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2260   Part XIII  Consultative Hematology


                                                                 taxanes,  and  corticosteroids)  is  less  likely  to  be  associated  with
         BOX 156.1  Recommendations for Patients
                                                                 interactions.  Caution  should  be  taken  with  other  agents  (e.g.,
          “All patients with hematologic problems should be asked specifically   antiangiogenic agents, tyrosine kinase inhibitors) for which there
          about their use of complementary and alternative therapies.”  is insufficient information.
           “All  patients  with  hematologic  problems  should  receive  guidance
          about the advantages and limitations of complementary therapies in
          an open, evidence-based, and patient-centered manner by a qualified
          professional.”                                      REFERENCES
         Adapted from Deng GE, Cassileth BR, Cohen L, et al: Integrative oncology
         practice guidelines. J Soc Integr Oncol 5:65, 2007.   1.  Schultz AM, Chao SM, McGinnis JM: Integrative medicine and the health
                                                                 of the public: a summary of the February 2009 summit, Washington, DC,
                                                                 Institute of Medicine, 2009, National Academies Press.
                                                               2.  McGuire  S:  Complementary  and  alternative  medicine  in  the  United
        concern is that antioxidants might somehow interfere with or coun-  States, Washington, DC, 2005, National Academies Press. Institute of
        teract  the  activities  of  these  anticancer  agents.  However,  to  date,   Medicine.
        preclinical  experiments  and  clinical  studies  have  not  definitively   3.  Clarke TC, Black LI, Stussman BJ, et al: Trends in the use of complemen-
                                    48
        shown impact on treatment outcome.  Of particular note, an obser-  tary health approaches among adults: United States 2002-2012, National
        vational  cohort  study  from  the  Fred  Hutchinson  Cancer  Research   Health Statistics Report; no 79, Hyattsville, MD, National Center for
        Center  in  Seattle  evaluating  the  prevalence  of  supplement  use  in   Health Statistics, 2015.
        persons before receiving hematopoietic stem cell transplant (HSCT)   4.  Gansler  T,  Kaw  C,  Crammer  C,  et al:  A  population-based  study  of
        and the association of select supplements with outcomes found that   prevalence of complementary methods use by cancer survivors: a report
        pretransplant  intake  of  vitamin  C  (≥500 mg/day)  or  vitamin  E   from the American Cancer Society’s studies of cancer survivors. Cancer
        (≥400 IU/day) was associated with increased risk of relapse or mortal-  113:1048, 2008.
          49
        ity.  Others have reported deficiencies before and immediately after   5.  Snyderman R, Weil AT: Integrative medicine: bringing medicine back to
             50
        HSCT.  However, few clinical studies have built upon observational   its roots. Arch Intern Med 162:395, 2002.
        studies. One small study performed among patients with AML and   6.  Eisenberg DM, Kessler RC, Van Rompay M, et al: Perceptions about
        ALL undergoing HSCT (NCT01432873) randomized adults (n =   complementary therapies relative to conventional therapies among adults
        77) to selenium (200 µg, twice daily) or placebo beginning on the   who use both; results from a national survey. Ann Intern Med 135:344,
        day of conditioning therapy and continuing to day 14 post-HSCT.   2001.
                                                   51
        No  effect  on  proinflammatory  cytokines  were  observed.   Another   7.  Sparreboom A: Herbal remedies in the United States: potential interac-
        small study investigated the addition of vitamin C to conventional   tions with anticancer agents. J Clin Oncol 22:2489, 2004.
        treatment for acute promyelocytic leukemia; no beneficial effects on   8.  Kelly KM: Bringing evidence to complementary and alternative medi-
        outcome were observed. 52                                cine in children with cancer: Focus on nutrition-related therapies. Pediatr
           Recent  studies  have  shown  interactions  of  antioxidant  supple-  Blood Cancer 50:490, 2008. discussion 8.
        ments  with  the  proteasome  inhibitor  bortezomib.  Vitamin  C,  at   9.  Sencer SF, Kelly KM: Bringing evidence to complementary and alterna-
        orally achievable concentrations (equivalent to 1 g/day, a dose fre-  tive medicine for children with cancer. J Pediatr Hematol Oncol 28:186,
        quently used by patients), inhibited the in vitro multiple myeloma   2006.
