CAMHerbal remedies in cancer

HAI conference 2007

Patricia Fox

School of Nursing, Midwifery & Health Systems, UCD

Outline

Definitions

Prevalence

Characteristics associated with use

Reasons for use

Herbs: helpful, harmless or harmful?

Implications for health professionals

Definitions

Different terminology has been used over time from

the negative “quackery” to “unorthodox”, “unconventional”, “questionable”, “unproven” and “alternative” (Cassileth & Deng 2004)

proponents may use terms such as ‘holistic’, ‘non-toxic’, ‘integrative’, ‘medicine douce (gentle medicine)’ (Ernst & Fugh-Berman 2002)

Definitions

Complementary therapies are used in addition to conventional treatment

include supportive approaches that treat symptoms and enhance well-being

Conversely, alternative therapies are frequently promoted for use

in place of mainstream treatment (Cassileth & Deng 2004)

The following categories are used to group CAM (NCCAM 2006)

Alternative medical systems such as homeopathy and naturopathic medicine;

Mind-body interventions such as meditation and prayer;

Biologically based treatments such as herbal products and dietary supplements;

Manipulative and body based methods such as massage and chiropractic manipulation

Energy therapies such as Reiki and qi gong

Definition of CAM (NCCAM 2004)

5 categories used in classification

‘CAM is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. ’

Prevalence of CAM use in adult patients with cancer

Systematic review: (26 surveys/n=3649)CAM use ranges from 7-64%, while average prevalence is 31.4% (Ernst & Cassileth 1998)

US study (n=453)83.3% had used at least one approach.

62.6% used vitamins/herbs (62.6%), 59.2% movement and physical therapies (Richardson et al. 2000)

2005 study: 35.9% uptake (n= 956) (least one form of CAM) (Molassiotis et al. 2005)

CAM prevalence in haematological cancers (Molassiotis et al. 2005)

European study:12 countries (n=68) Lmts*

26.5% use some form of CAM

Most common therapies used:homeopathy (38.9%),

herbal medicine (22.2%)

various psychic therapies, such as use of mediums, healers, rebirthing (22.2%)

Reasons for use:Increase ability of their body to fight cancer and improve physical/emotional well-being.

CAM prevalence in children with cancer

Surveys of families of children with cancer indicate that CAM is used worldwide:

with 31% to 46% use in the Netherlands, Finland, Australia, and Canada, and higher use (73%) in Taiwan (Post White & Hawkes 2005)

UK study (n=49)32.7% reported using some type of CAM

most commonly used therapies included multivitamins, aromatherapy massage, diets and music as therapy

(Molassiotis & Cubbin 2004)

Ireland: secondary analysis of SLAN studies: general population (Fox et al. in press)

1998 20% CAM uptake

2002 27% CAM uptake only looked at visits to CAM providers (did not include OTC CAM use)

In 1998 and 2002, of those who regularly take prescription drugs, 43.7% and 51.9% respectively also admitted taking vitamins, minerals, or food supplements.

Characteristics associated with use

Higher education Younger/middle ageFemale

Affluent above most consistently associated with CAM use

(Harris et al. 2003, Hana et al. 2005, Molassiotis & Cubbin 2004, Pud et al. 2005, Yates et al. 2004,)

Use in serious illness

Symptom control (Cassileth & Chapman 1996).

Curing the disease/controlling diseaseDecreasing adverse effects of conventional medicine Strengthening the immune systemEnhancing physical, emotional and spiritual well-being Improve overall health of childRegaining a sense of control

(Verhoef et al. 1993, Molassiotis & Cubbin 2004, Richardson et al. 2000).

Herbal supplements: potentially dangerous misconceptions

Some patients may believe that if a practice or product has been in use for hundreds of years, it must be effective

Many also believe that if a product is ‘natural’, it must be safe

(Smith & White 2001)

Herbal supplements

Herbs and Natural Products With potential to decrease cancer growth or as adjuvants (preliminary evidence only often based on in vitro/animal studies) no recommendations can be made to patients at this time.

