Open Discussions Help Nurses Introduce Integrative Services

Oncology nurses have an important role in the discussion of and education about complementary therapy, more commonly called integrative care.

“The word ‘integrative’ is key in the discussion,” said Eugenie Spiguel, MSN, ANP-BC, a nurse practitioner in the integrative medicine department at Memorial Sloan Kettering Cancer Center (MSK) in New York, New York. “When people look at the term ‘alternative,’ those therapies tend to be ones outside of the norms of cancer treatment—alternatives to standard of care. With integrative medicine, we are looking to complement standard of care.”

Education about the role of integrative medicine compared with alternative therapies is important, as more than 1 in 3 Americans believe that cancer can be cured solely through alternative therapies, according to the American Society of Clinical Oncology’s 2020 National Cancer Opinion Survey.1 Among women with breast cancer, only about half of patients disclosed use of complemen-tary and alternative medicines to their health care providers.2

Done successfully, integrative medicine can help manage a patient’s adverse events and enhance quality of life before, during, and after treatment into survivorship. “When you combine evidence-based treatments with the supportive services, that integrative approach to cancer care treats the disease with surgery, chemotherapy, and other conventional tools, [you're] supporting patients’ strength, stamina, and quality of life,” said Carolyn Lammersfeld, MBA, MS, RD, CSO, LD, vice president of integrative care services at Cancer Treatment Centers of America (CTCA).

Types of Care

Integrative care can include modalities as varied as behavioral health services, nutritional support, oncology rehabilitation, and pain management.

One example of integrative medicine used at MSK is acupuncture, according to Spiguel. Acupuncture involves the use of very thin needles along with heat, pressure, or electricity to stimulate points on the patient’s body.

“We have a robust acupuncture program and have used it to help patients deal with peripheral neuropathy associated with chemotherapy,” Spiguel said.

Researchers at MSK published a meta-analysis in 2012 that showed that acupuncture was an effective option for treating chronic pain.3 The center also has ongoing clinical trials to evaluate acupuncture in other areas, such as comparing it to massage for pain management in people with advanced cancer.4

“We also use acupuncture for hot flashes experienced by patients with breast, ovarian, or pros-tate cancer as a result of their treatment,” Spiguel said. “It can be used for joint pain caused by immunotherapy or other treatments and for the prevention of nausea and vomiting from chemotherapy.”

Spiguel also discussed treatments like meditation. “When we think about stress and anxiety from upcoming scans, or even while in an MRI machine, meditation can be helpful,” she said. “Patients can participate in classes and guided meditation.”

Clinicians may recommend integrative services as a complement to a patient’s initial treatment plan or at any point over the course of their treatment or survivorship, Lammersfeld said.

“For example, nutrition services may be used to complement antiemetics or antinausea medications to help reduce chemotherapy-induced nausea, making the treatment more tolerable and reducing treatment delays or interruptions,” Lammersfeld said. “Sexual health counseling may be offered to patients who have completed their cancer treatment and are now looking for a way to return their lives to normal.

”Another aspect of integrative medicine that should be discussed more with patients, Spiguel said, are physical activity and good sleep practices. During active treatment, studies have shown that regular physical activity can reduce fatigue, improve physical functioning, and have positive effects on self-esteem and quality of life.5-7

“When you consider that up to 80% of adults living with cancer are malnourished, and 1 in 2 patients has some form of nutritional deficit at the time of their diagnosis, nutritional support can be extremely important, too,” Lammersfeld said.

Alternatively, there are some things that oncology nurses should be on the lookout for that could cause harm to the patient. “We advise our patients to steer clear of any ‘therapy’ that is promoted as an alternative to evidence-based treatments like surgery, radiation, chemotherapy, and immunotherapy,” Lammersfeld said.

“For example, if a patient chooses to explore laetrile/shark cartilage, etc, instead of the chemotherapy recommended by their medical oncologist, they are not likely to change the trajectory of their cancer.”Patients should be cautioned against the use of vitamins, herbs, and supplements as a whole during active treatment. Supplements should be discussed with their provider or a medical professional with expertise in herbs and supplements and the effect on chemotherapy. Initiation of ServicesThese important services can be initiated by the patient or by the health care provider. “We have seen a lot of referrals from providers, whether they are advanced practice providers or physicians, as well asnurses who have seen good results with our services,” Spiguel said. “In other cases, the patients may have seen our services on the website."

Patients are pleasantly surprised, Lammersfeld said, when their health care providers offer supportive services as part of the treatment model.

Any conversation involving integrative medicine should be an open conversation, Spiguel said.

“You can’t just tell a patient no without discussing it; that shuts the patient down and they may end up taking things without discussing it with their providers,” Spiguel said. “Instead, open the conversation and explain things to your patient.

”For example, a nurse could explain that chemotherapy is metabolized by enzymes and herbs or supplements could interfere with that metabolism, causing side effects or making the treatment less effective.

The patient is at the heart of any treatment plan, so each conversation should take place on an individual basis, Lammersfeld said. “Create a safe environment for patients to share what they are doing or considering and allow them to ask questions,” she said. “Encourage their motivation to participate in their care by providing information on evidence-informed modalities, which may be helpful, while gently discouraging modalities which may be harmful or not safe during treatment.

”Nurses and patients looking to get more information about integrative medicine can look to the Society of Integrative Oncology (integrativeonc.org), which holds a conference each year, the American Holistic Nurses Association (ahna.org), which is not oncology specific but has great resources for integrative therapies, or the American Consortium of Integrative Medicine and Health (imconsortium.org), which has a nursing special interest group.

In addition, both MSKCC’s Integrative Medicine website and CTCA’s website contain great information for patients on the benefits of integrative care. “A lot of providers still view integrative or complementary medicine as a little bit outside of the realm of oncology, but a truly integrative approach can really provide benefits,” Spiguel said. “Every person who comes into contact with a patient can listen and dig deeper, especially if a patient is discussing problems they are having.”


References
1. National Cancer Opinion Survey, Harris Poll on behalf of the American Society of Clinical Oncology, 2020.
2. Wanchai A, Armer JM, Stewart BR. Complementary and alternative medicine use among women with breast cancer: a systematic review. Clinical J Oncol Nurs. 2020; doi:10.1188/10.CJON.E45-55
3. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172(19):1444-1453.
4. Memorial Sloan Kettering Cancer Center. A study comparing acupuncture with massage for pain and related symptoms in people with advanced cancer. Accessed December 8, 2020. https://www.mskcc.org/cancer-care/clinical-trials/19-341
5. Mishra SI, Scherer RW, Snyder C, Geigle PM, Berlanstein DR, Topaloglu O. Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database Syst Rev. 2012(8):CD008465.
6. Courneya KS, Segal RJ, Gelmon K, et al. Six-month follow-up of patient-rated outcomes in a randomized controlled trial of exercise training during breast cancer chemotherapy. Cancer Epidemiol Biomarkers Prev. 2007(16):2572-2578.
7. Courneya KS, Sellar CM, Stevinson C, et al. Randomized controlled trial of the effects of aerobic exercise on physical functioning and quality of life in lymphoma patients. J Clin Oncol. 2009(27):4605-4612.