Symptom Management with Complementary Therapies for Patients Receiving Radiation Therapy


Get Permission

It is therefore important that radiation oncologists ask their patients about complementary therapies during the initial consultation, have some basic knowledge of these therapies, and know about sources of further information and advice.

—Stephen M. Sagar, MD, FRCPC

The supportive care of patients with cancer receiving radiotherapy is an important responsibility for the radiation oncologist, and complementary therapies are an integral component of many patients’ treatment strategy.A recent prospective study suggests that 54% of patients with breast cancer receiving radiotherapy are also self-initiating complementary therapies. Many interventions (71%) are activity-based (including Reiki and meditation), 45% of patients ingest oral natural health products, and 26% use topical products. Some of these interventions have a potential to interact with radiotherapy, yet only 16% of patients received advice prior to initiating these therapies.1 It is therefore important that radiation oncologists ask their patients about complementary therapies during the initial consultation, have some basic knowledge of these therapies, and know about sources of further information and advice.

Indications

Because symptoms often are multifactorial, supportive care often requires multiple integrated interventions. Adverse effects remain a problem. Some pharmaceuticals may produce undesired side effects, such as constipation caused by opiates and some 5-HT3 antagonists. Substitution or supplementation with complementary therapies results in the reduction of drug-induced adverse effects.

In addition to supportive care, patients benefit from the sense of empowerment associated with self-selected, nonpharmaceutical interventions in addition to appropriate drugs. Empowerment and a sense of control can help reduce symptoms. The following symptoms represent patients’ common complaints.

Anxiety

Anxiety may be associated with radiation therapy procedures per se, or it may be generalized. Procedures during radiotherapy include MRI scanning, restriction in immobilization devices, application of tattoos, and insertion of radioactive sources. Many patients require interventional procedures such as a biopsy, feeding tube insertion, and insertion of gold seeds.

Although anxiolytic drugs are quite helpful, they may cause inappropriate sedation, prevent driving, and take away the patient’s sense of empowerment. Mind/body techniques are especially useful in avoiding such effects. These include hypnosis,2 relaxation exercises, guided imagery,3 control of breathing, and meditation.4,5 In addition, the practitioner can facilitate relaxation through massage6 and aromatherapy.

Over the longer term, generalized anxiety can be reduced by exercise programs, yoga,7 and tai chi. Mixed massage and so-called energy techniques, such as polarity therapy,8 also are safe and useful for anxiety reduction. These techniques also help reduce insomnia.

Chronic overactivation of the sympathetic nervous system exacerbates multiple symptoms, such as pain, emesis, and fatigue. Treating anxiety restores the sympathetic-parasympathetic balance and results in the reduction of multiple symptoms. Recent studies also suggest that a reduction in distress at the time of surgery can reduce metastases and improve wound healing. This is not surprising in view of the profound effect of chronic anxiety on both the immune and endocrine systems.9-12

Fatigue

In addition to moderate exercise and reduction of anxiety, acupuncture13 and North American ginseng (Panax quinquefolius)14 can alleviate nonanemic fatigue.

Mucositis and Dermatitis

Oral (topical or systemic) glutamine reduces mucositis,15 but there is no evidence that acetyl-L-carnitine helps with this symptom. Transmucosal N-acetylcysteine (RK-0202) reduces oral mucositis, without any evidence for tumor protection, through mopping up free radicals.16 Low-level laser therapy may be of benefit in preventing mucositis during chemoradiation therapy.17

Despite the popularity of aloe vera, clinical trials do not show an advantage for its topical application in reducing radiation dermatitis.18,19 No intervention seems better than any other for skin care.20

Pain

Acupuncture is useful for pain control, especially muscle spasm. It may allow lower doses of opiates to be used for cancer pain, thereby reducing opioids’ adverse effects, such as constipation.

In patients with head and neck cancer, acupuncture can improve postsurgical pain.21 Although a Cochrane systematic review is inconclusive,22 the higher-quality trials show efficacy.23 It can be helpful for chemotherapy-induced neuropathy, although definitive controlled trials are lacking.24,25 In general, acupuncture is an effective procedure for chronic pain, and its effect is greater than that of a placebo.26

Nausea, Vomiting, and Reduced Appetite

Nausea and vomiting during chemoradiation remains common, adversely affecting quality of life, reducing nutrition, and increasing other complications.27 A planned program for the prevention of nausea and vomiting is essential. Once vomiting commences, it is more difficult to control because of the conditioned reflex.

