When Betsy Glosik was diagnosed with estrogen receptor-positive, stage II breast cancer in October 2007, she suspected the treatment would be rough on her. Her doctor recommended three types of chemotherapy—docetaxel, doxorubicin and cyclophosphamide—a combination of drugs that carry a risk of severe side effects, including diarrhea, fatigue and neuropathy.
Glosik, who lives in Brecksville, Ohio, a suburb of Cleveland, was then 49 years old. She frequently had unusual reactions to medications, even over-the-counter ones, so she asked her oncologist if a less toxic approach might be just as effective.
“He looked at me with a blank face and said, ‘You have no choice.’” The response rubbed her the wrong way. “In the back of my head, I knew I had a choice. I could choose not to be treated.”
Glosik contacted an oncologist who had treated her for localized melanoma four years earlier, who referred her to another oncologist for a second opinion. The doctor reviewed her case and felt confident that omitting doxorubicin would not significantly affect her chance of survival.
After a life-threatening allergic reaction to the pared-down regimen, Glosik eventually finished three rounds of another drug, Abraxane (paclitaxel), in addition to radiation therapy. She went on to take tamoxifen for 6 1/2 years to decrease the risk of the cancer coming back. To this day, she believes the toxicity of the three-drug combination would have killed her.
Glosik wanted to know what more she could do to manage treatment side effects. “I was looking for something else that wasn’t going to be another drug that was going to tear my body down,” she says. She started with exercise, which had always helped her relieve stress. After chemotherapy treatments, she would nap and then head to the gym.
But the treatment side effects, especially pain and fatigue, became more intense. She met with an oncology social worker, who recommended meditation and reiki, a technique in which practitioners place their hands on or near a person’s body. How reiki works isn’t well understood, but practitioners say the technique stimulates a person’s healing mechanism. Glosik researched reiki online and decided to go ahead with it while she was undergoing chemotherapy.
The effects were immediate, relieving both her pain and fatigue. “I walked into the practitioner’s room feeling like I got hit by a bus, and I walked out and floated for two days,” she says.
Glosik is among a growing number of people diagnosed with cancer who are looking to include nontraditional therapies as a complement to their conventional treatment regimens. These approaches can include massage, acupuncture or reiki; movement activities like yoga or tai chi; and botanical or nutritional supplements.
A review of 61 studies, published in the May 2019 Complementary Therapies in Clinical Practice, found that 51% of more than 20,000 people in the studies, all of whom had been diagnosed with cancer in the previous decade and were undergoing treatment, reported using therapies that would qualify as complementary. In contrast, studies conducted on cancer patients in the 1970s and 1980s found that only about a quarter of people with cancer reported using such approaches.
This growing use has given rise to an inter-disciplinary, patient-centered field called integrative oncology, which aims to incorporate complementary therapies grounded in evidence with conventional cancer treatments to help patients improve their quality of life and manage side effects.
“We’re seeing more and more patients picking up things like meditation, movement therapies and music therapy,” says integrative oncologist Donald Abrams of the University of California, San Francisco Osher Center for Integrative Medicine. “A lot of these activities are about improving quality of life and coping with the distress that can come with a cancer diagnosis.”
Lynda Balneaves, a nurse researcher at the University of Manitoba in Winnipeg, Canada, and president of the Society of Integrative Oncology, advises patients to seek out trusted guidance on complementary medicine. Here are a few credible web resources:
- Find out what herbs, supplements and botanicals may help or hinder your cancer treatment using this online database from Memorial Sloan Kettering Cancer Center in New York City.
- The National Cancer Institute Office of Cancer Complementary and Alternative Medicine offers a workbook that provides tips for patients when talking to health care providers.
- For information on drug interactions related to your treatment, ask your pharmacist. You can also check MedlinePlus, a database of medications and supplements by the U.S. National Library of Medicine.
The rise in popularity of complementary therapies presents challenges. Interested patients may find themselves overwhelmed by choices, not all of them good. There is solid evidence showing that some complementary therapies can safely and effectively ease cancer-related symptoms. Acupuncture, for example, may relieve pain, fatigue and nausea in adults and children undergoing treatment, according to multiple studies.
Yoga has similarly been examined: A review published in the International Journal of Yoga in January 2018 included data from more than 10,000 patients with a variety of cancer types. Most studies reported that yoga, meditation and breathing exercises helped reduce anxiety, sleeplessness and fatigue. (Patients with bone metastases should first consult with their oncologists to avoid yoga positions that could lead to fractures.)
