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Risks & Benefits © Maddalena Carrai Complementary and integrative for patients A purely ideological debate?

With studies showing that around half of all cancer patients use therapies that are not part of mainstream medicine, Cancer World Editor Alberto Costa explores some aspects of the discussion on what complementary and integrative medicine can offer cancer patients, and the supporting evidence behind a range of options.

ancer patients have been patients using complementary or used along with standard medical turning to complementary alternative therapies in countries with treatments but are not considered to Cand integrative medicine in the lowest use, rising to three in every be standard treatments. ‘Integrative ever increasing numbers over recent four patients in countries with high use medicine’ denotes a total approach to decades. A survey published in 2005 (Ann Oncol 2005, 16:655–63). medical care that combines standard found that levels of use varied across The term ‘complementary medicine’ medicine with the complementary/ Europe, with around one in four cancer is used to denote therapies that are alternative practices that have been 34 May / July 2017 Risks & Benefits shown to be safe and effective. They Breast Cancer Specialists (EUSOMA) patients rely mainly on the advice given treat the patient’s mind, body, and published a report and recommenda- by other patients, family members and spirit. tions on the use of complementary and friends or on information extracted Integrative medicine is interdiscipli- (CAM) in caring from the internet.” nary, using the skills of several health- for patients with breast cancer (Eur J Clinical practice guidelines have care disciplines through referral and Cancer 2006, 42:1702–10; ibid 1711– also been published on the use of consultation. It emphasises using the 14; Eur J Cancer 2012, 48:3355–77). integrative therapies in the supportive individual’s capacity for self-healing in These recommend that all patients care of patients treated for breast cancer an approach that is personalised, col- with breast cancer should be treated (JNCI Monographs 2014, 50:346– laborative and comprehensive. by multidisciplinary teams that provide 58), on the use of complementary The National Center for Comple- the best chances of cure, palliation, and therapies and integrative medicine mentary and Integrative Medicine psychosocial and spiritual support. in lung cancer (Chest 2013, 143 (5 (NCCIM), within the US National The recommendations also suggest Suppl):e420–36) and on exercise for Institutes of Health, includes a range of that clinical case histories and ran- cancer survivors (Med Sci Sports Exerc therapeutic approaches under the head- domised trials should contain modules 2010, 42:1409–26). ing of complementary and integrative that identify patients’ belief systems medicine, many of which are listed in about complementary and alternative the table below. medicine, and establish whether it is CIM use in advanced disease: NCCIM distinguishes between being used concurrently, and support the case of pancreatic cancer natural products and mind–body open and factual discussions about it. practices, and defines its own role as A study of the use and experiences With so many new drugs being determining, “through rigorous scientific of complementary and alternative introduced into clinical practice to investigation”, the usefulness and safety medicine (CAM) among breast cancer prolong survival in advanced cancer, of complementary and integrative patients stated that the findings health interventions and their roles in “underscore the results obtained in improving health and healthcare. other studies, such as high overall Complementary and Complementary and integrative use of CAM in breast cancer patients integrative approaches* (CIM) approaches are more likely to and the association of CAM use with □□ be used by female patients, and those younger age, higher education and more □□ Chiropratic/ who are younger, white, more highly advanced clinical stages,” adding that, □□ /Guided educated and on a higher income. “This study clearly demonstrates the Imagery Patients use these types of therapy role of information sources outside the □□ Yoga/Meditation for many reasons, including improving medical system, sometimes reinforced □□ physical symptoms, supporting emo- by negative experiences within the □□ Music and Dance therapy tional health, boosting the immune sys- oncology speciality system,” (Eur J □□ Biofeedback tem and improving quality of life. Some Cancer 2012, 3133–39). □□ Ayurvedic medicine patients use CIM to relieve the side “Given the prevalence of CAM □□ TCM [Traditional Chinese effects of conventional cancer treat- use and the restraints patients felt,” Medicine] – ments or to obtain a more holistic treat- the authors conclude, “every attempt □□ ment, while others may be hoping to should be made by oncologists to □□ Phytotherapy gain better control of their disease. initiate communication about CAM □□ gong – Tai chi pro-actively (including the provision □□ of information regarding possible □ CIM use in breast cancer □ supportive options and cautioning □□ Diet Supplementation about the potential harm of some of Women with breast cancer have these therapies), rather than letting *Some of the treatments included in the CIM definition used by the US National particularly high rates of use of com- breast cancer patients slip into an Institutes for Health NCCIM (https:// plementary, integrative and alternative alternative world seemingly detached nccih.nih.gov/health/integrative- therapies. The European Society of from conventional medicine, where health#integrative) May / July 2017 35 Risks & Benefits

2017, states: “The use of mistletoe as extracts in advanced pancreatic cancer a treatment for people with cancer has been investigated in clinical studies. Reports of improved survival and/ or quality of life have been common, but nearly all of the studies had major weaknesses that raise doubts about the reliability of the findings. At present, the use of mistletoe cannot be recommended outside the context

Survival probability Survival of well-designed clinical trials. Such trials will be valuable to determine more clearly whether mistletoe can be useful in the treatment of specific subsets of cancer patients.”

