A Science‐Based Look at “Integrative Oncology” 27/03/2017

27/03/2017
1
AScience‐BasedLook
at“Integrative
Oncology”
ScottGavura,BScPhm,MBA,RPh,ACPR
Presentedat:CAPhO Conference2017
Imagecopyright:http://www.mattdawsonillustration.com,usedwithpermission
DisclosuresandDisclaimers
Ihavenofinancialorotherconflictsofinteresttoreportwithrespect
tothistopic.
Thispresentationwaspreparedbymeinmypersonalcapacity.
Anyopinionsexpressedaresolelymyown,andnottheopinionsofany
organizationsI’memployedby,oraffiliatedwith.
Howfarwe’vecome?
“Holisticmedicineisapablum ofcommonsenseandnonsenseofferedbycranks
andquacksandfailedpedantswhoshareanattachmenttomagicandan
animositytowardreason.Toomanypeopleseemwillingtoswallowtherhetoric–
eventoomanymedicaldoctors– andtheresultswillnotbebenign”
1983:NewEnglandJournalofMedicineeditorial:
Glymour C,StalkerD.NEJM1983;308:960‐64
2017:Whooffers“IntegrativeOncology”?
LearningObjectives
Byattendingthispresentation,attendeeswilllearn:
•Thepurportedrationaleforintegrativeoncology
•Thepotentialbenefits,andpossibleharms,ofintegrativeoncology
practices
•Implicationsandconsequencesofintegrativeoncology
•Howpharmacistscaneffectivelyadvocateforethical,science‐based
patientcare
Inthenext25minutes…
•Whatareweeventalkingabout?
•Whatis“complementaryandalternativemedicine”(CAM)?
•Whatis“integrative”medicineand“integrative”oncology?
•Challengeswith“integrating”CAMintocancercare
•What’stheharm,really?
•Isthereanythingwecanlearnfromintegrativeoncology?
•Thepharmacist’srole
•UnderstandingCAMvs.promotingCAM
•Advocatingforhighstandardsofcancercare

27/03/2017
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Whatareweeventalkingabout?
TheEvolutionofCAMandIntegrativeMedicine
HolisticMedicine/“Unconventional”therapies
Alternative Medicine
ComplementaryandAlternativeMedicine
IntegrativeMedicine
Functionalmedicine?
Whatis“IntegrativeMedicine”?
Integrated Medicineisnot
Integrative Medicine*
*Noteveryonefollowsthisrule
L.Kodner D,Spreeuwenberg C.Integratedcare:meaning,logic,applications,andimplications–adiscussionpaper.InternationalJournalofIntegratedCare.2002;2:e12.
USNationalCenterforComplementaryandIntegrativehealth:Complementary,Alternative,orIntegrativeHealth:What’sInaName?www.nccih.nih.gov
CAMandCancer
•TheuseofCAMappearstobeincreasing(Canada/USA)
•KnowledgerelatedtoCAMincancerislimited
•Prevalenceprobablyunderestimated
•CancerdiagnosismaymotivateuseofCAM(e.g.,supplements)
1
•Asubstantialproportion(29‐91%
2,3,4
)ofcancerpatientsmaybeusingsomeformof
CAM
•However,CAMdefinitionsinresearchvary:
•Spiritualism
•Mindfulness,medication
•Exercise
•Multivitamins
•Supplements(herbalremedies,etc).
1
PattersonREetal.Changesindiet,physicalactivity,andsupplementuseamongadultsdiagnosedwithcancer.JAmDietAssoc.2003Mar;103(3):323‐8.
2
See,forexampleBerrettaetal,Oncotarget 2016,where48.9%ofItaliancancerpatientsreportedCAMuse
3
BoonHetal.UseofComplementary/AlternativeMedicinebyBreastCancerSurvivorsinOntario:PrevalenceandPerceptions.JournalofClinicalOncology200018:13,2515‐2521
4
ToughSCetal.ComplementaryandalternativemedicineuseamongcolorectalcancerpatientsinAlberta,Canada.Altern Ther HealthMed.2002Mar‐Apr;8(2):54‐6,58‐60,62‐4.
Whatis“ComplementaryandAlternativeMedicine”?
•NationalCenterforComplementaryandIntegrativeHealth
1
:
•Useofproductslikeherbs,vitamins,minerals,andprobiotics,andmedical
practices(e.g.,acupuncture)whichareoutsideofthemainstreamWestern
medicine.
•‘alternative’whentheyareusedinplaceofconventionalmedicine
•‘complementary’whentheyareusedtogetherwithconventionalmedicine
•Edzard Ernst
2
:
•“..diagnosis,treatmentand/orpreventionwhichcomplementsmainstream
medicinebycontributingtoacommonwhole,satisfyingademandnotmetby
orthodoxy,ordiversifyingtheconceptualframeworkofmedicine.”
1
availableat:https://nccih.nih.gov/health/integrative‐health
2
ErnstE,Pittler MH,WiderB,Boddy K.Thedesktopguidetocomplementaryandalternativemedicine,2ndedition.Edinburgh:ElsevierMosby,2006
AsimplerdefinitionofCAM
1
1
attributedtoTimMinchin
Doyouknowwhattheycall
alternativemedicinethat’sbeen
proventowork?
Answer:
MEDICINE
Answer:
MEDICINE

