Opening Up the Alternative Medicine Dialogue

Advanced Nurse Practitioner in the department of hematology/oncology at the University of Chicago Medical Center in Chicago, Illinois

The use of alternative, complementary, and integrative treatments among cancer patients is high: In a 2011 study, 65 percent of Americans who had been diagnosed with cancer reported using complementary or alternative approaches – compared with 52.5 percent of people without a cancer diagnosis.1

What falls under the umbrella of complementary and alternative medicine (CAM)? According to the National Center for Complementary and Integrative Health, “complementary” medicine is defined as a non-mainstream health approach along with conventional Western medicine, and “alternative” medicine is using non-mainstream health approach in place of conventional Western medicine.2

Alternative, complementary, and integrative treatments come in many shapes and sizes in oncology care. Popular modalities for patients seeking CAM include using natural products (such as herbal and nutritional supplements), as well as meditation, chiropractic and massage, therapeutic touch, exercise, acupuncture, and yoga.

Certain approaches have been shown to be effective in managing cancer symptoms and side effects of anti-cancer treatments, but there are a larger proportion that have no scientific basis.

So, what should you do if your patient wants an alternative, complementary, or integrative treatment that you don’t recommend – or recognize?

Starting the CAM Dialogue

Patients are often unwilling to disclose their use of CAM to their advanced practice provider (APP) or their oncology nurse or physician, expecting providers to be uninterested or express disapproval of alternative medicine. Unfortunately, patients may also be unaware of the potentially dangerous drug–CAM interactions.

When patients do open up about their use of CAM to their health-care provider, the health-care provider may find him- or herself in an uncomfortable position, lacking the necessary relevant information for a helpful discussion. Given our limited clinic time, we may have a blind spot when it comes to understanding approaches outside the bounds of conventional Western medicine. As patients increasingly add CAM to their biomedical care, though, providers have an ethical responsibility to learn about CAM and get involved in the CAM dialogue.

Although patients may not expect their providers to be experts in CAM, they should reasonably expect those providers to address their interest in CAM. Remember: a conversation about CAM doesn’t necessarily imply endorsement, but it does keep the lines of communication open – and allows APPs and others to monitor safety related to CAM use, such as adverse effects or drug–CAM interactions.

Understanding the Alternatives

When health-care providers are deciding how to respond to their patients’ interests in using CAM, it is helpful to understand why they are seeking alternative methods. Cancer patients look to CAM for a variety of reasons: for symptomatic relief, to improve quality of life, to avoid potential toxicities associated with conventional therapies, because CAM aligns with their personal values and beliefs, or because they believe CAM can fight cancer or boost their immune system.3

As providers, we also need to be cognizant of how patients initiate the CAM discussion. For example, if a patient who is having difficulty with chemotherapy-induced nausea or vomiting that has not been controlled with recommended pharmacologic anti-emetic agents brings up an article he or she has read about acupressure to relieve nausea, he or she is actively demonstrating what is important and relevant to his or her care and offering clues to individual treatment preferences and values.

But, what if this same patient is due to receive his or her next cycle of highly emetogenic chemotherapy and decides that, instead of using any standard medications for nausea, he or she only wants to use acupuncture and acupressure to control his or her symptoms?

This situation illustrates exactly why engaging in the CAM conversation with the patient is critical. Discovering this patient’s reason for this decision will help you plan your response to ensure that both you and the patient are satisfied with the treatment plan.

Perhaps he or she believes standard anti-emetic medications are toxic and, in previous experiences, only felt symptom relief when receiving acupressure and acupuncture. In giving your patient an honest answer, it is your duty to acknowledge the lack of data for acupressure/acupuncture alone to relieve nausea and vomiting associated with highly emetogenic chemotherapy, but not to gloss over the realistic concerns your patient may express about receiving this type of chemotherapy.

Do Your Homework

When a patient or caregiver mentions CAM during a clinical encounter, health-care providers have a range of possible response options that can either discourage or encourage further conversation about CAM. How we respond to a patient-initiated CAM discussion has implications for how CAM can be integrated into the patient’s ongoing treatment plan, and how treatment decisions will be negotiated during future medical encounters.

For example, if I have a patient who is taking imatinib to treat her chronic myeloid leukemia (CML), and she tells me that all traditional anti-nausea medications have not worked for her, but marijuana has, I am faced with several ethical and legal implications. Although medical marijuana is now legal in the state where I practice (Illinois), there are no medical marijuana pharmacies in the state. In addition, I, personally, am not informed about possible drug interactions between imatinib and marijuana, or the risk of developing fungal infections with smoking marijuana.

In this scenario, my discussion with the patient – who needs long-term therapy with imatinib or another tyrosine kinase inhibitor to treat her CML – revolves around presenting all of the available options. My personal knowledge, though, is limited to my patient, and we agree she can try edible marijuana products (but no smoking), and I agree to do some homework so I can engage in a meaningful, well-informed follow-up discussion before our appointment next week.

We also need to have a clear discussion about the potential risks of CAM, including the areas where information is lacking. Even though the widespread use of CAM in patients with cancer is common, there are only a small number of studies regarding the efficacy and safety of such therapies. And, of course, “natural” does not necessarily correlate with “safe”; some CAM can be fatal, while others could safely improve patient’s quality of life. Some health-care providers may lack a complete understanding of the potential risks of CAM such as herbal medicines. Some herbal medicines have toxic effects (kava, for example, causes hepatoxicity), interact with prescription drugs (St. John’s Wort), or increase bleeding risks (ginkgo and ginseng).

CAM use also carries intangible risks, including a delay in treatment and a continuing distrust of conventional medicine.

CAM therapies are being used by our patients – even if they are not disclosing the information. Gaining knowledge and awareness of these therapies can benefit patients and improve our management of their disease. If a patient feels he or she is benefiting from CAM, it is our duty to investigate, educate, and discuss CAM with him or her. Remember, it may affect the patient’s life in a positive way, and it’s the patient’s life that matters.


 

References

  1. Mao JJ, Palmer C, Healy K, Amsterdam J. Complementary and alternative medicine use among cancer survivors: a population-based study. J Cancer Surv. 2011;5:8-17.
  2. National Institutes of Health, National Center for Complementary and Integrative Health. “Complementary, alternative, or integrative health: what’s in a name?” Accessed September 25, 2015 from nccih.nih.gov/health/integrative-health.
  3. Robotin MC, Penman AG. Integrating complementary therapies into mainstream cancer care: which way forward? Med J Austral. 2006;185:377-9.

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