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Portuguese physician and pharmacist attitudes towards the use of herbal complementary and alternative medicines in oncology
ARTICLE IN PRESS 228
Abstracts / European Journal of Integrative Medicine 1 (2009) 223–260
traditional healers were collected and identified at the Bangladesh National Herbarium. These plant species (with family name given in parenthesis) included Leonurus sibiricus (Labiatae), Croton tiglium (Euphorbiaceae), Zizyphus mauritiana (Rhamnaceae), Swertia chirata (Gentianaceae), Vitex negundo (Verbenaceae), Carica papaya (Caricaceae), Kaempferia galanga (Zingiberaceae), Jatropha gossypifolia (Euphorbiaceae), Wedelia chinensis (Asteraceae), Randia dumetorum (Rubiaceae), Streblus asper (Moraceae), Acanthus ilicifolius (Acanthaceae), Hygrophila auriculata (Acanthaceae), Mucuna pruriens (Leguminaceae), Withania somnifera (Solanaceae), Morus alba (Moraceae), Pilea microphylla (Urticaceae), and Piper betle (Piperaceae). It was clearly observed that medicinal plants from Sandarbans did have a positive healing effect upon many cancer cases. It was also shown to produce some encouraging effects in terms of several important factors like: delaying the tumor progression, pain reduction, enhancing the immune response and life expectancy, and over all well-being of the patients. Project support received in part by the Peoples Integrated Alliance and SHACO-Health & Education Society. 10.1016/j.eujim.2009.08.011
PO-009 Mistletoe therapy as a therapeutic option in a child with lymphomatoid papulosis/CD 30-positive cutaneous lymphoproliferative papulosis G. Kamedaa, K. Michaela, A. La¨nglera,b a
Gemeinschaftskrankenhaus, Pediatrics, Herdecke, Germany b University of Witten-Herdecke, Faculty of Medicine, Integrated Curriculum for Anthroposophic Medicine, Witten, Germany Lymphomatoid papulosis (LP) is a very rare skin disease in childhood within the spectrum of the CD30-positive lymphoproliferative disorders. The cause of the disease is unknown. Sometimes the disease resolves spontaneously, but also malignant courses are possible, either as a cutaneous or systemic CD 30-positive anaplastic large cell non-Hodgkin lymphoma. In adults between 5% and 20% of the LP-patients develop malignant lymphomas. In children the experiences are limited, but the overall survival seems to be excellent and similar to adults [1]. Different therapeutic regimens are performed. Besides watch-andwait therapy, topical steroids or PUVA therapy also lowdose methotrexate therapy are treatment options. A 12-year-old girl with weight loss, swelling of the lymph nodes and general weakness was admitted to our integrative pediatric oncology department. Also small erythematous and violaceous papules over the whole body were seen. In the diagnostic the ESR and CRP were elevated and an infectious or autoimmune etiology were ruled out. In
MRI the patient showed enlarged left cervical and left axillary lymph node regions. An open biopsy of the suspected lymph nodes and skin-lesions, including bone marrow puncture were performed. The immunhistochemical examination of the lymph nodes showed a malignant ALK-negative CD 30-positive lymphoma. But the immunhistochemical examination of the skin diagnosed a lymphomatoid papulosis. The bone marrow-smear did not show evidence for malignant infiltration. On the basis of the diagnosis lymphomatoid papulosis with involvement of the lymph nodes in a clinical stable patient without strong evidence of a malignant disease and based on experience of a second patient with LP and lymph-nodeinvolvement, a therapy with a mistletoe-preparation intravenously was initiated [2]. We escalated the dosage over 3 days given once per day as an infusion over 3 h. After the third day we continued mistletoe treatment subcutaneously 2 times per week. On the fourth day after beginning of the treatment the size of the cervical lymph nodes were decreasing and new papules were not seen any more. After 1 week of treatment the patient was discharged with almost normal blood samples. Four weeks after starting of the treatment all skin and suspected lymph nodes were vanished, proven by clinical examination and ultrasound. During the follow-up ultrasound was done every month and MRI of the lymph nodes was performed every 3 months. Six months after diagnosis the patient is in a stable remission. The therapy with mistletoe is continued twice per week. In conclusion we present a patient with a rare skin disease (LP) with lymph node involvement who is successful treated with mistletoe as a new promising therapeutic option for patients with lymphomatoid papulosis. Further studies should be initiated. References [1] Njsten T, Curiel-Lewandrowski C, Kadin M. Lymphomatoid papulosis in children. Arch Dermatol 2007;140:306–12. [2] Seifert G, Tautz C, Seeger K, Henze G, La¨ngler A. Therapeutic use of mistletoe for CD30+ cutaneous lymphoproliferative disorder/lymphomatoid papulosis. J Eur Acad Dermatol Venereol 2007;21(4): 558–60. 10.1016/j.eujim.2009.08.012
PO-010 Portuguese physician and pharmacist attitudes towards the use of herbal complementary and alternative medicines in oncology E. Mendes, M.T. Herdeiro, A. Figueiras, F. Pimentel Universidade de Aveiro, Ciencias da Sau´de, Aveiro, Portugal Background: Complementary and alternative medicines (CAM) are becoming extremely popular among health products consumers and patients in Portugal.
