Article

Integrative cancer care in Canada: curiosity and cautions

Joanne MacPhail was diagnosed with breast cancer  in 1993 at the age of forty three. At that time, her treatment included two surgeries, as well as a lengthy course of chemotherapy that had profound physical and emotional side effects. MacPhail details how she sought out reflexology, therapeutic touch and massage therapies to help her cope with side effects and the ongoing anxieties related to her cancer.

“You live with it every day… the fear can consume you that when something doesn’t feel quite right, the cancer has come back” she says.

And indeed MacPhail’s cancer did come back in 2008 when she discovered a tumour under one arm. When she saw her oncologist and was put on an estrogen limiting drug, her oncologist showed her a list of herbal and other medications, such as Black Cohosh, which she should not be taking because of potential interactions. In fact, she was taking this herbal medicine at the time and stopped immediately.

“I was really impressed by that [their knowledge of interactions]” she says, adding that her oncologist was supportive of her using non-conventional therapies to help her better cope, and they had many open discussions. Her providers, she says “were open, and there was a lot of information sharing.”

MacPhail’s experiences are echoed by many cancer patients. Surveys and research evidence have shown that nearly half of cancer patients in countries with modern medical systems seek out therapies that are outside of the conventional medical system’s standard of care. Alongside their patients, conventional cancer providers have become more open to these therapies.

The same is true in Canada. What are some of the reasons motivating Canadian cancer patients to seek these therapies, and how is conventional cancer care responding?

A move away from the language of ‘Complementary and Alternative Medicine’ towards Integrative Care

Therapies ranging from acupuncture to naturopathic medicine to homeopathy are often described as Complementary and Alternative medicine. Some experts in this field have criticized this term, saying “the words ‘complementary’ and ‘alternative’ have different meanings and should not be connected by ‘and’.”

The use of these therapies or treatments as an alternative to conventional cancer treatments is widely discouraged by both conventional and non-conventional health care providers. Patients who first try alternative therapies will often delay starting evidence-based conventional treatments.  Research has shown that this can dramatically worsen patient outcomes – seen in a higher risk of death, and cancer recurrence for these patients.

Apple founder Steve Jobs, for example, was reported to have delayed conventional cancer therapies and initially experimented with non-conventional therapies when first diagnosed with pancreatic cancer.

On the other hand, for cancer in particular, there has been a growing phenomenon known as ‘integrative medicine’ or integrative care where patients are using non-conventional treatments or therapies alongside their conventional course of care which are seen as supportive to the therapeutic process whether or not they have direct biological effects on cancer.

Many cancer centres in the United States have embraced this by opening centres for integrative medicine within hospitals where patients can have a direct referral from their oncologist to providers with expertise in non-conventional cancer therapies like acupuncture, massage, mind/body therapies, music therapy and nutritional counselling.

Research has shown that some of these therapies can play an important therapeutic and supportive role for cancer patients. Outcomes associated with integrative care  therapies described above include reduced anxiety and stress, and improved sleep and overall quality of life for patients undergoing conventional cancer treatments.

The American models of integrative care, however, have not been replicated in Canadian cancer centres. Wylam Faught, oncologist and medical director of The Ottawa Hospital Cancer Program notes that “there is a different business model in the United States” which has motivated the development of these integrative care programs.

Patients are paying for treatment out of pocket, or through insurers, and there is much more competition and choice among health care providers. One approach to attracting patients has been offering integrative cancer care within the walls of conventional cancer centres in the United States.

Canadian patients and integrative cancer care

While conventional, publicly funded cancer centres in Canada have not embraced integrative care, Canadian cancer patients have.

A study of Ontario breast cancer survivors found that over 40% had visited a practitioner like a chiropractor or naturopath and just over 60% used a product like vitamins/minerals or herbal medicines.

Similarly, a study of colorectal cancer patients in Alberta found that about half had used a non-conventional cancer therapy. About 65% of these patients had used psychological or spiritual therapies like mind/body therapies, 46% used vitamins and minerals and 42% used herbs.

An issue highlighted in these studies is that often cancer patients do not inform their oncologists or conventional health care providers that they are using these therapies. There are many reasons why patients don’t share this information with their doctors. Some are worried their doctors will react negatively or dismiss their questions, while others believe that because these are ‘natural’ therapies, they are safe. Studies suggest that patients will disclose their use of non-conventional treatment or therapies when directly asked about this. However, this does not always occur. In fact, guidelines to help conventional cancer providers discuss and question patients on complementary and alternative medicine use were published for the first time in 2010.

