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Complementary medicine (CM) and palliative (cancer) care

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Complementary medicine (CM) and palliative (cancer) care Edzard Ernst Emeritus Professor University of Exeter PC2-2012 Cancer v1 - * PC2-2012 Cancer v1 - Yoga in ... – PowerPoint PPT presentation

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Title: Complementary medicine (CM) and palliative (cancer) care


1
Complementary medicine (CM) and palliative
(cancer) care
Edzard Ernst Emeritus Professor University of
Exeter
2
CONFLICTS OF INTEREST
  • none

3
PPS-11-06 Köln-5-2
4
Background
  • Most cancer patients try some form of CM(50
    without telling their doctors)
  • Millions of websites, hundreds of books and
    newspaper articles promote all sorts of
    alternative cancer cures
  • Conventional healthcare practitioners know little
    about CM
  • Patients are often being left alone when trying
    to make decisions about CM-use

5
What is CM?
An umbrella term for a heterogeneous array of
therapeutic and diagnostic methods which have
little in common other than being outside
mainstream medicine
acupuncture
from
urin-therapy
to
PPS-04-07Herb 'Alt'MedCancer-3
6
CM seven common features
  • Emphasis on holism
  • Natural treatments
  • Safe treatments
  • Individualisation
  • Self-healing properties of body
  • Long tradition of usage
  • Private healthcare

7
Availability of CM for cancer (UK)
Design Sample Result
Internet search for all UK units providing
CM 142 units provided 62 different
therapies Counselling (available at 82 of all
units) Reflexology (62) Aromatherapy (59) Reiki
(43) Massage (42)
PPS-04-04CompTherCancer-11
Egan B et al CTCP 2012
8
Prevalence of CM-use for cancer in the UK
  • Design systematic review of surveys
  • Sample 25 surveys, 6798 patients
  • Result average prevalence 30.5
  • most popular herbal medicine
  • homeopathy
  • aromatherapy
  • reflexology
  • relaxation

9
WHY?
10
Great Expectations
  • Less side-effects
  • Symptom relief
  • Cure
  • Cope better
  • Improve QoL
  • Boost immune system
  • Prevention
  • Good therapeutic relationship
  • Holistic care
  • Emotional support
  • Control

11
UK Newspaper coverage of CM/Cancer
Method Sample Results
  • systematic review
  • 310 newspaper articles (2002, 3, 4)
  • coverage increased by 81
  • most frequently mentioned therapy was
    diets/supplements
  • articles were mainly on CM for treatment
  • 53 of all CMs were not backed up by evidence

Milazzo, Ernst Supp Care Cancer 2006, 14 885
12
(No Transcript)
13
Cancer recommended CMs
Acupressure Acupuncture Anti-neoplasons Antioxidan
ts Aromatherapy Ayurvedic medicine Bioelectric
treatment Biofeedback Carotenoids Cell
therapy Cell-specific cancer therapy Chelation
therapy Chinese herbs Chinese medicine Co-enzyme
Q10 Coleys toxins Dance therapy Detoxification
therapy
DHEA Diet Enzyme therapy Exercise Guided
imagery Green algae Herbal medicine High dose
vitamin E High fiber diet Homeopathy Hydrazine
sulfate Hydrotherapy Hypnotherapy Hypnotherapy
social support Imagery Immune enhancement
therapies Juice therapy Magnetic field
therapy Massage
Meditation Melatonin Metabolic therapies Mind-body
therapies Naturopathy Nutritional
supplements Oxygen therapy Pancreatic enzyme
therapy Pets Phytoestrogen Qigong Reflexology Rela
xation Shark cartilage Spirituality TCM
Therapeutic touch Yoga
14
CM for cancer is a complex issue
15
  1. Prevention
  2. Cure
  3. Palliative/supportive care

16
CM for cancer
1. Prevention
17
Allium for cancer prevention
Design Sample Result
systematic review 20 (mostly) case control
studies with only 1 exception, these studies
suggest that allium vegetables convey a
protective effect, in particular from GI cancers.
Ernst. Phytomed 1997479
18
Green tea for cancer prevention
Design Sample Result
Cochrane review 51 (mostly epidemiological)
studies with a total of 1.6 million
participants Risk of certain cancers may be
reduced by regular green tea consumption
Boehm, et al. Cochrane Database 2009
19
(No Transcript)
20
Summary of clinical evidence of cancer prevention
21
Take home message(prevention) CM offers very
little in addition to conventional healthcare
22
CM for cancer
2. Treatment
23
(No Transcript)
24
ALTERNATIVE CANCER CURES
  • there will never be one !!!

25
Mistletoe for cancer
Method Sample Results
  • systematic review of RCTs
  • 10 RCTs of various mistletoe preparations
  • most RCTs had considerable weaknesses
  • flawed RCTs tended to be positive
  • none of the stronger RCTs showed efficacy in
    terms of quality of life, survival or other
    outcomes

