is obtained concerning the pathogenesis of the disease and as new drugs are identified.

Along with numerous antivirals that emerge from the National Cancer Institute, there have been agents whose proponents, often patients or their advocates, cite dramatic if anecdotal case histories to support their claims of efficacy. So-called alternative therapies include not only drugs identified in the laboratory, but also traditional (folk) remedies used by ethnic minorities and nonmedicinal therapies, such as acupuncture, visualization, meditation, and special diets (Hand, 1989).

The use of alternative therapies is widespread among persons with HIV infection, especially gay men; less is known about the therapeutic choices of ethnic minorities. Alternative therapies were initially prohibited for patients in federal trials, but it quickly became clear that many patients continued to use them without reporting such use (Arras, 1990). Concerned that the possible effects of such unknown therapies might adversely affect interpretation of the trial design and aware that some patients were refusing to enter or stay in trials because of these prohibitions, clinical researchers gradually came to tolerate their use.

Nonmedicinal healing regimens and approaches in which empowerment of patients is encouraged ("survivors" rather than "victims"), already used by cancer patients prior to the AIDS epidemic, have increased in popularity during the AIDS epidemic for all life-threatening diseases. Although the degree of activism that has arisen in response to AIDS has yet to be seen for cancer, there are indications that it may occur for breast cancer, a disease that, like AIDS, can be associated with a long period of clinical well-being after initial diagnosis. Breast cancer patients are beginning to move beyond individual empowerment to group empowerment as a means of fighting the disease. Breast cancer advocates are demanding increased research funding, better dissemination of information concerning treatment options, and a more patient-centered approach to decision making (Gross, 1991). Although it did not rise directly from AIDS activism, it is probable that some of the inspiration for the new activist approach to breast cancer came from media coverage of AIDS activism, as well as from the feminist and natural childbirth movements.

Who Performs Clinical Trials

Clinical trials have been traditionally performed almost exclusively in tertiary care (specialized teaching or research) hospitals and clinics by academic physicians. Virtually all federally sponsored research and most of the research sponsored by the pharmaceutical industry has been conducted in this way. The advantages of such a centralized approach have included the interest and expertise of physicians at these sites, many of whom are

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