Integrative oncology: Addressing the global challenges of cancer prevention and treatment

The increase in cancer incidence and mortality is challenging current cancer care delivery globally, disproportionally affecting low- and middle-income countries (LMICs) when it comes to receiving evidence-based cancer prevention, treatment, and palliative and survivorship care. Patients in LMICs often rely on traditional, complementary, and integrative medicine (TCIM) that is more familiar, less costly, and widely available. However, spheres of influence and tensions between conventional medicine and TCIM can further disrupt efforts in evidence-based cancer care. Integrative oncology provides a framework to research and integrate safe, effective TCIM alongside conventional cancer treatment and can help bridge health care gaps in delivering evidence-informed, patient-centered care. This growing field uses lifestyle modifications, mind and body therapies (eg, acupuncture, massage, meditation, and yoga), and natural products to improve symptom management and quality of life among patients with cancer. On the basis of this review of the global challenges of cancer control and the current status of integrative oncology, the authors recommend: 1) educating and integrating TCIM providers into the cancer control workforce to promote risk reduction and culturally salient healthy life styles; 2) developing and testing TCIM interventions to address cancer symptoms or treatment-related adverse effects (eg, pain, insomnia, fatigue); and 3) disseminating and implementing evidence-based TCIM interventions as part of comprehensive palliative and survivorship care so patients from all cultures can live with or beyond cancer with respect, dignity, and vitality. With conventional medicine and TCIM united under a cohesive framework, integrative oncology may provide citizens of the world with access to safe, effective, evidence-informed, and culturally sensitive cancer care.     

Consumer health information: the role of breast cancer associations

Background. Providing information for patients is currently a growth need for health professionals, medical journals, and consumer associations. Despite several patients or consumers associations being active in Italy, scarce evidence is available on the volume and type of activities carried out. A national survey was carried out to investigate the volume and the nature of phone requests for information addressed to associations belonging to the Italian Forum of EUROPA DONNA, an European movement active in 28 countries, working to raise public awareness of breast cancer. Methods. A structured questionnaire was sent to all EUROPA DONNA breast cancer associations to be filled in by the persons in charge for delivering the telephone information. Results. Of the 87 breast cancer associations contacted, 41 (47%) participated to the survey, completing a total of 2383 questionnaires for 4251 kinds of information. Most of the people who called were women and about 57% were breast cancer patients. A wide range of information were required: 29% on prevention, 22% on practical problems of daily life, 23% on services actually offered by breast cancer associations, 10% on psychological counselling, and finally 14% for advice on primary therapy and follow-up. In more than one-third of phone calls, people were looking for opinion from women who personally experienced a breast cancer. Conclusion. This survey shows that breast cancer associations receive daily requests of information and convey a wide range of information. The findings underline the need to create meaningful partnership between health professionals and patient's associations in the complex field of information and communication.     

Use of formal and informal mental health resources by cancer survivors: differences between rural and nonrural survivors and a preliminary test of the theory of planned behavior

Objective: Previous research has identified rural residence as a risk factor for poorer mental health (MH) outcomes in cancer survivors. This may be due to less use of various MH resources due to poorer access and less favorable attitudes and social norms related to MH resource utilization. The present study sought to examine use of MH resources in rural and nonrural survivors and identify factors associated with MH resource use. Methods: Cancer survivors (n=113, 1–5 years postdiagnosis) completed a questionnaire packet and telephone interview. Accessibility and postdiagnosis use of various formal and informal MH resources were assessed along with constructs potentially linked to use of MH resources by the Theory of Planned Behavior (TPB; personal attitude, social norm, perceived behavioral control). Results: Results indicated no widespread differences between rural and nonrural cancer survivors in MH resource use although some evidence suggested poorer accessibility and less use of mental health professionals and cancer support groups among rural survivors. In general, rural survivors reported less favorable personal attitudes and social norms regarding MH resource use. TPB constructs accounted for a significant portion of variance in use of most MH resources with personal attitudes generally being the strongest predictor of MH resource use. Conclusions: Additional research is needed to expand the search for factors, particularly modifiable factors, which might account for disparities in MH outcomes between rural and nonrural survivors. Copyright © 2009 John Wiley & Sons, Ltd.     

