Complementary therapies in Cancer Care: Science or Fiction

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Complementary therapies in Cancer Care Science
or Fiction?

• Prof. Alex Molassiotis
• Professor Chair in Cancer Supportive Care
• University of Manchester, UK
• Francis Bloomberg International Distinguished
  Visiting Professor
• University of Toronto

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Complementary therapies 'put cancer patients at
risk' By Jeremy Laurance, Health EditorFriday,
19 March 2004

• Complementary therapies The big con?
• Jeremy Laurance reports
• Tuesday, 22 April 2008

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Adjectives that come to mind when talking about
CAM

• Scepticism
• Controversy
• Hostility
• Unscientific
• Clairvoyance - Psychic Medium
• Mysticism
• Natural

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Major categories of CAM therapies

• A. Alternative Medical Systems
• B. Energy Therapies
• C. Exercise Therapies
• D. Manipulative and Body-Based Methods
• E. Mind-body Interventions
• F. Spiritual Therapies
• G. Nutritional Therapeutics
• H. Pharmacological and biological treatments

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How much do we know about Complementary
Alternative Therapies?
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Reasons for use

• Push factors from orthodox medicine
• Failure to produce curative treatments
• Adverse effects from orthodox medicine
• Lack of time with practitioner, loss of bedtime
  skills
• Dissatisfaction with the technical approach
• Fragmentation of care due to specialisation

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Reasons for use

• Pull factors to complementary medicine
• Media reports of dramatic improvements
• Belief that these therapies are natural
• Empowerment of user
• Focus on spiritual and emotional well-being
• Provision of touch, talk and time
• Healing environment/physical setting
• Reclaiming the basic tenets of care

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Issues surrounding use

• Evidence
• whats the evidence that being rubbed down with
  lavender oil is better than a day trip to France,
  a shampoo and set, or giving patients a gift
  voucher? (Cancer surgeon)
• Training
• Doctors need training to have the knowledge and
  confidence to discuss complementary therapies
  with their patients (Physician)

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CAM use

• CAM use has increased in both America and Europe
  over past 10 years
• Little work in CAM use and cancer
• Large and heterogeneous group of unproved
  remedies used to treat cancer (Cassileth et al,
  2001)
• Major methodological problems in past research
  (ie. small sample sizes, lack of CAM precise
  definitions, single centre studies)
• Most work in America and in breast cancer
  patients
• Systematic review yields a 31.4 of CAM use in
  cancer (Ernst Cassileth, 1998)

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European Survey(Molassiotis et al, Annals of
Oncology, 2005 2006)

• Aimed at exploring the use of CAM by cancer
  patients, reasons behind this use, satisfaction,
  information about CAM, any side effects
• Cross-sectional survey
• Use of a descriptive questionnaire (27 items)
• Involving all National Societies part of the
  European Oncology Nursing Society

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The process

• 15/18 National Societies agreed to participate
  (1/15 did not deliver)
• Questionnaire had to be translated in 13
  languages
• Study had to be approved by over 25 Ethics
  Research Committees in 14 countries Different
  specifications from different committees
• Responses outside the standard questionnaire had
  to be translated back to English

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• 3 years later, with over 61 data collectors in 14
  countries and a lot of negotiation..
• The study was complete!! Data was available from
  956 patients.

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Participating countries
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Diagnostic group
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Use of CAM in cancer across Europe
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Use of CAM in cancer across Europe
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Types of therapies used (total 58)
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Similarities across countries

• Herbal medicine No 1 CAM used in 9/14 countries,
  13/14 (except ) in top 5.
• Homeopathy No 1 CAM used in and in 7/14
  countries in top 5 list
• Top 5 list Medicinal teas 7/14 countries
  Mega-vitamins/vitamins/minerals 8/14.
• Herbs were mostly based on specific plants grown
  in each respective country or products popular in
  a specific country (ie. Mistletoe in or
  olive leave paste in or Ovosan in Czech
  Republic, nettle teas in Turkey)

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Frequency of use by diagnostic group
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Reasons for using CAM
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Where information about CAM was obtained from
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Satisfaction with CAM (0-7)

• Satisfaction Mean 5.27 (SD1.52)
• Perceived effectiveness
• Mean 5.04 (SD1.52)

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Profile of CAM user

• Female
• Younger
• Higher Education
• Higher Annual Income
• (modest but significant correlations)

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Publications

• Molassiotis A, Fernadez-Ortega P, Pud D, et al.
  Use of complementary and alternative medicine in
  cancer patients a European survey. Ann Oncol.
  200516(4)655-63.
• Molassiotis A, Browall M, Milovics L, et al.
  Complementary and alternative medicine use in
  patients with gynecological cancers in Europe.
  Int J Gynecol Cancer. 200616 Suppl 1219-24.
• Molassiotis A, Fernandez-Ortega P, Pud D, et al.
  Complementary and alternative medicine use in
  colorectal cancer patients in seven European
  countries. Complement Ther Med. 200513(4)251-7.
  
