Complementary therapies in cancer care

This short overview is based on a talk I recently gave to the members of Sweet Louise, a New Zealand charity for the support of people with incurable breast cancer.

Complementary therapies can be loosely defined as those not included in orthodox medical training or practice, though this can change, for example acupuncture has been used in pain clinics for many years. Some therapies involve physically touching the body – examples include massage, reflexology, acupuncture. Others involve taking substances by mouth – herbal remedies, homeopathy, flower essences, special diets. Then the mind body therapies such as relaxation, meditation, yoga, visualisation and guided imagery, energy healing. And creative therapies with art, music, writing and dance. Several types can be combined.

They are often known as “natural” therapies, and the same ones may be called “complementary” when used alongside orthodox medical treatments, and “alternative” when used instead. The “integrative” approach combines them both but has been slow to get established, perhaps because of prejudice and misunderstanding on both sides. All these therapies are grounded in the “holistic” approach, which aims to balance the whole person in body, emotions, mind and spirit, and mobilise the potential for self-healing. This is in contrast to the approach of conventional medicine, which uses powerful drugs, surgery or radiation to suppress symptoms and destroy disease, and in which patients have a passive role. Both approaches have their place and can often be used alongside each other.

Surveys show that as many of two thirds of women with breast cancer are using one or more natural therapies, and there is good evidence that they can improve quality of life – helping to relieve physical symptoms such as pain and nausea, mental symptoms such as anxiety and depression, reducing the side-effects of radiotherapy and chemotherapy. They appeal because, in general, they are safe and natural and many of them are pleasant to receive. When I was practising with the Bach flower remedies, many of my clients told me they wanted a therapy that treated them as a unique person, rather than just one more case of a diseased body part.

While all the modalities have specific effects, their benefit is partly due to their positive influence on mind-body relationships. The self-help element, especially with therapies that require some active user participation, enhances a sense of choice and control. Spending time with an understanding therapist in a relaxed setting is comforting. Expectation of improvement can help to bring it about. Such general factors are important, and it is a mistake to devalue them as “just placebo”.

A key question is whether using these therapies can lead to a longer life expectancy or even to remission of the cancer. Many individual cases of remarkable recovery have been reported. But there are few formal research studies on this aspect, and it is a difficult thing to investigate for many reasons – for example treatments are used in individual combinations rather than standard protocols, and patients’ beliefs and motivation affect the outcome.

Some of the therapies carry risks, for example herbal remedies can have adverse interactions with prescribed drugs; massage and acupuncture occasionally cause physical injury. They can be expensive. The field is not tightly regulated and, while most therapists are skilled and honest, there are a few self-styled practitioners who cause more harm than good by making unrealistic promises of curing cancer while advising clients to refuse conventional treatment that would have been effective.

More detail about these topics, with case histories, can be found in some of my non-fiction books.

Fitbit and Zumba Gold

Having read a lot lately about the health benefits of exercise, and the health dangers of sitting down too long, I resolved to spend less time at my desk and more time on the move.

I replaced my wristwatch with a Fitbit Alta HR, in order to track my level of activity. I have always liked walking – though since getting a car I no longer do all the supermarket shopping on foot – so there has been no difficulty in meeting my goal of 12,000 steps per day. Sometimes I do more than that, and get a message on my iPhone about being an over-achiever. The Fitbit also provides heart rate data, and I was pleasantly surprised to be told that my cardiovascular fitness is “excellent”. Another pleasant surprise was that, assuming the reports are accurate, I sleep better than I thought I did and usually meet my target of seven hours per night. Fitbit also measures other physiological variables, and displays text messages, as well as telling the time. Whether wearing this sophisticated technological device does any harm to the body is not known.

So far well and good, but I know my physical coordination could be improved, so I have joined a Zumba Gold class. According to Wikipedia, Zumba draws on diverse traditions including cambia, salsa, merengue, mambo, flamenco, chachacha, reggaeton, soca, samba, hip hop, axe and tango. The “Gold” version is less strenuous than the others, being designed for older people and beginners. Along with about 15 other ladies of a certain age, and the occasional lone male, I spend an hour a week trying to follow the teacher as she dances along with the upbeat music. Hopefully, if I keep practising, the moves will become easier to follow and the class will be more fun.

I already quite enjoy Zumba, certainly much more than I ever enjoyed sports and gym at school. But, apart from walking and swimming in the summer, I have never been very keen on taking exercise for its own sake and am in no danger of getting obsessive about it. Besides, too much exercise can be bad for the joints and the heart. There are other ways to keep well, and a research finding that especially appeals to me is that proximity to a purring cat not only reduces stress, but can improve cardiovascular function and even help to prevent osteoporosis.

