ACANews ~ October 2015
By Jeffrey Sklar, DC
Regional Director of Chiropractic
Cancer Treatment Centers of America
Well known celebrities discussing their personal challenges with breast cancer has led to frequent media coverage. Primarily, the focus is on the oncological decisions regarding treatment: whether to have radical surgery along with chemo and radiation, just radiation or take a holistic approach. However, there isn’t much attention drawn to Quality of Life (QoL) factors that parallel the breast cancer patient experience.
In other words, treatment decisions and outcomes often seem to shadow the collateral damage experienced by patients who undergo conventional breast cancer treatment. Many premenopausal women face the inevitable decision to take the drug tamoxifen to help prevent recurrence of the disease at the risk of having menopausal-like symptoms. Also, reconstructive post-mastectomies can lead to complications during the healing process and beyond. These complications may include poor wound healing at the site of reconstruction, as well as the tissue donor site. Frozen shoulder is a common occurrence for post-mastectomy, breast reconstruction patients. Many breast cancer patients are forced to look outside their core oncology team to find services that will help with QoL.
It was reported in the Journal of Clinical Oncology that among 453 cancer patients surveyed, 83.3 percent had used at least one complementary alternative medicine (CAM) therapy concurrent with conventional treatment. Another discovery was that 24.7 percent of participants used seven or more CAM therapies. 
With early detection, survival outcomes are increased. This is partly because of innovative technological advances, such as intraoperative radiation therapy with the Novac 7, which allows qualified patients the opportunity to have a single dose of radiation to the tumor bed instead of six weeks of external radiation; and NanoKnife, which targets tumors in difficult-to-reach spaces while sparing healthy tissue. However, post-treatment pain and diminished QoL plague the overmedicated, under-treated patient population. This is discussed in an article, Adverse Effects of Breast Cancer Treatment,  about “adverse effects of breast cancer treatments and how they affect the health and quality of life of those receiving treatment.”
Call for Integration
Pain management is a necessary part of any breast cancer treatment plan, and it can be argued that pain medication, specifically opioids, has not produced the desired outcome. A 2012 study reported that pain is as prevalent with ambulatory solid tumor oncology patients today as it was 20 years ago, despite a more than tenfold increase in opioid prescriptions. Conclusions drawn from this information include a call for integration of non-oncology resources into oncology settings.  Note that when treatment plans formulated for breast cancer patients include aggressive therapies that could affect the patient’s fertility, serious discussions are required. It is this type of comprehensive care and compassion that create a benchmark for integrative whole-person cancer care.
In looking at this proposed model of whole-person QoL integrative therapy for breast cancer patients, there are several facets in which chiropractic intervention can positively influence pain reduction and improved function. Although chiropractic scope of practice varies by state, the application of chiropractic adjustments and some modalities offered by chiropractic physicians has been reported by patients to alleviate pain and discomfort, stress and anxiety and improve areas of diminished function. Many cancer patients are seeking chiropractic care in concert with their conventional treatment, as noted in a Washington State study that of the 7,915 insurance claimants with cancer, 11.6 percent had claims for chiropractic care. The study concluded that cancer patients will use alternative providers if given the choice and if the cost of treatment is modest; CAM providers are not replacing conventional providers, but instead are integrated into overall care. 
In 2006, CAM use was 7 percent and is now estimated to be as high as 54 percent of U.S. cancer patients who sought CAM therapies and hoped to boost the immune system, relieve pain and reduce cancer treatment side effects. 
The driving force for cancer patients is a desire to “counteract suffering symptoms from the cancer or medical treatment, to directly fight the disease or decrease the tumor, to assist conventional treatment, to improve physical well-being, to improve emotional well-being or provide hope and as well as to do everything possible to fight the disease.”  Researchers from Camp Pendleton, Calif. reported that doctors of chiropractic (DCs) can assist in treatment of the complications of prolonged bed rest, chronic pain related to radiation fibrosis, chemotherapy-related neuropathies and gait or functional abnormalities, thereby decreasing the patient’s reliance on pain medication. 
QoL for Breast Cancer
Stress and anxiety are likely to accompany a cancer diagnosis. Once a treatment plan turns into action, the side effects of chemotherapy, radiation and surgery will have a direct impact on the patient’s QoL. Chiropractic offers a useful role in minimizing collateral damage to these patients. For instance, bevacizumab (Avastin), the chemical commonly used to fight metastatic breast cancer, may cause severe high blood pressure (BP) in some patients. Although no literature exists for DCs helping to reduce blood pressure with patients on Avastin, in May 2007, researchers found that atlas realignment offered marked and sustained reductions in BP similar to the use of two-drug combination therapy.  With the daunting task of taking and managing many medications, using chiropractic to manage blood pressure issues is a welcome option.