Appropriate nutritional counseling is mandatory. There is excellent evidence that acupuncture can contribute to the reduction of emesis.28 Oral ginger (Zingiber officinale) is effective for nausea and vomiting.29,30

Hot Flashes

Hot flashes occur in association with both treatment-induced menopause and andropause (menopause-like condition in older men causing various symptoms, including hot flashes). Mind/body techniques including relaxation exercises and meditation are helpful in attenuating this distressing symptom and have no adverse effects. Appropriate nutritional modification includes the avoidance of coffee, alcohol, and spicy foods.

Results from randomized controlled trials of acupuncture are mixed,31 but acupuncture can be as effective as venlaxafine.32 Soy and other phytoestrogens are not effective.33 Despite their popular use for this purpose, there is no good evidence that either black cohosh or red clover is helpful against hot flashes, and both herbs may be associated with serious adverse effects.34

Xerostomia

Dry mouth syndrome, or xerostomia, is common following head and neck radiation therapy, although it can be improved by using intensity-modulated radiotherapy. Long-term consequences are severe, resulting in major tooth decay. Prevention is important. If pilocarpine is not effective, acupuncture is a reasonable option with good supportive evidence from randomized controlled trials.21,35

Antioxidants

The administration of high-dose antioxidants during radiotherapy is controversial. Their use is based on the pretext of reducing toxicity to normal tissues. On the other hand, it is not clear whether the effectiveness of radiotherapy also is reduced.36 While good nutrition, preferably with whole foods (vegetables, fruits, and whole grains) should be encouraged during radiotherapy, high-dose antioxidant treatment is best left until the course of radiation is complete.

Some antioxidant vitamins, such as beta-carotene and vitamin E, can increase the risk of second cancers in ex-smokers. The controversy is further discussed in published reviews.37,38

Recommendations

The goal of integrative oncology is to provide the best possible care for patients, drawing on all reasonable, evidence-based sources.39 It includes prevention, treatment, and rehabilitation in the continuum of care.40 In addition, it explores systems of care, recognizing the importance of synergy between the components.41

It is important for oncologists to obtain knowledge in this field and to ensure that a program of radiotherapy includes the best supportive care. Patients struggle with information that may include bogus “alternative” therapies.42 A knowledgeable and empathetic practitioner can gain patients’ trust to ensure that they receive appropriate management. ■

Dr. Stephen M. Sagar is a Professor in the Departments of Oncology and Medicine at McMaster University, and a Radiation Oncologist at the Juravinski Cancer Centre in Hamilton, Ontario, Canada.

Disclosure:Dr. Sagar reported no potential conflicts of interest.

Integrative Oncology is guest edited by Barrie R. Cassileth, MS, PhD, Chief of the Integrative Medicine Service and Laurance S. Rockefeller Chair in Integrative Medicine at Memorial Sloan-Kettering Cancer Center, New York.

The Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center developed and maintains a free website—About Herbs (www.mskcc.org/aboutherbs)—that provides objective and unbiased information about herbs, vitamins, minerals, and other dietary supplements, and unproved anticancer treatments. Each of the 265 and growing number of entries offer health-care professional and patient versions, and entries are regularly updated with the latest research findings.

In addition, the About Herbs app, Memorial Sloan-Kettering Cancer Center’s very first mobile application, was launched last fall. In the week following its release on September 21, the app was downloaded more than 6,300 times, making it #4 on the top new medical apps chart. The app is compatible with iPad, iPhone, and iPod Touch devices, and can be downloaded at http://itunes.apple.com/us/app/about-herbs/id554267162?mt=8.

Compiled by Barrie R. Cassileth, PhD, and Jyothi Gubili, MS, Memorial Sloan-Kettering Cancer Center. The About Herbs website is managed by K. Simon Yeung, PharmD, MBA, Lac, Memorial Sloan-Kettering Cancer Center.

References

1. Moran MS, Ma S, Jagsi R, et al: A prospective, multicenter study of complementary/alternative medicine (CAM) utilization during definitive radiation for breast cancer. Int J Radiat Oncol Biol Phys 85:40-46, 2013.

