Memphis, TN—One of the most popular presentations at the 4th Annual Navigation and Survivorship Conference of the Association of Oncology Nurse & Patient Navigators (AONN+) was delivered by Linda A. Lee, MD, AGAF. Dr Lee is the Clinical Director of the Division of Gastroenterology and Hepatology at Johns Hopkins Integrative Medicine and Digestive Center in Baltimore.
As an expert in the diagnosis and management of gastrointestinal complications of stem cell transplantation, Dr Lee appreciates the increasing interest patients with cancer have in complementary and alternative medicine (CAM), including massage therapy, acupuncture, and probiotic supplements.
What Is Integrative Medicine?
Integrative medicine represents the intersection of conventional medical treatments and other healing modalities to allow for comprehensive management of a patient’s condition.
To help navigators understand relevant terminology, Dr Lee clarified that alternative therapies are therapies that patients choose in lieu of conventional therapy. They may or may not have scientific evidence, and are often sought after based on knowledge that patients have acquired from friends, family members, and/or media, including the Internet. In contrast, complementary therapies are used as adjuncts to conventional medical treatments.
Dr Lee explained that the concept of partnering critically evaluated nonconventional therapies with conventional medical treatments, or integrative medicine, is particularly popular among academic centers. “We use the term integrative medicine because it conveys that we are looking for evidence-based therapies to support conventional care.”
Proactive discussion with patients with cancer of effective (traditional and nontraditional) supportive care measures is especially relevant in light of the myriad of disease- and drug-related adverse events these patients have. Examples include pain, neuropathy, fatigue, insomnia, osteoporosis, loss of libido, chemo brain, depression, and hot flashes.
Dr Lee outlined several important questions to ask when counseling a patient with cancer who has expressed interest in CAM:
- Why is the patient seeking CAM? What is the patient hoping to achieve by using this treatment?
- Does the patient have concerns about conventional therapy? What are those concerns?
- Do the patient’s values and cultural beliefs affect his or her choices? How?
- How can you, the patient’s nurse navigator, support him or her in this decision-making process? Can you facilitate referral to individuals who can help in the care of the patient?
In this context, Dr Lee reminded the group, “It is really important to remember that, when we talk with patients who want to use alternative therapies, we need to be very respectful. Some of these ideas come to them in ways other than scientific papers.”
Evidence for CAM in Cancer Patients
After introducing navigators to CAM, Dr Lee reviewed literature-based evidence supporting some of the most common modalities about which her patients express interest: acupuncture, massage therapy, nutrition and dietary supplements, and cognitive behavioral therapies.
She prefaced her review with the caveat that the literature for these therapies can be challenging, “You are not going to find randomized placebo-controlled trials performed on thousands of people.” Because the clinical development of CAM is typically not supported by large pharmaceutical or biotechnology firms, trials of CAM modalities are typically small with short-term follow-up. An additional challenge in trials of CAM is identification of valid placebos; Dr Lee provided specific examples when summarizing each type of CAM.
Acupuncture consists of a series of procedures that involve penetration of the skin with needles to stimulate certain points on the body. Classical acupuncture is a component of traditional Chinese medicine.
Dr Lee noted a significant debate among CAM researchers regarding the use of placebo controls in studies of acupuncture for cancer pain. Although acupressure has been recommended, it is problematic as a placebo according to Dr Lee. If pressure is applied to the same points in which the acupuncturist would place a needle, at least theoretically, the patient might realize a positive effect from acupressure. “I think the way to go is to compare therapies like acupuncture to therapies that we use right now, like a pharmacologic agent,” Dr Lee noted. “While it is not a true placebo, if you think about it from the patient’s point of view, this is often what they are going to decide, whether or not to use an alternative therapy or a medical therapy.”
To date, studies of acupuncture have shown value in reducing chemotherapy-induced nausea and vomiting when performed before chemotherapy. Dr Lee recalled that the American College of Chest Physicians also recommends acupuncture for patients with lung cancer and poorly controlled pain, or patients with adverse events such as neuropathy and xerostomia that are clinically significant.
Acupuncture can have value in patients who are trying to alleviate depression, anxiety, hot flashes, fatigue, insomnia, and neuropathy, Dr Lee suggested. “A very interesting study comparing acupuncture to venlafaxine showed that it is just as effective and has more durable benefits for patients with hot flashes.”