Ernst, et al. Int J Cancer 2003107262-267
26
Laetrile as an alternative cancer cure
Design Sample Conclusion
Cochrane review no RCT or non-RCT was
found The claim that Laetrile has beneficial
effects for cancer patients is not supported by
data
Milazzo, et al. Cochrane Database 2009.
27
CM for cancer
3.Palliative/supportive care
28
Palliative Care
the active, total care of patients whose
disease is not responsive to curative treatment
PPS-12-05CM-in-Palliative-Care-12
WHO 1990
29
Palliative/supportive cancer care
Physical symptoms pain fatigue constipation n
ausea dyspnea Psychological symptoms fear hop
elessness aggression grief depression resignat
ion Sociological issues family housing commun
ication finances
30
Do we really need scientific evidence?
31
EBM means integrating1 patients
preferences2 clinical experience3 best external
evidence
32
A few examples of RCTs
33
Individualised herbal medicine for reducing
toxicity of chemo
Design Sample Intervention Primary
endpoint Result
  • RCT
  • 120 patients with early breast or colon cancer
    undergoing chemotherapy
  • Individualised herbal mixtures prescribed
    by 3 Chinese herbalists
  • Placebo
  • Toxicity of chemotherapy
  • No inter-group differences

PPS-07-07Herb Alt Med Cancer-37
Mok, et al. Ann Oncol Jan 2007
34
Yoga in palliative cancer care
Design Sample Intervention Result
RCT 88 breast cancer patients (India) 1)
Yoga2) brief supportive therapy Compared to
control, yoga was associated with- improvement
in positive affect- better emotional function-
less negative affect
Vadiraja, et al. CMT 200917274
35
Aromatherapy for palliative cancer care
Design Sample Intervention Result
  • RCT
  • 46 cancer patients in palliative care (UK)
  • A)weekly aromatherapy standard care
  • B) standard care alone
  • Mood, QoL improved in both groups
  • With no inter-group difference
  • Patients were more satisfied with A)

Wilock, et al. Palliative Med 200418287
36
Beware of cherry-pickers!
37
Own systematic reviews CM for cancer
Therapy Symptom Number of studies Conclusion (quote) Reference
Acupuncture Pain 7 the notion that acupuncture may be an effective analgesic adjunctiveis not supported by the data Eur J Pain 2005
Acupuncture Hot flushes (breast cancer) 3 the evidence is not convincing Breast Cancer Res Treat 2008
Acupuncture Hot flushes (prostate cancer) 6 the evidence is not convincing Supp Care Cancer 2009
Co-enzyme Q10 Side-effects of conv. Therapy 6 CoQ10 provides some protection against cardio toxicity or liver toxicity during cancer treatment J Clin Oncol 2004
Guided imagery Any symptom 6 GImay be psycho-supportive and increase comfort Psychooncol 2005
38
Own systematic reviews CM for cancer
Therapy Symptom Number of studies Conclusion (quote) Reference
Homeopathy Any symptom 6 insufficient evidence to support clinical efficacy Eur J Cancer 2006
Massage Any symptom 14 the evidence is encouraging Supp Care Cancer 2009
Moxibustion Any symptom 5 The evidence is limited BMC Cancer 2010
Tai Chi Any symptom 4 The evidence is not convincing Supp Care Cancer 2009
Tai Chi Breast cancer symptoms 7 the existing trail evidence isnot convincing Breast Cancer Res Treat 2010
Qigong Any symptom 9 the effectivenessis not supported by the evidence from rigorous clinical trials Acta Oncol 2007
39
Systematic review massage for cancer palliation
and supportive care
Sample Results
14 RCTs
  • Most studies were of poor methodological quality
  • All suggest positive effects, e.g. on- pain-
    nausea- anxiety- depression- anger- stress-
    fatigue

Ernst. Supp Care Cancer 2009.
40
CM for palliative cancer care
  • direction of evidence
  • nausea ? pain ? ? ? ? ??
  • ?
  • ?
  • ?

weight of evidence 0000000000000000 00 00
00 00
treatment acupuncturebiofeedbackhypnosismassag
emelatoninmoxibustionmusic therapyrelaxationt
herap. touch Co Q10 homeopathy tai chi qigong
41
Take home message(supportive/palliative
care) CM is under-researched but may have a lot
to offer
42
Safety
43
Many patients believe CM to be risk-free (the
natural harmless fallacy)
44
CM for Cancer?
Retrospective chart review (1980 2006) 185
breast cancer patients who refused standard
treatments in favour of CM exclusive CM-use was
associated with 43 5-year survival compared to
82 in patients who also used conventional
treatments
Design Sample Results
Joseph K et al World J Surg Oncol JUNE 2012
45
Adverse effects of CM
Survey of gt3000 British CM users
Therapy reporting adverse effects Deaths
Spinal manipulation 15.8 (50) 100
Acupuncture 12.5 (7-11) 100
Homoeopathy 9.8 (20) 10
Herbal medicine 7.6 (depends) 1000
700 Vascular accidents, strokes Estimated
order of magnitude
Abbot, White, Ernst. Nature 1996 381 361
46
Real Life in the UK
Design Method Results
  • Journalistic undercover investigation
  • Journalist presents with curable Hodgkins
    disease to 6 London-based CAM practitioners
    chosen at random
  • All but 1 discourage conventional treatments
  • All but 1 offer unproven treatments
  • Costs are exorbitant (9845-, 11830-, 1137-,
    3712-, 9139-)

Calman, Ernst FACT 2007, 167
47
CONCLUSION CM, like conventional medicines,
should be subject to careful evaluation of their
effectiveness and safety. It is important that
treatmentsare properly tested and that patients
do not receive misleading informationNHS
provision for CMshould be confined to treatments
that are supported byevidence of both
effectiveness and safety
PPS-07-07Herb Alt Med Cancer-50
Royal Society 2006
48
Email Edzard.Ernst_at_pms.ac.uk Website
www.pms.ac.uk/compmed
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