The top two barriers to accessing complementary and integrative therapies, according to a survey of 576 patients with cancer and caregivers, were cost, cited by 56%, and a lack of knowledge about the therapies, cited by 52.1%. “Other barriers included a lack of time (29.2%), location of the services (31.5%), and a lack of interest (23.3%),” according to Larbi et al in JCO Oncology Practice.¹

The survey included 464 patients with cancer treated at University Hospitals Seidman Cancer Center, Case Western University School of Medicine Comprehensive Cancer Center, Cleveland, and 112 caregivers. All were asked about their past experiences with, interest in, and willingness to pay for five integrative therapy services: acupuncture, therapeutic massage, music therapy, meditation therapy, and yoga therapy.

“One of the questions we asked is patients’ interest level in integrative therapies if recommended by their medical team,” Richard T. Lee, MD, the report’s corresponding author, said in an interview with The ASCO Post. “We could see that their interest goes up significantly, somewhere between 10% to 15%, depending on the modality.”

Richard T. Lee, MD

Dr. Lee continued: “We always want our patients to be proactive in learning about their options.” However, it is the responsibility of a cancer center’s medical professionals “to provide information and guidance about what resources are available, including integrative therapies.” Dr. Lee is Director of Supportive and Integrative Oncology at University Hospitals Seidman Cancer Center.

Study Population

Among the total of 576 patients and caregivers responding to the survey in this single-institution study, 57.2% were female, and 68.8% were at least 50 years old. “The majority of respondents identified as White (65.6%), but there was a significant population of racial minorities (34.4%), of which the majority identified as Black or African American (28.3%),” the authors reported. “The three most common cancer types among the patients surveyed were hematologic (21.8%), breast (16.6%), and gastrointestinal (14.4%).”

More than half of those responding to the survey (51.4%) had used at least one of the five integrative services. Leading the list was therapeutic massage, used by 33.4%; followed by music therapy, used by 18.2%; meditation therapy, used by 15.8%; yoga therapy, used by 15.4%; and acupuncture, used by 12%.

The greater interest and use of massage therapy may be because “massage is very accessible and commercially available,” Dr. Lee ventured. “Many people are aware of it and may have actually used it in the past. It is a little more tangible than, for example, acupuncture, which may be a bit more mysterious.”

“Although caregivers had fewer experiences with these services overall, they had significantly more experience with yoga therapy than did patients (23.5% vs 13.3%),” the researchers reported.

Increased Interest

“When initially surveyed about the service, respondents were most interested in therapeutic massage (52.8%), followed by music therapy (36.9%), meditation therapy (35.7%), yoga therapy (34.6%), and acupuncture (30.1%),” the researchers reported. “When recommended by medical professionals, interest increased for all services by an average of 11.7%—specifically therapeutic massage (61.1%), music therapy (51.6%), yoga therapy (47.8%), meditation therapy (46.9%), and acupuncture (41.4%).”

Interest in some services also increased if they were provided for free as part of a clinical trial, “but not to the same degree as a recommendation from a medical professional,” the authors noted.

The Cost Factor

The cost of integrative therapies “is one of the reasons we did this survey,” Dr. Lee commented. “There is this debate among our team about how much cost is a barrier. Some believe it really wasn’t a barrier, but rather that we aren’t educating people enough or explaining integrative therapies well enough.”

In his own practice, however, Dr. Lee found that even after he talked to patients about integrative therapies and explained how meditation, acupuncture, or another therapy might be of benefit, “when they hear about the cost, that is a major barrier. Most of these services are provided in the community for much more than $60 for a single session, and the number of patients who are willing to pay beyond $60 is pretty low,” Dr. Lee pointed out. “It is probably underappreciated how much cost is a barrier.”

The survey found that, in general, less than 20% of those responding would pay $60 for a single session of any of the five integrative therapies in the study. About one-quarter to one-third of those responding were willing to pay $1 to $20 for a single session, and a similar proportion would pay $20 to $60. “A significant number of patients would not pay any amount for these services,” the researchers reported.

“When I give talks either here in Cleveland or at other institutions, one of the mostly commonly asked questions concerns what services are covered by insurance,” Dr. Lee said. “It is clear to me that oncologists are aware of financial issues when it comes to treatment, including with integrative therapies, and that, oftentimes, it is not covered by insurance. It is an out-of-pocket expense.”

In Addition to, Not Instead of, Conventional Treatment

Complementary and integrative medicine, as defined in the study, “focuses on evidence-based therapies that work in conjunction with conventional medical treatment rather than the use of alternative therapies that lack evidence for safety and efficacy.” In Dr. Lee’s experience, most patients do understand that integrative therapies work in conjunction with conventional medical treatment and should not be used instead of conventional treatment.

“As an integrative oncologist, I found a fair number of patients are open to talking about what the evidence is and the right approach,” Dr. Lee said. Some of these patients are already “open to the idea of maybe trying something different, like meditation,” rather than medication for pain, anxiety, or trouble sleeping.