Men with cancer change their health behaviour: a prospective study from the Danish diet, cancer and health study

Background:

Health behaviour changes may improve the quality of life and survival among cancer survivors. We prospectively examined changes in health behaviour among and between men with prostate cancer (PC), men with cancers other than PC and cancer-free men.

Methods:

We analysed data for 20 914 men (50–65 years), 426 with cancer, and 20 488 persons who were cancer-free between baseline (1993–1997) and follow-up (2000–2002) in multiple linear regression models to determine differences in changes in body mass index (BMI) and in alcohol and tobacco consumption.

Results

Body mass index and tobacco and alcohol consumption decreased significantly (P<0.001) between baseline and follow-up among both men with cancer and cancer-free men. Men with cancers other than PC significantly decreased their BMI (β=−058; 95% confidence interval (CI): −0.77, −0.40) and tobacco consumption (β=−1.36; 95% CI: −2.22, −0.49) compared with cancer-free men and were significantly more likely to quit smoking and lose weight.

Conclusion:

Men with cancers other than PC decreased their tobacco consumption and BMI significantly more than cancer-free men. Men with cancer do change their health behaviour; clinicians should take this into account in planning follow-up care for cancer survivors.     

Global patterns of cancer transitions: A modelling study

Cancer is a major contributor to global disease burden. Many countries experienced or are experiencing the transition that non-infection-related cancers replace infection-related cancers. We aimed to characterise burden changes for major types of cancers and identify global transition patterns. We focused on 10 most common cancers worldwide and extracted age-standardised incidence and mortality in 204 countries and territories from 1990 to 2019 through the Global Burden of Disease Study. Two-stage modelling design was used. First, we applied growth mixture models (GMMs) to identify distinct trajectories for incidence and mortality of each cancer type. Next, we performed latent class analysis to detect cancer transition patterns based on the categorisation results from GMMs. Kruskal-Wallis H tests were conducted to evaluate associations between transition patterns and socioeconomic indicators. Three distinct patterns were identified as unfavourable, intermediate and favourable stages. Trajectories of lung and breast cancers had the strongest association with transition patterns among men and women. The unfavourable stage was characterised by rapid increases in lung, breast and colorectal cancers alongside stable or decreasing burden of gastric, cervical, oesophageal and liver cancers. In contrast, the favourable stage exhibited rapid declines in most cancers. The unfavourable stage was associated with lower sociodemographic index, health expenditure, gross domestic product per capita and higher maternal mortality ratio (P < .001 for all associations). Our findings suggest that unfavourable, intermediate and favourable transition patterns exist. Countries and territories in the unfavourable stage tend to be socioeconomically disadvantaged, and tailored intervention strategies are needed in these resource-limited settings.     

Reassurance and the anxious cancer patient

Many cancer patients are anxious even when disease is in remission. Anxiety about health, 'health anxiety', has distinct features, notably seeking medical reassurance about symptoms. Doctors may then communicate that these symptoms are not due to serious illness, a process known as 'reassurance'. However, reassurance may inadvertently perpetuate some patients' anxiety. We aimed to observe the relation between symptoms, anxiety and reassurance in consultations with cancer patients. A total of 95 outpatients, with breast or testicular cancers in remission, completed questionnaires measuring health anxiety at study entry, then general anxiety - before a consultation, immediately afterwards, 1 week later, and before their next consultation. We examined symptoms reported and reassurance by oncologists from audio recordings of consultations, and the outcome of subjects' anxiety. The results showed that substantial health anxiety was reported by one-third of the patients. Patients with higher levels of health anxiety reported more symptoms during consultations. Reassurance was ubiquitous, but not followed by an enduring improvement in anxiety. Certain forms of reassurance predicted increased anxiety over time, particularly for subjects who were most anxious. In conclusion, health anxiety can be a problem after cancer. Reassurance may not reduce patients' anxiety. Some reassurance was counterproductive for the most anxious patients. Oncologists may need to use reassurance as a procedure, balancing risk, and benefits, and patient selection and to manage cancer patients in remission.     

