Mind-body medicine in oncology: "mind matters"- David Spiegel
At the end of the 20th century cancer emerged as the second leading
cause of death in the USA, exceeded only by cardiovascular disease.
Taking into account the emotional and psychological trauma associated
with the disease, and the fact that treatment is often as harsh as the
disease itself, cancer may be second to none in terms of suffering
experienced by those affected. (1) Conventional cancer therapy is
designed to reduce the tumour burden locally by means of surgical
excision and irradiation, and to eradicate primary and metastatic cancer cells by means of systemic chemotherapy. Because of the significant
side-effects of such invasive methods, the emotional trauma of the
diagnosis is often magnified by the physical trauma of these
interventions. Oncology is therefore a specialty practice in which
complementary and alternative approaches may synergistically employed
to reduce the sequelae of the disease itself and to limit the toxicity
of disease management. (1) Mind-body medicine, a major area of
complementary and alternative medicine focuses on the
interactions among the brain, mind, body and behaviour and on the
powerful ways in which emotional, mental, social, spiritual and
behavioural factors can directly affect health (2)
Background CAM refers to diverse medical and health care systems, practices and products that are not currently considered part of conventional medicine and generally have limited scientific evidence. (3) The National Centre for Complementary and Alternative Medicine (2005) suggested 5 categories of CAM: (i) alternative medical systems such as Homeopathy, Naturopathy, as well as culturally based systems such as Traditional Chinese Medicine and Ayurvedic Medicine; (ii) mind-body interventions such as art therapy, music therapy, guided imagery, yoga, prayer and meditation; (iii) biologically based systems such as diet and herbs; (iv) manipulative and body-based practices such as massage and chiropractic manipulation; (v) energy therapies such as Reiki, Qigong and magnets. magnets. (2) Diseases that have the most appeal for CAM therapies are those where conventional medicine has the least impact, such as HIV, chronic pain and cancer. (4) The use of CAM therapies is very high among cancer patients. It has been estimated that up to 83% of patients diagnosed with cancer use CAM, (5) and the incidence appears to be increasing, particularly the use of mind-body-type interventions. (6,7) Those that do not involve taking oral therapy may be perceived as having fewer potential adverse effects or interactions with conventional cancer treatments. Conventional practitioners possibly recommend these options or at least do not discourage patients from using them. (6) Cancer patients expect CAM to offer symptom management, improved quality of life, increased sense of control, hope of lessening the disease process and potential cure. CAM practitioners are also credited for incorporating emotional and overall support into their therapeutic armamentarium this disconnection between patient expectations of their physician and their CAM practitioner fuels the demand for CAM. Integrative medicine is a newly emerging field that strives to combine mainstream medical therapies and CAM therapies for which there are some high-quality scientific evidence of safety and effectiveness. (2) Integrative medicine emphasises relationship-centred care and develops an understanding of the patient's culture and beliefs to help to facilitate the healing process. It focuses on the unique characteristics of the individual person based on the interaction of mind, body, spirit and community, as health and healing are inherently unique to the individual. (1) Integrative medicine is gaining popularity by emphasising health and healing rather than disease and treatment, (4) and healing is always possible even when curing is not. (1) Issues in oncology The diagnosis of a life-threatening illness can be devastating to patients and their families. Patients are confronted with a sense of their own mortality, which often causes acute psychological stress. A significant proportion of cancer patients suffer sufficient emotional stress to qualify for a psychiatric diagnosis, especially anxiety or depression. (8) While disease and treatment exert a heavy physiological toll, accompanying anxiety about diagnosis and prognosis, taxing medical treatments, and disruption of social, vocational and family functioning constitute a series of psychological