Complementary and Alternative Medicine: An Introduction

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Complementary and Alternative Medicine: An Introduction

  1. 1. CAM Herbal remedies in cancer HAI conference 2007 Patricia Fox School of Nursing, Midwifery & Health Systems, UCD
  2. 2. Outline Definitions Prevalence Characteristics associated with use Reasons for use Herbs: helpful, harmless or harmful? Implications for health professionals
  3. 3. Definitions Different terminology has been used over time from the negative “quackery” to “unorthodox”, “unconventional”, “questionable”, “unproven” and “alternative” (Cassileth & Deng 2004) proponents may use terms such as ‘holistic’, ‘non-toxic’, ‘integrative’, ‘medicine douce (gentle medicine)’ (Ernst & Fugh-Berman 2002)
  4. 4. Definitions Complementary therapies are used in addition to conventional treatment include supportive approaches that treat symptoms and enhance well-being Conversely, alternative therapies are frequently promoted for use in place of mainstream treatment (Cassileth & Deng 2004)
  5. 5. The following categories are used to group CAM (NCCAM 2006) Alternative medical systems such as homeopathy and naturopathic medicine; Mind-body interventions such as meditation and prayer; Biologically based treatments such as herbal products and dietary supplements; Manipulative and body based methods such as massage and chiropractic manipulation Energy therapies such as Reiki and qi gong
  6. 6. Definition of CAM (NCCAM 2004) 5 categories used in classification ‘ CAM is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. ’
  7. 7. Prevalence of CAM use in adult patients with cancer Systematic review: (26 surveys/n=3649) CAM use ranges from 7-64%, while average prevalence is 31.4% (Ernst & Cassileth 1998) US study (n=453) 83.3% had used at least one approach. 62.6% used vitamins/herbs (62.6%), 59.2% movement and physical therapies (Richardson et al. 2000) 2005 study: 35.9% uptake (n= 956) (least one form of CAM) (Molassiotis et al. 2005)
  8. 8. CAM prevalence in haematological cancers (Molassiotis et al. 2005) European study:12 countries (n=68) Lmts* 26.5% use some form of CAM Most common therapies used: homeopathy (38.9%), herbal medicine (22.2%) various psychic therapies, such as use of mediums, healers, rebirthing (22.2%) Reasons for use: Increase ability of their body to fight cancer and improve physical/emotional well-being.
  9. 9. CAM prevalence in children with cancer Surveys of families of children with cancer indicate that CAM is used worldwide: with 31% to 46% use in the Netherlands, Finland, Australia, and Canada, and higher use (73%) in Taiwan (Post White & Hawkes 2005) UK study (n=49) 32.7% reported using some type of CAM most commonly used therapies included multivitamins, aromatherapy massage, diets and music as therapy (Molassiotis & Cubbin 2004)
  10. 10. Ireland: secondary analysis of SLAN studies: general population (Fox et al. in press) 1998 20% CAM uptake 2002 27% CAM uptake ⇒only looked at visits to CAM providers (did not include OTC CAM use) In 1998 and 2002, of those who regularly take prescription drugs, 43.7% and 51.9% respectively also admitted taking vitamins, minerals, or food supplements.
  11. 11. Characteristics associated with use Higher education Younger/middle age Female Affluent ⇒ above most consistently associated with CAM use (Harris et al. 2003, Hana et al. 2005, Molassiotis & Cubbin 2004, Pud et al. 2005, Yates et al. 2004,)
  12. 12. Use in serious illness Symptom control (Cassileth & Chapman 1996). Curing the disease/controlling disease Decreasing adverse effects of conventional medicine Strengthening the immune system Enhancing physical, emotional and spiritual well- being Improve overall health of child Regaining a sense of control (Verhoef et al. 1993, Molassiotis & Cubbin 2004, Richardson et al. 2000).
