Manuscripts

The Integrative Therapies Program for Children with Cancer is dedicated to evaluating complementary and alternative therapies in pediatric oncology. Below you will find a catalogue of our publications which include our relevant recent abstracts, book chapters, and journal articles. The manuscripts are catalogued by year. A description of the publication is provided.

 

 

 

Hughes D, Ladas E, Rooney D, Kelly K. Massage therapy as a supportive care intervention for children with cancer. Oncology Nursing Forum. 2008; 35(3): 431-442.

PURPOSE/OBJECTIVES: To review relevant literature about massage therapy to assess the feasibility of integrating the body-based complementary and alternative medicine (CAM) practice as a supportive care intervention for children with cancer. DATA SOURCES: PubMed, online references, published government reports, and the bibliographies of retrieved articles, reviews, and books on massage and massage and cancer. More than 70 citations were reviewed. DATA SYNTHESIS: Massage therapy may help mitigate pain, anxiety, depression, constipation, and high blood pressure and may be beneficial during periods of profound immune suppression. Massage techniques light to medium in pressure are appropriate in the pediatric oncology setting. CONCLUSIONS: Massage is an applicable, noninvasive, therapeutic modality that can be integrated safely as an adjunct intervention for managing side effects and psychological conditions associated with anticancer treatment in children. Massage may support immune function during periods of immunosuppression. IMPLICATIONS FOR NURSING: Pediatric oncology nurses are vital in helping patients safely integrate CAM into conventional treatment. Pediatric oncology nurses can help maximize patient outcomes by assessing, advocating, and coordinating massage therapy services as a supportive care intervention.

 

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Lawenda BD, Kelly KM, Ladas EJ, Sagar SM, Vickers A, Blumberg JB. Should supplemental antioxidant administration be avoided during chemotherapy and radiation therapy? Journal of the National Cancer Institute. 2008; 100(11): 773-783.

Despite nearly two decades of research investigating the use of dietary antioxidant supplementation during conventional chemotherapy and radiation therapy, controversy remains about the efficacy and safety of this complementary treatment. Several randomized clinical trials have demonstrated that the concurrent administration of antioxidants with chemotherapy or radiation therapy reduces treatment-related side effects. Some data indicate that antioxidants may protect tumor cells as well as healthy cells from oxidative damage generated by radiation therapy and some chemotherapeutic agents. However, other data suggest that antioxidants can protect normal tissues from chemotherapy- or radiation-induced damage without decreasing tumor control. We review some of the data regarding the putative benefits and potential risks of antioxidant supplementation concurrent with cytotoxic therapy. On the basis of our review of the published randomized clinical trials, we conclude that the use of supplemental antioxidants during chemotherapy and radiation therapy should be discouraged because of the possibility of tumor protection and reduced survival.

 

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Kelly KM. Bringing evidence to complementary and alternative medical therapies in children with cancer: Focus on nutrition related therapies. Pediatric Blood and Cancer. 2008; 50(2 suppl): 490-493.

Children with cancer frequently use complementary and alternative medicine (CAM), especially in conjunction with conventional therapy. Dietary supplements are a commonly used CAM modality, with the prevalence of supplement use ranging from 35% to 50% of children with cancer in surveys completed in the United States. Less is known about the use of dietary supplements in developing countries. The evidence for some dietary supplements providing some benefit to children with cancer is reviewed. Preliminary studies have shown that antioxidant status may affect chemotherapy tolerance in children with acute lymphoblastic leukemia. Other supplements, including TRAUMEEL S, glutamine, vitamin E, Immunocal, colostrum, and probiotics, may help to reduce gastrointestinal toxicities of chemotherapy and radiation. However, more definitive evidence is needed. Most dietary supplements have not been tested adequately to determine their safety and efficacy, with even less understood about their potential interactions with conventional chemotherapy and radiation. With the greater use of dietary supplements by patients with cancer, increasing scientific attention is being paid to the investigation of these therapies. But research on dietary supplements is complex and usually more difficult than that on conventional medications. Strong research designs are critical in obtaining information that will ultimately influence clinical practice and public awareness.

 

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Rogers PC, Melnick SJ, Ladas EJ, Halton J, Baillargeon J, Sacks N. Children’s Oncology Group (COG) Nutrition Committee. Pediatric Blood and Cancer. 2008; 50: 447-450.