Months at risk Flashpoints in the CAM/CIM The findings of a prospective trial of 220 patients with metastatic pancreatic cancer debates randomised to Viscum album L extract or placebo VaL – Viscum album L extract Source: W Tröger et al (2013) Eur J Cancer 49:3788–97, republished with permission from Elsevier While the potential of mind–body therapies such as Tai chi, meditation and massage to improve patient wellbeing the whole perception of metastatic EORTC (European’s leading cancer attracts little controversy, the same disease is changing. From the passive clinical trials organisation), EUSOMA, cannot be said for all complementary resignation of the past, clinical oncology (the European Society of Breast Cancer and alternative therapies. is moving to a point in which the fight Specialists) and ECCO (representing against the disease continues well Europe’s professional cancer societies), Alternative or complementary? beyond the transition to the metastatic whose editor in chief, Lex Eggermont, The key message to cancer patients stage, no matter how much this will has a strong reputation for both his is that using alternatives to standard cost, both financially and emotionally rigorous scientific approach and his proven therapies to treat the cancer for patients and their caregivers. attention to the emerging field of is extremely risky – Cancer World has With the exorbitant price tag immuno-oncology in advanced disease. republished two articles by Bernhard new drugs attach to every additional The paper describes a significant Albrecht, a German doctor-journalist month of survival, it may be expected survival benefit in a prospective who investigated the tactics used by that people will increasingly turn to randomised phase III trial in 220 people who promote these sorts of alternatives in the hope of obtaining patients with locally advanced or ‘alternative anti-cancer treatments’ similar results. One potential candidate metastatic pancreatic cancer, with a (‘In the jungle of the miracle healers’, will be mistletoe which, alongside median overall survival of 4.8 months Cancer World 50 Sept–Oct 2012, other natural compounds such as for patients receiving Viscum album L ‘Dangerous healers’, Cancer World 69 curcumin, has been used medicinally extract compared with 2.7 months Nov–Dec 2015). for thousands of years and is a key part for patients on no anti-cancer therapy Complementary therapies, by of some complementary/alternative (HR 0.49, 95%CI 0.36–0.65) (Eur J contrast, taken in addition to standard practitioners’ armoury. Cancer 2013, 49:3788–97; see figure approved anti-cancer treatments, A quite surprising paper on mistletoe above). could be beneficial or ineffective, (Viscum album extract) in advanced On the other hand, a very recent but they could also be harmful if they pancreatic cancer was quietly published statement by the US National Cancer interact biologically with the standard a few years ago by the European Journal Institute’s PDQ (Physician Data treatments. The advice to patients is: of Cancer. This is the official journal of Query service), updated on February “Always inform your doctor about what 36 May / July 2017 Risks & Benefits else you are taking,” – and the advice to doctors is: “Take the initiative in opening up that conversation.” A complicating factor Homeopathy The scientific rationale behind Some aspects of anthroposophic and homeopathic philosophy have homeopathy, an approach based on been used by opponents of to justify their assertions. the principle of ‘curing like with like’, Concerns that engaging on a scientific level with certain strands of and involving the use of highly diluted complementary and alternative practitioners could be presented by the substances, continues to attract anti-vaccine lobby as lending credibility to their arguments can be a particular controversy. deterrent to dialogue. The most authoritative agencies and medical organisations in the world agree that there is currently no good evidence ) and a reduced risk of clinical trials were finished. As it turned to show that homeopathy is effective. atopy (tendency to allergic diseases) in out, the conclusions of the trials were Cancer Research UK notes on its children. The credibility of the paper negative, so those centres are no longer website that homeopathy is one of the has been questioned by some who argue using IORT. The upshot, however, is most common complementary therapies that the decision to publish the study that patients received an unproven used by people with cancer, but advises was influenced by the fact that Prince treatment, which they even had to pay that, “Although there have been many Charles, heir apparent to the British for themselves, as public healthcare research studies into homeopathy there throne, is a follower of homeopathy and providers, rightly, do not reimburse is no scientific or medical evidence that , and that he supported unproven treatments. it can prevent cancer or work as a cancer some research on the topic. The list continues, as does the treatment.” However, in 2005 the same journal number of ‘scientific’ papers that are The role some homeopaths, among published an issue with a cluster of published and subsequently retracted, others, play in promoting an anti-vacci- articles accompanied by an editorial because of their flawed or fraudulent nation agenda has attracted particular entitled ‘The end of homeopathy’, calling data – with high impact factor journals controversy (Focus Altern Complement for “doctors to be bold and honest with no less guilty than the rest. (More Ther 2011, 16:110–4), though the their patients about homeopathy’s lack details of article retractions can be British Homeopathic Association, for of benefit, and with themselves about found at http://retractionwatch.com/ instance, states on its website that the failings of modern medicine,” (vol together with information about the “immunisation should be carried out in 366, p 690). worryingly high number of retracted the normal way using the conventional papers that continue to be cited in the tested and approved vaccines,” (www. Selling remedies without literature.) britishhomeopathic.org/media-centre/ evidence So, the first important conclusion vaccinations-statement). that can be drawn on this complicated A similar charge is also laid against More than a few of our readers issue is that we need to engage with the some in the will certainly remember that science rather than simply engaging community, whose voices have been many thousands of breast cancer in battles of references and counter- heard alongside elements in the patients were treated with high-dose references. homeopathic community in recent chemotherapy supported by bone The case of curcumin is emblematic: vaccine debates. marrow transplantation as a result of highly publicised in the media all over Opponents of vaccinations often a trial that was later found to contain the world, it was recently classified as support their position by citing a 1999 false data from one of the collaborative both a PAINS (pan-assay interference study published in (vol 353, centres. compounds) candidate, and an IMPS pp 1485–8). The study found a significant And more than one centre (invalid metabolic panaceas) candidate. trend (P=0.01) for an inverse relation treated breast cancer patients with “The activity of curcumin in vitro and between the number of anthroposophic intraoperative radiotherapy (IORT) in vivo has been tested in >120 clinical lifestyle characteristics (including fewer long before the relevant randomised trials of curcuminoids against several May / July 2017 37 Risks & Benefits

