صفحه 1:
www.t air
Children’s Hospital
of NewYork-Presbyterian
اهوم وا of Columba and Corel
صفحه 2:
ساف هیا ار
mplementary
Thera ies in the Care
of Children with
Cancer: Research and
Clinical Practice
Children’s Hospital
7 of NewYork-Presbyterian
The Unersty Hostal of columbian corel
Kara Kelly, M.D.
Inte
صفحه 3:
What is CAM?
= Group of diverse
medical and health
care systems,
practices and
products that are
not presently
considered to be
part of
conventional
medicine
Children’s Hospital
of NewYork-Presbyterian
The Univers Hostal of Columba and Corel
صفحه 4:
Complementary: Used together
with conventional medicine
Alternative: Used in place of
conventional medicine
Integrative: Combines
mainstream medical therapies and
CAM therapies for which there is
some high quality scientific
evidence of safety and efficacy
صفحه 5:
NCCAM
Classification
Alternative medical systems (Traditional
Chinese Medicine, Ayurveda, homeopathy)
Mind-body interventions (yoga, imagery,
meditation, prayer)
Biological based therapies (herbs, high
dose vitamins, antioxidants, mushrooms, enzymes )
Body based therapies (chiropractic or
osteopathic manipulation, massage)
Energy therapies (Reiki, therapeutic touch,
magnets)
i Children’s Hospital
necam.nih.gov of NewYork-Presbyterian
The Unersty Hostal of cumbia and corel
صفحه 6:
Children with Cancer are
using CAM
90
80
70
60
% 50
40
30
20
10
77-3 94-8 00-03
Year of Survey
صفحه 7:
Reasons for CAM Use
= "to try everything possible”
" to reduce stress of illness
= improve quality of life
= symptom care management
™ sometimes for cure
Columbia survey: Perceived effectiveness is high-
86% very or somewhat effective for intended purpose
Children’s Hospital
of NewYork-Presbyterian
The Unersty Hostal of cumbia and corel
صفحه 8:
How are Patients Using
CAM?
Reason Physician Told
Build Immune system, No
‘Stop Tumor Promoter with fat
Detoxify, Enhance immune system,
Wound healing, Antibiotic
Enhance immune sytem Detoxty,
Build white blood cells, Antil
Stop tumor growth, Replace good
bacteria in gut
Healing, Strengthening
Children’s Hospital
of NewYork-Presbyterian
The Univers Hospital of ClumbiandComel
CAM Supplement
Diet: Stopped Fried Foods;
Vegetables, Juicing
Nutrients: Grape seed extract, Pycnogenol,
CoenzymeQ10, Colloidal silver, Barley green,
mv
Herbs: Garlic, Herbal Preparation with
Echinacea, Goldenseal, Licorice, Myr,
Marshmallow, Black "Walnut, Tumeric,
‘Capsicum, Germanium
Supplements: Mataki mushroom, Acidophilus,
Royal bee jelly, Blue green algae
Mind/ Body: Prayer
sTupy ID#
020081
صفحه 9:
73% of children were enrolled on
clinical trials for treatment of
their malignancy
85% were using some form of
CAM:
Herbs 25%
Nutritional supplements 34%
J Pediatr Hematol Oncol 22:412,2000
صفحه 10:
Why the
Controversy?
= Few Clinical trials of safety and
efficacy, especially in children
= Regulation of herbs and dietary
supplements varies world wide,
although most are not subject
to the same regulations that
apply to conventional drugs
Children’s Hospital
of NewYork-Presbyterian
The dco
صفحه 11:
Adverse Effects
=" Pharmacologic
therapies:
* Direct effect
* Contamination
* Interactions with
conventional medications
صفحه 12:
Adverse Effects
Laxative
Nausea, Gl discomfort
Antiplatelet effects
Hypotension
Gastric irritation
Hepatitis, cirrhosis, liver failure
Nausea, vomiting, dizziness, diarrhea
Amenorrhea, diarrhea,
pseudohypoaldosteronism
Seizures
Hypertension, sudden death
Children’s Hospital
of NewYork-Presbyterian
The University Hospital of Columbia and Corel
Aloe vera
Evening primrose oil,
bovine colostrum
Borageseed oil
Cat's claw
Cayenne capsules
Kava
Lobelia
Glycyrrhizin (licorice root)
Star anise
Ephedra, ma huang,
Sida cordifolia, pinellia
صفحه 13:
Contamination of
herbs
Lead TCM, Surma/kajal,
bint al dhahab, Litargirio
Arsenic lu Huang Chieh Tu Pien,
other TCM
Mercury Watermelon frost (TCM)
Warfarin, DES |PC-SPES
Children’s Hospital
York-Presbyterian
ty Hostal of lumi and Come
Eur J Pediatr 162:72, 2003
صفحه 14:
Herb-Drug
Interactions:
Sources of Information
B Animal Studies
@ Theoretical
Empirical
UO Case reports
@ Clinical Studies
@ Clinical Trials
HerbalGram 49:2000.
صفحه 15:
SN-38 (ng/mL)
Time (h)
Fig. 1. Effect of St. John's wort on the
lasma concentration of the active
irinotecan metabolite SN-38 over time.