The Children's Oncology Group (COG) Nutrition Committee was established to further the knowledge of nutrition in children with cancer by education and the conduct of clinical trials. A survey of COG institutions revealed lack of conformity in evaluation and categorization of nutritional status, and criteria for nutritional intervention. The Committee subsequently established specific categories of malnutrition (Underweight and Overweight) based on ideal body weight or body mass index. An algorithm was developed as a guideline for nutritional intervention as well as references and resources for determining estimated needs. The Committee embarked on concepts for clinical trials of nutritional interventions. The first pilot study, evaluating the feasibility of using an immunoneutraceutical precursor for glutathione production, has been completed. This study showed weight gain and improvement in glutathione status. A pilot trial of proactive enteral feeding for patients at high risk of malnutrition has commenced. The Committee believes that nutrition is relevant to all aspects of cancer control. The paucity of nutritional investigation in children with cancer needs to be rectified.

 

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Kelly KM. Complementary and Alternative Medicines for Use in Supportive Care in Pediatric Cancer. Supportive Care Cancer. 2007; 15(4): 457-460.

Introduction: Complementary and alternative medical practices (CAM) are being used by increasing numbers of children with cancer. Discussion: Recent surveys report CAM use prevalence rates of 24-90% in children with cancer. Interest in supporting children through the side effects or stress of conventional treatment has been described as one of the major motivating factors for the use of CAM therapies. Research is difficult secondary to the complexity of the therapies and lack of standardization. However, several studies investigating CAM therapies for supportive care in children with cancer are ongoing. Information on several studies in progress through the Children's Oncology Group and other institutions will be reviewed. Conclusion: The progress made in the development of these studies demonstrates that CAM therapies can be investigated for their supportive care roles in the therapy if children with cancer.

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Sencer SF, Kelly KM. Complementary and alternative therapies in pediatric oncology. Pediatric Clinics of North America. 2007; 54(6): 1043-1060.

Evidence on the science of complementary and alternative medicine (CAM) in children with cancer is slowly evolving. Most parents of children with cancer want their children to receive state-of-the-art therapy, which generally includes chemotherapy, radiation, and surgery. Increasingly, they also want the concomitant use of CAM therapies to help effect a cure or to alleviate symptoms. The ideal model of integrative pediatric oncology offers safe and effective CAM therapies in a pediatric hospital or medical center setting which participates in the clinical trials network of a pediatric oncology cooperative group setting.

 

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Post-White J, Ladas EJ, Kelly KM. Advances in the use of milk thistle (Silybum marianum). Integrative Cancer Therapies. 2007; 6: 104-109.

Milk thistle (Silybum marianum) is an herbal supplement used to treat liver and biliary disorders. Silymarin, a mixture of flavanoid complexes, is the active component that protects liver and kidney cells from toxic effects of drugs, including chemotherapy. Although milk thistle has not significantly altered the course of chronic liver disease, it has reduced liver enzyme levels and demonstrated anti-inflammatory and T cell-modulating effects. There is strong preclinical evidence for silymarin's hepatoprotective and anticarcinogenic effects, including inhibition of cancer cell growth in human prostate, skin, breast, and cervical cells. Milk thistle is considered safe and well-tolerated, with gastrointestinal upset, a mild laxative effect, and rare allergic reaction being the only adverse events reported when taken within the recommended dose range. More clinical trials of rigorous methodology, using standardized and well-defined products and dosages, are needed to evaluate the potential of silymarin against liver toxicity, chronic liver disease, and human cancers.

 

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Greenlee H, Abascal K, Yarnell E, Ladas E. Clinical applications of Silybum marianum in oncology. Integrative Cancer Therapies. 2007; 6: 158-165.

Milk thistle (Silybum marianum) is an herb that is increasingly used in oncology research and treatment settings. Historically, it has been used to treat liver and biliary disorders and has been used in detoxification and cleansing protocols. However, milk thistle is increasingly being investigated for its use in adult and pediatric populations for oncology indications. Possible indications during cancer treatment include cleansing and detoxification after chemotherapy, preventing hepatotoxicity during chemotherapy, treating hepatotoxicity after chemotherapy, and potentiating chemotherapy and radiation therapy as an adjunctive treatment. Milk thistle may also have applications in ameliorating long-term hepatic and cardiovascular effects of cancer treatment. Preliminary studies are investigating its use as a chemopreventive agent and possibly to treat cancer directly. Much of milk thistle's current clinical use grows out of historical uses but is informed by an increasing number of clinical trials and animal studies. This article provides an overview of the current clinical applications of milk thistle in the oncology setting, including guidelines on commonly used forms and doses.

