Complementary Medicine in Palliative Care and Cancer Symptom Management

FOLFOX 4 combined with herbal medicine for advanced colorectal cancer: a systematic review

This systematic review evaluates the clinical evidence for the addition of herbal medicines (HMs) to FOLFOX 4 for advanced colorectal cancer (ACRC) in terms of tumor response rate (tRR), survival, quality of life and reduction in adverse events (AEs). Seven electronic databases were searched for randomized controlled trials (RCTs) of FOLFOX4 combined with HMs compared to FOLFOX4 alone. Outcome data for 13 randomized controlled trials were analysed using Review Manager 5.1. Risk of bias for objective outcomes including tumor response and survival was judged as low. Publication bias was not evident. Meta-analyses found the addition of HMs improved tRR (RR 1.25, 95%CI 1.06-1.47, I(2)  = 0%), one year survival (RR 1.51, 95%CI 1.19-1.90, I(2)  = 0%) and quality of life in terms of Karnofsky Performance Status (KPS) gained (RR 1.84, 95%CI 1.54-2.19, I(2)  = 0%); alleviated grade 3 and 4 chemotherapy-related AEs for neutropenia (RR 0.33, 95%CI 0.18-0.60, I(2)  = 0%), nausea and vomiting (RR 0.34, 95%CI 0.17-0.67, I(2)  = 0%) and neurotoxicity (RR 0.39, 95%CI 0.15-1.00, I(2)  = 0%), compared to FOLFOX4 alone. The most frequently used herbs were Astragalus membranaceus, Panax ginseng, Atractylodes macrocephala, Poria cocos, Coix lachryma-jobi and Sophora flavescens. In experimental studies, each of these herbs has shown actions that could have contributed to improved tumor response.

Complementary therapy: perceptions of older people with lung or colorectal cancer

AIM

To explore how older people with lung and colorectal cancer view registered complementary therapy (CT) services in Northern Ireland.

BACKGROUND

A literature review highlighted gaps around information, access, and communication between patients and health professionals regarding CT services.

METHODS

Using structured interviews, a survey of 68 patients in one hospital and one hospice was conducted in Belfast, Northern Ireland.

RESULTS

All respondents felt that CT services should be better promoted and more easily accessible to older people with cancer. Some patients were concerned about the lack of written information provided regarding CT services, which they believed led to poorer uptake and uncertainty regarding the potential benefits. Others were concerned that engaging in or disclosing CT usage might negatively affect existing relationships with medical professionals.

CONCLUSION

Patients should be offered high quality written information on CT services to enable choice, improve knowledge, and promote wider access. Increased physician education may facilitate provision of such information.

Use of Self-Care and Practitioner-Based Forms of Complementary and Alternative Medicine before and after a Diagnosis of Breast Cancer

Purpose. We examine factors associated with self-care, use of practitioner-based complementary and alternative medicine (CAM), and their timing in a cohort of women with breast cancer. Methods. Study participants were women with breast cancer who participated in the Long Island Breast Cancer Study Project. Self-care is defined as the use of multivitamins, single vitamins, botanicals, other dietary supplements, mind-body practices, special diets, support groups, and prayer. Within each modality, study participants were categorized as continuous users (before and after diagnosis), starters (only after diagnosis), quitters (only before diagnosis), or never users. Multivariable logistic regression was used for the main analyses. Results. Of 764 women who provided complete data, 513 (67.2%) initiated a new form of self-care following breast cancer diagnosis. The most popular modalities were those that are ingestible, and they were commonly used in combination. The strongest predictor of continuous use of one type of self-care was continuous use of other types of self-care. Healthy behaviors, including high fruit/vegetable intake and exercise, were more strongly associated with continuously using self-care than starting self-care after diagnosis. Conclusions. Breast cancer diagnosis was associated with subsequent behavioral changes, and the majority of women undertook new forms of self-care after diagnosis. Few women discontinued use of modalities they used prior to diagnosis.

Discussion networks, physician visits, and non-conventional medicine: probing the relational correlates of health care utilization

Building from the premise that network ties influence why and how people seek health care, this study examines whether different types of close relations predict two distinct, but overlapping forms of care utilization. To that end, I examine the use of conventional care and complementary and alternative medicine (CAM). Analyses are conducted with a national sample of older American adults aged 57-85 in 2005/2006 (n = 3005). I find that partnered men who are very likely to discuss health with a partner had a greater number of physician visits in the past year, net of their health status and other relevant factors. Having children with whom health is likely to be discussed was also associated with more visits, as was the presence of non-kin ties. On the other hand, the use of complementary and alternative medicine was predicted not by spousal or other kin-based relationships, but only by having non-kin ties with whom a respondent could discuss health. Results suggest that understanding the relational undercurrents of care utilization requires attention to diverse forms of social relations and to diverse expressions of care participation.

Prevalence and correlates of postdiagnosis initiation of complementary and alternative medicine among patients at a comprehensive cancer center

PURPOSE

Patients with cancer increasingly use complementary and alternative medicine (CAM) in conjunction with conventional oncology treatments. Previous studies have not investigated postdiagnosis initiation of CAM therapies or independent correlates of use of individual CAM modalities. The purpose of this study was to determine the prevalence and correlates of individual CAM modalities initiated after cancer diagnosis.

