By Gary Deng, MD, PhD
Nowadays, one of the first things most cancer patients do after a cancer diagnosis is search the Internet for treatment options. The search can lead to information overload, both informing and confusing the patient. Among the search results are therapies that are outside the realm of conventional Western medicine, ranging from “alternative cancer cures” to “tricks and tips” forwarded by well-meaning friends and relatives. Around 40% to 50% of cancer patients are interested in unconventional therapies. Patients may ask their oncologist: “What kind of food should I eat? Is noni-juice anti-cancer? How about ozone therapy? Will acupuncture help my cancer treatment?” Often the oncologist is equally puzzled by these questions and searching for answers too.
These so-called complementary and alternative medicine therapies are so numerous and so diverse that their value to cancer patients varies widely. At one end of the spectrum are therapies that have been shown in clinical trials to be safe and beneficial. These are called complementary therapies because they complement—support—conventional cancer care. Combining them with mainstream cancer treatment to reduce symptoms, improve quality of life, and strengthen the body, mind, and spirit is what integrative oncology is about.
At the other end are bogus “alternative” cancer therapies, often promoted as secret cancer “cures” that have been suppressed by conspirators. Pursuing these ineffective and risky therapies can actually be harmful if they delay or prevent the patient from getting real medical treatment.
How do we pick one therapy versus another? We cannot rely on stories or testimonials such as “a friend of my uncle was told he had only 3 months to live and is still alive after a year because he has been taking xyz herb.” When you investigate further, you may find he has also been taking a drug with proven efficacy.
A more reliable way to make a treatment decision is to rely on data from carefully designed and conducted clinical studies. To help oncologists and patients sort out the array of complementary and alternative therapies, a group of experts working in integrative medicine systematically searched all the professional literature published in the past 10 years for high-quality research on common complementary therapies. They evaluated the findings, graded the strength of the evidence, assessed risks and burdens to patients, and came up with a set of recommendations for clinicians taking care of cancer patients, especially lung cancer patients. The recommendations are presented in the chapter “Complementary Therapies and Integrative Medicine in Lung Cancer” of Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, which were published in May 2013.
The guidelines recommend that all cancer patients should be asked about their use of and interest in complementary and alternative medicine because not informing their doctors about their use can lead to a variety of problems. This is particularly important for patients interested in taking herbs or supplements, as they may have side effects or interact in a bad way with other medications. For example, an herb may make the blood too thin, thus raising the risk of bleeding during surgery or chemotherapy, or it may change the blood level of a chemo drug, leading to less effectiveness or more side effects. Clinicians are urged to have an open, receptive, yet evidence-based discussion with the patient about the pros and cons of these therapies, including what they can and cannot achieve. Simply stating, “Don’t use any of them” won’t be very effective. Patients are exploring complementary therapies for a reason, be it the lack of effective treatment options, the desire to feel empowered, or the belief that “anything natural is good.” These underlying needs must be addressed if the doctor wants to provide high-quality care.
Next, the guidelines make recommendations about individual therapies that have been found to be generally safe and helpful for specific problems. These include “mind-body” therapies, such as meditation; yoga, t’ai chi, and qigong; hypnosis; relaxation techniques, and music therapy, which can help improve anxiety, mood, sleep, pain, and anticipatory chemotherapy-induced nausea and vomiting (feeling nauseated just thinking about upcoming chemo). Massage therapy can be considered when anxiety and pain are not adequately controlled by standard care. For patients with compromised lung function, supervised exercised-based treatment is suggested. Acupuncture can be included for patients having nausea and vomiting from chemotherapy or radiation therapy, or pain that is not controlled by conventional treatment. A diet rich in nonstarchy vegetables and fruits and low in red meat and processed meat is suggested to reduce the risk of lung cancer. For patients who are losing weight or muscle mass, high-calorie and protein supplementations or omega-3 fatty acids are recommended, respectively.
These guidelines will help doctors feel more confident in answering patients’ questions about complementary therapies, knowing the current state of scientific data on these therapies. They will also encourage doctors to consider incorporating these therapies for patients who are not responding to treatment of bothersome symptoms or those who have too many treatment side effects. Keep in mind that none of the therapies will shrink cancer itself. But they can help reduce suffering and strengthen resilience, which, in quality cancer care, is equally important as treating the cancer itself.
