Breast Cancer Integrative Oncology Care and Its Costs

Dietary Supplement Use in Women Diagnosed with Breast Cancer

BACKGROUND

Vitamins, minerals, and natural product (NP)-derived dietary supplements are commonly used among women with breast cancer, where interactions with treatments and the disease are possible, emphasizing the importance for health care providers to be aware of supplement use.

OBJECTIVES

The study aimed to investigate current vitamin/mineral (VM) and NP supplement use among those diagnosed with breast cancer, including usage based on tumor type or concurrent breast cancer treatments and primary information sources for specific supplements.

METHODS

Social media recruiting to complete an online questionnaire self-reporting current VM and NP use and breast cancer diagnosis and treatment information primarily attracted US participants. Analyses, including multivariate logistic regression, were performed on 1271 women who self-reported breast cancer diagnosis and completed the survey.

RESULTS

Most participants reported current VM (89.5%) and NP (67.7%) use, with 46.5% (VM) and 26.7% (NP) using at least 3 products concurrently. Top-reported (>15% prevalence) products were vitamin D, calcium, multivitamin, and vitamin C for VM and probiotics, turmeric, fish oil/omega-3 fatty acids, melatonin, and cannabis for NP. Overall, VM or NP use was higher among those with hormone receptor-positive tumors. Although overall NP use did not differ according to current breast cancer treatments, VM use was significantly less common among those currently undergoing chemotherapy or radiation, but higher with current endocrine therapy. Among current chemotherapy users, specific VM and NP supplements with possible adverse effects were still used by 23% of respondents. Medical providers were the primary information source for VM, whereas NP information sources were more varied.

CONCLUSIONS

Because women diagnosed with breast cancer commonly reported concurrent use of multiple VM and NP supplements, including those with known or underexplored risks (or benefits) in breast cancer, it is important for health care providers to inquire about and facilitate discussions regarding supplement use in this population.

Tackling heterogeneity in treatment-resistant breast cancer using a broad-spectrum therapeutic approach

Tumor heterogeneity can contribute to the development of therapeutic resistance in cancer, including advanced breast cancers. The object of the Halifax project was to identify new treatments that would address mechanisms of therapeutic resistance through tumor heterogeneity by uncovering combinations of therapeutics that could target the hallmarks of cancer rather than focusing on individual gene products. A taskforce of 180 cancer researchers, used molecular profiling to highlight key targets responsible for each of the hallmarks of cancer and then find existing therapeutic agents that could be used to reach those targets with limited toxicity. In many cases, natural health products and re-purposed pharmaceuticals were identified as potential agents. Hence, by combining the molecular profiling of tumors with therapeutics that target the hallmark features of cancer, the heterogeneity of advanced-stage breast cancers can be addressed.

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.

Recurrence of Breast Cancer After Primary Treatment: A Matched Comparison Study of Disease-Free Survival in Women Who Do and Do Not Receive Adjunctive Naturopathic Oncology Care

PURPOSE

To compare disease free survival experienced by women who received usual oncologic care compared to a cohort of women who received naturopathic oncology care in addition to usual care.

METHODS

Women with breast cancer who received naturopathic oncology (NO) care in Western Washington State (WA) (N = 176) were recruited to a prospective study of clinical health-related quality of life outcomes and then matched to women who received usual care (UC) only (N = 334).

RESULTS

Among 510 women with breast cancer stages 1 to 3, a total of 50 women (10%) experienced a disease-free survival (DFS) ending event within the observation period; 23 (6.8% of those in the UC cohort, and 27 (15.3% of those in the NO cohort (P < .05). Although, women in the 2 cohorts received similar surgical, chemotherapy, and radiation treatment, women with breast cancer who received naturopathic oncology adjunctive care were less likely to use anti-estrogen therapy, and experienced poorer DFS (logrank test, P < .05). However, differences in DFS could not be shown to be due to cohort differences in anti-estrogen therapy, baseline HRQOL, or naturopathic oncology therapies prescribed. The stage 3 women in the naturopathic oncology group had more advanced disease at diagnosis. They were more likely to have 5 or more metastatic lymph nodes at baseline (18.5%) compared to their usual care matched control group (13%). Women in the naturopathic oncology group also had higher grade tumors at diagnosis.