Defining and investigating social disparities in cancer: critical issues

Research and action to address social disparities in cancer requires clarity about what constitutes and causes these persistent and onerous inequities in health. Currently, both scientific literature and government documents exhibit important disagreements, confused terminology, and considerable, if not deliberate, vagueness about the meaning of the phrase cancer disparities and the related term social disparities in health. This article accordingly reviews critical issues relevant to cohering understanding of what is meant by cancer disparities; offers a definition premised on the causal contention that social disparities in health, by definition, arise from social inequity; and considers its implications for developing a multidisciplinary research agenda on social inequalities in cancer. Tackling this issue will require rigorous and critical frameworks, questions, and methods derived from multiple disciplines, and will necessarily involve epidemiologic, clinical, and intervention research, both quantitative and qualitative. At issue is making conscious research choices: about which types of disparities we study, in relation to which aspect of cancer, so as to improve the likelihood our research will help inform a society-wide discourse about the extent, origins of, and remedies for social injustices in cancer, thereby aiding efforts to eliminate social inequalities in health. Financial support: This work was supported in part by the Dana Farber/Harvard Cancer Center (DF/HCC) Cancer Disparities program-in-development.     

Social inequities along the cervical cancer continuum: a structured review

ObjectiveTo reveal areas of research/knowledge related to social inequities and cervical cancer. Methods: A Medline search was performed looking for US based research on cervical cancer and social inequities since 1990. The papers found were organized into cells defined by a cancer disparities grid. Results: The majority of research published about cervical cancer and social inequities in the US, lies within the social domains of: race/ethnicity and socioeconomic position. Conflicting information exists as to whether race/ethnicity is a good predictor of screening and survival. Some research implied that differentials based on race/ethnicity are likely secondary to differentials in socioeconomic position. Some research about age, insurance status, and immigrant status and cervical cancer was found. Scarce information was found relating to sexuality, language, disability and geography and cervical cancer. Discussion: The cancer disparities grid facilitated a systematic and visual review of existing literature on social inequities and cervical cancer. The grid helped to elucidate uncontested existing social inequities, conflicting social inequities, and areas where social inequity data does not exist. The cancer disparities grid can be used as a research tool to help identify areas for future research, clinical programs, and political action related to cervical cancer and social inequities.Address correspondence to: Sara J. Newmann MD, MPH, 15 Massachusetts General Hospital, Vincent Gynecology and Obstetrics, 55Fruit Street, Boston, MA 02114, USA.     

Health literacy and the provision of information to women with breast cancer

Aims

Health literacy and functional health literacy are important for patients with cancer, as key information regarding treatment complications and clinical trials is often imparted using written educational material. This study measured the health literacy and functional health literacy levels in a population of women with breast cancer and compared these with the level of written information provided.

Materials and methods

A cross-sectional survey of women with stage I-III breast cancer attending an outpatient clinic was conducted. Health literacy levels were assessed using the Rapid Estimate of Adult Literacy in Medicine (REALM) score and functional health literacy was assessed using three validated screening questions. Patient education materials were assessed using the Simple Measure of Gobbledygook (SMOG) and Flesch Reading Ease (FRE) systems.

Results

One hundred and twenty-seven women were recruited. For patients, the mean REALM score was 64.3 (≥US 9th grade/reading age 14 years). The mean SMOG score of patient education materials was 80.5 (reading age 17 years). The mean FRE score of patient education materials was 55.7 (reading age 15-17 years). All patient information sheets assessed were written at ≥8th grade (reading age 13 years) and as a result up to 9% of patients would be unable to read them. Nineteen per cent of the population had inadequate functional health literacy.

Conclusions

Health literacy levels were high in the population studied. However, the reading level of written patient information was also high, meaning that up to 9% of patients would be unable to read the information provided. Functional health literacy levels were lower, with 19% of patients having inadequate ability. This means that although most patients are able read the information sheets provided, there is a larger proportion that would be unable to understand and act upon this information. Patient education materials should be written at an appropriate level and different modalities of communication should be used to ensure adequate comprehension.     

Improving the health and well-being of cancer survivors: past as prologue

During the past two decades, there have been a number of unsuccessful replication attempts of our finding that group psychotherapy improves cancer survival. One explanation for this failure is that the wrong phenomenon has been studied. Rather than focusing on the effects of the psychotherapeutic relationship, perhaps, the focus should have been on the social support provided and networks developed by these groups. Since the late 1970s, a growing body of research indicates the importance of social networks and social support on reductions in not only all cause mortality, but also disease specific mortality including cancer. We have learned about how the health, well-being, and ultimate survival of cancer patients is improved by social support and social networks. The social milieu within which we live can provide resources that facilitate reintegration into society. These resources at the individual level, such as one's perception of social and emotional support, at the level of one's social ties with family and friends, and at the community level appear to improve survival across disease conditions including cancer. Even though, the mechanisms by which these endpoints are achieved remain elusive, there is much that can be done. The challenge of our time is to translate what we already know into programs to improve quality of life and to focus research toward increasing our understanding the mechanisms.     

