October 2018

Abrams DI. An Integrative Approach to Prostate Cancer. J Altern Complement Med 2018 Sep/Oct;24(9-10):872-880 PMID 30247964

OBJECTIVES: The mostly indolent natural history and long overall survival associated with a diagnosis of prostate cancer provides a unique opportunity for men to explore diet and lifestyle interventions to alter the trajectory of their disease. As many patients may be appropriate for postponing conventional therapy, the effects of various integrative interventions can be investigated. In addition, treatment of prostate cancer with surgery, radiation, or androgen deprivation therapy, all may produce physical or psychological side effects that could be amenable to complementary therapies. This article serves to review salient information in the published literature. DESIGN: A review of published research was conducted. RESULTS: A plant-based antioxidant-rich diet with an emphasis on cruciferous vegetables, tomatoes, soy, pomegranate, and marine omega 3 fatty acids while avoiding saturated fats, including dairy products is the best option. Supplementation with vitamin D3, omega 3, and some nutraceutical-based preparations may be advised. It is likely prudent to avoid vitamin E and selenium supplements. Physical activity has been shown to have multiple benefits in men diagnosed with all stages of prostate cancer from strengthening bones, improving body habitus, and enhancing overall wellbeing. Yoga, combining physical activity with a mind-body component, has been shown to have a salutogenic effect in both prostate cancer patients and their caregivers. Traditional Chinese Medicine may be particularly useful in managing side effects of conventional treatments, especially the hot flashes associated with androgen deprivation therapy. Although the long natural history, availability of a useful blood marker of disease progression and prolonged survival are overall positive features, they also combine to allow men to live for a long time with diagnosed cancer, fear of progression, or recurrence and fixation on changes in their prostate-specific antigen level. The resultant stress can be deleterious to general health as well as possibly the natural history of their disease. Mind-body interventions to reduce stress, including mindfulness-based stress reduction and support groups may be useful adjunctive therapies. CONCLUSION: Men with prostate cancer may benefit from lifestyle and complementary interventions integrated with their conventional care.

Adair M, Murphy B, Yarlagadda S, Deng J, Dietrich MS, Ridner SH. Feasibility and Preliminary Efficacy of Tailored Yoga in Survivors of Head and Neck Cancer: A Pilot Study. Integr Cancer Ther 2018 Sep;17(3):774-784 PMID 29355046

PURPOSE: Treatment for head and neck cancer (HNC) results in long-term toxicities and increased physical and psychosocial survivor burden. There are a limited number of treatments for these late effects. Yoga postures, breath work, relaxation, and meditation, may improve these late effects. The purpose of this study was to examine the feasibility of a tailored yoga program in HNC survivors and obtain preliminary efficacy data. METHODS: This was a randomized wait-list control study of yoga-naive HNC survivors who were >3 months post-cancer treatment. Baseline data were collected. Participants were randomized to either an 8-week hatha yoga intervention group or a wait-list group. Feasibility and efficacy data were collected. At 4 and 8 weeks, patients underwent a repeat assessment of health. Wait-list control group participants were offered the yoga program after data collection. Descriptive statistics evaluated feasibility. Mixed effects general linear models were used to generate estimates of the efficacy outcomes. RESULTS: Seventy-three individuals were screened and 40 were eligible. All eligible individuals consented and enrolled. Five of the intervention group discontinued early and none in the wait-list control group. Feasibility was affirmed as participants were recruited and retained in the study, there were no adverse events, fidelity to protocol was demonstrated, and satisfaction rates were high. Efficacy measures indicated potential benefit for shoulder range of motion ( d = 0.57-0.86, P < .05), pain ( d = 0.67-0.90, P </= .005), and anxiety ( d = 0.59, P = .015). CONCLUSION: A tailored hatha yoga program is feasible and potentially efficacious for HNC survivors. Preliminary data supports further investigation of yoga in this population is needed.

Andersen MR, Sweet E, Hager S, Gaul M, Dowd F, Standish LJ. Use of Integrative Oncology, Involvement in Decision-Making, and Breast Cancer Survivor Health-Related Quality of Life in the First 5 Years Postdiagnosis. Integr Cancer Ther 2018 Sep;17(3):636-645 PMID 29607686

OBJECTIVE: This study sought to describe changes in the health-related quality of life (HRQOL) of women who do and do not seek naturopathic oncology (NO) complementary and alternative medicine (CAM) care during and immediately after breast cancer treatment, and to explore the predictive role of NO CAM care, demographic characteristics, and involvement in decision-making on HRQOL in breast cancer survivors. METHODS: Matched cohorts of breast cancer survivors who did and did not choose to supplement their breast cancer treatment with NO care within 2 years of diagnosis participated. NO users were identified through naturopathic doctors' clinics and usual care (UC) controls with similar prognosis were identified through a cancer registry. The registry provided information about all participants' age, race, ethnicity, marital status, stage of cancer at time of diagnosis, date of diagnosis, and use of conventional medical treatments (surgery, chemotherapy, radiation, and endocrine therapy). Data of participants' self-reported involvement in decision-making and HRQOL were collected at study enrollment and at 6-month follow-up. RESULTS: At 6-month follow-up, the NO patients reported significantly more involvement in decision-making about care and better general health than did UC patients ( P < .05). Self-reported involvement in decision-making about cancer treatment was associated with better role-physical, role-emotional, and social-functional well-being ( P < .05). Race, age, marital status, and congruence of preferred and achieved levels of involvement also predicted aspects of HRQOL in breast cancer survivors ( P < .05). CONCLUSIONS: Both NO CAM care and involvement in decision-making about cancer treatment may be associated with better HRQOL in breast cancer survivors.

Bao T, Li Q, DeRito JL, Seluzicki C, Im EO, Mao J. Barriers to Acupuncture Use Among Breast Cancer Survivors: A Cross-Sectional Analysis. Integr Cancer Ther 2018 Sep;17(3):854-859 PMID 29338443

INTRODUCTION: Increasing evidence suggests that acupuncture may be helpful to manage common symptoms and treatment side effects among breast cancer (BC) survivors. Acupuncture usage among BC survivors remains low with little known about the barriers to its utilization. We evaluated perceived barriers to acupuncture use among BC survivors and explored the sociodemographic variations of such barriers. METHODS: We conducted a cross-sectional analysis at an urban academic cancer center on 593 postmenopausal women with a history of stage I-III hormone receptor-positive BC who were taking or had taken an aromatase inhibitor. We used the modified Attitudes and Beliefs about Complementary and Alternative Medicine instrument to evaluate patients' perceived barriers to acupuncture. Multiple linear regression analysis was performed to determine sociodemographic factors associated with perceived barrier scores. RESULTS: The most common barriers were lack of knowledge about acupuncture (41.6%), concern for lack of insurance coverage (25.0%), cost (22.3%), and difficulty finding qualified acupuncturists (18.6%). Compared with whites, minority patients had higher perceived barriers to use acupuncture (beta coefficient = 1.63, 95% confidence interval = 0.3-2.9, P = .013). Patients with lower education had higher barriers to use acupuncture (beta coefficient = 4.23, 95% confidence interval = 3.0-5.4, P < .001) compared with patients with college education or above. CONCLUSION: Lack of knowledge and concerns for insurance coverage and cost are the common barriers to acupuncture use among BC survivors, especially among minority patients with lower education. Addressing these barriers may lead to more equitable access to acupuncture treatment for BC survivors from diverse backgrounds.

Bao T, Seidman AD, Piulson L, Vertosick E, Chen X, Vickers AJ, et al. A phase IIA trial of acupuncture to reduce chemotherapy-induced peripheral neuropathy severity during neoadjuvant or adjuvant weekly paclitaxel chemotherapy in breast cancer patients. Eur J Cancer 2018 Sep;101:12-19 PMID 30007894

PURPOSE: Chemotherapy-induced peripheral neuropathy (CIPN) is a common and potentially dose-limiting side-effect of neurotoxic chemotherapy for cancer patients. We evaluated the preliminary efficacy of acupuncture in preventing worsening CIPN in patients receiving paclitaxel. METHODS: In this phase IIA single-arm clinical trial, we screened stage I-III breast cancer patients receiving neoadjuvant/adjuvant weekly paclitaxel for development of CIPN. The primary objective was to assess acupuncture's efficacy in preventing the escalation of National Cancer Institute-Common Toxicity Criteria for Adverse Events (NCI-CTCAE), version 4.0, grade II CIPN to higher grades. Acupuncture was deemed worthy of further study if 23 or more of the 27 enrolled patients did not develop grade III CIPN. Outcome measures (NCI-CTCAE CIPN grade, Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity [FACT/GOG-Ntx], Neuropathic Pain Scale [NPS]) were obtained weekly during the intervention. RESULTS: Of 104 patients screened, 37 developed grade II CIPN (36%), and 28 (27%) enrolled into the intervention phase; one was removed due to protocol violation. Of the 27 patients receiving acupuncture, 26 completed paclitaxel treatment without developing grade III CIPN, meeting our prespecified success criteria for declaring acupuncture worthy of further study. FACT/GOG-Ntx and NPS scores remained stable during the intervention while continuing weekly paclitaxel. Acupuncture treatment was well tolerated; 4 of 27 (15%) patients reported grade I bruising. CONCLUSIONS: Acupuncture was safe and showed preliminary evidence of effectiveness in reducing the incidence of high grade CIPN during chemotherapy. A follow-up randomised controlled trial is needed to establish definitive efficacy in CIPN prevention for patients at risk.

