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Dürsch H, Boltenhagen U, Mahler C, Joos S, Szecsenyi J, Klafke N. A Qualitative Analysis of Cancer Patients' Perceptions of an Interprofessional Counseling Service on Complementary and Integrative Healthcare. QUALITATIVE HEALTH RESEARCH 2024:10497323241231530. [PMID: 38441438 DOI: 10.1177/10497323241231530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
Medical guidelines recommend actively addressing patients' information needs regarding complementary and integrative healthcare (CIH). Within the CCC-Integrativ study, an interprofessional counseling program on CIH was developed and implemented at four comprehensive cancer centers (CCCs) in Germany. As part of the process evaluation, this study examines cancer patients' experiences with interprofessional CIH counseling sessions conducted by a physician and a nurse. Forty problem-centered interviews were conducted using a semi-structured interview guide. All interviews were audio-recorded, transcribed verbatim, and analyzed using deductive-inductive content analysis based on Kuckartz and Rädiker's approach. Findings revealed that most participants had prior experience with CIH approaches and were burdened by physiological and psychological symptoms. Counseling sessions focused on cancer- and treatment-related symptoms and appropriate CIH recommendations (e.g., herbal poultice against anxieties and acupressure against nausea). Participants appreciated the mutual exchange and integration of perspectives from different healthcare professions within the interprofessional approach. They noted that the counseling team comprehensively addressed their healthcare and CIH information needs. Suggestions for improvement included the specificity of the CIH recommendations. As the participants only received counseling and no CIH treatments, information about reputable CIH providers was particularly important to many seeking advice. Patients with cancer receiving tailored CIH counseling from two healthcare professionals experienced benefits in CIH counseling for symptom management. The interprofessional teams offered a comprehensive perspective on patients' needs, proposing personalized recommendations for symptom control. These insights may foster collaboration between healthcare professionals interested in CIH counseling, enabling them to expand and consolidate their counseling services.
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Affiliation(s)
- Helena Dürsch
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Ursula Boltenhagen
- Department of Nursing Science, University Hospital Tuebingen, Tuebingen, Germany
| | - Cornelia Mahler
- Department of Nursing Science, University Hospital Tuebingen, Tuebingen, Germany
| | - Stefanie Joos
- Institute of General Practice and Interprofessional Care, University Hospital Tuebingen, Tuebingen, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
| | - Nadja Klafke
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
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Hutten RJ, Weil CR, King AJ, Barney B, Bylund CL, Fagerlin A, Gaffney DK, Gill D, Scherer L, Suneja G, Tward JD, Warner EL, Werner TL, Whipple G, Evans J, Johnson SB. Multi-Institutional Analysis of Cancer Patient Exposure, Perceptions, and Trust in Information Sources Regarding Complementary and Alternative Medicine. JCO Oncol Pract 2023; 19:1000-1008. [PMID: 37722084 DOI: 10.1200/op.23.00179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/02/2023] [Accepted: 07/11/2023] [Indexed: 09/20/2023] Open
Abstract
PURPOSE Complementary and alternative medicine (CAM) use during cancer treatment is controversial. We aim to evaluate contemporary CAM use, patient perceptions and attitudes, and trust in various sources of information regarding CAM. METHODS A multi-institutional questionnaire was distributed to patients receiving cancer treatment. Collected information included respondents' clinical and demographic characteristics, rates of CAM exposure/use, information sources regarding CAM, and trust in each information source. Comparisons between CAM users and nonusers were performed with chi-squared tests and one-way analysis of variance. Multivariable logistic regression models for trust in physician and nonphysician sources of information regarding CAM were evaluated. RESULTS Among 749 respondents, the most common goals of CAM use were management of symptoms (42.2%) and treatment of cancer (30.4%). Most CAM users learned of CAM from nonphysician sources. Of CAM users, 27% reported not discussing CAM with their treating oncologists. Overall trust in physicians was high in both CAM users and nonusers. The only predictor of trust in physician sources of information was income >$100,000 in US dollars per year. Likelihood of trust in nonphysician sources of information was higher in females and lower in those with graduate degrees. CONCLUSION A large proportion of patients with cancer are using CAM, some with the goal of treating their cancer. Although patients are primarily exposed to CAM through nonphysician sources of information, trust in physicians remains high. More research is needed to improve patient-clinician communication regarding CAM use.
