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Support Care Cancer (2007) 15: 457–460
DOI 10.1007/s00520-006-0162-2
Kara M. Kelly
Received: 29 August 2006
Accepted: 5 September 2006
Published online: 12 October 2006
# Springer-Verlag 2006
Presented as an invited lecture at the
MASCC/ISOO 18th International
Symposium of Supportive Care
in Cancer in Toronto, Canada, June 2006.
K. M. Kelly (*)
Division of Pediatric Oncology,
Columbia University Medical Center,
Morgan Stanley Children’s Hospital
of New York Presbyterian,
161 Fort Washington Avenue,
Irving Pavilion 7,
New York, NY 10032, USA
e-mail: [email protected]
Tel.: +1-212-3055808
Fax: +1-212-3055848
SH ORT COMMUNI CATIO N
Complementary and alternative medicines
for use in supportive care in pediatric cancer
Abstract Introduction: Complementary and alternative medical
practices (CAM) are being used by
increasing numbers of children with
cancer. Discussion: Recent surveys
report CAM use prevalence rates of
24–90% in children with cancer.
Interest in supporting children
through the side effects or stress of
conventional treatment has been described as one of the major motivating
factors for the use of CAM therapies.
Research is difficult secondary to the
complexity of the therapies and lack
of standardization. However, several
research studies investigating CAM
therapies for supportive care in children with cancer are ongoing. Infor-
Introduction
Complementary and alternative medical therapies (CAM)
are defined as a group of diverse medical and health care
systems, practices, and products that are not presently
considered to be part of conventional medicine. CAM
therapies constitute an extremely heterogeneous group of
therapies, and although widely used by the general public,
most of these therapies are not well-understood by
conventional health care providers. There is ongoing
need to educate both families and health care providers
on the potential risks and benefits of CAM therapies during
treatment for childhood cancer.
Classification
The National Center for Complementary and Alternative
Medicine (NCCAM) at the US National Institute of Health
was established in 1998 with its mission to investigate
mation on several studies in progress
through the Children’s Oncology
Group and other institutions will be
reviewed. Conclusion: The progress
made in the development of these
studies demonstrates that CAM
therapies can be investigated for their
supportive care roles in the therapy of
children with cancer.
Keywords Complementary .
Alternative . Children . Cancer
CAM therapies in the context of rigorous science and to
disseminate reputable information on CAM therapies to the
public and professional communities [17]. A standard
classification system for these therapies was developed by
NCCAM (Table 1) [10]. This classification system defines
the major categories of CAM therapies and is useful for
both research and education purposes.
CAM therapies use among children with cancer
Numerous surveys have demonstrated that patients frequently turn to CAM therapies upon being diagnosed with
cancer. Children with cancer also often use CAM therapies.
Although surveys completed in the 1970s and 1980s
revealed that less than 20% of children with cancer used
CAM, surveys over the past decade have found that the
prevalence of CAM therapies use among children with
cancer ranges from 24 to 90% (Fig. 1) [7], comparable to
prevalence rates of CAM use among adults with cancer.
458
Table 1 Categorization of CAM therapies by the National Center for Complementary and Alternative Medicine
Type of CAM
Definition
Examples
Alternative medical
systems
Mind–body
medicine
Complete systems of theory and practice
Homeopathy, naturopathy, traditional Chinese medicine,
Ayurvedic medicine
Meditation, prayer, mental healing, art, music, or dance
Biologically
based therapies
Manipulative and
body-based
methods
Energy Therapies
Biofield therapies
Variety of techniques designed to enhance the
mind’s capacity to affect bodily function
and symptoms
Substances found in nature
Manipulation and/or movement of one
or more parts of the body
Are intended to affect energy fields that
purportedly surround and penetrate the
human body
Bioelectromagnetic- Involve the unconventional use of
based therapies
electromagnetic fields
Dietary supplements, herbal products, and the use of other
so-called “natural” but as yet scientifically unproven therapies
Chiropractic or osteopathic manipulation, massage
Qi gong, Reiki, therapeutic touch
Pulsed fields, magnetic fields, or alternating current
or direct current fields
From [10]
These surveys have also found that most children are using
CAM therapies as adjunctive agents rather than as a
replacement to conventional treatment for cancer. Use of
CAM is further complicated by the observation that 50% of
therapies are not reported to health care providers [8].
