Integrative oncology (IO) modalities such as vitamins and supplements, acupuncture, yoga and meditation can play an important role in supporting patients who are receiving cancer treatment, a panel of experts noted during a session at the 2024 ACCP Annual Meeting, in Phoenix.
“I see breast cancer patients and survivors in the clinic, and lots of patients talk to me about managing their side effects of chemotherapy with the various IO modalities,” said Alexandre Chan, PharmD, MPH, FCCP, the founding chair and a professor of clinical pharmacy at the University of California, Irvine.
Since 2017, the Society for Integrative Oncology and the American Society of Clinical Oncology have issued multiple joint clinical practice guidelines about the role of IO modalities in reducing fatigue and pain, and lowering levels of anxiety and depression in people with cancer.
Dr. Chan turns to these guidelines when he answers patient questions about whether acupuncture will reduce fatigue after chemotherapy. He noted that the scientific robustness of published studies remains a main limitation to applying many IO modalities for symptom management in patients with cancer, although clinical trials of IO are ongoing.
Regardless of the strength of the evidence, the complementary and alternative medicine (CAM) market, which includes IO products, is large. According to the National Center for Complementary and Integrative Health, more than 30% of U.S. adults and 12% of children use some type of CAM, with more than $30 billion in annual spending. If there isn’t good evidence for a CAM modality in a particular situation, pharmacists should gently steer patients to more suitable alternatives, Dr. Chan said. This requires active engagement, trust and rapport with the patient. “Pharmacists should be more proactive in understanding which IO products patients are using,” he said.
Vitamins and Supplements An Opportunity for Education
Although vitamins and supplements are one of the most widely used CAMs, regulatory oversight of these products is lax when compared with the rigorous FDA approval process applied to prescription medications, noted Cathi Dennehy, PharmD, FCHSP, a professor of clinical pharmacy at the University of California, San Francisco. Per the 1994 Dietary Supplement Health and Education Act (DSHEA), the FDA treats dietary supplements as food and not drugs, Dr. Dennehy said. With DSHEA, the FDA cannot remove a supplement from the market unless it is demonstrably unsafe, even with evidence that it is contaminated or a label is deceptive.
“DSHEA works in favor of the dietary supplement manufacturers,” Dr. Dennehy noted. “Unsafe products can include contamination with a prescription drug, adulteration with an unlisted plant or dietary ingredient, or the presence of heavy metals.”
In 2007, the FDA began to require good manufacturing practices for supplements, such as producing supplements in facilities free of contamination and with accurate labels.
Even so, adulterated supplements persist, Dr. Dennehy noted, such as weight-loss and sexual performance enhancement products that contain active pharmaceutical ingredients (J Clin Pharmacol 2022;62:928-934). The FDA can send warning letters to manufacturers or requests to pull adulterated products from the market, after receiving reports of possible problems. “The FDA is in a reactive mode,” she said.
Independent third-party groups chemically analyze supplements to ensure labels are accurate, so she suggested looking for certification seals from groups such as the NSF or USP.
Pharmacists should welcome questions about supplement use, Dr. Dennehy stressed. As an example, a person taking a supplement with St. John’s wort may ask their pharmacist about it. “St. John’s wort is a great herb, honestly. It’s got [strong]evidence for improving mood,” Dr. Dennehy said, presuming the supplement has been manufactured properly (Syst Rev 2016;5[1]:148). If the pharmacist knows the patient is also taking birth control pills, however, they should inform them that St. John’s wort can render the pills less effective (Contraception 2005;71[6]:402-408). Providing the full picture builds patient trust, Dr. Dennehy said.
Similar to supplements, pharmacists should be prepared to answer questions about vitamin use, noted Nicole Albanese, PharmD, a clinical associate professor at the University of Buffalo School of Pharmacy and Pharmaceutical Sciences, in New York. “There’s something about a natural product or vitamin that people are willing to take and believe in, and trust more than a pharmaceutical product,” Dr. Albanese said.
At the ACCP meeting, Dr. Albanese detailed many benefits of vitamin use. Vitamin C intake of more than 40 mg daily, for instance, reduces the risk of developing hyperuricemia (Asia Pac J Clin Nutr 2018;27[6]:1271-1276).
A study (Pediatr Neonatol 2019;60[3]:237-244) showed that boosting vitamin D levels in infants with a vitamin D deficiency decreased their incidence of respiratory tract infections (odds ratio, 0.88; 95% CI, 0.81-0.96). Another study (BMJ 2019;366:l4673) found that boosting vitamin D levels in adults could lower the risk for death from cancer by 15% (risk ratio, 0.85; 95% CI, 0.74-0.97).
‘I Believe in the Science’
“I believe in the science behind [vitamins], and they do help,” Dr. Albanese said, who also tells patients what vitamins cannot do and describes their risks. For example, taking at least 2 grams of vitamin C will not prevent getting a cold, but could make someone’s cold end sooner (Nutrients 2017;9[4]). Both vitamins C and D could blunt the effectiveness of statins, Dr. Albanese reported. Vitamin E supplements may boost eye health, Dr. Albanese said, but do not appear helpful for cardiovascular health.
One challenge with vitamins, as with supplements, is that they are regulated as food in the United States, not drugs. Thus, there’s less guarantee that what’s on the label is what’s in the bottle. “You can’t just buy any product willy-nilly; you have to find a reputable source,” Dr. Albanese said. As with supplements, she added, certification seals from third-party analysts can be helpful.
The sources reported no relevant financial disclosures.
This article is from the March 2025 print issue.