Investigating the effects of rurality on stress, subjective well-being, and weight-related outcomes.

Purpose: Rates of obesity are significantly higher for those living in a rural versus urban setting. High levels of stress and low levels of subjective well-being (SWB) have been linked to poor weight-related behaviors and outcomes, but it is unclear if these relationships differ as a function of rurality. This study investigated the extent to which living in a rural versus urban county ("rurality") moderated associations between stress / subjective wellbeing (predictors) and diet quality, dietary intake of added sugars, physical activity, and BMI (outcomes). Methods: Participants were recruited from urban (n = 355) and rural (n = 347) counties in Washington State and self-reported psychological, demographic, and food frequency questionnaires while physical activity behavior was measured objectively. Findings: After controlling for relevant covariates, levels of stress were positively associated with added sugar intake for those living in the urban county while this relationship was non-significant for those residing in the rural county. Similarly, SWB was negatively associated with added sugar intake, but only for urban residents. County of residence was also found to moderate the relationship between SWB and BMI. Higher SWB was inversely associated with BMI for those living in the urban county while no relationship was observed for rural county residents. Conclusions: These findings support the hypothesis that the relationships between stress / SWB and weight function differentially based on the rurality of the residing county. This work adds to the growing body of literature highlighting the role stress and SWB play in the rural obesity disparity.

"I Made All Decisions Myself": Breast Cancer Treatment Decision-Making by Receivers and Decliners.

OBJECTIVE: Many women with breast cancer refuse adjuvant treatments. How they arrive at their respective decisions and whether they are passively or actively involved in making decisions is less known. We explored the different decision-making behaviors of women who received treatments (receivers) after being diagnosed with breast cancer and those who refused (decliners). METHODS: Seven women (four receivers and three decliners) were recruited from the Breast Cancer Integrative Oncology Study. We conducted an inductive content analysis based on in-depth semi-structured interviews with open-ended questions. RESULTS: Receivers reported that doctors and family members influenced their decision-making. Decliners perceived their doctors as supportive of their decisions and reported that the experience of adjuvant therapy of family and friends, the results of Oncotest, and concerns about side effects influenced their decision-making. Receivers expressed discomfort about their decisions, relied on books, whereas decliners used various sources to find information. Both receivers and decliners believed that they had made the decisions themselves. However, receivers were somewhat negative about doctors' advice. Receivers also reported that, sometimes, the decision-making process was lacking and reported discomfort with the treatment process. CONCLUSIONS: Women with breast cancer need support in understanding the care they are prescribed and getting essential care.

Financial Anxiety is Associated With Cancer Screening Adherence in Women at High Risk of Breast Cancer.

BACKGROUND: Previous studies have examined the impact of material financial hardship on cancer screening but without focusing on the psychological aspects of financial hardship. PURPOSE: This study examined the effects of different types of financial anxiety on adherence to breast cancer screening in women at high risk of breast cancer. Adherence to cervical cancer screening was also examined to determine whether associations between financial anxiety and screening adherence were unique to breast cancer screening or more general. METHODS: Women (n = 324) aged 30-50 and at high risk for inherited breast cancer completed a survey on general financial anxiety, worry about affording healthcare, financial stigma due to cancer risk, and adherence to cancer screening. Multivariate analyses controlled for poverty, age, and race. RESULTS: More financial anxiety was associated with lower odds of mammogram adherence (odds ratio [OR] = 0.97, confidence interval [CI] = 0.94, 0.99), Pap smear adherence (OR = 0.98, CI = 0.96, 0.996), and clinical breast examination adherence (OR = 0.98, CI = 0.96, 0.995). More worry about affording healthcare was associated with lower odds of clinical breast examination adherence (OR = 0.95, CI = 0.91, 0.9992) but not mammogram or Pap smear adherence (p > .05). Financial stigma due to cancer risk was associated with lower odds of Pap smear adherence (OR = 0.87, CI = 0.77, 0.97) but no other cancer screenings (p > .07). CONCLUSIONS: Financial anxiety may impede cancer screening, even for high-risk women aware of their risk status. Clinical interventions focused on social determinants of health may also need to address financial anxiety for women at high risk of breast cancer.