CAM therapies are frequently used by participants of
conventional clinical trials, thereby potentially introducing
bias into the results of some studies. In children, CAM
90
80
70
60
% of Children
Fig. 1 The prevalence of CAM
therapies use among children
with cancer. Each bar represents
the prevalence in a published
survey. The studies are clustered
by the time periods in which
the studies were completed.
Group 1 (1977–1983), group 2
(1994–1998), and Group 3
(2000–2006) [8]
therapies are primarily used as supportive therapies to
alleviate pain and symptoms of cancer and especially to
ameliorate actual or perceived toxicities of conventional
cancer treatment. Many factors are associated with CAM
use in this setting. Parents’ desire to try to do everything
possible to improve their child’s health likely plays a major
role in their decision to use CAM therapies for their child
[8]. Poor prognosis, prior CAM use, higher parental
50
40
30
20
10
0
77-83
94-98
00-06
Year Study Completed
459
education, older age, and religiosity have also been
associated with CAM use in children with cancer.
The state of the evidence for CAM therapies
for supportive care in children with cancer
The use of CAM therapies by patients with cancer is
controversial. Because there are few clinical trials of safety
or efficacy, little information is available to guide clinical
practice. The concern raised by the use of the dietary
supplements is especially magnified by the variability in
quality and differences in regulatory oversight as compared
with conventional medications. For CAM therapies
delivered by practitioners, similar concerns may exist.
Training and licensure standards are not consistent.
Clinical research of CAM therapies is complicated.
Complex therapeutic systems such as traditional Chinese
medicine are difficult to standardize, as many of the
therapies are individualized to a certain patient instead of a
particular disease in contrast to the approach used in many
clinical trials of conventional therapies. Recruitment to
clinical trials of CAM therapies may be hampered by
emotional biases either for or against the particular therapy.
The lack of standardization of dietary supplements
mandates the need for independent purity testing. Some
CAM practitioners may also have little incentive to
conduct trials of CAM therapies since the therapies are
already available in the mainstream.
Despite these limitations, evidence is available to
support the use of several CAM therapies among children
with cancer. Therapies with a demonstrated supportive care
role include hypnosis, guided imagery, music therapy,
massage, and acupuncture. Hypnosis and imagery reduced
anticipatory nausea, vomiting, and pain in children with
cancer [4, 6, 12, 19]. A child’s emotional state [1] and
immune function [9] may be affected by music therapy.
Massage therapy is associated with beneficial effects on
mood and anxiety [13] and possibly shortened duration of
time to neutrophil recovery [2]. Acupuncture has been
associated with reductions in nausea and vomiting [16] and
improvements in white blood cell recovery in adolescents
receiving chemotherapy [18].
The Children’s Oncology Group has developed two
phase III trials of CAM therapies [15]. The first trial opened
in April 2004 and is a randomized, double-blind, placebocontrolled clinical trial to assess the efficacy of the
homeopathic medication Traumeel® S for the prevention
and treatment of mucositis in children undergoing hematopoietic stem cell transplantation. This study was based
upon an Israeli pilot study that showed that Traumeel® S
significantly reduced the severity and duration of chemotherapy-induced mucositis in children undergoing bone
marrow transplantation [11]. The second trial is a
collaborative effort with investigators at the Pediatric
Oncology Branch at the National Cancer Institute. This
randomized trial is investigating electroacupuncture treatment for delayed chemotherapy-induced nausea and vomiting in patients with pediatric solid tumors. There are few
studies to date involving children and acupuncture, partly
because of a concern that children would not accept
placement of needles, although there is general consensus
that acupuncture is acceptable to children beginning at
10 years [14]. As prolonged delayed nausea is still a
clinical challenge, this study has real potential to identify a
useful adjunctive agent.
Conclusions
Despite the limited data specifically on CAM therapies in
children with cancer, the use of these therapies is increasing
worldwide. The International Society of Pediatric Oncology
(SIOP) has developed guidelines to enhance communication
between health care providers and families on the use of
these therapies [5]. SIOP calls for the health care team to be
attentive to complementary therapies that may be physically
or psychologically harmful to children and their parents and
for the health care team to not automatically and dismissively
discourage the use of non-harmful complementary therapies.
Further research is needed to evaluate CAM therapies in
children with cancer, and the same general research
principles used for investigating conventional therapies
should also be used [3]. The integration of CAM therapies
with conventional treatments for cancer may be especially
useful for symptom management.
Acknowledgements Supported in part by the Lerner and Schwartz
families and Origins Natural Resources.
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