Kelly ASCO

Integrating Complementary Therapies in the Care of Children with Cancer: Research and Clinical Practice: 

Kara Kelly, M.D. Integrating Complementary Therapies in the Care of Children with Cancer: Research and Clinical Practice

What is CAM?: 

What is CAM? Group of diverse medical and health care systems, practices and products that are not presently considered to be part of conventional medicine

Slide3: 

Complementary: Used together with conventional medicine Alternative: Used in place of conventional medicine Integrative: Combines mainstream medical therapies and CAM therapies for which there is some high quality scientific evidence of safety and efficacy

NCCAM Classification : 

NCCAM Classification Alternative medical systems (Traditional Chinese Medicine, Ayurveda, homeopathy) Mind-body interventions (yoga, imagery, meditation, prayer) Biological based therapies (herbs, high dose vitamins, antioxidants, mushrooms, enzymes ) Body based therapies (chiropractic or osteopathic manipulation, massage) Energy therapies (Reiki, therapeutic touch, magnets) nccam.nih.gov

Children with Cancer are using CAM: 

Children with Cancer are using CAM Year of Survey %

Reasons for CAM Use: 

Reasons for CAM Use "to try everything possible” to reduce stress of illness improve quality of life symptom care management sometimes for cure Columbia survey: Perceived effectiveness is high- 86% very or somewhat effective for intended purpose

How are Patients Using CAM?: 

How are Patients Using CAM?

Slide8: 

73% of children were enrolled on clinical trials for treatment of their malignancy 85% were using some form of CAM: Herbs 25% Nutritional supplements 34% J Pediatr Hematol Oncol 22:412,2000

Why the Controversy?: 

Why the Controversy? Few clinical trials of safety and efficacy, especially in children Regulation of herbs and dietary supplements varies world wide, although most are not subject to the same regulations that apply to conventional drugs

Adverse Effects: 

Adverse Effects Pharmacologic therapies: Direct effect Contamination Interactions with conventional medications

Adverse Effects: 

Adverse Effects

Contamination of herbs: 

Contamination of herbs Eur J Pediatr 162:72, 2003

Herb-Drug Interactions:Sources of Information: 

Herb-Drug Interactions: Sources of Information HerbalGram 49:2000.

Slide14: 

Fig. 1. Effect of St. John's wort on the plasma concentration of the active irinotecan metabolite SN-38 over time. JNCI 94:1247,2002

Chemotherapy/Herb Interactions: 

Chemotherapy/Herb Interactions

Oxidative Stress and Chemotherapy Drugs: 

Oxidative Stress and Chemotherapy Drugs High Anthracyclines Pt-complexes Alkylating agents Epipodophyllotoxins Camptothecins Purine/Pyrimidine Antimetabolites Low Taxanes Vinca alkaloids

Observational Studies: The Effect of Cancer Therapy on Antioxidant Levels (n=31): 

Observational Studies: The Effect of Cancer Therapy on Antioxidant Levels (n=31) JCO 22:517, 2004

Slide18: 

The Effect of Supplementation with Antioxidants in combination with Cancer Therapy on Antioxidant Levels (n=9) JCO 22:517, 2004

Immunostimulants: 

Immunostimulants Mistletoe, Asian mushrooms (maitake, reishi, shiitake, coriolus versicolor, PSK), Astralagus Actions: Increase cytotoxic T-cells or NK cells activity, increase endogenous production of interferon, interleukins, or cytokines Discourage in patients with: Hematologic malignancies, Stem cell transplants

Warning signs of Possible Interactions: 

Warning signs of Possible Interactions Tolerance to conventional drug administration that is better or worse than expected: Unexpected refractoriness to treatment Unusual toxic effects from treatment Labriola D, Livingston R. Oncology 13:1999

Non-pharmacologic Therapies: 

Non-pharmacologic Therapies Chiropractic cerebrovascular accidents, acute necrosis of holocord astrocytoma, vertebral artery dissection Acupuncture cardiac tamponade, epidural abscess formation, HIV infection overall underlying adverse event rate: 0-1.1 per 10,000 treatments

Practitioner Licensure varies from state to state: 

Practitioner Licensure varies from state to state Chiropractors: every state, Washington DC Massage therapists: ~25 states TCM practitioners: ~25 states Naturopathic physicians: 12 states Homeopathic physicians: 3 states Dermatologic Therapy 16:77,2003

Barriers to Research: 

Barriers to Research Difficulties in conducting studies of complex therapeutic systems Emotional issues leading to biases in patient recruitment Lack of standardization of herbs/dietary supplements Difficulty in determining an adequate placebo CAM providers may have little incentive for scientific evaluation of CAM therapies

Active Randomized Clinical Trials in Pediatric Cancer and CAM: 

Active Randomized Clinical Trials in Pediatric Cancer and CAM TRAUMEEL S (Homeopathy) for prevention and treatment of Mucositis in SCT (COG) Electroacupuncture for Chemotherapy induced Delayed Nausea/Vomiting in Pediatric Solid Tumors (NCI) Silymarin in Maintenance therapy in Children with ALL and Abnormal LFTs (Columbia) Aromatherapy for Reduction of Anxiety/Nausea during SCT (Columbia) Massage Therapy and Childhood Cancer (Childrens Minneapolis) Aromatherapy as an Intervention for Nausea and Vomiting in Children receiving Chemotherapy for Cancer (Childrens Minneapolis)

Clinical Services: 

Clinical Services

Nausea/Vomiting: 

Nausea/Vomiting Herbs Ginger, Peppermint, Fennel Chamomile Compresses Aromatherapy Citrus (Bergamont, Mandarin, Citrus Mixtures) Acupressure P-6 Point (Acupressure bands)

Palliative Care: 

Palliative Care Alternative medical systems: acupuncture Mind-body medicine: Meditation, prayer, music therapy Body-based therapies: Massage Energy therapies: Reiki, Therapeutic touch

Screening for child CAM use:: 

Screening for child CAM use: Do you give your child any herbal or plant products? Do you give your child any homeopathic products? Do you use any unconventional/alternative types of care or therapies for your child? Do you use any special vitamin therapy for your child? Do you use any unconventional treatments, alternative types of care, or therapies for yourself to stay healthy or to manage a health problem? J Pediatr Health Care 17:58,2003 Questions only identified 24% of parents using CAM

Slide29: 

www.integrativetherapiesprogram.org

The Bottom Line…: 

The Bottom Line… Children with cancer are using CAM therapies Physicians need to inquire about CAM use Biologically active therapies including herbs and dietary supplements are often used Adverse effects and especially interactions with conventional drugs are possible CAM therapies may be especially useful for symptom management