Evidence regarding opinions on integrative modalities by patients and physicians is lacking.
Evidence shows increased patient utilization of various integrative care modalities in oncology. In part, patients desire greater self-empowerment to manage their symptoms and improve quality of life and overall outcomes. Furthermore with increasing globalization, elements of eastern medicine are widely being recognized and embraced by patients and medical professionals. Measurements of patient and physicians opinions regarding the importance of integrative care are lacking. We aim to compare how National Comprehensive Cancer Network (NCCN) recommended “integrative care” modalities are valued between hematology/oncology physicians and patients.
After an institutional review board approval was obtained, a survey study was administered to 1008 hematology and oncology patients and 55 hematologists and oncologists at two outpatient clinical sites at a major tertiary medical center in Miami, Florida, from June 2013 to October 2015. Surveys were administered in the outpatient setting by nursing staff after consent was obtained. Patients filled out surveys in the waiting area; then they were placed in a locked box. Physicians filled out surveys in their office and were placed in a locked box. Both physician and patient surveys were anonymous. The survey was administered in both Spanish and English. The patient survey consisted of 7 questions assessing opinions on integrative care asking: “In addition to standard care, it is important to incorporate/provide the following services in my cancer plan”: (1) nutrition services, (2) exercise therapy, (3) spiritual/religious counseling, (4) supplement/herbal advice, (5) support groups, (6) music therapy, and (7) other complimentary medicine services (acupuncture, massage, and relaxation therapy). Answers were recorded on a 5-point scale (1 = highly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = highly agree) and then converted into 2 categories (
1008 patients were enrolled from June 2013 to October 2015. The mean patient age was 55 years with a range of 18–88 years. 45% of patients were male and 55% of patients were female. 62% of patients were Hispanic versus 38% of patients not Hispanic. 16% of patients were white, 14% black/African American, 2% Asian/Pacific Islander, and 6% other. 21% of patients had hematologic malignancies versus 79% of patients having solid malignancies. 55 physicians were enrolled from June 2013 to October 2015. The mean physician age was 47 years with a range of 29–75 years. 70% of physicians were male and 30% of patients were female. 38% of physicians were Hispanic versus 62% of physicians not Hispanic. 64% of patients were white, 14% black/African American, 11% Asian/Pacific Islander, and 11% other. Survey results were as follows: 84% of patients agree that nutritional advice is important versus 69% of physicians,
Our study reveals that the majority of patients felt that in addition to standard of care it was important to include nutrition services, exercise therapy, spiritual/religious counseling, supplement/herbal advice, support groups, music therapy, and other complimentary medicine services into their care plan. With the exception of support groups, patients valued integrative modalities more than physicians.
The exact mechanism for the significant discrepancies observed in our study between physicians’ and patients’ value of integrative modalities is unclear. One major contributing factor may be a physician knowledge gap. Several studies show that physicians currently lack the knowledge, confidence, and training to provide proper guidance to the increasing number of patients who are using integrative modalities [
The Federation of State Medical Boards (FSMB) has also responded to the increased interest in integrative modalities by issuing its own guidelines [
In the following sections, we discuss and highlight the evidence behind the integrative modalities with significant disparities.
The literature shows that exercise improves quality of life and physical function in patients with cancer [
Cancer related fatigue is a common and distressing symptom in cancer patients. Several reviews and meta-analyses of clinical trials show that not only is exercise therapy safe in cancer patients but it also significantly reduces cancer related fatigue [
Numerous observational studies have consistently found that physical activity is linked to decreased cancer recurrence, incidence, and increased survival for certain tumor types [
Acupuncture is increasingly used as a therapeutic measure for managing cancer related symptoms. Numerous trials have demonstrated that acupuncture is an effective adjunct in treating cancer related pain [
There are many benefits of music therapy for patients including improving mood, decreasing stress, pain, anxiety level, and enhancing relaxation [
One study examined 51 studies on 1867 patients exposed to passive music therapy and evaluated its effects in both children and adults [
The data on active music therapy in cancer patients is less robust than passive music therapy. One prospective study in terminally ill cancer patients utilizing components of active music therapy showed that the majority of patients experienced a positive benefit [
Music can be easily delivered to patients in a variety of formats such as live or recorded concerts and performances on tapes, video, and mobile devices. Also music therapy can easily be delivered in any setting such as the comfort of one’s own home, chemotherapy infusion suite, or hospital room. Furthermore, other forms of art therapy such as active music therapy and visual art therapy are safe, relatively inexpensive, and with no risk of systemic side effects to the patient. Due to the favorable risk/benefit profile all patients should be offered music therapy and art therapy as a part of their cancer care.