Although the mechanisms by which acupuncture exerts clinical effects are unclear, several researchers have proposed that it alters brain function, mood, and pain modulation. Acupuncture might affect autonomic nervous system activity, endogenous opioid release, and the function of neurotransmitters and receptors that block pain stimulation. “I tell people to try acupuncture 4 or 5 times,” Dr Lee stated. “If they see no improvement, then it is probably not going to work. I remind them that medications do not work for everybody, either. Going for 4 or 5 sessions usually gives an idea about whether acupuncture is going to be helpful.”
Massage is the manipulation of superficial and deeper layers of muscle, and connective tissue, using various techniques to enhance mobility and function, aid in healing, and promote relaxation and well-being. When introducing this topic, Dr Lee professed that she is a “huge believer” in massage therapy for chronically ill patients, including people diagnosed with cancer. “I meet people all the time who tell me they were perfectly healthy and then X happened. They are psychologically devastated. They were running, they were eating a healthy diet, and then, boom, they got cancer. It is normal to feel angry and disgusted with your body or to feel that your body let you down. One of our massage therapists explained to me how important it is to help each patient to reestablish a positive relationship with his or her body.”
It is very important for massage therapists who are treating patients with cancer to have specialized training in oncology massage, in addition to being a licensed massage therapist, according to Dr Lee. “We look for therapists who have worked not only in spas, but in hospitals. We deal with very complicated and complex patients. It is important that the therapists understand and pay attention to the unique medical needs of our patients.”
Dr Lee noted that clinical studies of massage therapy in patients with cancer show that the most consistent benefit is in the context of anxiety and depression, as well as some types of pain. “Many patients would rather have massage therapy than take an antidepressant or a benzodiazepine every day.”
In the past, massage was thought to increase circulation and cause cancer to spread. Dr Lee clarified that, while the process of metastasis is very complicated and poorly understood, increased circulation is not considered a significant part of that process.
Nutrition and Dietary Supplements
Patients with cancer typically query Dr Lee, a gastroenterologist, about nutrition and vitamins. Common questions include: Should I take a multivitamin? Should I use a food supplement, such as Ensure or Boost? Will taking supplements help me feel better? Will supplements help to fight my cancer?
Dr Lee described that she is not a “huge prescriber” of nutritional supplements. She generally believes that people who are able to ingest food and who have an intact gastrointestinal system should eat healthy foods, either whole or pureed, rather than use supplements or multivitamins. “I tell patients that the adverse effects of supplements are not always known. Supplements’ interactions with drugs are also often unknown.”
For detailed advice about supplements, Dr Lee strongly urges her patients with cancer to consult with the hospital’s nutritionists. Working with nutrition counselors, physicians and nurses can ensure that patients learn how to maintain their nutritional status during cancer-directed therapy and afterwards. “This is the best way to boost the immune system.”
When addressing use of probiotics—microorganisms such as lactic acid bacteria and bifidobacteria that may provide health benefits when consumed—Dr Lee noted that data are limited regarding their clinical value in cancer patients. “There is only 1 report that a very specific probiotic preparation, VSL #3, reduces radiation-induced diarrhea.”2
Dr Lee provided specific examples of patients who are unlikely to benefit from or who may be harmed by probiotics, including patients receiving total parenteral nutrition through a central venous catheter and patients with small bowel ulceration, such as those with graft versus host disease. She noted that a probiotic formulation containing Saccharomyces boulardii (Florastor) has been associated with higher rates of sepsis in people with central lines.
Because supplement and vitamin use is very common among patients with chronic illness, including cancer patients, Dr Lee reminded navigators of the importance of open communication. “I tell patients how important it is to communicate with their oncologists and nurses [about their use of and questions about CAM]. The good news is that, according to survey data, patients with cancer are more likely to disclose to us that they use complementary therapies compared with the average population. We just have to ask.”
Dr Lee summarized her thoughts regarding other common myths related to diet, nutrition, and cancer among her patients with cancer:
- “Because cancer cells thrive on glucose, patients should restrict carbohydrate and sugar intake.”
Dr Lee noted that some cancer patients adamantly avoid sugar because it might “feed” their cancer. She clarified that, while cancer cells thrive on glucose, eating sugary foods or carbohydrates does not preferentially drive glucose toward cancer cells or affect cancer growth.
- “Once you have had cancer, being overweight has no bearing on cancer recurrence.”
Dr Lee clarified that maintaining both good nutritional status and healthy weight after cancer treatment is highly important. Particularly in breast cancer, it has been documented that obesity correlates with hyperinsulinemia, which drives androgen and estrogen production, and that can result in breast cancer recurrence.