CONCLUSIONS

Results show that recurrence of breast cancer was associated with more advanced malignant lymph node involvement; and that naturopathic oncology services provided in 2009-2015 did not improve disease-free survival in these high-risk breast cancer patients.

A scoping review of acupuncture insurance coverage in the United States

BACKGROUND

Increasing access to non-pharmacologic pain management modalities, including acupuncture, has the potential to reduce opioid overuse. A lack of insurance coverage for acupuncture could present a barrier for both patients and providers. The objective of this scoping review was to assess the existing literature on acupuncture insurance coverage in the United States and to identify knowledge gaps and research priorities.

METHODS

We utilized the Arksey and O'Malley framework to guide our scoping review methodology. We followed a pre-determined study protocol for the level-one abstract and level-two full text screenings. We synthesized information into subject-area domains and identified knowledge gaps.

RESULTS

We found a lack of published data on acupuncture coverage in 44 states, especially in the Midwest and the South. Where data were available, a large proportion of acupuncture users did not have insurance coverage. Consumer demand, state mandates, and efforts to reduce opioid use were motivations to cover acupuncture. Licensed acupuncturists were less likely to be reimbursed and were reimbursed at lower rates compared to physicians. Reported barriers encountered when implementing coverage included a lack of providers, challenges determining when to offer non-pharmacologic treatments, and a lack of evidence for clinical efficacy and cost-effectiveness.

CONCLUSION

We found a lack of recent publications and data comparing regional coverage in the United States. A key challenge is that commercial insurance plan data are not in the public domain. Further research should assess insurance coverage implementation for acupuncture and measure the impact of policy changes on acupuncture utilization and rates of opioid overuse.

Evaluation of an Expert Guided Integrative Therapy Concept in Patients With Breast or Gynecological Cancer During Systemic Therapy

Purpose.

Breast and gynecological cancer patients undergoing systemic therapy frequently request integrative therapy concepts. The potential of integrative therapy (IM) lies in minimizing side effects of conventional cancer treatments and therefore decreasing treatment delays. IM can help to improve patients’ physical and emotional well-being, optimizing health and quality of life as IM involves patients in their own treatment. A counseling service for integrative medicine concepts as an outpatient program was implemented in our cancer center in 2013.

Methods.

In 2016 and 2017 144 breast and gynecological cancer patients were included into our specific IM program. The program comprises biological based complementary and alternative medicines (BB-CAM), a structured exercise therapy, manipulative and body-based practices, nutritional counseling, psycho-oncological and relaxing therapies. Therapists with additional specialization for IM, guide the treatment units. The program was evaluated via self-administered questionnaire.

Results.

78% of the participating patients noticed an improvement by using BB-CAMs. 86% stated to feel better through participation in the structured exercise program. 74% profited from nutritional counseling and 91% from manual therapy. 93% of the patients treated with body compresses considered the application as soothing. The Bio-Frequency Sound Color Bed led to a relaxation in 96%. Psychological therapy improved coping with the disease in 70% of the patients.

Conclusion.

Integrative oncology combines the best practices of conventional and complementary therapy, uniting them in a holistic concept. Data show that our integrative therapy concept is well accepted by the patients and that therapy- and disease-related side effects can be reduced.

Acupuncture for Hormone Therapy-Related Side Effects in Breast Cancer Patients: A GRADE-Assessed Systematic Review and Updated Meta-Analysis

