Complementary and Alternative Medicines

ONCOL 255 - Introduction to Oncology. University of Alberta

What does "complementary" medicine refer to?

Using a non-mainstream approach together with conventional medicine.

What does "alternative" medicine refer to?

Using a non-mainstream approach in place of conventional medicine.

What is integrative medicine?

A total approach to care that combines conventional medicine and CAM therapies that have been shown to be safe and effective.

Examples of cateogies of CAM

• biological products (herbs, vitamins, minerals)

• body based (chiropractic massage)

• mind body (meditation, relaxation)

• energy based (acupuncture, reiki)

• whole systems (traditional chinese medicine)

Why might patients not disclose CAM use to their physicians?

The physician didn’t ask, the patient thought the physician would disapprove, or the patient thought it wasn’t relevant.

What are the most common CAM practices used in the U.S. general population?

Natural products (18%), deep breathing (13%), meditation (9%), chiropractic manipulation (9%), massage (8%), yoga (6%).

How well is CAM use captured through standard medical history taking?

It is under-reported.

What disease-related factors are associated with increased CAM use?

Advanced stage and longer duration of disease.

What patient factors are associated with increased use of CAM in cancer patients?

female sex, younger age, higher education, prior CAM use, adverse psychological factors, and beliefs in alternative causes of cancer.

What are common reasons cancer patients pursue CAM?

To strengthen the immune system (63.4%), strengthen their own body (57.7%), feel proactive (53.7%), and improve the body’s ability to fight cancer (38.9%).

What are common sources of information about CAM for patients

Media (41.7%), family and friends (41.0%), physicians (28.7%), and the internet (22%).

Potential Benefits of CAM

symptom management, improved QOL, Cancer prevention/contro; (?)

Potential risks of CAM

Delaying treatment, interaction with conventional treatments, detrimental impact on cancer bio, side effects

What did the Joseph et al. (2012) study find about breast cancer patients who declined standard treatment?

5-year survival was 43% for those who declined treatment vs. 85% for those who received it; many re-presented with incurable stage IV disease.

• use these stats to talk to patietns who may be declining first line treatment for taking treatment such as fenbendazole or ivermectin

What are key strategies for discussing CAM use with cancer patients,

Always ask about CAM use in an open, non-judgmental way; give patients permission to discuss it freely; and remember that discussing CAM does not mean endorsing or promoting it.

What does the “I CARED” approach stand for in discussing CAM with patients?

• Inquire respectfully

• Consider the context

• Assess the motivating factors

• Research the intervention

• Explain findings and recommendations to the patient

• Do remain available

How should physicians handle their own knowledge limitations when discussing CAM with patients?

Be honest about limitations, and make helpful attempts to address questions—patients appreciate transparency and effort even when knowledge is limited.

What should physicians do when discussing CAM use with patients regarding efficacy, safety, and medical information?

Review issues of efficacy and safety, assist patients in navigating reliable medical information online, and help them understand uncertainty and potential contradictions in evidence.

What questions should physicians ask themselves when discussing CAM use with patients?

• Is the CAM therapy dangerous?

• Does it prohibit necessary medical care?

• Can you work within the patient’s belief system to provide good care?

If yes, proceed with negotiation and education. If no, work toward a mutually acceptable course of action.

4 potential concerns with natural products

1. quality of the product

   • standardization and purity

2. Biologic impact on cancer

   • hormone like effect

3. impact on cancer treatment

   • potential to effect PK/PD of cancer drug therapies and biologic effects

4. biologic impact on host

   • anti-platelet or anti-coagulant activity

How can natural products affect breast cancer, particularly ER/PR+ breast cancers?

Many breast cancers have estrogen and/or progesterone receptors, and their growth can be fueled by estrogen.

• Natural products with estrogenic effects could theoretically have adverse effects in patients with estrogen receptor-positive (ER+) or progesterone receptor-positive (PR+) breast cancers.

How can natural products affect the metabolism of tamoxifen in cancer treatment?

Tamoxifen is metabolized to its active metabolite, endoxifen, by cytochrome P450 enzymes (3A4 and 2D6).

• Inhibitors of these enzymes may reduce the active metabolite, potentially decreasing the effectiveness of tamoxifen.

What is the potential impact of Panax ginseng on hormone-sensitive cancers and conditions?

Preliminary evidence suggests that Panax ginseng may have estrogenic effects due to its ginsenosides constituents.

• Women with hormone-sensitive conditions like breast cancer, uterine cancer, ovarian cancer, endometriosis, and uterine fibroids should avoid Panax ginseng.

How might pomegranate juice interact with cancer treatments?

Pomegranate juice inhibits cytochrome P450 2D6 (CYP2D6) in vitro, potentially increasing levels of drugs metabolized by this enzyme, such as amitriptyline, codeine, fluoxetine, and others.