With potential to decrease side effects

That may increase cancer growth or recurrence

That can interact with conventional treatment and medications

Herbs and Natural Products With Potential to Decrease Cancer Growth or as

Adjuvants (Montbriand 2004)

Astragalus appears to enhance immune system (C/I)

Beta glucan stimulate the body’s macrophage phagocytosis of tumour cells

Baikal skullcap

In vitro anti-tumour activity(hepatotoxic/stupor)

Calcium-D-glucarate oestrogen, no clinical trials at this time

Herbs and Natural Products With Potential to Decrease Cancer Growth or as

Adjuvants (Montbriand 2004)

Cats claw leukaemia, (no human studies) inhibits CYP 3A4/additive effects. (SLE ARF)

Coriolus mushroom (PSK, PSP) Japan

Positive trials in gastric and colon ca

Green Tea

Soy(Natural Medicines Comprehensive Database (2003) and the Lawrence

Review of Natural Products Monograph System (Facts and �Comparisons, 2001).

Herbs and Natural Products With Potential to Decrease side effects (Montbriand 2004)

Glutamine may prevent GI toxicity (uptake concern)

Coriolus mushroom (PSK, PSP) animal studies suggest PSK can prevent chemo induced immunosuppression

Ginger

Herbs or Natural Products That May Increase Cancer Growth or Recurrence

(Montbriand 2004)

Herbs with estrogenic properties concern relating to hormone-sensitive cancers

alfalfa (pancytopenia), black cohosh (may interact with tamoxifen), flaxseed (conflicting),

ginseng (3), licorice, milkthistle, red clover, soy

Alfalfa Ingestion of large amounts of alfalfa seeds is associated with pancytopenia (Tyler, 1993)

(Natural Medicines Comprehensive Database (2003) and the Lawrence Review of Natural Products –Monograph System (Facts and Comparisons, 2001).

Interaction with chemotherapyagents (Montbriand 2004)

Vitamin C & Vitamin E chemo efficacy

Coenzyme Q-10Concern that cancer cells are protected from chemo when used concomitantly with agents such as cyclophosphamide,

Glucosamine (3)induce resistance to etoposide and doxorubicin by reducing inhibition of topoisomerase II

Folic acid Methotrexate/Irinotecan SJW

Echinacea MOABs

Patricia Fox, UCD, 2007

Review of literature (Ernst 1998)

Allergic reactions:

royal jelly bronchospasm

Toxic reactions aristolochic acid

Adverse effects r/t desired action

Ginseng tabs overt mania in depressed patient taking antidepressants

Mutagenic effects

Concern phytooestrogens in breast cancer

ContaminationArsenic, lead, corticosteroids

Patricia Fox, UCD, 2007

Drug interactions

Name (Latin) Anticoagulant/anti-platelet Potential interaction

• Panax (Panax ginseng) Warfarin Decreased INR• Garlic (Allium sativum) Warfarin, Aspirin May ↑risk

bleeding (T)Ginkgo (Ginkgo biloba) Warfarin May ↑risk

bleeding AspirinChamomile

(Matricaria chamomilla) Warfarin May ↑ bleeding time• Dong quai (Angelica sinensis) Warfarin ↑ bleeding time• Ginger (Zingiber officinale) Warfarin May enhance risk of

bleeding

Patricia Fox, UCD, 2007

Herbal supplements Some Key points

Just because it is labelled ‘natural’ does not mean it is safe or without side effects

Can act in the same way as drugs →may cause medical problems if taken incorrectly or in large amounts.