JNCI 94:1247,2002
صفحه 16:
Chemotherapy/Herb
Interactions
Cordyceps, country
mallow, ephedra,
marshmallow, fish oils,
garlic, grapefruit,
L-arginine, red yeast
Licorice, alfalfa
sprouts, astralagus,
cat’s claw, echinacea,
St John’s wort, vitamin
E, zinc
Black cohosh,
echinacea, salicylate
containing herbs:
bilberry, meadow
sweet, poplars, red
clover, white willow,
wintergreen
Reduced
immunosuppressi
on
Increased
immunosuppressi
on
Increased
hepatotoxicity
Corticosteroi
d
Cyclosporin
Methotrexat
e
صفحه 17:
Oxidative Stress and Chemotherapy
Drugs
High Anthracyclines
Pt-complexes
Alkylating agents
Epipodophyllotoxins
Camptothecins
Purine/Pyrimidine
Antimetabolites
Low Taxanes
Vinca alkaloids
صفحه 18:
Observational Studies: The Effect of
Cancer Therapy on Antioxidant Levels
(n=31)
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Otawia C Orawia @ Geleaiue سا TERE
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Gatioxtdast
JCO 22:517, 2004
صفحه 19:
The Effect of Supplementation with
Antioxidants in combination with
Cancer Therapy on Antioxidant Levels
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JCO 22:517, 2004
صفحه 20:
Immunostimulants
" Mistletoe, Asian mushrooms
(maitake, reishi, shiitake, coriolus
versicolor, PSK), Astralagus
= Actions: Increase cytotoxic T-cells
or NK cells activity, increase
endogenous production of
interferon, interleukins, or
cytokines
e
Discourage in patients with:
Hematologic malignancies, Stem cell
transplants
صفحه 21:
Warning signs of Possible
Interactions
= Tolerance to conventional drug
administration that is better or
worse than expected:
* Unexpected refractoriness to
treatment
* Unusual toxic effects from treatment
Labriola D, Livingston R. Oncology 13:1999
Children’s Hospital
of NewYork-Presbyterian
The Unersty Hostal of cumbia and corel
صفحه 22:
Non-pharmacologic
Therapies
™ Chiropractic
* cerebrovascular accidents,
acute necrosis of holocord
astrocytoma, vertebral artery
dissection
™ Acupuncture
* cardiac tamponade, epidural
abscess formation, HIV infection
* overall underlying adverse
event rate: 0-1.1 per 10,000
treatments Children’s Hospital
of NewYork-Presbyterian
The Unersty Hostal of cumbia and corel
صفحه 23:
۲ ۷ ۲ ,1سا 2۶۷۲5 2
varies from state to
state
= Chiropractors: every state, Washington
DC
= Massage therapists: ~25 states
= TCM practitioners: ~25 states
=" Naturopathic physicians: 12 states
=" Homeopathic physicians: 3 states
Dermatologic Therapy 16:77,2003
Children’s Hospital
ke Presbyte
صفحه 24:
Barriers to Research
" Difficulties in conducting studies of complex
therapeutic systems
" Emotional issues leading to biases in patient
recruitment
۶ Lack of standardization of herbs/dietary
supplements
" Difficulty in determining an adequate placebo
=" CAM providers may have little incentive for
scientific evaluation of CAM therapies
Children’s Hospital
of NewYork-Presb
The Unversity Hostal of Col
rial
ja and Cornell
صفحه 25:
۸۸۲۱۷ 6 ۳۵۲00۲۱2606 ۱
Trials in Pediatric Cancer and
CAM
TRAUMEEL S® (Homeopathy) for prevention and
treatment of Mucositis in SCT (COG)
Electroacupuncture for Chemotherapy induced Delayed
Nausea/Vomiting in Pediatric Solid Tumors (NCI)
Silymarin in Maintenance therapy in Children with ALL
and Abnormal LFTs (Columbia)
Aromatherapy for Reduction of Anxiety/Nausea during
SCT (Columbia)
Massage Therapy and Childhood Cancer (Childrens
Minneapolis)
Aromatherapy as an Intervention for Nausea and
Vomiting in Children receiving Chemotherapy for
Cancer (Childrens Minneapolis)
صفحه 26:
صفحه 27:
Nausea/Vomiting
" Herbs
Ginger, Peppermint, Fennel
™ Chamomile Compresses
=" Aromatherapy
Citrus (Bergamont, Mandarin, Citrus
Mixtures)
= Acupressure
P-6 Point (Acupressure ban
resbyterian
ها con
صفحه 28:
Cornel
Palliative Care
= Alternative medical systems:
acupuncture
۴۶ Mind-body medicine:
Meditation, prayer, music
therapy
" Body-based therapies: Massage
= Energy therapies: Reiki,
Therapeutic touch Children’s Hospital
of NewYork Presbyterian
The Univers Hostal of Columbia and
صفحه 29:
Screening for child CAM
use:
Do you give your child any herbal or plant products?
Do you give your child any homeopathic products?
Do you use any unconventional/alternative types of
care or therapies for your child?
Do you use any special vitamin therapy for your
child?
Do you use any unconventional treatments,
alternative types of care, or therapies for yourself to
stay healthy or to manage a health problem?
J Pediatr Health Care 17:58,2003
Questions only identified 24% of parents using CAM
صفحه 30:
۵1۵-2 سل صد |6۵ 8 ها 6 6۳
www.integrativetherapiesprogram.org
صفحه 31:
The Bottom Line...
" Children with cancer are using CAM
therapies
= Physicians need to inquire about CAM use
™ Biologically active therapies including herbs
and dietary supplements are often used
" Adverse effects and especially interactions
with conventional drugs are possible
= CAM therapies may be especially useful for
symptom management
Children’s Hospital
of NewYork-Presb
The Unversity Hostal of Col
rial
ja and Cornell