patients 35 35 26 22 18 18 18 6 4 4 4
The sum of the
percentages exceeds 100, because many patients indicated more than one reason
Table 5 Perceived causes of cancer
Perceived causes
no of patients users N 42 non-users N 66 6 9 1 2 21 32 12 18 7 11 6 9 32 48
P value
OR
OR: 95 CI
Environmental pollution Nutrition Heredity Stress Disharmony between body/mind Smoking Dont know
4 10 0 0 15 36 13 31 9 21 0 0 14 33
0923 1000 0722 0119 0155 0083 0060
1053 1191 2017 2299 0531
[01774324] [05132667] [07435469] [07577750] [02221200]
Table 6 Perception of the effect of conventional cancer treatment
Perceived effect
no of patients users N 42 non-users N 66 35 53 4 6 22 33 13 20 12 18
P value
OR
OR: 95 CI
Tumour regression Tumour progression Prevention of metastases It makes me feel better It makes me feel worse
28 67 0 0 20 48 3 7 11 26
0096 0253 0077 0089 0359
1771 1818 0313 1597
[07874250] [0835 4239] [00001053] [06194214]
more 14 used alternative therapies because they had heard that my disease is not curable
81 of the users expected to boost their immune system with the help of alternative therapy, 67 wanted to improve their quality of life, and 29 expected to prolong their life However, only 19 expected alternative therapy to cure the disease Disclosure of alternative therapy use to the oncologist/physician 79 of all users discussed the use of alternative therapy with their treating oncologist and/or medical practitioner 57 of the doctors encouraged their patients to continue this treatment, 36 were neutral about this issue but none told the patient to stop the therapy 7 of these patients did not report on the way their doctor reacted
Former use of alternative medicine for other diseases 45 42 of the 108 patients 36 of the nonusers and 50 of the users had previously used alternative therapies for diseases other than cancer They were slightly, though not significantly, more likely to use alternative therapies for their malignant disease as well p 008 Preferences for disclosing physical
and psychosocial health issues Patients were asked which physical and psychosocial health issues they wanted to discuss with their physician and whether they would raise these issues themselves or expected the physician to start the discussion 98 of the patients of both groups wanted to discuss their physical condition with their physician, 86 wanted to discuss their feelings about the disease, 74 wanted to talk about the implica-
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Table 7 Lifestyle before and after the diagnosis of cancer
Lifestyle characteristics
no of patients users non-users 34 52 12 18 20 30 4 20
OR
OR: 95 CI
Smoking: Before diagnosis 42 users, 66 non-users: Never smoked 27 64 Stopped smoking 9 21 Smoker 6 15 Behaviour of smokers, after diagnosis Stopped smoking 4 67
1694 1227 0383 8000 0862 1160 4909 1625 0615 1888 1011 0989 1516 0619 1616 0781
[07873904] [04213250] [0100 0977] [11671080] [03891882] [05312574] [16072600]
[0000, 1905] [0844, 4352] [02822909] [03443543] [06193667] [02681357] [07113724] [01552918]
Healthy nutrition: Before diagnosis 42 users, 66 non-users: On regular basis 22 52 37 56 No special emphasis 20 48 29 44 Behaviour of those not putting emphasis on healthy nutrition, after diagnosis More important 15 75 11 38 Vegetarian nutrition: Before diagnosis 41 users, 66 non-users: Vegetarian 1 2 1 2 Non-vegetarian 40 98 65 98 Behaviour of non-vegetarians, after diagnosis eating less meat 21 53 24 37 Regular relaxation: Before diagnosis 41 users, 65 non-users: Relaxing regularly 7 17 11 17 No special emphasis 34 83 54 83 Behaviour of those not putting emphasis on regular relaxation, after diagnosis Emphasis on regular relaxation 18 53 23 43 Sportive activity: Before diagnosis 40 users, 65 non-users: Regular sportive activitiy 15 38 Not doing sports 25 62 Behaviour of those not doing sports, after diagnosis Did more sport 5 20 32 49 33 51 8 24
tions of the disease on their social contacts
and 81 about the implications of the disease on their relations with partner and family Most patients 88 indicated that they would start the discussion on health issues themselves However one-quarter to one-third of all patients expected their physician to raise issues like social contacts and relations with partner and family 67 of the women indicated that they would initiate discussion of their feelings in relation to their disease and16 would like their physician to start this discussion For men, the corresponding figures are 36 and 36 p 003 There was no significant difference in disclosing health issues between users and non-users of alternative treatments Subjective conception of disease Patients were asked what they believed was the cause of their disease table 5 More non-users than users indicated that they did not know the origin p 006 More users believed stress to be a possible cause of their disease p 011 and emotional disharmony a possible risk factor p 015 Not a single
