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.
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