The Emerging Discipline of Integrative Oncology

As oncology nurses, we increasingly encounter issues related to integrative medicine in our community practices, clinics, and hospitals. Many of our patients take vitamins and supplements whose effects on cancer, chemotherapy, and radiation therapy are largely unknown. Some ask us if stress caused their disease and if relaxation techniques can help prevent a recurrence. Others want to know if acupuncture, massage, and aromatherapy are safe and can help alleviate pain or adverse effects of treatment. Nearly all cancer patients are seeking self-care measures to promote overall health, well-being, and quality of life.

A New Department in Oncology Nurse Edition

This issue of ONCOLOGY Nurse Edition marks the debut of a department dedicated to integrative oncology-the use of complementary health practices in combination with conventional cancer care (surgery, chemotherapy, radiation therapy, and biologic therapy), with an emphasis on comprehensive, multidisciplinary, patient-centered care.[1–3] (Integrative medicine does not include alternative medicine, which is used as a substitute for conventional medicine.) This department will explore topics in integrative healthcare as they apply to oncology, discuss the available evidence regarding the risks and benefits of various therapies, and offer additional resources for readers seeking in-depth information.

The aim of this new department is to help oncology nurses become more aware of, knowledgeable about, and comfortable with integrative healthcare so that we are better prepared to counsel and care for our patients. We hope that you find our first article for the department, on vitamin D, useful in your clinical practice. (See page 50 of this issue.)

Topics that we plan to cover in future issues of ONCOLOGY Nurse Edition include curcumin, ginger, ginseng, black cohosh, maitake mushrooms, saw palmetto, soy, and a variety of other herbs, botanicals, and dietary supplements, as well as massage, acupuncture, energy medicine, mind-body therapies, and whole systems approaches, such as homeopathy, naturopathy, and ayurvedic medicine.

The goals of integrative therapies are to use complementary health practices to enhance the efficacy of conventional medicine, better control symptoms, alleviate distress, and decrease suffering.[1] Therefore, this discipline offers a variety of important potential benefits that include helping patients to cope with their diagnosis and treatment, increasing their adherence to conventional therapy, and improving disease outcomes.

At the same time, integrating some complementary therapies with conventional medicine has potential risks, such as adverse interactions, interference with the effects of conventional therapies, exposure to contaminants, and financial drain on patients and their families.[3–6] Nurses play a critical role in apprising patients of what they can expect from a given therapy, activity, or practice, therefore it is essential that oncology nurses are well informed and have access to valuable resources on these issues.

Four Domains of Therapy

The therapies that fall under the complementary and alternative umbrella are remarkable for their diversity in origin and nature. The National Center for Complementary and Alternative Medicine groups them into four domains plus a category of whole medical systems, which span multiple domains[1]:

• Mind-body medicine (eg, meditation, prayer, music therapy);

• Biologically based practices (eg, vitamins, herbs, foods);

• Manipulative and body-based methods (eg, massage, chiropractic techniques, osteopathy);

• Energy medicine (eg, biofield therapies, such as Reiki, qigong, and therapeutic touch, and bioelectromagnetic-based therapies, such as magnets and pulsed fields); and

• Whole medical systems (eg, homeopathy, naturopathy, ayurvedic medicine, traditional Chinese medicine).

Of note, some therapies once classified as complementary and alternative are now part of conventional medicine.[1] Examples include patient support groups and cognitive-behavioral therapy.

Use of Integrative Therapies in the United States

Without question, integrative therapies are extremely popular among patients with cancer in the United States. A recent study found that 40% of adults with a prior cancer diagnosis report using nonprayer forms of complementary and alternative medicine, and 62% report using prayer for health-levels of use significantly higher than those in the general population.[7] In another study of metastatic breast cancer patients, the rates were even higher, with 78% having used at least one type of integrative therapy; 43% having used two or more, excluding spiritual practices and physical exercise; and 90% use when including spiritual practices and physical exercise.[8] Consistently, use of these complementary health practices is more prevalent among cancer patients who are white, female, younger than 55 years of age, more educated, and better-off financially.[8,9] Patients are drawn to complementary and alternative therapies for a variety of reasons.[1,5,6] They may perceive these therapies to be safer and more natural than conventional ones, and find their holistic aspect appealing. Or they want to take a more active role in their own care, seek relief of symptoms not provided by other interventions, or welcome the whole-patient approach of complementary practitioners and the time that they spend with patients. Alternatively, patients may turn to these therapies out of desperation or fear, or in the context of inadequate support from or communication with their healthcare providers.

Of great concern, up to 72% of oncology patients using complementary and alternative therapies do so without informing their healthcare provider.[1] Often, they report, no one brought up the topic during visits.[2,4] Patients may not mention using these therapies because they think they are not important, fear their provider will be indifferent or dismissive, or believe that conventional providers are not familiar with complementary therapies. Providers, for their part, may not ask about these therapies because they feel unprepared to counsel patients about them, which is not surprising given the limited coverage of such therapies in conventional medical education programs.[2,4] Another worrisome pattern is that patients often obtain their information about complementary therapies from sources other than healthcare professionals.[2]

A major issue in integrative medicine is a general lack of evidence about the safety and effectiveness of complementary therapies.[1,2] Well-designed clinical research about these therapies has historically been lacking, even though some of them have been used for thousands of years and predate conventional therapies.[1,2,5] As a result, there are large gaps in the evidence. However, research in complementary therapy modalities is on the increase thanks to efforts by the NIH and societies such as the Society of Integrative Oncology and the Oncology Nursing Society.
Guidelines in many areas of integrative oncology have been developed based on the strength of the available evidence and a weighing of risks and benefits.[2]

Taken together, this information suggests that it is imperative to communicate better with our cancer patients about integrative therapies. As patient educators, oncology nurses have a key opportunity to improve care in this regard. We can best serve our patients by routinely asking about their use of complementary and alternative therapies; approaching the topic in an open and nonjudgmental way; helping them to evaluate the evidence-safety and effectiveness of these therapies-as they would conventional ones; informing them about potential risks and benefits, realistic expectations, and financial implications; and monitoring developments in the field.[1,2,4,6] The sixth international conference of the Society of Integrative Oncology (www.integrativeonc.org) will take place on November 12–13, 2009, in New York City. This interdisciplinary meeting is open to nurses, physicians, integrative health practitioners, patients, and patient advocates. Original research data are shared as well as educational programs and workshops aimed at informing the daily care of patients with cancer.

As ONCOLOGY Nurse Edition takes up the challenge of providing current evidence-based information on myriad topics in integrative oncology, we invite you to share your issues, concerns, and experiences regarding this expanding component of clinical practice. Please direct correspondence to the attention of Executive Editor Anne Landry, at Anne.Landry@cmpmedica.com.

For More Evidence-Based Information
• SIO-www.integrativeonc.org
• National Institutes of Health (NIH), National Center for Complementary and Alternative Medicine-http://nccam.nih.gov
• NIH, Office of Dietary Supplements: International Bibliographic Information on Dietary Supplements (IBIDS) Database-http://tinyurl.com/oxxjhv
• Memorial Sloan-Kettering Cancer Center: About Herbs, Botanicals, and Other Products- http://tinyurl.com/5y55
• Medline Plus: All Herbs and Supplements- http://tinyurl.com/897f6