Wounded healers

During my medical career I met several doctors and nurses who had achieved excellence in their work despite – or maybe because of – health  difficulties of their own. I am sure I could not have coped so well as they did, but my recent experiences of the patient’s role have made me wonder what it would have been like if I was still in practice.

The term “wounded healer” is usually attributed to Carl Jung, who used it in a psychological context. Many of those who choose psychotherapy or counselling as a career are seeking, consciously or not, to cure problems of their own. If they have insight into these and have taken steps to resolve them, it may make their work more effective. If not, they risk causing further damage to their clients.

The term is also associated with Chiron, a figure from Greek mythology, who suffered from a chronic physical wound as the result of a poisoned arrow. He was able to heal other people but could never cure himself. I don’t know how Chiron felt about this, but many of today’s clinicians would be embarrassed by such a scenario – in line with the mantra “physician heal thyself”, there is a widespread assumption that healthcare professionals should not be ill themselves. Some patients do lack confidence in staff who have something evidently wrong with them. Others feel comforted to know that their attendants are vulnerable to the same ills as the rest of humanity, and encouraged to see them overcoming their limitations and carrying on their careers.

Compared to those in robust health, clinicians with personal experience of ill-health tend to be more sensitive and empathic, which within limits is a good thing but if taken too far can lead to over-involvement, excessive self-disclosure, loss of objectivity, and emotional exhaustion.

There is also the question of fitness to practise. There are both legal and ethical imperatives to give equal opportunities to those with illness or disability, and not discriminate against them. At the same time it must be acknowledged that they may be less capable of work than their healthy peers. Every case is different depending on the skills required in the specialty concerned, the nature of the physical and/or mental symptoms, and the time course of the condition – whether there is a chronic but stable handicap, or an episodic illness with recovery in between attacks. Whatever the diagnosis, it is likely that stamina will be impaired.

The main points that stand out from my own experience of the patient’s role relate to communication. I realised first-hand what a big impact the words of a healthcare professional can make; a casual or clumsily phrased statement regarding diagnosis or prognosis can stick in the patient’s mind, whether instilling fears that may prove unfounded, or providing reassurance that turns out to be false. Also, that the position of the patient’s relatives needs to be acknowledged, and considered in management of the case. Of course I knew about these things before, though I don’t recall being taught anything about them in my medical school days, and did not fully appreciate them till later in my career. Today’s students get more training in “soft” topics like communication skills, and hopefully do not need to wait till they or their loved ones are seriously ill to understand their importance.

Medical murder in fact and fiction

Having one of my medically themed crime novels entered for this year’s Ngaio Marsh Award has led me to reflect on the topic of murder in healthcare settings.

Deliberate killings by doctors or nurses, though rare, are probably more common than can ever be known. Clinical staff are better placed than most people to get away with murder. They have ready access to drugs, anaesthetic gases and surgical instruments, and deaths due to these agents can easily be passed off as natural or accidental. They are privileged to know intimate details of their patients’ lives. And as members of trusted professions they are not readily suspected.

Among the most notorious murderers of modern times was Dr Harold Shipman, who incidentally trained in the class ahead of me at medical school in Leeds in the 1960s. He was found guilty in a court of law of murdering 15 patients in his single-handed general practice and it is likely that he killed many more over his long career, usually by injecting large doses of diamorphine. The estimated number of his victims was 250, most of them being elderly women who were in good health although he fabricated a diagnosis of serious illness on their records. The nature of the mental aberration that led him to commit all these crimes is unknown, because he continued to deny them up until the time he hanged himself in his prison cell. As a result of Shipman’s case, much stricter controls were imposed on medical practice in the UK.

Other convicted serial murderers from medical settings have been nurses, popularly dubbed “angels of death”, working in hospitals or care homes. Their crimes usually masqueraded as mercy killings, but rather than arising from any genuine sense of compassion for someone whose incurable illness was causing unbearable suffering, they were committed for the perpetrators’ own satisfaction and without the knowledge or consent of the victims or their relatives.

Psychiatric evaluation of medical murderers would usually lead to a label of psychopathy, or personality disorder: the lack of moral sense, the inability to feel empathy, the enjoyment of killing, the grandiose belief of having a right to decide that certain persons are not fit to live. These are the extremes of the arrogance, cynicism and wielding of power that are occupational risks in medicine and related professions. Hallucinations and delusions secondary to psychosis or drug abuse are sometimes implicated.