• Molassiotis A, Scott JA, Kearney N, Complementary
  and alternative medicine use in breast cancer
  patients in Europe. Support Care Cancer.
  200614(3)260-7.

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'Thinking outside the box' complementary and
alternative therapies use in paediatric oncology
patients.Molassiotis A, Cubbin D. Eur J Oncol
Nurs 2004

• Most commonly used therapies included
• multivitamins,
• aromatherapy
• massage,
• diets and
• music as therapy

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Cheung YL, Molassiotis A, Chang AM. The effect
of progressive muscle relaxation training on
anxiety and quality of life after stoma surgery
in colorectal cancer patients. Psycho Oncol. 2003.

• Randomised controlled trial (n59) over 10 weeks
  post-stoma surgery.
• Treatment PMRT through two teaching sessions and
  practice at home for the first 10 weeks listening
  to casette.
• The use of PMRT significantly decreased state
  anxiety and improved generic quality of life in
  the experimental group (Pthe domains of physical health, psychological
  health, social concerns and environment.

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• Acupressure pilot study in nausea/vomiting

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Total Nausea Vomiting experience (Molassiotis
et al, Compl Ther Med) N37
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Key findings

• Key finding suggests acupressure improved the
  nausea experience
• Nausea and vomiting occurrence and distress
  improved across first 5 days of chemotherapy
• Mean percentage of improvement was 44.5 in
  experimental subjects over the control subjects

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Department of Health-funded multisite trial
(1M)Phase III randomised control trial with 3
arms700 patients to be recruited
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Massage, Aromatherapy, Reflexology

• Using a number of validated physiological and
  psychological measures massage has been
  demonstrated to reduce cortisol levels, anxiety,
  and pain
• Aromatherapy massage showed short term
  improvements in psychological well being in a
  systematic review, especially anxiety
• evaluation of healing by gentle touch in patients
  with cancer (n35) showed improvements in ratings
  of relaxation and stress, severe pain/discomfort,
  and depression/anxiety, with those experiencing
  more severe symptoms on entry to the study
  showing higher improvements

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• Relaxation study nausea and vomiting management
• (Molassiotis et al, Support Care Cancer, 2002)

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PMRT technique

• Progressive relaxation (tense-release) of 11
  groups of muscles (25 min) combined with
• Deep breathing exercises
• Guided imagery (5 minutes)
• Delivered by a trained nurse therapist

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Nausea frequency (N94)
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Nausea duration
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Vomiting frequency
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Vomiting duration
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• Acupuncture pilot study for Chemotherapy-related
  Fatigue
• (Molassiotis et al, Compl Ther Med 2007)

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Fatigue levels (total score) N47
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General Fatigue levels
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Activity Levels
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Fatigue Improvement ()
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• Breakthrough Breast Cancer funded multisite trial
  (750K)
• N320
• Phase 1 Testing acupuncture vs. enhanced
  standard care with education
• Phase 2 Maintenance treatment therapist vs
  self-needling vs no maintenance

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Discussion

• Use of CAM merely because of patient demand is
  not a good reason for providing it
• CAM needs to be evidence-based
• Major research and methodological problems exist
  and need to be tackled
• Oncology nursing at the forefront of being a
  patient educator and a knowledgeable professional
• Nurses may be called to provide advise and
  information to patients
• Need for accurate information
• Patients were overall satisfied with the
  therapies and gained much from their use
• Integration of some of these therapies in cancer
  clinical practice may be appropriate

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Ongoing problems

• Lack of funding for CAM research (in UK 0.008
  of total cancer research funding)
• Dissemination through publications
• Lack of acceptability
• professional power and medical autocratism
  ignorance prejudice medically-dominated health
  care system service costs

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The Three Stages of Truth(Schopenhauer, 19th c.)

• The naissance of every pioneering discipline
• First Stage It is ignored
• Second Stage It is violently opposed
• Third Stage It is accepted as self-evident