GUEST EDITOR

Jun J. Mao, MD, MSCE

Integrative Oncology is guest edited by Jun J. Mao, MD, MSCE, Laurance S. Rockefeller Chair in Integrative Medicine and Chief of Integrative Medicine Service at Memorial Sloan Kettering Cancer Center, New York.

The ASCO Post’s Integrative Oncology series is intended to facilitate the availability of evidence-based information on integrative and complementary therapies sometimes used by patients with cancer. In this article, Nirupa Raghunathan, MD, summarizes the available data on integrative medicine in pediatric cancer care and discusses future research challenges in pediatric symptom management. Accumulating evidence suggests the effectiveness of complementary modalities including acupuncture, massage, yoga, dance therapy, and music for mitigating both physical and psychological symptoms.

Nirupa Raghunathan, MD

Approximately 15,780 new cases of cancer are diagnosed in children annually, resulting in 1,960 deaths.¹ For children aged 1 to 19 years in the United States, cancer is the leading cause of death by disease.² Remarkably, advances in cancer treatment over the past 40 years have improved the 5-year survival rate from 10% to nearly 90% in children.^3,4 However, childhood cancer incidence rates have continuously risen since 1975.^5,6

Compared with the adult cancer population, pediatric patients tend to experience higher levels of pain, fatigue, dyspnea, and insomnia.⁷ Many of them may live with these symptoms for years, even after completion of treatment.⁸ Parents and/or caregivers also shoulder a substantial emotional and physical burden due to these symptoms.⁹ As such, palliating physical and emotional symptoms,¹⁰ as well as providing emotional support to pediatric patients throughout their procedures and treatments,^11,12 is an essential standard in care. A brief exploration of the integrative medicine strategies used in supportive care in pediatric cancer populations follows.

Current Research

As defined by the National Center for Complementary and Integrative Health, integrative medicine brings together conventional and complementary treatments (eg, acupuncture, massage, and music therapy) in a coordinated approach with the medical team.¹³ Estimates of the use of integrative therapies for symptom management in children with cancer range from 31% to 84%,^14,15 and evidence suggests that a number of these modalities may benefit this population.^16,17

As integrative strategies have become a mainstay of supporting adult patients with cancer, with ongoing research, soon the same may be true for pediatric patients with cancer.

— Nirupa Raghunathan, MD

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For instance, studies have demonstrated that dance therapy may help reduce the symptoms pediatric patients experience during hospitalization, such as anxiety, pain, and fatigue.^18-20 Additionally, mind-body therapies including meditation, self-hypnosis, guided imagery, and yoga may effectively decrease pain, nausea, and vomiting.^21-28 Music therapy has been demonstrated to improve pediatric patients’ state of mind²⁹ and immune function.³⁰ And massage was reported to decrease depressed mood as well as to increase white blood cell and neutrophil counts.^31,32 Furthermore, acupuncture has been shown to reduce chemotherapy-induced nausea and vomiting in children.³³

Dietary supplements have also been investigated in pediatric populations, including those with leukemia and Hodgkin lymphoma as well as recipients of bone marrow transplants. However, studies involving glutamine, vitamins A and E, and honey for alleviating mucositis yielded mixed results.^34-36 It is important to note here that the protocols across studies were not consistent nor was there a standardized dose.

For hepatotoxicity, small studies found milk thistle, omega-3 fatty acids, and black seed oil to decrease liver enzymes.^37-39 For febrile neutropenia, wheat germ extract, probiotics, and honey showed promise in small studies.^36,40,41

These findings suggest the potential for strengthening supportive care using supplements but also highlight the dearth of research, making evidence-based recommendations challenging to discuss with younger patients and their families.

Unique Considerations in Pediatric Care

When considering supplements and therapies that have been tested in adults for use in younger patients, it is important not to consider children as “little adults.” Due to variations in development and growth, it is not wise simply to adjust the dose based on adult studies. One example is the growing interest in using cannabis for symptom management and or its anticancer effects; evidence shows that the long-term risks of psychiatric disorders are real and should be balanced with the acute benefit in pediatric patients.⁴²

Photo Credit: blogs.rch.org.au

Caregiver support is crucial in cancer care. This is all the more pertinent in pediatric care, as it is integral to the day-to-day management of symptoms. Because the anxieties and concerns of parents can also be mirrored in the child, research on a holistic approach is needed. For example, the potential of family meditation sessions to ease anxiety, and thereby negate psychological harm, should be assessed.

Future Research Challenges

Despite the growing body of evidence indicating the usefulness of integrative therapies in pediatric symptom management, a preponderance of current literature focuses primarily on adult populations. According to the American Cancer Society, the rarity of childhood cancer challenges research development in this field by introducing added cost and complexity to the research

process.⁴³ In addition, age plays an important role in conducting pediatric research, as the distribution of the most common cancer types and the developmental stages (ie, motor, social, or mental maturity processes) in childhood varies by age, complicating eligibility criteria and appropriate assessment.^43,44

Concluding Remarks

Pediatric integrative medicine is a nascent field with great potential and in need of dedicated study. As integrative strategies have become a mainstay of supporting adult patients with cancer, with ongoing research, soon the same may be true for pediatric patients with cancer. Efforts should be made to involve both patients and caregivers in these studies. Pediatric oncology care teams, including oncologists, nurse practitioners, and social workers, should be educated about the variety of integrative therapies that can help mitigate treatment-related symptoms. Through better understanding, we can increase awareness about these modalities to improve the experience of pediatric cancer patients and their families. ■

Dr. Raghunathan is a Pediatric Integrative Medicine Specialist at Memorial Sloan Kettering Cancer Center, New York.

DISCLOSURE: Dr. Raghunathan reported no conflicts of interest.

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