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Affiliation(s)
- Ryan J Hutten
- Department of Radiation Oncology, University of Utah School of Medicine, Huntsman Cancer Institute, Salt Lake City, UT
| | - Christopher R Weil
- Department of Radiation Oncology, University of Utah School of Medicine, Huntsman Cancer Institute, Salt Lake City, UT
| | - Andy J King
- Department of Communication, University of Utah, Salt Lake City, UT
- Cancer Control and Population Sciences, Huntsman Cancer Institute, Salt Lake City, UT
| | - Brandon Barney
- Department of Radiation Oncology, Intermountain Cancer Centers, Salt Lake City, UT
| | - Carma L Bylund
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, FL
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT
| | - David K Gaffney
- Department of Radiation Oncology, University of Utah School of Medicine, Huntsman Cancer Institute, Salt Lake City, UT
| | - David Gill
- Department of Medical Oncology, Intermountain Cancer Centers, Salt Lake City, UT
| | - Laura Scherer
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Gita Suneja
- Department of Radiation Oncology, University of Utah School of Medicine, Huntsman Cancer Institute, Salt Lake City, UT
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
| | - Jonathan D Tward
- Department of Radiation Oncology, University of Utah School of Medicine, Huntsman Cancer Institute, Salt Lake City, UT
| | - Echo L Warner
- Cancer Control and Population Sciences, Huntsman Cancer Institute, Salt Lake City, UT
- College of Nursing, University of Utah, Salt Lake City, UT
| | - Theresa L Werner
- Department of Medicine, Oncology Division, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Gary Whipple
- Department of Radiation Oncology, Intermountain Cancer Centers, Salt Lake City, UT
| | - Jaden Evans
- Department of Radiation Oncology, Intermountain Cancer Centers, Salt Lake City, UT
| | - Skyler B Johnson
- Department of Radiation Oncology, University of Utah School of Medicine, Huntsman Cancer Institute, Salt Lake City, UT
- Cancer Control and Population Sciences, Huntsman Cancer Institute, Salt Lake City, UT
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Helmer SM, Rogge AA, King R, Canella C, Pach D, Witt CM. Effects of blended learning training for oncology physicians to advise their patients about complementary and integrative therapies: results from the multicenter cluster-randomized KOKON-KTO trial. BMC Cancer 2023; 23:836. [PMID: 37679678 PMCID: PMC10483860 DOI: 10.1186/s12885-023-11348-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/29/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Many oncology physicians are confronted with the topic of complementary and integrative medicine (CIM) by cancer patients. This study examined whether a blended learning (e-learning and a workshop) to train oncology physicians in providing advice on CIM therapies to their cancer patients, in addition to distributing an information leaflet about reputable CIM websites, had different effects on physician-reported outcomes in regard to consultations compared with only distributing the leaflet. METHODS In a multicenter, cluster-randomized trial, 48 oncology physicians were randomly allocated to an intervention group (CIM consultation and an information leaflet) or a control group (information leaflet only). After the training, the oncology physicians conducted 297 consultations with their cancer patients. Measurements were assessed at oncology physician, physician-patient-interaction (measured by external reviewers), and patient levels. This analysis focused on the physician outcomes of stress reaction and perceived consultation skill competency. In addition, qualitative interviews were conducted with a subsample of oncology physicians who experienced both, the intervention and control condition. RESULTS The oncology physicians in the intervention group showed a lower stress reaction in all measured dimensions after CIM consultations than those in the control group. There was no significant difference between oncology physicians in the intervention and control groups regarding the perceived consultation skill competency (overburden: intervention 1.4 [95% CI: 0.7;2.1]; control 2.1 [95% CI: 1.4;2.7], tension: 1.3 [95% CI: 0.7;2.0] vs. 1.9 [95% CI: 1.3;2.5], and discomfort with consultation situations: 1.0 [95% CI: 0.4;1.7]; vs. 1.7 [95% CI: 1.2;2.3]). The qualitative data showed that only providing the leaflet seemed impersonal to oncology physicians, while the training made them feel well prepared to conduct a full conversation about CIM and provide the information leaflet. CONCLUSIONS In our exploratory study providing structured CIM consultations showed positive effects on the perceived stress of oncology physicians, and the training was subjectively experienced as an approach that improved physician preparation for advising cancer patients about CIM, however no effects regarding perceived consultation skill competency were found. TRIAL REGISTRATION The trial registration number of the KOKON-KTO study is DRKS00012704 in the German Clinical Trials Register (Date of registration: 28.08.2017).
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Affiliation(s)
- Stefanie M Helmer
- Institute of Health and Nursing Science, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute of Public Health and Nursing Research, Faculty 11 Human and Health Sciences, University of Bremen, Bremen, Germany
| | - Alizé A Rogge
- Department of Psychosomatic Medicine, Center for Internal Medicine and Dermatology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ryan King
- Institute of Social Medicine, Epidemiology, and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Claudia Canella
- Institute of Social Medicine, Epidemiology, and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University Zurich, Sonneggstrasse 6, 8091, Zurich, Switzerland
| | - Daniel Pach
- Institute of Social Medicine, Epidemiology, and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University Zurich, Sonneggstrasse 6, 8091, Zurich, Switzerland
| | - Claudia M Witt
- Institute of Social Medicine, Epidemiology, and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University Zurich, Sonneggstrasse 6, 8091, Zurich, Switzerland.