Bozza C, Gerratana L, Basile D, Vitale MG, Bartoletti M, Agostinetto E, et al. Use and perception of complementary and alternative medicine among cancer patients: the CAMEO-PRO study : Complementary and alternative medicine in oncology. J Cancer Res Clin Oncol 2018 Oct;144(10):2029-2047 PMID 30043280

BACKGROUND: It is estimated that about half of cancer patients use at least one form of complementary and alternative medicines (CAM) in their life but there is a strong reticence of patients in talking about CAM with their oncologist. Primary aim of this study was to inform patients about CAM, focusing on their supposed benefits, toxicities and interactions with conventional therapeutic agents. The study also explored patients' perception about CAM and ascertained the level of CAM use among cancer patients of an Italian academic hospital. METHODS: From April 2016 to April 2017, the observational pilot trial "CAMEO-PRO" prospectively enrolled 239 cancer patients that were invited to attend a tutorial about CAM at the Department of oncology, University Hospital of Udine, Italy. Before and after the informative session, patients were asked to fill a questionnaire reporting their knowledge and opinion about CAM. RESULTS: Overall, 163 (70%) women and 70 (30%) men were enrolled. Median age was 61 years. At study entry, 168 (72%) patients declared they had never been interested in this topic previously; 24 patients (11%) revealed the use of a type of alternative therapy and 58 (28%) revealed the use of complementary therapy. In total, 139 (55.2%) patients attended the informative session. Bowker's test of symmetry demonstrated statistically significant opinion's change after the session on 9 out of 14 explored items. CONCLUSIONS: Informative sessions seem to have a relevant impact on patients' perceptions and opinions about CAM.

Carlson LE, Oberoi DV, Qureshi M, Subnis U. Integrative Oncology Trials in the Real World: Assessing the Pragmatism of an Ongoing Integrative Oncology Trial of Mindfulness and T'ai Chi/Qigong. J Altern Complement Med 2018 Sep/Oct;24(9-10):926-932 PMID 30247962

OBJECTIVES: The aim of this study was to highlight features of pragmatic real-world integrative oncology research by applying the PRagmatic Explanatory Continuum Indicator Summary (PRECIS-2) criteria to an ongoing integrative oncology clinical trial. The ongoing trial is a preference-based randomized comparative effectiveness trial of mindfulness-based cancer recovery (MBCR) versus t'ai chi/qigong (TCQ) for cancer survivors (the Mindfulness and T'ai Chi for Cancer Health [MATCH] study). The primary outcome of the MATCH study is distress, and secondary outcomes are quality of life, sleep disturbance, and physical functioning. The clinical trial is being undertaken at tertiary care cancer centers across two sites in Canada: Calgary (AB) and Toronto (ON), with a sample of 600 cancer survivors who have finished all cancer treatments and are distressed. METHODS AND RESULTS: The MATCH trial was scored on the explanatory-pragmatic continuum for each of the nine domains of the PRECIS-2 criteria on a scale of 1-5, and was rated as more explanatory than pragmatic, despite initial design efforts being more pragmatic. Areas that were least pragmatic were methods of recruitment, follow-up, and intervention delivery. The more pragmatic areas were setting, outcomes, and data analysis. CONCLUSIONS: More efforts toward conducting pragmatic trials are needed in the field of integrative oncology, as cancer-care institutions and policy makers are looking for sustainable interventions within already established treatment models. The PRECIS-2 criteria can help researchers meet these goals in the planning stages of trial development.

Chen X, Gong X, Shi C, Sun L, Tang Z, Yuan Z, et al. Multi-focused psychosocial residential rehabilitation interventions improve quality of life among cancer survivors: a community-based controlled trial. J Transl Med 2018 Sep 6;16(1):250-018-1618-0 PMID 30189876

BACKGROUND: Even though multi-focused psychosocial residence rehabilitation intervention (MPRRI) programs are widely implemented by the Shanghai Cancer Rehabilitation Club, these programs have not been rigorously evaluated. In this study, we evaluated the effects of a 21-day MPRRI program, on the quality of life (QoL) among cancer survivors. METHODS: A total of 388 cancer patients were enrolled to either receive the 21-day MPRRI (n = 129) intervention or a waiting-list comparison (WLC) intervention (n = 259). The intervention group was offered community-based 21-day MPRRI program, combining supportive-expressive group, cognitive-behavioral therapy, and Guolin Qigong. QoL was measured using the European Organization for Research and Treatment Quality of Life Version 3 Questionnaire. Multivariable linear models were used to compare changes in QoL values between the two groups. RESULTS: After adjustment for the QoL score and other covariates at baseline, there was no significant difference in global health status (mean = 3.8, 95% CI - 1.3-9.0, P = 0.14) between the two groups after 6 months intervention. While compared with the WLC group, the intervention group showed significant improvements in the QoL score (all P < 0.05); however, there were no clinically relevant changes in subscales including emotional functioning (ES = 0.58), cognitive functioning (ES = 0.53), pain (ES = 0.52), physical functioning (ES = 0.36), and insomnia (ES = 0.30). CONCLUSIONS: These preliminary results suggest the MPRRI program is both feasible and acceptable intervention for cancer survivors in community settings and is effective in significant improving QoL above.

Dangi AA, Aurangabadkar SK, Deo MV. Effect of a Structured Yoga Program on Fatigue, Depression, Cardiorespiratory Fitness, and Quality of Life in a Postmenopausal Breast Cancer Survivor. Int J Yoga 2018 Sep-Dec;11(3):255-257 PMID 30233122

A 52-year-old postmenopausal female diagnosed with duct carcinoma of the left breast underwent modified radical mastectomy 2 years ago. She had completed six cycles of chemotherapy postsurgery and complained of significant fatigue and depression. Her fatigue score on Piper Fatigue Scale was 4.1 and depression score on Beck's Depression Inventory was 22. She had a poor 6-min walking distance and a reduced quality of life. She was given a structured yoga program for 40 min five times a week for 4 weeks. Results showed a marked reduction in fatigue and depression scores and improvement in cardiorespiratory fitness. Her quality of life also showed improvement after the structured yoga therapy. This case report highlights the benefits of yoga for reducing fatigue, depression, and improving the cardiorespiratory fitness and overall quality of life in a breast cancer survivor.

Dionne A, Goulet S, Leone M, Comtois AS. Aquatic Exercise Training Outcomes on Functional Capacity, Quality of Life, and Lower Limb Lymphedema: Pilot Study. J Altern Complement Med 2018 Sep/Oct;24(9-10):1007-1009 PMID 30247973

OBJECTIVE: To investigate whether patients with lower limb lymphedema (LLL) can benefit from water immersion exercise training to improve functional capacity, quality of life (QOL), and help control/diminish limb volume. DESIGN: A before-after trial. SETTING: A community University Sports Center. SUBJECTS: Eleven participants were recruited to participate and four declined to pursue the study for personal reasons. A convenient sample of seven female affected by either bilateral or unilateral LLL volunteered for this pilot study. Patients had primary or secondary lymphedema as complications of melanoma or gynecologic cancers. INTERVENTIONS: An aquatic training exercise intervention of moderate to vigorous intensity was conducted for a 6-week period (12 sessions of 45 min). This innovative circuit training program consisted of yoga exercises, aqua-jogging, pedaling on a water bike, and muscular training on an aquastep and a trampoline. OUTCOME MEASURES: The physical characteristics of water could be used to overcome the physical and medical limitations encountered on dry land for patients with LLL to exercise and reach training benefits. Outcome measures were the 6-min walk test (6MWT), handgrip strength test, QOL for limb lymphedema questionnaire (LYMQOL), bioelectrical impedance spectroscopy, and limb circumference. RESULTS: The distance covered in the 6MWT and the handgrip strength were significantly improved. A trend toward an increase in the overall QOL score was noticeable, whereas a significantly improved emotions score was observed with the LYMQOL questionnaire. Limb circumferential volume was significantly lower and impedance was increased, denoting a decrease in lymphatic fluid. CONCLUSIONS: Innovative aquatic exercise training program allows moderate and vigorous intensity activities for patients with LLL, increases functional capacity and QOL. Thus, immersion exercise does not appear to exacerbate LLL and a randomized clinical trial with larger numbers is essential to consolidate the results of this study.