• The clinical significance of this interaction is not fully known, but caution is advised.

Challenges and Considerations when using nautral products with anti-cancer activity

Some natural products have anti-cancer activity, supported by preclinical data or lower-level evidence (e.g., anecdotal, case series).

• High-level evidence is lacking for many products.

• Many have not been extensively evaluated, and optimal formulations, routes of administration, doses, and dosing intervals remain undetermined.

How has the pacific yew tree contributed to the development of chemo

Paclitaxel, a chemotherapy drug, was derived from the Pacific Yew tree.

how has sea sponge contributed to the development of chemo

Halichondria okadai: Eribulin, a chemotherapy drug, is a synthetic compound derived from halichondrin B, a molecule found in the sea sponge Halichondria okadai.

Potential benefits of curcumin in cancer treatment

Curcumin, a component of turmeric, has reported antioxidant, anti-inflammatory, anti-cancer, and antimicrobial activity.

• Some epidemiological studies suggest an association with lower rates of malignancy.

limitations of curcumin in cancer treatment

Curcumin has poor bioavailability, and ongoing research is exploring formulations to improve it.

• There are no indications for treating existing cancer with curcumin-based compounds.

What is the physiology behind acupuncture’s pain-reducing effects?

Acupuncture activates descending diffuse noxious inhibitory controls, where applying a noxious stimulus to one area of the body can suppress pain in a remote area. It also modulates the autonomic nervous system, affecting BP, gut motility, immune response, glucose metabolism, and glucocorticoid

What are the common side effects of acupuncture?

Common side effects include local pain (3.3%), bruising (3.2%), minor bleeding (1.4%), orthostatic problems (0.5%), and rare pneumothorax.

What is the evidence for acupuncture in reducing fatigue in cancer patients?

The evidence for acupuncture’s effect on fatigue is mixed, but the most recent randomized controlled trial showed significant improvement in fatigue scores at 6 weeks.

What is mindfulness-based stress reduction, and how is it used in cancer care?

Mindfulness-based stress reduction involves focusing on the present moment through breathing exercises, body awareness, and yoga.

• It can be effective for managing pain, mood, fatigue, sleep, and quality of life.

• It is incorporated by psychosocial care departments in Edmonton and Calgary.

Financial toxicity of CAM

Expenditures on complementary medicine significantly increased risks of financial catastrophe and medical impoverishment in upper-middle-income countries

How does ivermectin affect anti-cancer drug metabolism and efflux?

Ivermectin modifies drug efflux by ABCB1 and metabolism by CYP3A4, potentially interacting with several anti-cancer drugs, including:

• Doxorubicin

• Mitoxantrone

• Paclitaxel

• Vinblastine

• Vincristine

• docetaxel

• cisplatin

DO NOT RECOMMEND IVERMECTIN EVER

What is the proposed mechanism of action of fenbendazole, and what is the potential risk associated with it?

Fenbendazole is proposed to act as a microtubule destabilizing agent, similar to chemotherapy drugs like paclitaxel and docetaxel. There may be a risk of febrile neutropenia associated with its use.

What are the key strategies for respecting patient autonomy and discussing complementary and alternative medicine (CAM) use in cancer care?

• Ask proactively about CAM use to ensure a complete history and assess for potential interactions.

• Discuss CAM options professionally, within the limits of your knowledge, skill, and judgment.

• Provide information on known benefits, side effects, and interactions; warn if CAM may be harmful.

• If unfamiliar with a CAM therapy, inform the patient and consider referral to another practitioner.

• Document all CAM-related discussions and decisions.

• Be aware of medicolegal risks of providing or communicating about CAM without credible scientific information.

Do oncologists have the obligation to order tests requested by CAM practitioners

there is no obligation to order tests

Massage Therapy

Massage: Application of pressure to muscle and connective tissue to reduce tension

and pain, improve circulation, and encourage relaxation

• in studies has been show to reduce pain, fatigue, and anxiety compared to no therapy

Aromatherapy

concurrent use of essential oils during massage

• no oncologic symptom relief or reduction of lymphedema

Mindufllness-Based Stress Reduction

The use of various modalities to influence and manage mental wellness, in turn aimed at improving physical well being

• meditation, hypnosis, relaxation techniques, cognitive behavioral therapy, biofeedback

Yoga

Movement, meditation, and breathing techniques to promote mental and physical well-being.

In breast cancer:

• • Improves QoL, reduces fatigue compared to no therapy

  • Superior to counseling in reducing depression, anxiety and fatigue

Ketegenic Diet/Fasting

Eating +/- fasting to promote a state of ketosis, typically by eating high-fat, moderate-

protein, low-carbohydrate foods.

• Promotion of an “unfavourable metabolic microenvironment” in animal models

• no evidence of anti cancer effect, but possibly improves QOL/fatigue