Where herbal supplements are used,it is preferable to do so under guidance of a medical professional, properly trained in herbal medicine (NCCAM 2004)

Patricia Fox, UCD, 2007

Herbal supplements Some Key points

Herbal supplementsnot subject to the same rigorous standards as mainstream medications

The active ingredient(s) in many herbs/ herbal supplements

are not knownPublished analyses have found differences

between what is on label and what is in the bottle

Some herbal supplements may be contaminated with metals, unlabelled prescription drugs, micro-organisms (NCCAM 2004)

Who is providing the information?

Internet

Internet information offered to patients with depression is highly variable

with some websites offering valuable information,

many recommending CAM therapies for which there is no evidence

some even dissuading patients from using conventional treatment for depression

(Ernst & Schmidt 2004)

Lack of disclosure to conventional providers

Eisenberg study39.8% of alternative therapies were disclosed to physicians in 1990 vs 38.5% in 1997

Limited discussion of CAM between conventional providers and their patients

may be a function of limited knowledge of CAM among the former.

Research indicates that health care professionals knowledge of CAM is low (Dekeyser et al. 2001, Uzun & Tan 2004)

Recommendations for conventional providers

It is recommended that nursing and medical curricula incorporate some teaching on CAM.

Increasing the knowledge base of conventional healthcare professionals

will serve to not only safeguard patients against potential harm from therapies (Uzun & Tan 2004)

Also enable them to provide advice and support in relation to beneficial supportive therapies (Risberg et al. 2003).

Recommendations by survey authors

Suggest government, corporations, foundations and academic institutions

adopt a more proactive position in relation to research and education in this area (MacLennan et al. 1996),

improve quality control of dietary supplements,

Initiate formation of post-market monitoring of drug-herb/supplement interactions

(Eisenberg et al. 1998, Nilsson et al. 2001).

Patricia Fox, UCD, 2007

Conclusion

Important to question patients regardingall medications, supplements, OTC remedies taken when taking initial history

Where unexpected signs/symptoms→ probe further, keep an open mind

Caution re: limited knowledge of effects/side effects of herbs and potential for interaction with medsConsult with pharmacist

Document, Document, Document!

Patricia Fox, UCD, 2007

Resources

National Centre for Complementary and Alternative Medicine for up-to-date information on research trials

www.altmed.od.nih.gov/NCCAM

American Cancer Society http://www.cancer.org

Agency for Healthcare Policy and Research http://healthit.ahrq.gov/search/ahrqsearch.jsp

MSKCC.Org http://www.mskcc.org/mskcc/html/1979.cfm

References

Cassileth B. R. & Chapman C. C. (1996) Alternative and Complementary Cancer Therapies. Cancer 77 (6), 1026-1034.Cassileth B. R. & Deng G. (2004) Complementary and alternative therapies for Cancer. The Oncologist 9 (1), 80-89.Dekeyser F. G., Bar Cohen B., & Wagner N. (2001) Knowledge levels and attitudes of staff nurses in Israel towards complementary and alternative medicine. Journal of Advanced Nursing 36 (1), 41-48.

References

Eisenberg D. M., Davis R. B., Ettner S. L., Appel S. Wilkey S., Van Rompay M. & Kessler. R. C. (1998) Trends in Alternative Medicine use in the United States:1990-1997. JAMA 280, 1569-1575.Ernst E. (1998) Harmless herbs? A review of recent literature. The American Journal of Medicine. 104 (2), 170-178.Ernst E. & Cassileth B. R. (1998) The prevalence of complementary/alternative medicine in cancer: a systematic review. Cancer 83 (4), 777-782.Fox P.A.M., Kelleher C., Coughlan B., Fitzsimon N. & Butler M. Complementary Alternative Medicine use in Ireland: a secondary data analysis of the SLAN studies (in press).

References

Ernst E. & Fugh-Berman A. (2002) Complementary and alternative medicine: what is it all about? Occupational and Environmental Medicine 59, 140-144.Ernst E. & Schmidt K. (2004) Alternative Cures for depression-how safe are websites? Psychiatry Research 129 (3), 297-301.Harris P., Finlay I. G., Cook A., Thomas K. J. & Hood K. (2003) Complementary and alternative medicine use by patients with cancer in Wales: a cross sectional survey. Complementary Therapies in Medicine 11(4), 249-253.