 

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Sencer SF, Kelly KM. Bringing Evidence to Complementary and Alternative Medicine for Children with Cancer. Journal of Pediatric Hematology Oncology. 2006; 28(3): 186-189

 

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Ladas EJ, Post-White J, Hawks R, Taromina K. Evidence for Symptom Management in the Child with Cancer. Journal of Pediatric Hematology Oncology. 2006; 28(9): 601-615.

 

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Ladas EJ, Sacks N, Brophy P, Rogers PC. Standards of Nutritional Care in Pediatric Oncology: Results From a Nationwide Survey on the Standards of Practice in Pediatric Oncology. A Children's Oncology Group Study. Pediatric Blood and Cancer. 2006; 46: 339-344.

Background: The prevalence of malnutrition in children with cancer ranges between 8% and 60%. Malnutrition is strongly associated with the nature of treatment and increases the individual risk of infection. Clinical studies have suggested that nutrition intervention may decrease toxicity and improve survival in the oncology population. In order to identify the standards of practice in the nutritional management of a child with cancer, we conducted an international survey in institutions that are part of the Children's Oncology Group (COG) consortium. Procedure: Surveys were submitted to 233 participating COG institutions. We requested one member in three disciplines complete the survey: physician, registered dietitian, and nurse or nurse practitioner. The survey was returned to the nutrition subcommittee of COG. Results: Fifty-four percent of institutions responded to the survey. We found no consistency in the provision of nutrition services. Assessment of nutritional status does not routinely occur and different indices are employed to indicate the nutrition status of a patient. Institutions rely upon different guidelines when categorizing malnutrition. When nutrition intervention is clinically indicated, a variety of approaches are employed. Conclusion: This survey did not find standardized nutrition protocols being employed in the pediatric population. The effect of varied nutrition practices on the quality of life, toxicity, and outcome in children with cancer is unknown. Prior to the initiation of clinical trials, uniform guidelines need to be developed and validated. Future clinical trials need to investigate the most efficacious method of nutrition assessment and intervention and its effects on quality of life, toxicity, and survival in children with cancer.

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Granowetter L, Ladas E, Taromina K, Rooney D, Kelly KM. Integrative Tumor Board: Pediatric Synovial Sarcoma. Integrative Cancer Therapies. 2006; 5(1): 48-55.

This article presents the case of an 11-year-old boy diagnosed with a synovial sarcoma of the left jaw and the multidisciplinary, integrative approach utilized by the Division of Pediatric Oncology, Columbia University for the patient. The approach included medical diagnosis and treatment summary, nutrition interventions, acupuncture, Chinese herbal therapy, and reflexology/therapeutic massage and is reviewed.

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Johnston DL, Nagel K, O'Halloran C, Sencer SF, Kelly KM, Friebert S, Hilden JM, Friedman DL. Complementary and Alternative Medicine in Pediatric Oncology: Availability and Institutional Policies in Canada-A Report From the Children's Oncology Group. Pediatric Blood and Cancer. 2006; 47: 955-958.

Abstract: Complementary and alternative medicine (CAM) is used frequently by pediatric oncology patients. A survey exploring the institutional practices and policies surrounding CAM use in pediatric oncology patients was completed by 17 pediatric hematology/oncology centers in Canada. We found that CAM was offered in only 18% of the institutions, but 94% of the communities. Only 6% of oncology divisions made direct referrals to community CAM providers, and only 20% of the centers had policies regarding use of CAM therapies for their patients. Despite published widespread use of CAM therapies, our study demonstrates that institutional CAM resources and policies on CAM are present in much lower proportions.

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Ladas EJ, Sacks N, Meacham L, Henry D, Enriguez L, Lowry GL, Hawkes R, Dadd G, Rogers P. A Multidisciplinary Review of Nutrition Considerations in the Pediatric Oncology Population: A Perspective from Children's Oncology Group. Nutrition in Clinical Practice. 2005; 20: 377-393.

Abstract: Over the past few decades, great progress has been made in the survival rates of childhood cancer. As survival rates have improved, there has been an increase focus on supportive care. Nutrition is a supportive-care modality that has been associated with improved tolerance to chemotherapy, improved survival, increased quality of life, and decreased risk of infection in children undergoing anticancer therapy. Guidelines and assessment criteria have been proposed for the nutrition management of a child with cancer; however there is no consistent use of criteria among institutions treating children with cancer. This review will present the current evidence and standards of practice incorporating aspects of nutrition, nursing, pharmacology, and psychosocial challenges to consider in the nutrition management of a child with cancer. Recommendations for clinical practice are presented.

