OncANP responds to article by Johnson, et al. “Complementary Medicine, Refusal of Conventional Cancer Therapy, and Survival Among Patients With Curable Cancers (1)” (JAMA Oncology)

An article by Skylar Johnson et al. appearing in the July 18, 2018 issue of JAMA Oncology has prompted a strong response from many members of the OncANP (Oncology Association of Naturopathic Physicians). This retrospective observational study used data from the National Cancer Database on 1,901,815 patients who were diagnosed with nonmetastatic breast, prostate, lung or colorectal cancer between 2004 and 2013.

The study compared outcomes of 258 of these patients who selected to use complementary or alternative therapies (CM) against matched controls.  Use of CM was purportedly associated with poorer 5-year overall survival compared with no CM (82.2% vs 86.6%; P = .001) and was independently associated with greater risk of death (hazard ratio, 2.08) in a multivariate model.

The central message of the article is clear: patients with cancer who refuse or delay proven, standard-of-care cancer treatments have a worse overall prognosis and survival.

This statement actually reinforces the philosophy and benefits of integrative oncology and ultimately the naturopathic approach to cancer care espoused by the Oncology Association of Naturopathic Physicians (OncANP).

However, the article is misleading in that it neglects to effectively describe the role of complementary and naturopathic medicine within integrative oncology. The article also portrays a relatively harsh view that seems to negate the value of integrative medicine when in fact the combination of conventional cancer treatment and care provided by naturopathic physicians or other integrative providers may offer the best outcomes to patients. The goals of integrative oncology are to empower patients, support informed decision-making, prevent treatment interruptions, and improve outcomes and quality of life without avoiding or delaying potentially curative therapy.

Patients benefit from a coordinated approach when a trained naturopathic physician (ND) collaborates with conventional providers at all stages along the continuum of cancer:

  • At the time of diagnosis: to prepare the patient for what lies ahead.

  • During active treatment: to reduce side effects and improve response to conventional care.

  • Post-treatment: to help with recovery and prevention of recurrence with healthy lifestyle education.

Medical oncologists, surgeons and radiation oncologists focus their treatment on targeting tumor eradication, whereas NDs practicing integrative cancer care use therapies to reduce side effects, to optimize conventional care, improve quality of life and prevent recurrence. NDs serve as critical advisors in this collaborative approach, offering evidence-informed guidance for patients and their conventional providers about options for safe, supportive complementary care.

Authors fail to explain “alternative” versus “complementary” cancer care

In their article, Johnson, et al. attempt but fail to clearly define the subset of patients who choose “alternative” cancer therapies (the term “alternative” is defined as a “substitute” or “replacement” for proven therapies) and who, refuse or delay conventional treatment. It does not differentiate these patients from those using complementary cancer care (the term “complementary” is analogous to “alongside” or “in tandem with”). The present study found that patients who choose to pursue alternative therapies (not in coordination with oncology care) demonstrate consistently poorer outcomes. The reported finding is not representative of those patients who choose integrative and complementary cancer care. An integrative approach is, in fact, associated with better patient outcomes. (2, 3, 4, 5, 6)

There are some patients who acquire a strongly-held belief that a “non-toxic” or “natural” approach to treating cancer is superior to conventional approaches presented by their oncologist. To the ND providing integrative cancer care, when these patients come seeking help, there is an opportunity to educate and redirect the patient toward making a fully informed choice, inclusive of conventional therapies. NDs can offer the reassurance that evidence- supported complementary therapies can help improve outcomes and mitigate many adverse toxicities of conventional treatments. In other words, an ND focused on integrative cancer care plays a pivotal role in encouraging patients to pursue an appropriate oncology-based treatment plan.