Receiving/declining adjuvant breast cancer treatments and involvement in treatment decision-making.

OBJECTIVES: This study compared women who received all recommended breast cancer treatments (Receivers) with those who did not (Decliners). We sought to understand women's integrative naturopathic oncology (INO) use in addition to usual conventional oncology (UCO) use, their involvement in treatment decision-making (TDM), and their satisfaction with healthcare providers. METHODS: A secondary analysis was conducted using baseline data from the Breast Cancer Integrative Oncology Study that recruited 427 women from INO clinics (INO cohort) and comparison women from the Cancer Surveillance System Registry who received UCO care (UCO cohort) in Western Washington State. Self-reported data and Registry data were analyzed using descriptive statistics, t-tests, and X2 tests to compare Receivers and Decliners in demographic and disease characteristics, use of INO in addition to UCO care, involvement in TDM, and satisfaction with healthcare providers. RESULTS: Significantly more Decliners were in INO cohort than UCO cohort. Decliners in INO cohort were less likely to receive radiotherapy. Women who used INO care, and Decliners, compared with Receivers, tended to be "very involved" in their TDM. No difference was found in participation congruence, correspondence between preferred and actual involvement in medical TDM, between groups. Decliners in INO cohort reported significantly less satisfaction with their conventional oncologist than Receivers in INO cohort. CONCLUSIONS: Decliners of conventional adjuvant therapies were very involved in their TDM and those Decliners who seek INO care were less satisfied with their conventional oncologist; these women may need the most attention to assure they receive the care they need.

Effects of Vitamin D Use on Health-Related Quality of Life of Breast Cancer Patients in Early Survivorship.

BACKGROUND: Vitamin D supplements may prevent recurrence, prolong survival, and improve mood for women with breast cancer, although evidence for these effects is preliminary. METHODS: This report describes vitamin D supplement use by 553 breast cancer patient/survivors (193 who used a naturopathic oncology [NO] provider and 360 who did not) participating in a matched cohort study of breast cancer outcomes. RESULTS: We found that more than half of breast cancer patients reported using vitamin D supplements. Women who received care from NO providers in early survivorship may be more likely to use vitamin D supplements ( P < .05). Approximately 30% of breast cancer patients with blood levels recorded in their medical chart were potentially vitamin D deficient (<30 ng/mL). Vitamin D supplement use at study enrollment was associated with higher levels of self-reported health-related quality of life (HRQOL) at enrollment ( P < .05) and predicted better HRQOL at 6-month follow-up ( P < .05). Sufficient blood levels of vitamin D recorded between enrollment and follow-up were also associated with better HRQOL at follow-up ( P < .05). CONCLUSIONS: Vitamin D supplementation by breast cancer patients is common both during and after treatment for breast cancer, but deficiency may also be common. NO and conventional providers may be able to promote vitamin D sufficiency through vitamin D supplementation and by encouraging healthy solar exposure. Further studies should be undertaken examining whether vitamin D supplementation and higher blood levels might improve HRQOL among women with breast cancer in early survivorship.

False-positive screening events and worry influence decisions about surgery among high-risk women.

OBJECTIVE: Studies of cancer screening have found that false positive screening events (FPSE) can affect worry about cancer risk and screening program use, we sought to further explore this. METHOD: In a study of 1,100 women at high risk for ovarian cancer who participated in a previously published randomized controlled trial (RCT), we sought to explore whether worry might also influence the use of risk-reducing surgical procedures by women. Participants included 234 women with BRCA1/2 mutations and 866 women with high-risk pedigrees. We followed the women for up to 6 years. RESULTS: Worry predicted risk reducing prophylactic bilateral salpingo-oophorectomy (pBSO) for both mutation carriers (HR = 1.74; p = .02), and women with high-risk pedigree (HR = 3.41; p < .001). FPSE also predicted subsequent pBSO among women with a high-risk pedigree (HR 2.31; p < .01). While screening may reduce worry among those who never receive a positive result, FPSE increase worry at least temporarily. Worry about ovarian cancer risk predicted use of preventative pBSO among high-risk women including those with BRCA1/2 mutations enrolled in an ovarian cancer-screening program. FPSE also predicted risk-reducing ovarian surgery among high-risk women without a known mutation at the time of screening program enrollment. CONCLUSIONS: Physicians who offer screening should know that false positive results may increase use of pBSO, how this should effect clinical practice is unclear. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Comparison of Health-Related Quality of Life Between Adjuvant Breast Cancer Treatment Groups.