  13. 13. Herbal supplements: potentially dangerous misconceptions Some patients may believe that if a practice or product has been in use for hundreds of years, it must be effective Many also believe that if a product is ‘natural’, it must be safe (Smith & White 2001)
  14. 14. Herbal supplements Herbs and Natural Products With potential to decrease cancer growth or as adjuvants (preliminary evidence only often based on in vitro/animal studies) → no recommendations can be made to patients at this time. With potential to decrease side effects That may increase cancer growth or recurrence That can interact with conventional treatment and medications
  15. 15. Herbs and Natural Products With Potential to Decrease Cancer Growth or as Adjuvants (Montbriand 2004) Astragalus → appears to enhance immune system (C/I) Beta glucan→ stimulate the body’s macrophage phagocytosis of tumour cells Baikal skullcap In vitro anti-tumour activity(hepatotoxic/stupor) Calcium-D-glucarate → ↓ oestrogen, no clinical trials at this time
  16. 16. Herbs and Natural Products With Potential to Decrease Cancer Growth or as Adjuvants (Montbriand 2004) Cats claw → leukaemia, (no human studies) inhibits CYP 3A4/additive effects. (SLE → ARF) Coriolus mushroom (PSK, PSP)→ Japan Positive trials in gastric and colon ca Green Tea Soy (Natural Medicines Comprehensive Database (2003) and the Lawrence Review of Natural Products– Monograph System (Facts and Comparisons, 2001).
  17. 17. Herbs and Natural Products With Potential to Decrease side effects (Montbriand 2004) Glutamine may prevent GI toxicity (uptake concern) Coriolus mushroom (PSK, PSP) animal studies suggest PSK can prevent chemo induced immunosuppression Ginger
  18. 18. Herbs or Natural Products That May Increase Cancer Growth or Recurrence (Montbriand 2004) Herbs with estrogenic properties concern relating to hormone-sensitive cancers alfalfa (pancytopenia), black cohosh (may interact with tamoxifen), flaxseed (conflicting), ginseng (3), licorice, milkthistle, red clover, soy Alfalfa Ingestion of large amounts of alfalfa seeds is associated with pancytopenia (Tyler, 1993) (Natural Medicines Comprehensive Database (2003) and the Lawrence Review of Natural Products –Monograph System (Facts and Comparisons, 2001).
  19. 19. Interaction with chemotherapy agents (Montbriand 2004) Vitamin C & Vitamin E ↓ chemo efficacy Coenzyme Q-10 Concern that cancer cells are protected from chemo when used concomitantly with agents such as cyclophosphamide, Glucosamine (3) induce resistance to etoposide and doxorubicin by reducing inhibition of topoisomerase II Folic acid → Methotrexate/Irinotecan → SJW Echinacea → MOABs
  20. 20. Patricia Fox, UCD, 2007 Review of literature (Ernst 1998) Allergic reactions: royal jelly → bronchospasm Toxic reactions → aristolochic acid Adverse effects r/t desired action Ginseng tabs → overt mania in depressed patient taking antidepressants Mutagenic effects Concern phytooestrogens in breast cancer Contamination Arsenic, lead, corticosteroids
  21. 21. Patricia Fox, UCD, 2007 Drug interactions Name (Latin) Anticoagulant/anti-platelet Potential interaction • Panax (Panax ginseng) Warfarin Decreased INR • Garlic (Allium sativum) Warfarin, Aspirin May ↑risk bleeding (T) Ginkgo (Ginkgo biloba) Warfarin May ↑risk bleeding Aspirin Chamomile (Matricaria chamomilla) Warfarin May ↑ bleeding time • Dong quai (Angelica sinensis) Warfarin ↑ bleeding time • Ginger (Zingiber officinale) Warfarin May enhance risk of bleeding
  22. 22. Patricia Fox, UCD, 2007 Herbal supplements Some Key points Just because it is labelled ‘natural’ does not mean it is safe or without side effects Can act in the same way as drugs → may cause medical problems if taken incorrectly or in large amounts. Where herbal supplements are used, it is preferable to do so under guidance of a medical professional, properly trained in herbal medicine (NCCAM 2004)
  23. 23. Patricia Fox, UCD, 2007 Herbal supplements Some Key points Herbal supplements not subject to the same rigorous standards as mainstream medications The active ingredient(s) in many herbs/ herbal supplements are not known Published analyses have found differences between what is on label and what is in the bottle Some herbal supplements may be contaminated with metals, unlabelled prescription drugs, micro-organisms (NCCAM 2004)
  24. 24. Who is providing the information?
