Complementary and Alternative Therapies Flashcards
Types of Complementary and Alternative Therapies
- Mind-body
- Biologically based practices
- Manipulative and body-based practices
- Energy therapies
- Whole medical systems
CAM: Mind-body therapies
- Focus on mind’s ability to influence physiology and WOL
- Sustained attention-focussed techniques, emotionally expressive and imaginative practices
Examples:
- Hypnosis
- Imagery
- Mindfullness
- Biofeedback
- Yoga
- Meditation
- Music
- Art therapies
CAM: Biologically based practices
- Use natural health products for ingestion, injection, topical application, or inhalation
Examples
- Vitamins
- Minerals
- Nutraceuticals
- Herbal products
CAM: Manipulative and body-based practices
- Involve physical touch of the patient’s body
Examples:
- Massage
- Chiropractic techniques
CAM: Energy therapies
- Based on conceptualization of the physiological body as consisting of energy fields which can be influenced through various techniques
Examples:
- Therapeutic touch (not physical touch)
- Reiki (involves touching, Japanese origin)
- Healing touch
- Qigong (Chinese practive)
- Magnetic therapy
- Acupuncture/acupressure
CAM: Whole medical systems
- Comprehensive systems of therapy and practice developed prior to or in parallel to conventional medicine
- Traditional Chinese medicine
- Ayurvedic medicine
- Naturopathy
- First Nations Healing
CAM use in cancer - Associations
- Higher prevalence of use than in other types of patients
- Women with gyne and breast cancers have the highest use, followed by men with prostate cancer
Associated factors:
- Younger age
- Higher educational level
- Higher SES
- Perceived risk of recurrence
- More advanced disease
- Ethnocultural background where traditional health systems are part of mainstream care
CAM use in cancer
- Rarely a single modality, rather most patients combine therapies
- Most use CAM as an adjunct to conventional tx
- Less than 10% forego conventional treatments in favour of CAM alone
Reasons for CAM use
- Mitigate side effects of cancer treatment
- Restore balance
- Reduce energy levels
- Foster wellness
- Perceived benefit
- Strong belief
- Last resort measure
- Way to find hope
- Dissatisfaction with quality of care providers in mainstream healthcare
- Sense of control or ability to be pro-active
Sources of information on CAM
- Friends/relatives
- Literature/Internet
Approaching CAM with patients
- Ask patient about main symptoms addressed
- Ask patient to maintain a daily symptom diary (pre and post treatment comparison)
- Discuss the patient’s preferences/expectations regarding CAM
- Review safety and efficacy of options - discourage any intervention that delays, negates, or accentuates the adverse effects of conventional treatments with proven efficacy
- Encourage patient to review professional credentials of a CAM provider
- Provide patients with questions to ask the CAM provider (what the therapy is, frequency of visits, costs, time frame for benefit, potential side effects, willingness to communicate findings/plans with conventional care providers)
- Schedule follow up to review progress
- Follow up and review response to tx
- Document
Evidence based resources on CAM
cam-cancer.org
naturaldatabase.com
National Centre for Complementary and Integrative Health (nccih.nih.gov)
Patients asking if herbs are “all natural” and therefore “safe” and the accuracy of labels/content of products
- Quality and standardisation may vary considerably between products (even with the same label)
- Quality requires correct botanical identification, prevention of contamination, adulteration, and accuracy of labelling of potency/strength
- Standardisation requires comparable and replicatable doses of compounds in each dose of herb, which is difficult with plants in which chemical composition may vary occurring to growing conditions, harvesting and drying process, extraction and concentration, etc. - Regulation
- In Canada, regulated as ‘natural health products’ if herbs are endorsed as preventing, diagnosis, treating disease, maintaining/promoting health, or self-care
- Requires pre-market approval by Health Canada
- Involves site licenses and manufacturing standards
- Check for a Natural Product Number (NPN) or Homeopathic Number: DIN-HM
Natural health side effects
Possible side effects/interactions:
- Antiplatelet activity
- Interact with steroids and CNS depressants
- Hepatotoxicity
- Nephrotoxicity
- Additive effects when used with analgesics
- Most commonly, allergic reactions (hives, itching, swelling) or GI side effects (N/V, constipation, etc.)
Natural products concurrent with chemo or rads
- Drug-herb interactions
- All antioxidants could reduce biological impact of rads
- Risk of inducing CYP isoforms (subtherapeutic plasma concentrations of other drugs)
- Risk of inhibiting CYP isoforms (supratherapeutic plasma concentrations and toxicity) - Additive effects (some argue)
- Selected AM with chemo/rads could be helpful as antioxidant therapy reduces oxidative stress (growth inhibiting) and increase responsiveness to chemo
- Some studies suggest decreased chemo/rads toxicities with antioxidant supplements
Given how little is known, best to advise patients to AVOID natural health products while receiving chemo/rads.
