Jyothirmai Gubili

Integrative Oncology Practice Guidelines

Integrative Oncology Practice Guidelines Yuan-Sheng Liu, Jong-Hoon Lee, Yeon-Weol Lee, Chong-Kwan Cho, Hwa-Seung Yoo East-West Cancer Center, College of Oriental Medicine, Daejeon University The Society for Integrative Oncology (SIO) is an international organization established to encourage scientific evaluation, dissemination of evidence-based information, and appropriate clinical integration of complementary therapies (http://www.Integrativeonc.org.). Practice Guidelines were developed by the authors listed below and by the Executive Committee of the Society for Integrative Oncology, which approved this document. Guidelines are a work in progress; they will be updated as needed and are available on the SIO Web site as well: www.IntegrativeOnc.org.

Integrating Dietary Supplements Into Cancer Care

Many studies confirm that a majority of patients undergoing cancer therapy use self-selected forms of complementary therapies, mainly dietary supplements. Unfortunately, patients often do not report their use of supplements to their providers. The failure of physicians to communicate effectively with patients on this use may result in a loss of trust within the therapeutic relationship and in the selection by patients of harmful, useless, or ineffective and costly nonconventional therapies when effective integrative interventions may exist. Poor communication may also lead to diminishment of patient autonomy and self-efficacy and thereby interfere with the healing response. To be open to the patient’s perspective, and sensitive to his or her need for autonomy and empowerment, physicians may need a shift in their own perspectives. Perhaps the optimal approach is to discuss both the facts and the uncertainty with the patient, in order to reach a mutually informed decision. Today’s informed patients truly value physicians who appreciate them as equal participants in making their own health care choices. To reach a mutually informed decision about the use of these supplements, the Clinical Practice Committee of The Society of Integrative Oncology undertook the challenge of providing basic information to physicians who wish to discuss these issues with their patients. A list of leading supplements that have the best suggestions of benefit was constructed by leading researchers and clinicians who have experience in using these supplements. This list includes curcumin, glutamine, vitamin D, Maitake mushrooms, fish oil, green tea, milk thistle, Astragalus, melatonin, and probiotics. The list includes basic information on each supplement, such as evidence on effectiveness and clinical trials, adverse effects, and interactions with medications. The information was constructed to provide an up-to-date base of knowledge, so that physicians and other health care providers would be aware of the supplements and be able to discuss realistic expectations and potential benefits and risks.

Integrative Oncology: Complementary Therapies in Cancer Care

Many cancer patients experience both physical and emotional symptoms associated with cancer and cancer treatments. Complementary therapies are gentle, noninvasive techniques that alleviate symptoms. They are offered along with conventional care to improve quality of life. Alternative therapies, on the other hand, are unproved and potentially harmful. They are administered in lieu of mainstream treatment and should be avoided. Healthcare professionals and patients should be aware of this distinction.

Integrative Oncology: Complementary Therapies for Cancer Survivors

Cancer survivors experience a wide range of symptoms during and following completion of treatment, and some of these symptoms may persist for years or even decades. While pharmacologic treatments relieve many symptoms, they too may produce difficult side effects. Complementary therapies are noninvasive, inexpensive, and useful in controlling symptoms and improving quality of life, and they may be accessed by patients themselves. Rigorous scientific research has produced evidence that acupuncture, massage therapy, music, and mind-body therapies effectively and safely reduce physical and emotional symptoms. These therapies provide a favorable risk-benefit ratio and permit cancer survivors to help manage their own care.

Herbs and other botanicals in cancer patient care.

Opinion statementNon-prescription herbal remedies are commonly used by cancer patients in efforts to control their disease or to manage symptoms associated with cancer and cancer treatments. We address the issues surrounding the use of herbs, herbal compounds, and other botanical agents in the oncology context. Botanicals are biologically active agents that can be useful under appropriate circumstances, but they may be counterproductive when used by patients on chemotherapy or on other prescription medications. Herbs and other botanical agents, despite common public belief, are not benign. They should be understood as unrefined pharmaceuticals, with the capacity to produce physiologic change for better or worse. Indeed, many prescription drugs, chemotherapeutic agents among them, were derived from plants and other natural agents, and the search for additional constituents of plants, animals, and minerals for use as pharmaceutical agents remains an active effort on many fronts. Cautions, appropriate application, and potential utility of botanical agents are discussed below, and sources of reliable information are provided.

