Legal and ethical issues relating to use of complementary therapies in pediatric hematology/oncology

German physicians' perceptions and views on complementary medicine in pediatric oncology: a qualitative study

Complementary and alternative medicine (CAM) use in children with cancer has a high prevalence. If (parents of) patients bring up the topic of CAM, pediatric oncologists (POs) face considerable challenges regarding knowledge and professional behavior. In this study, we explore German POs' understanding of CAM and related attitudes as well as challenges and strategies related to CAM discussions by means of semi-structured interviews analyzed according to principles of qualitative thematic analysis with parents of children with cancer. We could conduct 14 interviews prior to theoretical saturation. The interviews had a duration of 15-82 min (M = 30.8, SD = 18.2). Professional experience in pediatric oncology was between 0.5 and 26 years (M = 13.8, SD = 7.6). Main themes identified were a heterogeneous understanding and evaluation of CAM, partly influenced by personal experiences and individual views on plausibility; the perception that CAM discussions are a possible tool for supporting parents and their children and acknowledgement of limitations regarding implementation of CAM discussions; and uncertainty and different views regarding professional duties and tasks when being confronted with CAM as a PO. Our interdisciplinary interpretation of findings with experts from (pediatric) oncology, psychology, and ethics suggests that there is need for development of a consensus on the minimal professional standards regarding addressing CAM in pediatric oncology.

Additional treatment with mistletoe extracts for patients with breast cancer compared to conventional cancer therapy alone - efficacy and safety, costs and cost-effectiveness, patients and social aspects, and ethical assessment

Background

Chemotherapy is often used in the treatment of breast cancer in women. Side effects such as diarrhea, fatigue, hair loss, fever or disturbances in blood formation impair the women's quality of life. An essential treatment goal of the accompanying mistletoe therapy (MT) used in complementary medicine is to improve the health-related quality of life during cancer therapy.

Aim and methods

The HTA report on which this article is based examines the medical efficacy and safety, costs and cost-effectiveness, patient and social aspects, and ethical aspects of MT in women with breast cancer. Systematic reviews were conducted for this purpose. The search period of the literature search ranged from 2004 to October 2020.

Results

A total of 2 evidence-based medical guidelines, 3 randomized trials assessing efficacy and 1 additional non-randomized intervention trial, as well as 3 observational studies assessing safety, a cost analysis, 12 cross-sectional studies on patient aspects and 17 articles on ethical evaluation were included. Improvements in health-related quality of life compared to the control group were small to moderate. Due to the high risk of bias in the studies, it is possible that the difference is not caused by MT. One study with a small sample size showed no effect on progression-free survival after 5 years. Studies on the effect of MT on overall survival are lacking. In seven studies, local skin reactions of low and moderate severity were reported in a median of 25% (range 5 to 94%) of patients, and mild to moderate systemic reactions in a median of 2% (range 0 to 8%) of patients. A comparative cost analysis from Germany reported significantly lower medical costs within 5 years after surgery for patients with MT than for patients without MT, but the underlying observational study did not control for systematic bias. With regard to patient aspects, the frequency of use and the reasons for use from the patient's or practitioner's point of view were mainly investigated. A median of 25% (range 7 to 46%) of patients with breast cancer and 29% (range 29 to 79%) of treatment providers use MT. The main motivations of patients for use were to reduce side effects, strengthen the immune system and take an active role in the treatment process. Patients felt insufficiently advised. Studies on other aspects are lacking. The ethical evaluation was able to identify 6 overarching themes; the central challenge is the insufficient evidence on efficacy and safety.

Global Use of Traditional and Complementary Medicine in Childhood Cancer: A Systematic Review

Purpose

Traditional and complementary medicine (T&CM) strategies are commonly used in pediatric oncology. Patterns may vary based on country income. We systematically reviewed published studies describing T&CM use among pediatric oncology patients in low-income countries (LIC/LMIC), middle-income countries (UMIC), and high-income countries (HIC). Objectives included describing estimated prevalence of use, reasons for use, perceived effectiveness, modalities used, rates of disclosure, and reporting of delayed or abandoned treatment.

Methods

MEDLINE, EMBASE, Global Health, CINAHL, PsycINFO, Allied and Complementary Medicine Database, Cochrane Database of Systematic Reviews, and ProceedingsFirst were searched. Inclusion criteria were primary studies involving children younger than the age of 18 years, undergoing active treatment of cancer, and any T&CM use. Exclusion criteria included no pediatric oncology–specific outcomes and studies involving only children off active treatment. Data were extracted by two reviewers using a systematic data extraction form determined a priori.

Results

Sixty-five studies published between 1977 and 2015 were included, representing 61 unique data sets and 7,219 children from 34 countries. The prevalence of T&CM use ranged from 6% to 100%. Median rates of use were significantly different in LIC/LMIC (66.7% ± 19%), UMIC (60% ± 26%), and HIC (47.2% ± 20%; P = .02). Rates of disclosure differed significantly by country income, with higher median rates in HIC. Seven studies reported on treatment abandonment or delays.

Conclusion

The use of T&CM in pediatric oncology is common worldwide, with higher median prevalence of use reported in LIC/LMIC. Further research is warranted to examine the impact on treatment abandonment and delay.