 

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Ladas EJ. Is Supplementation with Antioxidants Safe During and After Cancer Therapy? Oncology Nutrition Connection. 2005; 13(3): 1-8.

Introduction: Supplementation with antioxidants during cancer therapy has emerged as one of the most controversial adjunct therapies in the field of oncology. Less controversial is the use of antioxidants after cessation of cancer therapy. However, the efficacy of antioxidants as a cancer preventative agent is unknown. This article will provide an overview of the laboratory and animal data surrounding antioxidants and cancer, review the published clinical trials, and provide recommendations for registered dietitians (RDs) to counsel patients on the risks and benefits of supplementation with antioxidants during and after cancer therapy.

 

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Kelly KM. Critique 2: Complementary and Alternative Medicine in Pediatric Oncology. Seminars in Oncology Nursing. 2005; 21(2), Suppl 2: 119-121.

Complementary and alternative medicine (CAM) is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. CAM use is highly prevalent among both adults and children with cancer. While there is scientific evidence supporting the efficacy of some CAM therapies, for most there is little efficacy or safety data from well-designed scientific studies, especially specific to childhood cancer. The research program by Post-White and Hawks describes the initial approach to developing evidence-based research studies of supportive CAM therapies in children with cancer.

 

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Harvey J, Bauer-Wu S, Hawks R, Kelly KM, Laizner AM, Post-White J. Consensus Statement: Complementary and Alternative Medicine Research in Childhood Cancer. Seminars in Oncology Nursing. 2005; 21(2), Suppl 2: 122-124.

Complementary and alternative medicine (CAM) refers to wide variety of potentially healing medical and health care systems and practices that are considered to be outside of mainstream "Western" medicine. As defined by the National Center for Complementary and Alternative Medicine at the National Institutes for Health, there are five major types of CAM:

• Alternative medical systems, (eg, homeopathy or traditional Chinese medicine)
• Mind-body interventions (eg, meditation, prayer, creative activities such as dance, art, music)
• Biologically-based therapies (eg, herbs, dietary supplements)
• Manipulative and body-based methods (eg, chiropractic, massage)
• Energy therapies (eg, qi gong, Reiki, healing touch)

Research is ongoing in each of these areas, especially in the field of oncology, although only limited data are available from the pediatric population.

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Kennedy DD, Ladas EJ, Rheingold SR, Blumberg J, Kelly KM. Antioxidant Status Decreases in Children with Acute Lymphoblastic Leukemia During the First Six Months of Chemotherapy Treatment. Pediatric Blood and Cancer. 2005; 44: 378-385.

Background: Children undergoing treatment for Acute Lymphoblastic Leukemia (ALL) receive combination chemotherapy and many of the components are associated with free radical production. Procedure: Among 103 children newly diagnosed with ALL, plasma concentrations of antioxidants, total antioxidant capacity (ORAC), and DNA oxidized base 8-oxodeoxyguanosine (8-oxo-dG) were analyzed at baseline and 3 and 6 months after diagnosis. Results: Plasma vitamin A, antioxidants, 8-oxo-dG, and ORAC changed from diagnosis through the first 6 months of ALL therapy. In patients with higher plasma concentrations of vitamin A, E, total carotenoids, ORAC, and 8-oxo-dG there was a beneficial association with fewer dose reductions, fewer infections, improved quality of life, less delay in chemotherapy treatment schedule, reduced toxicity, and fewer days spent in the hospital. There were also adverse relationships demonstrated. Conclusions: Among children with ALL, antioxidant levels and oxidative stress appear to be associated with duration and complications of treatment.

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Kelly KM. Complementary and Alternative Medical Therapies for Children with Cancer. 2004; European Journal of Cancer. 40(14): 2041-2046.

Complementary and alternative medical therapies ( CAM ) are treatments that generally fall outside of the mainstream of conventional medicine. CAM therapies are used by 31-84% of children with cancer, including many children enrolled on clinical trials. CAM therapies are often used for the treatment of side-effects of cancer or cancer therapy, and only rarely as an alternative to conventional therapy. Regulation of CAM therapies varies worldwide, and many therapies have not been subject to scientifically conducted analyses. Adverse events have been described, especially from the contamination of herbs. Only rare reports of interactions of CAM therapies with conventional anticancer treatments have been reported. Several research studies of CAM in children with cancer are underway. In the interim, non-pharmacological therapies such as mind-body medicine, manipulative and body-based therapies and energy therapies may be used for supportive therapy. Research is needed before biologically based CAM therapies may be recommended in conjunction with conventional therapy.