METHODS

A cross-sectional survey was conducted of a random sample of adults with a cancer diagnosis (N = 1,228) seeking care at a National Cancer Institute-designated comprehensive cancer center within a 12-month period.

RESULTS

The majority of patients were female (64.7%), white (86.9%), and married (72.8%).Three-quarters (75.2%) used at least one CAM modality, and 57.6% of those using CAM initiated use after cancer diagnosis. For all CAM therapies combined, women were 1.7 times more likely than men to initiate any CAM therapy after cancer diagnosis. However, when CAM modalities were differentiated by type, men and women were equally likely to initiate all therapies except for psychotherapy and mind-body approaches. Postdiagnosis initiation of every CAM modality, except mind-body therapies, differed by cancer type.

CONCLUSION

A significant proportion of patients initiated CAM use after diagnosis. However, specific type of CAM initiated varied by demographics and cancer type, suggesting there is not a "typology" of CAM user. Optimal comprehensive cancer treatment, palliation, and survivorship care will require patient and provider education regarding CAM use by modality type; improved provider-patient communication regarding potential benefits, limitations, and risks; and institutional policies to support integrated conventional and CAM treatment.

Role of music in intensive care medicine

The role of music in intensive care medicine is still unclear. However, it is well known that music may not only improve quality of life but also effect changes in heart rate (HR) and heart rate variability (HRV). Reactions to music are considered subjective, but studies suggest that cardio/cerebrovascular variables are influenced under different circumstances. It has been shown that cerebral flow was significantly lower when listening to “Va pensioero” from Verdi's “Nabucco” (70.4+3.3 cm/s) compared to “Libiam nei lieti calici” from Verdi's “La Traviata” (70.2+3.1 cm/s) (P<0,02) or Bach's Cantata No. 169 “Gott soll allein mein Herze haben” (70.9+2.9 cm/s) (P<0,02). There was no significant influence on cerebral flow in Beethoven's Ninth Symphony during rest (67.6+3.3 cm/s) or music (69.4+3.1 cm/s). It was reported that relaxing music plays an important role in intensive care medicine. Music significantly decreases the level of anxiety for patients in a preoperative setting (STAI-X-1 score 34) to a greater extent even than orally administered midazolam (STAI-X-1 score 36) (P<0.001). In addition, the score was better after surgery in the music group (STAI-X-1 score 30) compared to midazolam (STAI-X-1 score 34) (P<0.001). Higher effectiveness and absence of apparent adverse effects make relaxing, preoperative music a useful alternative to midazolam. In addition, there is sufficient practical evidence of stress reduction suggesting that a proposed regimen of listening to music while resting in bed after open-heart surgery is important in clinical use. After 30 min of bed rest, there was a significant difference in cortisol levels between the music (484.4 mmol/l) and the non-music group (618.8 mmol/l) (P<0.02). Vocal and orchestral music produces significantly better correlations between cardiovascular and respiratory signals in contrast to uniform emphasis (P<0.05). The most benefit on health in intensive care medicine patients is visible in classical (Bach, Mozart or Italian composers) music and meditation music, whereas heavy metal music or techno are not only ineffective but possibly dangerous and can lead to stress and/or life-threatening arrhythmias, particularly in intensive care medicine patients.

Use of complementary therapies for cancer symptom management: results of the 2007 National Health Interview Survey

OBJECTIVES

Complementary therapies are often used as adjuncts to conventional treatment by individuals with cancer. Patterns of use of these practices and products represent important data for health care providers in delivering adequate patient care.

DESIGN

This study compared use of complementary therapies between the cancer and noncancer populations in the United States through secondary analyses of the 2007 National Health Interview Survey data. The analysis compared use by cancer survivors (those individuals self-reporting a diagnosis of cancer; n=1785) and individuals without cancer (n=21,585), as well as self-report of symptoms affecting health-related quality of life (HQoL).

RESULTS

Data suggest similar patterns of use between cancer survivors and the general population; however, a greater percentage of cancer survivors use complementary modalities. Individuals with cancer reported a greater percentage of use of complementary therapies overall, with cancer status significantly associated with ever having used complementary and alternative medicine (p<0.001). The five most common complementary practices and products used by individuals with cancer and controls were vitamin/mineral supplements, prayer for self, intercessory prayer, chiropractic/osteopathic manipulation, and herbal therapies. Additionally, as might be expected, individuals with cancer experience greater frequency of deleterious symptoms associated with decreased HQoL. Individuals with cancer were more likely to sleep fewer than 7 hours (p=0.0108) or greater than 9 hours (p=0.0108), and have increased insomnia (p<0.001), excessive sleepiness (p<0.001), depression (p<0.001), and anxiety (p<0.001) versus those without cancer.

CONCLUSIONS

The current findings may inform health care providers about the use of complementary and integrative practices and products by patients with cancer in an effort to manage symptoms of the disease. Additionally, these results may also be used to promote research to define the merits of the use of such complementary and integrative practices and products.

