Complementary therapy (CT) use is on the rise among cancer patients and survivors across North America, including within Alberta, where more than half of all patients use some form of CTs following their diagnosis; most popular are natural health products, increasingly including cannabis, which has seen a surge of uptake since legalization in 2018. Unmet symptom needs and a desire for holistic health approaches or even cure are motivators for the use of CTs. There is evidence that combining some of these modalities such as mind-body therapies with conventional treatment can substantially improve patient outcomes including improved coping, psychological function and quality of life, decreased toxicity and side effects, and increased treatment tolerance and adherence, which can lead to increased survival. Properly supervised use also reduces potential harm from interactions or side-effects of natural health products used without discretion. On the flip-side, the use of natural health products and other therapies as an alternative to conventional care results in worse treatment outcomes.
To understand the use of CTs in Alberta, we surveyed close to 500 patients and 100 health care providers at the Tom Baker Cancer Centre in 2012, and again in 2015, about their CT use and knowledge. About half of the patients had used some form of CTs since their cancer diagnosis. The most commonly used were natural health products and mind-body therapies. Unfortunately, only 20%reported having any member of their health care team ask about such use or give them advice. In addition, about 85% reported not receiving enough information about CTs or enough help with making decisions about which therapies to use or not use. More than half, in fact, were choosing which therapies to use based on recommendations from their friends and family, rather than health care professionals. Many of the rest relied on the internet. More recently, a study conducted in Northern Ontario in 2017 showed that 52% of patients who were on active treatment with chemotherapy or radiation endorsed using at least one CT after their cancer diagnosis. Similar to the study conducted in Alberta, the majority of patients learned about CTs through friends or family members.
Currently, AHS patients have access to an online resource sheet on complementary therapies (https://www.albertahealthservices.ca/assets/info/cca/if-cca-complementary-medicine-resource-sheet.pdf) and we have a monthly group educational session taught by Dr. Linda Carlson, as well as access to some evidence-based CTs through group and individual supportive care programs. However, there is no access to 1:1 personalized counselling to develop holistic treatment plans to safely integrate complementary and conventional care. There is also no IO-trained expert who can help complex patients who may be taking multiple natural health products including herbs and cannabis, and using other complementary therapies as well as undergoing conventional treatments, or those contemplating foregoing conventional treatment altogether in favour of alternative approaches. It is these patients who would benefit from the IO clinic we propose below. We estimate that approximately 3-5% of cancer patients undergoing treatment would fit this criteria and benefit from personalized IO counseling, at a proper facilitated IO Clinic.
The AHS Integrative Oncology (IO) clinic would be the first of its kind in Canada, a cutting-edge service providing the highest quality, seamless, safe, fully-integrated evidence-based complementary and conventional care to our patients.
While some cancer centres internationally have incorporated an IO approach to care, resulting in improvements in patient satisfaction and outcomes, we are proposing the first truly integrated IO program in Canada, which will operate under Cancer Control Alberta (CCA) and be implemented through research/clinical partnerships with Alberta universities.
The IO clinic will provide one-on-one consultation, treatment planning and follow-up for complex patients, taking into account their individual medical histories, current diagnostic features (type of cancer, stage, and prognosis), conventional treatment plan, medications, comorbidities, personal values and preferences, finances, access to and current/past use of CTs and a host of other important individual factors. It will be run by a medical director (Dr. Karim) who is a medical oncologist with specialized training in IO. The IO clinic will incorporate existing CT services offered through CCA Supportive Care (i.e. mindfulness meditation and other mind-body therapies), the Alberta Cancer Exercise (ACE) Program, Rehabilitation Oncology as well as other evidence-informed therapies available in the community (i.e. acupuncture, massage).
The overall objective of the IO clinic is to provide high-needs individuals undergoing cancer treatment in Alberta with an individualized, patient-centered, safe, culturally-sensitive and evidence-informed IO care plan.
We will pilot this program for high needs patients across tumour types, focusing on breast cancer patients undergoing treatment (hormonal, radiation, chemotherapy,or immunotherapy), but not restricting service to others in need of support. Studies have shown that breast cancer patients are the highest users of complementary therapies, so this focus makes sense for a starting point. Furthermore there are clear guidelines from the Society for Integrative Oncology on the use of integrative therapies during and after breast cancer treatment that have also been endorsed by the American Society of Clinical Oncology.
The specific objectives of the consultation service are:
1) To provide high-needs patients undergoing traditional treatment for cancer with an individualized, patient-centered, safe, culturally-sensitive and evidence-based integrative oncology care plan which includes recommendations for specific CTs;
2) To promote quality and safety in the use of CTs for patients with cancer;
3) To evaluate the feasibility and effectiveness of IO care delivery in this model;
4) To develop a delivery approach for this service that is sustainable over the long-term.
For the pilot initiative, we would offer an integrative consultation via referral from a health care provider at the Tom Baker Cancer Centre (medical oncology, radiation oncology, surgical oncology, palliative care, psychosocial oncology, nursing, rehabilitation, pharmacy, nutrition), which could occur in person or remotely. Patients who meet the following criteria would be offered a consultation with an IO provider:
1) Patients on conventional treatment, using a high number (>5) of natural health products prior to or during treatment, without the direction of a trained medical professional knowledgeable in this area.
2) Patients at risk of foregoing one or more conventional treatments in favour of alternative approaches.
3) Patients with high symptom burden that may respond well to CTs (e.g. nausea, neuropathy, fatigue)
To submit a patient referral please click here.
During the clinical visit, the patient will be seen by a Medical Office Assistant (MOA) and the IO physician. The MOA will conduct a brief intake assessment of the patient, which will include reviewing their medical history, medications and herbal supplements and reasons for the IO consult. The MOA will also be responsible for sending any referrals for these patients after the clinic visit. The IO physician will seek to gain an understanding of the patient’s needs, previous use and experience with CTs, and current and planned conventional cancer treatments. Using this information, the physician will then develop an integrated care plan including recommendations for CT use. If there are any relevant clinical trials available through the ACTION centre that are applicable for the patient, these will also be proposed during this visit. A full consultation note will be dictated in ARIA, so that it is accessible to all health care professionals involved in the patient’s care. In addition, by having access to ARIA, the IO physician will be able to determine what referrals have already been made for symptom management and can coordinate care with the patient’s primary oncologist.
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