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Thomae AV, Rogge AA, Helmer SM, Icke K, Witt CM. Development, Implementation, and Evaluation of an e-Learning in Integrative Oncology for Physicians and Students Involving Experts and Learners: Experiences and Recommendations. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2023; 38:805-812. [PMID: 35776378 PMCID: PMC9247929 DOI: 10.1007/s13187-022-02189-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 06/02/2023]
Abstract
In this project, an e-Learning program for complementary and integrative medicine in oncology was systematically developed, implemented, and evaluated in a stepwise procedure. Learning objectives and content were defined within the KOKON project network, considering the educational competencies for integrative oncology. To design a valuable e-Learning, experts were involved in all relevant steps of the process, as well as stakeholders from various target groups (undergraduates: medicine students, postgraduates: oncology physicians). We used mixed methods including quantitative surveys, progress tests, and qualitative focus groups. The developed e-Learning program led to a significant measurable knowledge gain about complementary and integrative medicine. In parallel, physicians and students were subjectively satisfied with the training. For the majority of e-Learning elements, the needs of both target groups are comparable. Furthermore, both groups emphasized the value of formative assessment tools for gaining knowledge. From the various surveys and experiences collected in this project, we derive recommendations for others developing e-Learning programs.
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Affiliation(s)
- Anita V Thomae
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Sonneggstrasse 6, 8091, Zurich, Switzerland.
| | - Alizé A Rogge
- Department of Psychosomatic Medicine, Center for Internal Medicine and Dermatology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany
| | - Stefanie M Helmer
- Institute for Health and Nursing Science, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 13353, Berlin, Germany
| | - Katja Icke
- Institute for Social Medicine, Epidemiology, and Health Economics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany
| | - Claudia M Witt
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Sonneggstrasse 6, 8091, Zurich, Switzerland
- Institute for Social Medicine, Epidemiology, and Health Economics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 10117, Berlin, Germany
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Kwong MH, Ho L, Li ASC, Nilsen P, Ho FF, Zhong CCW, Chung VCH. Integrative oncology in cancer care - implementation factors: mixed-methods systematic review. BMJ Support Palliat Care 2023:spcare-2022-004150. [PMID: 37173126 DOI: 10.1136/spcare-2022-004150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Integrative oncology (IO) appears to be beneficial to patients with cancer, but its implementation remains a challenge. Guided by the Theoretical Domains Framework (TDF) and the Capability-Opportunity-Motivation-Behaviour (COM-B) model, this systematic review identified the barriers to and facilitators of IO implementation in conventional cancer care settings. METHODS We searched eight electronic databases from their inception until February 2022 for qualitative, quantitative or mixed-methods empirical studies reporting the implementation outcomes for IO services. Critical appraisal approach was tailored according to study types. The identified implementation barriers and facilitators were mapped onto TDF domains and the COM-B model, and subsequently onto the behavioural change wheel (BCW) for formulating behavioural change interventions. RESULTS We included 28 studies (11 qualitative, 6 quantitative, 9 mixed-methods and 2 Delphi studies) of satisfied methodological quality. The main implementation barriers were the lack of IO knowledge, the absence of funding and healthcare professionals' low level of IO receptiveness. The key implementation facilitators were the dissemination of evidence on IO clinical benefits, the equipping of professionals with IO service delivery skills and the provision of a supportive organisational climate. CONCLUSION Multifaceted implementation strategies are needed to address the determinants influencing IO service delivery. Based on our BCW-based analysis of the included studies, the key behavioural change techniques are: (1) educating healthcare professionals about the value and application of traditional and complementary medicine; (2) ensuring access to actionable clinical evidence on IO effectiveness and safety and (3) designing guidelines on communicating traditional and complementary medicine interventions with patients and caregivers for biomedically trained doctors and nurses.