This is a very important conversation that patients need to have with their doctors. Some herbal remedies, vitamins and minerals have been found to have problematic interactions with conventional cancer treatments, like chemotherapy and radiation. For example, studies have shown that a common naturopathic treatment of high-dose intravenous Vitamin C can be harmful in cancer patients with certain risk factors.

Oncologists are  “supportive of whole person care” says Wylam Faught. Though he adds that “when our patients take medications, we want to see these supported by trials, and make sure that these therapies do not take away from the efficacy of conventional cancer therapy.”

Who pays for & provides non-conventional cancer care in Canada?

A survey of Canadian family doctors echoed many of the same sentiments shared by oncologists about non-conventional therapies and treatments. Family doctors had positive attitudes towards therapies like acupuncture, massage therapy, relaxation therapy and spiritual or religious healing, which are perceived as low risk and potentially helpful.

Analysis accompanying the survey data notes that these treatments were for aspects of illness seen “to be chronic or psychosomatic  … which often confound biomedical approaches.” However, family doctors were less accepting of homeopathy and naturopathy.

Stephen Sagar, an oncologist at the Juravinski Cancer Center in Hamilton and past president of the Society for Integrative Oncology says that Canadian patients seeking out non-conventional cancer care first go to naturopaths. He says that because naturopaths are regulated by several Canadians provinces (Ontario, Alberta, Saskatchewan and British Columbia) they have “more power in Canada than elsewhere and we have a parallel private system of naturopathy.”

The majority of Canadian patients seeking non-conventional cancer care are paying for these services out of pocket.

One exception to this is InspireHealth, a group of integrative cancer practices in British Columbia where some services, such as a  consultation about diet and exercise a physician or nurse practitioner, are publicly-funded by the BC government. Other InspireHealth services are paid for out of pocket.  This funding decision was criticized by some voices in the BC medical community as not supporting evidence-based care.

Meeting patient demands for integrative care

In spite of the out of pocket costs associated with these therapies, patients are demanding them. For example, in 2010 the Ottawa Hospital undertook an extensive process to engage patients in how they could improve the patient experience and design a more patient and family-centred approach to care.

A report documenting the engagement process and its outcomes notes that patients believed ‘holistic’ ought to be a core value of the cancer program. Holistic was described as “the complete needs of the patients and their loved ones are met: mind, body and spirit.”

Paula Doering, Vice President of cancer services at the Ottawa Hospital says that when the hospital asked its community where it could improve – one area that consistently came up was non-conventional therapies. “Our patients are seeking out these therapies … if they can manage their symptoms then all the more power to them” she says.

This openness towards integrative care has been reflected in ties being built with the recently-opened Ottawa Integrative Cancer Centre (OICC). OICC services include supportive services such as mind/body therapies and nutrition counseling, which one would see in an American integrative cancer care. However, the OICC website notes that “alongside a whole-person approach to care, we also offer highly selected aggressive natural therapies for their potential benefit and low toxicity profile” including a number of intravenous therapies.

While there is no formal relationship or partnership between the OICC and the Ottawa Hospital, some staff from the two organizations have been working together on research and education.

Shail Verma, an oncologist at the Ottawa Hospital sits on the Scientific Advisory Board of the OICC. “I am open to collaboration” Verma says, highlighting his belief that research efforts on integrative cancer therapies should try to “produce high quality evidence through well controlled trials to generate some objective, truthful and believable evidence.” Verma’s perspective is in line with a broader culture of evidence-based care for cancer patients in Canada. For example, Cancer Care Ontario’s Program in Evidence-Based Care is internationally-recognized for evidence-based guideline development.

Verma says that improved collaboration and communication between patients who are choosing to seek out these therapies and their providers within the conventional system will lead to “a safer approach for patients.”

Similarly, Dugald Seely, a naturopathic doctor and OICC founder has been invited to speak to oncology staff and students at the Ottawa Hospital. Seely says these opportunities to engage conventional cancer providers can help “change perceptions that there is no evidence for the therapies we offer and speak about the evidence base to create more understanding and openness.”

While such relationships foster increased understanding, Seely does acknowledge that since patients pay for their care at OICC out of pocket, there is a stronger incentive to spend more time with each patient.  “We have the time to focus on the whole person, coach and support them and the Canadian reality is that the treatments we offer are not publicly funded ” Seely says.

While oncologists and conventional cancer care providers are increasingly open to integrative care, the practicalities of taking on these therapies and treatments within the conventional cancer system remain an open question. If integrative cancer care and providers grow in popularity, who should pay for these services and what outcomes would be needed to justify this, would join broader debates around access to supportive and survivorship services for cancer patients.