So if you have questions about or are using complementary and alternative medicine, we encourage you to let your doctor know. Doing so will keep everyone on the same page and reduce the risk of your taking something that may harm you. Meanwhile, you might want to take advantage of some of the safe and beneficial therapies that can make cancer treatment easier bear. If your doctor does not initiate the conversation and you are interested in these therapies, simply bringing up the subject will do you a lot of good.
Photo: Mark Hooper/Getty Images
Gary Deng, MD, PhD, is an attending physician with the Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center in New York. His clinical expertise is in cancer supportive care and integrative medicine. He served as topic editor of the chapter on integrative medicine in Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, released in May 2013.
by Cecilia M. Smith, DO
Sarcoidosis is an elusive disease. Even the TV series “House,” about the brilliant (but surly) Dr. Greg House and his team of brilliant (but demoralized) subordinates, picked up on that fact. Faced with the weekly challenge of diagnosing a mysterious and deadly disease, at some point during each episode, one of House’s protégés inevitably would suggest, “Maybe it’s sarcoidosis.” And with the disease’s wide variety of symptoms, the many organs it can affect, and the other diseases it can mimic, it was perhaps a diagnosis worth considering.
April is National Sarcoidosis Awareness Month, a good time to learn about this puzzling disease. It is often thought of as a lung disease because the organ most commonly involved is the lungs. But it can affect any organ of the body, such as the lymph glands, eyes, skin, liver, or salivary glands, without causing lung disease. In other cases, only the lungs are affected, a condition called pulmonary sarcoidosis. Pulmonary sarcoidosis can reduce the amount of air the lungs hold and cause breathing problems.
Sarcoidosis is characterized by granulomas—tiny lumps of cells that cluster together in a unique way within the tissue of the organs involved. To help the doctor diagnose the disease, the tissue must be biopsied and examined in a laboratory, and this unique cluster pattern must be present.
To complicate the matter, sarcoidosis is not the only disease associated with the formation of granulomas in tissue. Granulomas can also occur in certain infectious diseases and environmental/occupational exposures. So if granulomas are found, further investigation is needed to determine which disease is causing them.
What causes these clusters of cells to form is not known. Researchers suspect that exposure to certain substances may cause a reaction within a person’s immune system, but they don’t know what those triggers are.
Researchers do know that there is nothing a person “does” to cause sarcoidosis. It is found in every sex, age, race, and country of birth, although it occurs more commonly in Northern Europe and, within the United States, among African Americans. It affects younger adults, between 20 and 40 years of age, more than the very young or the elderly.
Diagnosing sarcoidosis can be tricky. Symptoms can vary widely, depending on the part of the body involved, or there may be no symptoms. When symptoms occur, they may be vague and not specific to sarcoidosis—such as weight loss, fever, depression, night sweats, and sleep problems. If a doctor is not considering it as a possibility, it is likely to be missed or misdiagnosed.
There is not one definitive test to diagnose sarcoidosis. A good history and physical is essential, including family members’ health history. It is important for the patient to mention even vague symptoms, as they could possibly be a clue. Further testing will focus on the organ of the body involved.
Once a diagnosis of sarcoidosis is established, not all individuals require treatment. It depends on which organ of the body is affected. For instance, when the eyes are involved, drug therapy is required. When the lymph nodes are involved, however, no therapy is needed. Treatment is aimed at reducing symptoms and preventing organ damage. Because sarcoidosis can clear in the lungs without therapy, there is some controversy among medical professionals as to when to treat for lung involvement.
Like everything else with this disease, prognosis for people diagnosed with sarcoidosis varies. Many individuals live a long life, while in others the disease progresses and causes organ damage. In rare cases it can be fatal. Comedian Bernie Mac died from complications of sarcoidosis in 2008.
For more on sarcoidosis, including information on living with the disease and chapters on specific organ involvement, see “Sarcoidosis: A Primer,” electronically published by the American College of Chest Physicians. Too bad Dr. House and his team didn’t have access to this great resource!