Responding to requests of families for unproven interventions in neurodevelopmental disorders: hyperbaric oxygen "treatment" and stem cell "therapy" in cerebral palsy

Faced with the limitations of currently available mainstream medical treatments and interventions, parents of children with neurodevelopmental disorders often seek information about unproven interventions. These interventions frequently have undetermined efficacy and uncertain safety profiles. In this article, we present a general background and case vignettes that highlight the use of hyperbaric oxygen chambers and stem cells in cerebral palsy, the leading cause of pediatric physical disability. We then review the current evidence about these interventions as exemplars of unproven therapies. Building on the background and cases, we explore and review two important questions related to unproven interventions: (1) How should clinicians respond to requests for innovative and alternative interventions? (2) What should clinicians keep in mind when such requests come from online sources?

Ethics in neurodevelopmental disability

Neurodevelopmental disabilities, like autism spectrum disorders and cerebral palsy are a common health problem in children. Given the impact of these conditions on children, families, and healthcare and social systems, the care of developmentally challenged children raises questions related to values and ethical principles. We review the common features of neurodevelopmental disorders that help understand the associated ethical questions. We focus on three major areas where ethical questions arise for clinicians and those involved in making decisions for or caring for these children: (1) the principles of decision-making and autonomy as they relate to developmental disability; (2) the issues related to quality of life that have long intersected with developmental disability; and (3) the use of unproven therapies and diagnostics that are particularly controversial given the extent that neurodevelopmental disabilities impact children and their families, yet active treatments options are limited.

Talking to cancer patients about complementary therapies: is it the physician's responsibility?

Background

To ensure the safety and effectiveness of cancer management, it is important for physicians treating cancer patients to know whether their patients are using complementary and alternative medicine (cam) and if so, why.

Objective

Here, we discuss the ethical and legal obligations of physicians to discuss cam use in an oncology setting, and we provide practical advice on how patient–provider communication about cam can be improved.

Results

Physicians have both ethical and legal obligations to their patients, including the obligation to respect patient autonomy. This latter obligation extends to use of cam by patients and needs to be addressed beginning early in the patient–provider relationship. Because lack of education in this field and lack of time during patient consultations are barriers to talking with patients about cam, we provide resources to facilitate such discussions. These resources include suggestions on how to discuss the topic of cam and a wide range of information sources.

Conclusions

Discussing cam with patients is the physician’s responsibility, and such discussion will facilitate evidence-based, patient-centred cancer care.

Acupuncture for zoological companion animals

Research in complementary and alternative veterinary medicine (CAVM) has increased dramatically in recent years. Acupuncture represents the most commonly practiced and extensively researched of all the CAVM modalities. Acupuncture is considered a valid therapeutic mode of treatment that can be integrated into Western veterinary medicine for the treatment of large, small, and zoological companion animal patients, especially in the area of analgesia. This article is intended to provide a guide for the zoological companion animal practitioner to gain a basic understanding of acupuncture and its potential for use in the zoological companion animal patient.

Pediatric oncologists' views toward the use of complementary and alternative medicine in children with cancer

BACKGROUND

Pediatric oncology patients commonly use complementary and alternative medicine (CAM), yet approximately only 50% of these patients discuss CAM with their oncologist.

OBJECTIVE

The aim of this study is to assess barriers to CAM communication in pediatric oncology.

DESIGN/METHODS

A 33-question survey was sent via electronic mail to 358 pediatric oncologists in the United States.

RESULTS

Ninety pediatric oncologists completed the survey. Ninety-nine percent of pediatric oncologists think it is important to know what CAM therapies their patients use. However, less than half of pediatric oncologists routinely ask their patients about CAM. This is primarily because of a lack of time and knowledge. Many physicians think some forms of CAM may improve quality of life, such as massage (74%) and yoga (57%). Over half of physicians thought that dietary supplements, herbal medicine, special diets, vitamins, and chiropractic might be harmful to patients.

CONCLUSIONS

Pediatric oncologists believe it is important to know which CAM therapies their patients use; however, they are not asking about them owing to lack of time and knowledge. To improve communication about CAM, increased physician education is needed. In addition, physicians should identify patients using potentially harmful CAM therapies. Furthermore, CAM research in pediatric oncology should focus on those modalities physicians believe may improve patient quality of life.

Medical Pluralism: Global Perspectives on Equity Issues

Over the last decades, awareness has increased about the phenomenon of medical pluralism and the importance to integrate biomedicine and other forms of health care. The broad variety of healing cultures existing alongside biomedicine is called complementary or alternative medicine (CAM) in industrialized countries and traditional medicine (TM) in developing countries. Considerable debate has arisen about ethical problems related to the growing use of CAM in industrialized countries. This article focuses on equity issues and aims to consider them from a global perspective of medical pluralism. Several dimensions of equity are explored and their interrelatedness discussed: access to care, research (paradigm and founding) and recognition. This so-called ‘equity circle’ is then related to Iris Marion Young’s justice theory and particularly to the concepts of cultural imperialism, powerlessness and marginalisation.

Pediatric massage therapy: an overview for clinicians

Pediatric massage therapy (MT), similar to its younger counterpart infant massage, has a limited number of rigorous studies supporting its clinical application and associated effects. However, clinicians and researchers have been intrigued by the potential benefits of pediatric MT for improving psychological and physiologic states in children who have various health conditions. This article provides a broad overview of pediatric MT, including proven and promising effects of MT across disease-specific clinical applications, contraindications, safety, context and availability of services, and future directions. Computerized databases were searched for relevant studies, including prior reviews, primary case studies, and randomized controlled trials of infant and pediatric MT. Current findings provide varying levels of evidence for the benefits of pediatric MT in children who have diverse medical conditions; however, anxiety reduction has shown the strongest effect. Future studies should use rigorous study design and methodology, with long-term follow-up, for examining the longitudinal effects of pediatric MT.