	Georgetown Lombardi Comprehensive Cancer Center

	Assistant Professor, Georgetown University

As I looked at Ms C, I was struck by the pensive but engaged smile she always sent my way. The same look continued as her daughter elaborated on her mother’s condition. Though her thin stature and wrinkled skin were not remarkable for a 96-yearold matriarch, her well-groomed appearance, stable weight, and increasing participation in physical therapy in the setting of a diagnosis of metastatic ovarian cancer given over a year ago was quite unusual.

Before I met her, she had received one dose of chemotherapy that resulted in hospitalization and opted to discontinue all chemotherapy. Her family had taken her to multiple alternative medicine specialists, one of whom prescribed mistletoe injections that she had been taking the last few months. They subsequently sought several opinions about oncologic interventions.

After each discussion, Ms C confirmed she was not feeling badly and did not want to start any therapies that could interfere with her current quality of life. Thus, supportive care and periodic follow-up visits continued. Her CA-125 continues to rise, although her clinical symptoms are unchanged. None of the sequelae I had expected from her diagnosis—the bloated abdomen, difficulty with bowel movements, abdominal pain, and muscle wasting&mdash;has ensued.

Although it is possible that the histology of her particular disease predicted for better behavior or that there was a misdiagnosis of ovarian cancer, I have added her name to a short list of patients who have acknowledged using herbal remedies as part of their therapies. Mistletoe has been studied and mentioned frequently in the alternative medicine literature as having a potential antitumor effect, although results have been mixed. Several studies report evidence of possible health-related quality of life (HRQoL) improvements in patients who take mistletoe injections in addition to adjuvant chemotherapy.

This has led the National Institutes of Health (NIH) to fund research trials assessing its use, and currently there are multiple trials in different tumor types studying its effect in cancer therapy.

It is encouraging to hear about clinical trials assessing numerous herbal remedies and their effects on various cancers. But these studies are limited in their number and scope. They take years to accrue and report and, unlike novel pharmacological therapies being researched, patients have access to these treatments now through other providers.

The NIH established its National Center for Complementary and Integrative Health (NCCIH) in October 1998 but, despite the increasing interest in complementary and alternative medicine (CAM), the more frequent scenario is that our patients use these therapies without our input and our knowledge.

A study published in 2004 assessed 500 patients with breast and gynecological cancers and reported that 48% used CAM as part of their care. The majority of patients were also receiving standard oncology treatment, yet only 53.5% had spoken to their healthcare provider about these CAM therapies.

Recent studies point to even greater use of these therapies within certain populations. A review of multiple trials conducted within the United States and abroad reported that women with breast cancer seek CAM options more than other populations, and the majority of these trials indicated a trend toward higher use in women of younger age and higher education level.

With growing evidence that these therapies may improve symptoms associated with treatment and quality of life, the disparities in access to CAM treatments should be addressed just as with other cancer therapies. However, these challenges will remain if the environment is one of nondisclosure.

The same month that I saw Ms C, I had a follow-up visit with Ms O, a 55-year-old woman with newly diagnosed hormone-negative, HER2-positive breast cancer with a large breast mass for which I had recommended neoadjuvant therapy. She would not consider clinical trial participation but had reluctantly agreed to chemotherapy and HER2-targeted therapy, asserting that juice cleanses and antibiotics had already begun to decrease the size of her mass.

After a long discussion, she scheduled her first chemotherapy visit but subsequently cancelled two appointments in a row in the weeks that followed. Eventually she called our office to inform us that her juice cleanses and topical oils had continued to work and that she did not want any additional therapy. She refused another visit and has not called or returned to our clinic since then.

I am concerned that her mass will grow and that her locally advanced disease will likely become metastatic. Though I had been supportive of Ms O’s dietary interventions, somehow I had missed an opportunity to connect with her and establish trust. Nutrition counseling, psychosocial interventions, and supportive options were recommended, but perhaps my cynicism and skepticism were apparent, as she had opted to avoid me and my recommendations altogether. Although I wouldn’t have recommended she adopt diet and herbal remedies over conventional therapies for her cancer, I wish she hadn’t perceived that such therapies were mutually exclusive.

Several major cancer centers have established integrative oncology programs to address this issue. The term integrative medicine describes the merging of conventional treatments with complementary therapies ranging from herbs and dietary supplements to mind-body practices such as meditation, massage, and acupuncture.

This is in contrast to the term alternative medicine in which these practices are used in place of conventional medical therapies. NCCIH research suggests that programs offering massage therapy, acupuncture, and yoga improve pain, cancer-related fatigue, and even nausea from cancer therapies.

I hope to provide a similar cohesive program to our patients at MedStar Montgomery Medical Center, a community location in our network.

Currently, our patients are able to connect with licensed providers who offer these services at Georgetown Lombardi, MedStar Georgetown University Hospital or nearby locations, and they are often educated by their oncology providers about the potential benefits of complementary practices.

However, the discussion of services varies among providers and, in most cases, the requests are patient driven and care is not on site. With an organized program, the discussion of these services can become part of our practice in caring for the patient as a whole, and our goal is to work toward this.

Regardless, most patients do not have access to large centers where such options are available with their medical care, and it is important to recognize that they may seek it elsewhere. With an increasing number of patients using these methods, we should all improve on the lack of communication reflected in these studies. When only 50% of patients feel comfortable disclosing therapies to their treating physicians, there is a potential for misunderstandings about care and even noncompliance with conventional treatments.

A recent study in the geriatric population reports more than 26% patients in this age group with cancer diagnoses using CAM. This study specifically focused on herbal and dietary supplements and assessed the problems with polypharmacy and potentially inappropriate medications that can occur with the unmonitored use of these remedies.

I have made it a point in my first visits with oncology patients to discuss these therapies and encourage the use of support staff skilled in these areas, with the hope of mitigating the traditional perception that oncologists are not supportive of such measures.

I also hope that with this approach I can continue treating patients such as Ms O, rather than creating an environment where such therapies are presented as mutually exclusive to the medical therapies I can offer them. Lastly, the goal of increasing communications with the patient about all available and useful therapies contributes to better care of individuals and allows for continued education from oncology providers on potential risks and benefits of such therapies.

			Marvibaigi M, Supriyanto E, Amini N, et al. Preclinical and clinical effects of mistletoe against breast cancer [published online July 20, 2014].

			Navo MA, Phan J, Vaughan C, et al. An assessment of the utilization of complementary and alternative medication in women with gynecologic or breast malignancies. 

			Wanchai A, Armer JM, Stewart BR. Complementary and alternative medicine use among women with breast cancer: a systematic review.

			Nightingale G, Hajjar E, Swartz K, et al. Evaluation of a pharmacistled medication assessment used to identify prevalence of and associations with polypharmacy and potentially inappropriate medication use among ambulatory senior adults with cancer [published online March 23, 2015]. 

Articles

The goal of increasing communications
with the patient about all available and
useful therapies contributes to better care of
individuals and allows for continued education
from oncology providers on potential risks and
benefits of such therapies.

Asma Dilawari, MD

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It's Time to Integrate Complementary Medicine Discussions Into Oncology Care