Wylam Faught says “a lot of the support offered by integrative care is through whole person care and mindfulness-type therapies, which are paid for out of pocket, and would be difficult for a public system to take on given the fiscal realities.”

9 Comments
  • karen says:

    Quoting Dr. Samuel Epsteins research “Since environmental contaminents account for 80% of cancers”, who should pay for integrative treatment care? Answer: the contaminators.

  • Milka V. Santoro, RMT says:

    As a Registered Massage Therapist (RMT) trained in Oncology Massage & Reiki- Level 1. I believe CAM should be available in cancer hospitals, treatment centres or hospice where there is supervision. Everyone, no matter who you are are physician, nurse, naturopath or RMT we have all had and will continue to have a client/patient that comes in with either something you have never dealt with before or have never seen on a diagnostic test result… another good reason to be in an institution where you are able to address the situation with a team member. I too believe the more health care professionals that work together will offer the best care to the client/patient.
    I took my training in Massachusetts and am so glad I did. Massage is in MANY cancer centres along with reiki and other therapies in the USA. I am not saying anything negative about Canada as I believe we have the best education but we do not like to branch out into the unknown. And how are we ever going to learn if physicians and complementary care therapists worked together, under one roof, the outcome may be of greater benefit to clients/patients if we don’t try.
    As an RMT I am finding it difficult to try to get oncology massage into a cancer centre or hospital. It would be great if a hospital with all their grants for research to be able to under take their own study of the effects of massage or other complementary therapy on cancer patients.
    I would encourage my clients to ask that such therapies be brought to hospitals/centres and especially discuss it with their oncologist and his/her team.
    We all are aware that cancer has a physical, mental and spiritual effect on patients. Why not give them their treatments along with something comforting that will decrease the anxiety and lift their spirit. A WHOLE person will emerge as they once were and begin to feel better and maybe feel as though they have more strength. And that would be the result of a team of physicians/therapists that worked together.

  • Dugald Seely says:

    Dugald Seely, ND, MSc, FABNO
    Founder & Executive Director; Ottawa Integrative Cancer Centre (www.oicc.ca)
    Director, Research & Clinical Epidemiology; Canadian College of Naturopathic Medicine (www.ccnm.edu)
    Affiliate Investigator; Ottawa Hospital Research Institute (www.ohri.ca)

    To preface my comments, I want to thank the author for a well written and researched piece and for exploring the many angles relevant to integrative cancer care. The issue is ripe for debate and there are positives and cons as in every argument. A health care system that becomes more open to complementary and integrative medicine is going to be faced with unforeseen risks and the way in which this is managed will have consequences. Evolution should happen in this context in a thoughtful way. The idea that this is a genie that can be returned to its bottle is deeply misguided, however. The phenomenon of integrative medicine is thoroughly grass roots, patient driven, and thriving and from my perspective we are the better for it. Integrative oncology is perhaps the area where the most movement is happening. Maybe this is because the personal stakes are profound, complementary medicine utilization rates so high and the potential for patient value great. How the system deals with this movement, and supports or counters it is important and the debate is indeed a healthy one.

    Aside from recognizing the value and including evidence-based complementary medicine, one of the things I like most about integrative oncology is a non-hierarchical patient-centric approach and the idea that a team can and should work together to offer the best care available for the patient according to his or her needs. This is an ideal which we often fall far short of; however, I believe it’s important to keep the goal in sight at all times.

    To engage a team in one’s care, it’s important to select those with the right level of knowledge and training to be sure of getting the safest and best care available. Just as I wouldn’t go to an acupuncturist to provide advice on the best course of chemotherapy or advise me of the chance of long term recurrence, nor would I ask my medical oncologist to advise on the impact nutrition and diet can have to optimize health, nor on natural therapies that may be useful to support active immuno-surveillance. Oncologists have the unenviable role of being perceived as the arbiter of care for the patient when it comes to cancer. The reality is however, that while highly trained and skilled at applying their tools and understanding the course and some conventional treatments for the disease, oncologists are not trained in the modalities of complementary medicine some of which can be exceptionally helpful and indeed evidence based. A team based approach to care whereby individual and (ideally) regulated health care practitioners, be they acupuncturists, counselors, naturopathic doctors, or physiotherapists are brought together to use their strengths seems to be a choice worth making.

