Helpful alternatives?

With complementary and alternative medical therapies gaining in popularity, Fred Hutchinson researchers are helping patients make safe choices

In a dimly lit room in north Seattle, David Flood lies on a bench as 20 slender acupuncture needles gently prick his arms, legs, ears and forehead. Soothing music drifts over him as the needles stimulate energy flow through his body during the hour-long session he describes as "a resting point during this long, strange hike through the mountains of my healing journey."

Flood, 40, began this journey last February when he discovered he had multiple myeloma, a cancer that causes abnormal white-blood cells to accumulate in the bones. At the time of his diagnosis, a large tumor had almost collapsed one of the vertebra in the middle of his back. Flood turned to oncologists at the Fred Hutchinson Cancer Research Center and Seattle Cancer Care Alliance for the stem-cell transplant that could save his life.

He turned to meditation, acupuncture and naturopathic medicine to manage stress, relieve back pain and provide the spiritual well-being he needed to cope with the disease.

"Cancer and chemotherapy inflict a lot of damage to the body," he said. "I wanted to use whatever means I could to protect my body that wouldn't interfere with the treatment for my disease. Acupuncture has helped me relax, gain circulation when I have not been able to exercise, helped my immune system remain steady and has been a kind of positive goal for me as I go through the stresses of the week."

Flood is one of a growing number of cancer patients who use complementary and alternative medicine to manage symptoms and side effects associated with their illness and its treatment. According to a recent study by scientists at Fred Hutchinson, more than 70 percent of adult cancer patients in western Washington use such therapies. Almost all report substantial improvements in well-being as a result of their use (see page 11). An earlier Fred Hutchinson study found that a similar percentage of pediatric cancer patients in western Washington use such therapies.

Despite widespread use of complementary and alternative medicine, there has been scant research conducted on potential effects of such therapies - particularly dietary and herbal supplements - on cancer patients undergoing treatment, many of whom may have weakened immune systems. That's why Fred Hutchinson researchers conduct studies to examine the use of complementary therapies among cancer patients as well as test for possible harmful interactions between popular supplements and commonly prescribed cancer medications. This fall, the center, in conjunction with the University of Washington, hosted a symposium that brought together oncologists, naturopaths and cancer-prevention researchers to share their expertise. What emerges from this research will help cancer-care specialists provide patients with the best possible information to assure that their safety-and the efficacy of their cancer treatment-is not compromised.

At the Seattle Cancer Care Alliance, patients treated in Fred Hutchinson's Bone Marrow Transplant Program are encouraged to maintain an open dialogue with health-care providers about their use of complementary therapies, particularly those that are ingested.

"We can't ignore the fact that complementary medicine is very important to the quality of life of many of our patients," said Jean Stern, a nutritional-education coordinator at the Alliance. "I believe that physical activity, yoga and relaxation therapy can be very beneficial to a patient's well-being."

"It's likely that there are as many positive as negative effects of dietary supplements-but we don't know much about these yet," Stern said. "So we work with patients individually to provide them with the best available information about what is safe and effective for them to use while undergoing treatment."

In 1997, nutrition experts at Fred Hutchinson first developed guidelines for use of herbal and nutrient supplements by bone-marrow and stem-cell transplant patients, which are updated regularly. Similar guidelines for general-oncology patients at the Alliance are now being formulated. All new patients complete an extensive questionnaire that details their dietary habits and use of medications or supplements and are offered classes in nutrition and food safety, where the emphasis is on learning to obtain proper nutrition through whole foods, which contain many more nutrients than can be obtained in a pill.

Patients like Flood, who choose to take supplements, are encouraged to consult with a member of the nutrition team.

"I brought in everything I was taking and stacked the bottles in a wall for the nutritionist to evaluate," he said. "She went through each one, giving me the pros and cons. I was impressed by how thoughtful and open-minded the staff was."

Among the concerns associated with herbal- and dietary-supplement use by cancer patients are unexpected or harmful interactions between these preparations and cancer medications. Some supplements increase or decrease the ability of certain medications to be absorbed and metabolized by the body, causing a patient to receive an inappropriate dose of a drug.

For example, St. John's wort, a popular herbal antidepressant, is known to reduce the effectiveness of certain drugs, including cyclosporine, an immunosuppressive drug used in stem-cell and solid-organ transplantation, and indinavir, used to treat HIV infection.

Dr. Danny Shen, who studies the pharmacology of pain, and Dr. Karen Syrjala, a biobehavioral researcher, both of Fred Hutchinson's Clinical Research Division, have recently begun to study interactions that occur between St. John's wort and a class of pain killers known as opioids, such as morphine and fentanyl, which are commonly prescribed for cancer patients. Their research is funded by the National Center for Complementary and Alternative Medicine, a recently established branch of the National Institutes of Health.

Based on similarities in the metabolic pathways of opioids and other drugs known to be compromised by St. John's wort, Shen said he believes there is a high probability that St. John's wort will interfere with the action of the analgesics he's testing. In standard pain treatment, a patient receives gradually increasing doses of opioid until the medication provides pain relief. If this patient took St. John's wort along with an opioid, then subsequently stopped treatment with St. John's wort, it is possible that the patient could be overdosed.

