Mr. Smith comes to the clinic for his first round of radia&shy;tion for prostate cancer. During check-in, he mentions that he just started taking selenium because his daughter read that it has anticancer effects and may help shrink his tumor. He asks if this works and if it’s safe.

In the past, complementary therapies, or nonstandard thera&shy;pies, were described as alternative or even irrational. Today, more and more complementary therapies are being integrated into care plans for patients with prostate cancer. Acupuncture, prayer, and meditation are examples of therapies that patients use to ease adverse events related to cancer or traditional cancer treatment.

In a recent study of men with prostate cancer, the find&shy;ings showed that 65% of patients used herbal remedies and nutritional supplements during their conventional treatment.1 Other common complementary therapies included exercise programs, dietary changes, calcium supplements, and prayer. The results also revealed that just half of the patients discussed the use of these treatments with their physicians, and that patients usually initiated the conversations.1

Many individuals continue to use complementary therapies after completing active cancer treatment. In a study published in the 

in 2016, approximately 79% of cancer survivors claimed to have used vitamins, minerals, or other complementary and alternative medicine modalities in the previous year.2

Some complementary therapies have undergone evaluation and been found to be safe and effective. Others are ineffective or even harmful.3 It’s important that oncology nurses are familiar with the most common complementary therapies so that they can help patients make safe decisions and communicate with a physician regarding potential interactions or issues.

A nutritious diet is an essential aspect of overall health. However, some nutritional supplements can cause harmful interactions with a patient’s therapy regimen.

Common nutritional therapies include antioxidants, such as beta-carotene, lycopene, and vitamins A, C, and E. Antioxidants may protect cells from damage caused by free radicals, which may lead to cancer.4 Patients with prostate cancer have commonly used antioxidants for both prevention and treatment.5

A 2009 study evaluated the use of vitamin E and selenium for prevention of prostate cancer in men over age 50. The results showed that neither supplement reduced the risk of prostate cancer development and that both were potentially harmful.5

Other common nutritional therapies include coenzyme Q10, dietary supplements, glutamine, and melatonin.4 Coenzyme Q10, an antioxidant made by the body and found in meat, fish, and whole grains, has been shown to stimulate the immune system and protect the heart during chemotherapy treatments that cause damage.

Glutamine, an amino acid, has been shown to reduce damage to the gastrointestinal tract that can happen during chemotherapy and radiation treatments. Supplemental use of glutamine during prostate cancer treatment may mini&shy;mize treatment delays and dose reductions and improve quality of life. The hormone melatonin assists with sleep—wake cycles and may limit sleep disturbances during treatment.4 More research is under way regarding the use of melatonin supple&shy;ments during cancer treatment.

A practice in traditional Chinese medicine, acupuncture is used to manage cancer-related symptoms, treat adverse events that might arise due to chemotherapy and radiation, boost blood cell counts, and enhance lymphocyte and natural killer cell activity.4 One study showed that acupuncture can help control cancer-related pain, decrease the frequency of vomiting, and reduce hot flashes and lethargy in prostate cancer patients.6 Overall, acupuncture is a useful supportive treatment when done in combination with allopathic medicine for prostate cancer treatment.6

Mind-body techniques such as cognitive-behavioral therapy (CBT) and hypnosis can combat the effects of cancer-related stress, anxiety, and depression. A type of psychotherapy, CBT helps patients change their behaviors by altering how they feel about certain aspects of care. CBT has been shown to be effec&shy;tive in treating anticipatory nausea and vomiting in patients undergoing cancer treatments. It has also proved effective in the treatment of depression and cancer-related posttraumatic stress.4 Hypnosis is also commonly used to treat anxiety and distress.4

The use of botanicals such as herbs ranges from controver&shy;sial to commonplace. One popular kind used by patients with cancer is St John’s wort (

), for example. As a treatment for depression, its major active ingredients are thought to be melatonin, hypericin, hyperforin, and adhyper&shy;forin.7 This herb can decrease the effectiveness of other drugs, however, so it is important to notify the physician about a patient’s concomitant use of St. John’s wort.7

Nurses who encounter an unfamiliar complementary therapy should do some investigative work before discussing it in detail with patients. Reliable resources include the National Center for Complementary and Alternative Medicine and the National Cancer Institute’s Office of Cancer Complementary and Alternative Medicine. At each visit, patients should be asked about any new medications or treatments, supplements, or therapeutic activities. Education regarding these therapies will help patients make the best decisions about all aspects of their cancer care.

