The use of unproven methods of treatment by cancer patients. Frequency, expectations and cost

Complementary and alternative medicine use and quality of life in patients with primary brain tumors

This study explored the use of complementary and alternative medicine (CAM) approaches and their relationship with demographic and disease characteristics and quality of life (QOL) in the primary brain tumor (PBT) population. One hundred one PBT patients were enrolled in this study. The results showed that 34% of patients reported using CAM. Forty-one percent reported using more than one type of CAM. The average cost of each CAM used per month was 69 dollars, with 20% of patients spending more than 100 dollars per month. The majority (74%) reported that their physicians were unaware of their use of CAM. Data analysis found a higher performance status to be the only factor significantly related to use of CAM therapy (P < 0.005). There was no difference in patient report of QOL between users and nonusers of CAM therapies. The high number of patients who do not report CAM use has potential implications for evaluation of symptoms and response to therapy in this population. This may be especially relevant in those patients with higher functional status participating in clinical trials.

The yin and yang of 15-lipoxygenase-1 and delta-desaturases: dietary omega-6 linoleic acid metabolic pathway in prostate

One of the major components in high-fat diets (Western diet) is the omega (ω, n)-6 polyunsaturated fatty acid (PUFA) called linoleic acid (LA). Linoleic acid is the precursor for arachidonic acid (AA). These fatty acids are metabolized to an array of eicosanoids and prostaglandins depending upon the enzymes in the pathway. Aberrant expression of the catabolic enzymes such as cyclooxygenases (COX-1 and/or -2) or lipoxygenases (5-LO, 12-LO, 15-LO-1, and 15-LO-2) that convert PUFA either AA and/or LA to bioactive lipid metabolites appear to significantly contribute to the development of PCa. However, PUFA and its cellular interactions in PCa are poorly understood. We therefore examined the mRNA levels of key enzymes involved in the LA and AA pathways in 18 human donor (normal) prostates compared to 60 prostate tumors using the Affymetrix U95Av2 chips. This comparative (normal donor versus prostate cancer) study showed that: 1) the level of 15-LO-1 expression (the key enzyme in the LA pathway) is low (P < 0.001), whereas the levels of delta-5 desaturase (P < 0.001, the key enzyme in the AA pathway), delta-6 desaturase (P = 0.001), elongase (P = 0.16) and 15-lipoxygenase-2 (15-LO-2, P = 0.74) are higher in donor (normal) prostates, and 2) Contrary to the observation in the normal tissues, significantly high levels of only 15-LO-1; whereas low levels of delta-6 desaturase, elongase, delta-5 desaturase and 15-LO-2 respectively, were observed in PCa tissues. Although the cyclooxygenase (COX)-1 and COX-2 mRNA levels were high in PCa, no significant differences were observed when compared in donor tissues. Our study underscores the importance of promising dietary intervention agents such as the omega-3 fatty acids as substrate competitors of LA/AA, aimed primarily at high 15-LO-1 and COX-2 as the molecular targets in PCa initiation and/or progression.

Complementary medicine use by Australian women with gynaecological cancer

AIMS AND OBJECTIVES

Social and cultural factors are identified that impact on complementary therapy use among Australia-born and immigrant women diagnosed with gynaecological cancer.

METHODS

A qualitative study design including in-depth interviews with women diagnosed with gynaecological cancer (N=53) and participant observation was conducted.

RESULTS

Approximately one-third of women utilized complementary and alternative medicine, with this being determined by current health concerns and health beliefs related to the efficacy of different modalities. Four types of complementary therapy users emerged: consequential, therapeutic, informed and exploratory.

CONCLUSION

There was a relatively low uptake of complementary treatments. Choice was influenced by women's socio-demographic background, clinical and personal history, lack of personal experiences of gynaecological cancer among study participants' kin and friends, and lack of popular alternative literature on such cancer.