integrating the best of conventional and complementary treatments for a Opening up the debate wide range of conditions. All are □□ We need to engage with the science rather led by consultants, doctors and other than simply judging papers on where they registered healthcare professionals come from or where they are published. who have received additional training □□ It’s too simple and too late to ignore in complementary medicine.” The complementary and integrative medicine. University of Exeter, also in the UK, has □□ Discussions about combining mainstream medicine with other a chair in Complementary Medicine, approaches to health, cure and wellbeing are already widespread and currently occupied by . increasing. So a possible third conclusion is □□ This is not ‘us versus them’, it is about empowering patients to make that efforts to combine the various informed choices. approaches to health, cure and wellbeing can be seen in many settings and countries. The key requirements diseases,” says the American Cancer and effectiveness with regulations and seem to be the quality and level of Society website, “but no double- promoting universal health coverage by knowledge of the professionals involved blinded, placebo controlled clinical integrating complementary and – as in every human field – the level trial of curcumin has been successful,” into national health systems.” of intellectual honesty. (http://bit.ly/ACS_curcumin). Several well-established cancer cen- The fourth and final conclusion (and True, say those convinced of the tres across the world have departments this is a very personal view) is that at potential of curcumin, but you should dedicated to complementary and inte- the end of the day what is really needed give us the time to see whether it grative medicine, which is seen, by both is more patient empowerment. will be more effective when put in patients and doctors, as an endorsement Only someone who is lucky enough formulations such as liposome, and of the general approach – but not of to have never experienced the panic and standardised, turning it into a modern every treatment that is included under angst generated by a diagnosis of cancer drug, like many others that originate the broad umbrella term of CIM. (or other life threatening condition) can from plants. The Integrative Medicine page on contemplate ignoring complementary The second conclusion is that it the Memorial Sloan Kettering Cancer and integrative medicine. is too late, and too simplistic, to just Center spells out their approach: “At It is easy for a doctor to dismiss it as ignore complementary and integrative Memorial Sloan Kettering, we believe unproven , but very difficult medicine. in caring for the whole person – not then to give an answer to cancer The World Health Organization just the disease or symptom. Integrative patients in pain, with impossible recently published a document medicine weaves natural treatments nausea and vomiting, with drug- outlining the strategy for traditional such as acupuncture, massage, and resistant permanent insomnia, with and complementary medicines for the yoga into your overall care plan. All weight loss and cachexia, who are open period 2014–2023, which can be found of our holistic health services and to any reasonable solution in the hope on the WHO website. programs are based on the latest of feeling better. The document has the twin scientific evidence.” Anyone who has practised oncology objectives of supporting Member Europe’s largest public sector in an outpatient in Europe or the States in enhancing the contribution centre for integrated medicine is The US has seen, and should in fairness of complementary medicines to Royal London Hospital for Integrated admit, that CIM can play a role for health and wellbeing and at the Medicine (RLHIM), which is part of some patients and for some conditions. same time promoting the safe and University College London Hospitals effective use of such medicines, by NHS Foundation Trust. We welcome contributions on this regulating professional products and Formerly known as the Royal topic based on science, but not pseudo­ skills. It asserts that, “These goals London Homeopathic Hospital, their science. Please post your comments at will be achieved by defining national website states that: “the RLHIM offers the end of the online version of this arti­ policies, reinforcing safety, quality an innovative, patient-centred service cle http://bitly/CW_CIM. 38 May / July 2017