by Marja J. Verhoef, PhD, Stacey A. Page, PhD
In 2008 we wrote a paper entitled “Talking to cancer patients about complementary therapies” and discussed whether these conversations are the physician’s responsibility.(1) Over the past years much has changed in regards to the use of complementary therapies or CAM – Complementary and Alternative Medicine – as it is often called. Complementary treatments are increasingly being integrated in conventional medicine, and the body of evidence for these treatments, continues to grow. New evidence has facilitated the development of clinical practice guidelines (CPGs) and it is expected that such guidelines will facilitate treatment decision making and have the potential to improve the patient-provider relationship. However, there are still many patients who do not disclose their CAM use to their doctors.
1. The Rise of Integrative Oncology
Over the past years, the term CAM has gradually evolved toward the more comprehensive term Integrative Oncology, which focuses on the combination of mainstream cancer treatments and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness.(2) Ben-Arye et al (3) have called this an “important paradigm shift” as it moves ‘from a strict bio-medical perspective to a bio-psycho-social-spiritual context’. Integrative Oncology has been described as both “a science and a philosophy that focuses on the complex health of people with cancer and proposes an array of approaches to accompany the conventional therapies of surgery, chemotherapy, molecular therapeutics and radiotherapy to facilitate health”.(4) Such approaches may include herbs, vitamins and minerals, diet and nutrition, alternative treatment systems, such as naturopathy, homeopathy and Traditional Chinese Medicine as well as practices such as mind-body therapies, massage, acupuncture and energy therapies. Within cancer care, we need to understand the context in which patients make decisions, the process of treatment decision-making and ultimately the combination of treatments patients use rather than simply focusing on discrete therapies. While integrative oncology is embraced as an important discipline, others argue that it should just be considered part of ‘good medical practice’.(5)
2. Evidence-based Clinical Practice Guidelines (CPGs) for Integrative Oncology
The need for evidence-based information about Integrative Oncology has led to the development of Clinical Practice Guidelines (6), which help health care professionals and patients make decisions about screening, prevention or treatment of a specific health condition. Most notable are the CPGs developed by the Society for Integrative Oncology in 2009 (4). The recommendations are labeled according to the strength of the recommendation (1 or 2): Level 1 stands for a strong and level 2 for a weak recommendation; A, B and C stand for high, moderate and low quality evidence respectively. Many of the guidelines deal with symptom control, side effects and quality of life. An example is: ‘Mind-body modalities are recommended as part of a multidisciplinary approach to reduce anxiety, mood disturbance and chronic pain and to improve QoL’ (graded as 1B). Other CPGs deal with only one type of cancer. A CPG for lung cancer (7) uses the same grading system as the SIO guidelines, for example: ‘Acupuncture is recommended as a complementary therapy when pain is poorly controlled or when side effects such as neuropathy or xerostoma from other modalities are clinically significant’ (graded as 1A).
3. Evidence-based guidelines for effective physician – patient communication about CAM
Schofield et al (8) have developed evidence-based recommendations to guide patient-provider communication about complementary and alternative medicine. They suggest clinicians should: 1) Elicit the person’s understanding of their situation, 2) Respect cultural and linguistic diversity and different epistemological framework, 3) Ask questions about CAM use at critical points in the illness trajectory, 4) Explore details and actively listen, 5) Respond to the person’s emotional state, 6) Discuss relevant concerns while respecting the person’s beliefs, 7) Provide balanced, evidence-based advice, 8) Summarize discussions, 9) Document the discussion and 10) Monitor and follow up. These guidelines were based on a systematic review of the literature and its aim was to assist oncologists to have respectful, balanced and useful discussions with patients about CAM.
4. Patient-provider communication
In our previous paper we emphasized the importance of physicians finding out whether their patients are using CAM. Not disclosing CAM use to their physicians, could result in potentially harmful consequences for the patient. Ge et al (9) report that in a survey of CAM use, 43.6% of patients reported to use CAM, but only 12.1% of them discussed the use of CAM with their physician. An NCCAM background paper reported three main reasons for non-disclosure (10): 1) The physician never asked (42%), 2) patients did not know they should tell (30%), and 3) there was not enough time during the office visit (19%). NCCAM has acted upon these findings, launching the “Time to Talk” campaign which encourages dialogue between practitioners and patients. Patients are often looking for informed advice and would like to talk about CAM with their physician. This is important as, whether patients receive information about CAM, as well as the quality of information, have been shown to affect patient satisfaction, decision-making, distress and well being and compliance.(11) Clinical practice guidelines are important tools for physicians to foster a healing relationship with their patients.
Several studies have found that effective communication between patients and physicians improves health by positively influencing emotional health, symptom resolution, functioning and pain control.(12) Patients with cancer, including those for whom a cure is not possible, need supportive physicians, friends and family members to care for them and be willing to discuss complementary therapies, disregarding their personal beliefs of whether these therapies are effective or not, as the psychological and emotional impact of these discussions have been shown to be of great importance to patients.
- Verhoef M, Boon H, Page S. Talking to cancer patients about complementary therapies: is it the physician’s responsibility? Curr Oncol 2008;15:88-93
- Ben-Arye E, Attias S, Tadmor T, Schiff E, Herbs in hemato-oncological care: an evidence-based review of data on efficacy, safety and drug interactions. Leukemia and Lymphoma 2010; 51(8):1414-1423
- Evidence-based clinical practice guidelines for integrative oncology: Complementary therapies and botanicals. Journal of the Society for Integrative Oncology 2009; 7(3): 85-120.
- Rayner, J, Willis K, Pirotta M. What’s in a name: integrative medicine or simply good medical practice? Family Practice, 2011;28: 655-66
- Cassileth B, Deng G, Gomez J, Johnstone P, Kumar N, Vickers A. Complementary therapies and Integrative Oncology in lung cancer: ACCP Evidence-Based Clinical Practice Guidelines. Chest, Supplement 2007: 340S-354S
- Schofield P, Diggins J, Charleson C, Marigliani, Jefford M. Effectively discussing complementary and alternative medicine in a conventional oncology setting: Communication recommendations for clinicians. Patient Education and Counseling 2010;79:143-151
- Ge J, Fishman J, Vapiwala N, Li S, Desai K, Xie, S, et al. Patient-physician communication about complementary and alternative medicine in a radiation oncology setting. Int J Radiation Oncology Biology, Physics, 2012. [Epub ahead of print]
- Frenkel M, Ben-Arye E, Cohen L. Communication in Cancer Care: Discussing Complementary and Alternative Medicine, Integrative cancer Therapies, 2010;9(2):177-185