Using dietary and herbal supplements, especially during treatment, is more controversial. Unlike prescription and over-the-counter drugs, which must be approved by the U.S. Food and Drug Administration before they can be used on patients, supplements have less restrictive requirements. They do not need to be proven safe and effective before they hit the store shelves. In addition, they can be expensive and may interfere with how the body metabolizes drugs used in chemotherapy, potentially making the drugs more toxic or less effective. Investigations have shown that many supplements don’t contain the mix of ingredients listed on their labels.
Hundreds of clinical trials have focused on the anticancer effects of supplements, including green tea, mistletoe, pomegranate, selenium and resveratrol, which is found in red wine. Most of these studies have found no survival benefits, and some supplements may increase a person’s risk of a cancer diagnosis or mortality. (For example, while selenium may reduce the risk of lung and gastric cancer in people with low selenium levels, it increases the risk of gastric cancer for everyone else.) So far, there’s no reason to believe that an herb or other supplement can help treat cancer.
In 2016, Glosik began working as a patient advocate with the Society for Integrative Oncology (SIO), a nonprofit professional organization for health care providers, researchers and patient advocates who are interested in advancing evidence-based ways to combine complementary therapy with standard treatments to help cancer patients and their families. She notes that many cancer patients are unaware that these options can help manage side effects.
This may be in part because many doctors don’t discuss integrative options with their patients. For a small study published in May 2019 in the Oncologist, for example, researchers reviewed 529 recorded conversations between doctors and patients at two cancer centers, one in Michigan and the other in Southern California. Only 12% of the conversations included some discussion of integrative therapy. Results of a survey published in the May 2019 issue of JAMA Oncology suggest that about 30% of patients who use complementary medicines don’t tell their health care providers.
Not having conversations about these treatments is a missed opportunity because many patients are unaware of options that could help them manage side effects, says Lynda Balneaves, a nurse researcher at the University of Manitoba in Winnipeg, Canada, and SIO president. Patients seeking information may rely instead on internet searches and advertisements, which often publicize overblown claims. “It’s distressing and concerning that patients might be getting misinformation and making those choices,” she says.
Overhyped claims about complementary approaches can have dire consequences, particularly when patients who use these therapies reject conventional treatments like surgery, chemotherapy and radiation. In these cases, patients use these therapies as alternative treatments to replace rather than complement conventional medicine. In October 2018, the American Society of Clinical Oncology (ASCO) released results from its second annual National Cancer Opinion Survey. Of nearly 5,000 respondents, 39% believed cancer could be cured entirely by alternative therapies.
A study published in the January 2018 issue of the Journal of the National Cancer Institute compared 280 people with nonmetastatic breast, lung, prostate or colorectal cancer who chose alternative treatments and rejected standard ones to 560 patients who underwent standard treatments. All of the patients included in the study had a new diagnosis that carried a good prognosis.
On average, people who chose alternative medicine and rejected conventional therapies were more than twice as likely to die in the five years following diagnosis, researchers found. The risk varied by tumor type. People with breast cancer who chose alternative treatments alone were more than five times as likely to die as those who chose conventional treatments, while the researchers found no difference in survival for men with prostate cancer, likely because most prostate cancers grow slowly. In a related study, researchers found that using complementary therapies alongside conventional treatments was not associated with a higher risk of death.
“It was very clear that people should not be refusing conventional cancer care in favor of these unproven therapies,” says radiation oncologist Skyler Johnson at the Huntsman Cancer Institute in Salt Lake City, who led the study while at Yale University School of Medicine in New Haven, Connecticut. In other work, he’s found that people who used alternative therapies often did not want to undergo the multiple stages of cancer treatment and would omit some components, for example, by choosing surgery but not chemotherapy. But those choices had a clear effect. “People making bad decisions had an increased risk of death,” he says.
What Patients Can Do
Walela Nehanda learned firsthand about assessing the new information that comes with a cancer diagnosis. In 2017, at the age of 23, Nehanda was diagnosed with phase III chronic myeloid leukemia and started taking a daily capsule of the drug Tasigna (nilotinib). The daily dose has exacted a heavy toll: Two years into treatment, the Los Angeles-based community organizer and poet still experiences insomnia, nausea and severe infections. Taking the drug also triggered the onset of pulmonary hypertension.