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Theintegrativecontinuum
Science‐based,even“conventional”
Manyareco‐optedas“integrative”
Diet
Exercise
Lifestylechanges
Somesupplements/herbs
Acupuncture
Reiki
Homeopathy
Naturopathy
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Reflexology
Chiropractic
Implausibleand/ordisproven,often
pseudoscience
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Canincludebothevidence‐basedandpseudoscientificpractices
Sowhatisintegrativemedicine,really?
Whatitis
•Abrand
1
•Astrategy
•Marketing
•Profitcentre
•Loweringtheevidence“bar”
Whatitisn’t
•ChoosingWisely
•Proventobesuperiorto
conventionalcare
1
e.g.,http://www.huffingtonpost.com/marc‐stoiber/who‐will‐own‐the‐brand‐of_b_910077.html
TheUnstatedMajorPremiseofIntegrative
Medicine
•IntegrativeMedicine/Oncologyclaimsto“integrate”avarietyof
treatments,treatingthe“wholeperson”inawaythatissuperiorto
“conventional”medicine.
•Itissaidtobetteraddress“rootcauses”anddeliversuperiorpatientcare.
•Theunstatedpremiseisthatscience‐basedmedicinedoesn’tprovide
patient‐centred care.
•Confusessciencewithalackofcompassion
•Assumesthat“conventional”medicinedoesn’tconcernitselfwiththewhole
personand/orrootcauses.
•Assumesthatprovidingunprovencareissomehowmorepatient‐centred.
CommonargumentsforIMandCAM
•“Abse nc e ofevidenceisn’tevidenceofabsence”
•Thisisanargumentfromignorance
•“SomeIMandCAMisbackedbygoodevidence”
•SeetheMinchindefinition
•“Conventional”oncologypracticeignorestheevidence‐base
•Doesanypracticechangemorequicklythanoncology,inthefaceofgoodevidence?
•Weneedtostudythesetreatmentstoseewhatworks
•Norationaletoexamineoutsideofcurrentframework
•e.g.,herbalismvs.pharmacognosy
WhydoinstitutionsofferIntegrative
Medicine?
•Patientdemand
•Argumentfrompopularity
•“Keepthecustomersatisfied”(USA)
•Manufactureddemand
•Notunderstandingthe(lackof)evidence
•Willingtoacceptweakevidence
Challengeswith“integrating”
CAMintocancercare