Eriksen WT, Singerman L, Romero SAD, Bussell J, Barg FK, Mao JJ. Understanding the Use of Acupuncture for Insomnia Among Cancer Survivors: A Qualitative Study. J Altern Complement Med 2018 Sep/Oct;24(9-10):962-967 PMID 30247951

OBJECTIVE: To understand cancer survivors' perceptions regarding the use of acupuncture for the treatment of cancer-related insomnia. DESIGN: Semistructured interviews with cancer survivors participating in a randomized controlled trial comparing the effectiveness of Cognitive Behavioral Therapy for Insomnia (CBT-I) and acupuncture for the treatment of insomnia. Interviews were conducted before randomization into either treatment option, and structured to elicit participants' experiences with insomnia as well as their beliefs and understanding surrounding acupuncture for the treatment of insomnia. An integrated approach was used for data analysis. SUBJECTS: Sixty-three cancer survivors with DSM-V diagnosed insomnia. RESULTS: Participants shared a broad lack of understanding regarding acupuncture for the treatment of insomnia. Specifically, individuals in this study expressed confusion surrounding what symptoms or medical conditions acupuncture could be used to treat, how acupuncture works, and how long the effects of acupuncture last. CONCLUSIONS: This study identified three specific gaps in knowledge, including treatment target, mechanism, and durability, surrounding the use of acupuncture for insomnia in cancer survivors. Addressing these gaps by providing appropriate and timely education surrounding the use of acupuncture to treat insomnia is essential to increase the evidence-informed utilization of acupuncture and to better meet patients' needs among cancer survivors.

Frawley JE, McIntyre E, Sibbritt D, Wardle J, Schloss J, Lauche R, et al. Associations Between Cancer Screening Behavior and Complementary Medicine Use: Results of a National Cross-Sectional Survey of 9151 Australian Women. Integr Cancer Ther 2018 Sep;17(3):979-985 PMID 29896978

INTRODUCTION: Complementary medicine (CM) use has been found to influence the uptake of conventional cancer treatment. This study examines associations between CM use and cancer screening rates. METHODS: Women aged 62 to 67 years from the Australian Longitudinal Study on Women's Health were surveyed regarding their use of cancer screening initiatives. Associations between cancer screening behavior and visits to CM practitioners were analyzed. RESULTS: Of the 9151 women, 9049 (98.9%) completed questions about cancer screening. A total of 65.1% of women had received a clinical skin examination, 54.3% colorectal cancer screening, 56.2% Pap test (within past 2 years), 83.3% mammogram (within past 2 years), 55.8% clinical breast examination, and 55.8% had conducted breast self-examination. Women who had consulted a massage therapist were more likely to undergo clinical skin examination ( P = .002), clinical breast examination ( P = .018), and mammogram ( P = .001). Women who had consulted a chiropractor were more likely to undergo a clinical skin examination ( P = .001), colorectal cancer screening ( P = .020), and mammogram ( P = .011). Women who had consulted an acupuncturist were more likely to undergo colorectal cancer screening ( P = .019), and those who consulted with an osteopath were more liable to have a Pap test ( P = .049). CONCLUSION: Women who visit CM practitioners are more likely to participate in cancer screening initiatives. Research is required to understand the current and potential role that CM practitioners (can) have as public health advocates, recommending preventative health measures such as cancer screening. Such an examination will help ensure optimal screening utilization and effective, timely care for all cancer patients.

Frenkel M, Slater R, Sapire K, Sierpina V. Complementary and Integrative Medicine in Lung Cancer: Questions and Challenges. J Altern Complement Med 2018 Sep/Oct;24(9-10):862-871 PMID 30247955

Lung cancer represents 13% of all cancers, making it the second most common type of malignancy in the United States. Lung cancer is the leading cause of cancer death in men and women in the United States and accounts for nearly 18% of all deaths from cancer. Because of its high mortality rate, lung cancer is associated with an increased rate of distress. Patients use various strategies to cope with this distress during and after cancer treatments, and complementary and integrative medicine (CIM) has become a common coping strategy. This review covers major questions and challenges of incorporating CIM during and beyond treatment for lung cancer. The questions revolve around determining the value of nutrition and nutritional supplements, assessing the role of exercise, addressing the mind-body connection, enhancing the benefit of immunotherapy, and determining the benefit of incorporating complementary therapies such as acupuncture and homeopathy. This review may provide a basis for discussion that can enhance patient-doctor dialogue regarding the use of CIM during and after treatment for lung cancer.

Gentile D, Boselli D, O'Neill G, Yaguda S, Bailey-Dorton C, Eaton TA. Cancer Pain Relief After Healing Touch and Massage. J Altern Complement Med 2018 Sep/Oct;24(9-10):968-973 PMID 30247960

OBJECTIVES: To establish and compare the effectiveness of Healing Touch (HT) and Oncology Massage (OM) therapies on cancer patients' pain. DESIGN: pretest/post-test, observational, retrospective study. SETTINGS/LOCATION: Outpatient oncology setting at an academic hybrid, multisite, community-based cancer institute. SUBJECTS: n = 572 cancer outpatients. INTERVENTIONS: Patients reported pain before and after receiving a single session of either HT or OM from a certified practitioner. OUTCOME MEASURES: Pain scores from 0 = no pain to 10 = worst possible pain. RESULTS: Two hundred ninety-one patients (50.9%) receiving HT and 281 (49.1%) receiving OM reported pretherapy and post-therapy pain. Pretherapy mean pain was higher in HT patients (M = 5.1, +/-2.2) than OM (M = 4.4, +/-2.2), p /=2-point reduction in pain score) were 0.68 HT and 0.71 OM. Adjusted for pretherapy pain, OM was associated with increased odds of pain improvement (odds ratio [OR] 1.49 95% confidence interval (1.02-2.19); p = 0.041). For patients with severe pretherapy pain, OM was not more effective in yielding clinically significant pain reduction (p = 0.236) when adjusting for pretherapy pain score. CONCLUSIONS: Both HT and OM provided immediate pain relief. Future research should explore the duration of pain relief, patient attitudes about HT compared with OM, and how this may differ among patients with varied pretherapy pain levels.

Gonzalez-Hernandez E, Romero R, Campos D, Burychka D, Diego-Pedro R, Banos R, et al. Cognitively-Based Compassion Training (CBCT((R))) in Breast Cancer Survivors: A Randomized Clinical Trial Study. Integr Cancer Ther 2018 Sep;17(3):684-696 PMID 29681185

CONTEXT: Breast cancer (BC) requires a significant psychological adaptation once treatment is finished. There is growing evidence of how compassion training enhances psychological and physical well-being, however, there are very few studies analyzing the efficacy of compassion-based Interventions on BC survivors. OBJECTIVE: To study the efficacy of the Cognitively-Based Compassion Training (CBCT) protocol in a BC survivor sample on quality of life, psychological well-being, fear of cancer recurrence, self-compassion, and compassion domains and mindfulness facets. Furthermore, enrollment, adherence, and satisfaction with the intervention were also analyzed. METHODS: A randomized clinical trial was designed. Participants (n = 56) were randomly assigned to CBCT (n = 28) or a treatment-as-usual control group (TAU; n = 28). Pre-post intervention and 6-month follow-up measures took place to evaluate health-related quality of life, psychological well-being; psychological stress, coping strategies, and triggering cognitions; self-compassion and compassion; and mindfulness in both intervention and wait-list groups. RESULTS: Accrual of eligible participants was high (77%), and the drop-out rate was 16%. Attendance to CBCT sessions was high and practice off sessions exceeded expectations). CBCT was effective in diminishing stress caused by FCR, fostering self-kindness and common humanity, and increasing overall self-compassion scores, mindful observation, and acting with awareness skillsets. CONCLUSION: CBCT could be considered a promising and potentially useful intervention to diminish stress caused by FCR and enhance self-kindness, common humanity, overall self-compassion, mindful observation, and acting with awareness skillsets. Nevertheless, future randomized trials are needed and a process of deeper cultural adaptation required.