user assigned a causative role to his/her smoking habit In the non-user group, 9 suspected smoking to be a causative factor of their cancer Perception of effect of conventional treatment Patients were asked what effects they thought conventional treatment had on their disease table
6 Users had a slightly more positive attitude in this respect; more often than non-users they believed that chemotherapy had prevented metastases occurring p 007 and had made the tumour regress, although this difference did not reach statistical significance Lifestyle Patients were asked about their lifestyle smoking, sports, relaxation, and nutrition before and after the diagnosis of their cancer table 7 Before cancer diagnosis, users smoked significantly less than non-users odds ratio [OR] 0383; 95 CI: 0100 to 0977 There were no significant differences in nutritional behaviour and relaxation 95 CI of OR includes unity Nonusers tended to do more sports than users, but this difference was not significant
either Of those patients, who smoked at diagnosis, significantly more users than non-users stopped OR 80; 95 CI: 1167 to 1080 Similarly, of the patients who had not put special emphasis on healthy nutrition, more users than non-users tried to eat in a more healthy fashion after diagnosis OR 4909; 95 CI: 1607 to 2600 Also, more users than non-users reduced their consumption of meat OR 1888, however, this difference does not reach statistical significance 95 CI of OR: 0844 to 4352, ie, including unity No statistical differences could be identified with regard to regular relaxation and sports
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Discussion
In our study, significantly more women than men used alternative therapies This finding corresponds to several other investigations [6, 1417] but differs from the studies of Berger et al [10] and Morant et al [3], which both found no correlation between gender and alternative therapy use With
increasing age, fewer patients used alternative therapies, which agrees with earlier results [6, 8, 14, 15, 17, 18] As in other investigations [14, 19] most patients in both groups were married We were unable to confirm the findings of several studies that users of alternative medicine are better educated [7, 8, 16, 18, 2022] On the contrary, in our investigation, patients with a high level of education or a managerial position tended to use alternative treatment even less often Patients with breast cancer were more likely to use alternative therapies than patients with other malignant diseases This study shows that a significant number of oncology outpatients use alternative therapies along with conventional cancer treatment also in a rural area of Switzerland Many patients even try several different alternative therapies simultaneously, a fact found by other authors as well [5, 6, 23] Table 3 shows that the prevalence of alternative medicine use in our investigation is comparable to
that found in earlier Swiss studies carried out in urban areas [24, 10, 24] Some of the differences may be due to the definitions of alternative treatment Morant et al [3] reported a prevalence rate of 52, with herbal teas and beetroot juice being the substances most commonly used We did not include these two methods in our study American publications [5, 6] showed prevalence rates of up to 80 for users of alternative treatment for cancer These figures may also result partly from a broader definition of alternative medicine As Ernst and co-workers stated in their review [1], one problem in comparing prevalences between studies is that definitions of alternative or complementary therapies vary so much They often include home remedies, wellness centres, and self-help groups The definition of alternative has been broadened in the last few years [25, 26] to include even religious sentiments, personal philosophies and relaxation methods In the present study, the definition of alternative
treatment tended to be more conservative than in other investigations The alternative therapy most often used in our study was Iscador , a mistletoe preparation 74 Homeopathy and special cancer diets were used by 24 and 12 of users, respectively These results are similar to many other European studies [2, 4, 8, 19] Comparison of the Swiss studies, however, shows that very different prevalences for the same therapies are found even in one small country This reflects the importance of factors such as the availability of a particular therapy in a certain region, tradition and cultural background, as well as underlying social trends and values which certainly influence a patients choice [2730] Mistletoe therapy, for example, is almost unknown in the United States [19] Compared to the very high prevalence 74 of mistletoe use in our study, other Swiss investigators found rates of only 34 [2], 21 [4], and 156 [3] In Germany, the prevalence of mistletoe therapy is high as well; Grothey et al