Other patients listen to the evidence but choose not to use integrative therapies. “And then there are those who may not necessarily have an evidence-based approach and may think of integrative therapies as alternatives to medical therapy,” Dr. Lee stated. “A small percentage want to pursue these integrative therapies as an alternative to medical therapy. Data indicate this is a relatively small percentage of our patients, probably up to 5%. It is the onus of health-care providers to try to educate them.”

We want [complementary services] all integrated together with social work and physical therapy, so there is no real separation. That has been our goal…

— Richard T. Lee, MD

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Being in Control

Patient interest in complementary and integrative medicine may be related to “their health, symptoms, and desire for control over their own medical treatment,” the study report noted.

“Other studies have identified having some control over what is happening as a factor in why patients may choose integrative therapies,”^2,3 Dr. Lee said. “Especially in cancer, with surgery, chemotherapy, and radiation therapy—things that patients really don’t have much control over. Control is one aspect that appeals to patients.”

Incorporated Into Guidelines

As a result of clinical research showing the benefit of complementary and integrative medicine for symptom management during cancer treatment, these therapies “are increasingly being incorporated into national guidelines for cancer care,” the authors pointed out.

“These guidelines are really helping to move the field forward and providing a degree of acceptance,” Dr. Lee noted. They include not only guidelines from cancer-focused organizations such as ASCO and the National Comprehensive Cancer Network (NCCN). “The American College of Physicians guidelines on low back pain, which came out a couple of years ago, specifically included the use of therapies such as acupuncture, meditation, and mind-body approaches,” Dr. Lee stated. “When you see these services listed in well-respected national guidelines, physicians are really taking another look at them.”

In addition, “driving this incorporation” of integrative therapies into guidelines “is the opioid epidemic. We need to do a better job and think beyond an opioid, or even a medicine, and there are evidence-based therapies that can provide patients with relief without depending on a pill,” noted Dr. Lee.

Some complementary and integrative medicine therapies have been shown to relieve pain and distress. In addition, they “may provide a cost-effective method for managing symptoms, reducing the [number] of opioids prescribed, and decreasing the risk of addiction among oncology patients,” the authors wrote.

Integrating Integrative Therapies

The Supportive and Integrative Oncology program at ­Seidman Cancer Center was created 5 years ago, with Dr. Lee as its Founding Director. He provides inpatient integrative oncology consultations, answering patients’ questions about integrative therapies and helping patients build treatment plans.

One of the big challenges Dr. Lee sees is how to integrate integrative therapy into a more encompassing supportive care program. “The traditional model is that integrative therapy clinics exist outside the main medical center,” Dr. Lee pointed out. “People have to travel to another place, and it is fee for service.” To bring these therapies into a cancer center would mean thinking about acupuncture, meditation, massage, or other integrative therapies similar to physical therapy, “which is well accepted and plays an important role in hospital care, including cancer care,” Dr. Lee noted. “How can we think about integrative therapies more like that, rather than as separate outside services?”

Currently, the Supportive and Integrative Oncology program at Seidman Cancer Center in collaboration with the Connor Integrative Health Network includes music and art therapy and last year piloted an acupuncture service. Open to both inpatients and outpatients, the acupuncture service relied on a sliding scale “to bring down the costs,” Dr. Lee said. The program proved successful, and “we are looking at ways to restart that program with the models we created. We are probably going to try a similar model with massage therapy once we get acupuncture going again. It really made us think about innovative ways to provide these types of services within a cancer center,” Dr. Lee remarked.

“We want it all integrated together with social work and physical therapy, so there is no real separation. That has been our goal, although it is challenging,” Dr. Lee said. “We are trying to create a new model, and it is not always easy, but that is our vision.”

Institutional Support

“We need to have the support of administration at all levels for bringing these types of therapies into a cancer center. Leadership has to be on board,” Dr. Lee continued. “One of the challenges is that these types of therapies aren’t necessarily revenue-generating, but they are clearly important, just like access to chaplaincy, dietitians, and social workers. They add value and help improve the care of our patients. We need to think about integrative approaches as another key tool to help patients through their treatment and survivorship.”

Dr. Lee continued: “We need to think of innovative ways to make sure there is access to these therapies. Part of that is education. Part of that is the financial model we utilize.”

“Given that cost was the largest barrier for patients to use integrative oncology services, the financial toxicity of cancer is a major issue to consider when designing integrative oncology programs,” the authors emphasized. “Integrative services are designed to improve the mental, emotional, and physical health outcomes of patients, but if they are priced too high, then they will not be used. When designing programs, these factors must be considered to make it more financially feasible to participate in integrative oncology services.” 

DISCLOSURE: Dr. Lee has received institutional research funding from Merck and Tracon Pharmaceuticals and has held other relationships with Grow Ohio Pharmaceuticals.

REFERENCES

1. Larbi OM, Jiang C, McLane B, et al: Interest and willingness to pay for integrative therapies of patients with cancer and caregivers. JCO Oncol Pract. January 22, 2021 (early release online).

2. Astin JA: Why patients use alternative medicine: Results of a national study. JAMA 279:1548-1553, 1998.

3. Mao JJ, Palmer CS, Healy KE, et al: Complementary and alternative medicine use among cancer survivors: A population-based study. J Cancer Surviv 5:8-17, 2011.