Cancer-related stress and complementary and alternative medicine: a review

A cancer diagnosis elicits strong psychophysiological reactions that characterize stress. Stress is experienced by all patients but is usually not discussed during patient-healthcare professional interaction; thus underdiagnosed, very few are referred to support services. The prevalence of CAM use in patients with history of cancer is growing. The purpose of the paper is to review the aspects of cancer-related stress and interventions of commonly used complementary and alternative techniques/products for amelioration of cancer-related stress. Feasibility of intervention of several CAM techniques and products commonly used by cancer patients and survivors has been established in some cancer populations. Efficacy of some CAM techniques and products in reducing stress has been documented as well as stress-related symptoms in patients with cancer such as mindfulness-based stress reduction, yoga, Tai Chi Chuan, acupuncture, energy-based techniques, and physical activity. Much of the research limitations include small study samples and variety of intervention length and content. Efficacy and safety of many CAM techniques and some herbs and vitamin B and D supplements need to be confirmed in further studies using scientific methodology. Several complementary and alternative medicine therapies could be integrated into standard cancer care to ameliorate cancer-related stress.

Developing Phytocompounds from Medicinal Plants as Immunomodulators

Imbalance or malfunction of the immune systems is associated with a range of chronic diseases including autoimmune diseases, allergies, cancers and others. Various innate and adaptive immune cells that are integrated in this complex networking system may represent promising targets for developing immunotherapeutics for treating specific immune diseases. A spectrum of phytochemicals have been isolated, characterized and modified for development and use as prevention or treatment of human diseases. Many cytotoxic drugs and antibiotics have been developed from phytocompounds, but the application of traditional or new medicinal plants for use as immunomodulators in treating immune diseases is still relatively limited. In this review, a selected group of medicinal herbs, their derived crude or fractionated phytoextracts and the specific phytochemicals/phytocompounds isolated from them, as well as categorized phytocompound groups with specific chemical structures are discussed in terms of their immunomodulatory bioactivities. We also assess their potential for future development as immunomodulatory or inflammation-regulatory therapeutics or agents. New experimental approaches for evaluating the immunomodulatory activities of candidate phytomedicines are also discussed.

Biofield therapies and cancer pain

The public and healthcare professionals have become increasingly aware and accepting of the benefit in physical, psychological, social, and spiritual support for patients with cancer. Patients with cancer often seek nonpharmacologic interventions to complement conventional care and decrease the pain associated with cancer and its treatment. Most often referred to as complementary and alternative medicine (CAM), these supportive therapies consist of a heterogeneous group of modalities used as adjuncts to allopathic health care. Biofield therapies are CAM modalities that involve the direction of healing energy through the hands to facilitate well-being by modifying the energy field of the body. This critical review of studies of biofield therapies emphasizes research using these modalities to decrease pain in patients with cancer. Although the therapies have demonstrated clinical efficacy, additional research is warranted. Oncology nurses should familiarize themselves with biofield therapies so they can offer informed recommendations to patients with cancer experiencing pain.

The journey of women with breast cancer who engage in mindfulness-based stress reduction: a qualitative exploration

This phenomenological study explores the "lived experience" of 8 women with stage I or II breast cancer who used mindfulness-based stress reduction (MBSR). The following 4 themes were identified: (1) the cancer journey: a shift in perception, (2) the treatment journey: the experience of MBSR, (3) the journey toward recovery, and (4) the journey toward self.

Utilizing mobile networks for the detection of clinically relevant interactions between chemotherapy regimens and complementary and alternative medicines

OBJECTIVES

Patients with cancer who use complementary and alternative medicines (CAMs) in conjunction with chemotherapy treatment are at risk of manifesting anticancer drug-CAM interactions (DCIs), which may lead to negative therapeutic outcomes. This article describes a novel iPhone application developed for the Mobile Internet, called OncoRx-MI, which identifies DCIs of single-agent and multiple-agent chemotherapy regimen (CReg) prescriptions.

METHODS

Drug-, CAM-, and DCI-related information was compiled from various hardcopy and softcopy sources, and published literature from PubMed. Overall management plans for the CRegs were then developed. The iPhone Web documents were constructed using Adobe software and programming scripts, and mounted onto a third-party server. DCI searches are based on CReg acronyms, and OncoRx-MI is designed to fit the iPhone screen configuration for improved usability. A small usability study was also carried out and the user feedback presented.

RESULTS

OncoRx-MI is able to detect over 2700 interactions between 256 CRegs and 166 CAMs, making up a total of over 4400 DCI pairs. The CAMs are classified into seven categories based on their uses in supportive care, and non-cancer-related CAMs are also included. The majority of the DCIs are pharmacokinetic in nature (79%), involving the induction and inhibition of the cytochrome P450 isozymes and p-glycoprotein. Pharmacodynamic DCIs include hepatotoxicity (39%), altered corticosteroid efficacies (30%), and increased risks of hypoglycemia (4%), hypertensive crisis (2%), bleeding, and serotonin syndrome (1% each).