OBJECTIVES: To compare the health-related quality of life (HRQOL) of women who did (receivers, n = 372) and did not (intentional nonreceivers, n = 46) receive all recommended adjuvant treatments for breast cancer. SAMPLE & SETTING: Women were recruited through integrative oncology clinics and the Cancer Surveillance System registry in western Washington. METHODS & VARIABLES: A cross-sectional and correlational study using secondary data was conducted. Self-reported data included involvement in treatment decision making (TDM) and HRQOL. Registry data included demographics, disease characteristics, and records on recommended treatments as well as receiving/not receiving them. Descriptive statistics, t tests, chi-square tests, correlations, and analysis of variance were used to compare receivers and intentional nonreceivers. RESULTS: Among women who were "very involved" in TDM and those who reported their involvement as "just right," intentional nonreceivers scored higher in role-physical, general health, and vitality than receivers after controlling for demographic and disease characteristics. IMPLICATIONS FOR NURSING: Nurses need to be aware that intentional nonreceivers of adjuvant therapy, particularly if assessed as "very involved" and "just right" involvement in deciding to refuse treatment, may report better HRQOL than receivers, which could be attributed to lack of common side effects from adjuvant treatment.

Use of Integrative Oncology, Involvement in Decision-Making, and Breast Cancer Survivor Health-Related Quality of Life in the First 5 Years Postdiagnosis.

OBJECTIVE: This study sought to describe changes in the health-related quality of life (HRQOL) of women who do and do not seek naturopathic oncology (NO) complementary and alternative medicine (CAM) care during and immediately after breast cancer treatment, and to explore the predictive role of NO CAM care, demographic characteristics, and involvement in decision-making on HRQOL in breast cancer survivors. METHODS: Matched cohorts of breast cancer survivors who did and did not choose to supplement their breast cancer treatment with NO care within 2 years of diagnosis participated. NO users were identified through naturopathic doctors' clinics and usual care (UC) controls with similar prognosis were identified through a cancer registry. The registry provided information about all participants' age, race, ethnicity, marital status, stage of cancer at time of diagnosis, date of diagnosis, and use of conventional medical treatments (surgery, chemotherapy, radiation, and endocrine therapy). Data of participants' self-reported involvement in decision-making and HRQOL were collected at study enrollment and at 6-month follow-up. RESULTS: At 6-month follow-up, the NO patients reported significantly more involvement in decision-making about care and better general health than did UC patients ( P < .05). Self-reported involvement in decision-making about cancer treatment was associated with better role-physical, role-emotional, and social-functional well-being ( P < .05). Race, age, marital status, and congruence of preferred and achieved levels of involvement also predicted aspects of HRQOL in breast cancer survivors ( P < .05). CONCLUSIONS: Both NO CAM care and involvement in decision-making about cancer treatment may be associated with better HRQOL in breast cancer survivors.

Do Women With Breast Cancer Who Choose Adjunctive Integrative Oncology Care Receive Different Standard Oncologic Treatment?