ARTICLE IN PRESS Abstracts / European Journal of Integrative Medicine 1 (2009) 223–260
Although many forms of CAM pose no risk or a minimal risk to consumers and patients, others make use of some herbal substances and preparations containing ingredients known to be toxic, genotoxic and carcinogenic, which may become reasons of concern at specific levels of exposure. The use of herbal complementary and alternative medicines is growing among Portuguese cancer patients, contributing to a higher risk for unwanted interactions, especially due to the narrow therapeutic index of most oncolytic drugs. Although physicians and pharmacists are becoming aware that patients use some forms of CAM, few discuss these therapies with them. Therefore, it is very important to assess both physicians and pharmacists familiarity with most commonly used forms of CAM and to evaluate their attitude towards its use by cancer patients. Unfortunately, in Portugal, no questionnaires have been developed to measure this topic. Objective: Evaluate the reproducibility of ad hoc designed questionnaires. Methods: Questionnaires were separately constructed for physicians and pharmacists. Both included 3 questions related with 15 most common CAM therapies and 1 set of questions related with phytotherapy. To assess reproducibility, each questionnaire was used in a pilot test. One pilot test was performed at the Hospital Infante D. Pedro (Aveiro) on a sample of 15 doctors and the other was performed at 8 pharmacies in the surrounding area of the Hospital, on a sample of 15 pharmacists. The questionnaires were administered twice, with 3 weeks interval. The questionnaires reproducibility was assessed using Cohen’s kappa coefficient. Results: Kappa values obtained in the pilot studies were above 0.6 for the majority of the questions, revealing a substantial degree of agreement. Conclusion: The level of reliability estimated suggests that physicians and pharmacists familiarity with CAM, and attitude towards its use by cancer patients, can be adequately measured by the developed questionnaires. 10.1016/j.eujim.2009.08.013
PO-011 Complementary treatment with plant food constituents— Powerful or harmful? J. Hu¨bner Habichtswald-Klinik, Oncology, Kassel, Germany
Question: Food and pharmaceutical industry are promoting complex preparations from fruit and/or vegetables and single preparations with high doses of flavonoids and other substances. Vegetables like tomatoes which are enriched with lycopene are designed. The question is which strategy
229
to recommend to the general population or to our cancer patients. Methods: This overview of the literature will focus on the 6 most promising plant food constituents: the flavonoids quercetin, resveratrol and EGCG, the isoflavone genistein, the carotinoid lycopene and curcumin from curcuma longa. Three topics are regarded: prevention, antitumoral effects and side effects. Results: For most of the discussed substances we do not know how much we consume with a healthy diet. Only few data on pharmacokinetics are known. Some substances seem to have special effects like genistein. This phytoestrogene is an example of a substance that seems to be useful in general but perhaps not in every situation. Its action is different in men and young women compared to older women with breast cancer. Whereas soy products are a healthy part of diet, isoflavones in greater concentrations are not recommended for women with breast cancer because of growth promoting effects. Interesting but still preliminary data are found for BRCA 1/2 positive cancer. Another concern is the question of dose and overdose which is accentuated by the lack of data on pharmacokinetics. Quercetin given at 2-fold concentration turns from a preventive to a toxic substance and may even induce tumors. Without exact data on bioavailability and normal dose preparations consumed by people may do more harm than good. Curcumin is tested as antitumoral substance and many patients are taking tablets with curcumin during chemotherapy or targeted therapy. We do not know much about interactions and these data mainly come from preclinical experiments. When using this substance as complementary we should look at consequences on the success of our therapies and we have to ask for data on primary endpoints like disease free and overall survival before giving recommendations for usage. Resveratrol is a most interesting molecule and two recent publications have provided (contradictory) first facts concerning its different effects on tumor cells with p53 wild type or mutation. While we have learned to take into consideration predictive factors and to plan studies with translational subquestions in conventional medicine we still seem to believe that natural substances will fit for any tumor situation. Perhaps important effects of these molecules are missed in studies because we do not plan targeted. Conclusions: In the presentation data concerning prevention, antitumoral therapy and side effects for each substance will be presented distinguishing epidemiological, experimental and clinical reports. Some suggestions on how to go on with clinical studies will be given. 10.1016/j.eujim.2009.08.014
