Impact of the Integrative Oncology Scholars Program on Oncology Providers' Key Knowledge of Dietary Supplements and Antioxidants for Providing Evidence-based Oncology Care.

Dietary supplements are commonly used among cancer survivors. Oncology providers rarely receive training about dietary supplements. We evaluated whether e-learning modules could improve oncology providers' dietary supplement knowledge. Oncology providers participated in the National Cancer Institute funded Integrative Oncology Scholars (IOS) program. We used posttest readiness assurance tests (RAT) to measure knowledge acquisition from modules. One cohort completed a pre and posttest RAT to assess change in knowledge. Multivariate linear regression models adjusted for gender, race, profession, and years in practice were used to determine if these characteristics were associated with posttest RAT performance and change in pre to posttest RAT scores. Scholars (N = 101) included 86% (N = 87) females; age 44 ± 10 years; 72% (N = 73) Non-Hispanic White; years in practice mean range 11-15 ± 10. There were 37 physicians, 11 physician assistants, 23 nurses, 21 social workers, 2 psychologists, 4 pharmacists, and 2 physical therapists. The posttest dietary supplement and antioxidant RAT scores for all Scholars were 67 ± 18% and 71 ± 14%. In adjusted models there were no significant associations between dietary supplement and antioxidant posttest RAT scores with Scholar characteristics. Change in RAT scores for dietary supplement and antioxidants were 25% ± 23 and 26% ± 27 (P < 0.0001). In adjusted models, there were no significant predictors of change in dietary supplement RATs. For antioxidant RATs, profession was associated with change in scores (P = 0.021). Improvement in Scholar's test scores demonstrate the IOS program can significantly increase oncology providers' knowledge of dietary supplements and antioxidants.

Education Competencies for Integrative Oncology-Results of a Systematic Review and an International and Interprofessional Consensus Procedure.

Integrative oncology is a burgeoning field and typically provided by a multiprofessional team. To ensure cancer patients receive effective, appropriate, and safe care, health professionals providing integrative cancer care should have a certain set of competencies. The aim of this project was to define core competencies for different health professions involved in integrative oncology. The project consisted of two phases. A systematic literature review on published competencies was performed, and the results informed an international and interprofessional consensus procedure. The second phase consisted of three rounds of consensus procedure and included 28 experts representing 7 different professions (medical doctors, psychologists, nurses, naturopathic doctors, traditional Chinese medicine practitioners, yoga practitioners, patient navigators) as well as patient advocates, public health experts, and members of the Society for Integrative Oncology. A total of 40 integrative medicine competencies were identified in the literature review. These were further complemented by 18 core oncology competencies. The final round of the consensus procedure yielded 37 core competencies in the following categories: knowledge (n = 11), skills (n = 17), and abilities (n = 9). There was an agreement that these competencies are relevant for all participating professions. The integrative oncology core competencies combine both fundamental oncology knowledge and integrative medicine competencies that are necessary to provide effective and safe integrative oncology care for cancer patients. They can be used as a starting point for developing profession-specific learning objectives and to establish integrative oncology education and training programs to meet the needs of cancer patients and health professionals.

Integrative Oncology Education: An Emerging Competency for Oncology Providers.

A growing number of cancer patients use complementary and alternative therapies during and after conventional cancer treatment. Patients are often reluctant to discuss these therapies with their oncologist, and oncologists may have limited knowledge and confidence on how to advise patients on the appropriate use. Integrative oncology is a patient-centered, evidence-informed field that utilizes mind-body practices, lifestyle modifications and/or natural products interwoven with conventional cancer treatment. It prioritizes safety and best available evidence to offer appropriate interventions alongside conventional care. There are few opportunities for oncologists to learn about integrative oncology. In this commentary, we highlight the Integrative Oncology Scholars (IOS) program as a means to increase competency in this growing field. We provide an overview of several integrative oncology modalities that are taught through this program, including lifestyle modifications, physical activity, and mind-body interventions. We conclude that as more evidence is generated in this field, it will be essential that oncology healthcare providers are aware of the prevalent use of these modalities by their patients and cancer centers include Integrative Oncology trained physicians and other healthcare professionals in their team to discuss and recommend evidence-based integrative oncology therapies alongside conventional cancer treatments to their patients.

Integrative Oncology Scholars Program: A Model for Integrative Oncology Education.