stressors. (9) Patients diagnosed with cancer have many needs that often include the expectation of cure. Where cure is unlikely there can always be hope and spiritual support. Patients require symptomatic control that encompasses control of this psychological distress. To achieve all of these goals there is a need that goes beyond the role of scientific medicine. (10) Mind-body interventions Evidence from multiple studies with various types of cancer patients suggests that mind-body interventions can improve mood, quality of life and coping, as well as ameliorate disease- and treatment-related symptoms, such as chemotherapy-induced nausea, vomiting and pain. Some studies have suggested that mind-body interventions can alter various immune parameters, but it is unclear whether these alterations are of sufficient magnitude to have an impact on disease progression or prognosis. (2) Meditation as a complementary therapy Meditation, one of the most common mind-body interventions, is a conscious mental process that induces a set of integrated physiological changes termed the relaxation response. (2) The two most widely studied meditation techniques are transcendental meditation and mindfulness-based meditation. Transcendental meditation uses the repetition of a specific mantra with the intent of quieting and ultimately 'transcending' the internal mental dialogue. Mindfulness-based meditation strives to develop an objective observer role, thus creating a non-judgemental mindful state of conscious awareness. (11-13) Studies of meditation as a supportive care in cancer report positive results, including improvements in mood and sleep quality and reduction in stress. (14) Hypnosis and guided imagery Although its mechanisms of action have not been fully characterised, recent neuroimaging studies suggest that hypnotic phenomena are associated with brain activity within brain structures involved in the regulation of consciousness. Hypnosis and guided imagery have potential applications in relieving cancer-related pain and symptom-related distress. (13) In a trial of 58 women with advanced breast cancer. Spiegel et al. demonstrated that supportive group therapy resulted in a statistically significant reduction in pain sensation and suffering over 10 months of follow-up and that the addition of hypnosis provided a further reduction in pain sensation. (15) Guided imagery, hypnosis and relaxation training have been effective in diminishing anticipatory nausea and vomiting in patients receiving chemotherapy, reducing anxiety and distress caused by invasive medical procedures and decreasing pain caused by aversive medical procedures. (16) However, these interventions have not demonstrated efficacy in moderating chronic pain in cancer populations or alleviating post-chemotherapy nausea and vomiting. The continued threat of cancer and pain can perpetuate an existential crisis characterised by feelings of uncertainty, fear of pain and death, and experiences of individual and social suffering. The pain is not necessarily physical but may also involve feelings of being out of control. Guided imagery may provide a vehicle for patients to make sense of their experiences with cancer and may provide a means of repairing this ruptured relationship with the body. (17) Yoga Yoga derives from the Ayurvedic medical system and enables the student to move slowly and safely into the asanas (postures), concentrating initially on relaxing the body, breathing fully, and developing awareness of sensations in the body and thoughts in the mind. (13) Yoga produces the relaxation response characterised by decreased sympathetic and increased parasympathetic activity. (18) Studies have supported its benefits for stress management, anxiety reduction, and insomnia. (13) A small pilot study of yoga in early breast cancer survivors revealed psychological improvements in participants, with a positive impact on mood, quality of life and stress. However, there were no significant physical improvements in the yoga participants versus the controls. (19) A similar pilot study of metastatic breast cancer patients found yoga to be helpful in boosting daily invigoration and a sense of acceptance. There were also trends for improvement in pain and relaxation. (18) No adverse events were related to yoga participation in these small pilot studies. Prayer In a survey of over 31 000 adults 45.2% indicated that they used prayer for health reasons. (20) Prayer is typically viewed as a religious practice, a form of communication