Gutsch J, Werthmann PG, Rosenwald A, Kienle GS. Complete Remission and Long-term Survival of a Patient with a Diffuse Large B-cell Lymphoma Under Viscum album Extracts After Resistance to R-CHOP: A Case Report. Anticancer Res 2018 Sep;38(9):5363-5369 PMID 30194190

BACKGROUND: A nodular lymphocyte predominant Hodgkin's lymphoma (NLPHL) is a lymphoproliferative neoplasm with a fair prognosis, but the possibility of a malignant transformation into a diffuse large B-cell lymphoma (DLBCL) is high. DLBCL progresses aggressively. Introduction of rituximab into therapy had led to improved outcomes. The use of Viscum album extracts (VAE) in cancer is established, but their application in lymphoma are rare. CASE PRESENTATION: A 65-year-old patient was diagnosed with DLBCL stage IIa with splenomegaly, transformed from a NLPHL, after a 30-year history of repeatedly enlarged inguinal lymph nodes. The patient initially rejected chemotherapy. After his tumor pain increased, he accepted the consecutive therapies bendamustine plus vincristine plus prednisolone, trofosfamide, and rituximab plus cyclophosphamide plus hydroxydaunorubicin plus vincristine plus prednisone (R-CHOP), inducing only a slight regression of the splenic lesions. VAE was additionally applied to R-CHOP. Five months after termination of chemotherapy - under continued VAE therapy in increasing dosage- regression of paraaortal lesions was found. The patient fully recovered under continuous VAE application and is in ongoing complete remission and in a good state of health 17 years after the initial diagnosis. CONCLUSION: As complete remission of lymphoproliferative disorders after VAE treatment has been previously reported, further investigations of VAE in lymphoma seem highly worthwhile.

Jong MC, Boers I, Schouten van der Velden AP, Meij SV, Goker E, Timmer-Bonte ANJH, et al. A Randomized Study of Yoga for Fatigue and Quality of Life in Women with Breast Cancer Undergoing (Neo) Adjuvant Chemotherapy. J Altern Complement Med 2018 Sep/Oct;24(9-10):942-953 PMID 30247961

OBJECTIVES: To compare the effectiveness of yoga added to standard care (SC) versus SC only, in women with breast cancer during chemotherapy. DESIGN: A multicenter pragmatic, randomized controlled study. SETTINGS/LOCATION: Three hospitals in the Netherlands. SUBJECTS: Women with stage I-III breast cancer undergoing chemotherapy. INTERVENTIONS: Women were randomized either to a program based on Dru Yoga, once a week yoga sessions for 12 weeks (N = 47), or SC only (N = 36). OUTCOME MEASURES: Primary outcome fatigue (Multidimensional Fatigue Inventory [MFI]; general fatigue) and secondary outcomes fatigue (MFI, Fatigue Quality List [FQL]), quality of life (30-item Quality of Life Questionnaire-C of the European Organization for Research and Treatment of Cancer [EORTC-QLQ-C-30]) and psychological distress (Hospital Anxiety Depression Scale [HADS], Impact of Events Scale [IES]) were measured at baseline (T0), 3 months (T1), and 6 months (T2) and analyzed on observed cases. Other outcomes were adequate relief, reintegration to work, and adverse events. RESULTS: No significant differences were found in general fatigue at T1 (MFI: yoga; 14.6 +/- 4.5 vs. SC; 14.2 +/- 4.2, p = 0.987). Similar findings were observed for other fatigue (sub)scales of MFI and FQL and functional domains of EORTC. With respect to EORTCs symptom scales, women in the yoga group reported significantly less nausea and vomiting compared with SC at T2 (p = 0.004), but not at T1 (p = 0.807). Depressive symptoms were significantly lower with yoga at T1 (HADS: yoga; 4.7 +/- 4.1 vs. SC; 5.1 +/- 4.2, p = 0.031). More women in the yoga group experienced adequate relief compared with SC at T1 (yoga; 51% vs. SC; 19%) and had returned to work at T2 (yoga; 53% vs. SC; 23%). No adverse events were reported with yoga. CONCLUSIONS: A Dru-based yoga program failed to demonstrate a significant beneficial effect on fatigue. Possible favorable effects of the yoga program on nausea and vomiting and early return to work in breast cancer survivors warrant further research.

Kessel KA, Klein E, Hack CC, Combs SE. Complementary medicine in radiation oncology : German health care professionals' current qualifications and therapeutic methods. Strahlenther Onkol 2018 Oct;194(10):904-910 PMID 30073483

INTRODUCTION: Recently, complementary and alternative medicine (CAM) has moved more into the focus, and cancer societies such as the German Cancer Society (Deutsche Krebsgesellschaft, DKG) have established working groups to develop a guideline for CAM. The present work aims to evaluate the acceptance of CAM in the whole radiation oncology community. METHODS: We conducted an online survey on CAM and sent the modified questionnaire that was successfully distributed to all members of the Research Group on Gynecological Oncology (Arbeitsgemeinschaft Gynakologische Onkologie, AGO) of the DKG in 2014 to the members of the German Society of Radiation Oncology (Deutsche Gesellschaft fur Radioonkologie und Strahlentherapie, DEGRO). The survey consisted of 17 questions regarding personal information and current CAM guidelines within the workplace/clinic. RESULTS: A total of 143 members participated. Of these, 12% had some CAM qualification. For hematological cancer in 35% and in up to 76% for breast cancer, CAM treatment is offered in German radiation oncology facilities, mainly due to fatigue symptoms. CAM is part of routine treatment in 32.2%, 22.0% are planning to incorporate it. Most physicians advise patients to partake in sports activities and recommend dietary supplements and nutritional counseling. The cost of CAM treatment is fully covered in 9.8% of all participating facilities. CONCLUSION: Today, CAM is integrated into cancer care; however, skepticism regarding its effect still exists. Evidence-based results must be generated to convince physicians of the effectiveness of CAM methods. CAM qualifications must be included in physicians' training to improve their understanding and counseling regarding CAM options in cancer care.

Kirkham AA, Paterson DI, Prado CM, Mackey JM, Courneya KS, Pituskin E, et al. Rationale and design of the Caloric Restriction and Exercise protection from Anthracycline Toxic Effects (CREATE) study: a 3-arm parallel group phase II randomized controlled trial in early breast cancer. BMC Cancer 2018 Sep 3;18(1):864-018-4778-7 PMID 30176834

BACKGROUND: Anthracycline chemotherapy agents are commonly used to treat breast cancer, but also result in cardiac injury, and potentially detrimental effects to vascular and skeletal muscle. Preclinical evidence demonstrates that exercise and caloric restriction can independently reduce anthracycline-related injury to the heart as well as cancer progression, and may be promising short-term strategies prior to treatment administration. For women with breast cancer, a short-term strategy may be more feasible and appealing, as maintaining regular exercise training or a diet throughout chemotherapy can be challenging due to treatment symptoms and psychosocial distress. METHODS: The Caloric Restriction and Exercise protection from Anthracycline Toxic Effects (CREATE) study will determine whether acute application of these interventions shortly prior to receipt of each treatment can reduce anthracycline-related toxicity to the heart, aorta, and skeletal muscle. Fifty-six women with early stage breast cancer scheduled to receive anthracycline treatment will be randomly assigned to one of three groups who will: 1) perform a single, 30-min, vigorous-intensity, aerobic exercise session 24 h prior to each anthracycline treatment; 2) consume a prepared diet reduced to 50% of caloric needs for 48 h prior to each anthracycline treatment; or 3) receive usual cancer care. The primary outcome is magnetic resonance imaging (MRI) derived left ventricular ejection fraction reserve (peak exercise LVEF - resting LVEF) at the end of anthracycline treatment. Secondary outcomes include MRI-derived measures of cardiac, aortic and skeletal muscle structure and function, circulating NT-proBNP, cardiorespiratory fitness and treatment symptoms. Exploratory outcomes include quality of life, fatigue, tumor size (only in neoadjuvant patients), oxidative stress and antioxidants, as well as clinical cardiac or cancer outcomes. MRI, exercise tests, and questionnaires will be administered before, 2-3 weeks after the last anthracycline treatment, and one-year follow-up. DISCUSSION: The proposed lifestyle interventions are accessible, low cost, drug-free potential methods for mitigating anthracycline-related toxicity. Reduced toxic effects on the heart, aorta and muscle are very likely to translate to short and long-term cardiovascular health benefits, including enhanced resilience to the effects of subsequent cancer treatment (e.g., radiation, trastuzumab) aging, and infection. TRIAL REGISTRATION: ClinicalTrials.gov NCT03131024; 4/21/18.

Koula MJ, Knight JM. Increasing provider awareness of and recommendations for yoga and meditation classes for cancer patients. Support Care Cancer 2018 Oct;26(10):3635-3640 PMID 29728846

OBJECTIVE: The purpose of the current study was to (1) assess healthcare providers' beliefs about and referral patterns to yoga and meditation services, and (2) evaluate the effectiveness of a brief yoga/meditation educational presentation to increase providers' intent to recommend these programs. METHOD: A brief 5-min presentation regarding the benefits of yoga and meditation for cancer patients and instruction about referring and enrolling patients was delivered in four different oncology settings: breast, gynecologic, radiation, and surgical. Healthcare provider participants filled out pre- and post-surveys assessing knowledge and attitudes surrounding yoga and meditation classes. RESULTS: A total of 40 healthcare providers were surveyed, consisting of 18 physicians, 12 nurses, six nurse practitioners, two physician assistants, one pharmacist, and one clinical researcher. Of these 40 healthcare providers, 43% were unaware at baseline that yoga and meditation classes were offered through the cancer center and 55% responded that they rarely or never recommend yoga or meditation for patients. Following a brief presentation about the benefits of yoga and meditation for cancer patients, 90% of providers stated they would be more likely to recommend these services to patients in the future. There was a significant (p < 0.01) increase in providers from pre- to post-presentation (65 to 85%) stating they strongly believe yoga and meditation can provide physical or emotional benefits for their patients. SIGNIFICANCE OF RESULTS: These data demonstrate that a brief educational intervention about yoga and meditation for cancer patients is effective at significantly increasing provider knowledge about the benefits of these therapeutic modalities, with a majority indicating they are more likely to recommend these services in the future. Increasing provider awareness regarding the health-promoting benefits of such supportive services for cancer patients could result in greater service utilization as well as physical and emotional benefits for patients.