CONCLUSIONS

OncoRx-MI is the first mobile application of its kind that allows searching of DCIs for CRegs through 3G networks, and is intended to improve pharmaceutical care of patients with cancer by assisting health care practitioners in managing CReg interactions in their clinical practices.

Management of treatment-related toxicity with targeted therapies for renal cell carcinoma: evidence-based practice and best practices

The advent of targeted agents for the treatment of advanced renal cell carcinoma has led to dramatic improvements in therapy. However, the chronic use of these medications has also led to the identification of new toxicities that require long-term management. Effective management of toxicity is needed to maximize the benefits of treatment and improve patients' quality of life. In addition, toxicity from these agents may affect treatment compliance, particularly with daily oral agents. This review delineates the toxicities that require monitoring, the underlying pathophysiology (when known), and treatments that may have benefits in relieving symptoms and side effects.

The efficacy of acupressure for symptom management: a systematic review

CONTEXT

Acupressure is a noninvasive strategy used to manage various symptoms.

OBJECTIVES

The purpose of this article was to review randomized controlled trials that investigated the efficacy of acupressure for the management of symptoms.

METHODS

A literature search was conducted in the Cumulative Index to Nursing and Allied Health Literature, Medline, and PubMed using the key words acupressure, clinical trial, human, and/or randomized. Randomized clinical trials published between January 1, 2000 and January 31, 2010, which used acupressure as the sole intervention for one group, were included when they were written in English and when there were four or more studies of the efficacy of acupressure for that particular symptom.

RESULTS

Forty-three studies were included in this review. Investigators in 16 of 23 studies concluded acupressure was effective, primarily for the management of nausea and vomiting in patients during pregnancy and during chemotherapy. Investigators in nine of 10 studies concluded that acupressure was effective for pain in patients with dysmenorrhea, during labor and after trauma. Investigators of four studies concluded that acupressure was effective in the management of dyspnea and investigators in six studies concluded that acupressure was effective in improving fatigue and reducing insomnia in a variety of populations. However, evaluation of the randomized controlled trial reports indicated a significant likelihood of bias.

CONCLUSION

Acupressure may be a useful strategy for the management of multiple symptoms in a variety of patient populations, but rigorous trials are needed. Inclusion of acupressure as an intervention may improve patient outcomes.

The use of massage therapy for reducing pain, anxiety, and depression in oncological palliative care patients: a narrative review of the literature

A considerable number of cancer patients use complementary medicine therapies in order to alleviate different symptoms such as pain, anxiety, and depression, occurring in connection with cancer. This paper explores the question to what extent massage therapies are able to reduce the amount of pain, anxiety, and depression. For this purpose, a systematic literature analysis was carried out in the electronic databases and specialist journals. There is already evidence that massage therapies can influence the symptoms of pain, anxiety, and depression in a positive way.

Palliative and end-of-life care in psychogeriatric patients

A rapidly growing number of elderly persons and their families are burdened by one or more terminal illnesses in the later years of their life. How best to support their quality of life is a major challenge for healthcare teams. Palliative and end-of-life (PEOL) care is well positioned to respond to this challenge. While the evidence of PEOL is just beginning, much of the suffering can be relieved by what is already known. PEOL care for the elderly needs to go beyond the focus on the patient and should rest on a broad understanding of the nature of suffering that includes family and professional caregivers in that experience of suffering. The dissemination of PEOL care principles should be a public health priority. This article aims to improve understanding of appropriate PEOL care in the elderly and discuss future perspectives.

Beliefs of New Zealand doctors about integrative medicine for cancer treatment

AIMS. This study aimed to give an up-to-date description of the views and knowledge that health professionals in New Zealand (NZ) have about complementary and alternative medicine (CAM) and its use in the context of integrative medicine.

STUDY DESIGN

A self-administered questionnaire.

METHODS

Doctors in the Otago region of New Zealand (n = 235 out of 395, 59% response rate) answered questions addressing attitudes toward the principle of integrative medicine, attitudes indigenous Ma-ori holistic views of health, and attitudes about CAM. Information on physician demographics was also gathered.

RESULTS

Almost all doctors (95%) agreed that they should address all aspects of a patient's health, whereas around 60% agreed that CAM can be integrated into a treatment regime to provide the best care for a patient. Most (93%) agreed that in a NZ context, it is important to be aware of Ma-ori holistic views of health. Doctors had many concerns about CAM, and only 26% personally used any CAM therapies themselves. However, many doctors wanted to learn more about CAM (58%) and Ma-ori holistic views of health (62%). Doctors who believed that they "knew enough" about CAM were more likely to ask about it and to recommend it to patients.

CONCLUSION

Integrative medicine is increasingly being accepted in medical practice, although many doctors still do not agree with the use of CAM. There is a need for increased patient-doctor discussions of CAM use. Doctors' lack of knowledge about CAM may be a barrier to communication and should be addressed with specific medical training.

Complementary and alternative medicine use among newly diagnosed prostate cancer patients

PURPOSE

We surveyed prostate cancer patients about complementary and alternative medicine (CAM) use and evaluated patient factors that correlated with CAM use 6 months following diagnosis.