    Unfortunately, there are not many integrative cancer centres across Canada or North America, but the number is growing and there are many well trained, ethical, competent, and compassionate practitioners around including community based integrative care centres. As a prospective patient, I would consider interviewing any and all of your health care practitioners to see if they are willing and able to work with other practitioners. Many oncologists, for instance are open to work with a naturopathic doctor, and vice versa. It is the exception to hear of a practitioner that truly wants to provide solely alternative care. If you see this, or hear of any promise for cure, this would be deep red flag and I would urge you to quickly back out the way you came in.

    If I were faced with a diagnosis of cancer, I personally would want to optimize my chances of: a) surviving as long as I could; and b) having the least possible negative impact on my current well-being and future health. Given my background and training, it’s probably no surprise that I would be one of the first users of integrative care and would select a team carefully asking questions all the way through. Some of the key questions to ask (both complementary and conventional practitioners) in assessing what treatments to include would be the following: what are the risks? what are the possible and likely benefits? what is the evidence suppoting this contention? does the therapy work well with the other therapies considered? what is the experience and knowledge base of the practitioner? what is the cost of the therapy? Is there any conflict of interest for the prescription of these therapies? how long do I need to do the treatment for? With enough information and a sense of what truly fit for me, and with whom I was working, I hope I would be supported in including all those options with at least an awareness and agreement from my health care team. Ideally this would be coordinated in a coherent and rational way as well but we are a long ways away from that.

    Selecting one’s team is important and at least from my perspective, I feel comfortable giving some advice on this selection for my profession. First of all, finding a naturopathic doctor from one of the accredited colleges is essential. In Canada you can find a ND with this training on the website for the Canadian Association of Naturopathic Doctors at http://www.cand.ca. In the USA the equivalent is the American Association of Naturopathic Physicians at http://www.aanp.com. Furthermore if you’re looking for an ND with a focus in cancer care, the Oncology Association of Naturopathic Physicians has a website which lists its members at http://www.oncanp.org. A good number of these members have at least five years post grad experience treating people living with cancer and have also completed additional education in cancer care and written an examination to gain the title of Fellow to the American Board of Naturopathic Oncology (FABNO). There is a realization within the profession that additional training is needed to effectively and safely co-manage patients with cancer. I know that my patients benefit from this additional training and the resources available via the organization. I can only hope that my conventional friends and colleagues see this as a strength as well that ultimately improves patient safety and professional communication.

    Integrative care is here to stay. I would argue that energy be invested in how we can best optimize the process of integration so as to strengthen the health care system not further divide it. For anyone seriously interested, the debate is active within the Society of Integrative Oncology (http://www.integrativeonc.org) where the 11th annual conference will be held in Houston Texas this year in conjunction with the MD Anderson Cancer Centre. Attendance for the conference is open and consists largely of oncologists, researchers, patient advocates, naturopathic doctors, nurses and other complementary and conventional health care practitioners involved in cancer care.

    • Zach S says:

      It would be far easier to “change perceptions that there is no evidence for the therapies we offer”, if this clinic sought to develop evidence before providing “highly selected aggressive natural therapies for their potential benefit”.

      Are these evidence-based therapies? If not, it is unclear why they should be protected under the ambiguous banner of “integrative medicine”.

      I see no reason why it should be true that “integrative medicine is here to stay” unless its practitioners seek as a first goal to provide a valid evidence base before they seek to change perceptions. The former is a precursor to the latter, and remains highly questionable so long as integrative medicine continues to “integrate” both the nonsense and the potentially useful (see the full list here: http://www.oicc.ca/en/cancer-care/therapies). Indeed, once the nonsense is removed, there will no longer remain any need to call such medicine “integrative”, it will simply be called “conventional”.

    • Allison C says:

      Thank you Dugald, this was an excellent reply to the professor. I’m so grateful that there are health care practitioners heading up relevant organizations such as this that are respectful and remain OPEN.

      • Stephen Sagar says:

        Hi Allison,

        In the interest of disclosure, would it be fair to say that you are a “counsellor” at a private clinic? If that were the case, your comments could be bias by context. Please confirm or refute, or tell us something about your background, if you wish.

        I am also very “open”. I am sure that would be validated by the several hundred new cancer patients whom I see every year. I also have personal family expertience of cancer.

        Where we differ, is that I believe in evidence, a patient-centered approach, and the best care for my patients within the restrictions of government resources. I cannot condone misleading people by recommending bogus therapies and those not based on science. I do support interventions that enable coping, improved mental status, symptom control, and a better quality of life.

        Once again,
        Best wishes.