PURPOSE: To determine if women with breast cancer who choose adjunctive naturopathic oncology (NO) specialty care receive different standard oncologic treatment when compared with breast cancer patients who receive only standard care. PARTICIPANTS: Women with breast cancer stages 0 to 4, aged 18+ who spoke English and sought care from outpatient naturopathic doctor clinics were enrolled in an observational study of clinical and quality of life outcomes. Women who sought NO care 2 or more times within the first 2 years postdiagnosis were identified as NO cases. A matched comparison group of breast cancer patients were identified using the Western Washington Cancer Surveillance System(CSS). METHODS: A longitudinal cohort design. In addition to self-report data, the CSS provided data on demographics, stage at the time of diagnosis, and initial treatment. Oncology medical records were abstracted in order to provide additional information on standard oncologic treatment for all participants. RESULTS: Cohorts were well matched with regard to demographic, histologic, and prognostic indicators at the time of diagnosis. Approximately 70% of women in both cohorts received standard oncologic care that met the National Comprehensive Cancer Network guidelines. There were no statistically significant differences between the cohorts in treatment received. Fewer women in the NO cohort with estrogen receptor-positive breast cancer appear to have received antiestrogen therapy. CONCLUSIONS: Women in both cohorts appear to receive guideline-concordant care. However, women who receive adjunctive NO care may be less likely to receive antiestrogen therapy.

The 'cause' of my cancer, beliefs about cause among breast cancer patients and survivors who do and do not seek IO care.

OBJECTIVE: We sought to describe survivors' beliefs about the cause of their breast cancer and to test the hypothesis that beliefs about cancer's cause are associated with treatment preferences in accordance with the common sense model of self-regulation of health and illness. METHODS: Breast cancer survivors (n = 552) participating in an observational study of cancer outcomes responded to an open-ended question about the cause of their cancer. Of these, 245 women had sought treatment from complementary and alternative integrative oncology (IO) clinics, and 307 women did not. RESULTS: Women frequently described theories for their cancer's cause including genetics and family history (31%), stress and coping (31%), toxins and chemicals (27%), a variety of lifestyle and epidemiological risk factors, and randomness (17%). Self-reported beliefs about cancer's cause differed among women in association with their use of IO. IO users were somewhat more likely to describe stress and poor coping as causes of their cancer and less likely to describe random chance as a cause of cancer (p < 0.05). CONCLUSIONS: Beliefs about the cause of cancer change over time and may predict decisions to use specific treatment including complementary and alternative medicine and IO. Copyright © 2015 John Wiley & Sons, Ltd.

Breast Cancer Integrative Oncology Care and Its Costs.

BACKGROUND: Naturopathic oncology in conjunction with conventional treatment is commonly referred to as integrative oncology (IO). Clinics directed by oncology board certified NDs (Fellows of the American Board of Naturopathic Oncology or FABNOs) provide high-quality data for describing IO therapies, their costs and measuring clinical outcomes. PURPOSE: To describe the types of IO therapies prescribed to breast cancer patients by ND FABNO physicians. Study participants (n = 324). Women who sought care at 1 of 6 naturopathic oncology clinics in Washington State were asked to enroll in a prospective 5 year observational outcomes study. METHODS: Medical records were abstracted to collect treatment recommendations and cost data. RESULTS: More than 72 oral or topical, nutritional, botanical, fungal and bacterial-based medicines were prescribed to the cohort during their first year of IO care. Trametes versicolor was prescribed to 63% of the women. Mind-body therapy was recommended to 45% of patients, and 49% received acupuncture. Also, 26% were prescribed injectable therapy, including mistletoe, vitamin B complex (12%), IV ascorbate (12%), IV artesunate (7%), and IV nutrition and hydration (4%). Costs ranged from $1594/year for early-stage breast cancer to $6200/year for stage 4 breast cancer patients. Of the total amount billed for IO care for 1 year for breast cancer patients, 21% was out-of-pocket. CONCLUSIONS: IO care for women with breast cancer consists of botanical and mushroom oral therapies, parenteral botanical and nutrient therapy, mind-body medicine and acupuncture. IO clinic visits and acupuncture are partially paid for by medical insurance companies.

Increasing Cardiomyopathy Screening in Childhood Cancer Survivors: A Cost Analysis of Advanced Practice Nurse Phone Counseling.

