Integrative Medicine in Pediatric and Adolescent Oncology: An Overview for the Nurse and Nurse Practitioner (008)

3.25CNE  The journey through cancer therapy is complex. While no two patients experience it the same way, there are predictable similarities when considering patient age, diagnosis, and therapy that is administered. Common problems encountered by many patients include diminished energy and physical stamina, neuropathy, disturbed sleep, poor appetite, weight loss, and exaggerated nausea.

Integrative medicine combines mainstream medical therapies with complementary therapies for which there is high quality scientific evidence of safety and effectiveness. In the setting of active treatment for children and adolescents with cancer, it consists primarily of complementary therapies intended to support general health or to limit specific treatment related toxicity. Numerous modalities may fall within this category, including dietary modification, nutrient and botanical supplements or applications, guided imagery, aromatherapy, acupuncture, and massage. It is estimated that 30–70% of pediatric patients use integrative medicine strategies; since this is by parental report, many studies likely underestimate their use.

Because of the breadth and diversity of integrative medicine, as well as its widespread use, oncology teams equipped to guide its safe implementation may be well positioned to deliver knowledgeable and patient centered care. This session will first provide an overview of commonly available integrative medicine strategies that can be safely incorporated into a patient care plan, whether for generalized wellbeing during cancer therapy, or for a more specific physical complaint. Common integrative medicine approaches used to combat the frequently encountered side effects of nausea, peripheral neuropathy, and excessive fatigue will be discussed in terms of safety, effectiveness, and physiologic effects. It is often these simple interventions that can significantly diminish distressing side effects, empower patients and their families, and drastically improve quality of life.

Although pediatric cancer survival rates have significantly increased over the past four decades, cancer treatments place patients at increased risk for psychiatric symptoms.  While there is limited longitudinal research on children and adolescents during active treatment, studies suggest that 10-15% of patients demonstrate increased symptoms of anxiety and depression.  Many within this subset exhibit significant psychiatric symptoms that necessitate intervention. Untreated, these symptoms may contribute to non-adherence with oncologic treatment which can affect long-term survival. Physical symptoms secondary to depression may result in unnecessary dose adjustments, transfusions, and increased frequency of follow-up.

There are many barriers that hinder the provision of comprehensive psychiatric care for pediatric oncology patients, including location and size of the center, lack of funding, and sparse qualified personnel to provide such care.  Patients may also have difficulties accessing psychiatric care due to lack of insurance, limited psychiatric providers near their home, heavy treatment burdens, and/or frequent appointments and hospitalizations.

A study in 2006 evaluated pediatric oncology staff assessment of depression and anxiety and found staff to underestimate psychosocial symptoms and to inaccurately attribute these symptoms to disease and treatment. Differentiating psychiatric symptoms from physiological effects of cancer and its treatment is challenging and best assessed by a multi-disciplinary team that includes behavioral health specialists.  Once psychiatric symptoms are identified, cognitive-behavioral therapy (CBT) is usually the initial treatment of choice; however, psychotropic medications are often indicated for children and adolescents undergoing cancer therapy.  A 2012 multi-site study of prescribing practices of pediatric oncologists found that 71% of pediatric oncologists prescribed SSRIs to their patients, and many admitted that the FDA’s Black Box Warning did not affect their prescribing practice and monitoring parameters. 

Starting in the Fall 2016, our pediatric oncology center initiated an innovative pilot telepsychiatry consultation service to allow better access to comprehensive mental health care for our patients.  One afternoon each week, a board-certified child and adolescent psychiatrist evaluated and provided recommendations for referred pediatric oncology patients via a confidential telecommunications system. Patients eligible for referral were identified by the behavioral medicine psychologist, who provides psychological care through an embedded clinic within the pediatric oncology center.  The patients were well known to this provider through their CBT treatment.  The telepsychiatry appointments were held within our center, thus providing a familiar environment for the patients and their families. After evaluation, the psychiatrist communicated all recommendations, including psychotropic medication guidelines, to the primary oncology team.  The oncologist or APN took responsibility for providing the prescription to the patient.  Adherence and follow-up were managed through close collaboration between the oncologist, APN, psychologist and psychiatrist.  Over several months, the psychiatrist consulted on 12 different patients and provided follow-up consultations for 9 of the 12 patients.  The pilot telepsychiatry clinic provided access to expert psychiatric evaluation by combining oncologic and behavioral health treatment appointments, thus improving management of our patient’s psychiatric symptoms, increasing physician/APN comfort in prescribing psychiatric medications, and improving overall patient and family treatment adherence and satisfaction.