In a recent article by John Weeks, editor in chief of The Journal of Alternative and Complementary Medicine (JACM), he interviews Scott Mist, PHD, MACOM, MS, MA, LAc, an assistant professor of anesthesiology and perioperative medicine at Oregon Health Sciences University School of Medicine. Dr. Mist raises the issue that in the study that there were only 258 cases out of 1,901,815 patients that were reported to be in the complementary and alternative medicine (CM) group. This accounts for less than 0.01% and contrasts dramatically with multiple surveys reporting that between 48% and 88% of people with various types of cancer use some complementary methods (7,8).  Dr. Mist states: “there should have been between 836,799 and 1,673,597 CM users. But they found less than 0.01%. That should have stopped the study right there.” It is not likely that less than 1/100th of the population is representative of the population of CM users and begs the question as to how these cases were identified and why so many were clearly missed. The incredibly poor representation of complementary and alternative medicine users largely invalidates the results of the study.

Authors omit the issue of patients who are not eligible for conventional treatment

The article by Johnson, et al. also does not effectively address the cohort of patients who may have been deemed poor candidates for conventional therapy due to age, advanced disease, comorbid conditions or treatment-limiting toxicities related to prior treatment.

In these cases, licensed naturopathic physicians (NDs) practicing integrative cancer care can provide lifestyle, nutrient, botanical and other therapies aimed at preserving quality and quantity of life. The ND has an important role in advising the patient, particularly in light of various purported treatment options which may have no benefit and could lead to harm. NDs work proactively to educate patients on recommended conventional treatments and evidence-informed natural approaches. This is of great value to patients as well as conventional providers, who may not have expertise in integrative care.

The OncANP is the leading professional organization in North America for naturopathic physicians working to support a standard of whole-person, patient-centered care for people living with cancer. A select group of providers within the OncANP has attained the designation of “Fellow of the American Board of Naturopathic Oncology” (FABNO) signifying a standardized level of competence and training for NDs working with cancer patients. FABNOs aim to collaborate with conventional oncology providers to deliver the highest standard of integrative cancer care, leading to better outcomes for patients.

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The OncANP advocates for collaboration with conventional providers and integration of care. We are dedicated to advancing the science and application of naturopathic medicine within the field of cancer care and treatment.

To learn more, please see: “The Role of Naturopathic Medicine in Cancer Care”  or visit www.oncanp.org

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(1) Johnson SB, Park HS, Gross CP, Yu JB. Complementary Medicine, Refusal of Conventional Cancer Therapy, and Survival Among Patients With Curable Cancers. JAMA Oncol. Published online July 19, 2018. doi:10.1001/jamaoncol.2018.2487

(2) Ben-Arye E, Samuels N, Schiff E, Raz OG, Sharabi I, Lavie O. Quality-of-life outcomes in patients with gynecologic cancer referred to integrative oncology treatment during chemotherapy. Support Care Cancer. 2015 Dec;23(12):3411-9.

(3) Ben-Arye E, Dahly H, Keshet Y, Dagash J, Samuels N. Providing integrative care in the pre- chemotherapy setting: a pragmatic controlled patient-centered trial with implications for supportive cancer care. J Cancer Res Clin Oncol. 2018 Sep;144(9):1825-1833.

(4) Johnson JR, Crespin DJ, Griffin KH, Finch MD, Dusek JA. Effects of integrative medicine on pain and anxiety among oncology inpatients. J Natl Cancer Inst Monogr. 2014 Nov;2014(50):330-7.

(5) Axtner J, Steele M, Kröz M, Spahn G, Matthes H, Schad F. Health services research of integrative oncology in palliative care of patients with advanced pancreatic cancer. BMC Cancer. 2016 Aug 2;16:579.

(6) McCulloch M, Broffman M, van der Laan M, Hubbard A, Kushi L, Kramer A, Gao J, Colford JM Jr. Lung cancer survival with herbal medicine and vitamins in a whole-systems approach: ten-year follow-up data analyzed with marginal structural models and propensity score methods. Integr Cancer Ther. 2011 Sep;10(3):260-79.

(7) Richardson MA, Sanders T, Palmer JL, et al. Complementary/Alternative Medicine Use in a Comprehensive Cancer Center and the Implications for Oncology. J Clin Oncol 2000 Jul;18(13):2505.

(8) Journal of Clinical Oncology, 2015 ASCO Annual Meeting (May 29 – June 2, 2015) Vol 33, No 15_suppl (May 20 Supplement), 2015: 9625.