Lee RT, Herrerich JA, Kwon N, Bylow K, et al. The relationship between anxiety about prostate cancer among patients with biochemical cancer recurrence and the use of complementary and alternative medicines, diet, and exercise. 

 2017;5(2):139-148. doi: 10.15212/FMCH.2017.0129

John GM, Hershman DL, Falci L, Shi Z, Tsai W, Greenlee H. Complementary and alternative medicine use among US cancer survivors. 

 2016;10(5):850-864. doi: 10.1007/s11764-016-0530-y.

Complementary and alternative medicine. National Cancer Institute website. cancer.gov/about-cancer/treatment/cam

 Updated April 10, 2015. Accessed November 11, 2018.

Topics in integrative, alternative, and complementary therapies (PDQ)—health professional version. National Cancer Institute website. cancer.gov/about-cancer/treatment/cam/hp/cam-topics-pdq#section/_16. Updated June 27, 2018. Accessed November 1, 2018.

Klempner S, Bubley G. Complementary and alternative medicines in prostate cancer: from bench to bedside?

. 2012;17(6):830-7. doi: 10.1634/theoncologist.2012-0094.

Andrew J. The role of acupuncture in the management of prostate cancer [published online June 17, 2015]. 

Cannabis and cannabinoids (PDQ) —health professional version. National Cancer Institute website. cancer.gov/about-cancer/treatment/cam/hp/cannabis-pdq. Updated August 16, 2018. Accessed November 1, 2018.

Articles

Some therapies can be safely integrated with traditional cancer care, but others can be harmful.

Complementary Therapies for Prostate Cancer Treatment

A cancer diagnosis can leave your patient with many questions. Sitting in a hospital room or infusion center for long hours might give them time to reflect on their diagnosis, life, and place in the universe. They may turn to you for support and answers as they meditate on their mortality. Is there a place for spiritual care in oncology nursing?

, RN, OCN, CBCN. Baldwin has been a nurse for 35 years, and most of that time has centered around oncology, hospice, quality improvement, and long-term care. Eleven years ago, she became a pastor, and today, she is chaplain of the Mitchell Cancer Institute in Mobile, Alabama.

In her current role, Baldwin brings her passions for nursing and as a spiritual counselor together to help patients and nurses. She describes spirituality as an integral part of any holistic nursing assessment, making it an essential component of active treatment and survivorship.

But for many nurses, engaging in these conversations can be uncomfortable. You may even question if this is indeed a part of your role. In a recent interview, Baldwin explained the difference between spirituality and religion and a few easy ways to handle these difficult conversations.

SPIRITUALITY VERSUS RELIGION IN NURSING CARE

There is no agreed-upon definition of spiritual care in nursing.

 Spirituality is personal and varies from one person to the next.

 defines spirituality as a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationships to self, family, others, community, society, nature, and the significant or sacred.

 Spirituality is expressed through beliefs, values, traditions, and practices.

Baldwin simplifies this definition. In her view, “spirituality is a personal interpretation of the soul.”

How does this differ from religion? Baldwin described religion as a community of faith. It is structured and often defined by rituals. The online Merriam-Webster Dictionary defines religion as the service and worship of God or the supernatural.

 It is a personal set or institutional system of religious attitudes, beliefs, and practices.

Religion and spirituality can occur together or separately, so it’s essential you first understand both. Then you can begin to practice a few ways to bridge these conversations easily or know when it is time to request help from a spiritual counselor.

Baldwin stressed the importance of knowing and understanding your own beliefs before engaging in conversations with your patients. One study that examined how nurses assist patients with spirituality found that the personality and background of the nurses influence how they approach these conversations.

Your comfort level with your spirituality is connected to how you view patients in illness.

 Your comfort zone should include your spiritual and religious beliefs, practices, and limitations. If prayer is outside of your comfort level, that’s okay, Baldwin says. You can still offer spiritual care to your patients by being present.

Nurses aren’t expected to know all the answers. You often don’t need any answers to meet the patient where they are on their spiritual journey.

Active listening is one of the best skills to use when dealing with difficult conversations. Listen to understand, not to respond. Acknowledge your patient’s courage in talking about their spiritual needs and thoughts. Baldwin also suggested using a technique like reflection, where you merely state back to the patient what they just said, to keep the conversation going. “Be open to [patients’] beliefs and allow them to talk freely,” Baldwin says. “A quiet moment of silence or simple prayer may be all that’s needed.”

