Nina N. Sanford, MD

Nearly one-third of patients with cancer who reported that they used complementary and alternative therapies in a nationwide survey did not tell their physicians about the use of those therapies, and the most frequently cited reason for not telling their physicians was that their physicians did not ask.¹ The results were reported in a research letter in JAMA Oncology by Nina N. Sanford, MD, Assistant Professor of Radiation Oncology at UT Southwestern Medical Center, Dallas, and colleagues.

In an interview with The ASCO Post, Dr. Sanford noted, “Although awareness about complementary and alternative medicines is increasing, many physicians have limited knowledge and experience on how to counsel patients on their use. Other studies have shown that physicians who receive questions about such therapies may be uncomfortable discussing these issues,” she added.

To remedy the situation, “the first step would be to better educate ourselves about complementary and alternative medicines and to make sure we have an improved understanding of what the different modalities are,” Dr. Sanford explained. “The second step would be simply to broach the topic with patients, take the initiative to ask about any alternative therapies they may be using or interested in using, and actively engage patients in the discussion.”

Range of Modalities

The researchers analyzed data from 3,118 patients who reported a history of cancer in the National Health Interview Survey of 2012. That year included a supplement on the use of complementary and alternative medicines, as defined by the National Center for Complementary and Alternative Medicine, since renamed the National Center for Complementary and Integrative Health. The median age of the participants was 66 years, with a range from 18 to beyond 85; 1,230 were men and 1,888 were women.

One-third of these patients (1,230 patients) reported using complementary and alternative medicines in the past 12 months. The most commonly reported complementary and alternative medicines used were herbal supplements (363 patients, 35.8%).

In general, supplements are not approved by the U.S. Food and Drug Administration, so a lot of companies make claims that are not supported by robust research.

— Nina N. Sanford, MD

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Chiropractic or osteopathic manipulation was used by 256 patients (25.4%); massage, by 129 patients (14.1%); yoga/tai chi/qigong, by 85 patients (7.6%); mantra/mindfulness/spiritual meditations, by 75 patients (6.9%); special diets, by 29 patients (2.9%); and acupuncture, by 26 patients (2.0%). Complementary and alternative medicines used by less than 2% of patients were homeopathy, movement or exercise techniques, naturopathy, traditional healers, energy healing therapy, biofeedback, hypnosis, and craniosacral therapy.

The survey data were collected in 2012, and Dr. Sanford said that interest in complementary and alternative medicines has grown since then. “There is more awareness from the patient’s perspective about alternative medicine, and in general, increasing patient autonomy regarding their cancer care, which overall, is a positive trend,” Dr. Sanford noted. “I would not be surprised if the proportion of patients using complementary and alternative medicines has increased [since the survey]. We don’t have updated data from the National Health Interview Survey database to show this yet, but my general sense is the interest in use of these therapies is increasing.”

Potentially Serious Implications

“Given the potentially serious, adverse, and wide-reaching implications of complementary and alternative medicines use (particularly alternative medicines) in patients with cancer, an accurate assessment of the prevalence of complementary and alternative medicines use is needed,” the authors wrote in the research letter.

“Herbal supplements can be quite harmful. They could potentially interfere with how some medications are metabolized and may interfere with the efficacy of chemotherapy,” Dr. Sanford explained. As an example, she cited St. John’s wort, “which is a commonly used supplement and interferes with how certain drugs are metabolized throughout the body. So, it could interfere with the levels of chemotherapy in the body,” she noted.

“In general, supplements are not approved by the U.S. Food and Drug Administration, so a lot of companies make claims that are not supported by robust research,” Dr. Sanford explained. “A concern is that patients could be taking supplements instead of what is prescribed, thinking the supplement could either cure their cancer or prevent it from coming back. If that happens in a survivorship setting, it is possible that they may not follow up as recommended.”

Dr. Sanford, a radiation oncologist who specializes in treating patients with gastrointestinal disease, specifically recommends that patients avoid using supplements during radiation therapy. “With radiation specifically, there is concern that high levels of antioxidants could make radiation less effective,” she said. Although she recommends that patients receiving radiation not take megadoses of vitamin D or other vitamins, she does encourage patients who take a multivitamin to continue to do so, as well as to eat a healthy varied diet with fruits and vegetables.

Positive Effects

Many complementary and alternative medicines can have positive effects, Dr. Sanford pointed out. Meditation and yoga can help patients cope with cancer and its treatment. “We advise patients to stay active and engage in exercise during treatment as best they can,” Dr. Sanford said. “A common side effect of radiation is fatigue. I let patients know that fatigue can be more of a problem for those who sedentary, whereas those who are doing exercise often have more energy.”

When patients ask if radiation therapy will incapacitate them or require them to stay in bed, Dr. Sanford replies, “Generally, no. We want you to be up, walking and exercising. That usually helps with energy levels.”

Nondisclosure Rates and Reasons

Overall, 29.3% (288 of the 1,023 survey patients with cancer) did not disclose complementary and alternative medicines use to their physicians. Dr. Sanford was not surprised by that percentage. “Ideally, it were lower, but in my personal experience of caring for patients, I am not really surprised by this proportion.”

