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Kara Kelly, M.D. Integrating Complementary Therapies in the Care of Children with Cancer: Research and Clinical Practice What is CAM? Group of diverse medical and health care systems, practices and products that are not presently considered to be part of conventional medicine

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Kara Kelly, M.D.

Integrating Complementary Therapies in the Care of Children with Cancer: Research and Clinical Practice


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What is CAM?

  • Group of diverse medical and health care systems, practices and products that are not presently considered to be part of conventional medicine


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Complementary: Used together with conventional medicine

Alternative: Used in place of conventional medicine

Integrative:Combines mainstream medical therapies and CAM therapies for which there is some high quality scientific evidence of safety and efficacy


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NCCAM Classification

  • Alternative medical systems(Traditional Chinese Medicine, Ayurveda, homeopathy)

  • Mind-body interventions(yoga, imagery, meditation, prayer)

  • Biological based therapies(herbs, high dose vitamins, antioxidants, mushrooms, enzymes )

  • Body based therapies(chiropractic or osteopathic manipulation, massage)

  • Energy therapies(Reiki, therapeutic touch, magnets)

nccam.nih.gov



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Reasons for CAM Use

  • "to try everything possible”

  • to reduce stress of illness

  • improve quality of life

  • symptom care management

  • sometimes for cure

Columbia survey: Perceived effectiveness is high-

86% very or somewhat effective for intended purpose



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73% of children were enrolled on clinical trials for treatment of their malignancy

85% were using some form of CAM:

Herbs 25%

Nutritional supplements 34%

J Pediatr Hematol Oncol 22:412,2000


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Why the Controversy? treatment of their malignancy

  • Few clinical trials of safety and efficacy, especially in children

  • Regulation of herbs and dietary supplements varies world wide, although most are not subject to the same regulations that apply to conventional drugs


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Adverse Effects treatment of their malignancy

  • Pharmacologic therapies:

    • Direct effect

    • Contamination

    • Interactions with conventional medications


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Adverse Effects treatment of their malignancy


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Contamination of herbs treatment of their malignancy

Eur J Pediatr 162:72, 2003


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Herb-Drug Interactions: treatment of their malignancySources of Information

HerbalGram 49:2000.


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Fig. 1. Effect of St. John's wort on the plasma concentration of the active irinotecan metabolite SN-38 over time.

JNCI 94:1247,2002


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Chemotherapy/Herb Interactions concentration of the active irinotecan metabolite SN-38 over time.


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Oxidative Stress and Chemotherapy Drugs concentration of the active irinotecan metabolite SN-38 over time.

High Anthracyclines

Pt-complexes

Alkylating agents

Epipodophyllotoxins

Camptothecins

Purine/Pyrimidine

Antimetabolites

Low Taxanes

Vinca alkaloids


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Observational Studies: The Effect of Cancer Therapy on Antioxidant Levels (n=31)

JCO 22:517, 2004


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The Effect of Supplementation with Antioxidants in combination with Cancer Therapy on Antioxidant Levels (n=9)

JCO 22:517, 2004


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Immunostimulants combination with Cancer Therapy on Antioxidant Levels (n=9)

  • Mistletoe, Asian mushrooms (maitake, reishi, shiitake, coriolus versicolor, PSK), Astralagus

  • Actions: Increase cytotoxic T-cells or NK cells activity, increase endogenous production of interferon, interleukins, or cytokines

Discourage in patients with:

Hematologic malignancies, Stem cell transplants


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Warning signs of Possible Interactions combination with Cancer Therapy on Antioxidant Levels (n=9)

  • Tolerance to conventional drug administration that is better or worse than expected:

    • Unexpected refractoriness to treatment

    • Unusual toxic effects from treatment

Labriola D, Livingston R. Oncology 13:1999


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Non-pharmacologic Therapies combination with Cancer Therapy on Antioxidant Levels (n=9)

  • Chiropractic

    • cerebrovascular accidents, acute necrosis of holocord astrocytoma, vertebral artery dissection

  • Acupuncture

    • cardiac tamponade, epidural abscess formation, HIV infection

    • overall underlying adverse event rate: 0-1.1 per 10,000 treatments


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Practitioner Licensure varies from state to state combination with Cancer Therapy on Antioxidant Levels (n=9)

  • Chiropractors: every state, Washington DC

  • Massage therapists: ~25 states

  • TCM practitioners: ~25 states

  • Naturopathic physicians: 12 states

  • Homeopathic physicians: 3 states

    Dermatologic Therapy 16:77,2003


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Barriers to Research combination with Cancer Therapy on Antioxidant Levels (n=9)

  • Difficulties in conducting studies of complex therapeutic systems

  • Emotional issues leading to biases in patient recruitment

  • Lack of standardization of herbs/dietary supplements

  • Difficulty in determining an adequate placebo

  • CAM providers may have little incentive for scientific evaluation of CAM therapies


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Active Randomized Clinical Trials in Pediatric Cancer and CAM

  • TRAUMEEL S (Homeopathy) for prevention and treatment of Mucositis in SCT (COG)

  • Electroacupuncture for Chemotherapy induced Delayed Nausea/Vomiting in Pediatric Solid Tumors (NCI)

  • Silymarin in Maintenance therapy in Children with ALL and Abnormal LFTs (Columbia)

  • Aromatherapy for Reduction of Anxiety/Nausea during SCT (Columbia)

  • Massage Therapy and Childhood Cancer (Childrens Minneapolis)

  • Aromatherapy as an Intervention for Nausea and Vomiting in Children receiving Chemotherapy for Cancer (Childrens Minneapolis)



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Nausea/Vomiting CAM

  • Herbs

    • Ginger, Peppermint, Fennel

  • Chamomile Compresses

  • Aromatherapy

    • Citrus (Bergamont, Mandarin, Citrus Mixtures)

  • Acupressure

    • P-6 Point (Acupressure bands)


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Palliative Care CAM

  • Alternative medical systems: acupuncture

  • Mind-body medicine: Meditation, prayer, music therapy

  • Body-based therapies: Massage

  • Energy therapies: Reiki, Therapeutic touch


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Screening for child CAM use: CAM

  • Do you give your child any herbal or plant products?

  • Do you give your child any homeopathic products?

  • Do you use any unconventional/alternative types of care or therapies for your child?

  • Do you use any special vitamin therapy for your child?

  • Do you use any unconventional treatments, alternative types of care, or therapies for yourself to stay healthy or to manage a health problem?

J Pediatr Health Care 17:58,2003

Questions only identified 24% of parents using CAM



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The Bottom Line… CAM

  • Children with cancer are using CAM therapies

  • Physicians need to inquire about CAM use

  • Biologically active therapies including herbs and dietary supplements are often used

  • Adverse effects and especially interactions with conventional drugs are possible

  • CAM therapies may be especially useful for symptom management


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