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
What constitutes comprehensive cancer care? Oneinterpretation, by the National Cancer Institute (NCI), defines it as a commitment toexploring the basic science and clinical care of patients with cancer. Cancercenters designated by the NCI as "comprehensive" are expected to offerstate-of-the-art, multidisciplinary clinical services and to conduct biomedicalresearch to advance the understanding and treatment of cancer.
More generally, comprehensive care reflects a broadened sense ofresponsibility for addressing all aspects of the cancer patient’s needs. Thereis a growing trend in oncology to "treat the patient, not thedisease," and to incorporate patient services into comprehensive care. Inaddition to traditional medical services, many cancer centers now recognize theimportance of dedicated nursing, symptom and pain management, psychosocialcounseling, patient advocacy, patient information centers, and other nonmedicalpatient services. Complementary and alternative therapies may be added to thisconventional 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-BodyMedicine, a nonprofit, educational organization in Washington, DC, that focuseson "models of healing that will transform all parties in the healingprocess." He is also clinical professor of psychiatry and family medicineat Georgetown University School of Medicine, and was recently appointed chairmanof the White House Commission on Complementary and Alternative Medicine Policy.Although not an oncologist, Gordon has hosted three annual Comprehensive CancerCare conferencesmeetings that have served as forums for alternative andcomplementary therapies in cancer to an audience of traditional andnontraditional practitioners.
Comprehensive Cancer Care is principally a distillation of the1998 and 1999 conferences, interspersed with summaries and text from Gordon andCurtin, along with clinical vignettes based on patients at the Center forMind-Body Medicine. (Content from both the conference’s formal presentationsand panel discussions can also be found at the Center’s website [www.cmbm.org]). The book seeks to be a "reliable guide" for thoseinterested in complementary and alternative therapies for cancer, with thetarget audience clearly intended to be patients, families, and friends.
Gordon’s background in psychiatry and Curtin’s strength as apatient advocate are evident in their sympathetic, insightful descriptions ofpatients confronting cancer. Introductory chapters on the psychologicalreactions to cancer and the understandable desires of diagnosed patients areclearly written; they are sensitive to a variety of emotional and physical needsof cancer patients, very supportive, and to the point. Cancer patients and theirfamilies will find that this book resonates with their own experiences. Gordonalso captures many of the conflicting thoughts of patients and families: theneed to trust in professionals, yet take control of one’s treatment; the hopefor successful therapy tempered by an understanding that many treatments areimperfect; the need for both acceptance and defiance.
Next, the authors present an overview of their mind-bodymedicine program, emphasizing techniques for relaxation, stress management,coping strategies, basic nutritional support, and social support from formalsupport groups, social networks, clergy, and family. Principles of suchcomprehensive care are well explained, and most of the recommendations arestraightforward and made without excessive claims. Emphasis is consistentlyplaced on improving quality of life for cancer patients, because clearly, suchactivities play important roles in the care of many patients.
The latter half of the book covers less widely accepted medicalperspectives and treatments, such as traditional Chinese medicine,phytochemicals, melatonin, therapeutic diets (involving soy, garlic, or sharkcartilage), "immunomodulation," and other therapies, such as Dr.Burzynski’s antineoplastons. Gordon and Curtin are eager to distinguish thesealternative medicine approaches from "old wives’ tales."
The text in the chapters on alternative treatments closelyfollows the presentations of various practitioners at the Comprehensive CancerCare conferences. Most chapters share a similar structure, consisting of apurported rationale for the therapy, anecdotal or limited clinical evidence forbenefit, and the declaration of resolve to further study the intervention.Alternative methods are described in reasonable detail, providing readers withan understanding of the origins and current status of many of the more familiarunconventional therapies.
The authors make little attempt to hide their enthusiasm forthese alternative treatments, which they view as the "changing paradigm ofcancer care." It is clear that many patients are using alternative andcomplementary therapies to address concerns about cancer symptoms, treatmentside effects, and quality of life. The possible benefits of alternativetherapies in addressing quality-of-life issues are explored at length, and avariety of anecdotal evidence is described, suggesting that by taking part inthese various health-related practices, patients feel better about their cancerexperience. By acknowledging the role of alternative and complementary healthpractices and by addressing the anxieties and psychological needs of patients,Gordon and Curtin have made an important statement about the way thesetreatments are used and how they may be helpful to patients.
Nonetheless, it becomes problematic when that enthusiasm leadsto claims about the therapeutic benefits of complementary health care intreating cancer. In many instances, it is not so clear that enthusiasm isjustified by adequate clinical experience. While Gordon and Curtin emphasize theneed for properly conducted prospective clinical trials, there are precious fewinstances of such data. I believe the book would have been stronger as avaluable reference document if the authors had used more circumspection and madea more critical appraisal of many of the reports presented at the ComprehensiveCancer Care conferences.
As it now stands, the bookwith its exuberant toneis aforum for upbeat presentations. The tone leads to occasional overstatements,subtle contradictory points, and endorsements of treatments for which, theauthors acknowledge, there are no adequate data. For instance, the authorsstate:
"...using [traditional Chinese] herbs appropriately incombination with chemotherapy and radiation significantly enhances theeffectiveness of these therapies."
"...virtually all those who offer comprehensive care nowrecommend the inclusion of green tea as part of an anti-cancer strategy and as achemopreventive agent."
"...only case studies have been published. Randomizedclinical trials have not been completed. The evidence is strong enough that someclinicians and many patients are using CoQ10 (co-enzyme Q10) as an adjunctivetherapy. We recommend it as well."
Cancer is a frightening disease, and it is understandable thatpatients will pursue every possible option to help conquer it. Alternative andcomplementary medicine is widely prevalent, and is becoming a standard part ofthe conversation between doctors and patients. That in itself is a landmarkevent, affording physicians a chance to more fully participate in the lives ofpatients.
It is, indeed, important for clinicians to be aware of thehealth-related activities in which our patients are engaged. But it is alsoimportant to acknowledge the limitations of our knowledge,and to distinguish recommendations built on compelling clinical trials fromthose based on good ideas and good intentions.
When the data are insubstantial or nonexistent, prudencedictates caution when making recommendations to patients. Patients will benefitfrom 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, aproliferation of "cures" across America prompted Mark Twain to write:"They claim the ability to cure malignant cancer, and other affectionswhich have never been cured in the history of the race. There would seem to bean element of danger here. It has the look of claiming too much, I think."
Organized medicine and the National Institutes of Health aremaking a commitment to study alternative medicine and integrative care in a morecomprehensive, systematic, and thorough fashion. While awaiting the results ofthese studies, we need to be careful not to claim too much.