Asma Dilawari, MD
Attending Physician, Breast Oncology
Georgetown Lombardi Comprehensive Cancer Center
MedStar Georgetown University Hospital
MedStar Montgomery Medical Center
Assistant Professor, Georgetown University
As I looked at Ms C, I was struck by the pensive but engaged smile she always sent my way. The same look continued as her daughter elaborated on her mother’s condition. Though her thin stature and wrinkled skin were not remarkable for a 96-yearold matriarch, her well-groomed appearance, stable weight, and increasing participation in physical therapy in the setting of a diagnosis of metastatic ovarian cancer given over a year ago was quite unusual.
Before I met her, she had received one dose of chemotherapy that resulted in hospitalization and opted to discontinue all chemotherapy. Her family had taken her to multiple alternative medicine specialists, one of whom prescribed mistletoe injections that she had been taking the last few months. They subsequently sought several opinions about oncologic interventions.
After each discussion, Ms C confirmed she was not feeling badly and did not want to start any therapies that could interfere with her current quality of life. Thus, supportive care and periodic follow-up visits continued. Her CA-125 continues to rise, although her clinical symptoms are unchanged. None of the sequelae I had expected from her diagnosis—the bloated abdomen, difficulty with bowel movements, abdominal pain, and muscle wasting—has ensued.
Although it is possible that the histology of her particular disease predicted for better behavior or that there was a misdiagnosis of ovarian cancer, I have added her name to a short list of patients who have acknowledged using herbal remedies as part of their therapies. Mistletoe has been studied and mentioned frequently in the alternative medicine literature as having a potential antitumor effect, although results have been mixed. Several studies report evidence of possible health-related quality of life (HRQoL) improvements in patients who take mistletoe injections in addition to adjuvant chemotherapy.1
This has led the National Institutes of Health (NIH) to fund research trials assessing its use, and currently there are multiple trials in different tumor types studying its effect in cancer therapy.
It is encouraging to hear about clinical trials assessing numerous herbal remedies and their effects on various cancers. But these studies are limited in their number and scope. They take years to accrue and report and, unlike novel pharmacological therapies being researched, patients have access to these treatments now through other providers.
Patients Acting on Their Own
The NIH established its National Center for Complementary and Integrative Health (NCCIH) in October 1998 but, despite the increasing interest in complementary and alternative medicine (CAM), the more frequent scenario is that our patients use these therapies without our input and our knowledge.
A study published in 2004 assessed 500 patients with breast and gynecological cancers and reported that 48% used CAM as part of their care. The majority of patients were also receiving standard oncology treatment, yet only 53.5% had spoken to their healthcare provider about these CAM therapies.2
Recent studies point to even greater use of these therapies within certain populations. A review of multiple trials conducted within the United States and abroad reported that women with breast cancer seek CAM options more than other populations, and the majority of these trials indicated a trend toward higher use in women of younger age and higher education level.3
With growing evidence that these therapies may improve symptoms associated with treatment and quality of life, the disparities in access to CAM treatments should be addressed just as with other cancer therapies. However, these challenges will remain if the environment is one of nondisclosure.
The same month that I saw Ms C, I had a follow-up visit with Ms O, a 55-year-old woman with newly diagnosed hormone-negative, HER2-positive breast cancer with a large breast mass for which I had recommended neoadjuvant therapy. She would not consider clinical trial participation but had reluctantly agreed to chemotherapy and HER2-targeted therapy, asserting that juice cleanses and antibiotics had already begun to decrease the size of her mass.