  25. 25. Internet Internet information offered to patients with depression is highly variable with some websites offering valuable information, many recommending CAM therapies for which there is no evidence some even dissuading patients from using conventional treatment for depression (Ernst & Schmidt 2004)
  26. 26. Lack of disclosure to conventional providers Eisenberg study 39.8% of alternative therapies were disclosed to physicians in 1990 vs 38.5% in 1997 Limited discussion of CAM between conventional providers and their patients may be a function of limited knowledge of CAM among the former. Research indicates that health care professionals knowledge of CAM is low (Dekeyser et al. 2001, Uzun & Tan 2004)
  27. 27. Recommendations for conventional providers It is recommended that nursing and medical curricula incorporate some teaching on CAM. Increasing the knowledge base of conventional healthcare professionals will serve to not only safeguard patients against potential harm from therapies (Uzun & Tan 2004) Also enable them to provide advice and support in relation to beneficial supportive therapies (Risberg et al. 2003).
  28. 28. Recommendations by survey authors Suggest government, corporations, foundations and academic institutions adopt a more proactive position in relation to research and education in this area (MacLennan et al. 1996), improve quality control of dietary supplements, Initiate formation of post-market monitoring of drug-herb/supplement interactions (Eisenberg et al. 1998, Nilsson et al. 2001).
  29. 29. Patricia Fox, UCD, 2007 Conclusion Important to question patients regarding all medications, supplements, OTC remedies taken when taking initial history Where unexpected signs/symptoms → probe further, keep an open mind Caution re: limited knowledge of effects/side effects of herbs and potential for interaction with meds Consult with pharmacist Document, Document, Document!
  30. 30. Patricia Fox, UCD, 2007 Resources National Centre for Complementary and Alternative Medicine for up-to-date information on research trials www.altmed.od.nih.gov/NCCAM American Cancer Society http://www.cancer.org Agency for Healthcare Policy and Research http://healthit.ahrq.gov/search/ahrqsearch.jsp MSKCC.Org http://www.mskcc.org/mskcc/html/1979.cfm
  31. 31. References Cassileth B. R. & Chapman C. C. (1996) Alternative and Complementary Cancer Therapies. Cancer 77 (6), 1026-1034. Cassileth B. R. & Deng G. (2004) Complementary and alternative therapies for Cancer. The Oncologist 9 (1), 80-89. Dekeyser F. G., Bar Cohen B., & Wagner N. (2001) Knowledge levels and attitudes of staff nurses in Israel towards complementary and alternative medicine. Journal of Advanced Nursing 36 (1), 41-48.
  32. 32. References Eisenberg D. M., Davis R. B., Ettner S. L., Appel S. Wilkey S., Van Rompay M. & Kessler. R. C. (1998) Trends in Alternative Medicine use in the United States:1990-1997. JAMA 280, 1569-1575. Ernst E. (1998) Harmless herbs? A review of recent literature. The American Journal of Medicine. 104 (2), 170-178. Ernst E. & Cassileth B. R. (1998) The prevalence of complementary/alternative medicine in cancer: a systematic review. Cancer 83 (4), 777-782. Fox P.A.M., Kelleher C., Coughlan B., Fitzsimon N. & Butler M. Complementary Alternative Medicine use in Ireland: a secondary data analysis of the SLAN studies (in press).
  33. 33. References Ernst E. & Fugh-Berman A. (2002) Complementary and alternative medicine: what is it all about? Occupational and Environmental Medicine 59, 140-144. Ernst E. & Schmidt K. (2004) Alternative Cures for depression-how safe are websites? Psychiatry Research 129 (3), 297-301. Harris P., Finlay I. G., Cook A., Thomas K. J. & Hood K. (2003) Complementary and alternative medicine use by patients with cancer in Wales: a cross sectional survey. Complementary Therapies in Medicine 11(4), 249-253.