METHODS

The Prostate CAncer Therapy Selection study was a prospective, observational multi-site study of men's treatment decision-making process after a diagnosis of local stage prostate cancer. Recruitment occurred in community urology practices in Washington State, hospital-based urology clinics affiliated with the University of Southern California, and Kaiser Permanente in Northern California. Eligible study participants included men over age 21 diagnosed with local stage prostate cancer between May 1, 2005 and December 31, 2006.

RESULTS

Fifty-two percent of survey respondents (379) reported using one or more types of CAM. Of the patients, 51% used one CAM method, 26% used two methods, and 23% used three or more methods. The most commonly reported category was mind-body therapies (65%). Only 43% of patients discussed their CAM use with a health professional; of those, 20% informed their primary care physician and 30% told the doctor managing their prostate cancer care. Less than half thought the CAM they used was "very helpful", but a majority thought it was somewhat helpful for their condition.

CONCLUSIONS

Further research is needed to characterize the goals prostate cancer patients have for CAM, whether the treatments met those goals, and how this translates into the perceived helpfulness of these therapies. The implications of patients not discussing CAM use with health professionals at the time of prostate cancer treatment need further studies.

Meditation therapies for attention-deficit/hyperactivity disorder (ADHD)

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common developmental disorders experienced in childhood and can persist into adulthood. The disorder has early onset and is characterized by a combination of overactive, poorly modulated behavior with marked inattention. In the long term it can impair academic performance, vocational success and social-emotional development. Meditation is increasingly used for psychological conditions and could be used as a tool for attentional training in the ADHD population.

OBJECTIVES

To assess the effectiveness of meditation therapies as a treatment for ADHD.

SEARCH STRATEGY

Our extensive search included: CENTRAL, MEDLINE, EMBASE, CINAHL, ERIC, PsycINFO, C2-SPECTR, dissertation abstracts, LILACS, Virtual Health Library (VHL) in BIREME, Complementary and Alternative Medicine specific databases, HSTAT, Informit, JST, Thai Psychiatric databases and ISI Proceedings, plus grey literature and trial registries from inception to January 2010.

SELECTION CRITERIA

Randomized controlled trials that investigated the efficacy of meditation therapy in children or adults diagnosed with ADHD.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently using a pre-designed data extraction form. We contacted study authors for additional information required. We analyzed data using mean difference (MD) to calculate the treatment effect. The results are presented in tables, figures and narrative form.

MAIN RESULTS

Four studies, including 83 participants, are included in this review. Two studies used mantra meditation while the other two used yoga compared with drugs, relaxation training, non-specific exercises and standard treatment control. Design limitations caused high risk of bias across the studies. Only one out of four studies provided data appropriate for analysis. For this study there was no statistically significant difference between the meditation therapy group and the drug therapy group on the teacher rating ADHD scale (MD -2.72, 95% CI -8.49 to 3.05, 15 patients). Likewise, there was no statistically significant difference between the meditation therapy group and the standard therapy group on the teacher rating ADHD scale (MD -0.52, 95% CI -5.88 to 4.84, 17 patients). There was also no statistically significant difference between the meditation therapy group and the standard therapy group in the distraction test (MD -8.34, 95% CI -107.05 to 90.37, 17 patients).

AUTHORS' CONCLUSIONS

As a result of the limited number of included studies, the small sample sizes and the high risk of bias, we are unable to draw any conclusions regarding the effectiveness of meditation therapy for ADHD. The adverse effects of meditation have not been reported. More trials are needed.

Acupuncture as Palliative Therapy for Physical Symptoms and Quality of Life for Advanced Cancer Patients

Background. Acupuncture is underutilized as an adjunct cancer therapy. The main study objectives were to determine the feasibility of administering acupuncture as palliative therapy to patients with advanced ovarian or breast cancer and to assess the effect on symptoms and quality of life (QOL). Methods. This study was a pilot, single-armed prospective clinical trial for patients with advanced cancer to receive 12 acupuncture sessions over 8 weeks with follow-up at weeks 9 and 12. Ambulatory patients with advanced ovarian or breast cancer were enrolled to receive treatments at an outpatient academic oncology center. Symptom severity was measured before and after each acupuncture session. A composite QOL assessment tool, consisting of validated instruments, was completed at 5 time points. Results. Forty patients enrolled in the study. Twenty-eight patients (70%; 95% confidence interval [CI] = 53%-83%) completed 4 weeks of treatment, and 26 patients (65%; 95% CI = 48%-79%) completed 8 weeks. Eight patients (20%) withdrew before receiving acupuncture, and 6 patients (15%) discontinued treatment early because of disease progression or scheduling demands. Among all 32 assessed patients, there was self-reported improvement immediately post-treatment in anxiety, fatigue, pain, and depression and significant improvement over time for patients with anxiety ( P = .001) and depression ( P = .02). Among patients experiencing baseline symptoms, there was improvement in anxiety ( P = .001), fatigue ( P = .0002), pain ( P = .0002), and depression ( P = .003). QOL measures of pain severity and interference, physical and psychological distress, life satisfaction, and mood states showed improved scores during treatment, with sustained benefit at 12 weeks. Conclusions. This pilot study demonstrates that an 8-week outpatient acupuncture course is feasible for advanced cancer patients and produces a measurable benefit that should be evaluated in controlled trials.

