CORRESPONDENCE LINK TO ORIGINAL ARTICLE LINK TO AUTHOR’S REPLY

oncology programmes is to ease the suf- fering of patients with cancer, which is as Integrative oncology — strong science worthy a goal as shrinking the tumour. The SIO clinical guidelines6 pro- is needed for better patient care vide evidence that there is a large enough body of literature to systematically evaluate Heather Greenlee, Suzanna M. Zick, David Rosenthal, Lorenzo Cohen, what works, what does not work, and where more research is needed; the evidence can Barrie Cassileth and Debu Tripathy then help guide clinical decisions. In the cases where there is an absence of clear We read David Gorski’s Opinion article on patients to control -induced clinical research data providing guidance, integrative oncology (Integrative oncology: nausea and vomiting. More than 30 interven- patients and clinicians need to engage in really the best of both worlds? Rev. tions received a Grade C recommendation shared decision-­making when assessing the Cancer 14, 692–700 (2014))1 with both inter- that suggested weaker evidence of benefit due risk–benefit ratio for each therapy. est and dismay. We firmly agree with Gorski to either conflicting study results or small Heather Greenlee is at the Department of that all forms of medical practice should be sample sizes. Seven therapies are not recom- Epidemiology, Mailman School of Public Health, based on evidence supporting safety and mended due to lack of effect, and one was Columbia University, New York, New York 10032, USA. efficacy. In addition, we concur that the field found to be harmful. All others lacked suf- Suzanna M. Zick is at the Department of of integrative oncology encompasses a wide ficient evidence to form a recommendation. Family Medicine, , Ann Arbor, range of therapeutic approaches that vary in These guidelines will provide patients, clini- Michigan 48109, USA. their level of evidence. However, we are con- cians and policy makers with the evidence David Rosenthal is at Harvard Medical School and the Dana-Farber Cancer Institute, Boston, cerned that Gorski’s article selectively focuses needed to make informed treatment decisions Massachusetts 02115, USA. on practices with the weakest mechanistic in the care of patients with breast cancer. Lorenzo Cohen is at the Departments of General evidence base (for example, homeopathy and Importantly, Gorski’s article fails to Oncology and Behavioural Science, University of Texas ) and, by doing so, ignores the current acknowledge the public health significance MD Anderson Cancer Center, Houston, body of evidence that demonstrates where of integrative oncology. In the United States, Texas 77030, USA. integrative oncology can be the most useful. 65–75% of cancer survivors use at least one Barrie Cassileth is at the Memorial Sloan Kettering In oncology, integrative therapies are often form of a complementary or an integra- Cancer Center, New York, New York 10021, USA. used and tested in conditions that are not tive therapy, often without the supervision Debu Tripathy is at the Department of Breast Medical well-controlled by conventional approaches of a physician9,10. The associated cost is not Oncology, University of Texas MD Anderson Cancer (for example, fatigue, pain and anxiety). Poor insubstantial and in 2012 was estimated at Center, Houston, Texas 77030, USA. control of cancer symptoms and side effects of US$9 billion per year in out-of-pocket costs10. H.G. is the Immediate Past President of the Society for Integrative Oncology, S.Z. currently serves as treatment are associated with non-adherence Clearly, science is not always the driver of how the President, and all other authors are or discontinuation of standard oncology treat- individuals make health-related decisions. It is Past Presidents of the Society. 2–4 5 ments , which can decrease cancer survival . incumbent on medical institutions to discuss Correspondence to H.G. Patients and clinicians need clear guidance on all options with patients so that they can make e-mail: [email protected] which integrative approaches can be useful to informed and wise choices. Integrative oncol- doi:10.1038/nrc3822‑c1 manage and control cancer-related symptoms. ogy programmes provide patients with access 1. Gorski, D. Integrative oncology: really the best of both The Society for Integrative Oncology to trained integrative medicine clinicians, who worlds? Nature Rev. Cancer 14, 692–700 (2014). 2. Kidwell, K. M. et al. Patient-reported symptoms and (SIO) recently published comprehensive collaborate closely with conventional clinicians discontinuation of adjuvant aromatase inhibitor clinical guidelines on the use of integra- and become part of the medical team. These therapy. Cancer 120, 2403–2411 (2014). 3. Walker, M. S. et al. Early treatment discontinuation tive therapies for symptom management programmes also provide a venue to discuss and switching in first-line metastatic breast cancer: the among patients with breast cancer in an issue healthy lifestyle modifications (for example, role of patient-reported symptom burden. Breast Cancer Res. Treat. 144, 673–681 (2014). of Journal of the National Cancer Institute diet, physical activity and weight manage- 4. Chim, K. et al. Joint pain severity predicts premature Monograph on integrative oncology6. The ment) that may improve cancer outcomes, discontinuation of aromatase inhibitors in breast cancer survivors. BMC Cancer 13, 401 (2013). clinical guidelines are based on a systematic while improving other health parameters 5. Hershman, D. L. et al. Early discontinuation and non- review of randomized controlled clinical tri- related to cardiovascular and metabolic dis­ adherence to adjuvant hormonal therapy are associated with increased mortality in women with breast cancer. als using rigorous methods put forth by the orders. Integrative oncology programmes also Breast Cancer Res. Treat. 126, 529–537 (2011). Institute of Medicine7 and a grading system serve an important role in conducting the nec- 6. Greenlee, H. et al. Clinical practice guidelines on the use of integrative therapies as supportive care in developed by the US Preventive Services Task essary clinical research to further the knowl- patients treated for breast cancer. J. Natl Cancer Inst. 8 Monogr. 50, 346–358 (2014). Force . More than 80 separate therapies were edge base for better oncology care. The absence 7. Institute of Medicine. Clinical Practice Guidelines We assessed, and the guidelines are organized of integrative oncology programmes forces Can Trust (The National Academies Press, 2011). 8. Grade definitions. U.S. Preventive Services Task Force by symptoms to help guide clinical decision patients to coordinate their own care using [online], http://www.uspreventiveservicestaskforce.org/ making. There is high-level Grade A evidence interventions that may be dangerous, limits the uspstf/grades.htm (2014). 9. Mao, J. J. et al. Complementary and alternative recommending routine use of meditation, infrastructure to conduct much needed clini- medicine use among cancer survivors: a population- yoga and relaxation with imagery to control cal trials, and leaves patients and clinicians to based study. J. Cancer Surviv. 5, 8–17 (2011). 10. John, G. et al. Costs associated with complementary depression and mood disorders. The same make uninformed clinical decisions. and use among cancer survivors practices are also recommended for routine Modern comprehensive cancer care in the United States: results from the 2012 National Health Interview Survey. J. Altern. Complement. Med. use with Grade B evidence to reduce stress, extends beyond merely changing the biol- 20, A4 (2014). depression and fatigue. received ogy of cancer cells. In addition to improving Competing interests statement a Grade B and can be recommended to most clinical outcomes, the purpose of integrative The authors declare no competing interests.

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