Understanding and addressing social determinants to advance cancer health equity in the United States: A blueprint for practice,research, and policy

Although cancer mortality rates declined in the United States in recent decades, some populations experienced little benefit from advances in cancer prevention, early detection, treatment, and survivorship care. In fact, some cancer disparities between populations of low and high socioeconomic status widened during this period. Many potentially preventable cancer deaths continue to occur, and disadvantaged populations bear a disproportionate burden. Reducing the burden of cancer and eliminating cancer-related disparities will require more focused and coordinated action across multiple sectors and in partnership with communities. This article, part of the American Cancer Society's Cancer Control Blueprint series, introduces a framework for understanding and addressing social determinants to advance cancer health equity and presents actionable recommendations for practice, research, and policy. The article aims to accelerate progress toward eliminating disparities in cancer and achieving health equity.     

Disparities in mental health between rural and nonrural cancer survivors: a preliminary study

Objective: While much research has sought to identify disparities in cancer incidence, survival, and treatment, little research has sought to identify disparities in mental health (MH) outcomes among cancer survivors. The present study aims to identify disparities in MH outcomes between rural and nonrural cancer survivors. Methods: Cancer survivors who met eligibility criteria were identified through the Kentucky SEER Cancer Registry. Rural status was determined by 2003 USDA Rural–Urban Continuum Codes. 116 (n=54 rural, 62 nonrural) survivors with diagnoses of breast (n=42), hematologic (n=39), or colorectal (n=35) cancer completed mail‐back questionnaires and/or a telephone interview. Results: Rural cancer survivors reported poorer MH functioning (effect size (ES)=0.45 SD), greater symptoms of anxiety (ES=0.70) and depression (ES=0.47), greater distress (ES=0.41), and more emotional problems (ES=0.47) than nonrural cancer survivors. Rural and nonrural cancer survivors did not differ consistently in regard to positive MH outcomes, such as benefit finding. The pattern of results was maintained when adjusted for education and physical functioning. Conclusions: Clinically important disparities in MH outcomes were evident between rural and nonrural cancer survivors. Interventions aimed at raising access and utilization of MH services may be indicated for cancer survivors in rural areas. Copyright © 2009 John Wiley & Sons, Ltd.     

Fear of cancer and older people's beliefs about cancer treatment in Poland

Throughout Europe and the United States, more than 60% of all cancer incidents occur in older people. Therefore, the aim of this study was to understand the level of fear people have regarding cancer and older people's beliefs about cancer pain, cancer treatment, and the curability of cancer. We conducted a survey in 2012, in which the sample was comprised of 910 adult residents of Wroclaw, Poland, to ascertain the beliefs people have about cancer and the degree of fear people have with respect to cancer. The majority of the respondents reported having a high level of fear, and this level of fear increased with age. Moreover, the oldest people (65 years and above) expressed fatalistic beliefs with respect to cancer. Our observations may guide health promotion campaigns and cancer prevention programs.     

Social disparities and prostate cancer: mapping the gaps in our knowledge

To evaluate the current state of our knowledge regarding social disparities and prostate cancer and to map the domains where substantial knowledge has been acquired as well as those where little is known, with the purpose of identifying important areas for future research.A Medline research was conducted to identify published papers regarding social disparities in prostate cancer since 1990. The results of this review are presented in a social disparities and prostate cancer grid designed to highlight which domains of social disparities have been researched and which neglected.The major social disparity in prostate cancer concerns the extremely high prostate cancer incidence and mortality seen among black Americans. This is also the area where the most research has been performed. Low socioeconomic position is associated with poorer prostate cancer outcomes but not with higher prostate cancer incidence. It remains poorly defined to what extent racial/ethnic differences in prostate cancer result from differences in socioeconomic position (SEP). Understanding the causes of the high prostate cancer mortality seen among black men remains the major challenge in the area of social disparities and prostate cancer.