When engaging in conversations around spirituality, be careful not to overstep the bounds of your professional responsibility. Always speak with compassion and honesty.

If the conversation goes in a direction outside of your abilities or inclinations, it is okay to let the patient know that you would like to call in a spiritual counselor to be sure that their needs are met.

KNOW WHEN TO TURN TO A SPIRITUAL COUNSELOR

“Even pastors need to lean on others for help,” said Baldwin. She described fellow spiritual leaders as a necessity. Keep a list of religious leaders in your area and call on them for spiritual needs outside of your comfort zone and abilities. If your health system has a chaplain, use their services. And you can always ask the patient if they have a pastor, rabbi, or another spiritual counselor they would like you to call.

To increase your spiritual literacy, read books and journal articles. Understand different religions and spiritual beliefs. Talk about spiritual care practices in in-services or nurse meetings. Have a chaplain present on common topics.

Nurses deal with life-or-death situations. Your soul connects with others. This makes self-care imperative. “Acknowledge your own beliefs and sadness,” says Baldwin. “Make your physical, emotional, and spiritual health a priority. Nurses are at a high risk for compassion fatigue, which can lead to depression, anxiety, and exhaustion. You must care for your own spiritual needs to be able to provide needed spiritual care to others.”

Offering spiritual care doesn’t have to be difficult. Prayers can be simple and words don’t have to be fancy. Be present and connect to the spiritual needs of your patients and care for yourself, too. And if you don’t feel comfortable in the role, call in an expert.

Melissa Mills, BSN, RN, CCM, MHA is a freelance healthcare writer and the owner of MakingSpace.company. She has been a registered nurse for 20 years and is passionate about case management, nursing leadership, and finding the right care for patients in every setting.

Giske T, Cone P. Discerning the healing path — how nurses assist patient spirituality in diverse health care settings. 

2015;24(19-20):2926-2935. doi: 10.1111/jocn.12907.

Hughes Rev BP, DeGregory C, Elk R, Graham D, Hall Rev EJ, Ressallat J. Spiritual care and nursing: a nurse’s contribution and practice. HealthCare Chaplaincy Network website. healthcarechaplaincy.org/docs/about/nurses_spiritual_care_white_paper_3_3_2017.pdf. Published March 2017. Accessed September 6, 2018.

Religion. Merriam-Webster Dictionary website. merriam-webster.com/dictionary/religion. Accessed September 6, 2018.

How should oncology nurses deal with patients' spiritual needs?

Difficult Conversations: Dealing with the Spiritual Needs of Patients with Cancer

Although placebo use in cancer clinical trials has been rare, it is becoming more common in today’s advanced pharmaceutical environment.

 Some trials have started to incorporate randomization and placebo.

 Placebo-controlled trials are justifiable when they are supported by sound methodologic consideration and when their use does not expose research participants to excessive risk of harm.

 What do you need to know regarding placebo in cancer clinical trials? Below is a look at the use of placebos in oncology practice.

The use of placebos dates back to at least the end of the 18th century.

 After World War II, randomized controlled trials gained in popularity, making the inclusion of placebos more common. A placebo is a pharmaceutically inert substance, often a sugar pill.1 Investigators use placebos to prove a new treatment is effective above and beyond the simple belief in the ability of the drug to cure.

During a trial, one group will be given a placebo, and the other group will receive the new active drug therapy being studied. The results of the outcome of the drug use are then compared between the 2 groups. The placebo-controlled trial is considered the gold standard for testing the efficacy of new treatments in most clinical research areas other than oncology.

During a recent interview with Cancer.Net, Richard L. Schilsky, MD, senior vice president and chief medical officer of the American Society of Clinical Oncology, discussed recent changes in the structure of clinical trials for cancer treatments. In past years, he said, it was not necessary or even possible to use placebos in cancer clinical trials.

A randomized double-blind, placebo-controlled study is considered the benchmark of epidemiologic research.

 Randomly assigning treatment reduces complicating variables.

 In double-blind studies, the participants, the investigators, and the staff do not know which patient is receiving which treatment.

One of the reasons placebos were not used in cancer research is that investigators could easily identify patients randomized to the placebo group based on the change in tumor size.

 Another was related to adverse events (AEs). Many past chemotherapeutic agents caused severe and easily identifiable effects, potentially unmasking randomization of patients to placebo or active treatment groups.