Public illness: how the community recommended complementary and alternative medicine for a prominent politician with cancer

When a prominent Australian politician, the then Premier of Tasmania, The Honourable Jim Bacon, publicly announced in February 2004 that he had lung cancer, he was inundated with well-wishing communications sent by post, email and other means. They included 157 items of correspondence recommending a wide variety of complementary and alternative medicines (CAMs). The most common CAMs recommended were meditation, Chinese medicine, "glyconutrients", juices, Laetrile and various diets and dietary supplements. Although proof of benefit exists or promising preliminary laboratory studies have been carried out for a small number of the recommendations, no scientific evaluation has been performed for most of these treatments. Their potential benefits and harms are not known. Several recommendations were for treatments known to be useless, harmful or fraudulent. Bacon's experience suggests that cancer patients may receive unsolicited advice to adopt one or more forms of CAM. Both patients and practitioners need access to authoritative evidence-based information about the benefits and dangers of CAMs.

Research-design issues in cancer-symptom-management trials using complementary and alternative medicine: lessons from the National Cancer Institute Community Clinical Oncology Program experience

PURPOSE

To identify major research-design issues in proposals submitted by investigators in the Community Clinical Oncology Program (CCOP) for clinical trials of complementary and alternative medicine (CAM) for cancer-symptom management.

METHODS

We conducted content analysis of all scientific reviews of concepts and protocols submitted by the CCOP to the National Cancer Institute (NCI) to identify research challenges in conducting clinical trials designed to evaluate CAM interventions for cancer-symptom management.

RESULTS

Since the inception of the NCI Office of Cancer Complementary and Alternative Medicine in 1998, a total of 46 symptom-management studies using CAM interventions have been proposed by CCOP investigators, with 20 studies now in progress comprising 22% of the current total CCOP symptom-management portfolio. Proposals fell into four categories: complex natural products; nutritional therapeutics; mind-body interventions; and alternative medical systems. The most significant research-design issues arose as a consequence of the lack of preclinical data for CAM interventions and the lack of quality-control standards comparable with those used in regulating new pharmaceutical agents.

CONCLUSION

Across the different types of CAM interventions, the most common problems found in proposed research designs are related to unwarranted assumptions about the consistency and standardization of CAM interventions, the need for data-based justifications for the study hypotheses, and the need to implement appropriate quality control and monitoring procedures during the course of the trial. To advance the state of the science, future research must address these critical issues if CAM interventions are to be evaluated rigorously and have a consequent impact on clinical practice and general public awareness.

Is a biopsychosocial-spiritual approach relevant to cancer treatment? A study of patients and oncology staff members on issues of complementary medicine and spirituality

BACKGROUND

Complementary and alternative medicine (CAM) is increasingly being used by patients with cancer.

OBJECTIVES

Our aim is to compare the attitudes of cancer patients who use CAM to those of nonusers, on issues of CAM, biopsychosocial considerations, and spiritual needs.

METHODS

Questionnaires were administered to patients and medical care providers in a tertiary teaching hospital with a comprehensive cancer center.

RESULTS

Forty-nine percent of the study patients reported integrating CAM into their conventional care. Health care providers considered psychological and spiritual needs as major reasons for CAM use, while patients considered the familial-social aspect to be more important.

CONCLUSIONS

Cancer patients do not correlate CAM use with spiritual concerns but expect their physicians to attend to spiritual themes. Health care providers involved in oncology cancer care should emphasize spiritual as well as CAM themes. The integration of these themes into a biopsychosocial-spiritual approach may enrich the dialogue between patients and health providers.

Effect of individual psychological intervention in Chinese women with gynecologic malignancy: a randomized controlled trial

PURPOSE

To evaluate the effectiveness of psychological intervention in the care of cancer patients and to determine whether routine use of individual psychological therapies is indicated.

PATIENTS AND METHODS

Patients with newly diagnosed gynecologic malignancies from August 1999 to November 2000 were recruited and randomly assigned to either a control group receiving routine medical care or to an intervention group receiving individual psychotherapy. A set of fixed-choice, self-report questionnaires assessing the patients' psychological status, quality of life, and their perceptions related to the medical consultations was completed at recruitment and then every 3 months for 18 months. Data analysis was performed according to the intention-to-treat principle by fitting the data into a linear mixed-effects model. Multivariable analyses were performed to examine the effects of confounding factors.

RESULTS

One hundred fifty-five patients participated in the trial. There were no statistically significant differences between the two groups at baseline. There was a trend toward better quality of life and functional status and also improvement of the symptoms over time for both groups. No differences were found between the groups in the scores measured by any of the instruments at baseline and at any time points after the cancer diagnosis. Psychological intervention had no significant effects on the psychosocial parameters.