Purpose: To determine the efficacy of acupuncture on the management of hormone therapy-related side effects in breast cancer patients. Methods: Randomized controlled trials of acupuncture versus a control or placebo in breast cancer patients that examined reductions in therapy-related side effects were retrieved from PubMed, EMBASE, Web of Science, and the Cochrane Library through April 2020. Data on patient symptoms (hot flashes, fatigue, pain, stiffness, and gastrointestinal symptoms), physical capacity, cytokines, and general psychosomatic well-being were analyzed. We evaluated and analyzed the quality of all included studies with the 5.2 Cochrane Handbook standards using Stata software (version 10.0) and Revman software (version 5.2), respectively. We assessed the risk of bias using the Cochrane Risk of Bias tool and evaluated the quality of evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach. Results: The pooled results suggested that acupuncture led to moderate improvements in hot flashes, fatigue, and stiffness. No significant differences were observed in pain, gastrointestinal symptoms, Kupperman index scores, Overall quality of life, tumor necrosis factor levels, and interleukin levels. Conclusions: Evidence for outcome indicators of symptom management were downgraded by the GRADE system for inconsistency, indirectness, and imprecision in the included RCTs. Nonetheless, acupuncture is a moderately appropriate alternative therapy for hormone therapy-related side effects in breast cancer patients. However, it still lacks large-sample, multicenter, prospective RCTs. Future research should focus on standardizing comparison groups and treatment methods, be at least single-blinded, assess biologic mechanisms, have adequate statistical power, and involve multiple acupuncturists.

When Patients Take Charge of Opioids: Self-Management Concerns and Practices Among Cancer Outpatients in the Context of Opioid Crisis

CONTEXT

With concerns about opioid prescribing practices prominent in the professional and lay literature, there is less focus on patients' self-management of opioids for cancer pain and potential safety risks.

OBJECTIVES

To investigate reports of opioid self-management practices and concerns among patients undergoing active cancer treatments-a group excluded from the scope of most policy initiatives on prescription opioids.

METHODS

This sequential multimethod study used freelisting (n = 65) and open-ended semistructured interviews with a racially diverse subgroup (n = 32). Adult ambulatory patients with solid malignancies or multiple myeloma and pain (≥4 on a scale of 0-10) were recruited from an urban National Cancer Institute-designated cancer center in Philadelphia. Freelists were analyzed using consensus analysis and semistructured interview data were analyzed using thematic analysis.

RESULTS

In freelisting, "pain relief" emerged as the primary term in relation to taking pain medications preceding "addiction" concerns. In interviews, patients described several heuristics and some potentially unsafe practices to minimize opioid use to a self-defined "normal." These included reducing opioid dose by cutting pills; self-tapering off opioids; using extended-release/long-acting opioids on an as-needed basis; mixing over-the-counter, nonopioid analgesics; and using illicit drugs to avoid "harder medicines" (opioids). Many patients preferred nonopioid treatments for pain but invariably faced access barriers. Some described assuming stewardship of their prescribed opioids and felt that oncology clinicians are quick to prescribe opioids without providing workable alternatives.

CONCLUSIONS

Risks related to self-management of opioids among cancer outpatients, including potential overdose risks, need urgent attention. Interventions are needed for improving clinician-patient communication, patient education, safety, and access to effective nonopioid alternatives.

A Hierarchy of Healing: Origins of the Therapeutic Order and Implications for Research

The philosophy, principles, and theories of naturopathic medicine include the six Principles of Naturopathic Medicine and the Therapeutic Order. Together these constructs, describe the core principles of the practice of naturopathic medicine, as established by thought leaders throughout the formation and development of the profession. The naturopathic medicine research agenda (NMRA) set forth recommendations for the codification of the foundational theories of naturopathic medical practice. The "Therapeutic Order, Whole-systems, Evidence-based Research Standards" (TOWERS) initiative is proposed with the primary objective to conduct the rigorous evaluation of the Principles of Naturopathic Medicine and the Therapeutic Order constructs. It is envisioned that this initiative will result in the development of an evidence-base concerning the clinical theory, philosophy and principles of whole-systems naturopathic medicine. After over one hundred years of professional organization and formal practice, there is a need to translate these empirically derived constructs into an evidence-informed theory of naturopathic medicine.

Receiving/declining adjuvant breast cancer treatments and involvement in treatment decision-making

OBJECTIVES

This study compared women who received all recommended breast cancer treatments (Receivers) with those who did not (Decliners). We sought to understand women's integrative naturopathic oncology (INO) use in addition to usual conventional oncology (UCO) use, their involvement in treatment decision-making (TDM), and their satisfaction with healthcare providers.