Music therapy in an integrated pediatric palliative care program

National experts have recommended that children with life-limiting illnesses receive integrated palliative and medical care. These programs offer a variety of services, including music therapy. Using survey data from parents whose were enrolled in Florida's Partners in Care: Together for Kids (PIC:TFK) program, this study investigates parents' experiences with music therapy. About 44% of children with life-limiting illnesses and 17% of their siblings used music therapy. For children who used music therapy, multivariate results suggest that their parents were 23 times as likely to report satisfaction with the overall PIC:TFK program (P < .05) versus parents whose children did not use music therapy. Pediatric palliative care programs should include music therapy, although recruiting licensed music therapists may be challenging.

Dynamic Interactions Between Musical, Cardiovascular, and Cerebral Rhythms in Humans

Background— Reactions to music are considered subjective, but previous studies suggested that cardiorespiratory variables increase with faster tempo independent of individual preference. We tested whether compositions characterized by variable emphasis could produce parallel instantaneous cardiovascular/respiratory responses and whether these changes mirrored music profiles.

Methods and Results— Twenty-four young healthy subjects, 12 musicians (choristers) and 12 nonmusician control subjects, listened (in random order) to music with vocal (Puccini’s “Turandot”) or orchestral (Beethoven’s 9th Symphony adagio) progressive crescendos, more uniform emphasis (Bach cantata), 10-second period (ie, similar to Mayer waves) rhythmic phrases (Giuseppe Verdi’s arias “Va pensiero” and “Libiam nei lieti calici”), or silence while heart rate, respiration, blood pressures, middle cerebral artery flow velocity, and skin vasomotion were recorded. Common responses were recognized by averaging instantaneous cardiorespiratory responses regressed against changes in music profiles and by coherence analysis during rhythmic phrases. Vocal and orchestral crescendos produced significant ( P =0.05 or better) correlations between cardiovascular or respiratory signals and music profile, particularly skin vasoconstriction and blood pressures, proportional to crescendo, in contrast to uniform emphasis, which induced skin vasodilation and reduction in blood pressures. Correlations were significant both in individual and group-averaged signals. Phrases at 10-second periods by Verdi entrained the cardiovascular autonomic variables. No qualitative differences in recorded measurements were seen between musicians and nonmusicians.

Conclusions— Music emphasis and rhythmic phrases are tracked consistently by physiological variables. Autonomic responses are synchronized with music, which might therefore convey emotions through autonomic arousal during crescendos or rhythmic phrases.

The existential experiences of receiving soft tissue massage in palliative home care--an intervention

BACKGROUND

Soft tissue massage is currently used in palliative care for the relief of anxiety and pain. Only few studies have focused on patients' deeper experience of receiving the massage.

AIM

The purpose of this study was to explore how patients with cancer in palliative home care experienced soft tissue massage.

MATERIALS AND METHODS

Twenty-two patients received soft tissue massage (hand or foot) nine times over a period of 2 weeks. Each session lasted for 25 min. Following the last massage session, a qualitative interview was conducted. The analysis was performed using a hermeneutic approach.

FINDINGS

Soft tissue massage generated feelings of existential respite with perceptions of being released from illness for a while. Two categories constituted the basis of the experiences: (1) "an experience of thoughtful attention" and (2) "a sensation of complete tranquility" resulting in the overarching theme "A time of existential respite."

CONCLUSION

The patients experienced the massage to give meaning and to be important as it generated feelings of an inner respite.

RELEVANCE TO CLINICAL PRACTICE

Soft tissue massage appears to be an appreciated source of support to dying patients in palliative home care. The method is easy to comprehend and relatively short (25 min) which may imply that it is a suitable complement in nursing care for this patient group.

Medical pluralism among American women: results of a national survey

BACKGROUND

Medical pluralism can be defined as the employment of more than one medical system or the use of both conventional and complementary and alternative medicine (CAM) for health and illness. American women use a variety of health services and practices for women's health conditions, yet no national study has specifically characterized women's medical pluralism. Our objective was to describe medical pluralism among American women.

METHODS

A nationally representative telephone survey of 808 women >or=18 years of age was conducted in 2001. Cross-sectional observations of the use of 11 CAM domains and the use of an additional domain--spirituality, religion, or prayer for health--during the past year are reported. Women's health conditions, treatments used, reasons for use, and disclosure to conventional physicians are described, along with predictors of CAM use.

RESULTS

Over half (53%) of respondents used CAM for health conditions, especially for those involving chronic pain. The majority of women disclosed such practices at clinical encounters with conventional providers. Biologically based CAM therapies, such as nutritional supplements and herbs, were commonly used with prescription and over-the-counter (OTC) pharmaceuticals for health conditions.