Kumbamu A, Geller G, Leppin A, Fernandez C, Tilburt J, Koenig B. Contending Worldviews in the Clinical Encounter: An Empirical Study of Complementary and Alternative Medicine Deliberations in Contemporary Medical Oncology. J Altern Complement Med 2018 Sep/Oct;24(9-10):996-1002 PMID 30156425

OBJECTIVE: In this article, the authors characterize the different ways patients and clinicians discuss complementary and alternative medicine (CAM) during routine cancer care. METHODS: Over a period of two years, the authors audio-recorded clinical interactions between 37 medical oncology clinicians and a sample of 327 oncology patients at an academic cancer center in the Midwest United States. Recordings of conversations that included any discussion of CAM were transcribed and analyzed using a qualitative content analysis approach. RESULTS: Out of 327 conversations, CAM was mentioned and/or discussed in only 31 encounters. Communication dynamics between clinician and patient involve several factors: the condition of the patient and his or her knowledge about and experience with CAM, the clinician's knowledge and values about CAM, perceived assumptions and stereotypes about CAM, and institutional response to the integration of CAM in cancer care. CONCLUSION: Addressing the difficult and sensitive topic of CAM in cancer care requires hearing patients in a manner meaningful to them. In that sense, CAM can serve as an important marker and test case in the march toward shared decision-making and patient-centered communication generally.

Ladas EJ. Integrative Medicine in Childhood Cancer. J Altern Complement Med 2018 Sep/Oct;24(9-10):910-915 PMID 30247963

The diagnosis of cancer in a child leaves parents and families devastated and vulnerable. In an effort to do everything possible, families often choose an integrative medicine approach to their child's care. Surveys have found that 31%-84% of children with cancer use complementary and alternative medicine and most often as supportive care agents. Several systematic reviews have demonstrated a clinical benefit for some select therapies; however, the safety and efficacy of the combination of biological therapies with conventional treatment remain largely unknown and garner concern due to the potential for interactions with conventional therapy. Given the sustained use and potential benefit of integrative medicine, additional research is warranted in pediatric oncology. Utilizing the available literature, clinical providers should aim to conduct open and nonjudgmental discussions with families about the use of integrative medicine so as to guide the safe integration of the two modalities.

Lemanne D, Maizes V. Advising Women Undergoing Treatment for Breast Cancer: A Narrative Review. J Altern Complement Med 2018 Sep/Oct;24(9-10):902-909 PMID 30247957

A majority of women undergoing conventional treatment for breast cancer also undertake complementary and integrative approaches. Practitioners knowledgeable about the evidence base behind common integrative approaches can help patients attain improved quality of life, and at times, improved survival. Evidence-based recommendations include the following: a plant-based diet for general health after diagnosis, and carbohydrate restriction for patients with estrogen receptor-positive postmenopausal breast cancer may be prudent. Other dietary recommendations include a 13-h daily overnight fast. Carefully selected patients may choose to fast the day before and the day of chemotherapy to decrease side effects. Specific food recommendations include avoidance or limitation of alcohol, and liberal culinary use of cruciferous vegetables, coffee, green tea, soy, and flaxseed. Promising supplements include diindolylmethane and melatonin. Omega 3 fatty acids may help with bone density in patients on aromatase inhibitors, but may increase chemotherapy resistance. Findings regarding the usefulness of multivitamins, vitamin D, vitamin C, and vitamin E are weak and/or mixed different exercise modalities may have different effects and thus play different roles in breast cancer therapy. Aerobic and resistance training combined during breast cancer chemotherapy may confer a survival benefit, while yoga may improve outcome in lymphedema patients. Current evidence suggests that meditation, yoga, breathing, music therapy, guided imagery, and hypnosis may improve mood and quality of life during breast cancer treatment. Acupuncture is useful for treating side effects of breast cancer therapies, including hot flushes, aromatase inhibitor-induced joint pain, chemotherapy-induced peripheral neuropathy, and vulvodynia. Vaginal moisturizers and vaginal rings supplying low-dose estrogen can be useful in the treatment of symptoms of estrogen-deprivation states caused by breast cancer treatments; such symptoms include vaginal dryness, dyspareunia, and sexual dysfunction. Carbon dioxide laser technology can rejuvenate atrophied vaginal mucosa and relieve dyspareunia, allowing avoidance of estrogen therapy. Tertiary sexual health centers are available for referral.

Lucas CJ, Galettis P, Song S, Solowij N, Reuter SE, Schneider J, et al. Cannabinoid Disposition After Human Intraperitoneal Use: AnInsight Into Intraperitoneal Pharmacokinetic Properties in Metastatic Cancer. Clin Ther 2018 Sep;40(9):1442-1447 PMID 29317112

BACKGROUND: Medicinal cannabis is prescribed under the provision of a controlled drug in the Australian Poisons Standard. However, multiple laws must be navigated in order for patients to obtain access and imported products can be expensive. Dose-response information for both efficacy and toxicity pertaining to medicinal cannabis is lacking. The pharmacokinetic properties of cannabis administered by traditional routes has been described but to date, there is no literature on the pharmacokinetic properties of an intraperitoneal cannabinoid emulsion. CASE DESCRIPTION: A cachectic 56-year-old female with stage IV ovarian cancer and peritoneal metastases presented to hospital with fevers, abdominal distension and severe pain, vomiting, anorexia, dehydration and confusion. The patient reported receiving an intraperitoneal injection, purported to contain 12g of mixed cannabinoid (administered by a deregistered medical practitioner) two days prior to presentation. Additionally, cannabis oil oral capsules were administered in the hours prior to hospital admission. RESULTS: THC concentrations were consistent with the clinical state but not with the known pharmacokinetic properties of cannabis nor of intraperitoneal absorption. THC concentrations at the time of presentation were predicted to be ~60ng/mL. Evidence suggests that blood THC concentrations >5ng/mL are associated with substantial cognitive and psychomotor impairment. The predicted time for concentrations to drop <5ng/mL was 49days after administration. DISCUSSION: The unusual pharmacokinetic properties of the case suggest that there is a large amount unknown about cannabis pharmacokinetic properties. The pharmacokinetic properties of a large amount of a lipid soluble compound given intraperitoneally gave insights into the absorption and distribution of cannabinoids, particularly in the setting of metastatic malignancy.

Maurya N, Velmurugan BK. Therapeutic applications of cannabinoids. Chem Biol Interact 2018 Sep 25;293:77-88 PMID 30040916

The psychoactive property of cannabinoids is well known and there has been a continuous controversy regarding the usage of these compounds for therapeutic purposes all over the world. Their use for medical and research purposes are restricted in various countries. However, their utility as medications should not be overshadowed by its negative physiological activities. This review article is focused on the therapeutic potential and applications of phytocannabinoids and endocannabinoids. We further highlights their mode of action, overall effects on physiology, various in vitro and in vivo studies that have been done so far and the extent to which these compounds can be useful in different disease conditions such as cancer, Alzheimer's disease, multiple sclerosis, pain, inflammation, glaucoma and many others. Thus, this work is an attempt to make the readers understand the positive implications of these compounds and indicates the significant developments of utilizing cannabinoids as therapeutic agents.

