Clinical Practice Guidelines for the management of locally advanced ...

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8 COMPLEMENTARY AND ALTERNATIVE (UNPROVEN) THERAPIES 8.1 Definitions Complementary medicine Complementary medicine is any intervention that is used in conjunction with standard western health practices. Integrative medicine Integrative medicine is an approach that combines standard western health interventions and evidence based complementary medicines. For example: the use of a course of relaxation therapy in conjunction with standard radiotherapy or chemotherapy regime to reduce stress anxiety. Alternative medicine Alternative medicine is an intervention or product offered as an alternative treatment to standard western medical practices. (Source: Clinical Oncological Society of Australia CAM Definitions www.cosa.org.au) The use of complementary and alternative (or unproven) medicine (CAM) has continued to increase. In 2004 it was reported that 52.2% of the Australian population used CAM. 1 In North America the reported prevalence of CAM usage in prostate cancer lies between 18 and 45%. 2 It is important that clinicians know about their patient's current and proposed CAM use as some CAM therapies can interfere with other therapies. However, a survey of patients using both conventional and complementary therapies found that many patients do not inform their doctor of their CAM use because they were not asked and because they did not see it important for the doctor to know. 3 To gain a comprehensive picture of CAM use and thus avoid possible adverse interactions it is important that all patients be carefully questioned as to their current or proposed usage of CAM agents in a supportive, understanding and non-judgmental way. 4, 5 Schofield et al 5 provides recommendations and suggestions on how to discuss CAM usage. Their systematic review revealed that there is no level IV or higher evidence for communicating about CAM with cancer patients. As a result their recommendations are based on a systematic review of descriptive studies of, a review of generic communication skills and expert opinion. Recommendation Health professionals should ask their patients about their use of CAM therapies in a supportive, understanding and non-judgmental way. Grade D While there have been numerous reports on the level of CAM usage in men with prostate cancer, there are limited studies on the factors motivating them to use it. One study 2 hypothesised that users of CAM did not assess conventional and non-conventional treatments in the same way as non-users. CAM users perceived CAM to be safer than conventional treatments and showed greater concern for side effects of conventional therapy such as impotence. Non-users of CAM questioned its validity, perceived conventional care as ’curing‘ cancer and were more accepting of possible side effects such 105 Complementary and alternative therapies
as impotence and secondary cancers. They had more definite views on the benefits flowing from conventional medicine and trusted their doctors more fully. A prospective study 6 involving 111 men noted that those who used CAM were more uncertain about prostate cancer and its treatment than men who chose to follow the conventional therapy route. However it was noted that CAM users were less distressed than non-users after a year of treatment. In general there are two large areas of therapy for advanced prostate cancer under the CAM umbrella: touch therapies (eg Reiki, massage, acupuncture and mind–body interventions) dietary interventions (eg dietary modifications, vitamin and herbal supplements). There are no randomised controlled trials (RCTs) examining the benefit of touch therapies in prostate cancer and so these are not discussed further in this chapter. A wide range of products has been offered for the treatment of prostate cancer. While there is an increasing number of RCTs investigating the use of dietary interventions for treating cancer, the general rigour of such trials is frequently deficient or of poor quality. This feature, however, is not limited to CAM studies. 7 Quality of life was not measured formally in any of the studies found. The following summary describes the RCTs that met the criteria for inclusion in these guidelines. Only four dietary interventions have been subjected to RCTs that were completed and were not part of a chemotherapy-centred regimen. (see also section 2.3 Effect of diet and lifestyle interventions on quality of life, p7) CAMs showing potential were high-dose vitamin D (calcitriol), lycopene, ellagic acid, and the dietary supplement verum. Lycopene is a carotenoid and is claimed to be a quencher of free radicals and an immunomodulator. Ellagic acid, a polyphenol extracted from Punica Granatum (pomegranate) seeds may have pro-apoptotic and anti-oxidant properties. Verum is a dietary supplement that contains selenium, carotenoids and other putative prostate cancer inhibitors. The role of vitamin D in treating cancer is not fully understood. It may block cancer cell proliferation or improve immune system function, however, further research is needed to clarify this association. Folinic acid forms part of some chemotherapy regimens and therefore is not included under CAM. Another trial 8 was planned to evaluate the efficiency of PC-SPECS, a herbal conglomerate, with that of diethylstilbestrol (DES) in a crossover study in patients with androgen-independent prostate cancer. This study was discontinued because the researchers found traces of DES in four samples of PC- SPECS. Further studies by the California Department of Health found contamination with warfarin, alprazolam and DES. These observations highlight the need for investigators to ensure the purity of herbal cocktails they are using. In a small, low powered study, Ansari et al compared lycopene with orchidectomy against orchidectomy alone among 54 patients with advanced prostate cancer. 9 Patients in the lycopene and orchidectomy arm had a statistically significant increased survival as compared with the group who had orchidectomy alone (p
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Clinical Practice Guidelines for th
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4 Biochemical relapse .............