CONCLUSIONS

Medical pluralism is common among women and should be accepted as a cultural norm. Although disclosure rates of CAM use to conventional providers were higher than in previous population-based studies, disclosure should be increased, especially for women who are pregnant and those with heart disease and cancer. The health risks and benefits of polypharmacy should be addressed at multiple levels of the public health system.

Mindfulness-based stress reduction training for oncology patients: patients' appraisal and changes in well-being

OBJECTIVE

This study explores satisfaction and changes in well-being in cancer patients following mindfulness-based stress reduction training.

METHOD

Data were collected in 47 cancer patients before and after the training, and also 1 year later. Standardized questionnaires were used to measure quality of life, joy in life, mood disturbances (depression, anger, vigor, fatigue, and tension), meaning in life and physical symptoms.

RESULTS

Participants were highly satisfied and said they had reached their goals with the training. The results show that directly after the training patients reported a better quality of life, more joy in life, less tension, and fewer physical symptoms. These effects appeared even stronger at follow-up. A year after the training a decrease was also found in depression, anger, vigor and total mood disturbance. No changes could be established for meaning in life and fatigue. Effect sizes varied between 0.28 and 0.60, indicating small-to-moderate changes.

CONCLUSION

Mindfulness training potentially supports cancer patients in handling the stress due to their life-threatening disease and increases their well-being. Several suggestions for further research are discussed.

PRACTICE IMPLICATIONS

Mindfulness training provides cancer patients with tools to deal with their limitations and worries, both during and after their treatment.

Acupuncture Is Underutilized in Hospice and Palliative Medicine

Acupuncture is a complementary and alternative medical modality. A considerable body of acupuncture research has accumulated since 1998. Acupuncture has been integrated into palliative care settings in the United Kingdom but is yet to be widely offered in the United States. The literature was searched to identify clinical trials involving acupuncture, palliative care, hospice, chronic obstructive pulmonary disease, bone marrow, and cancer. Twenty-seven randomized controlled clinical trials of acupuncture were found that reported on conditions common to the hospice and palliative care setting, including dyspnea, nausea and vomiting, pain, and xerostomia, and 23 reported statistically significant results favoring acupuncture use for the conditions investigated. Acupuncture is safe and clinically cost-effective for management of common symptoms in palliative care and hospice patients. Acupuncture has potential as adjunctive care in palliative and end-of-life care, and the evidence warrants its inclusion in reimbursed palliative and end-of-life care in the United States.

The conjoint use of music therapy and reflexology with hospitalized advanced stage cancer patients and their families

Advanced stage cancer patients experience debilitating physical symptoms as well as profound emotional and spiritual struggles. Advanced disease is accompanied by multiple changes and losses for the patient and the family. Palliative care focuses on the relief of overall suffering of patients and families, including symptom control, psychosocial support, and the meeting of spiritual needs. Music therapy and reflexology are complementary therapies that can soothe and provide comfort. When used conjointly, they provide a multifaceted experience that can aid in the reduction of anxiety, pain, and isolation; facilitate communication between patients, family members, and staff; and provide the potential for a more peaceful dying experience for all involved. This article addresses the benefits of the combined use of music therapy and reflexology. Two case studies are presented to illustrate the application and benefits of this dual approach for patients and their families regarding adjustment to the end of life in the presence of anxiety and cognitive impairment.

(Using) complementary and alternative medicine: the perceptions of palliative patients with cancer

Use of complementary and alternative medicine (CAM) is increasingly common within Western societies, including Australia. This parallels calls for or claims of integration of CAM into mainstream medical practice, with oncology and palliative care specifically nominated as appropriate arenas for integration. However, there is an absence of studies examining patient perceptions of both CAM and CAM users. In this study, 28 adult patients with cancer close to death were interviewed regarding treatment decisions at the end of life, including decisions about CAM. Thematic analysis of transcribed interviews found consistent differences in talk around CAM between 12 users and 16 nonusers of CAM, primarily related to the perceived value of these treatments. Drawing upon a mind-body discourse that holds individuals responsible for their health, users valued CAM for the perceived benefit to physical or psychological well-being and compatibility with a holistic approach to health care, deemed to complement or augment conventional medicine. However, some were self-critical of their failure to continue with CAM, despite practical and financial difficulties experienced. Nonusers devalued CAM as unable to cure their disease (but did not similarly devalue conventional medicine), and negatively construed CAM users as desperate, or as challenging medical wisdom. Despite increased legitimation and medicalization of CAM, patients assess CAM differently to allopathic medicine, with different (positive and negative) assessments attributable to users. The misperception by many (nonusers) that CAM are intended to cure and available negative moral and social judgments centred around CAM use may deter patient uptake of CAM in areas where they have proven efficacy in symptom control.