OBJECTIVES: Oncology providers are often confronted by patients who use complementary or alternative therapies, but have limited knowledge or confidence on how to advise patients on appropriate use. Despite this, there are few opportunities for oncology providers to learn about complementary or alternative therapies, while at the same time there is a high demand for integrative oncology (IO) training. To address a gap in IO educational opportunities, and particularly for nonphysicians, we created the Integrative Oncology Scholars (IOS) Program. The program's goal is to train 100 IO leaders and facilitate partnerships between them and complementary practitioners. DESIGN: Four iterations of a year-long National Cancer Institute-funded educational program that combines in-person team-based learning and eLearning to teach the evidence, application, and philosophy supporting IO. SETTINGS: In-person sessions take place at the University of Michigan, and eLearning is implemented using a Canvas website (Instructure, Inc., Salt Lake City, UT). SUBJECTS: Nurses, social workers, physician assistants, psychologists, physicians, pharmacists, and physical/occupational therapists with active oncology practices. Educational intervention: Four cohorts of 25 oncology providers per year will learn the evidence base for complementary and alternative approaches to a wide number of oncology topics, including symptom control, dietary supplements commonly used by cancer patients, diet, and the utility of specific integrative approaches for common oncology side-effects such as fatigue. OUTCOME MEASURES: A mixed methods approach will be used to evaluate overall IOS Program progress and individual scholar's impact on IO research, education, and clinical endeavors. RESULTS: The first cohort of 25 IOS has been recruited and their education will begin in Summer 2018. Scholars come from 13 states and represent 23 different healthcare systems. CONCLUSIONS: The IOS Program has the potential to increase the number of trained IO providers, educators, and researchers in the United States.

Integrative Therapies During and After Breast Cancer Treatment: ASCO Endorsement of the SIO Clinical Practice Guideline.

Purpose The Society for Integrative Oncology (SIO) produced an evidence-based guideline on use of integrative therapies during and after breast cancer treatment that was determined to be relevant to the American Society of Clinical Oncology (ASCO) membership. ASCO considered the guideline for endorsement. Methods The SIO guideline addressed the use of integrative therapies for the management of symptoms and adverse effects, such as anxiety and stress, mood disorders, fatigue, quality of life, chemotherapy-induced nausea and vomiting, lymphedema, chemotherapy-induced peripheral neuropathy, pain, and sleep disturbance. Interventions of interest included mind and body practices, natural products, and lifestyle modifications. SIO systematic reviews focused on randomized controlled trials that were published from 1990 through 2015. The SIO guideline was reviewed by ASCO content experts for clinical accuracy and by ASCO methodologists for developmental rigor. On favorable review, an ASCO Expert Panel was convened to review the guideline contents and recommendations. Results The ASCO Expert Panel determined that the recommendations in the SIO guideline-published in 2017-are clear, thorough, and based on the most relevant scientific evidence. ASCO endorsed the guideline with a few added discussion points. Recommendations Key recommendations include the following: Music therapy, meditation, stress management, and yoga are recommended for anxiety/stress reduction. Meditation, relaxation, yoga, massage, and music therapy are recommended for depression/mood disorders. Meditation and yoga are recommended to improve quality of life. Acupressure and acupuncture are recommended for reducing chemotherapy-induced nausea and vomiting. Acetyl-l-carnitine is not recommended to prevent chemotherapy-induced peripheral neuropathy because of a possibility of harm. No strong evidence supports the use of ingested dietary supplements to manage breast cancer treatment-related adverse effects. Additional information is available at: www.asco.org/supportive-care-guidelines .

A pilot study of the feasibility and outcomes of yoga for lung cancer survivors.

PURPOSE/OBJECTIVES: To determine the feasibility of a standardized yoga intervention for survivors of non-small cell lung cancer (NSCLC) and, effects on sleep, mood, salivary cortisol levels, and quality of life (QOL). DESIGN: This 14-week, one-group, repeated-measures study included a three-week preintervention phase, eight weeks of yoga classes (40 minutes once per week) and home practice, and a three-week postintervention phase. Follow-up occurred at three and six months poststudy. SETTING: A community-based cancer support center in the midwestern United States. SAMPLE: 7 adults who had completed initial treatment for stages I-IIIa NSCLC. METHODS: A standardized yoga protocol was developed prior to the study by experts in the field. Breathing ease was monitored before, during, and after classes to assess feasibility of movement without compromising respiratory status while doing yoga. Data analysis included descriptive statistics, repeated-measures analysis of variance, and salivary cortisol analysis. MAIN RESEARCH VARIABLES: Sleep quality, mood, salivary cortisol, and QOL were assessed using the Pittsburgh Sleep Quality Index, Profile of Mood States-Brief, a cortisol measurement, and the Medical Outcomes Survey SF-36®, respectively. Breathing ease was assessed using a dyspnea numeric rating scale as well as observation of participants. FINDINGS: Participants with varying stages of disease and length of survivorship were able to perform yoga without respiratory distress. Class attendance exceeded 95%, and all practiced at home. Mood, sleep efficiency, and QOL significantly improved; salivary cortisol levels decreased over time. CONCLUSIONS: Yoga was feasible for NSCLC survivors without further compromising breathing with movement. Potential benefits were identified, supporting the need for future clinical trials with larger samples stratified by cancer stage, treatment, and length of survivorship. IMPLICATIONS FOR NURSING: Nurses and healthcare providers should consider yoga as a mind-body practice to manage stress, improve mood and sleep, and potentially enhance QOL for NSCLC survivors.