2. Lang EV, Berbaum KS, Faintuch S, et al: Adjunctive self-hypnotic relaxation for outpatient medical procedures: A prospective randomized trial with women undergoing large core breast biopsy. Pain 126:155-164, 2006.

3. Kwekkeboom KL, Hau H, Wanta B, et al: Patients’ perceptions of the effectiveness of guided imagery and progressive muscle relaxation interventions used for cancer pain. Complement Ther Clin Pract 14:185-194, 2008.

4. Garland SN, Carlson LE, Antle M, et al: I-CAN SLEEP: Rationale and design of non-inferiority RCT of mindfulness-based stress reduction (MBSR) and cognitive behavioral therapy (CBT) for the treatment of insomnia in cancer survivors. Contemp Clin Trials 32:747-754, 2011.

5. Campbell TS, Labelle LE, Bacon SL, et al: Impact of mindfulness-based stress reduction (MBSR) on attention, rumination and resting blood pressure in women with cancer: A waitlist-controlled study. J Behav Med 35:262-271, 2012.

6. Sagar S, Dryden T, Wong R: Massage therapy for cancer patients. Curr Oncol 14:45-56, 2007.

7. Shannahoff-Khalsa DS: Patient perspectives: Kundalini yoga meditation techniques for psycho-oncology and as potential therapies for cancer. Integr Cancer Ther 4:87-100, 2005.

8. Mustian KM, Roscoe JA, Palesh OG, et al: Polarity therapy for cancer-related fatigue in patients with breast cancer receiving radiation therapy: A randomized controlled pilot study. Integr Cancer Ther 10:27-37, 2011.

9. Lutgendorf SK, Lamkin DM, DeGeest K., et al: Depressed and anxious mood and T-cell cytokine expressing populations in ovarian cancer patients. Brain Behav Immun 22:890-900, 2008.

10. Sood AK, Bhatty R, Kamat AA, et al: Stress hormone-mediated invasion of ovarian cancer cells. Clin Cancer Res 12:369-375, 2006.

11. Su F, Ouyang N, Zhu, P, et al: Psychological stress induces chemoresistance in breast cancer by upregulating mdr1. Biochem Biophys Res Commun 329:888-897, 2005.

12. Neeman E, Zmora O, Ben-Eliyahu S: A new approach to reducing postsurgical cancer recurrence: Perioperative targeting of catecholamines and prostaglandins. Clin Cancer Res 18:4895-4902, 2012.

13. Molassiotis A, Bardy J, Finnegan-John J, et al: Acupuncture for cancer-related fatigue in patients with breast cancer: A pragmatic randomized controlled trial. J Clin Oncol 30:4470-4476, 2012.

14. Barton DL, Soori GS, Bauer BA, et al: Pilot study of Panax quinquefolius (American ginseng) to improve cancer-related fatigue: A randomized, double-blind, dose-finding evaluation: NCCTG trial N03CA. Support Care Cancer 18:179-187, 2009.

15. Aquino VM, Harvey AR, Garvin JH, et al: A double-blind randomized placebo-controlled study of oral glutamine in the prevention of mucositis in children undergoing hematopoietic stem cell transplantation: A pediatric blood and marrow transplant consortium study. Bone Marrow Transplant 36:611-616, 2005.

16. Chambers MS, Welsh DV, Scrimger RA, et al: RK-0202 for radiation-induced oral mucositis. J Clin Oncol 24(18S):Abstract 5523, 2006.

17. Castro G, de Lima AG, Lopes DR, et al: Oral mucositis prevention by low-level laser therapy in head and neck cancer patients submitted to concurrent chemoradiation: A prospective randomized study. J Clin Oncol 27(15S):Abstract 6019, 2009.

18. Heggie S, Bryant GP, Tripcony L, et al: A phase II study on the efficacy of topical aloe vera gel on irradiated breast tissue. Cancer Nurs 25:442-451, 2002.

19. Richardson J, Smith JE, McIntyre M, et al: Aloe vera for preventing radiation-induced skin reactions: A systematic literature review. Clin Oncol (R Coll Radiol) 17:478-484, 2005.

20. Salvo N, Barnes E, van Draanen J, et al: Prophylaxis and management of acute radiation-induced skin reactions: A systematic review of the literature. Curr Oncol 17:94-112, 2010.