  34. 34. References Hana G., Bar-Sela G., Zhana D., Mashiach T. & Robinson E. (2005) The use of complementary and alternative therapies by cancer patients in northern Israel. Isr Med Assoc . 7, 243-7. Maclennan A.H., Wilson., D. H. & Taylor A. W., (1996) Prevalence and cost of alternative medicine in Australia. The Lancet 437, 569-573
  35. 35. References Molassiotis A. & Cubbin D. (2004) ‘Thinking outside the box’: Complementary and alternative therapies in paediatric oncology patients. European Journal of Oncology Nursing 8 (1), 50- 60. Molassiotis A., Fernadez-Ortega P., Pud D., Ozden G., Scott JA., Panteli V., Margulies A, Browall M, Magri M, Selvekerova S, Madsen E, Milovics L, Bruyns I., Gudmundsdottir G., Hummerston S., Ahmad A.M., Platin N., Kearney N. & Patiraki E. (2005) Use of complementary and alternative medicine in cancer patients: a European survey. Annals of Oncology 16, 655- 663.
  36. 36. References Molassiotis A., Margulies A, Fernadez-Ortega P., Pud D., Panteli V., Bruyns I., Scott JA., Gudmundsdottir G., Browall M, Madsen E, Ozden G., Magri M, Selvekerova S, Platin N., Kearney N. & Patiraki E. (2005) Complementary and alternative medicine use in patients with haematological malignancies in Europe. Complementary therapies in Clinical Practice 11 (2), 105-110. Montbriand M. (2004) Herbs or Natural Products That Decrease Cancer Growth: Part One of a Four-Part Series. ONF 31 (4)
  37. 37. References National Centre for Complementary and Alternative Medicine (2004) What is complementary and alternative medicine? http://nccam.nih.gov/health (accessed 3 March 2005) Internet. Nilsson M., Trehn G., & Asplund K., (2001) Use of complementary and alternative medicine remedies in Sweden. A population-based longitudinal study within the northern Sweden MONICA Project.Journal of Internal Medicine 250, (3) 1365- 2796.
  38. 38. References Post-White J. & Hawkes R. P. (2005) Complementary and alternative medicine in pediatric oncology. Seminars in Oncology Nursing 21(2), 107-114. Pud D., Kaner E., Morag A., Ben-Ami S. & Yaffe A. (2005) Use of complementary and alternative medicine among cancer patients in Israel. European Journal of Oncology Nursing 9, (2),124- 30.
  39. 39. References Richardson M. A., Sanders T., Lynn Palmer J., Greisinger A., & Singletary S. E. (2000) Journal of Clinical Oncology 18 (13), 2505-2514. Risberg T., Kolstad A., Bremnes Y., Holte H. & Wist E.A (2004) Knowledge of and attitudes toward complementary and alternative therapies: a national multicentre study of oncology professionals in Norway. European Journal of Cancer 40, 529-535. Smith W. B. & White J. D. (2001). Complementary and alternative medicine in cancer: a National Cancer Institute perspective. Exp. Opin. Biol. Ther. 1 (3), 339-341.
  40. 40. References • Uzun O & Tan M.(2004) Nursing students opinions and knowledge about complementary and alternative medicine therapies. Complementary Therapies in Nursing and Midwifery 10 (4), 239- 244. Yates J. S., Mustian K. M., Morrow G. R., Gillies L. J., Padmanaban D., Atkins J. N., Issell B., Kirshner J. & Colman L.K. (2005) Prevalence of complementary and alternative medicine use in cancer patients during treatment. Support Care in Cancer 13 (10), 806-811.
  41. 41. References Verhoef M. J., White M. A. & Doll R. (1993) Cancer patients’ expectation of the role of family physician in communication about complementary therapies. Cancer Prevention Control 3, 181-187.

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