The nondisclosure rates varied from 11.8% for those using herbal supplements to 58.2% for those using spiritual and mindfulness meditation. “It is reassuring that the nondisclosure rates for herbal supplements were lowest, since this modality could potentially be the most harmful,” Dr. Sanford said.

The top two reported reasons why patients did not tell their physicians about complementary and alternative medicines use were because physicians did not ask—cited by 155 patients (57.4%)—and patients did not think their physicians needed to know—cited by 140 patients (47.4%). Less frequently cited reasons were that complementary and alternative medicines users thought their physicians did not know as much about the therapy (8.5%); they were not given enough time to tell their physicians about the therapy (5.7%); and concern that physicians would have a negative reaction (3.9%), discourage complementary and alternative medicines use (3.6%), or had discouraged such use in the past (1.9%).

What’s in the Bottle?

Patients often “want to be perceived as doing what their providers have instructed them to do—nothing more or less,” Dr. Sanford commented. “In our study, the proportion of patients who reported concern regarding a potential negative reaction from their providers was actually quite small, which is reassuring. In my personal experience, however, I think it is certainly possible that a subset of patients are worried about upsetting their providers by partaking in therapies that have not been prescribed.”

Dr. Sanford noted that she does not think most physicians possess a negative attitude toward patients using something that is not on their list of prescribed medications. Rather, she said, there is discomfort in not knowing what patients are taking and how to counsel them about unprescribed therapies, as well as concern that patients may not be taking what is prescribed or complying with follow-up procedures.

“If a patient brings in a supplement, and it is in an unlabeled bottle, although we want to be supportive in their initiatives, we also need to let them know that we really have no idea of the components making up the supplement.” Sometimes patients will say they received the unprescribed substance from a relative or a friend, or learned of it through social media or online message boards. “You want to encourage them to have those supports during a very difficult time, but also need to inform them of the lack of evidence on safety or efficacy of the supplement,” Dr. Sanford remarked.

“The cost of these therapies can be high,” said Dr. Sanford. “Unfortunately, we have all heard very upsetting stories of patients who have stopped using therapies and then spent a significant amount of money on unproven therapies (which are almost never covered by insurance), with negative and possibly devastating effects on their outcomes.”

Study Impetus

The researchers cited a study published in 2018 showing that a small subset of patients who reported complementary and alternative medicines use had worse survival than those who had not used these medicines.² “This finding appeared to be mediated by the refusal of conventional cancer therapy,” Dr. Sanford noted. This retrospective observational study focused on data from the National Cancer Database on more than 1.9 million patients.²

I am hoping to put together a prospective survey of our patients, assessing the costs associated with these additional therapies.

— Nina N. Sanford, MD

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“Among the 1.9 million patients, 258 (0.01%) were recorded as using complementary and alternative medicines, but that was physician-reported, not patient-reported,” commented Dr. Sanford. “The study found that this subset of patients were more likely to refuse additional conventional cancer treatments and had worse survival,” Dr. Sanford said.

“This article garnered significant media attention, in part because a common interpretation of the findings was that if you have cancer and use complementary and alternative medicines, you are more likely to die,” Dr. Sanford noted. “However, only a very small proportion of patients in the study were recorded as using these therapies, which did not appear concordant with my own experience as an oncologist.”

Dr. Sanford explained that the impetus for the study was to determine the rate of complementary and alternative medicines use as well as the nondisclosure rate. “A major difference between these studies is that our database is patient-reported,” whereas the previous study used physician-reported data. “The National Cancer Database is a great resource, but patients need to first disclose complementary medicine use to their providers, who then have to remember to record the information,” Dr. Sanford explained.

Future Directions

The authors of the research letter call for policy and guidelines to encourage discussion of complementary and alternative medicines. Dr. Sanford, who just recently relocated from Boston to Dallas to join UT Southwestern Medical Center, said further work involving complementary and alternative medicines is definitely something she is interested in doing. “We are privileged to care for a culturally diverse patient population, many of whom do choose to use complementary and alternative therapies,” she added. “Having a centralized way for patients to report this use, and ways to engage patients in modalities such as exercise and yoga in a safe setting, is something I am interested in developing within our department and the Simmons Comprehensive Cancer Center.”

The authors also call for additional research to assess health-care outcomes, quality of life, and the cost implications associated with the use of complementary and alternative medicines. “I am interested in looking at cost because anecdotally, I have heard of patients spending quite a bit of money on these therapies,” Dr. Sanford said. “I am hoping to design a survey assessing longitudinal out-of-pocket costs incurred by complementary and alternative medicines.” Other planned research will focus on “patient perceptions of efficacy of complemenatry and alternative medicines and qualify of life.” ■

DISCLOSURE: Dr. Sanford reported no conflicts of interest.

REFERENCES

1. Sanford NN, Sher DJ, Ahn C, et al: Prevalence and nondisclosure of complementary and alternative medicine use in patients with cancer and cancer survivors in the United States. JAMA Oncol. April 11, 2019 (early release online).

2. Johnson SB, Park HS, Gross CP, et al: Complementary medicine, refusal of conventional cancer therapy, and survival among patients with curable cancers. JAMA Oncol 4:1375-1381, 2018.