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Affiliation(s)
- Ming Hong Kwong
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Leonard Ho
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Angus S C Li
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Per Nilsen
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Östergötland, Sweden
| | - Fai Fai Ho
- School of Chinese Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Claire C W Zhong
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Vincent C H Chung
- Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
- School of Chinese Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
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Mao JJ, Witt CM. Acupuncture as an Evidence-Based Treatment for Cancer Pain Management: The Joint Society for Integrative Oncology-American Society for Clinical Oncology Guideline. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2023; 29:209-211. [PMID: 36847338 DOI: 10.1089/jicm.2023.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Affiliation(s)
- Jun J Mao
- Integrative Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Claudia M Witt
- Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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Akeeb AA, King SM, Olaku O, White JD. Communication Between Cancer Patients and Physicians About Complementary and Alternative Medicine: A Systematic Review. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2023; 29:80-98. [PMID: 36149678 PMCID: PMC10081707 DOI: 10.1089/jicm.2022.0516] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: Complementary and alternative medicine (CAM) has become increasingly popular among cancer patients and is often used concomitantly with standard cancer therapies. Nonetheless, disclosure of CAM utilization by cancer patients to physicians, along with the provision of information on CAM therapies by physicians, is poor. This review explores the literature to synthesize existing information on communication about CAM usage, reasons for nondisclosure, and the clinical implications thereof. Methods: A search of medical literature published between December 1, 2009, and October 1, 2021 (last searched on April 18, 2022), on communications between physicians and cancer patients about CAM treatments was conducted through MEDLINE and EMBASE. Results were screened for inclusion, dually reviewed, and assessed using the QualSyst quality appraisal instrument. Findings were categorized and synthesized for review. Results: A total of 30 articles were located (n = 8721 total participants), which discussed elements related to patient disclosure of CAM use (n = 16), provider experiences or perceptions related to communication about CAM (n = 3), patterns of this communication (n = 6), and recommendations for effectively discussing CAM with cancer patients (n = 5). Reports indicate that nondisclosure is common throughout the cancer care spectrum. Factors influencing nondisclosure range from patient beliefs and attitudes about their provider, demographic characteristics, disease progression, physician-patient relationship, physician noninquiry, and type of CAM used; ultimately creating a gap in care that may have serious medical implications. Discussion: Many of the studies identified are small and confined to a single-center, hospital-network, or geographic setting, thereby limiting the applicability of findings and recommendations. Nonetheless, improving patient-physician communication is essential in delivering evidence-informed, patient-centered care and crucial for achieving patient satisfaction and positive health outcomes. The lack of adequate CAM dialogue about CAM use increases the risk of adverse interactions with conventional cancer treatments and results in missed opportunities for providers and patients to engage in vital information exchange. Future research and education are necessary to further identify barriers surrounding patient-provider communication about CAM treatments.
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Affiliation(s)
- Ameenat A. Akeeb
- Office of Cancer Complementary and Alternative Medicine, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Sophia M. King
- Office of Cancer Complementary and Alternative Medicine, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Oluwadamilola Olaku
- Office of Cancer Complementary and Alternative Medicine, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Jeffrey D. White
- Office of Cancer Complementary and Alternative Medicine, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
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Rogge AA, Helmer SM, Kiessling C, Witt CM. Development and Implementation of Situational Judgment Tests as an Evaluation Method for Training Oncology Physicians: Application in the KOKON-KTO Training. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:1414-1421. [PMID: 33655466 PMCID: PMC9550743 DOI: 10.1007/s13187-021-01973-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/07/2021] [Indexed: 06/12/2023]
Abstract
Situational judgment tests (SJTs) are often used in aptitude testing and present practice-specific challenges. Their implementation into online training programs provides the opportunity to assess learning progress and improve training quality. In this study, text-based SJTs for oncology physicians were developed, validated, and implemented into the KOKON-KTO training which uses a blended learning training format to teach oncology physicians how to consult cancer patients on complementary and integrative medicine (CIM). The SJT was implemented to measure the e-learning results. In the development and validation phase, a total of 15 SJTs (each SJT including 1 best choice answer based on training content and 4 distractors; 9 SJTs for oncologists and 6 SJTs for oncology gynecologists only) were developed by an interprofessional team (n=5) using real-case vignettes and applying an in-depth review process. Best answers were validated by experts (oncologists and oncology gynecologists) with experience in advising cancer patients on CIM. In the implementation and evaluation phase, SJTs were answered by KOKON-KTO training participants (n=19) pre- and post e-learning. Results were analyzed using descriptive measurements, item difficulties, and Cohen's d for effect size pre- and post-training. The experts (n=12, 49.8% gynecologists) agreed with best choice answers (69.4% for oncology gynecology; 81.5% for oncology) in 12 out of 15 SJTs. Comparing pre- and post-training scores, KOKON-KTO training participants were able to improve knowledge substantially (effect sizes for oncologists d=1.7; oncology gynecologists d= .71). Future studies need to increase the number of experts and SJTs in order to apply further psychometric measurements. As part of the KOKON-KTO study, this project is registered as DRKS00012704 on the "German Clinical Trials Register" (Date of registration: 28.08.2017).
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Affiliation(s)
- Alizé A Rogge
- Institute for Social Medicine, Epidemiology, and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Psychosomatic Medicine, Center for Internal Medicine and Dermatology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Stefanie M Helmer
- Institute for Social Medicine, Epidemiology, and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Institute for Health and Nursing Science, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Claudia Kiessling
- Chair for Personal and Professional Development in Health Profession Education, Faculty for Health, Department for Human Medicine, University of Witten/Herdecke, Witten, Germany
| | - Claudia M Witt
- Institute for Social Medicine, Epidemiology, and Health Economics, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Institute for Complementary and Integrative Medicine, University of Zurich and University Hospital Zurich, Sonneggstrasse 6, 8091, Zurich, Switzerland.
- Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
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Complementary and Integrative Medicine in Head and Neck Cancer. Otolaryngol Clin North Am 2022; 55:993-1006. [PMID: 36088155 DOI: 10.1016/j.otc.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Complementary/integrative medicine (CIM) is an evolving area of collaboration between oncology, patient and their beliefs, and practitioners of complementary medicine. Evidence-informed decision-making is necessary to advise patients on which treatments may be incorporated into standard of care treatments for cancer. Patients use CIM for a variety of reasons and often have unrealistic expectations of cure or disease modifications; on the other hand, there is increasing evidence that symptoms, side effects, and dysfunction related to cancer and its treatment can be ameliorated by CIM approaches to improve patient satisfaction and quality of life. Open communication between patients and providers is paramount.
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Homberg A, Scheffer C, Brinkhaus B, Fröhlich U, Huber R, Joos S, Klose P, Kramer K, Ortiz M, Rostock M, Valentini J, Stock-Schröer B. Naturopathy, complementary and integrative medicine in medical education - position paper by the GMA Committee Integrative Medicine and Perspective Pluralism. GMS JOURNAL FOR MEDICAL EDUCATION 2022; 39:Doc16. [PMID: 35692361 PMCID: PMC9174075 DOI: 10.3205/zma001537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/07/2021] [Accepted: 02/16/2022] [Indexed: 06/15/2023]
Abstract
Background A large part of the population in Germany makes use of naturopathic, complementary and integrative medical treatments. There are now numerous scientific studies that provide evidence of efficacy for certain indications. At German medical faculties, selected procedures and their application are taught within the cross-sectoral unit called QB 12 and some elective courses, with a focus on specific aspects are offered. So far, however, there has been no structured curriculum that longitudinally anchors teaching across medical studies and enables all students to consider naturopathic and complementary medical options for patient care later on and to integrate them effectively into the diagnostic and treatment process. Objective The aim of this position paper is to show the relevance of this topic for medical education, to clarify terminology and to present core competencies and possible implementation options for training. Method The Integrative Medicine and Perspective Pluralism Committee of the German Association for Medical Education developed this position paper in a multi-stage consensual process, in cooperation with the Forum of University Work Groups on Naturopathic Treatment and Complementary Medicine. Results First, different umbrella terms were discussed and an existing definition of integrative medicine and health was chosen for subsequent use. Building on this step, the status of education and its scientific foundation in Germany was considered in an international context. In the next step, a competency profile for medical training, consisting of seven areas of competency, was developed and described in detail with regard to naturopathic, complementary and integrative medicine. Implementation options were identified using possible starting points in the curriculum and using established examples of best practice. Conclusion Despite different priorities at each faculty, it was possible to find an agreement on the development of competencies and anchoring them in medical education on the basis of a common definition of terms. Currently, the implementation in the mandatory and elective areas is very heterogeneous. As part of the current revision of the Medical Licensure Act, there are many possible starting points for the integration of naturopathic and complementary medical teaching content, especially in interprofessional and general practice courses. The implementation and accompanying research of targeted teaching settings should lay the foundations for a long-term and binding integration into medical education. Overall, it is clear that medical education in the field of naturopathy and complementary and integrative medicine has the potential to develop comprehensive core medical competencies.