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FOREWORD The management of prostate
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SUMMARY OF CLINICAL PRACTICE RECOMM
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SUMMARY OF RECOMMENDATIONS Chapter
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Chapter Recommendations Grade Refs
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1 INTRODUCTION 1.1 Natural history
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2 PSYCHOSOCIAL CARE The diagnosis a
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2.2 Effect of psychological and cog
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Evidence summary Level References T
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Recommendation Men with advanced pr
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An Australian cross-sectional study
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10. Dunn J, et al. A review of peer
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41. Sharpley CF, Christie DRH. An a
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different treatments from different
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Evidence summary Level References I
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Evidence summary Level References F
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Despite these reservations and the
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For non-metastatic disease there we
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Evidence summary Level References T
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monotherapy for low-to-intermediate
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Evidence summary Level References M
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for surgery, suggesting that surger
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Microscopic fully resected node pos
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All three trials demonstrated impro
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Evidence summary Level References B
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of an international multicentre ran
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45. Melton LJ, III, Alothman KI, Kh
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76. Little DJ, Kuban DA, Levy LB, Z
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105. Thompson IM, Tangen CM, Parade
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4.2 Androgen deprivation therapy (e
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Evidence summary Level References F
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therapy since such studies would be
Page 74 and 75: apparent in trials comparing CAB wi
Page 76 and 77: QLQ instrument published by Cleary
Page 78 and 79: Note: Larger well-powered studies h
Page 80 and 81: Eight trials examined acute toxicit
Page 82 and 83: half of patients experienced pain r
Page 84 and 85: olus) in addition to radiotherapy a
Page 86 and 87: References 1. Seidenfeld J, Samson
Page 88 and 89: Cooperative Group. Scandinavian Jou
Page 90 and 91: Oncology Group, TROG 96.05). Radiot
Page 92 and 93: trial. European Journal of Cancer 1
Page 94 and 95: 6 CASTRATION-RESISTANT PROSTATE CAN
Page 96 and 97: the median overall survival for pat
Page 98 and 99: There are two points regarding bisp
Page 100 and 101: with bone pain at study entry. At n
Page 102 and 103: Recently, there have been reports o
Page 104 and 105: of these studies 56, 58 and in the
Page 106 and 107: Side effects (toxicity) As these ra
Page 108 and 109: hydrocortisone respectively. Tannoc
Page 110 and 111: 5. Manikandan R, Srirangam SJ, Pear
Page 112 and 113: 33. Elomaa I, Kylmala T, Tammela T
Page 114 and 115: 60. Janknegt RA, Abbou CC, Bartolet
Page 116 and 117: physiotherapists, occupational ther
Page 118 and 119: 7.5 Q2: Symptom control There was e
Page 120 and 121: Informal or family caregivers deriv
Page 122 and 123: 8. Hughes SL, Weaver FM, Giobbie-Hu
Page 126 and 127: corresponding benefit in obstructiv
Page 128 and 129: 3. Eisenberg DM, Kessler RC, Van Ro
Page 130 and 131: areas of the state were more likely
Page 132 and 133: 8 Miller DC, Litwin MS, Bergman J,
Page 134 and 135: 10 EMERGING THERAPIES It is impossi
Page 136 and 137: APPENDIX 1 GUIDELINE DEVELOPMENT PR
Page 138 and 139: study type. Studies published befor
Page 140 and 141: Grade of recommendation Description
Page 142 and 143: 2. National Health and Research Cou
Page 144 and 145: Dr Carole Pinnock AM Principal rese
Page 146 and 147: Surgery Professor Villis Marshall A
Page 148 and 149: APPENDIX 3 TNM CLASSIFICATION OF PR
Page 150 and 151: Summary Prostate T1 T2 T3 T4 N1 M1a
Page 152 and 153: APPENDIX 4 ABBREVIATIONS AND GLOSSA
Page 154 and 155: Glossary Actuarial survival A metho
Page 156 and 157: Effectiveness The extent to which a
Page 158 and 159: Lymph nodes Small, generally pea-si
Page 160 and 161: Each stage is divided into subgroup
Page 162 and 163: APPENDIX 6 - ORGANISATIONS WHICH PR
Page 164 and 165: Consultant Urologist, Royal Brisban
Page 166 and 167: No conflict of interest to declare.
Page 168 and 169: Index to Clinical practice guidelin
Page 170 and 171: cardiovascular mortality 19, 54, 55
Page 172 and 173: androgen deprivation therapy (ADT)
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and surgery 32-34 survival 18 toxic
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and chemotherapy 89-90 see also bon
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spinal cord compression 62-63 see a
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systemic 141 Tasmania Association f
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