Abstracts / European Journal of Integrative Medicine 1 (2009) 223–260
traditional healers were collected and identified at the Bangladesh National Herbarium. These plant species (with family name given in parenthesis) included Leonurus sibiricus (Labiatae), Croton tiglium (Euphorbiaceae), Zizyphus mauritiana (Rhamnaceae), Swertia chirata (Gentianaceae), Vitex negundo (Verbenaceae), Carica papaya (Caricaceae), Kaempferia galanga (Zingiberaceae), Jatropha gossypifolia (Euphorbiaceae), Wedelia chinensis (Asteraceae), Randia dumetorum (Rubiaceae), Streblus asper (Moraceae), Acanthus ilicifolius (Acanthaceae), Hygrophila auriculata (Acanthaceae), Mucuna pruriens (Leguminaceae), Withania somnifera (Solanaceae), Morus alba (Moraceae), Pilea microphylla (Urticaceae), and Piper betle (Piperaceae). It was clearly observed that medicinal plants from Sandarbans did have a positive healing effect upon many cancer cases. It was also shown to produce some encouraging effects in terms of several important factors like: delaying the tumor progression, pain reduction, enhancing the immune response and life expectancy, and over all well-being of the patients. Project support received in part by the Peoples Integrated Alliance and SHACO-Health & Education Society. 10.1016/j.eujim.2009.08.011
PO-009 Mistletoe therapy as a therapeutic option in a child with lymphomatoid papulosis/CD 30-positive cutaneous lymphoproliferative papulosis G. Kamedaa, K. Michaela, A. La¨nglera,b a
Gemeinschaftskrankenhaus, Pediatrics, Herdecke, Germany b University of Witten-Herdecke, Faculty of Medicine, Integrated Curriculum for Anthroposophic Medicine, Witten, Germany Lymphomatoid papulosis (LP) is a very rare skin disease in childhood within the spectrum of the CD30-positive lymphoproliferative disorders. The cause of the disease is unknown. Sometimes the disease resolves spontaneously, but also malignant courses are possible, either as a cutaneous or systemic CD 30-positive anaplastic large cell non-Hodgkin lymphoma. In adults between 5% and 20% of the LP-patients develop malignant lymphomas. In children the experiences are limited, but the overall survival seems to be excellent and similar to adults [1]. Different therapeutic regimens are performed. Besides watch-andwait therapy, topical steroids or PUVA therapy also lowdose methotrexate therapy are treatment options. A 12-year-old girl with weight loss, swelling of the lymph nodes and general weakness was admitted to our integrative pediatric oncology department. Also small erythematous and violaceous papules over the whole body were seen. In the diagnostic the ESR and CRP were elevated and an infectious or autoimmune etiology were ruled out. In
MRI the patient showed enlarged left cervical and left axillary lymph node regions. An open biopsy of the suspected lymph nodes and skin-lesions, including bone marrow puncture were performed. The immunhistochemical examination of the lymph nodes showed a malignant ALK-negative CD 30-positive lymphoma. But the immunhistochemical examination of the skin diagnosed a lymphomatoid papulosis. The bone marrow-smear did not show evidence for malignant infiltration. On the basis of the diagnosis lymphomatoid papulosis with involvement of the lymph nodes in a clinical stable patient without strong evidence of a malignant disease and based on experience of a second patient with LP and lymph-nodeinvolvement, a therapy with a mistletoe-preparation intravenously was initiated [2]. We escalated the dosage over 3 days given once per day as an infusion over 3 h. After the third day we continued mistletoe treatment subcutaneously 2 times per week. On the fourth day after beginning of the treatment the size of the cervical lymph nodes were decreasing and new papules were not seen any more. After 1 week of treatment the patient was discharged with almost normal blood samples. Four weeks after starting of the treatment all skin and suspected lymph nodes were vanished, proven by clinical examination and ultrasound. During the follow-up ultrasound was done every month and MRI of the lymph nodes was performed every 3 months. Six months after diagnosis the patient is in a stable remission. The therapy with mistletoe is continued twice per week. In conclusion we present a patient with a rare skin disease (LP) with lymph node involvement who is successful treated with mistletoe as a new promising therapeutic option for patients with lymphomatoid papulosis. Further studies should be initiated. References [1] Njsten T, Curiel-Lewandrowski C, Kadin M. Lymphomatoid papulosis in children. Arch Dermatol 2007;140:306–12. [2] Seifert G, Tautz C, Seeger K, Henze G, La¨ngler A. Therapeutic use of mistletoe for CD30+ cutaneous lymphoproliferative disorder/lymphomatoid papulosis. J Eur Acad Dermatol Venereol 2007;21(4): 558–60. 10.1016/j.eujim.2009.08.012
PO-010 Portuguese physician and pharmacist attitudes towards the use of herbal complementary and alternative medicines in oncology E. Mendes, M.T. Herdeiro, A. Figueiras, F. Pimentel Universidade de Aveiro, Ciencias da Sau´de, Aveiro, Portugal Background: Complementary and alternative medicines (CAM) are becoming extremely popular among health products consumers and patients in Portugal.