CONCLUSION

Routine use of psychological therapies as given in our format has no significant effect on the patients' quality of life and psychological status.

Influence of mistletoe lectins and cytokines induced by them on cell proliferation of human melanoma cells in vitro

Although aqueous mistletoe extracts are widely used in complementary cancer therapy, the precise mode of action of their main therapeutic agents, the three mistletoe lectins (MLs), is poorly understood as they act both as cytotoxic agents and as immunomodulators due to their cytokine release by mononuclear cells. Thus, this study aims to investigate both the direct and the indirect effects of MLs on the growth of human melanoma cells in vitro. Proliferation of six human melanoma cell lines under ML treatment and additionally under the influence of cytokines induced by them (TNF-alpha, IL-1, IL-6) was assessed by means of the tetrazolium derived reduction (XTT) assay. Furthermore, ML binding patterns were analysed and correlated with the biological effects. All three MLs inhibited melanoma cell proliferation in a dose-dependent manner starting at very low ML concentrations (0.001-100 ng/ml) with ML-I being the most cytotoxic lectin (significant inhibition of ultra-sensitive cell line MV3 at 1 x 10(-13) ng ML-I/ml). Even if applied in a broad concentration range (0.0001-100 ng/ml) cytokines had no influence on cell proliferation at all. For ML-I, no association between binding intensity and cytotoxicity was observed, while for ML-II and -III an association between binding and toxicity was established. In conclusion, this study emphasises the direct anti-proliferative effect of the mistletoe lectins on melanoma cells with ML-I being superior to MLs-II and -III. The observation of an ultra-sensitivity of one cell line towards ML-I toxicity may serve as an explanation for the therapeutic success in anecdotal case reports and needs further investigations.

The Use of Complementary and Alternative Medicine Among Pediatric Patients

The overall objective of this research was to obtain information through the use of open-ended interviews, about the diagnosis and treatment of children who had cancer. The interviews, completed with 29 parents whose children had been diagnosed with cancer within the previous 5-year period, were designed to allow mothers and fathers to share their experiences about childhood cancer. From this process, many salient issues were identified by the interviewed parents, one of these issues being that of complementary and alternative medicine (CAM) use among children being treated for cancer. Analysis of the CAM theme resulted in the identification of the following subthemes: (1) parents' opposition to CAM utilization; (2) parents' support of CAM use with their children with cancer; and (3) physicians' views of CAM as perceived by parents. Implications for the use or nonuse of CAM among pediatric populations will be discussed.

Use of complementary and alternative therapies: a national multicentre study of oncology health professionals in Norway

GOALS OF WORK

It is well documented that an increasing proportion of cancer patients today use complementary and alternative medicine, mostly alongside conventional therapies. This study investigates the use of complementary and alternative medicine among oncology health workers and the reported effects.

PATIENTS AND METHODS

In June 2002, we conducted a national multicentre survey including 828 Norwegian oncologists, nurses, clerks and therapeutic radiographers. The response rate was 61.5%.

MAIN RESULTS

We found that females were more often users of both complementary and alternative methods than males (39% versus 15% and 47% versus 17%) and that few oncologists had tried such treatments compared to nurses, therapeutic radiographers and clerks (20/12% versus 50/40%, 41/33%,and 31/50%). Interestingly, the majority of those who had tried unconventional methods reported some or very good effects. Acupuncture, homeopathy, aromatherapy and massage were the most popular therapies. Sub-group analyses including only oncologists showed that female physicians were more often users of both complementary and alternative methods compared to males (33% versus 12%, 25% versus 3%). Moreover, participants below the age of 35 years and Christians more often reported use.

CONCLUSIONS

This survey demonstrates that significant proportion of oncology health workers in Norway have used non-proven therapies and that most have had a positive experience. Differences in use is highly dependent on gender, profession, age and religion.

Approaching Complementary and Alternative Medicine Use in Patients With Cancer

Complementary and alternative medicine (CAM) is becoming a significant factor in the arena of cancer care. There is an increasing body of research along with widespread popularity and use by patients with cancer. This article reviews current knowledge about the worldwide use of CAM in the treatment of cancer and patients' motives and reasoning for this use. Clinical research in CAM cancer treatments and physicians' attitudes toward this popular trend among patients with cancer are discussed as well. The physician-patient communication and its relevance to CAM use is emphasized. A step approach is suggested for primary care physicians including the discussion of CAM in the management of cancer in order to enrich the physician-patient dialogue and improve the quality of the clinical encounter.