METHODS

A secondary analysis was conducted using baseline data from the Breast Cancer Integrative Oncology Study that recruited 427 women from INO clinics (INO cohort) and comparison women from the Cancer Surveillance System Registry who received UCO care (UCO cohort) in Western Washington State. Self-reported data and Registry data were analyzed using descriptive statistics, t-tests, and X2 tests to compare Receivers and Decliners in demographic and disease characteristics, use of INO in addition to UCO care, involvement in TDM, and satisfaction with healthcare providers.

RESULTS

Significantly more Decliners were in INO cohort than UCO cohort. Decliners in INO cohort were less likely to receive radiotherapy. Women who used INO care, and Decliners, compared with Receivers, tended to be "very involved" in their TDM. No difference was found in participation congruence, correspondence between preferred and actual involvement in medical TDM, between groups. Decliners in INO cohort reported significantly less satisfaction with their conventional oncologist than Receivers in INO cohort.

CONCLUSIONS

Decliners of conventional adjuvant therapies were very involved in their TDM and those Decliners who seek INO care were less satisfied with their conventional oncologist; these women may need the most attention to assure they receive the care they need.

Effects of Vitamin D Use on Health-Related Quality of Life of Breast Cancer Patients in Early Survivorship

Background: Vitamin D supplements may prevent recurrence, prolong survival, and improve mood for women with breast cancer, although evidence for these effects is preliminary. Methods: This report describes vitamin D supplement use by 553 breast cancer patient/survivors (193 who used a naturopathic oncology [NO] provider and 360 who did not) participating in a matched cohort study of breast cancer outcomes. Results: We found that more than half of breast cancer patients reported using vitamin D supplements. Women who received care from NO providers in early survivorship may be more likely to use vitamin D supplements (P < .05). Approximately 30% of breast cancer patients with blood levels recorded in their medical chart were potentially vitamin D deficient (<30 ng/mL). Vitamin D supplement use at study enrollment was associated with higher levels of self-reported health-related quality of life (HRQOL) at enrollment (P < .05) and predicted better HRQOL at 6-month follow-up (P < .05). Sufficient blood levels of vitamin D recorded between enrollment and follow-up were also associated with better HRQOL at follow-up (P < .05). Conclusions: Vitamin D supplementation by breast cancer patients is common both during and after treatment for breast cancer, but deficiency may also be common. NO and conventional providers may be able to promote vitamin D sufficiency through vitamin D supplementation and by encouraging healthy solar exposure. Further studies should be undertaken examining whether vitamin D supplementation and higher blood levels might improve HRQOL among women with breast cancer in early survivorship.

Medicinal mushrooms as an attractive new source of natural compounds for future cancer therapy

Medicinal mushrooms have been used throughout the history of mankind for treatment of various diseases including cancer. Nowadays they have been intensively studied in order to reveal the chemical nature and mechanisms of action of their biomedical capacity. Targeted treatment of cancer, non-harmful for healthy tissues, has become a desired goal in recent decades and compounds of fungal origin provide a vast reservoir of potential innovational drugs. Here, on example of four mushrooms common for use in Asian and Far Eastern folk medicine we demonstrate the complex and multilevel nature of their anticancer potential, basing upon different groups of compounds that can simultaneously target diverse biological processes relevant for cancer treatment, focusing on targeted approaches specific to malignant tissues. We show that some aspects of fungotherapy of tumors are studied relatively well, while others are still waiting to be fully unraveled. We also pay attention to the cancer types that are especially susceptible to the fungal treatments.

Do Women With Breast Cancer Who Choose Adjunctive Integrative Oncology Care Receive Different Standard Oncologic Treatment?