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Kennedy DD, Santella RM, Wang Q, Ladas EJ, Kelly KM. 8-oxo-dG Elevated in Children During Leukemia Treatment. Integrative Cancer Therapies. 2004; 3(4): 301-309.

Changes in oxidative stress in children undergoing chemotherapy for acute lymphoblastic leukemia (ALL) have not been well documented. To determine whether the measurement of the DNA oxidized base 8-oxodeoxyguanosine (8-oxo-dG) may be a useful biomarker in this population, the authors conducted an observational study on 103 children with ALL. Blood samples were collected at diagnosis, during interim maintenance (IM), and during delayed intensification (DI). Blood mononuclear cell 8-oxo-dG, measured with an immunohistochemical method, decreased from diagnosis to IM (P=.01) and increased between IM and DI (P.01). In a pilot study, bone marrow was also collected from 16 patients at diagnosis and after 28 days of treatment, but 8-oxo-dG remained the same. The relationship between plasma and dietary intake of antioxidants and the level of 8-oxo-dG was also explored. There was a direct relationship between the intake of vitamin E at diagnosis and bone marrow 8-oxo-dG (P=.03) and an inverse relationship between ß-carotene intake and blood 8-oxo-dG at IM (P=.03) and vitamin A intake and blood 8-oxo-dG at DI (P=.003). Plasma vitamin C (P=.02) and total carotenoids (P=.01) were inversely related to blood 8-oxo-dG at IM. In contrast, higher plasma E/ total lipid levels were associated with higher 8-oxo-dG at IM and DI (P.01). At IM, patients with higher 8-oxo-dG had an increased risk of chemotherapy dose reduction (P=.04). In conclusion, the level of 8-oxo-dG in blood mononuclear cells decreases after the start of chemotherapy and increases during aggressive chemotherapy in children with ALL.

 

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Kennedy DD, Tucker KL, Ladas EJ, Rheingold SR, Blumberg J, Kelly KM. Low Antioxidant Vitamin Intakes are Associated with Increases in Adverse Effects of Chemotherapy in Children with Acute Lymphoblastic Leukemia. The American Journal of Clinical Nutrition. 2004; 79(6): 1029-1036.

Background: Chemotherapy leads to an increase in reactive oxygen species, which stresses the antioxidant defense system. Children with acute lymphoblastic leukemia rarely are overtly malnourished, which makes this population ideal for an investigation of the relations between dietary antioxidant consumption, plasma antioxidant concentrations, and chemotherapy-induced toxicity. Objective: This study was conducted to investigate the effect of therapy on antioxidant intakes in children with acute lymphoblastic leukemia, the relation between dietary antioxidant intakes and plasma antioxidant concentrations, and the relation between the incidence of side effects due to treatment and antioxidant intake. Design: We conducted a 6-mo observational study of 103 children with acute lymphoblastic leukemia. Plasma micronutrient concentrations, dietary intakes, and incidence of side effects of chemotherapy were ascertained at diagnosis and after 3 and 6 mo of therapy. Results: Throughout the 6-mo study period, subjects ingested vitamin E, total carotenoid, ß-carotene, and vitamin A in amounts that were 66%, 30%, 59%, and 29%, respectively, of the US recommended dietary allowance or of the amounts specified in the third National Health and Nutrition Examination Survey. Greater vitamin C intakes at 6 mo were associated with fewer therapy delays, less toxicity, and fewer days spent in the hospital. Greater vitamin E intakes at 3 mo were associated with a lower incidence of infection. Greater ß-carotene intakes at 6 mo were associated with a decreased risk of toxicity. Conclusion: A large percentage of children undergoing treatment for acute lymphoblastic leukemia have inadequate intakes of antioxidants and vitamin A. Lower intakes of antioxidants are associated with increases in adverse side effects of chemotherapy.

 

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Ladas EJ, Jacobson JS, Kennedy DD, Teel K, Fleischauer A, Kelly KM. Antioxidants and Cancer Therapy: A Systematic Review. Journal of Clinical Oncology. 2004; 22(3): 517-528.