Choice of Unconventional Treatment by Patients with Cancer

OBJECTIVES

Previous studies conducted on the use of unconventional treatment by patients with cancer have focused on unconventional treatment as a joint group of therapies. The objective of this study is to gather preliminary information about the use of different modes of unconventional cancer treatment by patients with cancer and to describe user profiles of standardized and individualized treatments.

DESIGN

Data originate from an ongoing explorative 5-year study of 441 consecutively registered cancer patients who have consulted medical doctors and alternative therapists practicing unconventional treatment in Denmark. This paper is based on data from the first and second of six questionnaires. The unconventional treatments included in this study are categorized into two forms of treatment: standardized and individualized treatment.

SUBJECTS

Four hundred and forty-one (441) Danish patients with cancer who use unconventional cancer treatment.

OUTCOMES MEASURES

The analysis shows significant correlations between type of treatment and the following variables: gender, education, occupational status, type of cancer, purpose of seeking unconventional treatment, metastatic spread, opinion regarding appropriate unconventional treatment, and simultaneous use of unconventional treatment.

RESULTS

The study shows that there are significant differences between patients with cancer choosing standardized and those choosing individualized unconventional treatment. The probability of choosing standardized unconventional treatment is greatest among male participants, patients having shorter school education, and for patients who have recovery as the goal of seeking unconventional treatment. The probability of choosing individualized unconventional treatment is greatest among women, for patients with longer school education, and for patients wanting relief from symptoms, information, and improvement of general condition as the purpose of seeking unconventional cancer treatment. Patients with breast and gynecologic cancer are more inclined to seek individualized treatment than patients with all other cancer diseases.

CONCLUSIONS

The study points to the fact that it might be essential to differentiate between different forms of unconventional treatment to understand the use by patients with cancer and the outcomes of these treatments.

How oncologists discuss complementary therapy use with their patients: an audio-tape audit

Understanding the dynamics of oncologist-patient communication regarding complementary therapy (CT) use is essential for the development of much-needed clinical guidelines. Discussions of CT use in 314 audio-taped initial consultations between cancer patients and their oncologists were identified and coded. Patients' anxiety levels and coping styles were also assessed. Reference to CT use was found in 91 consultations (29%). Patients and kin initiated most CT discussions, commonly during discussions of patients' medical history, treatment options or prognosis. In half of these discussions, patients volunteered that they were currently using a CT or were considering its use. Discussion of CT use was more likely to occur in consultations with patients who were younger, were better educated, spoke poorer English, had metastatic disease or limited life expectancy and expressed higher levels of fighting spirit and anxious preoccupation and lower levels of fatalism. The most commonly discussed CTs were: changes in diet; use of multivitamins, vitamin C or antioxidants; and having a positive attitude or fighting spirit. The doctor's overall response to CTs was most frequently coded as "encouraging", although 35% of attempts to initiate discussion were ignored by the oncologist. Doctors were more likely to make encouraging statements about CTs typically perceived to be potentially helpful versus potentially harmful. The current findings point to a need for practical consensus on how to communicate with cancer patients on the subject of CT use so that patients can receive the support and guidance that they are seeking from their oncologists.

Dangerous nutrition? Calcium, vitamin D, and shark cartilage nutritional supplements and cancer-related hypercalcemia

The use of nutritional supplements in the general population and in cancer patients has become very popular. These supplements are not perceived as medications and are presumed to be safe by cancer patients, who may however be at risk for hypercalcemia. We note that many of our patients who have developed symptomatic hypercalcemia were taking vitamin D, calcium, or shark cartilage supplements. We report eight cases of hypercalcemia in cancer patients seen at the Cleveland Clinic Foundation in whom these nutritional supplements may have contributed to the prevalence or severity of hypercalcemia.