Using a standardized Viniyoga protocol for lung cancer survivors: a pilot study examining effects on breathing ease.

Although lung cancer is perceived as a dire diagnosis, increases in the 5-year survival rate of individuals with non-small cell lung cancer (NSCLC) have been reported. Survivors, however, continue to be excessively burdened with symptoms such as respiratory distress which interfere with functioning and quality of life. While exercise and physical activity are strongly recommended, NSCLC survivors may be reluctant to participate due to actual or anticipated shortness of breath exacerbated with movement.This quasi-experimental, intervention-only pilot study aimed to determine the effects of an 8-week standardized yoga protocol for Stage I-IIIa NSCLC survivors (n=9). The protocol was developed within the Viniyoga (Hatha) tradition with respiratory experts. Breathing ease, dyspnea, oxygen saturation, and respiratory function were explored in relationship to yoga practice (45-minute sessions once per week and home practice) using repeated-measures analysis. Number of participants reporting dyspnea ranged from 25 to 50% prior to practice with no significant increase during sessions, and moderate decreases noted at times. Oxygen saturation remained high and vital signs stable; forced expiratory volume in 1 second (FEV1) values increased significantly over the 14-week study period (p<0.0001). Yoga, with an emphasis on postures coordinated with breathing and meditation practices, offers a potentially feasible and beneficial option that requires further study in this population.

Understanding CAM Natural Health Products: Implications of Use Among Cancer Patients and Survivors.

Herbs, vitamins, and other natural health products are being used by cancer patients and survivors with increasing prevalence in the United States. These complementary and alternative medicine (CAM) products, which are also referred to as natural health products in Canada and abroad, are used during cancer treatment and the survivorship period to ease the burden of symptoms such as pain, fatigue, insomnia, anxiety, and depression and hence improve overall quality of life. Data indicate that while patients choose these products for self-treatment, they often do not inform their health-care providers, thereby presenting the potential for negative interactions. This article gives an overview of CAM natural health products, including discussion of herbs, vitamins, and other supplements such as minerals, enzymes, and more. Related research is presented, and implications for advanced practitioners are discussed. Insights into guiding safe and effective use among patients as well as appropriate decision-making strategies are explored.

Self-treatment of pain among adolescents in an urban community.

Pain occurrence among adolescents, whether acute or chronic, persistent or intermittent, remains high, with potentially serious effects on quality of life, physical and emotional functioning, and psychosocial adjustment. The prevalence of pain in adolescents varies widely, and although discussed in the literature for more than two decades, data on adolescent knowledge and pain self-treatment is scarce. This descriptive-correlational study identified pain prevalence and intensity and pain self-treatment choices among adolescents in a diverse urban community. Almost 90% (n = 253) of high school students reported pain in the preceding 2 weeks and completed a series of study questionnaires (demographic data form, Brief Pain Inventory-Short Form, Adolescent Self-Treatment Survey). Respondents ranged in age from 14 to 19 years (mean 16) and were predominantly female (70%) and caucasian (75%). The sample was representative of all high school grades, and the majority (86%) reported participation in sports, dance, and physical activities. Mean pain scores ranged from 3.0 (current pain) to 6.5 (worst pain), with significantly higher scores among girls. A gender-related effect was also noted for pain interference in activities, mood, and sleep among the adolescent girls compared with the boys. Gender also predicted use of self-treatment methods, with girls more likely to use over-the-counter medications and nonpharmacologic therapies. Number of pain sites was also a strong predictor of use of self-treatment methods among adolescents. Knowledge of the pain experience during adolescence will help guide community-based nursing initiatives aimed at increasing awareness, promoting knowledge about pain and its treatment, and ensuring safety and positive outcomes related to self-treatment.

Complementary and alternative modalities to relieve osteoarthritis symptoms: a review of the evidence on several therapies often used for osteoarthritis management.

