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

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Presentation on theme: "Kara Kelly, M.D. Integrating Complementary Therapies in the Care of Children with Cancer: Research and Clinical Practice."— Presentation transcript:

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

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

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

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

5 Children with Cancer are using CAM Year of Survey %

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

7 How are Patients Using CAM?

8 73% of children were enrolled on clinical trials for treatment of their malignancy 85% were using some form of CAM: Herbs 25% Nutritional supplements 34% J Pediatr Hematol Oncol 22:412,2000

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

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

11 Adverse Effects

12 Contamination of herbs LeadTCM, Surma/kajal, bint al dhahab, Litargirio ArsenicIu Huang Chieh Tu Pien, other TCM MercuryWatermelon frost (TCM) Warfarin, DESPC-SPES Eur J Pediatr 162:72, 2003

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

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

15 Chemotherapy/Herb Interactions Corticosteroid Cyclosporin Reduced immunosuppression Cordyceps, country mallow, ephedra, marshmallow, fish oils, garlic, grapefruit, L- arginine, red yeast Increased immunosuppression Licorice, alfalfa sprouts, astralagus, cat’s claw, echinacea, St John’s wort, vitamin E, zinc Methotrexate Increased hepatotoxicity Black cohosh, echinacea, salicylate containing herbs: bilberry, meadow sweet, poplars, red clover, white willow, wintergreen

16 Oxidative Stress and Chemotherapy Drugs HighAnthracyclines Pt-complexes Alkylating agents Epipodophyllotoxins Camptothecins Purine/Pyrimidine Antimetabolites LowTaxanes Vinca alkaloids

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

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

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

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

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

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

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

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

25 Clinical Services

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

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

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


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

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