Description and predictors of direct and indirect costs of pain reported by cancer patients

The purpose of this study was to describe direct and indirect costs associated with pain in cancer patients and to examine potential predictors of these costs. The study surveyed cancer outpatients about direct costs resulting from pain-related hospitalizations, emergency department visits, physician office visits, and use of analgesic medications and indirect costs related to money spent on pain-related transportation, complementary methods to improve pain management, educational materials, over-the counter medication, domestic support, and childcare. Furthermore, the study examined age, marital status, race, income level, pain severity, pain interference, and presence of breakthrough pain as predictors of direct and indirect costs. Three hundred and seventy-three cancer outpatients were sampled. One hundred and forty-four cancer patients (39%) reported experiencing cancer-related pain and completed the study questionnaires. Seventy-six percent (76%) of the patients had experienced at least one pain-related cost, resulting in an average monthly direct cost of US$ 891/month per patient. Sixty-nine percent (69%) of patients had experienced some type of direct medical cost due to pain, resulting in an average total direct pain-related cost of US$ 825/month per patient. Fifty-seven percent (57%) of patients reported incurring at least one indirect pain-related expense for an average indirect cost of US$ 61/month per patient. Higher pain intensity, greater pain interference, and presence of breakthrough pain predicted higher direct and indirect medical expenses. Younger age and lower income level also predicted higher direct medical expenses.

Communicating in a multicultural society. II: Greek community attitudes towards cancer in Australia

BACKGROUND

Open and full disclosure of information regarding diagnosis and prognosis is the prevailing approach to cancer patients. However, such a view appears contrary to the preferences of many ethnic groups in Australia.

AIMS

This study sought to examine the range of attitudes to cancer, its treatment and disclosure of information among unaffected Greek adults, as part of an ongoing project to develop culturally appropriate cancer care in Australia.

METHODS

Respondents were recruited from first generation Australian residents. Twenty-nine men and 29 women, half over and half under the age of 60 years, participated. Eight focus groups were conducted by a bilingual facilitator and supplemented with eight individual face to face interviews.

RESULTS

Several areas of misunderstanding were identified concerning the causes and outcomes of cancer. Having a cancer was regarded as a source of shame. Disclosure of diagnosis, but less so prognosis, was favoured, and only to immediate family members. Family members translating for the doctor were reported to commonly alter or 'soften' the doctor's message without the patient's knowledge in order to protect the patient. Greek doctors were favoured, and open discussion of alternative medicines was sought.

CONCLUSIONS

The Greek community is the most established migrant community in Australia, but clearly many of their attitudes to cancer are at variance with what is considered good practice by clinicians. An increased awareness of cultural differences is needed to achieve optimal health outcomes in the diverse communities that make up modern Australia.

Alternative medicine use worldwide: the International Union Against Cancer survey

BACKGROUND

In the current study, the authors attempted to surmount the deficiencies of previous surveys and elicit information regarding the use of alternative treatments of cancer worldwide.

METHODS

The International Union Against Cancer (UICC), an international, nongovernment volunteer organization, E-mailed a questionnaire concerning alternative therapy use to its members.

RESULTS

A total of 83 responses from 33 countries were received. Descriptive analyses of this dataset were conducted, indicating the existence of a large and heterogeneous group of unproved remedies used to treat cancer in both developed and developing countries around the world.

CONCLUSIONS

Improved public education concerning the importance of early medical attention and the value of documented cancer therapies, the wider availability of useful cancer treatments, and public policies that are sensitive to the patient's need to play a meaningful role in his or her own care are required.

The effect of an adjuvant mistletoe treatment programme in resected head and neck cancer patients: a randomised controlled clinical trial

The effect of an adjuvant mistletoe extract treatment was tested in a prospective, randomised controlled clinical trial involving 477 patients with head and neck squamous cell carcinoma. The patients were stratified into two treatment groups that underwent surgery or surgery followed by radiotherapy and both groups were randomised for additional treatment with mistletoe extract. Patients treated with a mistletoe lectin-1 (ML-1) standardised mistletoe preparation had no lower risk of local/locoregional recurrences, distant metastases or second primaries. In the main analysis based on 202 patients treated with surgery and 275 patients treated with surgery and radiotherapy the adjusted hazard ratio for the disease-free survival (DFS) was 0.959 (95% confidence interval (CI) 0.725-1.268). The 5-year survival rates of patients from the mistletoe group were no better than the survival rates of patients from the control group. Furthermore, no significant changes in the cellular immune reaction or in quality of life could be detected. We conclude that the used mistletoe preparation has no indication in the adjuvant treatment of patients with head and neck cancer.

