Individual Enquiry Research Paper 2012 Title Author

Individual Enquiry Research Paper 2012

Title: Oncologists and cancer specialists’ expert opinion on the role of osteopathic treatment on patients with cancer

Author: Dawn Hammond BSc (Hons) Supervisor: Mr Chris Thomas MA (Med Ed) BSc (Hons) Ost, PGCAP, FHEA

The British School of Osteopathy 275, Borough High Street, London, SE1 1JE

Abstract Background: 1 in 3 people in the UK are affected by cancer according to Sasieni et al (2010). Despite this Walters et al (2011) report improving cancer survivorship. Mallik & Leonard, (2009) predict increasing numbers of these patients presenting to manual therapists with musculoskeletal problems. Hann et al (2004) suggest little is known about cancer specialists’ views on manual therapy. Objectives: Explore cancer specialist’s opinions on the risks and benefits of osteopathy on patients with cancer. Explore their experiences of patients having manual therapy. Investigate their rationale for referral. Methods: 12 semi-structured qualitative interviews were conducted with cancer specialists’. The interviews were analysed using elements of grounded theory. Intrarelater reliability found 98% agreed. Inter-rater reliability found 89% was agreed after discussion of errors and omissions. Results: Benefits were associated with osteopathic treatment on patients with cancer. Oncologists did not believe osteopathy increased metastatic spread risk but were concerned about increased fracture risk. Few oncology consultants informally recommended osteopathic treatment. Conclusion: Participants agreed there could be a role for osteopathy in the care of patients with cancer. Education, collaboration and research are required to facilitate inclusion into oncology healthcare. Key Search Words: Osteopathy, Chiropractic, Physiotherapy, Manipulation, Massage, Manual therapy, Cancer, Oncologists

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Introduction Rationale Sasieni et al (2011) state, that 1 in 3 people are affected by cancer in the United Kingdom (UK) and according to Cancer Research UK (CR UK) (2011) the most common cancers diagnosed in the UK, in order of prevalence are: Breast, Prostate, Lung, Bowel, Malignant Melanoma, Lymphoma, Bladder and Kidney Cancer. Walters et al (2011) report UK cancer survival rates improved in 21 common cancers. Mallik & Leonard, (2009) propose long survivorship of patients with cancer, means an increased chance of developing other chronic conditions which may initiate use of complementary and alternate medicine (CAM). Increasing cancer prevalence and improving survival rates suggest osteopaths might be more likely to come into contact with people who have a history of cancer. It is therefore beneficial to gain opinions of cancer specialists’ with expertise in the most commonly diagnosed cancers into treatment of this patient population. Existing research on Oncologists opinions Hyodo et al (2003) and Samano et al (2005) conducted questionnaire studies on oncologists’ opinions of CAM of 751 and 119 participants respectively. They found the majority had a lack of knowledge of CAM citing a lack of supportive scientific evidence but despite this 92% and 68.8% respectively accepted the use of CAM on patients with cancer. Hyodo et al (2003) and Hann et al (2004) found a large proportion of oncologists support the use of massage on patients with cancer. Hann et al (2004) found physicians commonly believed patients pursued CAM to take control of their treatment. Samano et al (2005) identified a significant positive correlation between oncologists with personal experience of CAM and their Page 2 of 61

recommendation of CAM to patients. Hann et al (2004), Habermann et al (2009) and Cox (2010) recommended research into cancer specialists’ opinions specifically on manual treatment on patients with cancer, where as existing research investigated opinions on CAM in general. Existing referral recommendations The G.Os.C (2006) and Schneider & Gilford (2008), report most patients self refer. The G.Os.C (2006) found that only 1/5th of all patients presenting to an osteopath were referred by a doctor, however Schneider & Gilford (2008) provided no evidence to support this statement. The Department of Health musculoskeletal services framework (2006) recommend development of multidisciplinary teams to reduce waiting times and better care for common musculoskeletal complaints. CR UK (2009) advocates the use of osteopathic treatment, The National Institute for Health and Clinical Excellence (NICE) (2009) suggest manual and manipulation treatment for non specific low back pain, whilst The National Cancer Action Team (NCAT) (2009) recommend physiotherapy for patients with cancer, guidelines include; teach exercise, set purposeful activity, postural re-education, massage/mobilise soft tissue, use of a TENS machine, use of heat and cold to ease pain and help with positioning. Cancernet UK (2011) state osteopaths use similar treatment modalities to physiotherapists with additional training in manipulative therapy. Bengough (2010) proposed barriers to osteopathic treatment of life limiting illnesses to be lack of knowledge, guidelines and the need to improve communication.