Pan Y, Yang K, Shi X, Liang H, Shen X, Wang R, et al. Clinical Benefits of Acupuncture for the Reduction of Hormone Therapy-Related Side Effects in Breast Cancer Patients: A Systematic Review. Integr Cancer Ther 2018 Sep;17(3):602-618 PMID 30117343

IMPORTANCE: Acupuncture can help reduce unpleasant side effects associated with endocrine therapy for breast cancer. Nevertheless, comprehensive evaluation of current evidence from randomized controlled trials(RCTs) is lacking. OBJECTIVE: To estimate the efficacy of acupuncture for the reduction of hormone therapy-related side effects in breast cancer patients. EVIDENCE REVIEW: RCTs of acupuncture in breast cancer patients that examined reductions in hormone therapy-related side effects were retrieved from PubMed, EMBASE, Web of Science, Ovid MEDLINE, and Cochrane Library databases through April 2016. The quality of the included studies was evaluated according to the 5.2 Cochrane Handbook standards, and CONSORT and STRICTA (Revised Standards for Reporting Interventions in Clinical Trials of Acupuncture) statements. INTERVENTION: Interventions included conventional acupuncture treatment compared with no treatment, placebo, or conventional pharmaceutical medication. Major outcome measures were the alleviation of frequency and symptoms and the presence of hormone therapy-related side effects. Findings/Results. A total of 17 RCTs, including a total of 810 breast cancer patients were examined. The methodological quality of the trials was relatively rigorous in terms of randomization, blinding, and sources of bias. Compared with control therapies, the pooled results suggested that acupuncture had moderate effects in improving stiffness. No significant differences were observed in hot flashes, fatigue, pain, gastrointestinal symptoms, Kupperman index, general well-being, physical well-being, tumor necrosis factor (TNF), and interleukin (IL). CONCLUSIONS: Acupuncture therapy appears to be potentially useful in relieving functional stiffness. However, further large-sample trials with evidence-based design are still needed to confirm these findings.

Park H, Oh S, Noh Y, Kim JY, Kim JH. Heart Rate Variability as a Marker of Distress and Recovery: The Effect of Brief Supportive Expressive Group Therapy With Mindfulness in Cancer Patients. Integr Cancer Ther 2018 Sep;17(3):825-831 PMID 29417836

OBJECTIVES: We aimed to investigate the effects of brief supportive expressive group therapy with mindfulness for cancer patients and to assess the utility of heart rate variability (HRV) as a biomarker of distress and treatment effect. METHODS: A total of 28 female patients with nonmetastatic cancer at a university hospital in South Korea received a 4-week modified group therapy for distress reduction. The BESTMIND (Brief Expression and Support Therapy with Mindfulness) program consisted of supportive-expressive group therapy and mindfulness-based stress reduction. The subjective outcomes of distress, anger, sleep quality, and sense of well-being and the physiological outcome of HRV were assessed before and after the program. RESULTS: After the program, patients showed significantly reduced distress, perceived stress, anger, and sleep disturbance and increased quality of life. No significant change was observed in the degree of mindfulness. A significantly increased SD in the normal beat-to-beat intervals and normalized high-frequency (HF 0.15-0.4 Hz) power from spectral analysis were observed after treatment. According to the correlation analyses, HF power correlated with depression scores, and normalized HF power was associated with depression, anxiety, perceived stress, and anger at baseline. The pretreatment and posttreatment comparison indicated that an increase in HF power was associated with a decrease in anger. CONCLUSIONS: These results suggest the effectiveness of this modified group-based program for distress reduction and also provide preliminary evidence for the use of HRV as a biomarker of distress and recovery. HF power from HRV variables may serve as a quantitative biomarker of the treatment response of distress management, including anger.

Qureshi M, Zelinski E, Carlson LE. Cancer and Complementary Therapies: Current Trends in Survivors' Interest and Use. Integr Cancer Ther 2018 Sep;17(3):844-853 PMID 29629606

BACKGROUND: Cancer survivors use complementary therapies (CTs) for a variety of reasons; however, with interest and use reportedly on the rise and a widening range of products and practices available, there is a need to establish trends in and drivers of interest. We aimed to determine (1) frequencies of use, level of interest, and barriers for 30 specific CTs and (2) whether physical symptoms, perceived stress (PS), or spiritual well-being were related to interest levels. METHOD: A total of 212 cancer outpatients were surveyed at the Tom Baker Cancer Centre in Calgary, Canada. RESULTS: Overall, up to 75% of survivors already used some form of CTs since their diagnosis. The most highly used were the following: vitamins B12 and D, multivitamins, calcium, and breathing and relaxation exercises. Those who had not used CTs indicated highest interest in massage, vitamin B12, breathing and relaxation, mindfulness-based stress reduction, and antioxidants. The most frequently reported barriers for all CTs were not knowing enough about what a therapy was and not having enough evidence on whether it worked. High PS predicted higher interest for all CTs, but spirituality was not significantly related to any. Physical symptoms, anxiety, and depression were significant predictors of interest for some CTs. CONCLUSION: These findings provide a blueprint for future clinical efficacy trials and highlight the need for clinical practice guidelines.

Radl D, Vita M, Gerber N, Gracely EJ, Bradt J. The effects of Self-Book((c)) art therapy on cancer-related distress in female cancer patients during active treatment: A randomized controlled trial. Psychooncology 2018 Sep;27(9):2087-2095 PMID 29744966

OBJECTIVE: National attention on patients' cancer-related emotional distress produced a need for evidence-based, psychosocial interventions in oncology care. The purpose of this study was to evaluate the efficacy of Self-Book((c)) art therapy for emotional distress and psychological well-being of female oncology patients during active oncology treatment. METHODS: Sixty consenting women with cancer were randomly assigned to either a 6-session Self-Book((c)) art therapy program or standard care. A repeated measures randomized controlled trial design was employed. Data were collected by using the Distress Thermometer, Perceived Emotional Distress Inventory, Patient-Reported Outcomes Measurement Information System Brief Psychological Well-being test, and the Functional Assessment of Chronic Illness Therapy Spiritual Well-being. Measurements were obtained at baseline, week 3, week 6, and 1 to 2 months post intervention. RESULTS: Forty participants were included in the final analysis. No significant differences between groups were found for the primary outcome measures: emotional distress and psychological well-being. Greater improvements in Self-Book((c)) art therapy participants' spiritual well-being were found compared with the standard care control participants (P = .02). CONCLUSIONS: Although no statistically significant differences were present between the groups for the primary outcomes, several positive trends were noted. Thirty percent of Self-Book((c)) art therapy participants reported postintervention emotional distress scores that were below the abnormal range for emotional distress, compared with only 5% of standard care control participants, suggesting that Self-Book((c)) art therapy may have clinical value. Further studies are recommended to better understand the therapeutic mechanisms of Self-Book((c)) art therapy for enhancing psychological well-being.

Saadeh CE, Rustem DR. Medical Marijuana Use in a Community Cancer Center. J Oncol Pract 2018 Sep;14(9):e566-e578 PMID 30205775

PURPOSE: The primary purpose of this study was to compare the incidence of marijuana use between patients with early- versus advanced-stage cancers. Differences in adverse effects, drug-drug interactions, and drug-disease interactions between those who use marijuana and those who do not were also compared. METHODS: Patients age 18 years and older who were receiving chemotherapy were asked to complete an electronic self-reported questionnaire. In addition to questions about patient demographics, current adverse effects, cancer type and stage, comorbidities, performance status, treatment regimen, and general marijuana use, those patients who used marijuana within the last 30 days (current marijuana users) were asked additional questions about the route and frequency of marijuana administration, about reason(s) for use, about possession of a marijuana card, and if they had received any counseling about marijuana. Drug-drug and drug-disease interactions were also analyzed. RESULTS: The overall incidence of marijuana use was 18.3% (32 of 175 patients). The incidence of marijuana use in patients with early- versus advanced-stage cancers was 19.6% (11 of 56 patients) versus 17.6% (21 of 119 patients; P = .75). Patients who use marijuana reported more pain, nausea, appetite issues, and anxiety. There were more drug-drug interactions associated with marijuana use, primarily with concurrent CNS depressants. The frequency of drug-disease interactions between those who use marijuana versus those who do not was similar. CONCLUSION: Approximately one in five patients with cancer who were receiving chemotherapy were using marijuana, and the frequency was equal in early- and advanced-stage cancer groups. The risks versus benefits should be discussed with all patients who use marijuana.

Seely D, Ennis JK, McDonell E, Zhao L. Naturopathic Oncology Care for Thoracic Cancers: A Practice Survey. Integr Cancer Ther 2018 Sep;17(3):793-805 PMID 29558830

BACKGROUND AND OBJECTIVES: There is a lack of information on therapies recommended by naturopathic doctors (NDs) for lung and gastroesophageal cancer care. Study objectives were to: (1) identify the most common interventions considered for use by NDs; (2) identify interventions NDs recommend to support key therapeutic goals; and (3) identify potential contraindications between integrative and conventional therapies. METHODS: Oncology Association of Naturopathic Physicians (OncANP) members (n = 351) were invited to complete an electronic survey. Respondents provided information on interventions considered for thoracic cancer pre- and postoperatively across 4 therapeutic domains (supplemental natural health products, physical, mental/emotional, and nutritional), therapeutic goals, and contraindications. This survey was part of the development of the Thoracic Perioperative Integrative Surgical Evaluation trial. RESULTS: Forty-four NDs completed the survey (12.5% response rate), all of whom were trained at accredited colleges in North America and the majority of whom were Fellows of the American Board of Naturopathic Oncology (FABNO) (56.8%). NDs identified significantly more interventions in the postoperative compared to preoperative setting. The most frequently identified interventions included modified citrus pectin, arnica, omega-3 fatty acids, vitamin D, probiotics, exercise, acupuncture, meditation, stress reduction, low glycemic index diet, and Mediterranean diet. Potential contraindications with conventional treatment (surgery, chemotherapy, radiotherapy) differed across natural health products. CONCLUSIONS: These findings highlight naturopathic interventions with a high level of use in thoracic cancer care, describe and characterize therapeutic goals and the interventions used to achieve these goals, and provide insight on how practice changes relative to conventional cancer treatment phase.

