Education of non-medical practitioners in Germany-an analysis of course subjects of specialized schools.

In Germany, non-medical practitioners (NMPs; in German: Heilpraktiker) offer a broad range of complementary and alternative (CAM) methods. Our aim was to characterize schools for NMPs in Germany in terms of basic (medical) training and advanced education. We found 165 schools for NMPs in a systematic web-based search. As the medical board examination NMPs must take before building a practice exclusively tests their knowledge in conventional medicine, schools hardly include training in CAM methods. Only few schools offered education on CAM methods in their NMP training. Although NMP associations framed requirements for NMP education, 83.0% (137/165) of schools did not meet these requirements. Patients and physicians should be aware of the lack of training and consequent risks, such as harm to the body, delay of necessary treatment, and interaction with conventional drugs. Disestablishing the profession of NMPs might be a reasonable step.

Interactions from complementary and alternative medicine in patients with melanoma.

Biological-based (BbCAM) methods from complementary and alternative medicine (CAM) may interact with cancer treatments, reduce efficacy, or enhance adverse effects. Although CAM usage has been evaluated well in other cancer entities, data on melanoma patients are still missing. The aim of this study was to determine CAM usage of melanoma patients using a standardized questionnaire to identify potential interactions with established and new systemic melanoma therapies. This multicenter study was carried out in seven German skin cancer centers. During routine care contact, CAM usage of former and current melanoma treatment was assessed in melanoma patients. The probability of interaction was classified into four categories ranging from 'interaction unlikely' (I), 'possible' (II), 'likely' (III), or 'no data' (IV). The questionnaire was filled out by 1157 patients, of whom 1089 were eligible for evaluation. CAM usage was reported by 41% of melanoma patients, of whom 63.1% took BbCAM such as vitamins, trace elements, supplements, or phytotherapeuticals. Of 335 patients with former or current therapy, 28.1% used BbCAM. The melanoma treatment included interferon, radiotherapy, chemotherapy, BRAF-inhibitor, or other tyrosine kinase inhibitors and ipilimumab. On the basis of our model of likelihood of interaction, we found that 23.9% of those on cancer therapy and 85.1% of those also using BbCAM were at some risk of interactions. The main limitation of our study is that no reliable and comprehensive database on clinical relevant interactions with CAM in oncology exists. Most patients receiving a melanoma-specific treatment and using BbCAM methods are at risk for interactions, which raises concerns on the safety and treatment efficacy of these patients. To protect melanoma patients from potential harm by the combination of their cancer treatment and CAM usage, patients should systematically be encouraged to report their CAM use, while oncologists should be trained on evidence of CAM, and patient guidance for saver CAM use.

Use of complementary and alternative medicine: A multicenter cross-sectional study in 1089 melanoma patients.

BACKGROUND: About half of patients with cancer use complementary and alternative medicine (CAM). So far, data on melanoma patients are missing. OBJECTIVE: The aim of our study was to evaluate the prevalence and predictors for the use of CAM in this patient group. METHODS: All patients with melanoma being attended at one of 7 skin cancer centres in Germany between March 2012 and March 2013 were invited to take part in a survey using a structured questionnaire on CAM. The physicians filled in a second part on the diagnosis, state and former and current therapy. RESULTS: Nearly half of the 1089 participants (41.0%) used CAM and half of those using CAM (56.8%) marked that this made them feel better. Biological-based CAMs which consists of substances taken were used by 25.9% of all patients (63.1% of those using CAM). Predictors of CAM use were education, psychological support, interest in CAM and previous CAM use. CAM users show higher physical activity, more often use psychosocial help and have contact with a self-help group. Family and friends (41.0%) as well as print media (41.7%) are the main sources of information. Most important reasons to use CAM are to strengthen one's own forces (57.7%) or the immune system (63.4%) and to be able to do something for oneself (53.7%). CONCLUSION: Communication on CAM should become a regular topic in counselling melanoma patients. To increase safety, patients and physicians must have access to evidence-based information on these methods and their interactions with modern cancer treatments.

Economic Evaluation of Complementary and Alternative Medicine in Oncology: Is There a Difference Compared to Conventional Medicine?