Evidence-Based Botanical Research: Applications and Challenges

Use of herbal supplements is on the rise around the world, but limited data exist on the safety and efficacy of botanical products. Efforts to subject botanicals to rigorous scientific research began recently. There are many problems associated with botanicals research, however. These include procuring the study agents, selecting appropriate study method and clinical trial design, navigating through regulatory obstacles, and obtaining funding. Evidence-based botanical research can help to validate traditional uses and to facilitate new drug development. Concerted efforts of governmental agencies and industry are essential to ensure continuance of high-quality botanicals research.

An Evidence-based Review of Astragalus membranaceus (Astragalus) for Cancer Patients

Astragalus membranaceus (astragalus), originally described in the Shennong’s Classic of Materia Medica two thousand years ago, is used as a Qi-tonifying herb in traditional Chinese medicine. It is an important ingredient in many herbal formulas used to treat a variety of symptoms and ailments including fatigue and rectal prolapse. The root of astragalus is rich in saponins and polysaccharides. Modern research suggests antioxidant, immunomodulatory, and cytostatic properties. Animal and anecdotal human data show that astragalus reduces immunosuppression, a side effect of chemotherapy and it may also enhance the effects of such treatments. Whereas oral and parenteral preparations have been developed in Asia, products containing astragalus are consumed as dietary supplements in the West. Several formulas containing astragalus have been studied in cancer patients. Data indicate that they are safe to use in conjunction with chemotherapy and reduce treatment associated adverse effects. Based on existing evidence, there is also substantial interest in developing astragalus-based preparations for certain cancers. Although all products studied to date contain astragalus as the main ingredient, the variation across formulas makes it difficult to draw definitive conclusions. Future studies should address this issue. Astragalus is generally considered safe for traditional use, but the potential for herb-drug interactions exists because botanicals contain biologically active compounds. This chapter presents information about the use of astragalus in traditional medicine and summarizes existing scientific evidence of its benefits and limitations as an adjuvant cancer treatment.

Herbal medicine for depression and anxiety: A systematic review with assessment of potential psycho-oncologic relevance

Anxiety and depression are prevalent among cancer patients, with significant negative impact. Many patients prefer herbs for symptom relief to conventional medications which have limited efficacy/side effects. We identified single‐herb medicines that may warrant further study in cancer patients. Our search included PubMed, Allied and Complementary Medicine, Embase, and Cochrane databases, selecting only single‐herb randomized controlled trials between 1996 and 2016 in any population for data extraction, excluding herbs with known potential for interactions with cancer treatments. One hundred articles involving 38 botanicals met our criteria. Among herbs most studied (≥6 randomized controlled trials each), lavender, passionflower, and saffron produced benefits comparable to standard anxiolytics and antidepressants. Black cohosh, chamomile, and chasteberry are also promising. Anxiety or depressive symptoms were measured in all studies, but not always as primary endpoints. Overall, 45% of studies reported positive findings with fewer adverse effects compared with conventional medications. Based on available data, black cohosh, chamomile, chasteberry, lavender, passionflower, and saffron appear useful in mitigating anxiety or depression with favorable risk–benefit profiles compared to standard treatments. These may benefit cancer patients by minimizing medication load and accompanying side effects. However, well‐designed larger clinical trials are needed before these herbs can be recommended and to further assess their psycho‐oncologic relevance.

Correction: Integrative medicine: complementary therapies and supplements

Cassileth, B. et al. Integrative medicine: complementary therapies and supplements. Nat. Rev. Urol. 6, 228–233 (2009). In the April 2009 issue of Nature Reviews Urology, the following Acknowledgment should have been included: “This work was supported in part by Award Number P50AT002779 from the National Center for Complementary & Alternative Medicine.

Herbs and Other Botanicals: Interactions with Pharmaceuticals

Herbal supplements are being used by an increasing number of cancer patients for symptom relief both during and after treatment. But botanicals contain biologically active compounds that can interfere with chemotherapeutic drugs and other medications. Research is underway to determine the mechanism of action and beneficial effects of botanicals.