Serce S, Ovayolu O, Pirbudak L, Ovayolu N. The Effect of Acupressure on Pain in Cancer Patients With Bone Metastasis: A Nonrandomized Controlled Trial. Integr Cancer Ther 2018 Sep;17(3):728-736 PMID 29649905

BACKGROUND: Pain is a serious and common problem in bone metastases. For this purpose, complementary and supportive practices are also applied along with medical treatment. This study was conducted for the purpose of evaluating the effect of acupressure on pain in cancer patients with bone metastasis. METHODS: The study was conducted in a nonrandomized controlled trial with patients who applied to the radiotherapy unit of an oncology hospital. The data of the study were collected by using a questionnaire and the Visual Analog Scale. A total of 8 acupressure sessions, which lasted for approximately 10 minutes each (with warming and acupressure periods), was applied to the intervention group. The data were analyzed by using chi(2) test, paired t test, and Pearson's correlation coefficient. RESULTS: It was determined that the pain mean score of the intervention group was 7.6 +/- 1.9 before the acupressure and decreased to 6.8 +/- 1.9 after the acupressure and this result was statistically significant. On the other hand, no significant difference was determined in the pain mean score of the control group. CONCLUSIONS: Acupressure is applicable for cancer patients with bone metastasis by nursing staff after receiving brief training and may make a difference in relieving pain of the patients. Further well-designed trials should be conducted.

Shaffer KM, Garland SN, Mao JJ, Applebaum AJ. Insomnia among Cancer Caregivers: A Proposal for Tailored Cognitive Behavioral Therapy. J Psychother Integr 2018 Sep;28(3):275-291 PMID 30245560

Caregivers are relatives, friends, or partners who have a significant relationship with and provide assistance (i.e., physical, emotional) to a patient with often life-threatening, serious illnesses. Between 40 and 76 percent of caregivers for people with cancer experience sleep disturbance. This is thought to be due, in part, to the unique responsibilities, stressors, and compensatory behaviors endemic to caregiving that serve as precipitating and perpetuating factors of insomnia. Sleep disturbances are associated with significant alterations in one's mental and physical health. Once chronic, insomnia does not remit naturally. Cognitive-behavioral therapy for insomnia (CBT-I) is well-suited to address the multifaceted contributing factors unique to caregivers' sleep disturbance, yet only one intervention has tested a CBT-I informed intervention among cancer caregivers. Toward the goal of developing effective, tailored treatments for insomnia in caregivers, we address the distinct presentation of insomnia among cancer caregivers and describe key modifications to standard CBT-I that address these specific needs and enhance sensitivity and feasibility, modeled in a demonstrative case vignette. Future research must seek to provide a wide range of effective treatment options for this population, including internet-based, dyadic, and alternative integrative medicine treatments. Applicability of key modifications for caregivers of patients with other chronic illnesses is discussed. Establishing empirically-supported interventions for insomnia among cancer caregivers has the potential to enhance their quality of life and care provided, lead to improved bereavement outcomes, and attenuate the notable mental and physical health disparities present in this vulnerable population.

Sikorskii A, Victorson D, O'Connor P, Hankin V, Safikhani A, Crane T, et al. PROMIS and legacy measures compared in a supportive care intervention for breast cancer patients and caregivers: Experience from a randomized trial. Psychooncology 2018 Sep;27(9):2265-2273 PMID 29956396

OBJECTIVE: Accurate and efficient measurement of patient-reported outcomes is key in cancer symptom management trials. The newer Patient Reported Outcomes Measurement Information System (PROMIS) and previously developed measures of similar conceptual content (legacy) are available to measure symptoms and functioning. This report compares the performance of two sets of measures, PROMIS and legacy, in a recently completed trial of a supportive care intervention that enrolled breast cancer patients and their friend or family caregivers. METHODS: Patient-caregiver dyads (N = 256) were randomized to either reflexology delivered by caregivers or usual care control. Post-intervention, PROMIS and legacy measures of symptoms and functioning were analyzed in relation to trial arm, while adjusting for baseline values. Responsiveness of the two sets of measures was assessed using effect sizes and P-values for the effect of trial arm on patients' and caregivers' symptom and functioning outcomes. RESULTS: Similar conclusions about intervention effects were found using PROMIS and legacy measures for pain, fatigue, sleep, anxiety, physical, and social functioning. Different conclusions were obtained for patient and caregiver depression: legacy measures indicated the efficacy of reflexology, while PROMIS depression measure did not. CONCLUSION: Evidence of similar responsiveness supports the use of either set of measures for symptoms and functioning in clinical and general populations. Differences between PROMIS and legacy measures of depression need to be considered when choosing instruments for use in trials of supportive care interventions and in clinical practice.

Stan DL, Wahner-Roedler DL, Yost KJ, O'Byrne TJ, Branda ME, Leppin AL, et al. Absent and Discordant Electronic Health Record Documentation of Complementary and Alternative Medicine in Cancer Care. J Altern Complement Med 2018 Sep/Oct;24(9-10):988-995 PMID 30247970

OBJECTIVES: Many patients with cancer use complementary and alternative medicine (CAM), but the quality of CAM documentation in their electronic health records (EHRs) is unknown. The authors aimed to describe (i) the prevalence and types of CAM used after cancer diagnosis and the influence of oncologists on CAM use, as per patients' self-report, and (ii) the prevalence of CAM documentation in the EHR and its consistency with self-reported usage. DESIGN: Patient and provider surveys and chart review. SETTINGS/LOCATION: Medical oncology practices at one institution. SUBJECTS: Patients with cancer at oncologist visits. OUTCOME MEASURES: Patient self-reported rate of 3-month postvisit CAM use; provider EHR documentation of CAM use or discussion and its concordance with patient self-report. RESULTS: Among 327 patients enrolled, 248 responded to the 3-month postvisit survey. Of these, 158 reported CAM use after diagnosis (63.7%). CAM users were younger (p < 0.001) and had a higher percentage of women (p = 0.03) than nonusers. Modalities most commonly used were supplements (62.6%), special diets (38.6%), chiropractor (28.4%), and massage (28.4%). CAM was used to improve well-being (68.7%), manage adverse effects (35.5%), and fight cancer (22.9%). Oncologists suggested CAM in 22.5% of instances of use. CAM use/discussion was documented for 58.2% of self-reported CAM users. Of the documented modalities, EHR and self-report were concordant for only 8.2%. CAM documentation was associated with physician provider (p = 0.03), older patients (p = 0.01), and treatment with radiation (p = 0.03) or surgery (p = 0.001). After adjusting for other factors, patients with breast cancer or "other" tumor category were four times more likely than patients with gastrointestinal cancer to have CAM use documentation (odds ratio [95% confidence interval]: 4.41 [1.48-13.10]; 3.76 [1.42-9.99], respectively). CONCLUSIONS: Most patients with cancer use CAM after diagnosis, yet EHR documentation is complete for very few. Oncologists should inquire about, document, and discuss CAM benefits and harm or refer patients to CAM specialists.

Sun L, Mao JJ, Vertosick E, Seluzicki C, Yang Y. Evaluating Cancer Patients' Expectations and Barriers Toward Traditional Chinese Medicine Utilization in China: A Patient-Support Group-Based Cross-Sectional Survey. Integr Cancer Ther 2018 Sep;17(3):885-893 PMID 29888609

BACKGROUND: Traditional Chinese medicine (TCM) is widely used among Chinese cancer patients. However, little is known about Chinese patients' expectations and barriers toward using TCM for cancer. METHODS: We conducted a cross-sectional survey within a patient-support group, the Beijing Anti-Cancer Association. We measured the outcome, Chinese cancer survivors' expectations and barriers toward TCM utilization, using a modified version of ABCAM (Attitudes and Beliefs towards Complementary and Alternative Medicine), the ABTCM (Attitudes and Beliefs towards Traditional Chinese Medicine). We used multivariate models to evaluate the impact of socioeconomic status and clinical factors on their expectations and barriers (including treatment concerns and logistical challenges domain) toward TCM. RESULTS: Among 590 participants, most patients expected TCM to boost their immune system (96%), improve their physical health (96%), and reduce symptoms (94%). Many had logistical challenges (difficulty decocting herbs (58%) and finding a good TCM physician (55%)). A few were concerned that TCM might interfere with conventional treatments (7.6%), and that many TCM treatments are not based on scientific research (9.1%). In the multivariable regression model, age </=60 years was independently associated with higher expectation score ( P = .031). Age </=60 years (coefficient 5.0, P = .003) and localized disease (coefficient 9.5, P = .001) were both associated with higher treatment concerns. Active employment status (coefficient 9.0, P = .008) and localized disease (coefficient 7.5, P = .030) were related to more logistical challenges. CONCLUSION: Age and cancer stage were related to Chinese cancer patients' perceived expectations and barriers toward TCM use. Understanding these attitudes is important for reshaping the role that TCM plays in China's patient-centered comprehensive cancer care model.