ARTICLE IN PRESS Abstracts / European Journal of Integrative Medicine 1 (2009) 223–260
Although many forms of CAM pose no risk or a minimal risk to consumers and patients, others make use of some herbal substances and preparations containing ingredients known to be toxic, genotoxic and carcinogenic, which may become reasons of concern at specific levels of exposure. The use of herbal complementary and alternative medicines is growing among Portuguese cancer patients, contributing to a higher risk for unwanted interactions, especially due to the narrow therapeutic index of most oncolytic drugs. Although physicians and pharmacists are becoming aware that patients use some forms of CAM, few discuss these therapies with them. Therefore, it is very important to assess both physicians and pharmacists familiarity with most commonly used forms of CAM and to evaluate their attitude towards its use by cancer patients. Unfortunately, in Portugal, no questionnaires have been developed to measure this topic. Objective: Evaluate the reproducibility of ad hoc designed questionnaires. Methods: Questionnaires were separately constructed for physicians and pharmacists. Both included 3 questions related with 15 most common CAM therapies and 1 set of questions related with phytotherapy. To assess reproducibility, each questionnaire was used in a pilot test. One pilot test was performed at the Hospital Infante D. Pedro (Aveiro) on a sample of 15 doctors and the other was performed at 8 pharmacies in the surrounding area of the Hospital, on a sample of 15 pharmacists. The questionnaires were administered twice, with 3 weeks interval. The questionnaires reproducibility was assessed using Cohen’s kappa coefficient. Results: Kappa values obtained in the pilot studies were above 0.6 for the majority of the questions, revealing a substantial degree of agreement. Conclusion: The level of reliability estimated suggests that physicians and pharmacists familiarity with CAM, and attitude towards its use by cancer patients, can be adequately measured by the developed questionnaires. 10.1016/j.eujim.2009.08.013
PO-011 Complementary treatment with plant food constituents— Powerful or harmful? J. Hu¨bner Habichtswald-Klinik, Oncology, Kassel, Germany
Question: Food and pharmaceutical industry are promoting complex preparations from fruit and/or vegetables and single preparations with high doses of flavonoids and other substances. Vegetables like tomatoes which are enriched with lycopene are designed. The question is which strategy
229
to recommend to the general population or to our cancer patients. Methods: This overview of the literature will focus on the 6 most promising plant food constituents: the flavonoids quercetin, resveratrol and EGCG, the isoflavone genistein, the carotinoid lycopene and curcumin from curcuma longa. Three topics are regarded: prevention, antitumoral effects and side effects. Results: For most of the discussed substances we do not know how much we consume with a healthy diet. Only few data on pharmacokinetics are known. Some substances seem to have special effects like genistein. This phytoestrogene is an example of a substance that seems to be useful in general but perhaps not in every situation. Its action is different in men and young women compared to older women with breast cancer. Whereas soy products are a healthy part of diet, isoflavones in greater concentrations are not recommended for women with breast cancer because of growth promoting effects. Interesting but still preliminary data are found for BRCA 1/2 positive cancer. Another concern is the question of dose and overdose which is accentuated by the lack of data on pharmacokinetics. Quercetin given at 2-fold concentration turns from a preventive to a toxic substance and may even induce tumors. Without exact data on bioavailability and normal dose preparations consumed by people may do more harm than good. Curcumin is tested as antitumoral substance and many patients are taking tablets with curcumin during chemotherapy or targeted therapy. We do not know much about interactions and these data mainly come from preclinical experiments. When using this substance as complementary we should look at consequences on the success of our therapies and we have to ask for data on primary endpoints like disease free and overall survival before giving recommendations for usage. Resveratrol is a most interesting molecule and two recent publications have provided (contradictory) first facts concerning its different effects on tumor cells with p53 wild type or mutation. While we have learned to take into consideration predictive factors and to plan studies with translational subquestions in conventional medicine we still seem to believe that natural substances will fit for any tumor situation. Perhaps important effects of these molecules are missed in studies because we do not plan targeted. Conclusions: In the presentation data concerning prevention, antitumoral therapy and side effects for each substance will be presented distinguishing epidemiological, experimental and clinical reports. Some suggestions on how to go on with clinical studies will be given. 10.1016/j.eujim.2009.08.014