[19] found 45 users of Iscador In a survey among German gynaecologists by Kalder et al [31], more than 50 of the providers of alternative therapies prescribed mistletoe preparations Münstedt et al [32] found that 44 of those medical doctors who prescribe alternative treatments mainly use mistletoe preparations One reason for the high prevalence in our study may be the geographical proximity of our hospital to the Lukasklinik in Arlesheim, a hospital specialising in anthroposophical cancer treatment Feeling more hopeful, doing everything possible against the disease oneself, and harnessing mental energy, are the reasons most often mentioned for using an alternative therapy Patients expect to boost their immune system and improve their quality of life with the help of alternative treatment These findings confirm the results of other studies [35, 7, 10, 19, 23, 33, 34] Only 19 of the users expected the alternative therapy to cure their disease, but 29 hoped that alternative treatment
would help them to prolong their life, findings comparable with other investigations [14, 21, 35] In the study conducted by Richardson et al [5], however, 375 of the users of alternative treatment expected the alternative therapy to cure their disease while 625 hoped that the therapy would help to prolong life Regarding the reasons found in our study for using alternative therapies to treat cancer, we can say that hope seems to be an important, perhaps the most important, issue [1, 5, 14, 23, 25] From research in this field, we know that any belief which increases the hope of cure will improve a patients quality of life and this may contribute to the decision to seek help from alternative therapies [36] Another important stimulus to seek alternative care is clearly the wish of cancer patients to take an active role in their own care and to be able to make their own decisions concerning therapy [9, 19] a desire often not adequately met by the conventional health system In a recent
study by Paltiel et al [37] unmet needs were strongly associated with the use of alternative treatment Providers of alternative care seem to be more aware of cancer patients needs in maintaining hope and being involved in their own care However, the literature indicates that there is little reason to believe that patients are choosing
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alternative treatment instead of standard oncological care [17, 25, 39, 40] Patients choose alternative therapies as a complement rather than as an alternative to conventional treatment Most of our patients using alternative treatment informed their physician of this The majority of physicians reacted positively or neutrally and not one discouraged the patient In contrast, Richardson et al [5] found that 606 of the users did not in fact tell their physician about the alternative therapy and disclosure was found to be low by other investigators as well [8, 23, 33, 35, 41, 42]
Physicians knowledge of alternative therapies was not investigated in our study, although we know from the literature that it is generally rather limited [4, 39, 43] There was a significant difference between users and non-users of alternative therapies in the subjective conception of the cause of their disease, Non-users more often did not have their own hypothesis about the origin of the disease Users frequently believed that stress and emotional disharmony could possibly be causes of their disease These findings correspond with previous research [8, 21, 38] The belief that there is a preventable cause of disease could explain the use of alternative care; by changing lifestyle diet, stress reduction the patient tries to influence the outcome of his/her disease Users of alternative treatment tended to have a slightly more positive view on the effect of conventional care than non-users Many of them believed that it had prevented metastases and made the tumour regress Users, however,
more often reported feeling worse after treatment The finding that users more often report side-effects of conventional care corresponds to the study by Obrist et al [4] Studying women with breast cancer, Boon et al [9] found that users of alternative treatments more often thought that conventional therapies weakened the bodys natural reserves and had serious side effects Users of alternative therapies were more health conscious than non-users after the diagnosis of their cancer The difference was most obvious regarding changes in smoking and nutritional behaviour; more users than non-users stopped smoking after the diagnosis of cancer Several investigations confirm that users of alternative therapies are more health conscious [10, 29] and, according to Berger et al [10], they are so inclined even before their cancer is diagnosed This difference in health consciousness between users and non-users again reflects the desire