In the interview, Schilsky went on to report that today, many of the newer, targeted drugs slow tumor growth rather than shrinking the tumor, thus allowing placebo use in cancer trials.

 Because visible changes are now more difficult to see, a control group in these trials is beneficial to show whether the stabilization of tumor growth is from the treatment or the natural behavior of the tumor.

The other change Schilsky discussed is related to the pharmacokinetics of the newer cancer treatments. Many of the latest cancer drugs are given by mouth and have fewer AEs, such as fatigue, for which the cause—the cancer itself or the drug&mdash;is difficult to determine.

 So, this study design, once not used in cancer clinical trials, is on the rise.

Schilsky offered this support for the necessity of the advancement of cancer research: “The fastest way to improve access to new cancer treatments for all patients is the timely completion of well-designed, definitive clinical trials that provide evidence of the safety and effectiveness of a new drug and lead to marketing approval.”

 To achieve this goal, the inclusion of placebo control may be necessary in some circumstances.

Ethical concerns about placebos have existed for as long as they have been in use. It is important that the use of placebos be disclosed to all study participants upon entry into a clinical trial.

 Because clinical trials use human subjects, there must be a balance of science, ethics, and human protection.

 When there is no standard treatment, the use of a placebo is typically accepted. However, in placebo-controlled trials, ethical concerns arise when an effective treatment exists.

 If a placebo increases the risk of the control group’s having an adverse outcome, such as death, irreversible illness, disability, or other injuries, it should not be used.

 If a highly effective or potentially curative treatment is available, the use of placebo is considered unethical.

“The bottom line is that there are no ‘ethical considerations’ when placebos are used appropriately in cancer clinical trials,” said Lisa Schulmeister, MN, RN, FAAN, in an interview with 

. “The important thing is that a placebo is not being compared to known effective cancer treatment. They are being used alone in symptom management trials. They’re being used alone when there is no known effective treatment. They’re being used in conjunction with known effective treatment.”

The increased use of placebos in oncology makes it important for nurses to familiarize themselves with how they are used. Patients may have misconceptions about placebos in clinical trials, and it is a nurse’s role to provide education about them. Schulmeister also says that nurses need to reinforce the importance of noting and reporting side effects during a trial. If patients have questions or concerns regarding the use of placebo in a clinical study, nurses should contact the research coordinator or primary investigator for more information and support. They can also refer patients to their informed consent document, which should clearly explain the purpose of the study and any placebo use.

Melissa Mills, BSN, RN, CCM, MHA, is a freelance healthcare writer and owner of the website makingspace.company. She has been a registered nurse for 20 years and is passionate about case management, nursing leadership, and finding the right care for patients in every setting.

Milestones in cancer research and discovery. National Cancer Institute website. cancer.gov/research/progress/250-years-milestones. Published January 21, 2015. Accessed June 14, 2018. 

Placebos in cancer clinical trials. Cancer.Net website. cancer.net/research-and-advocacy/clinical-trials/placebos-cancer-clinical-trials. Published April 2018. Accessed June 8, 2018.

Misra S. Randomized double blind placebo control studies, the “gold standard” in intervention based studies. 

 2012;33(2):131-134. doi: 10.4103%2F0253-7184.102130.

Gupta U, Verma M. Placebo in clinical trials. 

 2013;4(1):49-52. doi: 10.4103/2229-3485.106383.

Millum J, Grady C. The ethics of placebo-controlled trials: methodological justifications. 

 2013;36(2):510-514. doi: 10.1016/j.cct.2013.09.003.

Why are more oncology trials incorporating placebos today?
 

Exploring the Use of Placebo in Cancer Clinical Trials

You have been working with Mrs Smith for the past month. With each passing day, you notice that she appears more depressed, angry, and anxious. She doesn't chat like she did when she started her treatments for breast cancer. She rarely maintains eye contact. She is quiet and sullen.

Your mind starts wandering over ways to help her that go beyond the bag of chemo you give each week. At the next few appointments, you notice that she is never without her earbuds and music. As she sits in the chair, eyes closed, she quietly drums her fingers to a beat you can't hear. Could this be the way to help Mrs Smith? You have read a few stories about drumming as a means of helping patients with breast cancer deal with emotional side effects. But does it work?

Life is set to a rhythm. The first sound heard by every child is the beat of their mother's heart. It is no surprise, then, that the beat of a drum can bring peace, calm, and even transcendence to a hurting soul.

According to the American Music Therapy Association, music therapy combines the clinical and evidence-based use of music interventions to help patients reach specific goals.