Purpose: To determine if women with breast cancer who choose adjunctive naturopathic oncology (NO) specialty care receive different standard oncologic treatment when compared with breast cancer patients who receive only standard care. Participants: Women with breast cancer stages 0 to 4, aged 18+ who spoke English and sought care from outpatient naturopathic doctor clinics were enrolled in an observational study of clinical and quality of life outcomes. Women who sought NO care 2 or more times within the first 2 years postdiagnosis were identified as NO cases. A matched comparison group of breast cancer patients were identified using the Western Washington Cancer Surveillance System(CSS). Methods: A longitudinal cohort design. In addition to self-report data, the CSS provided data on demographics, stage at the time of diagnosis, and initial treatment. Oncology medical records were abstracted in order to provide additional information on standard oncologic treatment for all participants. Results: Cohorts were well matched with regard to demographic, histologic, and prognostic indicators at the time of diagnosis. Approximately 70% of women in both cohorts received standard oncologic care that met the National Comprehensive Cancer Network guidelines. There were no statistically significant differences between the cohorts in treatment received. Fewer women in the NO cohort with estrogen receptor–positive breast cancer appear to have received antiestrogen therapy. Conclusions: Women in both cohorts appear to receive guideline-concordant care. However, women who receive adjunctive NO care may be less likely to receive antiestrogen therapy.

Naturopathic Oncology Care for Thoracic Cancers: A Practice Survey

Background and Objectives: There is a lack of information on therapies recommended by naturopathic doctors (NDs) for lung and gastroesophageal cancer care. Study objectives were to: (1) identify the most common interventions considered for use by NDs; (2) identify interventions NDs recommend to support key therapeutic goals; and (3) identify potential contraindications between integrative and conventional therapies. Methods: Oncology Association of Naturopathic Physicians (OncANP) members (n = 351) were invited to complete an electronic survey. Respondents provided information on interventions considered for thoracic cancer pre- and postoperatively across 4 therapeutic domains (supplemental natural health products, physical, mental/emotional, and nutritional), therapeutic goals, and contraindications. This survey was part of the development of the Thoracic Perioperative Integrative Surgical Evaluation trial. Results: Forty-four NDs completed the survey (12.5% response rate), all of whom were trained at accredited colleges in North America and the majority of whom were Fellows of the American Board of Naturopathic Oncology (FABNO) (56.8%). NDs identified significantly more interventions in the postoperative compared to preoperative setting. The most frequently identified interventions included modified citrus pectin, arnica, omega-3 fatty acids, vitamin D, probiotics, exercise, acupuncture, meditation, stress reduction, low glycemic index diet, and Mediterranean diet. Potential contraindications with conventional treatment (surgery, chemotherapy, radiotherapy) differed across natural health products. Conclusions: These findings highlight naturopathic interventions with a high level of use in thoracic cancer care, describe and characterize therapeutic goals and the interventions used to achieve these goals, and provide insight on how practice changes relative to conventional cancer treatment phase.

Implementation of an Integrative Oncological Concept in the Daily Care of a German Certified Breast Cancer Center

BACKGROUND

In recent decades the concept of integrative medicine has attracted growing interest in patients and professionals. At the Gemeinschaftskrankenhaus Havelhöhe (GKH), a hospital specialized in anthroposophical medicine, a breast cancer center (BCC) has been successfully certified for more than 5 years. The objective of the present study was to analyze how integrative strategies were implemented in the daily care of primary breast cancer patients.

METHODS

Clinical, demographic, and follow-up data as well as information on non-pharmacological interventions were analyzed. In addition, BCC quality measures were compared with data of the National Breast Cancer Benchmarking Report 2016.

RESULTS

Between 2011 and 2016, 741 primary breast cancer patients (median age 57.4 years) were treated at the GKH BCC. 91.5% of the patients showed Union for International Cancer Control (UICC) stage 0, I, II, or III and 8.2% were in UICC stage IV. 97% of the patients underwent surgery, 53% radiation, 38% had hormone therapy, and 25% received cytostatic drugs. 96% of the patients received non-pharmacological interventions and 32% received Viscum album L.

THERAPY

Follow-up was performed in up to 93% of the patients 2 years after first diagnosis. Compared to nationwide benchmarking BCCs, the GKH BCC met the requirements in central items.

CONCLUSIONS

The results of the present study show that integrative therapies offered by the concept of anthroposophical medicine can be implemented in the daily care and treatment of a certified BCC. However, as national guidelines on integrative concepts in oncology are missing, further studies are needed for a systematic evaluation of integrative treatment and care concepts in this field.