  • Stephen Sagar, Professor of Oncology, McMaster University says:

    Having been involved in complementary and alternative medicine (CAM) research for 20 years, I conclude that supervision must be in the regional cancer centres, which are best placed for evidence-based management, credibility, research, safety, and supportive care. The office of the naturopath does NOT provide the equivalent fundamental standards. The advantage of the U.S. and some European cancer centres is the integration into their multidisciplinary programs on site, thereby providing accreditation and regulation for professional standards, efficacy, safety, and research. This is not the case in Canada, a country where some naturopaths even dissuade patients away from vaccination, prescribe homeopathic placebos, and sell their own supplements (a clear conflict of interest not tolerated by the Canadian Medical Colleges).%featured% In Canada, we do not have integrative oncology. Instead, we have a parallel alternative system, called naturopathy (an oxymoron, since most of its prescriptions are not natural). It is an unusual dichotomy of various alternative systems (many having no underlying evidence of efficacy for anti-cancer treatment), mish-mashed with intravenous pharmaceutical doses of vitamins, minerals, and supplements, and experimental or off-label agents, that could pose a safety risk. Mixed into all of this is an eclectic mix of coffee enemas and homeopathy. This is not the direction in which Canadian cancer care should be heading. Ideally, the cancer centres should be providing limited evidence-based complementary therapies for supportive care, symptom control, psychological and physical coaching, as well as cancer prevention and rehabilitation. Unfortunately, most cancer centres are struggling with being able to afford evidence-based anti-neoplastic therapies. Clearly, a new model of care and appropriate funding is necessary that meets patients psychological and physical needs throughout their cancer journey. %featured%We also require more research into the therapeutic relationship and its power for psycho-spiritual healing (that is the person, not the cancer), as well as psychosocial interventions. Instead, society is spending vast amounts of money on ineffective, so-called natural health products that mainly represent a non-evidence based pseudo-pharmaceutical industry.

    • Allison Cassidy says:

      Dear Prof Sagar, I have the utmost respect for all that your education and work life has informed you of. I am however, as a victim of western medical treatment approaches and I am jaded about the way western medicine is practiced by enlarge here in North America. I find your your throw-away comments about homeopathy being mixed in with coffee enema’s, deeply offensive and it only serves to increase my sense of hopelessness that anything of REAL significance wrt OPEN collaboration with western medicine in North America will ever be possible. Please don’t pretend that your profession ‘has all the answers’ – you might say you’re not saying that, but that’s the message. Your form of research isn’t the only valid one either. I came to this page hoping to find the exact opposite of what you write of. How dare you attack the health-supplement industry when the pharmaceuticals are FAR more damaging. I am not the only patient who’s quality of life has been changed dramatically for the better because of the ‘pseudo-pharmaceutical industry’. It’s not perfect, no system is, but it’s a LOT less damaging and life threatening than yours. And before you write about homeopathy/naturopathy again, have the decency to spend a year shadowing a homeopath/naturopath and see what success they have, and the work that they put into a patient, and how they struggle to earn a living in this country. It’s a disgrace. Wake up – there is SO much that patients like myself would gain if there could be REAL co=operation between the different approaches. I find your way of looking at things demeaning and disrespectful.

      • Stephen Sagar says:

        Dear Allison,
        I am sorry you have been a “victim of Western medical approaches”. However, I have also witnessed some quite appalling and damaging interventions from some “alternative” practitioners. To pretend that this does not occur would make me an ostrich. You sound rather angry, and that may be quite justified. However, to let that cloud the truth and disparage the most effective medical system in history would not be favourable for most people, especially when funding and resources for the “biomedical” system are under acute threat. My role is to enable the best care for my patients and that has included not only the best of biomedicine, but also the best of counseling and complementary medicine (used in the appropriate context), including such treatments as acupuncture, massage, mind-body therapies, appropriate nutrition, etc.
        I hope you find the right combination of interventions that help you personally and find peace of mind. Thank you for your comments and my best wishes for the future.

Authors

Karen Born

Contributor

Karen is a PhD candidate at the University of Toronto and is currently on maternity leave from her role as a researcher/writer with healthydebate.ca.

Greta Cummings

Contributor

Greta is the Dean of, and a Professor in, the Faculty of Nursing at the University of Alberta.

Terrence Sullivan

Contributor

Terrence Sullivan is an editor of Healthy Debate, the former CEO of Cancer Care Ontario and the current Chair of the Board of Public Health Ontario.

Republish this article

Republish this article on your website under the creative commons licence.

Learn more