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Affiliation(s)
- Angelika Homberg
- Medical Faculty Mannheim of Heidelberg University, Department for Medical Education Research, Mannheim, Germany
| | - Christian Scheffer
- University of Witten/Herdecke, Integrated Curriculum of Anthroposophic Medicine, Witten, Germany
| | - Benno Brinkhaus
- Charité - University Medicine Berlin, corporate member of Freie Universität Berlin and Humboldt University of Berlin, Institute for Social Medicine, Epidemiology and Health Economics, Berlin, Germany
| | - Ulrike Fröhlich
- Hahnemann Association of Homeopathic Physicians, Wiesbaden, Germany
| | - Roman Huber
- University Hospital Freiburg, University Center for Naturopathy, Freiburg, Germany
| | - Stefanie Joos
- University Hospital Tübingen, Institute for General Medicine and Interprofessional Care, Tübingen, Germany
| | - Petra Klose
- Evang. Kliniken Essen-Mitte, Clinic for Naturopathy and Integrative Medicine, Essen, Germany
| | - Klaus Kramer
- University Hospital Ulm, Department of Integrative Medicine, Clinic for General and Visceral Surgery, Ulm, Germany
| | - Miriam Ortiz
- Charité - University Medicine Berlin, corporate member of Freie Universität Berlin and Humboldt University of Berlin, Institute for Social Medicine, Epidemiology and Health Economics, Berlin, Germany
| | - Matthias Rostock
- University Hospital Hamburg-Eppendorf, University Cancer Center Hamburg, Hubertus Wald Tumor Center, Hamburg, Germany
| | - Jan Valentini
- University Hospital Tübingen, Institute for General Medicine and Interprofessional Care, Tübingen, Germany
| | - Beate Stock-Schröer
- University of Witten/Herdecke, Integrated Curriculum of Anthroposophic Medicine, Witten, Germany
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11
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Balneaves LG, Watling CZ. "Part of the Conversation": A Qualitative Study of Oncology Healthcare Professionals' Experiences of Integrating Standardized Assessment and Documentation of Complementary Medicine. Integr Cancer Ther 2022; 21:15347354221077229. [PMID: 35130735 PMCID: PMC8829709 DOI: 10.1177/15347354221077229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction: The use of complementary medicine (CM) among individuals with cancer is common, however, it is infrequently assessed or documented by oncology healthcare professionals (HCPs). A study implementing standardized assessment and documentation of CM was conducted at a provincial cancer agency. The purpose of this study was to understand the perspectives and experience of oncology HCPs who took part in the study, as well as withdrew, regarding the feasibility and the challenges associated with assessment and documentation of CM use. Methods: An interpretive descriptive study methodology was used. A total of 20 HCPs who participated, managed staff, or withdrew from the study were interviewed. Interviews were recorded and transcribed verbatim. Thematic, inductive analysis was used to code and analyse themes from the data. Results: Oncology HCPs who participated in the study felt that CM use was common among patients and recognized it went underreported and was poorly documented. Facilitating factors for the implementation of standardized assessment and documentation of CM use included having a standard assessment form, embedding assessment within existing screening processes, and leveraging self-report by patients. Barriers included limited time, perceived lack of knowledge regarding CM, hesitancy to engage patients in discussion about CM, and lack of institutional support and resources. Recommendations for future implementation included having explicit policies related to addressing CM at point-of-care, leveraging existing electronic patient reporting systems, including the electronic health record, and developing information resources and training for HCPs. Conclusions: With the high prevalence of CM use among individuals with cancer, oncology HCPs perceive addressing CM use to be feasible and an essential part of high-quality, person-centered cancer care. Institutional and professional challenges, however, must be overcome to support the assessment, documentation and discussion of CM in patient-HCP consultations.
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Affiliation(s)
- Lynda G Balneaves
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Cody Z Watling
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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12
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Vogel J, Zomorodbakhsch B, Stauch T, Josfeld L, Hübner J. The role of the general practitioner in cancer care in general and with respect to complementary and alternative medicine for patients with cancer. Eur J Cancer Care (Engl) 2021; 31:e13533. [PMID: 34708899 DOI: 10.1111/ecc.13533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/10/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Cancer patients often use complementary and alternative medicine (CAM). The aim of this study was to assess the expectations of cancer patients towards their general practitioner (GP) regarding information on and offers of CAM procedures. METHODS A standardised anonymous questionnaire was developed and handed out to cancer patients in GP practices and oncology clinics in Germany. RESULTS One hundred and eighty questionnaires were evaluable. For 88.1% of the patients, it was important that their GP regularly receives information on cancer therapy. Only a minority consulted with the GP regarding diagnosis and therapy of the cancer (32.4%) or approached him about side effects of the therapy (46.9%). About one fifth of the GPs offered CAM. Before the cancer diagnosis, only 7% of the patients received a CAM offer from the GP; after the diagnosis, it was 14%. A large majority wanted the GP to offer more complementary (70.9%) and alternative (54.3%) medicine. CONCLUSION Our survey points to a clear mismatch of supply and demand regarding CAM for cancer patients in the primary care sector. Training for GPs on scientific evidence of as well as communication skills on CAM will be indispensable in the future to optimise the care of cancer patients by GPs.
