Support Care Cancer (2007) 15: 457–460 DOI 10.1007/s00520-006-0162-2
Kara M. Kelly
Received: 29 August 2006 Accepted: 5 September 2006 Published online: 12 October 2006 # Springer-Verlag 2006 Presented as an invited lecture at the MASCC/ISOO 18th International Symposium of Supportive Care in Cancer in Toronto, Canada, June 2006. K. M. Kelly (*) Division of Pediatric Oncology, Columbia University Medical Center, Morgan Stanley Children’s Hospital of New York Presbyterian, 161 Fort Washington Avenue, Irving Pavilion 7, New York, NY 10032, USA e-mail:
[email protected] Tel.: +1-212-3055808 Fax: +1-212-3055848
SH ORT COMMUNI CATIO N
Complementary and alternative medicines for use in supportive care in pediatric cancer
Abstract Introduction: Complementary and alternative medical practices (CAM) are being used by increasing numbers of children with cancer. Discussion: Recent surveys report CAM use prevalence rates of 24–90% in children with cancer. Interest in supporting children through the side effects or stress of conventional treatment has been described as one of the major motivating factors for the use of CAM therapies. Research is difficult secondary to the complexity of the therapies and lack of standardization. However, several research studies investigating CAM therapies for supportive care in children with cancer are ongoing. Infor-
Introduction Complementary and alternative medical therapies (CAM) are defined as a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. CAM therapies constitute an extremely heterogeneous group of therapies, and although widely used by the general public, most of these therapies are not well-understood by conventional health care providers. There is ongoing need to educate both families and health care providers on the potential risks and benefits of CAM therapies during treatment for childhood cancer.
Classification The National Center for Complementary and Alternative Medicine (NCCAM) at the US National Institute of Health was established in 1998 with its mission to investigate
mation on several studies in progress through the Children’s Oncology Group and other institutions will be reviewed. Conclusion: The progress made in the development of these studies demonstrates that CAM therapies can be investigated for their supportive care roles in the therapy of children with cancer. Keywords Complementary . Alternative . Children . Cancer
CAM therapies in the context of rigorous science and to disseminate reputable information on CAM therapies to the public and professional communities [17]. A standard classification system for these therapies was developed by NCCAM (Table 1) [10]. This classification system defines the major categories of CAM therapies and is useful for both research and education purposes.
CAM therapies use among children with cancer Numerous surveys have demonstrated that patients frequently turn to CAM therapies upon being diagnosed with cancer. Children with cancer also often use CAM therapies. Although surveys completed in the 1970s and 1980s revealed that less than 20% of children with cancer used CAM, surveys over the past decade have found that the prevalence of CAM therapies use among children with cancer ranges from 24 to 90% (Fig. 1) [7], comparable to prevalence rates of CAM use among adults with cancer.
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Table 1 Categorization of CAM therapies by the National Center for Complementary and Alternative Medicine Type of CAM
Definition
Examples
Alternative medical systems Mind–body medicine
Complete systems of theory and practice
Homeopathy, naturopathy, traditional Chinese medicine, Ayurvedic medicine Meditation, prayer, mental healing, art, music, or dance
Biologically based therapies Manipulative and body-based methods Energy Therapies Biofield therapies
Variety of techniques designed to enhance the mind’s capacity to affect bodily function and symptoms Substances found in nature Manipulation and/or movement of one or more parts of the body
Are intended to affect energy fields that purportedly surround and penetrate the human body Bioelectromagnetic- Involve the unconventional use of based therapies electromagnetic fields
Dietary supplements, herbal products, and the use of other so-called “natural” but as yet scientifically unproven therapies Chiropractic or osteopathic manipulation, massage
Qi gong, Reiki, therapeutic touch
Pulsed fields, magnetic fields, or alternating current or direct current fields
From [10]
These surveys have also found that most children are using CAM therapies as adjunctive agents rather than as a replacement to conventional treatment for cancer. Use of CAM is further complicated by the observation that 50% of therapies are not reported to health care providers [8]. CAM therapies are frequently used by participants of conventional clinical trials, thereby potentially introducing bias into the results of some studies. In children, CAM
90 80 70 60 % of Children
Fig. 1 The prevalence of CAM therapies use among children with cancer. Each bar represents the prevalence in a published survey. The studies are clustered by the time periods in which the studies were completed. Group 1 (1977–1983), group 2 (1994–1998), and Group 3 (2000–2006) [8]
therapies are primarily used as supportive therapies to alleviate pain and symptoms of cancer and especially to ameliorate actual or perceived toxicities of conventional cancer treatment. Many factors are associated with CAM use in this setting. Parents’ desire to try to do everything possible to improve their child’s health likely plays a major role in their decision to use CAM therapies for their child [8]. Poor prognosis, prior CAM use, higher parental
50 40 30 20 10 0
77-83
94-98
00-06
Year Study Completed
459
education, older age, and religiosity have also been associated with CAM use in children with cancer.
