What constitutes comprehensive cancer care? One interpretation, by the National Cancer Institute (NCI), defines it as a commitment to exploring the basic science and clinical care of patients with cancer. Cancer centers designated by the NCI as "comprehensive" are expected to offer state-of-the-art, multidisciplinary clinical services and to conduct biomedical research to advance the understanding and treatment of cancer.
More generally, comprehensive care reflects a broadened sense of responsibility for addressing all aspects of the cancer patient’s needs. There is a growing trend in oncology to "treat the patient, not the disease," and to incorporate patient services into comprehensive care. In addition to traditional medical services, many cancer centers now recognize the importance of dedicated nursing, symptom and pain management, psychosocial counseling, patient advocacy, patient information centers, and other nonmedical patient services. Complementary and alternative therapies may be added to this conventional rosteradditions that put the "comprehensive" in Comprehensive Cancer Care, a new book by Dr. James S. Gordon and Sharon Curtin.
Gordon is founder and director of the Center for Mind-Body Medicine, a nonprofit, educational organization in Washington, DC, that focuses on "models of healing that will transform all parties in the healing process." He is also clinical professor of psychiatry and family medicine at Georgetown University School of Medicine, and was recently appointed chairman of the White House Commission on Complementary and Alternative Medicine Policy. Although not an oncologist, Gordon has hosted three annual Comprehensive Cancer Care conferencesmeetings that have served as forums for alternative and complementary therapies in cancer to an audience of traditional and nontraditional practitioners.
Comprehensive Cancer Care is principally a distillation of the 1998 and 1999 conferences, interspersed with summaries and text from Gordon and Curtin, along with clinical vignettes based on patients at the Center for Mind-Body Medicine. (Content from both the conference’s formal presentations and panel discussions can also be found at the Center’s website [www.cmbm.org]). The book seeks to be a "reliable guide" for those interested in complementary and alternative therapies for cancer, with the target audience clearly intended to be patients, families, and friends.
Gordon’s background in psychiatry and Curtin’s strength as a patient advocate are evident in their sympathetic, insightful descriptions of patients confronting cancer. Introductory chapters on the psychological reactions to cancer and the understandable desires of diagnosed patients are clearly written; they are sensitive to a variety of emotional and physical needs of cancer patients, very supportive, and to the point. Cancer patients and their families will find that this book resonates with their own experiences. Gordon also captures many of the conflicting thoughts of patients and families: the need to trust in professionals, yet take control of one’s treatment; the hope for successful therapy tempered by an understanding that many treatments are imperfect; the need for both acceptance and defiance.
Next, the authors present an overview of their mind-body medicine program, emphasizing techniques for relaxation, stress management, coping strategies, basic nutritional support, and social support from formal support groups, social networks, clergy, and family. Principles of such comprehensive care are well explained, and most of the recommendations are straightforward and made without excessive claims. Emphasis is consistently placed on improving quality of life for cancer patients, because clearly, such activities play important roles in the care of many patients.
The latter half of the book covers less widely accepted medical perspectives and treatments, such as traditional Chinese medicine, phytochemicals, melatonin(Drug information on melatonin), therapeutic diets (involving soy, garlic, or shark cartilage), "immunomodulation," and other therapies, such as Dr. Burzynski’s antineoplastons. Gordon and Curtin are eager to distinguish these alternative medicine approaches from "old wives’ tales."
The text in the chapters on alternative treatments closely follows the presentations of various practitioners at the Comprehensive Cancer Care conferences. Most chapters share a similar structure, consisting of a purported rationale for the therapy, anecdotal or limited clinical evidence for benefit, and the declaration of resolve to further study the intervention. Alternative methods are described in reasonable detail, providing readers with an understanding of the origins and current status of many of the more familiar unconventional therapies.
The authors make little attempt to hide their enthusiasm for these alternative treatments, which they view as the "changing paradigm of cancer care." It is clear that many patients are using alternative and complementary therapies to address concerns about cancer symptoms, treatment side effects, and quality of life. The possible benefits of alternative therapies in addressing quality-of-life issues are explored at length, and a variety of anecdotal evidence is described, suggesting that by taking part in these various health-related practices, patients feel better about their cancer experience. By acknowledging the role of alternative and complementary health practices and by addressing the anxieties and psychological needs of patients, Gordon and Curtin have made an important statement about the way these treatments are used and how they may be helpful to patients.
Nonetheless, it becomes problematic when that enthusiasm leads to claims about the therapeutic benefits of complementary health care in treating cancer. In many instances, it is not so clear that enthusiasm is justified by adequate clinical experience. While Gordon and Curtin emphasize the need for properly conducted prospective clinical trials, there are precious few instances of such data. I believe the book would have been stronger as a valuable reference document if the authors had used more circumspection and made a more critical appraisal of many of the reports presented at the Comprehensive Cancer Care conferences.
As it now stands, the bookwith its exuberant toneis a forum for upbeat presentations. The tone leads to occasional overstatements, subtle contradictory points, and endorsements of treatments for which, the authors acknowledge, there are no adequate data. For instance, the authors state:
"...using [traditional Chinese] herbs appropriately in combination with chemotherapy and radiation significantly enhances the effectiveness of these therapies."
"...virtually all those who offer comprehensive care now recommend the inclusion of green tea as part of an anti-cancer strategy and as a chemopreventive agent."
"...only case studies have been published. Randomized clinical trials have not been completed. The evidence is strong enough that some clinicians and many patients are using CoQ10 (co-enzyme Q10) as an adjunctive therapy. We recommend it as well."
Cancer is a frightening disease, and it is understandable that patients will pursue every possible option to help conquer it. Alternative and complementary medicine is widely prevalent, and is becoming a standard part of the conversation between doctors and patients. That in itself is a landmark event, affording physicians a chance to more fully participate in the lives of patients.
It is, indeed, important for clinicians to be aware of the health-related activities in which our patients are engaged. But it is also important to acknowledge the limitations of our knowledge, and to distinguish recommendations built on compelling clinical trials from those based on good ideas and good intentions.
When the data are insubstantial or nonexistent, prudence dictates caution when making recommendations to patients. Patients will benefit from openness, confidence, and optimismnot false hope.
Our era is not the first to be fascinated by alternative, nonstandard medical treatments. Such therapies have existed alongside "traditional" medicine for millennia. At the last fin de siecle, a proliferation of "cures" across America prompted Mark Twain to write: "They claim the ability to cure malignant cancer, and other affections which have never been cured in the history of the race. There would seem to be an element of danger here. It has the look of claiming too much, I think."
Organized medicine and the National Institutes of Health are making a commitment to study alternative medicine and integrative care in a more comprehensive, systematic, and thorough fashion. While awaiting the results of these studies, we need to be careful not to claim too much.