Prevalence of complementary therapy use by women with breast cancer. A population-based survey

The study measured the prevalence and costs of complementary therapy use by women diagnosed with breast cancer in the South Thames NHS region. A postal questionnaire was sent to a sample of 1023 women from the Thames Cancer Registry who had been diagnosed with breast cancer in the previous 7 years. Just over a fifth (22.4%) had consulted a complementary practitioner in the previous 12 months. Almost one third (31.5%) had done so since diagnosis. Almost pound17000 had been spent on visits in the previous year. The women using complementary medicine after diagnosis were slightly younger, more educated and more likely to have used complementary medicine before their diagnosis than non-complementary medicine users. In conclusion, significant numbers of women are visiting complementary therapists for health reasons following a breast cancer diagnosis. The out of pocket costs per user, with notable exceptions, are modest. Use of practitioners of complementary therapies following diagnosis is a significant and possibly growing phenomenon.

Communication styles in the cancer consultation: preferences for a patient-centred approach

OBJECTIVE

Although doctor-patient communication has been the focus of numerous studies, there is a lack of empirical evidence on which to base a curriculum for teaching effective communication skills for use in an oncology setting. Research within the general practice area identifies patient-centred and doctor-centred behaviours as the most important dimensions of doctor-patient communication. This study examined patients and their relatives/friends' preferences for and satisfaction with patient-centred and doctor-centred consulting styles. It was argued that by determining patient preferences for consulting styles, specific recommendations for improving communication in the oncology setting could be formulated.

PARTICIPANTS AND METHODS

One hundred and thirteen women who had been treated for breast cancer and 48 of their relatives or friends watched videotaped scenarios of an oncology consultation, using professional actors. Viewers were randomly allocated to either a good prognosis or poor prognosis video, in which the oncologist discussed the patient's diagnosis, treatment and prognosis. These segments were presented in both styles to allow viewers to directly compare and contrast the patient-centred and doctor-centred approach. Outcomes included style preference and satisfaction. Demographic details, information and involvement preferences, anxiety and depression levels were also obtained.

RESULTS

Both patients and their relatives or friends significantly preferred a patient-centred consulting style across all aspects of the consultation (p<0.0001), except within the treatment segment of the good prognosis video where there was no significant difference. One third of the viewers preferred a doctor-centred style for the treatment and prognosis segments. Predictors of a patient-centred style preference in the treatment and prognosis segments included watching a poor prognosis video (OR=2.45, 95% CI 1.04-5.81, p=0.04; OR=3.22, 95% CI 1.22-8.50, p=0.02, respectively), and being employed in a professional occupation (OR=2.38, 95% CI 1.02-5.53, p=0.04 for the treatment segment only). Satisfaction ratings varied within and across videos.

CONCLUSION

Despite some methodological limitations, this study provides empirical data indicating that patients and their relatives or friends prefer a patient-centred approach to the consultation, particularly when the patient has a poor prognosis. The fact that a substantial minority of patients preferred a doctor-centred style emphasizes the need to enhance physicians' abilities to recognize different patient needs throughout the consultation.

Complementary therapies and cancer care: an overview

The use of complementary therapies by patients with cancer is increasingly common, despite limited evidence for their efficacy and safety. The widespread use of complementary therapies has major implications for research and practice. In this paper, we provide an overview of the current state of knowledge regarding issues related to the use of complementary therapies by patients with cancer. So far, complementary therapies have not been defined very well, which makes it difficult to assess the precise extent of their use. The difference in philosophy underlying conventional and complementary treatments appears to contribute to the attractiveness of complementary therapies. Conventional medical practitioners are beginning to recognize the importance of many of the elements of this philosophy, which is evidenced in the patient-centered model. Explaining how patients with cancer make the decision to use complementary therapies has been the subject of many studies. However, as yet, no formal theory of decision making has been developed. Communication between patients and physicians about complementary therapies is an important part of the patients' decision-making process. Many gaps can be identified in knowledge of complementary therapy use by patients with cancer. Not only is there a need to increase knowledge by conducting more research and improving the research infrastructure, but attention should also be paid to information dissemination, education, and planning and development of health policies.