21. Pfister DG, Cassileth BR, Deng GE, et al: Acupuncture for pain and dysfunction after neck dissection: Results of a randomized controlled trial. J Clin Oncol 28:2565-2570, 2010.

22. Paley CA, Johnson MI, Tashani OA, et al: Acupuncture for cancer pain in adults. Cochrane Database Syst Rev 19(1):CD007753, 2011.

23. Alimi D, Rubino C, Pichard-Léandri E, et al: Analgesic effect of auricular acupuncture for cancer pain: A randomized, blinded, controlled trial. J Clin Oncol 21:4120-4126, 2003.

24. Wong R, Sagar S: Acupuncture treatment for chemotherapy-induced peripheral neuropathy: A case series. Acupunct Med 24:87-91, 2006.

25. Schroeder S, Meyer-Hamme G, Epplée S: Acupuncture for chemotherapy-induced peripheral neuropathy (CIPN): A pilot study using neurography. Acupunct Med 30:4-7, 2012.

26. Vickers AJ, Cronin AM, Maschino AC, et al: Acupuncture for chronic pain: Individual patient data meta-analysis. Arch Intern Med 172:1444-1453, 2012.

27. Ezzo J, Vickers A, Richardson MA, et al: Acupuncture point stimulation for chemotherapy-induced nausea and vomiting. J Clin Oncol 23:7188-7198, 2005.

28. Ernst E, Pittler MH: Efficacy of ginger for nausea and vomiting: A systematic review of randomized clinical trials. Br J Anaesth 84:367-371, 2000.

29. Ryan JL, Heckler CE, Roscoe JA, et al: Ginger (Zingiber officinale) reduces acute chemotherapy-induced nausea: A URCC CCOP study of 576 patients. Support Care Cancer 20:1479-1489, 2012.

30. Doranne LN. Hilarius DL, Kloeg PH, et al: Chemotherapy-induced nausea and vomiting in daily clinical practice: A community hospital-based study, Support Care Cancer 20:107-117, 2012.

31. Deng G, Vickers A, Yeung S, et al: Randomized controlled trial of acupuncture for the treatment of hot flashes in breast cancer patients. J Clin Oncol 25:5584-5590, 2007.

32. Walker EM, Rodriguez AI, Kohn B, et al: Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor-positive breast cancer: A randomized controlled trial. J Clin Oncol 28:634-640, 2010.

33. Gold EB, Leung K, Crawford SL, et al: Phytoestrogen and fiber intakes in relation to incident vasomotor symptoms: Results from the Study of Women’s Health Across the Nation. Menopause. October 29, 2012 (early release online).

34. Geller SE, Shulman LP, van Breemen RB, et al: Safety and efficacy of black cohosh and red clover for the management of vasomotor symptoms: A randomized controlled trial. Menopause 16:1156-1166, 2009.

35. Meng Z, Garcia M K, Hu C, et al: Randomized controlled trial of acupuncture for prevention of radiation-induced xerostomia among patients with nasopharyngeal carcinoma. Cancer 118:3337-3344, 2012.

36. Watson J: Oxidants, antioxidants and the current incurability of metastatic cancers. Open Biol 3:120144, 2013.

37. Sagar S: Should patients take or avoid antioxidant supplements during anticancer therapy? An evidence-based review. Curr Oncol 12:44-54, 2005.

38. Lawenda BD, Kelly KM, Ladas EJ, et al: Should supplemental antioxidant administration be avoided during chemotherapy and radiation therapy? J Natl Cancer Inst 100:773-783, 2008.

39. Deng GE, Frenkel M, Cohen L, et al: Evidence-based clinical practice guidelines for integrative oncology: Complementary therapies and botanicals. J Soc Integr Oncol 7:85-120, 2009.

40. Sagar S, Lawenda B: The role of integrative oncology in a tertiary prevention survivorship program. Prev Med 49:93-98, 2009.

41. Lawenda BD, Friedenthal SA, Sagar SM, et al: Systems modeling in integrative oncology. Integr Cancer Ther 11:5-17, 2012.

42. Sagar SM: Alternative therapies as primary treatments for cancer, in Abrams D, Weil A (eds): Integrative Oncology, chapter 26, pp 502-529. New York, Oxford University Press, 2009.



Advertisement

Advertisement



Advertisement