Wang AW, Bouchard LC, Gudenkauf LM, Jutagir DR, Fisher HM, Jacobs JM, et al. Differential psychological effects of cognitive-behavioral stress management among breast cancer patients with high and low initial cancer-specific distress. J Psychosom Res 2018 Oct;113:52-57 PMID 30190048

OBJECTIVE: Cognitive-behavioral stress management (CBSM) improves adaptation to primary treatment for breast cancer (BCa), evidenced as reductions in distress and increases in positive affect. Because not all BCa patients may need psychosocial intervention, identifying those most likely to benefit is important. A secondary analysis of a previous randomized trial tested whether baseline level of cancer-specific distress moderated CBSM effects on adaptation over 12months. We hypothesized that patients experiencing the greatest cancer-specific distress in the weeks after surgery would show the greatest CBSM-related effects on distress and affect. METHODS: Stages 0-III BCa patients (N=240) were enrolled 2-8weeks after surgery and randomized to either a 10-week group CBSM intervention or a 1-day psychoeducational (PE) control group. They completed the Impact of Event Scale (IES) and Affect Balance Scale (ABS) at study entry, and at 6- and 12- month follow-ups. RESULTS: Latent Growth Curve Modeling across the 12-month interval showed that CBSM interacted with initial cancer-related distress to influence distress and affect. Follow-up analyses showed that those with higher initial distress were significantly improved by CBSM compared to control treatment. No differential improvement in affect or intrusive thoughts occurred among low-distress women. CONCLUSION: CBSM decreased negative affect and intrusive thoughts and increases positive affect among post-surgical BCa patients presenting with elevated cancer-specific distress after surgery, but did not show similar effects in women with low levels of cancer-specific distress. Identifying patients most in need of intervention in the period after surgery may optimize cost-effective cancer care.

Wang XP, Zhang DJ, Wei XD, Wang JP, Zhang DZ. Acupuncture for the relief of hot flashes in breast cancer patients: A systematic review and meta-analysis of randomized controlled trials and observational studies. J Cancer Res Ther 2018 Sep;14(Supplement):S600-S608 PMID 30249875

Objective: To critically assess the effectiveness and safety of acupuncture for treating hot flashes (HFs) among breast cancer (BC) patients, and to get much more highly compelling evidence then to guide clinical practice. Methods: Comprehensive systematic literature searches were carried out for identifying randomized controlled trials and observational studies (OSs) published before January 2015. The meta-analysis (MA) was performed by Review Manager 5 software if data could be merged routinely, if not descriptions would be given. Results: A total of 18 studies were eligible ultimately. With respect to HFs frequency, the MA during treatment showed a significant difference (MD = -1.78, 95% confidence intervals [95% CIs]: -3.42--0.14), but no statistical differences were observed when posttreatment or follow-up period. While electroacupuncture versus applied relaxation, they both helped to promote HFs markedly but did not reveal statistically significance between them. Referring to Kupperman's index, all the treatment brought out great assistance when compared with baseline conditions, and there was significant difference between real acupuncture sham acupuncture (posttreatment: MD = -4.40, 95% CI: -6.77--2.03; follow-up: MD = -4.30, 95% CI: -6.52--2.08). In terms of OS, 7 prospective single arm studies focused on exploring the efficacy of traditional acupuncture, and all revealed moderate or great benefit for BC patients suffering from HFs. Conclusions: Acupuncture still appeared to be an efficacious therapeutic strategy, especially for the less/no side effects. Because of its widespread acceptance and encouraging effectiveness for improving HFs, much more high-quality studies are in need urgently.

Yalcin S, Hurmuz P, McQuinn L, Naing A. Prevalence of Complementary Medicine Use in Patients With Cancer: A Turkish Comprehensive Cancer Center Experience. J Glob Oncol 2018 Sep;(4):1-6. doi(4):1-6 PMID 30241173

PURPOSE: Complementary and alternative medicine (CAM) has been popular among patients with cancer for several decades. The objectives of this study were to evaluate the prevalence of CAM use and to identify the factors affecting CAM use in a large patient cohort seen at a comprehensive cancer center in Turkey. PATIENTS AND METHODS: An investigator-designed survey was completed by volunteer patients who visited the outpatient clinic in the medical oncology department. CAM use encompassed pharmacologic agents including vitamins, dietary supplements, and herbal products or nonpharmacologic methods like prayer, meditation, hypnosis, massage, or acupuncture. RESULTS: Of 1,499 patients who answered the survey, 1,433 (96%) used nonpharmacologic CAM and 60 (4%) used pharmacologic CAM (pCAM). The most frequent types of CAM used were prayer (n = 1,433) followed by herbal products (n = 42). pCAM use was not significantly associated with age ( P = .63), sex ( P = .15), diagnosis ( P = .15), or income level ( P = .09). However, it was significantly associated with the level of education ( P = .0067) and employment status ( P < .001). Patients with higher education levels used more pCAM products ( P = .025). Among 60 pCAM users, six patients (10%) used pCAM for more than 2 years and 22 (36%) did not consult their physicians about their pCAM use. Only nine patients (15%) reported unpleasant adverse effects related to pCAM. CONCLUSION: Although CAM use was high among our patients, prevalence of pCAM use was lower than expected. Patients with higher education levels tended to use more pCAM.

Zeng Y, Cheng ASK, Song T, Sheng X, Wang S, Xie J, et al. Effects of Acupuncture on Cancer-Related Cognitive Impairment in Chinese Gynecological Cancer Patients: A Pilot Cohort Study. Integr Cancer Ther 2018 Sep;17(3):737-746 PMID 29806502

BACKGROUND: Among women in China, gynecological cancers are the second most common cancers after breast cancer. Cancer-related cognitive impairment (CRCI) has emerged as a significant problem affecting gynecological cancer survivors. While acupuncture has been used in different aspects of cancer care, the possible positive effects of acupuncture on cognitive impairment have received little attention. This study hypothesized that patients would demonstrate lower neurocognitive performance and lower structural connectivity compared to healthy controls. This pilot study also hypothesized that acupuncture may potentially be effective in treating CRCI of cancer patients by increasing brain structural connectivity and integrity. METHODS: This prospective cohort study consisted of 3 stages: the first stage included a group of gynecological cancer patients and a group of age-matched healthy controls. This baseline stage used a core set of neurocognitive tests to screen patients with cognitive impairment and used a multimodal approach of brain magnetic resonance imaging (MRI) to explore the possible neurobiological mechanism of cognitive impairment in cancer patients, comparing the results with a group of noncancer controls. The second stage involved assigning CRCI patients into the acupuncture intervention group, while patients without CRCI were assigned into the cancer control group. The third stage was a postintervention assessment of neurocognitive function by the same set of neurocognitive tests at baseline. To explore the possible neurobiological basis of acupuncture for treating CRCI, this study also used a multimodal MRI approach to assess changes in brain structural connectivity, and neurochemical properties in patients at pre- and postacupuncture intervention. RESULTS: This study found that the prevalence of cognitive impairment in Chinese gynecological cancer patients at diagnosis was 26.67%. When investigating the microstructural white matter in the brain, diffusion tensor imaging data in this study indicated that premorbid cognitive functioning (before clinical manifestations become evident) has already existed, as the global and local connectome properties in the entire patient group were lower than in the healthy control group. Using magnetic resonance spectroscopy, this study indicated there was a significant reduction of relative concentration of NAA ( N-acetyl aspartate) in the left hippocampus, comparing these results with healthy controls. Regarding the effects of acupuncture on reducing CRCI, patients in the acupuncture group reported better neurocognitive test performance after matching for age, menopausal status, cancer stage, and chemotherapy regimen dosage. On a microstructural level, acupuncture's ability to reduce CRCI may be attributed to a reduction in demyelination and an enhancement of the neuronal viability of white matter in the hippocampus. CONCLUSION: This pilot study indicates that acupuncture is a promising intervention in treating CRCI in gynecological cancer patients undergoing chemotherapy; however, it requires evaluation in larger randomized controlled studies to definitively assess its benefit. By using a multimodal imaging approach, this pilot study also provides novel insights into the neurobiological basis of cognitive impairment on the human brain that has been induced by cancer and/or its treatment.