of users to fight against the disease as much as possible
themselves, to influence their own health by means of nutrition, relaxation etc From the findings of this study we can draw the following conclusions: First of all, it is most important for oncologists and physicians treating cancer patients to be aware of the needs and characteristics of patients seeking alternative care Physicians can help patients to feel they are receiving the best possible care by establishing good communication, addressing feelings like hopelessness and fear, discussing possible emotional and social distress and talking about issues like nutrition and stress reduction, as well as offering supportive services Secondly, as stated by Downer et al [14], physicians should be prepared to accept that for some cancer patients complementary therapies fulfil an important psychological need In the face of a potentially life-threatening disease, many patients understandably try to do anything possible to fight for their recovery Thirdly, physicians are often not
sufficiently well-informed about alternative therapies and whether these therapies are potentially harmful They cannot therefore recommend a particular therapy or warn patients about side-effects or interactions with conventional treatment Physicians should acquaint themselves with the therapies their patients use and help in making decisions In Switzerland, a good source of primary information is the Swiss Cancer League, which provides information brochures on a variety of alternative therapies [44] It may then be useful to contact providers of alternative care to obtain more information about a specific therapy, and in some cases there will be the possibility of working together The patient will appreciate the fact that the physician takes his/her needs seriously
We are indepted to Peter de Haan, PhD for statistical help and to Meryl Clarke, PhD for linguistic improvement of the manuscript
Correspondence: Prof R A Streuli Department of Medicine SRO-Hospital CH-4900 Langenthal
E-Mail: rstreuli@sroch
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What Swiss Medical Weekly has to offer: SMWs impact factor has been steadily rising, to the
current 1537 Open access to the publication via the Internet, therefore wide audience and impact Rapid listing in Medline LinkOut-button from PubMed with link to the full text website http://wwwsmwch direct link from each SMW record in PubMed No-nonsense submission you submit a single copy of your manuscript by e-mail attachment Peer review based on a broad spectrum of international academic referees Assistance of our professional statistician for every article with statistical analyses Fast peer review, by e-mail exchange with the referees Prompt decisions based on weekly conferences of the Editorial Board Prompt notification on the status of your manuscript by e-mail Professional English copy editing No page charges and attractive colour offprints at no extra cost Editorial Board Prof Jean-Michel Dayer, Geneva Prof Peter Gehr, Berne Prof André P Perruchoud, Basel Prof Andreas Schaffner, Zurich Editor in chief Prof Werner Straub, Berne Prof Ludwig von Segesser, Lausanne International
Advisory Committee Prof K E Juhani Airaksinen, Turku, Finland Prof Anthony Bayes de Luna, Barcelona, Spain Prof Hubert E Blum, Freiburg, Germany Prof Walter E Haefeli, Heidelberg, Germany Prof Nino Kuenzli, Los Angeles, USA Prof René Lutter, Amsterdam, The Netherlands Prof Claude Martin, Marseille, France Prof Josef Patsch, Innsbruck, Austria Prof Luigi Tavazzi, Pavia, Italy We evaluate manuscripts of broad clinical interest from all specialities, including experimental medicine and clinical investigation We look forward to receiving your paper Guidelines for authors: http://wwwsmwch/set_authorshtml
Impact factor Swiss Medical Weekly
2 18 16 14 12 1 08 06 04 02
1995 1996 1997 1998 1999 2000 2002 2003 2004
1537
Editores Medicorum Helveticorum
1162
All manuscripts should be sent in electronic form, to:
0770
0
EMH Swiss Medical Publishers Ltd SMW Editorial Secretariat Farnsburgerstrasse 8 CH-4132 Muttenz Manuscripts: Letters to the editor: Editorial Board: Internet:
submission@smwch letters@smwch red@smwch http://wwwsmwch
Schweiz Med Wochenschr 18712000 Swiss Med Wkly continues Schweiz Med Wochenschr from 2001
Source:homeopathy.org