PURPOSE/OBJECTIVES: To document the per survivor and per additional survivor screening costs of a mailed survivorship care plan (SCP) with advanced practice nurse (APN) telephone counseling (SCP+C) or without APN telephone counseling (SCP).
. DESIGN: Randomized, longitudinal clinical trial.
. SETTING: St. Jude Children's Research Hospital in Memphis, Tennessee.
. SAMPLE: 411 at-risk pediatric cancer survivors (aged 26-59 years), stratified by age (younger than 30 years versus 30 years or older), recommended screening frequency (every one, two, or five years), gender, and cancer diagnosis (hematologic versus solid tumor).
. METHODS: Clinical and resource data costs were derived from trial data and external estimates.
. MAIN RESEARCH VARIABLES: The cost-effectiveness of left ventricular systolic function screening per survivor and per each additional survivor screened.
. FINDINGS: The per-survivor costs of SCP (n = 206) and SCP+C (n = 205) were $74.91 and $224.69, respectively. The estimated costs of SCP and SCP+C per additional survivor screened for two years disseminated in a medium-sized clinic (n = 101 survivors annually) were $345.41 and $293.85, respectively.
. CONCLUSIONS: Adding APN counseling to a printed SCP may help preserve cardiac health at little or no cost per additional survivor screened.
. IMPLICATIONS FOR NURSING: APN counseling is cost-effective and superior to the standard of care in supporting at-risk survivors' cardiac screening participation.

The Use of Complementary and Alternative Medicine Supplements of Potential Concern during Breast Cancer Chemotherapy.

Objective. While many Complementary and Alternative Medicines (CAM) are unlikely to interact negatively with conventional oncology treatment, some ingestible CAM substances have biological activities that may reduce the effectiveness of chemotherapy or radiation. This study surveyed women with breast cancer in order to document the extent to which women with breast cancer use these CAM substances of concern concurrently with conventional treatments. Methods. A total of 398 women completed a survey describing their use of CAM at various time points in their cancer treatment. This report focuses on a subsample of 250 women receiving chemotherapy or radiation who reported using specific one or more of several chemotherapies. Results. Of those participating, 104 (43.7%) of those receiving chemotherapy (n = 238) and 45 (32.3%) of those receiving radiation (139; 58.4% of all patients) reported using one or more CAM substances that could be cause for concern when taken concurrently. Conclusion. Research is needed to understand the real risks associated with CAM and conventional polypharmacy. If risks associated with CAM conventional polypharmacy use prove to be substantial then improved systems to assure all women get advice regarding herb and supplement use during breast cancer treatment appear to be needed.

The effect of referral for genetic counseling on genetic testing and surgical prevention in women at high risk for ovarian cancer: Results from a randomized controlled trial.

BACKGROUND: Guidelines recommend genetic counseling and testing for women who have a pedigree suggestive of an inherited susceptibility for ovarian cancer. The authors evaluated the effect of referral to genetic counseling on genetic testing and prophylactic oophorectomy in a randomized controlled trial. METHODS: Data from an electronic mammography reporting system identified 12,919 women with a pedigree that included breast cancer, of whom 625 were identified who had a high risk for inherited susceptibility to ovarian cancer using a risk-assessment questionnaire. Of these, 458 women provided informed consent and were randomized 1:1 to intervention consisting of a genetic counseling referral (n = 228) or standard clinical care (n = 230). RESULTS: Participants were predominantly aged 45 to 65 years, and 30% and 20% reported a personal history of breast cancer or a family history of ovarian cancer, respectively. Eighty-five percent of women in the intervention group participated in a genetic counseling session. Genetic testing was reported by 74 (33%) and 20 (9%) women in the intervention and control arms (P < .005), respectively. Five women in the intervention arm and 2 in the control arm were identified as germline mutation carriers. Ten women in the intervention arm and 3 in the control arm underwent prophylactic bilateral salpingo-oophorectomy (P < .05). CONCLUSIONS: Routine referral of women at high risk for ovarian cancer to genetic counseling promotes genetic testing and prophylactic surgery. The findings from the current randomized controlled trial demonstrate the value of implementing strategies that target women at high risk for ovarian cancer to ensure they are offered access to recommended care. CA Cancer J Clin 2016. © 2016 American Cancer Society, Inc. Cancer 2016;122:3509-3518. © 2016 American Cancer Society.