OBJECTIVE: To analyze the financial burden of complementary and alternative medicine (CAM) in cancer treatment. MATERIALS AND METHODS: Based on a systematic search of the literature (Medline and the Cochrane Library, combining the MeSH terms 'complementary therapies', 'neoplasms', 'costs', 'cost analysis', and 'cost-benefit analysis'), an expert panel discussed different types of analyses and their significance for CAM in oncology. RESULTS: Of 755 publications, 43 met our criteria. The types of economic analyses and their parameters discussed for CAM in oncology were cost, cost-benefit, cost-effectiveness, and cost-utility analyses. Only a few articles included arguments in favor of or against these different methods, and only a few arguments were specific for CAM because most CAM methods address a broad range of treatment aim parameters to assess effectiveness and are hard to define. Additionally, the choice of comparative treatments is difficult. To evaluate utility, healthy subjects may not be adequate as patients with a life-threatening disease and may be judged differently, especially with respect to a holistic treatment approach. We did not find any arguments in the literature that were directed at the economic analysis of CAM in oncology. Therefore, a comprehensive approach assessment based on criteria from evidence-based medicine evaluating direct and indirect costs is recommended. CONCLUSION: The usual approaches to conventional medicine to assess costs, benefits, and effectiveness seem adequate in the field of CAM in oncology. Additionally, a thorough deliberation on the comparator, endpoints, and instruments is mandatory for designing studies.

Risk of interactions between complementary and alternative medicine and medication for comorbidities in patients with melanoma.

Complementary and alternative medicine (CAM) is used widely among cancer patients. Beside the risk of interaction with cancer therapies, interactions with treatment for comorbidities are an underestimated problem. The aim of this study was to assess prevalence of interactions between CAM and drugs for comorbidities from a large CAM usage survey on melanoma patients and to classify herb-drug interactions with regard to their potential to harm. Consecutive melanoma outpatients of seven skin cancer centers were asked to complete a standardized CAM questionnaire including questions to their CAM use and their taken medication for comorbidities and cancer. Each combination of conventional drugs and complementary substances was evaluated for their potential of interaction. 1089 questionnaires were eligible for evaluation. From these, 61.6% of patients reported taking drugs regularly from which 34.4% used biological-based CAM methods. Risk evaluation for interaction was possible for 180 CAM users who listed the names or substances they took for comorbidities. From those patients, we found 37.2% at risk of interaction of their co-consumption of conventional and complementary drugs. Almost all patients using Chinese herbs were at risk (88.6%). With a high rate of CAM usage at risk of interactions between CAM drugs and drugs taken for comorbidities, implementation of a regular assessment of CAM usage and drugs for comorbidities is mandatory in cancer care.

Complementary and Alternative Medicine in Palliative Care: A Comparison of Data From Surveys Among Patients and Professionals.

PURPOSE: Many cancer patients use complementary and alternative medicine (CAM) during or after their therapy. Because little is known about CAM in palliative care, we conducted 2 surveys among patients and professionals in the palliative setting. PARTICIPANTS AND METHODS: Patients of a German Comprehensive Cancer Center were interviewed, and an independent online survey was conducted among members of the German Society for Palliative Care (DGP). RESULTS: In all, 25 patients and 365 professional members of the DGP completed the survey (9.8% of all members); 40% of the patients, 85% of the physicians, and 99% of the nurses claimed to be interested in CAM. The most important source of information for professionals is education, whereas for patients it is radio, TV, and family and friends. Most patients are interested in biological-based methods, yet professionals prefer mind-body-based methods. Patients more often confirm scientific evidence to be important for CAM than professionals. CONCLUSIONS: To improve communication, physicians should be trained in evidence for those CAM methods in which patients are interested.

Perception of cancer patients of their disease, self-efficacy and locus of control and usage of complementary and alternative medicine.

PURPOSE: A high percentage of cancer patients use complementary and alternative medicine (CAM). The aim of our study was to learn more about the association of CAM usage, information needs, perceived impact of disease, locus of control and self-efficacy of cancer patients. METHODS: We asked patients attending a series of lectures on CAM using a standardized questionnaire which integrated questions on information needs, CAM and validated short questionnaires on self-efficacy, perception of the disease and locus of control of reinforcement. RESULTS: One hundred and eighty-five patients answered the questionnaire, from whom 45 % used CAM. Sixty percentage disclosed using CAM to the general practitioner and 57 % to the oncologist. Physicians and nurses, print media and the Internet are the most important source of information on CAM (used by 20-25 % each). Impact on neither daily life, perceived personal control nor coherence was associated with CAM usage, disclosure to physicians or sources of information. There also was no association between CAM usage and self-efficacy. In contrast, there was a significant association between CAM user rate and a high external locus of control. CONCLUSION: While CAM usage is agreed upon by many physicians due to the idea that it helps patients to become active and feel more in control of the disease, our data are in favor of the contrary. A strong perception of external locus of control seems to be a driver of CAM usage. Physicians should be aware of this association when counseling on CAM.