Purpose: Many patients with cancer take antioxidant nutritional supplements during cancer treatment to alleviate treatment toxicities and to improve long-term outcomes, but little is known about the efficacy and safety of antioxidant use during cancer treatment. We reviewed English-language manuscripts published in the biomedical literature, reporting the results of observational studies of antioxidant status and cancer outcomes and of intervention trials of antioxidants among patients receiving chemotherapy with or without radiation for various malignancies. Methods: We searched the Medline database and the bibliographies of the retrieved manuscripts, reviews, and books on antioxidants and cancer. The retrieved studies are grouped by study design, malignancy, and end points. Results: More than 100 citations were retrieved; 52 met our criteria, 31 were observational studies, and 21 were intervention trials. The studies varied in study design, timing of observation/intervention, intervention protocol, and anticancer regimen. Conclusion: These inconsistencies preclude a definitive conclusion as to the effect of chemotherapy on antioxidant status in patients undergoing anticancer therapy. However, our review suggests that total antioxidant status (measured by total radical antioxidant parameter) declines during cancer treatment. Adequately powered trials or observational studies among patients with a specific cancer diagnosis receiving a specific treatment regimen are needed to address patients' and physicians' concerns regarding these associations.

 

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Ladas EJ, Kelly KM. Milk Thistle: Is There a Role for Its Use as an Adjunct Therapy in Patients with Cancer? The Journal of Alternative and Complementary Medicine. 2003; 9(3): 411-416.

The use of complementary and alternative medicine ( CAM ) is common among patients with cancer. Many of these patients use CAM therapies to decrease the risk of late effects that are sometimes associated with cancer therapy. Certain classes of effective anticancer agents can induce short- and long- term toxicity to the liver. Currently, there are no safer alternatives to these medications. Milk Thistle ( Silybum marianum ) is a botanical that may be useful in the prevention or treatment of liver dysfunction in patients undergoing anticancer therapy.

 

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Edelblute J. Pediatric Oncology Patients Find Help and Hope in New York City . Alternative Therapies. 2003; 9(2): 106-107.

A descriptive report on The Integrative Therapies Program model and essential program components.

 

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Ladas EJ. The neutropenic diet: an examination of the evidence. ON-LINE. 2002; 10(2).

 

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Antman K, Benson MC, Chabot J, Cobrinik D, Grann VR, Jacobson JS, Joe AK, Katz AE, Kelly K, Neugut AI, Russo D, Tiersten A, Weinstein IB. Complementary and alternative medicine: The role of the cancer center. Journal of Clinical Oncology. 2001; 19(18s): 55-60.

 

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Kelly KM, Jacobson JS, Kennedy DD, Braudt SM, Mallick M, Weiner MA. Use of Unconventional Therapies by Children with Cancer at an Urban Medical Center. Journal of Pediatric Hematology/Oncology. 2000; 22(5): 412-416.

 

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Kelly KM. Antioxidants and cancer: The Labrioloa/ Livingston article reviewed. Oncology, 1999; 13(7): 1008-1011.

 

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Ladas EJ, Kelly KM. Complementary therapies in Children with Cancer. In Barraclough J, ed. Enhancing Cancer Care: Complementary Therapy and Support. USA: Oxford University Press, 2007.

 Book Description: Around one in three people in the western world will develop cancer at some stage in life and complementary therapies are increasingly being used alongside orthodox treatments as part of the 'integrative' approach to cancer care. Enhancing Cancer Care is a practical, evidence-based guide to complementary cancer therapies, also described as natural or holistic therapies. More and more patients are turning to these therapies as there is now considerable evidence that they can help with symptom-control and quality-of-life, and that some may also extend survival. Complementary therapies can also provide the patient with a greater sense of control regarding the management of their illness. From the editor of Integrated Cancer Care, this new title provides detailed commentary on a broad range of complementary therapies and features practical advice on how to implement therapies to enhance current practice. The first part of the book deals with the general principles behind complementary therapies and the factors driving their growing popularity, the challenges of evaluating their benefits and unwanted effects, and experience of using them in oncology units, hospices, the private sector and primary care. The second part includes chapters on specific interventions, including complementary therapies such as acupuncture and aromatherapy massage; lifestyle modifications through diet and exercise; creative therapies using art and music; and psychological and spiritual support for individuals and groups. These chapters provide descriptions of the therapies, a summary of the evidence for their benefits in cancer care, and illustrative case histories. The emphasis throughout this book is on enhancing practice; that is, using the therapies alongside conventional medicine, rather than as alternatives to it.

