Evaluation of a Patient CAM-with-Chemotherapy Educational Brochure

Biologically active CAM may detrimentally interfere with chemotherapy treatment, so cancer patients require targeted, evidence-based information on chemotherapy-CAM integration consequences. The object of this study was to investigate the potential for medical doctor recommendation and patient acceptance of a purpose-designed patient educational brochure on the safe use of CAM with chemotherapy. Cancer care doctors (n = 17) were provided a draft version of a patient educational brochure developed by the authors and completed a structured feedback form. Cancer patients receiving treatment (n = 12) were provided with the brochure and completed the local health service consumer testing feedback form. All 17 doctors perceived a need for the brochure and all would recommend the brochure to their patients. Approximately 59% of the doctors indicated they would recommend the brochure to all patients receiving chemotherapy and 41% preferred that only patients using CAM or who enquired about CAM be given the brochure. Cancer patients receiving chemotherapy reported that the brochure information answered their questions and was easy to understand. This evidence-based CAM-chemotherapy patient brochure may be a useful adjunct for use by cancer care health professionals to educate patients on the potential dangers of biologically active CAM use with chemotherapy and to provide patients with safe CAM alternatives.


Introduction
The majority of patients receiving chemotherapy will consider taking complementary and alternative medicine (CAM) [1] at some time during their treatment. CAM is defined as a broad and diverse group of treatments and products that do not tend to be widely used by conventional healthcare professions [2]. Biologically active CAM have the potential to interact with conventional medicines, including antineoplastic treatments [3] and herbal CAM interactions with chemotherapy have been estimated to be responsible for a substantial number of unexpected toxicities and possible undertreatment of some cancers [4]. Studies on patients receiving chemotherapy have concluded that one-quarter of patients taking biologically active herbal and/or vitamin supplemental CAM are at risk of a clinically relevant interaction [5,6].
Mind-body CAM has shown efficacy in supportive care for patients receiving chemotherapy and when applied by appropriately trained therapists, using reasonable patient specific precautions, it is safe to use at that time [7]. Mindbody therapy CAM is a safe option for cancer patients who wish to use CAM during chemotherapy.
Patients would like to receive specific information on which CAM is safe to use with chemotherapy before their treatment commences [6]. The purpose of this study was to evaluate the acceptance by doctors and consumers of an evidence-based brochure designed to provide answers to common questions chemotherapy patients have about CAM use with chemotherapy.

Methods
An educational brochure was developed by the authors (see Appendix in Supplementary Material available online at http://dx.doi.org/10.1155/2015/408430) with the aim of providing a tool for use by cancer care doctors and associated cancer health professionals to give evidence-based guidance 2 Evidence-Based Complementary and Alternative Medicine

Doctor Feedback.
All 17 doctors thought there was a need for the brochure and responded that they would recommend the brochure to their patients ( Table 2). Approximately 59% of doctors said they would recommend the brochure to all patients receiving chemotherapy, but 41% preferred that only patients using CAM or asking about CAM be given the brochure. Two doctors preferred to personally give the educational CAM brochure to the patient, 7 at nurse education clinic, 3 by the doctor or at nurse clinic, and 5 by doctor, nurse clinic, or other cancer care health professional. No doctors sought to limit the brochure to early stage/curative intent patients. Feedback received from doctors on the brochure wording and/or phrasing, when thought to be appropriate by the authors, was incorporated into the brochure. A haematologist indicated that it "May be worth noting that 'invasive' mindbody techniques (eg acupuncture) could be an issue in [a] setting of low platelets, and so forth" but did note the limitation for such details within the brochure's scope and intended broad message. Another clinician was concerned: "some fish oils have antiplatelet effect and could be an issue with haematology patients with low platelets. " A fish oil caution was not included in the brochure because at risk patients are closely monitored, the antiplatelet effect is not great (10 g of fish oil per day has less effect on platelet function than 100 mg of aspirin given intravenously [8]), and dietary fish oil may be consumed in amounts similar to standard supplements. One doctor sought the inclusion of B group vitamins and vitamin E for the treatment of peripheral neuropathy; however, a 2008 Cochrane review concluded insufficient evidence for the use of vitamin B [9], and vitamin E may have chemotherapy interaction complications [10]. Another prescriber's suggestion of adding grapefruit prohibition was not considered within the brochure brief.
Doctors were generally positive when optional extra feedback was given: One doctor criticized the brochure for being too academic: "Needs editing for English-it's written in academic English, needs to be properly edited for patient reading". However, the brochure was considered to be appropriate by the authors and so few changes were made; the brochure was instead submitted for publication and subsequent consumer testing to determine if it was understandable.

Patient Feedback.
Patients were generally enthusiastic about the brochure and all 12 found the information clear and easy to understand. All patients thought that the information was relevant to them and that the brochure contained enough information to answer their CAM questions (     Additional patient feedback indicated that the main messages in the brochure, that is biologically active CAM may interact with chemotherapy and should be declared to conventional health professionals, were understood: The brochure was also effective in making patients aware that CAM therapies are effective and safe to use for support during chemotherapy treatment:

Complementary therapies can work
Good to know about the yoga and other things which won't affect the chemo but could be substantially helpful with your wellbeing Would certainly look into more of the massage, reflexology, and so forth, also the meditation and yoga

Discussion
The evidence-based educational brochure was designed to be brief and as neutral as possible, neither supportive of, or against CAM use. The authors deemed this necessary to not alienate potential CAM users who may be receiving alternative CAM advice [7]. Chemotherapy patients are likely to be contending with CAM advice from a variety of sources including family, friends, practitioners, and even casual acquaintances, who may be particularly insistent and persuasive when they regard themselves as having CAM expertise [1,6,11,12]. Conventional health practitioners need to provide evidence-based CAM information to chemotherapy patients to counter CAM misconceptions patients may have and to guide patients away from taking CAM which may be potentially detrimental to their treatment. All cancer care doctors indicated they would use the brochure for their patients. A proportion of doctors wanted only patients asking about or using CAM to receive the brochure. These doctors were concerned that giving CAM information to patients may be misconstrued as being promotional of CAM use with chemotherapy and one patient did report she would look into more mind-body CAM and supplements that may help if she were able to take them, as a result of reading the brochure. If only patients who ask about CAM were offered the brochure, patients in need of CAM guidance with chemotherapy may be missed; cancer patients do not necessarily volunteer their CAM consumption unless asked [3], prefer their health care providers to initiate discussions regarding CAM use [13], want safety information regarding CAM with chemotherapy before they start treatment [6], and make CAM decisions at the same time as standard medical decisions [11].
Though there are existing general information resources on CAM use, chemotherapy patients want to receive specific evidence-based information on CAM use at the time of receiving chemotherapy [6]. This small population study demonstrated that a brochure showed promise in providing Evidence-Based Complementary and Alternative Medicine 5 cancer patients' educational requirements on the safe use of CAM with chemotherapy and may be a useful tool for use by cancer care health professionals to educate patients on potential dangers of biologically active CAM use with chemotherapy and to provide patients with safe CAM alternatives if required.

Conclusion
The evidence-based CAM-chemotherapy patient brochure developed herein may be a useful adjunct for cancer care health professionals to educate patients on the potential dangers of biologically active CAM use with chemotherapy and to provide patients with safe CAM alternatives.