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Affiliation(s)
- Johanna Vogel
- Medizinische Klinik II, Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | | | - Thomas Stauch
- Medizinische Klinik II, Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Lena Josfeld
- Medizinische Klinik II, Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | - Jutta Hübner
- Medizinische Klinik II, Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
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13
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Mentink M, Noordman J, Busch M, van Vliet L, Timmer-Bonte JA, van Dulmen S. Towards an open and effective dialogue on complementary medicine in oncology: protocol of patient participatory study 'COMMON'. BMJ Open 2021; 11:e053005. [PMID: 34670766 PMCID: PMC8529983 DOI: 10.1136/bmjopen-2021-053005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Approximately half of patients with cancer use some form of complementary medicine alongside conventional cancer treatment. The topic of complementary medicine often remains undiscussed in consultations between patients with cancer and their healthcare providers. This results in increased risks for adverse or interaction effects and decreased access to the benefits of evidence-based complementary medicine for patients with cancer. This paper describes the design of patient participatory study titled 'COMMON' that aims to explore and enhance open and effective communication about complementary medicine in oncology. The study is carried out in collaboration with 12 (former) patients with breast cancer as coresearchers. METHODS AND ANALYSIS The study complies with the six steps of the intervention mapping framework. Three non-academic hospitals recruit participants (patients with cancer, oncology healthcare providers and managers) for interviews about the organisation, experiences and needs regarding complementary medicine. To assess communication about complementary medicine, recorded oncology consultations are analysed. For an overview of evidence-based complementary medicine available to patients with cancer, a review of reviews is conducted on the evidence on cancer patient-reported outcomes of complementary medicine frequently used by patients with cancer, supplemented with an online search and survey among organisations and persons providing complementary medicine to patients with cancer. Together, these steps generate input for the development of a toolbox that supports an open and effective discussion on complementary medicine in oncology. In a pilot study, acceptability and usability of the toolbox are assessed among patients with cancer and oncology healthcare providers. Dissemination of the toolbox is covered by the commitment of stakeholder parties. ETHICS AND DISSEMINATION The Medical Ethics Committee Arnhem-Nijmegen declared the study was exempted from formal approval under the Dutch Medical Research Involving Human Subjects Act. The results will be disseminated through open-access, peer-reviewed publications, stakeholder-reporting and presentations at relevant conferences.
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Affiliation(s)
- Marit Mentink
- Netherlands Institute for Health Services Research, NIVEL, Utrecht, The Netherlands
- Radboud Institute for Health Sciences, Department of Primary and Community Care, Radboudumc, Nijmegen, The Netherlands
| | - Janneke Noordman
- Netherlands Institute for Health Services Research, NIVEL, Utrecht, The Netherlands
| | | | - Liesbeth van Vliet
- Health, Medical, and Neuropsychology, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden University, Leiden, The Netherlands
| | | | - Sandra van Dulmen
- Netherlands Institute for Health Services Research, NIVEL, Utrecht, The Netherlands
- Radboud Institute for Health Sciences, Department of Primary and Community Care, Radboudumc, Nijmegen, The Netherlands
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14
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Muecke R, Gosenheimer R, Schulz C, Heim G, Schmitz V, Harvey C, Zosel-DeIturri A, Nissen A, Hemberger U, Romeis V, Lochhas G, Metzmann U, Bussmann M, Paschold M. Counseling on Complementary Methods in the Treatment of Side Effects of Oncological Therapies: A Project of the Breast and Bowel Center Nahe at the Hospital Sankt Marienwoerth Bad Kreuznach. Integr Cancer Ther 2021; 20:15347354211043199. [PMID: 34581221 PMCID: PMC8481747 DOI: 10.1177/15347354211043199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Increasingly, patients with cancer are asking for additional, complementary therapy options for treating the side effects of oncological therapy. Thus, the members of the Breast and Bowel Center Nahe at the Sankt Marienwörth Hospital Bad Kreuznach decided to define the content of this type of counseling for patients before treatment. METHODS In 2018, a team of internal oncologists, gynecological oncologists, radio-oncologists, nutritionists, psycho-oncologists, and study nurses met several times to define the content of counseling. To inform the team, an intensive literature review was conducted. RESULTS Counseling content was determined for complementary treatment options for the most frequent side effects of oncological therapies. Counseling sessions were formulated as frontal lectures (slide presentations), given at regular intervals for patients and relatives. These lectures were highly appreciated by patients. CONCLUSION These counseling sessions increased patient understanding of both useful complementary measures and harmful measures they should not use.