Cancer Risk Awareness and Concern among Women with a Family History of Breast or Ovarian Cancer.

Women with a documented deleterious mutation in BRCA1 or BRCA2 are at substantially elevated risk for ovarian cancer. To understand what percentage of women with high-risk family histories know their risk is elevated we surveyed 1,885 women with a high- or moderate-risk family history and no personal history of breast or ovarian cancer, and asked about their perceived risk of breast and ovarian cancer. Among high-risk women, fewer than 20% reported use of genetic counseling, and knowledge of elevated risk of ovarian cancer was low. Prior genetic counseling was associated with greater perceived risk for ovarian cancer. Results suggest that most high-risk women (>75%) do not know their risk for ovarian cancer. Identification of potentially high-risk women for referral to genetic counseling may improve informed ovarian cancer risk management.

Complementary and alternative medicine use by breast cancer patients at time of surgery which increases the potential for excessive bleeding.

OBJECTIVE: The use of complementary or alternative medicine has increased greatly over the last decade. This study describes a cross-sectional survey of women with breast cancer to describe their use of herbs and supplements that might have placed them at elevated risk for bleeding at the time of their primary treatment surgery for breast cancer. METHODS: We present cross-sectional survey results from a cohort of 316 women with breast cancer. The participants included a convenience sample of 98 women who received integrative oncology treatment from local providers and a larger group of women recruited from the local cancer registry who were matched on their similarity to the integrative oncology patients' demographic characteristics and stage of cancer at time of diagnosis. RESULTS: Almost 16% of women with breast cancer report using one or more herbs or supplements thought to potentially increase their risk for adverse bleeding-related outcomes at the time of their primary surgical treatment. This does not include the 22% who used fish and flaxseed oils, which were at one time thought to increase risk for bleeding but for which there is now evidence to suggest that they are safe. conclusion: Further research is needed to better understand the risks associated with use of a variety of herbs and supplements among women approaching surgery.

Use of CA125 and HE4 serum markers to predict ovarian cancer in elevated-risk women.

BACKGROUND: Serum markers are used before pelvic imaging to improve specificity and positive predictive value (PPV) of ovarian cancer multimodal screening strategies. METHODS: We conducted a randomized controlled pilot trial to estimate surgical PPV of a "2 of 3 tests positive" screening rule, and to compare use of HE4 as a first-line (Arm 1) versus a second-line (Arm 2) screen, in women at high and elevated risk for epithelial ovarian cancer (EOC) at five study sites. Semiannual screening was offered to 208 women ages 25 to 80 years with deleterious BRCA germline mutations and to 834 women ages 35 to 80 years with pedigrees suggesting inherited susceptibility. Annual screening was offered to 130 women ages 45 to 80 years (Risk Group 3) with epidemiologic and serum marker risk factors. Rising marker levels were identified using the parametric empirical Bayes algorithm. RESULTS: Both strategies yielded surgical PPV above 25%. Protocol-indicated surgery was performed in 6 women, identifying two ovarian malignancies and yielding a surgical PPV in both arms combined of 33% (95% confidence interval: 4%-78%), 25% in Arm 1 and 50% in Arm 2. Surgical consultation was recommended for 37 women (26 in Arm 1 and 11 in Arm 2). On the basis of 12 women with at least 2 of 3 tests positive (CA125, HE4, or imaging), an intent-to-treat analysis yielded PPV of 14% in Arm 1 and 20% in Arm 2. CONCLUSIONS: Positive screens were more frequent when HE4 was included in the primary screen. IMPACT: HE4 may be useful as a confirmatory screen when rising CA125 is used alone as a primary screen.

Value of symptom-triggered diagnostic evaluation for ovarian cancer.

