New guidelines released this week can help people being treated for breast cancer determine what complementary therapies help relieve side effects of treatment or improve quality of life. The evidence-based guidelines were sponsored by the Society for Integrative Oncology.
We talked to Suzanna M. Zick, N.D., M.P.H., associate professor of family medicine and environmental health sciences at the University of Michigan. Dr. Zick was part of the guidelines panel and begins a one-year term this week as president of the Society for Integrative Oncology.
mCancerPartner: Can you explain what you mean by integrative oncology?
Dr. Zick: Integrative oncology is the combination of both conventional and complementary treatments that are evidence-based to bring about the best outcome for each patient. That can be for the prevention or treatment of cancer, the treatment of symptoms, and improvement in quality of life during survivorship.
mCancerPartner: Why develop guidelines?
Dr. Zick: Somewhere between 48 percent and 80 percent of breast cancer patients use complementary therapies. There have been numerous clinical trials – we identified over 4,900 articles and ended up analyzing and including more than 200 into the clinical guidelines. Despite the large number of clinical trials, there is nothing available to help doctors and patients know which therapies are safe and effective.
Our guidelines are based on data from randomized clinical trials that used some kind of complementary therapy to address one of our outcomes of interest (for instance pain, fatigue, quality of life), and either focused exclusively on breast cancer patients or had at least half of their samples made up of breast cancer patients. Studies were published as recently as December 2013 and we went back at least through January 1990. We included practices such as:
- acupuncture and acupressure
- dietary supplements (from the common vitamin to the rare such as mistletoe)
- energy conservation
mCancerPartner: The guidelines read like a report card. Why take that approach?
Dr. Zick: We wanted to make sure the guidelines are very useful for both doctors and patients. First, we set up the guidelines by symptoms – pain, sleep disorders, nausea, quality of life. None of the studies we looked at had evidence that complementary therapies were effective at treating cancer. Instead, all the clinical trials were about symptom control and quality of life.
After assessing the studies, we modified the U.S. Preventative Task Force letter grading system (A to D) and assigned grades for each treatment such as yoga for helping sleep quality, or meditation for improving depression. We felt everyone could easily understand a grading system. We also used H, which meant the intervention caused actual harm and should never be used and I, meaning insufficient evidence. The grade was based on how effective the intervention was, the quality of the studies, and any potential toxicity or side effects of the intervention.
An A or B means we should be actively promoting this therapy because there’s high-quality evidence in clinical trials that it’s effective. An A grade means that the amount of benefit is large, while B indicates that the amount of benefit is more moderate. For grade C, studies showed mixed benefit or a very small benefit, but we suggest doctors discuss it with their patients on a case-by-case basis because there also may be some benefit for individual patients.
For many C and I grade therapies, there is a tremendous need for more studies to truly understand their potential benefit and harms.
mCancerPartner: So which therapies received a top grade?
Dr. Zick: Examples of treatments that received an A grade include meditation, yoga and relaxation for improving depression, while music therapy and yoga were graded B for treating anxiety. For fatigue, energy conservation received a B grade and American ginseng a C grade. Importantly, one therapy acetyl-L-carnitine received an H (causes harm) for chemotherapy-induced neuropathy. This was the only therapy that received an H.
mCancerPartner: How easy is it for patients to access some of these therapies?
Dr. Zick: It varies, depending on the therapy and the community. For example, there may be components of yoga that are very good for breast cancer patients. But is this form of gentle yoga always available in the community? Often no. Another question is whether people have the money and time to pursue some of these therapies. You can’t just do this once and see benefit. Acupuncture may be recommended for a six-week course, for example. For some people, this is exactly what they want and it’s brilliant. For others, it’s not affordable or practical.
On the other hand, supplements are easily available. The key here, though, is quality control. It’s important for patients to talk to their doctor about any supplement use to ensure they are accessing high-quality supplements. We tried to put as much of these details as possible into the guidelines so that doctors and patients will know how best to use these therapies.
mCancerPartner: Is integrative oncology right for everyone?
Dr. Zick: In my mind, the evidence is there that every breast cancer patient should be meeting with their care team right after diagnosis to get a plan for exercising and maintaining a healthy weight. We know this reduces recurrence.
For another example, we know that about one in four women will stop taking an aromatase inhibitor because of joint and muscle pain. This is a treatment that significantly cuts recurrence. If you can manage these symptoms, such as with acupuncture, you’re actually improving survival.
The key is that complementary therapies are integrated with conventional treatments. Every patient should make her own decision in cooperation with the health care team. And they should know the evidence.
Learn more about complementary therapies:
- View the guidelines and more on integrative oncology as published in the Journal of the National Cancer Institute Monographs
- Alternative Medicine at the U-M Cancer Center
- Complementary Therapies at the U-M Cancer Center
- Deep Breaths: Harnessing the power of yoga to recover from breast cancer
- Getting Back to Your Life as Usual
Still have questions? Call the nurses at the University of Michigan Cancer AnswerLine™. They can help patients or their loved ones find a clinical trial or provide insights into the newest and latest cancer treatments. Feel free to call at 1-800-865-1125 or send an e-mail.
Suzanna Zick, N.D., M.P.H., is an associate professor of family medicine at the U-M Medical School and of environmental health sciences at the U-M School of Public Health. Dr. Zick received a naturopathic degree from the National College of Naturopathic Medicine and a master’s of public health in epidemiology from the University of Michigan. She started practicing naturopathy in Ann Arbor in 1997 and helped to found the Complementary and Alternative Medicine Research Center (CAMRC) at the University of Michigan. Dr. Zick presently focuses on investigating complementary therapies (diet and self-administered acupressure) to control symptoms such as fatigue and chronic pain in cancer survivors.
The University of Michigan Comprehensive Cancer Center’s 1,000 doctors, nurses, care givers and researchers are united by one thought: to deliver the highest quality, compassionate care while working to conquer cancer through innovation and collaboration. The center is among the top-ranked national cancer programs, and #1 in Michigan according to U.S. News & World Report. Our multidisciplinary clinics offer one-stop access to teams of specialists for personalized treatment plans, part of the ideal patient care experience. Patients also benefit through access to promising new cancer therapies.