Levels of stress and intervention preferences of caregivers of brain tumor patients

The purpose of this pilot study was to assess the level of stress experienced by caregivers of brain tumor patients and to examine both their interest in and preferences for stress reduction programs. Using a convenience sample of 60 adult caregivers, we distributed a study questionnaire that examined the caregivers' level of stress, beliefs, past experiences, and preferences in regard to stress reduction programs. A majority of respondents reported elevated stress levels (72%), believed that stress reduction techniques can help reduce stress (87%), and were interested in learning about programs to reduce stress (81%). Overall, most participants wanted to receive information about stress reduction programs (65%) and were interested in programs such as exercise (73%) and massage (66%) as methods to reduce stress. Concerning mode and format preferences, 46% indicated that they could participate in a program at least twice a week, and 70% could participate in a program for an interval of 30 minutes or more. Ninety percent of the caregivers preferred programs that could be undertaken in their own homes either alone (37%), with a spouse (35%), or with the brain tumor patient for whom they were providing care (28%). Overall, 44% of caregivers sampled were interested in participating in the various stress reduction programs presented to them in this study. These data provide further evidence that caregivers experience elevated levels of stress and are willing to learn more about and participate in programs to reduce stress.

Patient perspectives: barriers to complementary and alternative medicine therapies create problems for patients and survivors

There are multiple barriers to better understanding of complementary and alternative medicine (CAM) approaches and the use of natural substances to reduce cancer risk. CAM approaches are not patentable, and the pharmaceutical industry has no interest in the area. Research generally approaches concepts from the deconstructionist side: there may be interest in herbal mixtures but its "active" constituents are explored one at a time, missing any synergistic or even additive effects. Little attention has been paid to environmental pollutants and exposures. Most patients believe these are active causes of their disease, but researchers are still exposing animals to one chemical one time, which fails to duplicate human exposures. Attention to lifestyle issues is presented almost solely in terms of obesity--a concept that is a barrier to change by itself. Research animals rarely if ever are fed dietary components that humans normally eat, such as soda or diet soda, potato chips, and high-fructose corn syrup, artificial colors, artificial flavors, other additives, or combinations of bad fats with too much sugar, too much salt, and artificial ingredients. Long-term treatment effects on survivors may not necessarily require a solely pharmaceutical approach. Drugs to treat each condition separately may require even more drugs to offset the unwanted effects of each. Whole systems approaches to research are urgently needed. A final barrier is that once a treatment is accepted in mainstream, it ceases to be considered "alternative." The genesis is soon forgotten and the remaining alternative modalities continue to be viewed with suspicion, doubt, and misunderstanding, to the detriment of both patients in treatment and cancer survivors.

Complementary therapies for cancer pain

Pharmacologic treatment of pain does not always meet patients' needs and may produce difficult side effects. Complementary therapies, which are safe, noninvasive, and generally considered to be relatively free of toxicity, may be used adjunctively with standard pain management techniques to improve outcome and reduce the need for prescription medication. Approaches such as acupuncture, massage therapy, mind-body interventions, and music therapy effectively reduce pain, enhance quality of life, and provide patients with the opportunity to participate in their own care. Such therapies have an important role in modern pain management.

Rationales for CAM Education in Health Professions Training Programs

The authors review the use of complementary and alternative medicine (CAM) in the United States. They then present and discuss the rationales used by the 15 National Center for Complementary and Alternative Medicine CAM educational grantees in their original proposals for incorporating CAM content into conventional health professions training programs. Fourteen of the grantees were from major U.S. medical and nursing schools, and one was from a medical student foundation. Awards were for five-year periods (with the exception of one three-year grant) from 2000 to 2008. Rationales for developing educational programs about CAM for conventional health professionals included (1) the prevalence and growth of CAM in the United States, (2) response to governmental, legislative, and other mandates, (3) need for enhanced communication between conventional providers and patients using CAM, (4) need to enhance safety of CAM use and interactions with conventional care, (5) CAM education's positive impact on broadening core competencies for conventional health care professionals, (6) positive impact on enhancing cultural competency, (7) need for better communication between conventional and CAM providers, (8) potential for improving health care coordination, (9) potential impact on increasing CAM research quality and capacity, and (10) potential for enhancing quality of care through informed CAM use. Integration of CAM with conventional health care requires educational venues that prepare conventionally trained caregivers with a sufficient knowledge base for assessing beneficial and detrimental interactions between CAM and conventional care approaches; development of criteria for making informed referrals to CAM practitioners; and enhanced research capacity.

Longitudinal screening and management of fatigue, pain, and emotional distress associated with cancer therapy

GOALS OF WORK

Fatigue, pain, and emotional distress are common symptoms among patients with cancer. We sought to learn about patient perceptions of these symptoms and their treatment.

MATERIALS AND METHODS

At a baseline assessment and two monthly follow-up assessments, we asked a diverse sample of patients with solid tumor or lymphoma (N = 99) about their fatigue, pain and distress, their treatment for these symptoms, and their satisfaction with treatment via standardized questionnaires and semistructured interviews.

MAIN RESULTS

In this observational study, patients reported fatigue, pain, emotional distress, and general quality of life at expected levels. Across all assessments, at least half of our sample experienced at least some fatigue, pain, or distress. On the whole, patients and providers do communicate about these concerns, and at least 75% of patients found these discussions helpful when they occurred.

CONCLUSIONS

Improved symptom identification and communication may optimize the detection of those at risk of morbidity and decreased quality of life because of excess symptom burden.