Photo: Fox TV
Cecilia M. Smith, DO, is a Clinical Professor of Medicine at Jefferson Medical College in Philadelphia and chairs the Department of Medicine at Reading Health System in West Reading, Pennsylvania. She served as co-editor of “Sarcoidosis: A Primer,” published by the Interstitial and Diffuse Lung Disease Network of the American College of Chest Physicians.
by Harish Rao, MD, MBBS
All of us have an “internal clock” or circadian rhythm that regulates our sleep and wake cycles. For most of us, our internal clock is more or less in synch with the natural day/night cycle, which is why we sleep at night and are awake during the day. But for some people, that “internal clock” is shifted late. The problem usually presents as trouble falling asleep at night and trouble waking up in the morning, especially for school or work. These people are often called night owls or, worse, lazy.
Sound like any teenagers you know? The disorder is common among adolescents, although it can occur at any age. One study reported a prevalence of 1 in 1,000 people, but it is several times higher in adolescents. Sometimes called night-owl disorder, the actual name of the problem is delayed sleep phase disorder, or DSPD.
This shift in the internal clock most often occurs when a person’s weekday and weekend wake-up times differ by more than 1 or 2 hours, and may be aggravated by daytime naps and caffeine. In many individuals, DSPD is a genuine neurological disorder with a probable genetic basis. These individuals live in a state of sustained jet lag. They are often thought of as lazy or irresponsible, as it is difficult for others to understand that the abnormal sleep hours are out of the sufferer’s control.
Among teenagers and young adults, PSPD is often a “social malady,” the result of chronic late-night exposure to electronic and social media compounded by peer pressure to be connected at all hours. But biological changes during adolescence can also contribute to the problem. Many sleep experts have been calling for delayed school start times for adolescents to address this concern.
Many people try to cope with DSPD by forcing themselves to keep a normal schedule (ie, waking earlier than desired by the internal clock), leading to sleepiness/grogginess on waking as well as a chronic sleep deficit. This sleep deficit manifests as fatigue, depression, and inability to focus at work or school. DSPD symptoms are frequently misdiagnosed as insomnia, chronic fatigue syndrome, or attention deficit disorder.
To address the problem, wake-up time must be controlled to help re-set the internal clock. Sleep charts and actigraphy (watch-like devices with motion sensors that can monitor rest/activity cycles) are extremely useful in tracking an individual’s sleep schedules. Use of low-dose melatonin at night and well-timed exposure to light in the morning (either daylight or a light box) corrects the problem in many individuals. A light box (with light intensity of 10,000 lux) is useful during times when daylight is scarce, such as during the winter in many parts of the world.
Sleep phase chronotherapy is used in more difficult cases with close monitoring by a sleep physician. During chronotherapy an attempt is made to move bedtime and rising time later and later each day, around the clock, until the person is sleeping on a normal schedule.
Good “sleep hygiene” is then required to maintain an appropriate sleep/wake cycle:
• Wake up at the same time every day to readjust internal clock.
• In the morning be up, active, and exposed to bright light, and eat breakfast. Being active sends the brain a strong message that it is morning, and will help your body clock adjust.
• Have a calm bedtime routine, such as reading with a dim light for 15 minutes before turning out the light. Turn off music before falling asleep.
• Avoid bright lights and TV, computer, cell phone, or other screens for 1 to 2 hours before bedtime. Keep all screens outside of the bedroom.
• Avoid caffeine after 12:00 pm (coffee, tea, chocolate milk, cola, energy drinks).
• Avoid daytime naps.
Important tip for parents of night-owl adolescents:
• Do not let your child’s weekday and weekend wake-up time differ by more than 1 or 2 hours.
• If your child’s sleep schedule is off during vacation, you can correct the schedule by bringing wake time forward by 30 minutes every 2 or 3 days.
And be sure to see a sleep physician if you are a “night owl” and are struggling to correct your sleep schedule.
Learn more about healthy sleep habits and sleep disorders, and explore our collection of useful links and resources at onebreath.org. OneBreath is an initiative of The CHEST Foundation, the philanthropic arm of the American College of Chest Physicians.
Photo: Bruce Rogovin, Photolibrary
Harish Rao, MD, MBBS, is a Fellow at the Center for Pediatric Sleep Disorders at Boston Children’s Hospital. He sees four to five patients with DSPD each week.Read More
by Steve Storms
It’s Wednesday, “hump” day. For me, this particular Wednesday – March 27, 2013 – marks a more significant “hump” than usual. For today I have been cigarette-free for 365 days.
