Integrated health in cancer care

Ten million people a year in the world are diagnosed as having cancer.  For many it will be the first time they face a life threatening disease with a high level of uncertainty in terms of outcome.  Integrated medicine (IM) interventions of many types have become increasingly popular with patients.   Surveys have shown that, in NHS centres where complementary therapy packages are offered, up to 70% of women and 40% of men with cancer are taking some form of complementary or alternative therapy. 

Some of these are simple and cheap – a limited number of weekly group therapy sessions – whilst others, involving prolonged one to one professional contact, are more costly and realistically can only be used selectively.  Practitioners often work in isolation and provide just a single modality rather than a holistic service. There are many options available but very little true integration around the needs of an individual person living with cancer. 

Supportive therapies

There is very little research in this area.  Most of the literature is anecdotal.  A further problem is the multiplicity of treatments often given by dedicated but single modality practitioners.  In 1982, the Bristol Cancer Help Centre (now Penny Brohn Cancer Care), was founded to pioneer the use of a wide range of complementary therapies for cancer.  The initial approach was to provide an alternative to conventional care but over the last two decades the centre has moved to a truly integrative approach.  This has spawned out into various conventional cancer centres in both the NHS and private sectors.

Two leading groups are at Hammersmith Hospital and the Harley Street Clinic. In both centres an integrated approach with six sessions of therapy offered as part of routine radiotherapy or chemotherapy. The aim of these hospital based programmes is to give the patient psychological and physical support during a time of stress.  This may allow patients to withstand some of the toxicities of conventional therapy so enhancing their chances of survival. IM is not used as an alternative to conventional medical care.

Simple low cost strategies are currently prominent.  These include counselling in which the patient’s hidden fears and anxieties are explored more fully not in the context of the disease but in the context of the whole person.  Modern cancer treatment is essentially mechanistic and a more personal approach helps many people.  Cancer support groups have been around for many years.  Even in waiting areas patients share their fears and anxieties and get relief from doing so.  A properly run patient support group with a professional counsellor is of great help.  Clearly patients have to be willing to go.  A good facilitator avoids repeated discussion of specific individual symptoms and encourages contributions from the less vocal members of the group. 

Treatment with radiotherapy and chemotherapy is not always pleasant and there is the additional worry that the disease will not be cured or that palliation will only be obtained with considerable side effects.  Relaxation in a quiet room with an experienced therapist enables patients to get through their treatment more easily.  The visualisation of healing images is also helpful to many patients who can see radiation and drugs as a powerful and destructive force to attack their cancer.

Modern medicine often uses military metaphors such as waging a war on cancer destroying it with magic bullets, guided missiles, targeted drugs and trying to avoid collateral damage.   Whilst such metaphors may be helpful to patients, getting to a level of acceptance of their disease and to healing is far more challenging.   IM can help with this.  The boutique of  complementary therapies below is often offered:

• Counselling
• Acupuncture
• Homeopathy
• Herbalism
• Naturopathy
• Meditation
• Visualization
• Relaxation 
• Reflexology 
• Massage
• Osteopathy
• Hypnotherapy
• Nutritional support

Surprisingly, certain complementary therapies are already covered within the NHS.  There is no evidence that homeopathy is of more value in cancer treatment than other complementary therapies, yet several outlets exist for a free homeopathic consultation and treatment at British hospitals.  There needs to be a rethinking of funding to a more balanced format allowing other modalities to be offered side by side with orthodox care.  The cost of providing IM support is only a fraction of that used for cancer treatments, many of which are still given in situations where they have little benefit.  Diverting resources to supportive care could provide a new realism for modern healthcare and promote real patient empowerment.

Those involved in delivering the softer side of cancer care tend not to be very hard-nosed about business decisions but health economics is becoming an increasingly used policy tool in rich and poor healthcare environments alike.  Although we may sometimes find it uncomfortable, professionals ration medical care delivery all the time often without realising it.  Robust economic analysis allows us to do the job better without imposing our own prejudices, values and baggage.

Research

Understanding the costs and benefits of IM requires three inputs.  Firstly what is the delivery cost involved?   90% of this is for professional salaries, which are easy to determine within a defined environment.  The second question is how much benefit in terms of quality of life gain is actually delivered.  Measuring quality of life is not an exact science but reasonably reliable and validated instruments are available.  Some believers and indeed randomised controlled trials, already suggest that simple psychological interventions can bring about a modest survival improvement in cancer patients but the studies have been mostly inadequately powered for the purposes of economics.  The third and perhaps most difficult factor to assess accurately is how much money does effective intervention save the medical care system, the patient and society.

Medical care forms only part of the overall financial equation.  Indirect cancer related costs to the patient include loss of earnings, travel and accommodation and the need for carers to take time off their work.  These are far more difficult costs to estimate and vary enormously by socio-economic grouping.   Can IM get patients back to work faster and more effectively?  Probably so, but what does this really mean financially.   The price tag for society in supporting distressed, depressed and in some cases disturbed cancer patients is impossible to assess.  Marital breakdown, family disintegration and mental illness in carers can all be part of this price.  Of course the potential for financial saving goes into many different pockets so estimating the reduction in overall medical care costs is a good place to start for future research.

Conclusion

The rise in the popularity of complementary and alternative medicines for cancer reflects in part the inability of orthodox medicine to deliver what people want – hope in a caring environment with the increased ability to cope with the stress caused by the disease.  The internet now lists over three hundred million cancer sites.  Agency relationships in which healthcare professionals act as the patient’s agent making decisions on complex technical matters such as the benefits of different types of adjuvant chemotherapy have increasingly put the patient more fully in the driving seat.  Different people respond differently to these approaches and find the information bewildering and are not able to assimilate the options.  Others get confused and frightened and are pushed further into denial.  Good IM is rapidly becoming an essential tool in cancer care as the technical options increase and the patient plays a greater role in their choice of care.