OVERVIEW: Conventional medical treatment of osteoarthritis often successfully relieves pain but can also produce adverse gastrointestinal and cardiovascular effects, especially with long-term use. Hence, many patients use complementary and alternative medicine (CAM) to prevent, control, and manage the pain of osteoarthritis. The author reviews the evidence on the efficacy and safety of several CAM therapies often used for osteoarthritis management, including mind-body therapies, supplements, and body-based treatments.

Complementary and alternative modalities to relieve osteoarthritis symptoms.

Conventional medical treatment of osteoarthritis often successfully relieves pain but can also produce adverse gastrointestinal and cardiovascular effects, especially with long-term use. Hence, many patients use complementary and alternative medicine (CAM) to prevent, control, and manage the pain of osteoarthritis. The author reviews the evidence on the efficacy and safety of several CAM therapies often used for osteoarthritis management, including mind-body therapies, supplements, and body-based treatments.

Nondrug therapies for pain management among rural older adults.

This quasiexperimental two-group pilot study tested an intervention aimed at educating older adults in rural communities about the appropriate use of nondrug treatments for pain. Earlier data reveal that older adults use significantly less nonpharmacologic modalities than their younger counterparts, and that pain self-treatment is prevalent in rural areas. Individuals aged ≥60 years who experienced pain in the preceding 2 weeks were recruited from rural Midwestern communities through the use of flyers and information sessions at hospitals, churches, and community organizations. Upon enrollment, participants selected a date for an educational session, which was randomized to the experimental or control condition. All participants (n = 53) completed a series of questionnaires (Brief Pain Inventory, Symptom Distress Scale, Perceived Control Scale) at the initial educational session (T1) and at a two-week follow-up session (T2). Participants in the control and experimental groups attended a 30-minute educational session on safe use of over-the-counter medications; the experimental group also received an additional 30-minute session on safe and effective use of heat, cold, and relaxation breathing. Hot and cold packs and relaxation breathing instruction were provided for use over the 2-week period. There was a significant increase in the use of all nondrug treatments and a decrease in pain-related distress and current pain scores in the experimental group compared with the control group. This study informs nurses and other health care providers on the value of education for use of nondrug therapies in conjunction with pharmacologic pain management among rural older adults.

Inner Correspondence and Peacefulness with Practices among Participants in Eurythmy Therapy and Yoga: A Validation Study.

Several mind body medicine interventions require an active participation of the practitioners. We intended to develop a questionnaire to operationalize and measure the "inner correspondence" of individuals practicing Yoga or Eurythmy Therapy. In an anonymous cross-sectional study we enrolled 501 individuals (61% yoga). Exploratory factor analysis (study 1) of the 12-item instrument (Cronbach's alpha = .84) pointed to a 3-factor solution, with one major scale and good internal consistency (alpha = .83) and two minor scales with weak internal consistency. To improve the quality of the main scale, we added 8 new items which were tested in a sample of 135 individuals (study 2: 71% Yoga). Factor analysis confirmed a 12-item single factor (alpha = .95), that is, Inner Correspondence/Peaceful Harmony with Practices (ICPH). The scale correlated strongly with mindfulness (FMI; r > .50), moderately with life and patient satisfaction (BMLSS; r between .32 and .43), and weakly negative with symptom score (VAS; r = -.23). In conclusion, the scale ICPH was confirmed as a relevant tool to measure the inner correspondence and feelings of peacefulness with practices. It can be used in clinical studies to assess the efficacy of mind-body practices involving physical movements.

Gender, symptom experience, and use of complementary and alternative medicine practices among cancer survivors in the U.S. cancer population.