The state of the evidence for CAM therapies for supportive care in children with cancer The use of CAM therapies by patients with cancer is controversial. Because there are few clinical trials of safety or efficacy, little information is available to guide clinical practice. The concern raised by the use of the dietary supplements is especially magnified by the variability in quality and differences in regulatory oversight as compared with conventional medications. For CAM therapies delivered by practitioners, similar concerns may exist. Training and licensure standards are not consistent. Clinical research of CAM therapies is complicated. Complex therapeutic systems such as traditional Chinese medicine are difficult to standardize, as many of the therapies are individualized to a certain patient instead of a particular disease in contrast to the approach used in many clinical trials of conventional therapies. Recruitment to clinical trials of CAM therapies may be hampered by emotional biases either for or against the particular therapy. The lack of standardization of dietary supplements mandates the need for independent purity testing. Some CAM practitioners may also have little incentive to conduct trials of CAM therapies since the therapies are already available in the mainstream. Despite these limitations, evidence is available to support the use of several CAM therapies among children with cancer. Therapies with a demonstrated supportive care role include hypnosis, guided imagery, music therapy, massage, and acupuncture. Hypnosis and imagery reduced anticipatory nausea, vomiting, and pain in children with cancer [4, 6, 12, 19]. A child’s emotional state [1] and immune function [9] may be affected by music therapy. Massage therapy is associated with beneficial effects on mood and anxiety [13] and possibly shortened duration of time to neutrophil recovery [2]. Acupuncture has been associated with reductions in nausea and vomiting [16] and improvements in white blood cell recovery in adolescents receiving chemotherapy [18]. The Children’s Oncology Group has developed two phase III trials of CAM therapies [15]. The first trial opened
in April 2004 and is a randomized, double-blind, placebocontrolled clinical trial to assess the efficacy of the homeopathic medication Traumeel® S for the prevention and treatment of mucositis in children undergoing hematopoietic stem cell transplantation. This study was based upon an Israeli pilot study that showed that Traumeel® S significantly reduced the severity and duration of chemotherapy-induced mucositis in children undergoing bone marrow transplantation [11]. The second trial is a collaborative effort with investigators at the Pediatric Oncology Branch at the National Cancer Institute. This randomized trial is investigating electroacupuncture treatment for delayed chemotherapy-induced nausea and vomiting in patients with pediatric solid tumors. There are few studies to date involving children and acupuncture, partly because of a concern that children would not accept placement of needles, although there is general consensus that acupuncture is acceptable to children beginning at 10 years [14]. As prolonged delayed nausea is still a clinical challenge, this study has real potential to identify a useful adjunctive agent.