        cell cytotoxicity of bortezomib and blocked its inhibitory effect on   10.  Valji  R,  Adams  D,  Daganis  S,  et al:  Complementary  and  alternative
        20S  proteasome  activity.  In  addition,  green  tea  polyphenols  and   medicine: a survey of its use in pediatric oncology. Evid Based Comple-
        dietary supplements carrying hydroxyl groups, including flavonoid   ment Alternat Med 2013:527163, 2013.
        compounds such as quercetin, bind and inhibit the activity of bort-  11.  O.Connor N, Graham D, O’Meara A, et al: The use of complementary
        ezomib on malignant B cells and multiple myeloma cells in vitro,   and alternative medicine by Irish pediatric patients. J Pediatr Hematol
        although by mechanisms independent of their antioxidant activity.   Oncol 35:537–542, 2013.
        Taken together, these studies suggest that antioxidant supplements   12.  Wesa KM, Cassileth BR: Is there a role for complementary therapy in
        should be avoided in patients taking bortezomib and other boronic   the management of leukemia? Expert Rev Anticancer Ther 9:1241, 2009.
        acid proteasome inhibitor therapy.                    13.  Barton DL, Loprinzi C, Jatoi A, et al: Can complementary and alterna-
           The precise role of antioxidant supplementation in the patients   tive medicine clinical cancer research be successfully accomplished? The
        with  hematologic  malignancies  remains  to  be  determined.  Studies   Mayo Clinic-North Central Cancer Treatment Group experience. J Soc
        adequately evaluating the impact of supplementation on toxicity and   Integr Oncol 4:143, 2006.
        disease-free survival have not yet adequately demonstrated that the   14.  Verhoef MJ, Leis A: From studying patient treatment to studying patient
        benefits of supplementation clearly outweigh the risks; therefore the   care: arriving at methodologic crossroads. Hematol Oncol Clin North Am
        possibility of harm must be strongly considered (Box 156.1). Recom-  22:671, viii–ix, 2008.
        mendations  for  clinical  practice  at  the  present  time  include  the   15.  Yeung  KS,  Gubili  J,  Cassileth  B:  Evidence-based  botanical  research:
        following:                                               applications and challenges. Hematol Oncol Clin North Am 22:661. viii,
                                                                 2008.
        •  Patients should be advised to avoid dietary antioxidant supple-  16.  Weiger W, Smith M, Boon H, et al: Advising patients who seek comple-
           ments above the basic nutritional requirements as defined by the   mentary and alternative medical therapies for cancer. Ann Intern Med
           National Academy of Science, Dietary Reference Intakes during   137:889, 2002.
           radiation therapy and stem cell transplantation. Until safety data   17.  Gordon JS: Mind-body medicine and cancer. Hematol Oncol Clin North
           is  available,  doses  should  not  exceed  the  upper  tolerable  limit   Am 22:683. ix, 2008.
           during treatment.                                  18.  Dusek  J,  et al:  Stress  management  versus  life-style  modification  on
        •  Patients  should  avoid  dietary  antioxidant  supplements  while   systolic  hypertension  and  medication  elimination,  a  randomized  trial.
           receiving bortezomib and other boronic acid proteasome inhibitor   J Altern Complement Med 2:129–138, 2008.
           therapy.  Counseling  patients  to  avoid  supplementation  while   19.  Niles H, Mehta DH, Corrigan AA, et al: Functional genomics in the
           receiving  chemotherapy  associated  with  high  oxidative  stress   study of mind-body therapies. Ochsner J 14:681–695, 2014.
           (anthracyclines,  alkylating  agents,  platinum-containing  agents,   20.  Rossman M, Shrock D: Mind-body medicine in integrative cancer care.
           topoisomerase I and II inhibitors) is encouraged.     In  Abrams  D,  Weil  A,  editors:  Integrative  oncology,  New  York,  2009,
        •  Use  of  antioxidant  supplements  while  receiving  chemotherapy   Oxford University Press, p 244.
           associated  with  low  oxidative  stress  (purine  or  pyrimidine  ana-  20a.  Park ER, et al: A relaxation response training for women undergoing
           logues,  antimetabolites,  monoclonal  antibodies,  vinca  alkaloids,   breast biopsy: exploring integrated care. Breast 22(5):799–805, 2013.
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