Acupuncture and reflexology for patients undergoing chemotherapy : a cohort study

Purpose: Around three quarters of individuals undergoing chemotherapy self-report multiple symptoms. There is clinical trial evidence of effectiveness for acupuncture for commonly experienced symptoms, and emerging evidence for reflexology, but little is known about the effects of these therapies on multiple symptoms when implemented in a real world setting during active chemotherapy treatment. Methods: This was a cohort study of participants receiving reflexology and/or acupuncture while attending chemotherapy. Participants received a 20 minute reflexology treatment or a 20 minute acupuncture treatment or a combination of both. Patient reported outcome measures were administered before and after the treatment using the Edmonton Symptom Assessment Scale (ESAS). Results: During the study period, 330 unique patients received a total of 809 acupuncture and/or reflexology treatments. Participants had, on average, 5.3 symptoms each which they reported as moderate to severe (≥4/10) using the ESAS at baseline. Following treatment, participants reported 3.2 symptoms as moderate to severe. The symptom change for all participant encounters receiving any therapy was statistically significant for all symptoms, and clinically significant (a reduction of more than 1) for all symptoms except financial distress, appetite, and memory. Clinically significant levels of global distress (<3) were reduced in 72% of all participants receiving either therapy. No adverse events were recorded. Conclusions: The results indicate that acupuncture and reflexology administered alongside chemotherapy may reduce patient reported symptom burden and patient global symptom related distress. Future research would include an active control group, and consider confounding factors such as chemotherapy stage and medication

Establishing an integrative oncology service in the Australian healthcare setting : the Chris O’Brien Lifehouse Hospital experience

Comprehensive cancer centres are on the rise as patients seek a more holistic approach to maintaining their wellbeing when living with a cancer diagnosis. Many cancer centres worldwide now incorporate a selection of evidence-based complementary therapies and qualified therapists into their offerings. The Chris O’Brien Lifehouse, a comprehensive cancer centre in Sydney, Australia, provides integrative oncology services including acupuncture, massage, reflexology, dietetics and exercise physiology for individual patients, along with group programmes, and an integrative and supportive care medical specialist. The purpose of this paper is to reflect on one model of integrative oncology service and approach to integration and team and service development

Integrative medicine : adjunctive element or essential ingredient in palliative and supportive cancer care?

The aim of supportive cancer care is to actively manage patients’ physical, psychologic, and spiritual concerns, independent of prognosis. Complementary and integrative medicine (CIM) is increasingly gaining greater acceptance and support for its beneficial value in supportive cancer care. The utilization of CIM early in the cancer trajectory, during treatment and during survivorship periods, as well as during end of life, addresses a great number of unmet needs that patients affected by cancer raise. In addition, recent research supports the role that CIM has in reducing suffering and distress both physically and emotionally, as well as enhancing well-being in patients affected by cancer and their families. CIM is increasingly seen not only as an adjunctive add-on treatment or perhaps even as a luxury item for the affluent but actually as an important component in supportive cancer care for all patients. It addresses many aspects of care that sometimes are not being addressed with conventional means. With the increase in CIM-related research, as well as the increased clinical experience in oncology programs worldwide, CIM is gradually becoming an essential ingredient in supportive and palliative cancer care. In this narrative review, the authors look systematically at the contribution that CIM has in supportive care in each stage of the cancer trajectory, reflecting the needed role that CIM has in supportive care. The presented data will provide a sampling of the available clinical research for each of the broad stages being described

Patient-reported outcome measures and supportive care need assessment in patients attending an Australian comprehensive care centre : a multi-method study

Purpose: Patient-reported outcome measures (PROMs) are useful clinical tools to recognise symptoms, patient needs and their severity. Whilst PROMs are routinely utilised in integrative oncology (IO) and supportive care (SC) services to improve patient care, they are not as common in general oncology. We explored our patients’ symptom burden, the approach taken by clinicians to identify and manage patient needs, and barriers and facilitators to using PROMs in an Australian tertiary comprehensive cancer centre to inform wider implementation of PROMs. Methods: From 2017 to 2018, PROM data collected for patients accessing IO and SC was retrospectively analysed. Semi-structured interviews with oncology doctors and nurses explored their approach to patient needs assessment and their use of PROMs. Results: A total of 404 patients completed the Edmonton Symptom Assessment Scale (ESAS). The most frequently identified symptoms were sleep disturbance, fatigue and lack of wellbeing. Symptom clusters included drowsiness, fatigue and shortness of breath; anxiety and depression; sleep and pain; appetite and nausea. In total, 9 nurse consultants, 5 surgeons, 7 medical and 5 radiation oncologists were interviewed. Most participants took an intuitive approach to identifying and managing patient needs and did not routinely use PROMs. Perceived risks, barriers and facilitators to using PROMS are presented. Conclusions: High and complex symptom burden was found in our IO and SC patient population, reinforcing the need for screening. Whilst wider clinical use of PROMs within the hospital may improve clinical outcomes, the barriers and facilitators identified by Health Care Professionals (HCPs) need to be addressed before implementing PROMs more broadly