Nehanda, who identifies as nonbinary, manages side effects with a suite of complementary medicines. “Acupuncture has been a real lifesaver” for stress relief, nausea and gastrointestinal discomfort, says Nehanda, who also uses some cannabis-derived products, including gummy candies that contain cannabidiol (CBD) to help with sleep. Clinical trials focused on CBD, a nonintoxicating compound in cannabis, have found it to be safe for cancer patients, though they haven’t shown evidence of it treating or curing the disease.
Pharmacists and journal studies found online provide reliable information for Nehanda, who knows firsthand what misinformation looks like. Right after diagnosis, Nehanda was deluged with advice, mostly from commenters in online discussions, about supplements and natural cures. Almost all of it was bogus. “People were like, take garlic and you’re cured,” says Nehanda, “but I found that garlic can interfere with Tasigna.”
Nehanda learned to be vigilant and skeptical, but the onslaught of advice became irritating. “I found it to be infantilizing,” Nehanda says. “You really didn’t think I decided to look it up?”
Although the U.S. Drug Enforcement Administration classifies cannabis (marijuana) as a Schedule I drug, it has long been used as a medicine. Marijuana was first legalized as medicine in California in 1996; as of June 2019, 33 states and the District of Columbia had followed suit.
Some people with cancer turn to the drug to treat symptoms and alleviate the often-harsh side effects of treatment, including anorexia, nausea, vomiting, pain, insomnia and anxiety. When marijuana is smoked, however, it contains some of the same carcinogenic chemicals as cigarettes, and at least one small study has linked heavy marijuana use (via smoking) to an increased risk for lung cancer.
Researchers have identified compounds called cannabinoids as some of the active ingredients in marijuana; they include THC (delta-9-tetrahydrocannabinol) and CBD (cannabidiol). Taking cannabinoids has been shown to be safe for most cancer patients. In addition, some cannabis-related treatments have cleared the stringent requirements for safety and effectiveness set by the U.S. Food and Drug Administration (FDA). The FDA has approved three marijuana-related drugs—Marinol (dronabinol) and Syndros (dronabinol), which contain a synthetic form of THC, and Cesamet (nabilone), which contains a compound similar to THC—to treat nausea associated with chemotherapy.
Marijuana dispensaries, which often sell CBD products and other forms of cannabis not approved by the FDA, are popping up across the country, but they pose a challenge to patients and advocates. The CBD oils are expensive and are often sold with unverified claims of anti-cancer benefits.
And then there is the issue of trust. “What is the dosage, and what are you actually getting?” asks Betsy Glosik, a survivor of estrogen-receptor positive, stage II breast cancer who integrated some complementary therapies with her standard treatments. No guidelines exist for how much cannabis to use or in what form.
An Integrated Future
Twelve years ago, when Glosik was being treated for her cancers, she thought oncologists were suspicious of complementary treatments. Since then, clinical trials have provided more information on ways to integrate approaches like acupuncture and meditation while patients undergo conventional treatment. For example, the Sept. 1, 2018, issue of the Journal of Clinical Oncology included integrative oncology guidelines developed by the SIO for oncologists treating breast cancer patients.
The guidelines, based on the outcomes of recent studies, recommend treatments like yoga and meditation for stress; yoga, massage and music therapy for depression; and acupuncture and acupressure for reducing nausea and vomiting caused by chemotherapy. They advise against using a supplement called acetyl-L-carnitine because it can increase nerve pain from chemotherapy, and they report finding a lack of strong evidence for using dietary supplements to manage adverse effects related to treatment.
Glosik sees the guidelines as a step toward fully integrative cancer care. Other efforts suggest integrative oncology is reaching more patients. Many major cancer centers now have integrative medicine centers that steer patients toward safe, evidence-based ways to use complementary therapies.
Patient interest in integrative approaches is so high that Abrams, at UCSF, started organizing group sessions with patients to present information and field questions about nutrition, supplements and other complementary methods.
Balneaves, at SIO, thinks the recent shift to patient-centered care has helped smooth the path for patients seeking integrative care and for providers to become more open to these discussions with patients. “There’s been so much progress in many of these therapies with strong evidence,” she says.
Still, Nehanda, in Los Angeles, thinks it’s nearly impossible for some people to navigate the tricky world of complementary medicine, drug interactions and evidence on their own, which is why it makes sense to consult with experts before trying anything new. Maximizing the benefits of these treatments “requires us to do a lot of self-research and double-checking our sources,” Nehanda says. “Let your care team and caregivers help you with that process.”
September 23, 2019