Most if not all murderers are found to have a psychiatric diagnosis of some kind, and this may be sufficient to explain their crimes. In the context of fiction, however, using mental disorder as the sole reason for killing would usually be seen as a cop-out. Readers of crime novels expect a murder mystery to have a more complex solution,  perhaps involving money, sex, revenge, or concealment of discreditable secrets. These motives may of course account for real-life cases too.

Some would say there is a fine line between deliberate criminal killings and the various other forms of unnatural death that can occur through the actions of medical personnel. Some result from malpractice, others are sanctioned by law in certain jurisdictions. They include euthanasia, abortion, execution, experiments such as those carried out in Nazi Germany, drugs or surgery used inappropriately for commercial gain, and simple carelessness or incompetence.

My novel Unfaithful unto Death is intended as a light read with elements of black comedy, but touches on some of these serious themes.

“Across a Sea of Troubles”

Following on from my previous post about Writing a medical memoir, here is a short extract from my new book Across a Sea of Troubles.

***

“I don’t feel very well,” said my husband Brian, and slumped down on a nearby chair. His eyes were rolling upwards so that the whites were showing, and his face was very pale.

I said “I’ll call the ambulance.”

“No.”

It was a fine spring night and we were on Devonport Wharf, having just got off a late ferry from downtown Auckland. We had been attending a ballet performance of A Midsummer Night’s Dream with my mother, Clare, in celebration of her recent 91st birthday. It had been a pleasant relaxing evening and Brian had seemed perfectly alright at the theatre, but now he looked very ill indeed.

Again I proposed the ambulance, and again Brian refused, insisting that he wanted to go home. I looked around for assistance but we were alone on the wharf, my mother having gone on ahead to her own house with some neighbours we had met on the ferry.

I helped Brian onto the bus which took us halfway home, and while we slowly walked the rest of the way, I supported him as he swayed from side to side and had to keep stopping to rest.

At last we reached our house. I turned the key in the front door. As it swung open, Brian fell against it and collapsed unconscious in the hall.

I rang 111. The operator asked me a few questions and told me to check the pulse in Brian’s neck; it was around 200 beats per minute and irregular. She said that help was on its way. Meanwhile Brian had woken up and I sat beside him on the floor until the St John ambulance arrived.

The two ambulance officers helped Brian to move onto a couch, inserted a venous cannula into his arm, and ran an ECG which showed fast atrial fibrillation with left bundle branch block and ischemic changes. After making a telephone call they put up a drip and started an infusion of amiodarone, a drug that slows the heart rate and is used for the control of cardiac arrhythmias.

Brian, having a medical background, was apparently taking a detached interest in the proceedings. But when it became clear that preparations to take him to hospital were underway, he said “I’m not going.”

The senior ambulance man told him “You’re probably going to die if you don’t, mate.”

Brian continued to refuse, until I kneeled at his side and begged him to accept any treatment which might save his life. Then he suddenly said “Oh, alright.” Afterwards, he told me that he had not felt any pain or distress and would not have minded dying.

The local fire brigade came to help carry Brian down the garden steps and into the ambulance, and we set off on the first of the six urgent visits to North Shore Hospital that I was to make over the next few months.

***

Links to book: Smashwords, Amazon US, Amazon UK.

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Sugar

 

Guidelines for “healthy eating” come and go. At one time we were advised to avoid fat, now it is said that certain fats are extremely valuable. There are conflicting views about whether such foods as meat, dairy and legumes are good to eat. But one thing on which most of today’s experts do agree is that sugar is extremely bad for the health, and contributes to diverse forms of chronic disease.

Many authorities are now telling us to give up refined sugar completely, although a moderate intake of naturally occurring sugars such as fructose in fruit is okay. I don’t presume to question their advice, which is based on good evidence from large population studies. But there are always individual exceptions to general rules – consider for example the case of my friend Jenks.

Jenks is about to celebrate his 104th birthday. A widower, he lives alone and independently in his own house in England. Every year he flies, on his own, to New Zealand to visit his daughter. He cannot walk very well, but otherwise he is in good physical health and is not overweight. His mental faculties are intact and he uses the internet to keep in touch with the outside world. He has a calm and cheerful temperament.

Jenks has a hearty appetite and has loved sweet foods all his life. In England, besides the main meal of the “meat and two veg” variety which is delivered to his home each day, he eats plenty of processed cereals, biscuits and cakes, fruit juice, fruit tinned in syrup, milk chocolate, cakes and sweets. He takes sugar in coffee and tea. He also enjoys cheese and wine.