Certainty within uncertainty : a qualitative study of the experience of metastatic melanoma patients undergoing pembrolizumab immunotherapy

Objective: Little is known about the lived experiences of patients with metastatic melanoma undergoing checkpoint inhibitor treatment. We conducted a feasibility study of a supportive care intervention for melanoma patients being treated with pembrolizumab. Here, we report a secondary objective of the study, which was to explore the lived experience of being on pembrolizumab treatment for advanced melanoma. Methods: Twenty-eight participants with metastatic melanoma were recruited across two cohorts, all receiving 3-weekly immunotherapy treatment. Semi-structured interviews were conducted with 26 participants once at 9 weeks. Thematic analysis using interpretative phenomenological analysis (IPA) was performed with multiple iterations of data review to achieve consensus. Results: Three overarching themes were identified; here, we report the first and most dominant theme: how metastatic melanoma patients live within uncertain spaces. Although immunotherapy increases overall survival, metastatic melanoma patients live within an uncertain spectrum. They confront uncertainty related to immunotherapy treatment, their disease trajectory, family relationships, and decision-making. Melanoma patients attempt to normalize their lives, engaging in their usual activities. Uncertainty increases prior to active treatment and intensifies during investigation phases. Conclusions: Despite progress in melanoma patient treatment and outcomes, these patients face sustained uncertainty about their disease trajectory

Patient-reported outcomes in integrative oncology : bridging clinical care with research

There is growing interest in the value of routine collection and monitoring of patient-reported outcomes as part of high-quality, patient-centered, oncology care. Integrative oncology, with its focus on providing symptom and lifestyle support for patients throughout the cancer care continuum, serves a diverse patient population with a complex, changing symptom burden. Monitoring of patient-reported outcomes can contribute significantly to the successful comprehensive evaluation and management of patients receiving integrative oncology care. Data collected as part of an integrative oncology evaluation can also support real-world clinical research efforts to help learn more about the effects of integrative oncology interventions on patient symptoms, quality of life, and treatment outcomes

Cancer survivors' experiences, barriers and preferences with yoga : a cross-sectional survey to inform a yoga intervention

Purpose: Evidence suggests that yoga may help improve cancer-related symptoms though knowledge of the experiences, barriers and preferences of people diagnosed with cancer is limited. This study sought to examine the use of yoga in an Australian sample and identify the experiences and preferences associated with undertaking yoga practice as formative research to help inform a future yoga intervention. Methods: Adults diagnosed with any type of cancer completed a cross-sectional survey including questions regarding their demographics, experiences and preferences for yoga practice. Results: Sixty-eight people who had been diagnosed with cancer completed the survey. Most of the participants (70.8%) had practiced yoga since their diagnosis. A variety of reasons for practice were endorsed, and benefits experienced included physical and psychological factors. The most common barrier to practice was related to the physical ability to undertake yoga. Participants indicated a preference for group classes (44.1%), with a frequency of practice of 2–3 times per week (60.3%), 60 min in length (75%). The preferred time of practice was 9am–12pm (51.5%) and travel distance 5–10 km (44.1%). Online yoga delivery was endorsed, with participants preferring pre-recorded sessions. Conclusions: Results from this study provide insights into the experiences, barriers and preferences for yoga practice in people with cancer which will assist in developing yoga programs in this cohort to investigate the effects on cancer and treatment-related symptoms

A supportive care intervention for people with metastatic melanoma being treated with immunotherapy : a pilot study assessing feasibility, perceived benefit, and acceptability