Proposed mechanism of acupuncture in pain relief
- Stimulation of small afferent sensory muscle nerve fibres projecting to the spinal cord
- Relays to the subcortical nuclei, limbic system, periaquaductal gray, and pituitary gland
- Activation of the relay path blocks pain transmission
Evidence for acupuncture in treatment of cancer pain relief
- Poor quality studies with limited evidence
- Most patients appear to derive some benefit, though duration of response varies (hours vs several months) and may depend upon treatment frequency and duration
- Some studies show decreased analgesic use and improved mobility and ADL performance
Evidence for acupuncture in treatment of chemotherapy induced nausea and vomiting
- Mixed evidence but Cochrane review found that electro acupuncture has benefit for acute CINV
- Response depends on type/mode of acupuncture and timing of administration
- Best response with electroacupuncture added to standard antiemetics
- Non-invasive electrostimulation is not likely to have an effect
- May be beneficial
Evidence for acupuncture in dyspnea
- Limited studies with mixed results
- Inconvlusive
When to avoid acupuncture
- Thrombocytopenia
- Bleeding disorders
- Severe cachexia
- Low ANC is not a contraindication as long as aseptic technique is used
- Caution with deep muscle acupuncture points or areas of moist desquamation from rads
- Avoid in limbs with severe lymphedema
- Avoid electroacupuncture with ICD or PM
Evidence base for meditation, hypnosis, and guided imagery
- Mixed study results, but evidence is strongest for mind-body therapies to reduce anxiety, mood disturbance, chronic pain, and to improve QOL
Components of relaxation techniques
- Repetitive focus on word, sound, image, prayer, phrase, body sensation, or muscular activity
- Adoption of passive attitudes toward intruding thoughts and a return to focus
Meditation - evidence
- Effective for cancer pain, psychosocial distress, sleep problems, and improves QOL
- Useful for anxiety/depression
Hypotherapy/guided imagery - evidence
- Management of cancer pain (symptom reduction) and chemo side effects (reduces N/V from chemo)
Evidence for massage
- Systematic reviews suggest massage may reduce anxiety, pain, depression, stress, and fatigue
- Lack of rigorous research
- Deep or intense pressure should be avoided in cancer patients, especially near lesions or enlarged LN
- Patients with bleeding tendencies should receive only gentle, light-touch massage
Unproven therapy: Metabolic therapies
- Gerson Institute
- Belief that toxic-by products of cancer accumulate in the liver and cause liver failure and death
- Goal is to counteract liver failure with low salt, high K diet, coffee enemas, and a galloon of fruit and veggie juice daily - Mega dose vitamin therapy
- Ozone therapy
No evidence.
Unproven therapy: Dietary supplements
- E.g. shark cartilege
- Contains a substance with anti angiogenic activity, but is such a large molecule it likely cannot be absorbed in the digestive tract or reach the target tumour at high enough concentration
E.g. cesium therapy
- Theory that alkaline environment discourages tumour growth
- Ingesting cesium will alkalinize the body and kill cancer cells
- Unfortunately, will kill all cells and has resulted in life-threatening cardiac arrhythmias
Natural products side effects: Garlic
Garlic
- For cancer prevention/treatment, circulatory disorders, skin infections
- Interacts with CYP450
- Antiplatelet effects
- Interferes with hypoglycemic meds
Avoid if thrombocytopenic, on anticoagulants, or peri-op
Natural products side effects: Gingko
Gingko
- For circulatory disorders, dementia, hearing loss, tinnitus
- Interacts with CYP450 and UGT
- Lowers seizure threshold, especially with antipsychotics
- Platelet dysfunction and anticoagulant effect
Avoid if thrombocytopenic, on anticoagulants, or peri-op
Natural products side effects: Ginseng
Ginseng
- For cancer prevention/treatment, DM, immunostimulation, strength/stamina
- May stimulate growth of hormone-sensitive cancers
Interactions:
- Anticoagulants (antagonists effects)
- Imatinib (increased hepatotoxicity)
- Sulfonylureas (increased hypoglycemia)
Natural products side effects: Green Tea
Green Tea
- For BP and cholesterol, cancer prevention/treatment, heart disease, weight loss
- Interacts with CYP450 and UGT
- May antagonise antiplatelets/anticoagulants
- Diuretic effects
- Nausea, GI upset
Natural products side effects: Saw palmetto
Saw palmetto
- For Prostate cancer/prostatitis
- Interacts with CYP450/UGT
- Additive anticoagulant effect (avoid in peri op patients, those on antiplatelets/anticoagulants)
- Reports of pancreatitis and liver damage
Natural products side effects: St. John’s Wort
St. John’s Wort
- For mood/sleep disorders
- May interact with many drugs
- Can cause photosensitivity or enhance skin toxicity of radiation therapy
- May reduce efficacy of chemo
- May cause serotonin syndrome with antidepressants
Natural products side effects: Turmuric
Turmuric
- Used for cancer prevention, infection, inflammation
- Interacts with CYP450, UGT
- Increases risk of bleeding (antiplatelet)
CAM: Exercise
- May prevent chronic disease and improve survival in cancer patients
- May improve breathing problems, relaxation, fear and anxiety, and improve mobility, improve nutritional status
- Tai Chi shown to reduce falls risk in elderly patients