Other side effects of bevacizumab (Avastin), and numerous other chemical compounds used to fight cancer, are headaches, nausea, neuropathy and even hiccups. The literature in favor of chiropractic intervention is absent with respect to cancer patients. However, the Journal of Manipulative and Physiological Therapeutics (JMPT) published encouraging findings in a literature review on the effectiveness of chiropractic treatment of headaches. 
In looking at visceral symptoms, the impact of spinal adjustments on the autonomic nervous system may show promise as noted in the literature review in JMPT by Budgell,  reporting that “recent neuroscience research supports a neurophysiologic rationale for the concept that aberrant stimulation of spinal or paraspinal structures may lead to segmentally organized reflex responses of the autonomic nervous system, which in turn may alter visceral function.” If the possibility of the neurologic reflex exists in which stimulation of the spinal structures and supportive anatomy may minimize breast cancer treatment side effects such as nausea, indigestion, hiccups, neuropathy and fatigue, it behooves science to investigate with vigor as it calls DCs to action to offer services to this patient population. The caveat is, “The clinical challenge facing the chiropractor is selecting adjusting techniques which are safe and effective in such circumstances.” 
In a study that looked at patients in early stage breast cancer, the research team notes that adverse events from treatment such as fatigue, nausea and neuropathy greatly affect patient QoL.  The anecdotal reports are numerous with regard to adjustments creating extraordinary results. It is common for a chiropractic patient to say, “I feel like the light was just turned on” or “I feel a rush of energy through my body.” Such sensations are welcome for an individual plagued with fatigue. Additionally, there are many DCs certified in acupuncture. Acupuncture is represented significantly in the literature as being effective for nausea, vomiting and pain control.
Another complication often seen with breast cancer patients is radiation positioning. The literature suggests that patient comfort is a significant issue as the radiation therapists work to minimize dosage and maximize treatment outcomes.  It is common for patients who are undergoing weeks of daily radiation to develop musculoskeletal discomfort from prolonged positioning. In fact, there have been cases where patients develop cervical radiculopathy and brachial plexus syndromes.
Chiropractic intervention holds promise to quickly alleviate pain levels enough to prevent a delay of radiation treatment, thus allowing the patient care to continue with minimal interruption.
It is important to include spiritual and emotional concerns when addressing this patient population. The stress and anxiety of dealing with interpersonal relationships while undergoing treatment for breast cancer can be overwhelming. Psychosocial support interventions are shown to improve QoL and emotional well-being. 
An article on patient-centered care concluded, “A patient-centered paradigm offers a useful model to critically study what benefits patients and to prepare chiropractic students to practice in the patient’s interest.” 
Part of being a quality care provider involves being engaged with the practice community. Having brochures and offering office space for support groups to hold meetings is a great way to expand the ideal of patient-centered care outside the treatment room.
As medical interventions move from the infusion clinic into the operating room, breast cancer patients face even more physical and functional challenges, such as extended bed rest, scar tissue, slow healing and frozen shoulder. Another modality used by DCs is cold laser therapy. Clinical studies confirm that thermal lasers could effectively promote skin wound healing if used in a controlled manner.  Regarding frozen shoulder, a 2014 preliminary study from England suggested that manipulation under anesthesia and subsequent physiotherapy offered positive outcomes in a series of patients with frozen shoulder secondary to breast cancer treatment. 
The chiropractic profession has a historic reputation for advocating good diet, sleep and fitness. DCs are well-trained in administering exercise modalities to facilitate healing and improve function. A 2004 study reported, “A mixed-type, moderate-intensity exercise program in a group format is acceptable to women following breast cancer treatment, with the potential to reduce fatigue and improve quality of life, without exacerbating or precipitating lymphedema.” 
The Cancer Patient Journey
Quality of life of every minute of every day should be a focus as important as survival. While cutting-edge oncology teams around the world look for innovative treatments, the chiropractic profession would be wise look at and understand the journey of not only breast cancer patients but also all cancer patients.
DCs have talents that should be part of the frontline arsenal for improving QoL for this patient population. This article discusses where chiropractic intervention would be an asset to the care team. However, it is far from complete and will take effort and creative thinking to positively affect the lives of cancer patients and caregivers with chiropractic care.
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A 2012 study reported that pain is as prevalent with ambulatory solid tumor oncology patients today as it was 20 years ago, despite a more than tenfold increase in opioid prescriptions.
Dr. Sklar is the eastern regional director in the Department of Chiropractic for ACA’s corporate partner, Cancer Treatment Centers of America. www.cancercenter.com
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