Online survey of cancer patients on complementary and alternative medicine.

INTRODUCTION: Complementary and alternative medicine (CAM) is often used by cancer patients, yet, communication with the oncologist is poor. The objective of our study was to gather information on patients' usage of CAM, source of information, and aims, in order to derive strategies to improve the communication between physicians and patients on this topic. MATERIALS AND METHODS: An online survey was conducted by linking a standardized questionnaire to the largest internet portal for cancer patients in Germany. The questionnaire addresses CAM usage, disclosure to physicians, source of information, objectives for using CAM, and perceived reasons for cancer. RESULTS: Of 170 participants, 77% were currently using CAM. Disclosure to a physician was rather high with 63% having informed their oncologist. Asked whether the oncologist took time to discuss CAM, 74% answered 'no'. Most frequently used are biologically based therapies, relaxation techniques, prayer, and meditation. Most patients want to reduce side effects, boost their immune system, and get active. Almost half the participants had positive experiences with some type of CAM before they fell ill. CONCLUSION: Understanding patients' concepts of the etiology of cancer and accepting their goals for using CAM may help oncologists communicate with their patients and guide them to a safe use of CAM.

Online survey of patients with breast cancer on complementary and alternative medicine.

About 50% of cancer patients use complementary and alternative medicine (CAM). Women with breast cancer use CAM more frequently than others. We linked a questionnaire to the largest internet portal for cancer patients in Germany. The questionnaire addresses attitude towards CAM, disclosure to the oncologist, source of information, and objectives for use of CAM. 80 patients with breast cancer took part in our study, 61 currently using CAM. Most frequently used CAM methods were selenium, relaxation techniques, prayer, vitamin C, and meditation. Satisfaction was highest with relaxation techniques, vitamin C, homeopathy, yoga and Chinese herbs, lowest with mistletoe and acupuncture. 70% of participants did not think their oncologist took time to discuss CAM. Only 16% believed that their oncologist was well-informed about CAM. 46% relied on naturopaths and non-medical practitioners concerning CAM. Objectives for the use of CAM were to reduce side effects, boost the immune system, and become active.

Survey of German non-medical practitioners regarding complementary and alternative medicine in oncology.

BACKGROUND: In total, 40-70% of cancer patients use complementary or alternative medicine (CAM). Many of them ask for advice from non-medical practitioners (NMPs). Our aim was to investigate the attitude of NMPs regarding their treatments for cancer patients. METHODS: A survey was performed on members of NMP associations, using an online questionnaire on diagnosis and treatment, goals for using CAM, communication with the oncologist, and sources of information. RESULTS: Of the 1,500 members of the NMP associations, 299 took part. The treatments were found to be heterogeneous. Homeopathy is used by 45% of the NMPs; 10% believe it to be a treatment directly against cancer. Herbal therapy, vitamins, orthomolecular medicine, ordinal therapy, mistletoe preparations, acupuncture, and cancer diets are used by more than 10% of the NMPs. None of the treatments is discussed with the respective physician on a regular basis. CONCLUSIONS: Many therapies provided by NMPs are biologically based and therefore may interfere with conventional cancer therapy. Thus, patients are at risk of interactions, especially as most NMPs do not adjust their therapies to those of the oncologist. Moreover, risks may arise from these CAM methods as NMPs partly believe them to be useful anticancer treatments. This may lead to the delay or even omission of effective therapies.

User rate of complementary and alternative medicine (CAM) of patients visiting a counseling facility for CAM of a German comprehensive cancer center.

BACKGROUND: In Europe about 40% to 50% of patients with cancer use complementary or alternative medicine (CAM). Only scarce data regarding the use of CAM have been reported from comprehensive cancer Centers. PATIENTS AND METHODS: We carried out a survey on patients attending the counseling Unit for CAM of a German comprehensive cancer Center using a standardized questionnaire. RESULTS: A total of 165 patients participated in the survey; 60% had already used CAM. Trace elements and vitamins were most often used. Strengthening oneself and one's immune system were the two main reasons (73% and 69% respectively for CAM use). The most important sources of information are print media and physicians (41% and 35% respectively). The two main reasons for using CAM were practitioners spending more time with patients and patients having experienced positive effects from CAM. CONCLUSION: For patients with cancer becoming active is an important goal, while disappointment in conventional medicine is not. Accepting patients' motivation for autonomy may help oncologists to increase adherence to conventional therapy.

