ASCO/ACS Symposium on Integrative Medicine 2001
The Oncologist’s Role
The American Society of Clinical Oncology’s brochure describing this meeting states that 83% of cancer patients have used some form (s) of CAM (complementary/alternative therapies).
The stated objectives for this meeting included: “(to)describe how oncologists should respond when asked about research studies being conducted in this area” and “(to)identify differences and similarities in current cancer-specific integrative medicine programs”.
During her remarks on The Role of Cancer Centers in Complementary and Alternative Medicine Research , Karen Antman, MD at Columbia University, NYC used the figure 64%. Either way, it is clear that a huge number of patients are involved.
Dr. Antman suggested that the terminology describing non-conventional “alternatives” be proven and unproven.
Ann’s NOTE: This would be acceptable if we could just be assured that studies would be done on the unproven substances so that patients would have answers to their questions. Ann has raised the issue of studies for almost 9 years but their may now be more reason to hope studies will get done.
Barrie Cassileth, PhD at Memorial Sloan Kettering, spoke next on Enhancing Doctor/Patient Communication.
She told the audience that patients want open communication, to speak freely, get honest answers coupled with a display of caring and concern, and to be treated as a whole person, not a tumor.
She suggested that the doctors touch their patients and show respect for their ideas and questions. If the physician is in doubt as to what the patient is doing, s/he should ask.
She said if the doctor was visiting a patient who was in bed, the doctor should sit down to facilitate communication.
Patients have unprecedented access to information via the Internet. Doctors do not always know the answers to patients’ questions on CAM issues.
Dr. Cassileth said that the Health and Human Services Department’s report from the Office of Inspector General on Adverse Effects Reporting showed an inadequate safety valve.
She then told the audience that Memorial Sloan Kettering was doing a study of Maitake mushrooms. A 1999 survey of almost 1000 patients showed that 17% were using herbs. 55% of those used one product with 45% using more than one herb.
Dr. Cassileth then showed a slide with three of the four basic herbs in the Essiac formula (no explanation as to why Slippery Elm was left off).
She reported that St. John’s Wort could interfered with the liver dealing with chemotherapy. This was an illustration to the audience of the dangers of bad communication between doctors and their patients.
The next speaker was Lisa Vincler, JD, MA, University of Washington, “Medical and Legal Risks in Integrative Medicine. Ms. Vincler’s master’s degree is in Bioethics.
She stated that an article in J of Health and Housing Law, Vol 30, No 3, (1997) had said there were NO cases of malpractice (so far) in the area of Integrative Medicine.
Ms. Vincler suggested that the best defense against malpractice was a good physician/patient relationship. A physician could start by telling the patient that they want to have an open dialogue.
that CAM be defined when spoken about, since the value of yoga, massage, music and art have been clearly recognized.
that communication is complicated by the extent, variety, rapid changes, access and possible conflicts with diagnosis and treatment.
that doctors find out what hospitalized patients were doing, and should they be allowed to use CAM in hospitals?
that doctors attend CME training on CAM, and read the journals.
that doctors be willing to hear patient preferences because it is part of their rights, values and what they want.
that doctors help try to obtain information for their patients on treatments. Are these therapies better than nothing? As safe as a placebo or doing nothing? Does its potential benefit exceed the potential harm? Does it give the patient hope? Does it allow patients the opportunity to take a more active role in their treatment? Of course, one needs to remember that cancer patients are an exceptionally vulnerable population.
What is the institutional policy approach? Is there a support group program? Do a risk/benefit analysis for the patient. If there is a known substantial material risk, do not authorize the treatment. Tell the patient you cannot follow them if they do it. Patients can sign an informed awareness document called “Assumption of Risk”.
Mary Ann Richardson,DrPh, NIH Center for Complementary and Alternative Medicine told the audience:
there is a PubMed (way to research) for CAM. NIH will fund to establish CAM centers. they are currently looking at shark cartilage, drug/herb interactions and CAM at end of life.
Charles Loprinzi, MD, Mayo Clinic told the audience that a placebo-controlled study is being conducted on gingko for ‘chemo brain’. He also said that he envisioned soy and phytoestrogens being used like a SERM. He said it did nothing to help hot flashes.
David Rosenthal, MD, Dana Farber Cancer Institute told the audience that this is a patient-driven movement and that one obstacle is ‘dinosaur docs’. He stated that there is clear evidence for the use of acupuncture for pain and nausea.
Debu Tripathy, MD, University of California, San Francisco, spoke about his research into Tibetan herbs and other CAM issues. He said that they can demonstrate in the lab that soy binds to the estrogen receptors in a different way from estradiol. It seems to bind to the Estrogen Beta receptor. They have a pilot study looking at soy versus Tamoxifen.
Dr. Tripathy stated that while he could appreciate the need to have a scientific basis for a study of antioxidants and chemotherapy (question raised by Ann Fonfa), he was torn since we must study it since it was already being used by patients. He felt it would be a difficult study to start but that it was important. On this same question, Dr. Loprinzi stated that “the devil is in the details”, if seems halfway safe…
Dr. Rosenthal said that radiotherapists were concerned and eager to study antioxidants since they might decrease the adverse effects and increase success.
Simone Zappa, Memorial Sloan Kettering, stated that patients are being referred for massage (anxiety, depression, pain, fatigue) and levels were decreasing by up to 80%. They are making patients feel better. Using acupuncture and mind/body techniques was providing relief from pain and nausea, fear and anxiety.
Dr, Tripathy said that group support was very good for cancer patients and that there was no doubt that acupuncture, which has been fairly extensively studied for pain and nausea, was effective.
Lisa Vincler, in response to a question, said that the ‘Assumption of Risk’ form is needed due to unknown benefits, unknown risk of substances that may not be regulated, may have contaminants or unknown ingredients. The standard approach may be best, thus the form.