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

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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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what is cam
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
slide3

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

nccam classification
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

reasons for cam use
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

slide8
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

why the controversy
Why the Controversy?
  • 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
adverse effects
Adverse Effects
  • Pharmacologic therapies:
    • Direct effect
    • Contamination
    • Interactions with conventional medications
contamination of herbs
Contamination of herbs

Eur J Pediatr 162:72, 2003

slide14

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

oxidative stress and chemotherapy drugs
Oxidative Stress and Chemotherapy Drugs

High Anthracyclines

Pt-complexes

Alkylating agents

Epipodophyllotoxins

Camptothecins

Purine/Pyrimidine

Antimetabolites

Low Taxanes

Vinca alkaloids

observational studies the effect of cancer therapy on antioxidant levels n 31
Observational Studies: The Effect of Cancer Therapy on Antioxidant Levels (n=31)

JCO 22:517, 2004

slide18

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

JCO 22:517, 2004

immunostimulants
Immunostimulants
  • 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

warning signs of possible interactions
Warning signs of Possible Interactions
  • 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

non pharmacologic therapies
Non-pharmacologic Therapies
  • 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
practitioner licensure varies from state to state
Practitioner Licensure varies from state to state
  • 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

barriers to research
Barriers to Research
  • 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
active randomized clinical trials in pediatric cancer and cam
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)
nausea vomiting
Nausea/Vomiting
  • Herbs
    • Ginger, Peppermint, Fennel
  • Chamomile Compresses
  • Aromatherapy
    • Citrus (Bergamont, Mandarin, Citrus Mixtures)
  • Acupressure
    • P-6 Point (Acupressure bands)
palliative care
Palliative Care
  • Alternative medical systems: acupuncture
  • Mind-body medicine: Meditation, prayer, music therapy
  • Body-based therapies: Massage
  • Energy therapies: Reiki, Therapeutic touch
screening for child cam use
Screening for child CAM use:
  • 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

the bottom line
The Bottom Line…
  • 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