Conclusions Despite the limited data specifically on CAM therapies in children with cancer, the use of these therapies is increasing worldwide. The International Society of Pediatric Oncology (SIOP) has developed guidelines to enhance communication between health care providers and families on the use of these therapies [5]. SIOP calls for the health care team to be attentive to complementary therapies that may be physically or psychologically harmful to children and their parents and for the health care team to not automatically and dismissively discourage the use of non-harmful complementary therapies. Further research is needed to evaluate CAM therapies in children with cancer, and the same general research principles used for investigating conventional therapies should also be used [3]. The integration of CAM therapies with conventional treatments for cancer may be especially useful for symptom management. Acknowledgements Supported in part by the Lerner and Schwartz families and Origins Natural Resources.
References 1. Barrera EM, Rykov MH, Doyle SL (2002) The effects of interactive music therapy on hospitalized children with cancer: a pilot study. Psychooncology 11:379–388
2. Field T, Cullen C, Diego M et al (2001) Leukemia immune changes following massage therapy. J Bodyw Mov Ther 5:271–274
3. Institute of Medicine at the National Academy of Sciences (2005) Report on use of complementary and alternative medical therapies. NAS Press, Washington, DC
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4. Jacknow D, Tschann J, Link M et al (1994) Hypnosis in the prevention of chemotherapy-related nausea and vomiting: a prospective study. J Dev Behav Pediatr 15:258–264 5. Jankovic M, Spinetta JJ, Martins AG et al (2004) Non-conventional therapies in childhood cancer: guidelines for distinguishing non-harmful from harmful therapies: A report of the SIOP working committee on psychosocial issues in pediatric oncology. Pediatr Blood Cancer 42:106–108 6. Kazak AE, Penati B, Brophy P et al (1998) Pharmacologic and psychologic interventions for procedural pain. Pediatrics 102:59–66 7. Kelly KM (2004) Complementary and alternative medical therapies for children with cancer. Eur J Cancer 40:2041–2046 8. Kelly KM, Jacobson JS, Kennedy DD, Braudt SM, Mallick M, Weiner MA (2000) Use of unconventional therapies by children with cancer at an urban medical center. J Pediatr Hematol Oncol 22:412–416
9. Marwick C (1996) Leaving concert hall for clinic, therapists now test music’s charms. JAMA 275:267–268 10. NIH National Center for Complementary and Alternative Medicine (2002) Classification of complementary and alternative medical practices. NCCAM Publication No. D156. Available at http://www.nccam.nih.gov/health/ whatiscam. Accessed July 2006 11. Oberbaum M, Yaniv I, Ben-Gal Y et al (2001) A randomized, controlled clinical trial of the homeopathic medicine TRAUMEEL® S in the treatment of chemotherapy-induced stomatitis in children undergoing stem cell transplantation. Cancer 92:684–690 12. Olness K (1981) Imagery (self-hypnosis) as an adjunct therapy in childhood cancer: clinical experience with 25 patients. Am J Pediatr Hematol Oncol 3:313–321 13. Post-White J, Hawks RG (2005) Complementary and alternative medicine in pediatric oncology. Semin Oncol Nurs 21:107–114 14. Rusy LM, Weisman SJ, Kemper KJ (2000) Complementary therapies for acute pediatric pain management. Complementary and alternative medicine for children: does it work? Pediatr Clin North Am 47:589–599
15. Sencer S, Kelly KM (2006) Bringing evidence to complementary and alternative medicine for children with cancer. J Pediatr Hematol Oncol 28:186–189 16. Shaoxiang L, Zhifeng C, Jun H et al (1991) Magnetic disk applied on neiguan point for prevention and treatment of cisplatin-induced nausea and vomiting. J Trad Chin Med 11:181–183 17. Straus SE, Chesney MA (2006) In defense of NCCAM. Science 313: 303–304 18. Ximei H, Huiling C, Xiumei G, Yemei M (1993) Treatment with cone moxibustion of chemotherapeutic leucocytopenia in 114 cases. J Trad Chin Med 13:266–267 19. Zeltzer L, LeBaron S, Zeltzer P (1984) The effectiveness of behavioral intervention for reduction of nausea and vomiting in children and adolescents receiving chemotherapy. J Clin Oncol 2:683–690
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