Evidence shows increased utilization of herbal medications among cancer patients [
Herbal medications have also been used to manage side effects. For example, Mistletoe has been well studied and several reviews and clinical trials have shown that the application of Mistletoe extract has been associated with a reduction of chemotherapy-related side effects as well as an improvement in quality of life during chemotherapy [
Drug-herb interactions also remain of great concern regarding potential harmful interactions and increased toxicity, as well as decreased efficacy of prescribed treatments [
It is estimated that 79–85% of cancer survivors take vitamin or mineral supplementation, often without disclosing this information to their providers [
Evidence shows massage therapy benefits cancer patients by relieving symptoms and improving well-being [
Numerous studies have shown that various aspects of nutrition are important in cancer patients. Some studies focus on the importance of avoiding malnutrition and assessing nutritional status in cancer patients [
Nutrition has also been shown to play an important role in the perioperative setting. For example, assessments of nutritional status and use of prognostic indices can help predict postoperative complications and clinical outcomes in patients with gastrointestinal cancers [
Larger studies have focused on outcomes related to nutritional intake in cancer patients. Studies have shown that healthy dietary patterns are associated with decreased risk of cancer development overall [
Studies have also shown that healthy dietary patterns are associated with a decrease in cancer recurrence and improved outcomes in survivors. For example, in survivors of stage III colon cancer, a diet with more fruits, vegetables, chicken, and fish showed improved outcomes in terms of cancer recurrence and overall survival [
Evidence also exists for tailored nutrition to specific cancers. For example, omega 3 polyunsaturated fatty acids (PUFAs) have been shown to be beneficial after surgery performed for gastric cancer, have been shown to play a role in inflammation in Colorectal Cancer [
Of importance, the interrelation between obesity and nutrition plays an important role in cancer outcomes. It has been shown that weight gain or being overweight or obese can worsen a survivor’s risk for cancer recurrence or death. For example, a meta-analysis showed that there is a correlation between BMI and higher risk of total and breast cancer specific mortality [
Per current evidence and NCCN guidelines, the following is recommended: in terms of food volume, fruits and vegetables should take up half of the volume on the plate (30% vegetables, 20% fruit), whole grains should be 30% of the plate, and protein should be 20% of the plate. In terms of food components, fat in the diet should be obtained from plant oils, avocados, seeds, nuts, and fatty fish. Carbohydrates should be obtained from fruits and vegetables, legumes, and whole grains. Proteins should be obtained from poultry, fish, legumes, low fat dairy foods, and nuts. In addition, limited intake of red or processed meats and refined sugars is encouraged. Referral to a Certified Specialist in Oncology Nutrition (CSO) if available is ideal [
Spiritual and religious support has become increasingly important component of supportive care for cancer patients as this is associated with improved mental health in cancer patients [
Our study has several limitations. First, survey studies are prone to response bias. In terms of demographics, our patient population was predominantly Hispanic and white; therefore caution should be used in extrapolating our data to the general hematology/oncology populations. Last, our study was conducted in South Florida which has unique sociocultural influences compared to other states so again extrapolation of this study to the general cancer population is cautioned.
Our study enjoyed several strengths including a large number of patients (over 1000) and a large number of physicians (over 50) and the power of the study was adequate for confident analysis. Furthermore, we followed strict guidelines to maintain anonymity among participants to minimize bias. Also, this is the first and largest study addressing opinions integrative modalities in both hematology oncology patients and providers. Although the patient population was predominately white Hispanic, there was a significant amount of population heterogeneity included in this study. Last, the physician population was heterogeneous which likely reflects general hematologist oncologist population in the United States.
The majority of patients feel that in addition to standard of care it is important to include nutrition services, exercise therapy, spiritual/religious counseling, supplement/herbal advice, support groups, music therapy, and other complimentary medicine services such as acupuncture, massage, and relaxation therapy into their care plan. With the exception of support groups, patients value integrative modalities more than their physicians. Since physicians formulate and execute patient care plans, it is important that they recognize these modalities as desired by the majority of patients and also that these modalities are endorsed by the NCCN as category 1 and 2A recommendations. Addressing these major disparities between physician and patients should be a top priority for tertiary care sites. Perhaps with increasing education, awareness, and acceptance by providers and traditional institutions, integrative modalities could be equally valued between patients and providers. Furthermore, it is possible that increased availability and utilization of integrative oncology modalities at tertiary hospital sites could improve patient satisfaction, quality of life, and other clinical endpoints.
An abstract for this research was originally published in the Journal of Clinical Oncology [
The authors declare that there are no conflicts of interest to disclose.