 

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Sencer SF, Reaman GH, Kelly KM. Use of Complementary and Alternative Medicine in Childhood Cancer: Truth or Consequences. 2007 American Society of Clinical Oncology Educational Book.

Overview: The use of complementary and alternative medicine (CAM) during illness is as old as medical systems themselves, yet the present day use of CAM modalities by children with cancer causes many traditionally trained pediatric oncologists grave concern. Worries about drug--herb or drug--supplement interactions are understandable, and there is also the possibility that a family might eschew lifesaving chemotherapy, radiation, or surgery for a more natural approach. Oncologists look to conventional research techniques, such as the large-scale randomized double-blinded control trial, to study the efficacy and safety of CAM modalities but find that these methods are limited in their ability to address the questions that parents and patients pose. The ready availability of anecdotal stories and commercial promises of cure especially on the Internet increase the frustrations of the practitioner. Nonetheless, a body of science on CAM and children with cancer is developing. This article attempts to address the concerns that practicing oncologists have about CAM use and their patients. It discusses the modalities that have evidence of benefit, as well as those that should be discouraged for use with children with cancer. Large-scale clinical trials within the context of the cooperative group setting have been the hallmark of pediatric oncology research, and the large advances in survival have been the direct result of these endeavors. This manuscript outlines the challenges of applying similar standards and attempting CAM research within the cooperative group setting and highlight those areas of promising research.

 

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Ladas EJ, Hawkes R. "Pediatric Cancers." Nutritional Issues in Cancer Care. Ed. Valerie Kogut and Sandra Luthringer. Pittsburgh: Oncology Nursing Society, 2005. 235-252.

A practical guide on nutrition for healthcare professionals, Nutritional Issues in Cancer Care provides site-specific information regarding the disease, common treatment modalities, and nutritional implications related to the disease and its treatment. Co-authored by a registered nurse and registered dietician, this chapter provides a comprehensive background on pediatric cancers and treatment modalities. Nutritional management, nutritional assessment guidelines, nutritional interventions, and recommendations in the management of obesity and late effects in the pediatric cancer patient are reviewed.

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Kelly KM. Integrating Complementary Therapies in the Care of Children with Cancer: Research and Clinical Practice. 2004 American Society of Clinical Oncology Education Book, pages 614-619.

Complementary and alternative medicine ( CAM ) therapies are being used by increasing numbers of children with cancer. Recent surveys report CAM use prevalence rates of 31% to 84% of children with cancer. Interest in supporting children through the side effects or stress of conventional treatment has been described as one of the major motivating factors for the use of CAM therapies. Adverse events have been reported with CAM therapies, especially from contamination of herbal products. Herbs are marketed as dietary supplements and are not subject to the same United States Food and Drug Administration oversight as conventional drugs. Much concern has been raised regarding interactions with conventional chemotherapy and radiotherapy; however, no actual herb-drug interactions have been reported in humans who undergo cancer treatment. St. John's wort induces CYP3A4 that, in turn, may lead to a reduction in levels of chemotherapy drugs that are metabolized through the cytochrome P450 system. Antioxidant supplements may quench chemotherapy-initiated antitumor free radicals and adversely affect outcome or, alternatively, reduce toxicity from chemotherapy and ultimately improve overall outcome. Research in CAM is lacking, especially studies of CAM in children with cancer. Research is difficult secondary to the complexity of the therapies and lack of standardization. However, several research studies in childhood cancer and CAM are ongoing. In the interim, nonpharmacologic therapies, such as mind-body medicine, biofield therapies, and manipulative and body-based methods, may often be used safely. Further research is needed before biologically based therapies can be recommended routinely.

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Ladas EJ, Kroll D, Kelly KM. "Milk Thistle." Encyclopedia of Dietary Supplements. Ed. Paul Coates. New York: Dekker Publications, 2004.

Abstract: Milk thistle [Silybum marianum (L.) Gaertn. (Asteraceae); also Carduus marianus L.] is a herb widely used in Europe for the treatment of liver and biliary disorders. Although milk thistle is the most commonly used name for the herb, other names include silymarin, holy thistle, St. Mary thistle, Mary thistle, Marian thistle, Mariendistel, and lady s thistle. The plant is indigenous to Europe but can be found in the western and southwestern United States. In ancient times, the leaves of milk thistle were used as part of the European diet. The medicinal properties of the herb reside in its seeds. The primary active component, silymarin, is a potent antioxidant mixture composed of several related flavonolignans.