Introduction: Increasing numbers of metastatic melanoma (MM) patients are receiving immunotherapy treatment, including pembrolizumab, and the impact on their well-being is underexplored. Objectives: To assess the feasibility of a multimodal supportive care program to MM patients being treated with pembrolizumab. Methods: This pre-post-test feasibility cohort study recruited MM participants treated with pembrolizumab: (i) supportive care intervention with usual care and (ii) usual care. The intervention comprised comprehensive medical assessment by supportive care physician (SCP), exercise physiologist (EP), and dietitian then a tailored supportive care program. Programs included exercise, dietary advice, non-invasive complementary therapies, and psychology consultation. Outcome measures included adherence, patient-reported symptoms, anxiety and depression, and toxicity. Descriptive data are reported. Results: We recruited 28 participants: 13 intervention and 15 control; three did not complete the study. Most were male, with median age 66 (range 42–85) years. All intervention participants completed baseline assessments with SCP, EP, and dietitian. Two missed follow-up with EP or dietitian. Symptoms most troubling at baseline were as follows: fatigue (n = 6), sleep (n = 6), general aches and pains (n = 5), and memory (n = 4). All intervention participants were prescribed 16 exercise sessions; 8 (50%) completed all; overall exercise adherence was 85%. Integrative therapies were accessed by 85% (11) participants. Immunotherapy-related adverse event rates were low and SCP consultation identified symptoms not captured by CTCAE 4.0. Conclusions: A holistic supportive care intervention tailored to individual needs is feasible. The symptom burden in MM patients was low. Further investigation of the intervention is warranted, focused on populations with higher symptom burden to improve outcomes

Exploring a multi-disciplinary model of supportive cancer care for monoclonal antibody treatment-related dermatological symptoms

Context and objectives: The present study examined the perspectives of healthcare providers (HCPs) in designing a multi-disciplinary model of supportive cancer care for the relief of dermatology-related symptoms caused by monoclonal antibody therapies. Methods: The study employed a mixed research methodology, with qualitative research embedded within a pragmatic prospective study of a registry protocol study. Patients undergoing oncology therapy with MoAB, anti-HER2, and anti-PD-L1 monoclonal antibodies were identified among a cohort of patients referred to an integrative oncology (IO) consultation for symptom relief and improved quality of life (QoL). Case studies with significant dermatology-related concerns were selected and presented to a panel of 6 HCPs trained in medical oncology, oncology nursing, family medicine, supportive cancer care, and IO. HCP narratives were qualitatively analyzed and assessed using ATLAS.Ti software for systematic coding. Results: Of the 924 patients referred to the IO consultation, 208 were treated with monoclonal antibodies, from which 50 were selected for further evaluation. Of these, 7 cases were presented to the HCP team who were asked to identify treatment gaps requiring a multi-disciplinary approach. Qualitative analysis identified 3 major themes: a biophysical perspective; a psycho-social-spiritual perspective; and the implementation of integrated care. Discussion: There is a need for a multi-disciplinary approach when treating patients suffering from monoclonal antibody treatment-related skin toxicities. HCP-reported themes highlight the need to identify patients for whom such an approach is warranted; conditions in which a psycho-social-spiritual perspective should be considered, in addition to a bio-physical approach; and considerations of who should be designated as the patient’s primary case manager

Yoga for depression and anxiety symptoms in people with cancer : a systematic review and meta‐analysis

Objective: Cancer and its treatment can lead to a variety of physical and emotional concerns impacting on those affected, including subclinical or clinical depression and anxiety, which in turn have a significant impact on wellbeing, quality of life and survival. The aim of this review was to evaluate the effect of yoga‐based interventions on self‐reported depression and anxiety symptoms in people with cancer in randomized controlled trials. Method: Six databases were searched to identify relevant studies. Systematic review procedures were followed including a quality assessment. Meta‐analysis of suitable studies was conducted. Results: 26 studies from our search criteria were eligible for inclusion for depressive and 16 for anxiety symptoms. Meta‐analyses revealed evidence for significant medium effects of yoga on depression symptoms (N=1,486, g=‐0.419, 95% CI=‐0.558 to ‐0.281, p<0.001) and anxiety (N=977, g=‐0.347, 95% CI=‐0.473 to ‐0.221, p<0.001) compared to controls. Subgroup analyses for depressive symptoms revealed significant effects for all analyses performed (type of cancer, type of control, treatment status, duration of intervention or frequency of yoga sessions), with effect sizes being comparable between subgroups. Similar findings were found for anxiety symptoms except for treatment status, where the only significant effect was found when yoga was delivered during active treatment. Conclusions: This review provides evidence that in people with cancer, yoga‐based interventions are associated with amelioration of depression and anxiety symptoms and therefore a promising therapeutic modality for their management. However, the potential for risk of bias together with control group design challenges means the results should be interpreted with caution