Some of the most common questions oncology pharmacists address with patients who are receiving cancer therapies relate to their concurrent use of complementary and alternative medicine (CAM) supplements and natural products. Although herbal remedies, vitamins, and antioxidants are among the most popular options, patients are increasingly turning to cannabis, probiotics, and psilocybin for their potential anticancer effects as well as to alleviate treatment-associated adverse effects (AEs).
Recently, a patient on oral targeted therapy at my practice shared the treatment plan her naturopathic oncologist had prescribed, which included a couple of the products we had specifically recommended she avoid, at least as we initiated the targeted agent. Our advice was based on the potential for overlapping AEs and drug-drug interactions that might impede our ability to optimize her anticancer treatment. There were no absolutes, as there rarely are, and we continue to work with this patient as we do with others who pursue concurrent treatments. Yet I wonder if and how we might better meet patients’ needs in this area.
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For several decades, survey findings have indicated that 30% to 60% of patients with cancer—and even 80% in some reports—choose supplements and nontraditional therapies in conjunction with conventional cancer treatment, and about half of them don’t inform their oncologists because of fear that they would be discouraged or that the oncologist lacks the knowledge to offer accurate advice. Most often, patients take complementary therapies with conventional treatments to manage treatment- or cancerrelated AEs but sometimes to augment treatment efficacy. The patient mentioned had been advised by her naturopathic oncologist that the recommended supplement inhibited the same signaling pathway targeted by the cancer treatment. Although acupuncture, massage, meditation, tai chi, yoga, prayer, spiritual practices, biofeedback, and art and music therapy have been studied and can help patients feel better during treatment, alternative therapies that are promoted as treatments or cures in lieu of conventional modalities are a different story.
According to the American Society of Clinical Oncology National Cancer Opinion Survey published in 2018, 40% of Americans believe that cancer can be cured solely with alternative remedies. In 2020, the same survey found that 35% of respondents agreed with that statement and 73% of Americans thought that alternative therapies are a good supplement to standard cancer treatments. Many of these therapies have been studied and remain unproven, but published evidence shows higher mortality rates for individuals who use them instead of conventional treatment.
Clearly, many of our patients are seeking more than we’re providing. The importance of complementary therapeutic approaches cannot be overstated, and the increasing number of centers that incorporate integrative oncology within their cancer prog rams reflects increased interest in this area. Oncology care providers, and particularly oncology pharmacists, are very familiar with potential drug-drug interplay between anticancer agents and supplements, be they prescribed or selfadministered, and would therefore benefit from having discussions with patients on these interactions as a part of cancer care and treatment.
In addition, concomitant use of antioxidants, vitamins, and supplements with anticancer treatments is paradoxical, given that their protective effects often target the same reactive oxygen species generated by cancer drugs and radiotherapy as mediators of anticancer activity. Most of the research to date, however, does not suggest detrimental anticancer effects, and some patients report a reduction in AEs.
Because patients choose complementary therapies for a variety of reasons, our support promotes patient autonomy and helps them cope with treatment and achieve better quality of life. To this end, proactive discussions about CAM supplements and natural products when reviewing medication histories and sensitivities may be helpful. Furthermore, eliciting information about why a patient is taking a specific supplement may help us understand trends at our centers and topics being discussed in patient forums and social media.
Although it can be quite challenging to navigate through the dozens of dietary supplements and herbal remedies some patients take, if we think about these conversations as opportunities, we can all become more knowledgeable about caring for patients today and in the future.
About the Editor
Lisa E. Davis, PharmD, FCCP, BCPS, BCOP, is the editor in chief of Pharmacy Times Oncology Edition. Davis holds positions as a clinical pharmacist in early-phase clinical trial and breast cancer programs at the University of Arizona (Arizona) Cancer Center and a clinical professor of pharmacy practice and science at the Arizona R. Ken Coit College of Pharmacy. Davis also sits on the Hematology/Oncology Pharmacy Association Board of Directors and is a member of the Cancer Prevention and Control Program and scientific review committee at the Arizona Cancer Center.