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Hughes D, Ladas E, Cheg B, Kelly K. Complementary/Alternative Medicine (CAM) Use by Survivors of Childhood Cancer. Presented at the American Public Health Association 136th Annual Meeting 2008.

 

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Ladas EJ, Yeh L, Orjuela M, Cheng B, Kelly KM . Dietary Antioxidant Intake among Survivors of Childhood Cancer. Presented at the Society for Integrative Oncology, 5th International Conference 2008.

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Weitzman A, Taromina K, Rooney D, Ladas EJ, Hughes D, Li E, Kelly KM . Bridging diagnostic relationships between Traditional Chinese Medicine (TCM) and conventional medicine in the care of children with cancer. Presented at the Society for Integrative Oncology, 5th International Conference 2008.

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Taromina K, E Ladas, D Rooney, D Hughes, A Meyer, K Kelly. Acupuncture is feasible in children with cancer with low platelet counts. Presented at the Society for Integrative Oncology, 4th International Conference 2007.

 

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E J Ladas, D Hughes, B Cheng, K Kelly. Complementary/ Alternative Medicine (CAM) Therapies Use By Survivors of Childhood Cancer. Presented at the Society for Integrative Oncology, 4th International Conference 2007.

 

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Amie Dave BS, Elena Ladas RD MS, Deborah Hughes BA, Steve Sands PsyD, David Kroll PhD, Linda Vahdat MD, Olga Bessmertny PharmD ,Michael Weiner MD, Kara Kelly MD, Julia Glade Bender MD. A pilot study investigating the effects of glutamine and vincristine-induced neuropathy in pediatric patients with cancer. Presented as oral presentation at the Society for Integrative Oncology's (SIO) Fourth International Conference, November 2007.

 

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Rooney D, Ladas EJ, Taromina K, Hughes D, Kelly KM. A Retrospective Review Investigating the Feasibility of Acupuncture as a Supportive Care Agent in a Pediatric Oncology Service (Abstract). Presented at the Society for Integrative Oncology, 3rd  International Conference 2006, and the Society for Acupuncture Research Annual Conference 2007.

 

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Elena J Ladas, Bin Cheung, Deborah Hughes, David J Kroll, T N Graf, N H Oberlies, Susan Rheingold, Nancy Sacks, and Kara M Kelly, MD. Milk Thistle is Associated With Reductions in Liver Function Tests (LFTs) in Children Undergoing Therapy for Acute Lymphoblastic Leukemia (ALL). Presented at the American Society of Hematology, 48th Annual Meeting and Exposition 2006.

 

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Melnick, SJ, Rogers, P, Sacks, N, Kwyer, TA, Halton, J, Sandler, E, Escalon, E, Ladas, EJ. A Pilot Limited Institutional Study to Evaluate the Safety and Tolerability of Immunocal®, a Nutraceutical Cysteine Delivery Agent in the Management of Wasting in High-Risk Childhood Cancer Patients. Chicago Supportive Oncology Conference, August 2005.

This pilot study, conducted through the Nutrition subcommittee of the Children's Oncology Group (COG), evaluated the safety and tolerability of Immunocal®, an undenatured whey-protein derivative which provides glutathione precursors. Depletion of reduced glutathione (GSH) in various organs including the immune system is a common finding in cachexia, reduced immune function, and poor wound healing, which are among the serious consequences cancer patients endure due to their disease and/or therapy. The study was a 90-day, two-dose evaluation of Immunocal® (0.5 g/kg/d vs. 1.0 g/kg/d) added to the standard institutional nutritional regimen. Twelve patients with high-risk tumors were enrolled from three institutions. Clinical and biochemical data were assessed at baseline and days 45 and 90. Immunocal® was successfully administered by one or more of three routes: oral, gastric tube, and nasogastric tube and was generally well tolerated. Compliance ranged from 50%-100% (7 patients with > 80%). All but 4 patients gained weight ranging from 7.1%-26.9% from the prestudy weight. Though not statistically significant, GSH levels were increased and oxidized glutathione (GSSG) levels decreased in all but 1 patient. Other observations include the amelioration of severe mucositis in 2 patients and abatement of nausea and vomiting in 2 patients. The findings indicate Immunocal® can be given safely and was well tolerated in the majority of pediatric cancer patients. The results are being used to establish end-points for a double-blind placebo controlled trial to be submitted to the COG scientific committee to evaluate of the efficacy of Immunocal® in high-risk cancer patients.

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Last updated: October 13, 2009