Counseling patients on cancer diets: a review of the literature and recommendations for clinical practice.

BACKGROUND: Many cancer patients use cancer diets. MATERIALS AND METHODS: We listed 13 cancer diets simulating an internet search for which we systematically reviewed clinical data. In the next step we derived recommendations on counseling patients using a Delphi process. RESULTS: We evaluated the following diets: raw vegetables and fruits, alkaline diet, macrobiotics, Gerson's regime, Budwig's and low carbohydrate or ketogenic diet. We did not find clinical evidence supporting any of the diets. Furthermore, case reports and pre-clinical data point to the potential harm of some of these diets. From published recommendations on counseling on complementary and alternative medicine, we were able to derive 14 recommendations for counseling on cancer diets. CONCLUSION: Considering the lack of evidence of benefits from cancer diets and potential harm by malnutrition, oncologists should engage more in counseling cancer patients on such diets. Our recommendations could be helpful in this process.

Primary malignant melanoma of the urethra: a systematic analysis of the current literature.

BACKGROUND: Primary malignant melanoma of the urethra is a rare tumour that most commonly affects the meatus and distal urethra. General prognosis seems to be poor. To date, there have been no systematic reviews on this topic. Therefore, we aimed to gain more insight into this rare type of tumour. METHODS: Medline and PubMed were searched and all cases of urethral melanoma reported as single case reports or small case series were reviewed as the first step in the combined analyses of all the cases reported. RESULTS: We reviewed 150 cases. The most frequent presentation was urethral mass. The first line of treatment was surgery such as tumour excision or total urethrectomy. Three times more women were diagnosed than men with a mean age of 64.7 years (SD 10.7; median 65.5; range 28-96 years). Forty-three patients (36 %) underwent adjuvant treatment including chemotherapy, radiotherapy or immunotherapy. Recurrences were observed in 71.4 % (n = 80) of the cases, mainly local recurrences (n = 44; 55 %) and metastases in the inguinal lymph nodes (n = 31; 28 %). Recurrences occurred within 12.5 months on average (SD 12.6; range 1-48). The treatments of recurrences were surgery, chemotherapy, radiotherapy and immunotherapy. These treatment options influenced the course of the disease. CONCLUSIONS: Urethral melanoma is mainly a disease of older people with an average age of 64 years. The study showed that the T-stage as a basis of depth invasion is a prognostic factor for urethral melanoma. Moreover, pulmonary metastases (cM2), local recurrence and systemic recurrence influence prognosis. The T-stage classification is useful because of its prognostic ability.

Online information on complementary and alternative medicine for cancer patients: evidence-based recommendations.

BACKGROUND: Many cancer patients use complementary and alternative medicine (CAM). Most websites offering online information on CAM are not helpful for them. METHODS: We extracted decisive elements for online information on CAM by analyzing the literature on the information needs of cancer patients and on counseling cancer patients on CAM. RESULTS: Key issues for online information on CAM are the qualification of the authors, transparency and accountability of the information, description of the aims, a scientific approach, description of treatment alternatives, support for the patient-physician relationship, individualized information, a summary of the information, disclosure of funding, and the privacy policy. CONCLUSIONS: The communicative challenge will be to convey information without destroying hope and motivation. We suggest that CAM topics should be integrated into broader information provided on cancer (etiology, conventional treatment). By also providing information for physicians, such a website could promote shared decision-making. Online information will gain the status of independent expert knowledge if provided by a well-known scientific organization as, e.g., a national cancer society.

Survey on the worldwide Chronic Myeloid Leukemia Advocates Network regarding complementary and alternative medicine.