In this context, Dr Lee summarized results of a 2006 study known as the Women’s Intervention Nutrition Study.3 In this research effort, approximately 2500 women with a history of breast cancer were randomized to either a low-fat (33 g of fat daily) or a controlled diet (51 g of fat daily) and were followed for more than 5 years. Study results showed that the low-fat diet group had a 3.7% difference in body weight at the end of the study, which was associated with a 24% difference in breast cancer recurrence risk. “Just a little bit of weight loss seemed to be beneficial in terms of breast cancer recurrence….I am always on my patients about maintaining their weight at a normal body mass index,” Dr Lee summarized.
Cognitive Behavioral Therapy
To introduce mind/body therapies and their role in cancer patient management, Dr Lee stated, “I am a strong believer that, not only do we want to pay attention to patients’ diet and nutrition, we need to figure out what is going on with their psychological health.” She observed that when patients with cancer are anxious, they are often unable or unwilling to state this. They, or their caregivers will, however, describe 1 or more related symptoms, which can include difficulty sleeping, fatigue, diarrhea or constipation, worsening pain, appetite and/or weight changes, headaches, and changes in cognition.
Dr Lee characterized cognitive behavioral therapy (CBT) as a technique performed by trained mental health professionals, usually over multiple sessions. The goal of CBT is to help people understand how their cognitions (thoughts), emotions, and behaviors interact and affect one another. “CBT does not tell someone how to feel, but it can change their response to stress.” Dr Lee noted that many studies support the ability of CBT to reduce anxiety and depression. “I think all of our patients should be engaged in this. I think if you can offer CBT in your center, it really takes away the stigma versus sending them to the department of psychiatry.”
Paying for CAM
A significant challenge associated with CAM includes accessing and paying for these specialized services. To help navigators appreciate the costs involved, Dr Lee estimated that in her area of the country, nutritional counseling is billed at approximately $150 for the initial visit, which can last from 1 to 2 hours. Massage therapy costs $80 for a 1-hour session, and private acupuncture services can range from $85 to $150 per session. Most of her patients pay out of pocket for these services.
Insurance coverage for CAM is rare and varies greatly depending on state laws, regulations, and patients’ specific insurance plans. Dr Lee noted that, in her experience, some private insurance plans reimburse for acupuncture and psychotherapy. Medicare reimburses for nutritional counseling only for patients with diabetes and kidney disease, and CBT may be covered under workers’ compensation.
To facilitate patient access to CAM, both Dr Lee and audience members highlighted the importance of professionals who volunteer their services, as well as philanthropic individuals and organizations, in funding CAM. “At our breast cancer survivor retreats, we have been fortunate enough to have volunteers: massage therapists, Reiki masters, yoga masters, and experts in healing touch,” one of the audience members stated. “They are amazing!”
Advice for Navigators
To conclude her comprehensive lecture, Dr Lee summarized important take-home advice for navigators regarding CAM:
- To prepare for patients’ inquiries, familiarize yourself with commonly used CAM modalities: acupuncture, massage therapy, nutrition and diet counseling, and CBT, as well as traditional Chinese medicine, Ayurvedic medicine, naturopathy, homeopathy, yoga, and meditation.
- Identify and refer patients to CAM practitioners whom you trust and with whom you can collaborate. If your university or hospital has an integrative medicine center, start there. Learn how these practitioners are trained and if they are licensed in your state. Dr Lee noted that the National Center for Complementary and Alternative Medicine, the federal government’s lead agency for scientific research on CAM, offers a comprehensive website (http://nccam.nih.gov/health/providers) with news and research summaries related to CAM, as well as advice regarding finding CAM specialists.
- Realize that patients with cancer often look to CAM therapies as a way to mitigate symptoms and gain control, rather than as a cancer cure. Talk with them so that you understand their motivations.
- Be highly respectful of patients’ ideas and decisions. To ensure that you are engaged with the patient (rather than alienating them), approach discussions of CAM in a supportive and open-minded fashion.
1. Walker EM, Rodriguez AI, Kohn B, et al. Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor–positive breast cancer: a randomized controlled trial. J Clin Oncol. 2010; 28(4):634-640.
2. Delia P, Sansotta G, Donato V, et al. Use of probiotics for prevention of radiation-induced diarrhea. World J Gastroenterol. 2007;13(6):912-915.
3. Women’s Intervention Nutrition Study (WINS). www.cancer.gov/clinical trials/search/view?cdrid=63537&version=healthprofessional. Accessed March 14, 2014.