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Whatarewereallyintegrating?
1
Reasonableand/orEvidenceBased
•AskpatientsaboutCAM
•Provideevidence‐basedguidanceonCAM
•Evaluatesupplementsforinteractions
•Mind/bodytherapiesforQOL
•Meditation,CBT
•“Energytherapies”safebutnotencouraged
duetolackofevidence
•ReferpatientstoRDsfordietaryadvice
•Botanicalsasactivetreatmentonlyincontext
ofclinicaltrial
•Avoidtreatmentspromotedas“alternatives”
tomainstreamcare
UnprovenorProvenIneffective
•Acupunctureforpain,
xerostomia,N&V,smoking
1
JournaloftheSocietyforIntegrativeOncology5(2)2007:65‐84.
Theplacebonarrativeor“thinkingmakesitso”
•ManyformsofCAMoncethoughttohavemedicinaleffectsas
demonstratedintrials
•Manyofthesetrialshadseriousmethodologicaldeficiencies
•e.g.,acupuncture
•Asstudieshavegrownmorerigorous,thoseeffectshavedisappeared
•Proponentsnowarguethesetreatmentsworkthroughthe“Powerof
Placebo”
1,2
•Consequently,effectivenessisreliantonproviderdeceptionabout
evidencebase
1
e.g.,MarchantJ.Aplacebotreatmentforpain.NYTimes2016Jan9;SR5.
2
e.g.,WangSS.Whyplacebosworkwonders.WallStreetJournal2012Jan10.
What’stheharminIntegrative
Oncology?
(Atleast)threemajorharmsfromIntegrative
Oncology
• Willitimprovecancercare?
Clinical
•Isitethicallydefensible?
Ethical
•IsprovidingCAMagooduseoflimitedresources?
Economic
Harm1:Clinical
•ImprovementsinsurvivalandQOLhavebeenderivedfromthe
increasingapplicationofevidence,notfromignoringthescience.
ManyCAMtherapiespositimplausibleorimpossiblemechanismsofaction.
BeforetheeraofCAM,rarefortherapiestoproceedtoclinicaltrialsbased
onlyonlaboratoryoranimalplausibility.
•e.g.,acupuncturehasnoviablemechanism,norhasonebeenshown.
•Evidencesuggeststhatacupuncture’soveralleffectsareindistinguishablefromplacebo
1
.
•Possible,butunlikely,exception:chemotherapy‐inducedN&V
2
.
•NotclearthatallformsofCAMcanbeusedwithoutriskofharm.
E.g.herbalremediesareeffectivelyimpure,unstandardizeddrugs.
LittleevidenceCanadiansupplementshavemeaningfulqualitycontrol
3
1
ColquhounD,NovellaSP.Acupunctureistheatricalplacebo.Anesth Analg.2013Jun;116(6):1360‐3
2
GarciaMKetal.Systematicreviewofacupunctureincancercare:asynthesisoftheevidence.JClin Oncol.2013Mar1;31(7):952‐60.
3See,forexample,Erland LAEandSaxenaPK.MelatoninNaturalHealthProductsandSupplements:PresenceofSerotoninandSignificantVariabilityofMelatoninContent,J
SleepMedicine2017;13(3).
Harm2:Ethical
•Givenimplausibility,isitreasonabletosubjectpatientstotreatments
thatlackanypre‐clinicalsignsofeffectiveness?
•Isthereanyjustificationfor“integrating”therapiesthatarenotthe
standardofcareintoroutinecancercare?
•Shouldunproventherapiesberoutinelyofferedoutsidethecontext
ofaclinicaltrial?
Integrativecentres routinelyofferhomeopathy,reiki,acupuncture,etc.
•Pharmacists(andotherHCPs)sellingCAMviolateethicalprinciples
1
1
MacdonaldC,Gavura S.Alternativemedicineandtheethicsofcommerce.Bioethics2016;30(2):77‐84.

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Harm3:Economic
•Everdollarspentonunproventherapyresultsintimeandmoney
spentoninterventionsthathavenotbeendemonstratedtoimprove
QOLorsurvival.
•Integrativeoncologywastestheresourcesofpatients(timeandoften
money),providers,andsystemadministrators.
Isthereanythingwecanlearnfromintegrative
oncology?
•Integrativeoncologyreflects,inpart,consumerenthusiasmforCAM
•UnderstandtheevidencetosupportcandiddiscussionswithpatientsandHCPs
•Muchofthegoodinintegrativeoncologyiswhatweshouldalreadybeen
offeringtoourpatients:
•Promotingprevention,wherepossible
•Healthylifestyle&discontinuingactionsknowntobeharmful
•Propernutrition
•Exercise(itdoesn’thavetobeyoga!)
•Adequatesleep
•Understandpatientvaluesandpreferences
Noneofthisis“alternative”or“integrative.”It’sjustgoodpatientcare.
Thepharmacist’srole
ThePharmacist’sRole
“Patientstrustthatashealthcareprofessionalswewillrespectand
protecttheirvulnerabilityandmaintainprofessionalboundarieswithin
thehealthcareprofessional/patientrelationshipasweuseour
knowledge,skillsandabilitiestomakedecisionsthatenhancetheir
healthandwell‐being”
‐OntarioCollegeofPharmacists–CodeofEthics(Dec2015)
Pharmacist’sRole
•UnderstandingCAMapproachesandperspectivesarecritical.
•Pharmacistsarethe drugtherapyexperts.
•AssessingCAMtherapieslikeherbalismorhomeopathyisnotoutsidethe
expertiseofpharmacists
•IfaCAMtherapyworks,itworksaccordingtoscientificprinciples,notalternativeones
•Don’trelinquishthatrole(andresponsibility)
•Theprofessionmustmaintainaclearidentitygroundedinevidence
andscience,notonewillingtoignorescienceonthebasisof
“alternative”ideas.
•Popularityshouldn’tdrivewhatweoffer,evidenceshould.
Conclusion
Imagecopyright:http://www.mattdawsonillustration.com,usedwithpermission