By Yen Nien (Jason) Hou, PharmD, Dipl OM, LAc, and Eugenie Spiguel, MSN, ANP-BC
Nearly 60% of patients with cancer turn to herbal supplements for symptom relief, but patient-physician communication about that use remains inadequate. Unsupervised herbal use can lead to adverse events and herb-drug interactions for patients during active treatment. Many physicians and providers also lack sufficient knowledge about herbal supplements to help patients make informed decisions.
Sow the Seeds
Memorial Sloan Kettering’s Integrative Medicine Service (IMS) initiated an herbal oncology program (HOP) in 2019 to address two important gaps: symptom control for patients with cancer and patient-physician dialogue about herbal use.
IMS established an herbal formulary and dispensary to offer patients quality-controlled traditional Chinese medicine (TCM) formulas with preliminary safety and efficacy evidence. HOP addresses gastrointestinal symptoms such as constipation or diarrhea, insomnia, and mood. To build the program, IMS providers held in-depth discussions with TCM oncologists in China; reviewed classic herbal medicine textbooks; and conducted systematic literature reviews.
Nurture the Sprouts
When an IMS physician or advanced practice provider determines that a patient may benefit from herbal medicines, assesses the potential risk-benefit ratio, and deems that there are no alternative options, they recommend herbal formulas for symptom management. The provider has a thorough discussion with the patient about the rationale and involves the oncology team as needed.
An IMS pharmacist trained in TCM herbology and conventional pharmacy procures the herbal products under a rigorous quality assurance process and counsels patients on their questions about the herbal medicines. The prescriptions are dispensed through the outpatient pharmacy or by mail. Although most insurances do not cover herbal medicines, many patients use pretax health savings accounts or flexible spending accounts for purchasing the prescriptions.
A senior IMS physician tested the HOP workflow and process over the course of a year before implementation. The program uses a data tracking system to monitor prescription patterns, fill patterns, and potential adverse effects.
Harvest the Outcomes
To measure the symptoms and other concerns that motivated patients to seek herbal medicines, types and numbers of dispensed TCM herbal prescriptions, and patient demographics, the IMS team conducted a retrospective chart review of all patients who participated in the program from February 1, 2019–January 31, 2022. Patients who received an herbal prescription from May 1–August 31, 2021, were also invited to complete a brief 10-question survey.
Over the study period, 1,266 herbal prescriptions were dispensed to 851 patients with cancer, of whom 712 (84%) were receiving active treatment. The majority of patients were female (606, 71%), white (594, 70%), and publicly insured (498, 59%), and patients’ median age was 61 years (range = 18–98 years). Common symptoms for which herbal medicines were prescribed included gastrointestinal (467, 37%), pain (353, 28%), and fatigue, sleep, and mood disorders (346, 27%).
Of the 269 patients invited to participate in the survey, 107 (40%) responded:
- The majority of patients (73, 70.9%) reported being satisfied with the effectiveness of herbal prescriptions in managing their symptoms.
- Few patients (7, 6.7%) experienced adverse effects related to herbal use, including constipation, bloating, heartburn, acid reflux, and skin discoloration and peeling. All were mild in nature and resolved after the herbs were stopped.
- Nearly all of the participants (86, 80.4%) rated the ability to discuss herbal medicines with an IM provider as “very to extremely important.”
The findings support the feasibility of incorporating herbal medicines into an academic oncology setting using a model like HOP. Also, the prescription patterns can inform future research efforts to expand the evidence base surrounding safe and effective use of herbal medicines.
What Oncology Nurses Need to Know
Many patients with cancer are using herbal supplements with or without their providers’ knowledge. Because of the risk for side effects or medication interactions, oncology nurses should conduct regular medication reviews with their patients to assess for herbal supplement use. Patients are interested in speaking to their trusted healthcare providers about herbal supplements, and nurses are well positioned to facilitate conversations about herbal supplements and guide patients on their appropriate use, risks, and potential side effects.