OBJECTIVE: To evaluate the potential harms and ovarian cancer outcomes associated with symptom-triggered diagnostic evaluation of all women with symptoms of ovarian cancer. METHODS: Five thousand twelve women older than age 40 years were prospectively enrolled in a cohort study of proactive symptom-triggered diagnostic evaluation. Women who tested positive on a symptom index were offered testing with CA 125 and transvaginal ultrasonography. Results of these tests and any subsequent procedures were recorded. Assessment of ovarian cancer outcomes for all participants through Surveillance, Epidemiology, and End Results was performed 1 year after enrollment was complete. RESULTS: A positive symptom index was found in 241 (4.8%) participating patients, and 211 (88%) underwent CA 125 testing, transvaginal ultrasound screening, or both. Twenty surgical procedures (laparoscopy, laparotomy, vaginal) were performed in the study population (0.4% of participating women). However, only six (0.12%) were performed for a suspicious ovarian mass and only four (0.08%) were performed solely as a result of study participation. A total of eight ovarian cancers were diagnosed, 31-843 days after symptom assessment (50% distant, 50% local or regional). Of the two cancers diagnosed within 6 months, one was symptom index-positive. CONCLUSIONS: Proactive symptom-triggered diagnostic evaluation for ovarian cancer results in minimal unindicated surgery. A small number of ovarian cancers was identified solely on the basis of symptom-triggered diagnostic testing. LEVEL OF EVIDENCE: II.

Adverse events associated with complementary and alternative medicine use in ovarian cancer patients.

INTRODUCTION: Many women with ovarian cancer are choosing to include complementary and alternative medicine (CAM) substances in conjunction with their conventional treatment for ovarian cancer. Many oncologists express concern that the adjunct use of CAM substances may be detrimental to the achievement of therapeutic levels of chemotherapy leading to increases in drug toxicity, under-treatment of disease or other adverse events. In an effort to ascertain the extent of the potential problem with simultaneous use of CAM with conventional treatment we undertook comprehensive systematic review of published case reports describing CAM-related adverse events among ovarian cancer patients. STUDY DESIGN: This article describes a systematic literature review. METHODS: The Natural Medicines Comprehensive Database (NMCD). PubMed, EMBASE® and the Cochrane Central Register of Controlled Trials (CCTR) were systematically reviewed for research articles pertaining to case reports describing adverse events in patients, and clinical trials which examined the effects of herbs and supplements used during cancer treatment. RESULTS: Only one case report and one clinical trial were identified which met our inclusion criteria and were relevant to the current investigation. CONCLUSION: Although there are concerns about the potential for adverse events related to concurrent use of CAM substances during conventional treatment we found few case reports and clinical trials in the literature which support this.

Dangerous combinations: Ingestible CAM supplement use during chemotherapy in patients with ovarian cancer.

OBJECTIVE: Some ingestible complementary and alternative medicine (CAM) supplements, including herbal remedies, teas, and vitamins, have biological activities that make them likely to interact poorly with conventional chemotherapeutic treatments. This study surveyed women with ovarian cancer to document the extent to which women use ingestible CAM supplements and conventional chemotherapeutic treatments that are believed to be of potential concern when used together. METHODS: A total of 219 patients with ovarian cancer who received care from 1 of 2 participating conventional oncology practices were surveyed about CAM use during and after ovarian cancer treatment. RESULTS: A total of 200 women reported having chemotherapy to treat their ovarian cancer. Of those, 79 (40%) reported using 1 or more CAM supplements that could be cause for concern when taken with 1 or more of the chemotherapy medications they were receiving. Many patients took multiple supplements of potential concern. Of these women, 42% (n=33) consulted with a conventional provider and 24% (n=19) consulted with a CAM provider about the contraindicated supplements they used. CONCLUSION: Although it is not clear that any of these contraindicated combinations of CAM and conventional therapy actually caused adverse outcomes, increased toxicities, or reduced the effectiveness of primary therapies, all these effects are possible given the substances being used in combination. Research is needed to understand the real risk associated with CAM and conventional polypharmacy. If risks associated with CAM use prove substantial, then improved systems to assure that all women get advice regarding supplement use during ovarian cancer treatment will be needed.