between individuals and divine or spiritual beings. Research indicates that prayer is a coping strategy that is often intimate and private, and very important to many patients. (21) It is a valuable resource that can influence one's perception of cancer, (22) and cancer survivors have been found to pray for health more than all other populations without cancer. (23) While it is inconclusive as to whether prayer contributes to physiological healing, there is growing empirical evidence indicating that personal prayer is associated with positive emotional outcomes. (20) Psychosocial interventions Psychosocial interventions span a range of approaches, many involving multiple components such as education regarding cancer and its treatment, provision of emotional support, training in coping skills, challenging unhelpful thoughts and relaxation training. (24) Short-term psychological interventions, particularly those with cognitive behavioural components, improve mood and quality of life in cancer patients. (25) However, the long-term effects of such interventions have not been studied extensively. Some trials have suggested a survival benefit for patients receiving psychosocial interventions, while other trials have found no such benefit. (26-28) Music and art therapy The objectives of music and art therapy are to use the creative process to allow awareness and expression of an individual's deepest emotions. For many years music therapists have served the needs of hospitalised patients by helping to alleviate isolation, anxiety, fear, and sometimes boredom associated with lengthy hospital stays. Studies specific to cancer care have identified pain management, nausea control, and psychosocial concerns, such as depression and anxiety, as targets for music therapy intervention. (29) Art therapy is a clinical intervention based on the belief that the creative process involved in the making of art is healing and life enhancing. It is used to help patients or their families to increase awareness of self, cope with symptoms, and adapt to stressful and traumatic experiences. Some cancer patients may prefer art as they may be uncomfortable with conventional psychotherapy or find verbal expression difficult. Art therapy has been used in a variety of clinical settings and populations, although few studies have explored its use in cancer symptom control. (30) Conclusions In the ever-changing world of cancer care, exploring treatment approaches that are holistic and emphasise the patient's role in the healing process is essential. (31) It is a plausible hypothesis that if a patient feels better and spiritually at ease then the abovementioned approaches may help the physical recovery. Based on the study of several systematic reviews and randomised controlled trials, a number of mind-body interventions may have a role in the management of cancer and cancer treatment-related symptoms. The judicious use of complementary therapies together with conventional therapies within a therapeutic and empathic doctor-patient relationship may also help to ensure that the patient is treated as a whole person. In a nutshell * Up to 83% of patients with cancer diagnoses use CAM. * Integrative medicine emphasises relationship-centred care and develops an understanding of the patient's culture and beliefs to help to facilitate the healing process. * Cancer patients require symptomatic control that encompasses control of their psychological distress. * Evidence from multiple studies with various types of cancer patients suggests that mind-body interventions can improve mood, quality of life and coping, as well as ameliorate disease and treatment-related symptoms, such as chemotherapy-induced nausea and vomiting and pain. * These interventions include meditation, hypnosis and guided imagery, yoga, prayer, psychosocial interventions and music and art therapy. References (1.) Benda W, Grant KL. Integrative approach to cancer. In: Rakel Integrative Medicine. 1st ed. Elsevier, Philadelphia, USA, 2003. (2.) National Center for Complementary and Alternative Medicine. Mind-body medicine: An overview. URL:http://nccam.nih.gov (accessed: May 2007). (3.) Rosenthal DS, Dean-Clower E. Integrative medicine in hematology/oncology: Benefits, ethical considerations, and controversies. Hematology 2005; 491-497. (4.) Penson RT, Castro CM, Seiden MV, Chabner BA, Lynch TJ. Complementary, alternative, integrative, or unconventional medicine? Oncologist 2001; 6: 463-473. (5.) Richardson MA, Sanders T, Palmer JL, Greisinger A, Singletary SE. Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol 2000; 18: 2505-2514. (6.) Boon H, Olatunde F, Zick S. Trends in complementary/alternative medicine use by breast cancer survivors: Comparing survey data from 1998 and 2005. BMC Women's Health 2007; 7: 4. (7.) Chong O. An integrative approach to addressing clinical issues in complementary and alternative medicine in an outpatient oncology center. Clin J Oncol Nursing 2005; 10(1): 83-88. (8.) Blake-Mortimer J, Gore-Felton C, Kimerling R, Turner-Cobb JM, Spiegel D. Improving the quality and quantity of life among patients with cancer: A review of the effectiveness of group psychotherapy. Eur J Cancer 1999; 35(11): 1581-1586. (9.) Sephton SE, Sapolsky RM, Kraemer HC, Spiegel D. Diurnal cortisol rhythm as a predictor of breast cancer survival. J Natl Cancer Inst 2000; 92: 9941000. (10.) Baum M, Cassileth BR, Daniel R, et al. The role of complementary and alternative medicine in the management of early breast cancer: Recommendations of the European Society of Mastology (EUSOMA). Eur J Cancer 2006; 42: 1711-1714. (11.) Tac[acute accent]on AM. Meditation as a complementary therapy in cancer. Family and Community Health 2003; 26(1): 64-73. (12.) Carlson LE, Speca M, Patal KD, Goodey E. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosom Med 2003; 65: 571-581. (13.) Mansky PJ, Wallerstedt DB. Complementary medicine in palliative care and cancer symptom management. Cancer J 2006; 12(5): 425-431. (14.) Smith J, Richardson J, Hoffman C, Pilkington K. Mindfulness-based stress reduction as supportive therapy in cancer care: Systematic review. J Adv Nurs 2005; 52(3): 315-327. (15.) Spiegel D, Bloom JR, Yalom I. Group support for patients with metastatic cancer. A randomized outcome study. Arch Gen Psychiatry 1981; 38(5): 527-533. (16.) Redd WH, Montgomery GH, DuHamel KN. Behavioral intervention for cancer treatment side effects. J Natl Cancer Inst 2001; 93: 810-823. (17.) Moore R, Spiegel D. Uses of guided imagery for pain control by African-American and white women with metastatic breast cancer. Integrative Medicine 1999; 2: 115-126. (18.) Carson JW, Carson MK, Porter LS, Keefe FJ, Shaw H, Miller JM. Yoga for women with metastatic breast cancer: Results from a pilot study. J Pain Symptom Manage 2007; 33: 331-341. (19.) Culos-Reed SN, Carlson LE, DaRoux LM, Hately-Aldous S. A pilot study of yoga for breast cancer survivors: Physical and psychological benefits. Psychooncology 2006; 15: 891-897. (20.) Taylor EJ. Spiritual complementary therapies in cancer care. Sem Oncol Nurs 2005; 21(3): 159-163. (21.) Taylor EJ, Outlaw FH, Bernardo TR, Roy A. Spiritual conflicts associated with praying about cancer. Psychooncology 1999; 8: 386-394. (22.) Meraviglia M. Prayer in people with cancer. Cancer Nurs 2002; 25(4): 326-331. (23.) Mao JJ, Farrar JT, Xie SX, Bowman M, Armstrong K. Use of complementary and alternative medicine and prayer among a national sample of cancer survivors compared to other populations without cancer. Complement Ther Med 2007; 15: 21-29. (24.) Stanton A. Psychosocial concerns and interventions for cancer survivors. J Clin Oncol 2006; 24: 51325137. (25.) Edmonds CVI, Lockwood GA, Cunningham AJ. Psychological response to long term group therapy: A randomized trial with metastatic breast cancer patients. Psychooncology 1999; 8: 74-91. (26.) Cunningham AJ, Edmonds CVI, Jenkins GP, Pollack H, Lockwood GA, Warr D. A randomized controlled trial on the effects of group psychological therapy on survival in women with metastatic breast cancer. Psychooncology 1998; 7: 508-517. (27.) Kuchler T, Mestmann B, Rappat S, Henne-Bruns D, Wood-Dauphinee S. Impact of psychotherapeutic support for patients with gastrointestinal cancer undergoing surgery: 10-year survival results of a randomized trial. J Clin Oncol 2007; 25: 27022708. (28.) Spiegel D, Bloom JR, Kraemer HC, et al. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 1989; 2: 888-891. (29.) Kruse J. Music therapy in United States cancer settings: Recent trends in practice. Music Therapy Perspectives 2003; 21(2): 89-98. (30.) Nainis N, Paice JA, Ratner J, Wirth JH, Lai J, Shott S. Relieving symptoms in cancer: Innovative use of art therapy. J Pain Symptom Manage 2006; 31: 162-169. (31.) Abdallah-Baran R. Nurturing spirit through complementary cancer care. Clin J Oncol Nurs 2003; 7(4): 468-470. SYLVIA RODRIGUES, MB ChB, BSc (Hons), MPharmMed, MPhil (Pall Med), FCRadOnc Oncologist, Gauteng Oncology, Union Hospital, Alberton Source : SA Journal CPD Link to Full Article |
|