PURPOSE: Many cancer patients use complementary and alternative medicine (CAM). However, data in hematological cancers are lacking on which types of CAM are being used, what information sources on CAM patients use and to what extent CAM is being addressed in the consultation with the hematologist. METHODS: We developed a standardized questionnaire on CAM which was provided online to the representatives of the worldwide Chronic Myeloid Leukemia Advocates Network. RESULTS: A total of 53 leaders of patients' advocacy groups for chronic myeloid leukemia (CML) patients from 35 countries responded to the survey. In almost all countries, CAM is important for CML patients and is widely used in addition to conventional leukemia treatment. Mostly, patients have to pay by themselves. General practitioners, herbalists, healers and naturopaths are the main sources for CAM treatments. Information on CAM is derived most frequently from the Internet, and family and friends, but rarely provided by the oncologist. Disclosure of CAM use to the oncologist is low, but increases if oncologists offer CAM. CONCLUSIONS: In spite of very different health care systems, the features of CAM usage are similar in the different countries. We suggest extending the cooperation of self-help and scientists in order to provide training of oncologists on CAM and quality-controlled, evidence-based information on CAM on the Internet both for patients as well as health professionals as a promising strategy to increase safe use of CAM in patients with CML.

Management of adult primary vulvar Langerhans cell histiocytosis: review of the literature and a case history.

Primary vulvar Langerhans cell histiocytosis (LCH) is extremely rare and there are no standard treatment options. This review of the published literature with a case report aimed to clarify the optimal treatment for patients with this condition. Medline and PubMed were searched and all cases of primary vulvar LCH reported as single case reports or small case series were reviewed. A patient with vulvar LCH treated in this department is also reported. Twenty-seven cases, including the reported case, were reviewed. First-line treatments included surgery, radiotherapy, chemotherapy, thalidomide and local treatment. The mean follow-up time was 21.1±17.7 months. Although no patient died from the disease, recurrence rates were high (62%) and the mean time to relapse was 10.9±11.8 months (range 1-36 months). Treatment with thalidomide was successful, resulting in long-lasting remission. Disease recurrence is likely after surgery and or radiotherapy, and these treatments together with chemotherapy affect the patient's wellbeing adversely. Although definitive conclusions await further work, thalidomide has minimal adverse effects, is easy to administer and should be considered as a first-line treatment or as maintenance therapy in some patients.

Primary diagnosis of metastatic breast cancer in the third trimester of pregnancy: a case report and review of the literature.

To the best of our knowledge, we are presenting the first documented primary diagnosis of a 32-year-old pregnant patient at 29 + 4 weeks' gestation with poorly differentiated, metastatic scirrhous breast cancer, with negative hormone receptors, HER-2/neu receptor overexpression and metastases in the lumbar spine. The patient was administered neoadjuvant chemotherapy with vinorelbine and trastuzumab, and received ibandronate for the bone metastases. The tumor responded well to treatment; however, treatment was associated with anhydramnios, probably related to the trastuzumab treatment. Delivery was planned for 33 + 5 weeks' gestation by cesarean section due to concurrent breech presentation and anhydramnios, and the infant is in good health. After delivery, the patient underwent a mastectomy. Following completion of six courses of vinorelbine and ongoing treatment with trastuzumab and ibandronate, the patient's tumor went into regression and currently the patient does not present with any clinical evidence of disease.

Intra-abdominal adhesion formation: does surgical approach matter? Questionnaire survey of South Asian surgeons and literature review.

AIM: The impact of postsurgical intra-abdominal adhesions, which represent a considerable burden for patients and health services, is often underestimated. Various factors influence adhesion formation, including the surgical approach. This study aimed to further understand the condition by investigating surgeons' perceptions of adhesion formation, particularly differences after laparoscopic and open surgery, and by performing a selective literature review. MATERIALS AND METHODS: South Asian surgeons attending endoscopy symposia in India and in Germany completed Likert-scale-based questionnaires on awareness of adhesion formation and associated consequences in gynecology. MEDLINE and PubMed were searched for articles published in 2000-2010 comparing laparoscopy and laparotomy in relation to adhesion formation. The results of the questionnaire study were then considered in view of findings from this review. RESULTS: In total, 43.1% (97/225) of questionnaires were completed. Respondents considered that laparoscopy caused fewer adhesions than laparotomy for all gynecological procedures. Although they believed their knowledge of adhesion formation was satisfactory, they widely underestimated the risk, giving estimated rates of 12.5% after laparoscopy and 36.3% after laparotomy. Twenty-eight studies were identified in the review. Most concluded that laparoscopy was less likely to cause adhesions than laparotomy but further statistical analysis was precluded because so many different definitions and classifications of adhesions had been used. CONCLUSIONS: The risk of adhesion formation was widely underestimated in the study group. Both the questionnaire study and the review concluded that laparoscopy results in less adhesion than laparotomy but further statistical comparison necessitates the development of standard definitions and classifications of adhesions.