"I think it's our job to alert people to the possibility of drug interactions," he said. "With increasing use of herbal and dietary supplements, we have a glut of things to look out for now."

Even vitamin and mineral supplements, other than the multivitamin prescribed for transplant patients, must be carefully evaluated, Stern said.

"If patients take too much of one mineral, it can affect the absorption and availability of another mineral in the body," she said. "How the body utilizes all these compounds is not a simple process."

Stern noted that impure preparations of herbs can be contaminated with molds or other fungi, which can cause severe infections in immunocompromised patients such as those undergoing stem-cell transplants. She urges those seeking complementary care to choose naturopaths who have experience working with cancer patients and are willing to communicate with a patient's physician.

Flood regularly shares the results of blood-chemistry tests with his naturopath, and his acupuncturist encourages him to follow the advice of his oncologist. The holistic approach he has chosen-a combination of traditional medicine to attack his cancer and complementary therapies to boost his quality of life-have kept his health and spirit strong during his illness.

"Both aspects of my care have been wonderful," said Flood, a copywriter and book reviewer for The Seattle Times. "It's up to the patient to be informed and draw the best from both worlds."

Barbara Berg, Ph.D., is a science writer for the Fred Hutchinson Cancer Research Center.

Naturopath joins center's cancer-prevention team

Naturopathic physicians and cancer-prevention researchers alike feel that the best way to counteract disease is to stop it before it starts.

That mutual conviction is what drew naturopath Dr. Heather Greenlee to Fred Hutchinson, where she is beginning to conduct prevention research with Dr. Johanna Lampe in the Public Health Sciences Division.

Greenlee, who is the division's first naturopathic postdoctoral fellow, is the recent recipient of a three-year training grant from the National Center for Complementary and Alternative Medicine, a recently established branch of the National Institutes of Health.

"Ideally, we shouldn't have to treat disease at all," Greenlee said. "The fundamentals of naturopathic medicine are focused on disease prevention, and I see my research in the Cancer Prevention Research Program as a good fit with the naturopathic approach."

Greenlee and Lampe plan to evaluate the impact of natural "alternatives" - including dietary changes and herbal supplements - on estrogen metabolism in premenopausal women. Greenlee eventually plans to study these effects in women at high risk of developing breast cancer. Estrogen is a known risk factor for the disease.

In clinical practice, naturopaths use combinations of many of these natural remedies to regulate hormone levels, said Greenlee, who maintains a clinical practice at the Bastyr Center for Natural Health in Seattle.

"We know many of these interventions can have potent biologic effects on different hormonal pathways in the body," she said. "While researchers have focused on some of the individual therapies, no one has investigated the effects of the multidimensional approach used routinely by naturopathic physicians on estrogen metabolism."

For more on complementary and alternative medicine

American Cancer Society 
www.cancer.org/eprise/main/docroot/eto/eto_5?sitearea=ETO
National Center for Complementary and Alternative Medicine
www.nccam.nih.gov/health/

Many cancer patients use alternative medicine

More than 70 percent of adult cancer patients in western Washington use alternative or complementary therapies and almost all report substantial improvements in well-being as a result of using alternative medicine, according to a recent Fred Hutchinson survey.

The first population-based study of its kind to look at predictors, motivators and costs of different types of alternative- and complementary-medicine use in adults with cancer - the survey was led by Dr. Ruth Patterson and colleagues in the Public Health Sciences Division. Researchers at Bastyr University in Kenmore, Wash., and Oregon Health & Science University in Portland, Ore., also consulted.

"This is the first study to specifically inquire about patients' attitudes regarding the effectiveness of alternative treatments," Patterson said.

Patients were considered users of alternative or complementary medicine if they received care from an alternative provider within the past year or had used at least one alternative supplement or therapy. Depending on the type of therapy, 83 percent to 97 percent of patients surveyed said they used such medicine for general health, and nearly all reported that use of these therapies improved their well-being.

Seventeen percent of the patients received care from an alternative provider such as a naturopathic doctor, spiritual adviser, acupuncturist or massage therapist, and 20 percent used mental or energy-based therapy such as biofeedback, hypnotism, guided imagery, crystals, chelation therapy and magnets.

The most common form of treatment among those surveyed was the use of dietary supplements, taken by 65 percent of the patients, many of whom used several such products simultaneously. The investigators classified all types of individual supplements (vitamins, minerals, herbals and botanicals) as alternative, with the exception of one-a-day-type multivitamins that are accepted by mainstream medicine.

Exactly what is complementary and alternative medicine?

The National Center for Complementary and Alternative Medicine of the National Institutes of Health defines complementary and alternative medicine as a group of diverse medical and health-care systems, practices and products that are not presently considered to be part of conventional medicine. While some scientific evidence exists regarding some therapies, for most there are key questions - are they safe, do they work - yet to be answered through well-designed scientific studies.

• Complementary medicine is used together with conventional medicine. For example, using aromatherapy to help lessen a patient's discomfort following surgery.
• Alternative medicine is used in place of conventional medicine. For example, using a special diet to treat cancer instead of undergoing surgery, chemotherapy or radiation that has been recommended by a doctor.