PURPOSE/OBJECTIVES: To identify relationships among gender, physical and psychological symptoms (pain, insomnia, fatigue, and depression), and use of specific complementary and alternative medicine (CAM) practices among survivors in the U.S. cancer population. DESIGN: Secondary analysis of the 2002 National Health Interview Survey (NHIS). The CAM Healthcare Model, an extension of the Behavioral Model for Health Services Use, guided the study. SETTING: United States. SAMPLE: 2,262 adults (aged 18 years and older) diagnosed with cancer representing more than 14.3 million cancer survivors in the United States . METHODS: NHIS interview data on use of CAM practices (diet, yoga, tai chi, qigong, meditation, guided imagery, relaxation, and deep breathing) were examined in relationship to gender and symptoms. Analysis was conducted using Stata 9.2 software for population estimation. Binary logistic regression, the primary statistical model employed in the analysis, focused on between-subject differences in practice use. MAIN RESEARCH VARIABLES: Dichotomous outcome variables included use of at least one CAM practice and use of specific individual CAM practices. Independent variables included gender, age, education, race, provider contact, cancer diagnosis, pain, insomnia, fatigue, depression, and health status. FINDINGS: CAM practice use was more prevalent among female, middle-aged, Caucasian, and well-educated subjects. Pain, depression, and insomnia were strong predictors of practice use, with differences noted by gender and practice type. CONCLUSIONS: CAM practices are widely used in the U.S. cancer population, especially among women. Symptom experience influences likelihood of use, with increased odds when men report symptoms. IMPLICATIONS FOR NURSING: Study findings inform oncology nurses on the benefits of integrating self-care CAM practices in relationship to gender into the symptom management care plan for cancer survivors. Findings reported in this study will help guide future CAM practice intervention studies.

Predictors of use of complementary and alternative therapies among patients with cancer.

PURPOSE/OBJECTIVES: To determine predictors of use of complementary and alternative medicine (CAM) therapies among patients with cancer. DESIGN: Secondary analysis of two federally funded panel studies. SETTING: Urban and rural communities in the midwestern United States. SAMPLE: Patients with lung, breast, colon, or prostate cancer (N = 968) were interviewed at two points in time. 97% received conventional cancer treatment, and 30% used CAM. The sample was divided evenly between men and women, who ranged in age from 28-98; the majority was older than 60. METHODS: Data from a patient self-administered questionnaire were used to determine CAM users. Responses indicated use of herbs and vitamins, spiritual healing, relaxation, massage, acupuncture, energy healing, hypnosis, therapeutic spas, lifestyle diets, audio or videotapes, medication wraps, and osteopathic, homeopathic, and chiropractic treatment. MAIN RESEARCH VARIABLES: Dependent variable for analysis was use or nonuse of any of the identified CAM therapies at time of interviews. Independent variables fell into the following categories: (a) predisposing (e.g., gender, age, race, education, marital status), (b) enabling (e.g., income, health insurance status, caregiver presence, geographic location), and (c) need (e.g., cancer stage, site, symptoms, treatment, perceived health need). FINDINGS: Significant predictors of CAM use were gender, marital status, cancer stage, cancer treatment, and number of severe symptoms experienced. CONCLUSIONS: Patients with cancer are using CAM while undergoing conventional cancer treatment. IMPLICATIONS FOR NURSING: Nurses need to assess for CAM use, advocate for protocols and guidelines for routine assessment, increase knowledge of CAM, and examine coordination of services between conventional medicine and CAM to maximize positive patient outcomes.

Patients' choices for the self-treatment of pain.

Pain is a common problem that affects the functional status and quality of life of people in all communities. This study explored the occurrence of pain and the pain self-treatment modalities used by 723 community residents. Mean worst pain scores were moderate to severe and interfered with all activities at a low-to-moderate level. Participants reported taking nonopioid analgesics (75%), opioid analgesics (15%), adjuvant analgesics (11.6%), and herbal products and supplements (29%); 68% used nonpharmacological modalities. Current regimens were reported to relieve only 45% of pain. Twenty-eight percent of participants reported that they had not informed their primary care practitioner of their self-treatment choices. Knowledge of self-treatment choices is imperative in planning treatment regimens for pain or other health problems to prevent potential interactions or side effects.

Self-treatment of pain in a rural area.

CONTEXT: In the United States, 42% of adults say they experience pain daily, the majority often relying on self-treatment. In addition, an increasing number of people are seeking complementary/alternative therapies, often without informing their health care providers. PURPOSE: To explore the occurrence of pain and the modalities of self-treatment used by community members (N = 108) from a rural area of Michigan, the potential for interactions between pain self-treatment modalities and other medications currently being taken, and demographic variables that might affect self-treatment choice. METHOD: This exploratory descriptive study was conducted using a survey method. FINDINGS: Findings revealed that 66% were taking prescription medications, 75% over-the-counter medications, 20% herbal supplements, and 35% nonpharmacological treatments. Of the reported prescription and over-the-counter medications, 18% were opioids, 77% were nonopioids, and 18% were adjuvant medications. One-third of the subjects were taking more than 1 medication and/or herbal product or supplement, increasing their risk for potential drug-herb interactions, complicated by the fact that 20% did not inform their primary care practitioner of their self-treatment choices. CONCLUSIONS: This study contributes to the knowledge of current self-treatment choices regarding pain management and potentially harmful interactions that might occur from using multiple medications and supplements.