Complementary therapies in Cancer Care: Science or Fiction

1. 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

2. Complementary therapies: The big con? Jeremy Laurance reports Tuesday, 22 April 2008

3. Adjectives that come to mind when talking about CAM Scepticism Controversy Hostility �Unscientific� Clairvoyance - Psychic Medium Mysticism Natural

4. 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

5. How much do we know about Complementary & Alternative Therapies?

7. 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

8. 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

9. Issues surrounding use Evidence �what�s 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)

10. 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)

11. 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

12. 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

13. 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.

14. Participating countries

15. Diagnostic group

16. Use of CAM in cancer across Europe

17. Use of CAM in cancer across Europe

18. Types of therapies used (total= 58)

19. 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)

20. Frequency of use by diagnostic group

21. Reasons for using CAM

22. Where information about CAM was obtained from:

23. Satisfaction with CAM (0-7) Satisfaction: Mean = 5.27 (SD=1.52) Perceived effectiveness: Mean = 5.04 (SD=1.52)

24. Profile of CAM user Female** Younger** Higher Education** Higher Annual Income* (modest but significant correlations)

25. Publications Molassiotis A, Fernadez-Ortega P, Pud D, et al. Use of complementary and alternative medicine in cancer patients: a European survey. Ann Oncol. 2005;16(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. 2006;16 Suppl 1:219-24. 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. 2005;13(4):251-7. Molassiotis A, Scott JA, Kearney N, Complementary and alternative medicine use in breast cancer patients in Europe. Support Care Cancer. 2006;14(3):260-7.

26. '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

27. 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 (n=59) 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 (P<0.05), especially in the domains of physical health, psychological health, social concerns and environment.

28.  Acupressure pilot study in nausea/vomiting

29. Total Nausea & Vomiting experience (Molassiotis et al, Compl Ther Med) [N=37]

30. 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

31. Department of Health-funded multisite trial ($1M)Phase III randomised control trial with 3 arms700 patients to be recruited

32. 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 (n=35) 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

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

34. 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

35. Nausea frequency (N=94)

36. Nausea duration

37. Vomiting frequency

38. Vomiting duration

39. Acupuncture pilot study for Chemotherapy-related Fatigue (Molassiotis et al, Compl Ther Med 2007)

41. Fatigue levels (total score) [N=47]

42. General Fatigue levels

43. Activity Levels

44. Fatigue Improvement (%)

46. Breakthrough Breast Cancer funded multisite trial ($750K) N=320 Phase 1: Testing acupuncture vs. enhanced standard care with education Phase 2: Maintenance treatment: therapist vs self-needling vs no maintenance

47. 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

48. 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

49. 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