More than 80% of breast cancer survivors in the United States rely on some form of complementary or integrative therapies like vitamins, acupuncture, meditation, and yoga. Yet until recently there has been little rigorous research to see if these products and practices are helpful or harmful.
Heather Greenlee, an assistant professor of Epidemiology at the Mailman School of Public Health, developed a new set of clinical practice guidelines on the use of integrative therapies, which she presented on October 27 at the meeting of the Society for Integrative Oncology. After a rigorous review of nearly 5,000 articles published between 1990 and 2013, Greenlee and fellow authors from the Society for Integrative Oncology explored 203 separate randomized control trials of these interventions to establish clinical guidelines for practitioners and breast cancer survivors.
Based on the strength of available evidence, the researchers graded each therapy. Those earning grades of A and B had a high certainty of patient benefit and were recommended for use. Clinical use of therapies at the lower end earned grades of D and H—for harmful—and were discouraged.
“When patients are diagnosed with cancer, they want to know what they can do in addition to receiving the best possible standard of oncology care,” said Greenlee. “They want to know what they can be doing to improve their prognosis and quality of life, and manage symptoms and side effects of conventional cancer treatment.”
At the Mailman School, Greenlee teaches students to apply epidemiologic methods to complementary and alternative medicine, and she considers rigorous study of complementary therapies an emerging public health responsibility. While the article acknowledges that breast cancer patients need the best of standard medical care in addition to the science-based use integrative therapies, its authors recognized that the growing popularity of integrative therapies, and the U.S. Food and Drug Administration’s lack of oversight, this area of research is an important role for public health scientists.
“We need to figure out what works and doesn’t work, what’s safe and what’s not safe,” she said. “After all, these therapies are all researchable. We want to study them from the medical practice side, to consider what patients need to be offered, and to study them from the public health side, what’s important for the public’s safety and well-being.”
Greenlee’s guidelines demonstrated that a number of integrative therapies show promising results for symptom and side-effect management and should be offered to breast cancer patients. Those earning As and Bs included meditation and yoga for anxiety, depression and mood disorders, and acupuncture for nausea and vomiting.
Therapies that the study recommended against using were, among others, glutamine for nausea and vomiting, soy for treatment of hot flashes, and aloe vera for skin problems associated with radiation. For treatment of neuropathy, a common side effect of some chemotherapy drugs, the review found strong evidence that acetyl-L-carnitineis actually harmful to the patient and its use should be discontinued.
The larger question posed by the guidelines, and by Greenlee herself, is how public health science can be brought to bear on a growing marketplace in complementary and integrative medicine. While medical oncology combats cancer at the cellular level, many patients have an understandable desire to manage other aspects of their illness. In some cases, integrative therapies provide enough benefit to extend the period of time a patient can receive medical treatment, increasing quality of life, and perhaps prolonging life itself.
“The person is much more than their disease,” Greenlee says. “We want them to invest wisely in therapies that work."