His daughter has been keeping a record of his diet while he is staying with her in New Zealand, and here is a typical day’s entry:

Breakfast: Apple juice, Muesli type cereal with milk, Toast and jam, Coffee with 1 sugar, Nectarine

 Mid-morning: Coffee with 1 sugar, 2 sweet biscuits

 Lunch: Bread, crackers & cheese

 Afternoon: Tea with 1 sugar, Cake, Biscuit

 Dinner: Fish & chips, Passion fruit, Chocolate, 2 glasses wine.

In between meals he will have eaten nibbles of sweets, dried fruits and nuts. He has a secret stash and tucks in on demand. 

Most people who ate like this every day without taking any exercise might be expected to become obese and diabetic and die from heart disease long before the age of 104. But not Jenks. Perhaps, as my late mother-in-law was fond of saying, “It’s all in the genes”.

Soldier’s heart, shellshock and lack of moral fibre

When I was unwell last year, my husband Brian explained my symptoms in military terms: “You’ve been in the front line, and now you’ve got shell shock.” Brian had researched this condition while editing A Physician in Spite of Himself, the autobiography of DW Carmalt Jones who was in charge of a shell shock hospital during World War 1.

Stressed and exhausted by dealing with a series of medical and surgical emergencies in the family, I had developed a variety of symptoms. Repeated attacks of rapid irregular heart beat and breathlessness accompanied by high blood pressure, on two occasions so severe that I was taken to hospital by ambulance. Separate episodes of feeling very cold, or very hot, shaking all over, or suddenly feeling drained of energy and having to lie down. Loss of appetite and weight. Insomnia. The symptoms were  mainly of a physical nature, but various medical tests did not indicate a definite diagnosis. As a former psychiatrist I knew they might be due to anxiety and depression, but a trial of antidepressant drugs made me worse.

Syndromes of this kind can be triggered by any sort of traumatic experience, especially when there seems no scope for controlling the situation or escaping from it. Most of the early descriptions were carried out on servicemen exposed to great physical and emotional stress in wartime. In the American Civil War, men who complained of palpitations, chest pain, shortness of breath and fatigue but had no signs of organic heart disease were said to have “soldier’s heart”. Other terms included da Costa’s syndrome, cardiac neurosis, and neurasthenia. In World War 1, the condition of “shell shock” could include symptoms in many different bodily systems, for example headache, tremor, confusion, nightmares, loss of balance, impaired sight and hearing, as well as the cardiovascular symptoms listed above. Some sufferers received no sympathy or understanding, being accused of cowardice or malingering and punished by firing squad. Others were sent to field hospitals for a brief period of sleep, food and graded exercise before being returned to duty. In World War 2, British airmen who refused to fly on bombing missions were labelled as “lacking moral fibre” (LMF) and usually demoted to menial jobs. Some of these men would have been suffering from the type of illness described above, others just could not bring themselves to take part in the killing of civilians. LMF was highly stigmatised, and concealed as far as possible, so that when I came to write something about it in my novel Blue Moon for Bombers I found little published information. In more recent conflicts, notably the Vietnam war, attitudes were more sympathetic and it became more acceptable to talk about the psychological side of these conditions. The concept of “post-traumatic stress disorder” (PTSD) was born, and continues to generate a great deal of interest and research.

Body and mind are interconnected, and patients with stress-related illness usually have some combination of physical and mental symptoms. For this reason the orthodox medical system, in which the different specialties are separated, may not be well placed to meet their needs. Patients who present with mainly mental symptoms would often be diagnosed as having PTSD and referred to psychiatrists or psychologists, perhaps without having a medical evaluation to exclude the organic pathology that will in fact be present in some cases. Patients for whom physical symptoms predominate might find their way to cardiac, respiratory, neurological or other specialist clinics, and if no organic disease is found the psychological aspect may not be taken seriously if it is recognised at all. The plethora of terms that have been used for such conditions over the years – psychosomatic, functional, medically unexplained, somatoform, and many more – suggests the difficulty of understanding and managing them. Many patients turn to alternative therapies for a more holistic approach.

There is no specific treatment although different medications, psychological therapies and natural remedies prove helpful for individual patients. Sometimes the illness becomes chronic so I was fortunate that my own symptoms recovered within a year, with support from kind relatives and friends, orthodox and alternative healthcare professionals, and an improvement in my life situation.

Only a minority of people who are exposed to severe stress will develop a stress-related illness. Those who do may well feel ashamed about being over-sensitive and lacking in resilience, as I did myself, even though I have chosen to go public by writing about it in this blog and in a forthcoming memoir.