 It addresses physical, emotional, cognitive, and social needs. Patients work with a music therapist to create, sing, move to, and/or listen to music.

Drumming can be used as a type of music therapy. In a 2017 interview with Medscape, Theodore Zanto, PhD, a top music therapy researcher, states that the rhythmic sounds of music and drumming can be healing.

Similar to meditation, drumming produces positive mental health effects in patients. The brain is also rhythmic, so during drumming, the brain is interpreting every sound wave created. Drumming creates both a sound and a physical effect on the body. This creates a good environment for meditation and relaxation to take place.

There is limited research on the effects of drumming on patients with breast cancer. What we do know is that music can be healing. One encouraging study looked at the effects of group drumming on anxiety, depression, social resilience, and inflammatory immune response among mental health patients.

 It found that levels of anxiety and depression decreased in patients who participated in group drumming for 10 weeks compared with those in a control group.3 Drumming produces plenty of other health benefits, as well. This form of music therapy:

Drumming releases endorphins and oxytocin, hormones that elevate mood and decrease stress.

 Breast cancer treatment is stressful, and drumming offers patients an outlet.

 Researchers at the Mind-Body Wellness Center, an outpatient medical facility in Meadville, Pennsylvania, investigated whether group drumming music therapy alters stress-related hormones and enhances specific immunologic measures associated with natural killer cell activity and cell-mediated immunity. Killer cells, a type of white blood cell, destroy infected or cancerous cells. This study is the first known research using group drumming music therapy to create biological changes in patients.

 This important experimental research indicated that group drumming does boost the immune system's ability to fight cancer and other viruses by increasing the release of killer cells. Done regularly, group drumming may produce lasting, sustained immunological effects on patients facing long-term conditions for which an increase in killer cells is beneficial.

 Drumming classes are often done in a group setting, which helps create a connection between the instructor and students. Each person is challenged to connect with their own spirit and the spirits of others in the group during class. Community and connection is important during breast cancer treatment and beyond—having someone else understand firsthand what you are feeling and experiencing can be healing and validating.

This form of self-expression can help release anger, frustration, and fear. Literally drumming out and releasing negative feelings can improve the overall health and well-being of patients with breast cancer.

Indigenous communities across the globe have practiced ceremonial and medicinal drumming for millennia.

Drumming can connect the body and mind to time, space, self, environment, community, cosmology, and spirit.

 Patients who take part in drumming on a physical, emotional, and cognitive level will likely experience many positive effects, similar to those of exercise, laughter, and meditation.

Drumming is still a relatively new complementary therapy in the United States, but it has been used for centuries in other countries. If you have a patient with breast cancer who might benefit from drumming or another kind of music therapy, talk with your supervisor about opportunities in your facility or community. You can also search for classes and music therapists online at the 

American Music Therapy Association's website

What is music therapy. American Music Therapy Association website. musictherapy.org/about/musictherapy. Accessed May 4, 2018.

Stetka, BS. The therapeutic potential of drumming and rhythm. Medscape

website. medscape.com/viewarticle/886726. Published October 12, 2017. Accessed May 4, 2018.

Fancourt D, Perkins R, Ascenso S, Carvalho L, Steptoe A, Williamon A. Effects of group drumming interventions on anxiety, depression, social resilience and inflammatory immune response among mental health service users. 

. 2016;11(3):e0151136. doi: 10.1371/journal.pone.0151136.

Vinesett, A, Price, M, Wilson, K. Therapeutic Potential of a Drum and Dance Ceremony Based on the African Ngoma Tradition. Journal of Alternative and Complementary Medicine. 2015(8): 460-465.

Bittman BB, Berk LS, Felten DL, et al. Composite effects of group drumming music therapy on modulation of neuroendocrine-immune parameters in normal subjects. 

Nunez, S. Medicinal drumming: An ancient and modern day healing approach. 

. 2016;14(2). neuroquantology.com/index.php/journal/article/view/939. Accessed May 9, 2018.

Videos

The rhythmic sounds and sensations of drumming can be healing for patients with breast cancer.

Melissa Mills, BSN, RN, CCM, MHA

Articles

Complementary Therapies for Prostate Cancer Treatment

Difficult Conversations: Dealing with the Spiritual Needs of Patients with Cancer

Exploring the Use of Placebo in Cancer Clinical Trials

Finding a New Beat: Drumming as Therapy for Breast Cancer