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The Department of Health (2006), CR UK (2009), NCAT (2009) and NICE (2009) recommendations all imply a potential role for osteopathy. Concerns about Metastasis Cox (2010) found osteopaths were concerned that improving fluid health in a patient with cancer might accelerate the disease. Lerner (1994) and The International Society of Lymphology (2003), theorise that massage increases blood flow and mechanical compression could promote metastasis by tumour cell mobilisation. Godette et al (2006) argued metastasis of cancer is a biologic process, not the cell’s capacity to disseminate but ability to grow in a new location facilitated by the microenvironment. Godette et al (2006) argue manual lymphatic drainage does not contribute to the spread of cancer and should not be withheld from patients with metastasis however evidence was not provided to support these claims. Wu et al (2010), investigated 70 patients with osteosarcoma that had manipulative therapy with massage to the site of an osteosarcoma tumour prior to diagnosis of cancer, and found a significantly poorer five year survival rate and significantly greater incidence of lung cancer metastasis compared to 68 with no manipulative therapy. Wu et al (2010) theorise this may serve as a mechanism to spread tumour cells recommending manipulative treatment should be avoided in osteosarcoma. Shah & Salzman, (2011) conducted a review of imaging techniques and appearance of spinal metastases, reporting spinal metastasis occur in 60-70% of systemic cancer patients but only 10% were symptomatic. They believe the mechanism to be haemodynamic with the venous route of Batson's plexus thought

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more important than the arterial route, rarely via the lymphatic system or direct invasion. Risks of reduced bone mineral density Howe (1993), Davis & Taylor, (2007), Roudier (2008) and Shah & Salzman, (2011) believe bone metastases result in bone mineral density reduction. Ernst (2007) identified three patients with pathological fractures following manipulative therapy when a diagnosis of cancer had been missed in a systematic review of manipulative therapy between 2001 and 2006. However, Breen (2006) found his exclusion criteria neglected studies which tested the effectiveness of manipulation. Roudier (2008) found bone metastases from prostate cancer appearing with increased bone density on x-ray, were under mineralised resulting in increased bone fragility. The small sample of 12 cannot be generalised to all prostatic metastases. CR UK (2009) caution against the strong manipulative techniques on patients with: osteoporosis, bleeding disorders, broken bones, cancer of the bone, spinal cord or marrow, during radiotherapy treatment and anticoagulant or steroid use. Benefits of manual therapy on patients with cancer According to the World Health Organisation (2010) osteopaths undergo extensive training over a minimum of four year’s full time, which overlaps medical training covering: anatomy, physiology, pathology, clinical methods and identification of pathology where treatment is not appropriate and referral for further investigation is required.

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Osteopathy Guide (2010) proposes the benefits are: assist pain management, reduce tension, help mental outlook and relieve debilitating side effects from chemotherapy and radiotherapy. However, there was limited research identified on the effects of osteopathy on patients with cancer therefore this study explores the effects of the manual therapies of: massage, chiropractic and osteopathic treatment on patients with cancer. Effects on pain, mood and quality of life Kutner, et al (2008) performed a multisite study of 380 participants with advanced cancer examining massage effects on pain and mood compared to simple touch demonstrating the benefit of massage over touch. This was well documented and reproducible, performance bias was possible. Jane et al (2009) found massage significantly reduced pain and fatigue in 30 patients with bone metastasis for up to 18 hours. The method was well documented although weakened by variations in analgesia and small sample and therefore difficult to extrapolate to the population with bone metastases. Performance bias was possible. Kutner et al (2008) and Jane et al (2009) reported improvement in pain levels and mood in patients with cancer treated with manual therapy. Effects on function Schneider & Gilford (2008) and Hojan, et al (2011) report improved range of movement in individual case studies. In a case of chiropractic treatment of a terminally ill cancer patient with low back pain Schneider & Gilford (2008) reports reduction of medication and improved quality of life. In a case of abdominal cancer

