Oncologists Underestimate Patients' Use of Complementary Tx

A large percentage of cancer patients use some form of complementary and alternative medicine, typically with the goal of relieving pain and controlling the adverse effects of disease or treatment.

But oncologists underestimate how much patients use these therapies.

A new survey, released in conjunction with the annual meeting of the American Society of Clinical Oncology (ASCO), shows a disconnect between the two.

Almost three quarters of patients with breast cancer (73%) reported that they used at least one type of complementary medicine following their diagnosis, but oncologists believe that number is much smaller and that fewer than half (43%) of their patients use these approaches during cancer care.

"There is a disconnect in communication between patients and physicians in the area of complementary medicine," said Wayne Jonas, MD, one of the study authors and executive director of the Samueli Foundation's Integrative Health Programs, Corona del Mar, California. "This is a well-known and ongoing problem between practitioners and patients," he said.

Patients are much more likely to use complementary and integrative medicine than healthcare professionals assume, he told Medscape Medical News. "Providers often know very little about these areas or have a negative opinion about them, and so the patients don't bring them up," said Jonas. "This results in a major communication gap that is not good for delivery of optimal healthcare."

Efforts are needed to close the gap, he said. "It is the responsibility of both parties to bring the topics up and have respectful and open communication about these practices," he said.

The Samueli Foundation is funding a project by the Society for Integrative Oncology to work in concert with ASCO to develop a series of clinical practice guidelines on integrative approaches to common symptoms, such as pain, anxiety, stress, fatigue, and insomnia, as well as clinical practice guidelines regarding prevalent cancers, such as colorectal, prostate, and breast cancer.

"The first set of guidelines is set to be released in the fall of 2021," he said. "Evidence-based tools, such as these guidelines, can help clinicians more proactively engage with their patients about the use of complementary or integrative medicine and close that communications gap."

The new survey also found that physicians discussed the use of complementary therapies with only about half of their patients. This is in line with results of previous surveys, which have shown that fewer than half of US oncologists initiate discussions about the use of these therapies or talk about them with their patients.

It also found that about two thirds of oncologists and patients agreed that complementary and lifestyle approaches contributed to improved quality of life and well-being. However, these viewpoints differed significantly when it came to survival and treatment outcomes; only 36% of oncologists believed that these therapies improve survival and treatment outcomes, compared to 60% of patients.

In addition, the survey found that although 55% of oncologists discussed complementary and lifestyle approaches with patients with breast cancer, only 28% of patients said that they became aware of these approaches from the oncologists or care team. Patients said that they would like to receive this type of information from their healthcare professionals.

Survey Details

The survey involved 164 patients with breast cancer (all disease stages) who were diagnosed within the past 2 years across the United States. It also included 115 clinical oncologists, sampled from a panel of community and academic practices across the United States. Participating oncologists were required to have treated at least 10 patients with breast cancer in a typical 3-month period and to have been in practice for at least 6 years since residency or fellowship.

Most oncologists reported familiarity with at least one complementary and lifestyle approach. More oncologists were familiar with such approaches than their patients were (92% vs 61%).

There were also differences as to how the various modalities were viewed. Oncologists saw nutrition consultation, support groups, psycho-oncology support, and exercise consultation as the most important integrative services. They gave relatively low importance to spiritual services and meditation or mindfulness. But patients viewed these two latter approaches as important to them.

Differences were also noted in the types of approaches that physicians discussed with patients. Most patients did not receive the information from the healthcare team. For example, 55% of patients reported learning about support groups through healthcare professionals, whereas only 25% learned about acupuncture/acupressure and 16% learned about music or art therapy through them.

"Oncologists should be asking patients about what they need and want and what matters to them in their treatment plan," said Jonas. "This is person-centered care, and I've found that many physicians haven't been taught how to have these conversations."

Although oncologists and patients agree that oncologists, oncology nurses, or patient navigators are good sources of information for complementary medicine and lifestyle therapies, patients have expressed a preference to hear it directly from the oncologist. When asked who the ideal individual was to have these discussions with, 62% of oncologists said it was the oncology nurse, vs 48% of patients; 53% of oncologists said the patient navigator, vs 33% of patients; and 52% of oncologists said that they were the best source, vs 63% of patients.

The level of insurance coverage for these interventions varies widely across institutions. Academic practices offered more modalities that were covered either partially or in full as compared to community practices, and most patients were unaware of this potential lack of coverage. More than half of the patients reported that they were uncertain about current coverage of the cost of these therapies. The percentage ranged from 45% for nutrition consultation to 74% for tai chi/qi gong.

The so called "financial toxicity" due to high costs of cancer care is a growing problem in oncology, Jonas pointed out, and complementary and lifestyle approaches should not exacerbate that problem. He noted that physicians need to be aware that cost can be a barrier to any treatment.

"However, with continued evidence, we are seeing some of the modalities in the survey begin to be covered," he said. "Overall, we're also seeing more momentum to finance a healthcare system that is focused on the health and well-being of the whole person, not just disease treatment."

Some of these modalities are free of cost. "Meditation, for instance, can be done without heavy financial investment but potentially holds a lot of power for the patient," he said. "Having an honest conversation with a patient that takes into account their motivations, as well as their needs and beliefs, can help create a comprehensive path to healing."

No Surprises Here

Commenting on the study, Charles Shapiro, MD, professor of medicine, hematology, and medical oncology at the Icahn School of Medicine at Mount Sinai and the director of translational breast cancer research for the Mount Sinai Health System, New York City, agreed that many individuals with cancer seek complementary medicines and pursue lifestyle interventions or alternative approaches.

"In this survey study of women with breast cancer and oncologists, three things stand out," he said. "About two thirds of oncologists and women with breast cancer think that lifestyle interventions and alternative approaches improve quality of life. That's good news, especially that the oncologists recognized the importance of these approaches."

The second point is that there is a disconnect between oncologists and women with breast cancer regarding what each group thinks is important. "Spirituality, meditation, and mindfulness were rated higher by women with breast cancer than oncologists ― no surprises here, never assume anything," said Shapiro.

"And third, women with cancer have a slight preference to hear from their oncologists about these complementary approaches rather than other members of the health team ― no surprises here either," he said.

"This survey study provides useful information and serves as a model, in terms querying both oncologists and individuals with cancer," he added.

The survey was funded by IQVIA. Jonas is executive director of the Samueli Foundation's Integrative Health Programs. Shapiro has disclosed no relevant financial relationships.

American Society of Clinical Oncology (ASCO) 2021: Abstract e24123.

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