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Affiliation(s)
- Ralph Muecke
- Mainz-Ruesselsheim-Bad Kreuznach, Bad Kreuznach, Germany.,Ruhr University Bochum, Bochum, Germany.,German Cancer Society, Berlin, Germany
| | | | | | - Gabor Heim
- Hospital Sankt Marienwoerth, Bad Kreuznach, Germany
| | | | | | | | | | | | | | | | - Ute Metzmann
- Mainz-Ruesselsheim-Bad Kreuznach, Bad Kreuznach, Germany
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15
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Rogge AA, Helmer SM, King R, Canella C, Icke K, Pach D, Witt CM. Effects of training oncology physicians advising patients on complementary and integrative therapies on patient-reported outcomes: A multicenter, cluster-randomized trial. Cancer 2021; 127:2683-2692. [PMID: 33905536 DOI: 10.1002/cncr.33562] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/19/2021] [Accepted: 03/12/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Many patients with cancer do not disclose complementary medicine use but want their physician's advice on this matter. This study evaluated whether using blended learning (e-learning plus a workshop) to train oncology physicians in providing advice on complementary and integrative medicine (CIM) therapies to their patients with cancer, in addition to distributing an information leaflet on reputable CIM websites, had different effects on patient-reported outcomes for the consultation than only distributing the leaflet. METHODS In this multicenter, cluster-randomized trial, patients from private practices/hospital departments, recruited by 48 oncology physicians randomly allocated to an intervention group (CIM consultation plus information leaflet) or a control group (information leaflet), received CIM information. Patient-reported outcomes included satisfaction (Patient Satisfaction With Information on Cancer Treatment), readiness to make a decision (Preparation for Decision Making), and physician-patient communication (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire and Communication 26 [EORTC QLQ-COMU26]) for the consultation. Qualitative interviews were conducted with a physician subsample. RESULTS A total of 291 patients (128 in the intervention group and 169 in the control group) advised by 41 physicians participated. Patients in the intervention group rated physician-patient communication higher on all EORTC QLQ-COMU26 scales (mean total score, 84.3 [95% CI, 79.5-89.2] vs 73.6 [95% CI, 69.3-78.0]; P = .002), were more satisfied with the advice (mean, 4.2 [95% CI, 4.0-4.4] vs 3.7 [95% CI, 3.5-3.8]; P < .001), and were readier to make a decision (mean, 63.5 [95% CI, 57.4-69.6] vs 53.2 [95% CI, 47.8-58.7]; P = .016) than the control group. Physicians who reported patients in both settings seemed satisfied with the advice given. CONCLUSIONS This study evaluated a novel education intervention for training oncology physicians in providing CIM advice in routine care. Providing structured CIM consultations had positive effects on patient satisfaction, readiness to make decisions, and physician-patient communication.
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Affiliation(s)
- Alizé A Rogge
- Institute for Social Medicine, Epidemiology, and Health Economics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Stefanie M Helmer
- Institute for Social Medicine, Epidemiology, and Health Economics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Institute for Health and Nursing Science, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Ryan King
- Institute for Social Medicine, Epidemiology, and Health Economics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Claudia Canella
- Institute for Complementary and Integrative Medicine, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Katja Icke
- Institute for Social Medicine, Epidemiology, and Health Economics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Daniel Pach
- Institute for Social Medicine, Epidemiology, and Health Economics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Institute for Complementary and Integrative Medicine, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Claudia M Witt
- Institute for Social Medicine, Epidemiology, and Health Economics, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Institute for Complementary and Integrative Medicine, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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16
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The use of complementary and integrative therapies as adjunct interventions during radiotherapy: a systematic review. Support Care Cancer 2021; 29:6201-6209. [PMID: 33822240 DOI: 10.1007/s00520-021-06173-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 03/21/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Literature supporting the efficacy of complementary and integrative medicine (CIM) alongside radiotherapy is fragmented with varying outcomes and levels of evidence. This review summarizes the available evidence on CIM used with radiotherapy in order to inform clinicians. METHODS A systematic literature review identified studies on the use of CIM during radiotherapy. Inclusion required the following criteria: the study was interventional, CIM therapy was for human patients with cancer, and CIM therapy was administered concurrently with radiotherapy. Data points of interest were collected from included studies. A subset was identified as high-quality using the Jadad scale. Fisher's exact test was used to assess the association between study results, outcome measured, and type of CIM. RESULTS Overall, 163 articles met inclusion. Of these, 68 (41.7%) were considered high-quality trials. Articles published per year increased over time (p < 0.01). Frequently identified therapies were biologically based therapies (47.9%), mind-body therapies (23.3%), and alternative medical systems (13.5%). Within the subset of high-quality trials, 60.0% of studies reported a favorable change with CIM while 40.0% reported no change. No studies reported an unfavorable change. Commonly assessed outcome types were patient-reported (41.1%) and provider-reported (21.5%). Rate of favorable change did not differ based on type of CIM (p = 0.90) or outcome measured (p = 0.24). CONCLUSIONS Concurrent CIM may reduce radiotherapy-induced toxicities and improve quality of life, suggesting that physicians should discuss CIM with patients receiving radiotherapy. This review provides a broad overview of investigations on CIM use during radiotherapy and can inform how radiation oncologists advise their patients about CIM.
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17
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Lee RT, Greenlee H. Don't ask, don't tell: It's time to talk about complementary, alternative, and integrative medicine with our patients. Cancer 2020; 126:2968-2970. [PMID: 32286684 DOI: 10.1002/cncr.32844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/24/2020] [Accepted: 02/25/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Richard T Lee
- Division of Hematology and Oncology, Department of Medicine, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio.,Supportive and Integrative Oncology Program, University Hospitals Seidman Cancer Center, Cleveland, Ohio.,Case Center for Integrative Oncology, Case Western Reserve University Comprehensive Cancer Center, Cleveland, Ohio
| | - Heather Greenlee
- Cancer Prevention Program, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington.,Integrative Medicine Program, Seattle Cancer Care Alliance, Seattle, Washington
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