References

Hana G., Bar-Sela G., Zhana D., Mashiach T. & Robinson E. (2005) The use of complementary and alternative therapies by cancer patients in northern Israel. Isr Med Assoc . 7, 243-7.

Maclennan A.H., Wilson., D. H. & Taylor A. W.,(1996) Prevalence and cost of alternative medicine in Australia. The Lancet 437, 569-573

References

Molassiotis A. & Cubbin D. (2004) ‘Thinking outside the box’: Complementary and alternative therapies in paediatric oncology patients. European Journal of Oncology Nursing 8 (1), 50-60.Molassiotis A., Fernadez-Ortega P., Pud D., Ozden G., Scott JA., Panteli V., Margulies A, Browall M, Magri M, Selvekerova S, Madsen E, Milovics L, Bruyns I., Gudmundsdottir G., Hummerston S., Ahmad A.M., Platin N., Kearney N. & Patiraki E. (2005) Use of complementary and alternative medicine in cancer patients: a European survey. Annals of Oncology 16, 655-663.

References

Molassiotis A., Margulies A, Fernadez-Ortega P., Pud D., Panteli V., Bruyns I., Scott JA., Gudmundsdottir G., Browall M, Madsen E, Ozden G., Magri M, Selvekerova S, Platin N., Kearney N. & Patiraki E. (2005) Complementary and alternative medicine use in patients with haematological malignancies in Europe. Complementary therapies in Clinical Practice 11 (2), 105-110.

Montbriand M. (2004) Herbs or Natural Products That Decrease Cancer Growth: Part One of a Four-Part Series. ONF 31 (4)

References

National Centre for Complementary and Alternative Medicine (2004) What is complementary and alternative medicine? http://nccam.nih.gov/health (accessed 3 March 2005) Internet.

Nilsson M., Trehn G., & Asplund K., (2001) Use of complementary and alternative medicine remedies in Sweden. A population-based longitudinal study within the northern Sweden MONICA Project.Journal of Internal Medicine 250, (3) 1365-

2796.

References

Post-White J. & Hawkes R. P. (2005) Complementary and alternative medicine in pediatric oncology. Seminars in Oncology Nursing 21(2), 107-114.

Pud D., Kaner E., Morag A., Ben-Ami S. & Yaffe A. (2005) Use of complementary and alternative medicine among cancer patients in Israel. European Journal of Oncology Nursing 9, (2),124-30.

References

Richardson M. A., Sanders T., Lynn Palmer J., Greisinger A., & Singletary S. E. (2000) Journal of Clinical Oncology 18 (13), 2505-2514.Risberg T., Kolstad A., Bremnes Y., Holte H. & Wist E.A (2004) Knowledge of and attitudes toward complementary and alternative therapies: a national multicentre study of oncology professionals in Norway. European Journal of Cancer 40, 529-535.Smith W. B. & White J. D. (2001). Complementary and alternative medicine in cancer: a National Cancer Institute perspective. Exp. Opin. Biol. Ther. 1 (3), 339-341.

References

• Uzun O & Tan M.(2004) Nursing students opinions and knowledge about complementary and alternative medicine therapies. Complementary Therapies in Nursing and Midwifery 10 (4), 239-244.

Yates J. S., Mustian K. M., Morrow G. R., Gillies L. J., Padmanaban D., Atkins J. N., Issell B., Kirshner J. & Colman L.K. (2005) Prevalence of complementary and alternative medicine use in cancer patients during treatment. Support Care in Cancer 13 (10), 806-811.

References

Verhoef M. J., White M. A. & Doll R. (1993) Cancer patients’ expectation of the role of family physician in communication about complementary therapies. Cancer Prevention Control 3, 181-187.