After all my previous failed attempts at quitting, I have to admit that I had serious doubts that I could succeed. But quitting smoking proved to be easier than I thought it would be, once I really and truly made up my mind to quit.
It’s a cliche, but I will say it anyway: If I can do it, so can you. It takes making a vow to yourself and keeping it. You have to really want it. You have to be serious about it. You have to be strong, very strong. But it’s worth it.
I smoked my first cigarette when I was 12 years old, and smoked for 46 years. For those keeping score, that means the underdog nonsmoking team is still way behind: Smoking Years: 46 – No-Smoking Years: 13.
But the underdog has grit and determination on his side. If I am lucky and blessed, the game will last long enough for me to at least even the score. Only 33 more “humps” to go!
So today, join me in celebrating my one-year smoke-free anniversary. I am more than just a little proud of myself for remaining true to my vow.
Read Steve’s earlier post about his quit-smoking experience for inspiration, and for expert advice from the American College of Chest Physicians, check out the Tobacco Dependence Treatment Tool Kit. This great source of free information for people thinking about quitting or struggling to quit includes “Thinking about Stopping Smoking?” and “You Deserve to Stop Smoking Comfortably.”
Steve Storms works for IBM at Research Triangle Park, North Carolina, and is the team lead for Global Memory Procurement. In his spare time he plays with a Raleigh-based acoustic Americana band, the Gravy Boys.Read More
by Barbara Granner
A few years ago, my friend’s boyfriend had something called a pulmonary embolism – a blood clot in his lung. The only thing I knew about it at the time was that it was scary-sounding and life-threatening.
I have since learned that pulmonary embolism – PE – is a serious complication of deep vein thrombosis – DVT. I have also learned that March is DVT Awareness Month.
DVT awareness deserves its own month. According to the results of an informal poll (mine), most people do not know what DVT is or what PE is, other than another name for gym class. Yet someone dies from PE every six minutes. That’s more people than die each year from breast cancer and AIDS combined. Yikes!
So to help combat this lack of awareness, I present to you: A DVT/PE Primer, based on authoritative information from the American College of Chest Physicians, which has compiled the best available evidence-based recommendations on diagnosing and treating DVT and PE in Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: Evidence-Based Clinical Practice Guidelines.
DVT, or deep vein thrombosis, occurs when a blood clot forms in one of the deep veins, most commonly in the lower leg or thigh. The clot can block blood flow and cause leg swelling, pain, tenderness, and skin discoloration. Or it can be symptomless.
The big danger is that part of the clot can break loose and travel to the lungs – a pulmonary embolism. PE is a medical emergency. If the clot blocks a pulmonary artery or one of its branches, it will prevent oxygen from entering the lungs and can cause death.
DVT/PE is not specific to any age, race, or gender. But there are certain risk factors that make you more susceptible. According to the ACCP, major risk factors include: major surgery, major trauma to the legs and/or pelvis, prolonged bed rest and immobility, cancer, advanced age, hereditary predisposition, and previous venous thrombosis. Other risk factors include estrogen use (oral contraceptives or hormone replacement therapy), pregnancy and post-pregnancy, chronic illness, varicose veins or phlebitis, and obesity.
Airplane travel is another risk factor for venous thrombosis, primarily in travelers who have other risk factors or on flights that are 6 hours or longer. Still, it’s always a good idea when traveling, either by train, plane, or automobile, to stop, stretch your legs, and walk around if possible. And the ACCP recommends that high-risk patients wear elastic compression stockings when flying.
The good news is that most patients do not develop long-term complications and recover completely if they receive proper treatment, which usually consists of taking a “blood-thinner” (anticoagulant medication). In extreme circumstances, such as very large venous thrombosis or pulmonary embolism, “clot-busting drugs” may be used.
So know the symptoms of PE: sudden shortness of breath; sharp, stabbing chest pain that may get worse with deep breaths; rapid heart rate; or unexplained cough, sometimes with bloody mucus. CALL 911 IMMEDIATELY if you experience these symptoms. Luckily, my friend’s boyfriend did.