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Hojan et al (2011) describes physiotherapy and osteopathic techniques improving pain and fatigue. Individual case studies cannot be generalised to the population of patients with cancer but demonstrate treatment approach and effect. Clemens et al (2010) found 94% of 90 patients had symptomatic relief with lymphatic drainage reporting improvement. Variations in analgesia, small sample and lack of control group weaken this study. Treatment was discontinued in four, as manual therapy exacerbated their neuropathic pain which the authors dismissed as oversensitivity to touch rather than an adverse response to treatment. Stringer (2008) found one 20 minute light massage on 39 haematological participants undergoing intensive chemotherapy, significantly reduced cortisol levels temporarily and improved well-being. She suggests a potential effect on the immune system, if reduction of high levels of cortisol were sustained. The sample was small but the procedure was well explained and reproducible. Noll et al (2010) conducted a multicentre study on 406 participants reporting a statistical significant improvement with osteopathic treatment on patients with pneumonia resulting in reduced antibiotic duration, reduced hospital stay and reduced respiratory failure suggesting an influence on immune function. Noll et al (2010) did not investigate participants with cancer. Study relevance The aim of the study was to find out if oncologists refer patients with cancer to osteopaths and what they refer patients for. Investigate oncologists’ views on the risks and benefits of osteopathic treatment on patients with cancer and explore a potential role of osteopathy in the treatment of musculoskeletal symptoms in patients with cancer. Page 7 of 61

Method Design Qualitative semi-structured interviews were used to obtain cancer specialists opinions, views and experiences. Dawson (2009) recommends semi-structured interviews to compare and contrast interview content, explore detailed participant experiences and provide time and opportunity to discuss opinions and views. Recruitment 160 oncologists were invited within 50 miles of the British School of Osteopathy (BSO) taking every third name from the Dr Foster database and members of the National Cancer Research Institute. Recruitment and interviews took place between October and November 2011. Response rate was 8.75%. Participation A purposive sample of 12 currently practicing cancer professionals participated in the study: nine Oncology consultants, two specialist cancer nurses and one palliative care registrar. Sample size was determined by the BSO (2008) guideline for interview studies of four hours of recorded interview material or 8-12 participants. Participant criteria 

Inclusion: A preliminary questionnaire (see appendix 3) identified participants that either referred a patient or had personal experience of osteopathy, chiropractic or massage.

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Exclusion: One participant was excluded as they had no personal experience and had not referred a patient with cancer for manual therapy.

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Materials sent to participants: 

Letter of invitation (see appendix 8),

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Participant information sheet (see appendix 1),

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Two consent forms (see appendix 2)



Preliminary questionnaire (see appendix 3)

Other materials: 

Researcher Interview Script (see appendix 7),

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Digital Voice Recorder.

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Weft QDA software (2006).



MindApp Premium (2011).

Procedure The

participant

information

sheet,

two

consent

forms,

preliminary

questionnaire, and invitation to participate were sent to participants. Participants were given two weeks following receipt of a signed consent form before arranging the interview to facilitate a period allowing participants to change their mind about participation. 11 face-to-face Interviews were conducted in mutually convenient quiet locations, two over the phone due to these participants current location. An introducing question advocated by (Kvale, 1996 pp.133) was used to “break the ice”. Open ended questions (see appendix 7) allowed participants to respond with “richness and spontaneity” as recommended by (Oppenheim 1992 pg 81). Interviews

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were recorded using a digital voice recorder lasting between 5 and 32 minutes, four hours in total were transcribed by the author. Reliability Interview question content, validity and efficiency were discussed with the supervisor and reviewed by a professor of oncology. One pilot interview was conducted to trial the questions, identify bias, improve interviewer skills and check interview timing. This identified confusion about the therapies being discussed after discussing CAM therapies. Manual therapies were specified as osteopathy, chiropractic and massage and CAM questions were removed to prevent confusion. Intra-rater reliability was assessed as 98%. Assessed with inter-rater reliability 89% Data Analysis Interview transcriptions were offered to participants to review the content prior to inclusion in the study. No participants requested this option. Interview data was analysed with content analysis and elements of grounded theory. The interview transcripts read, reread and analysed for themes, meaning and associations. Software package Weft QDA version 1.0.1 (2006) was used to collate themes. Software package MindApp Premium version 7.0 (2011) was used to graphically display the data. Study ethics approval The BSO research committee gave approval on May 14th 2011. The NHS Ethics committee stated approval was not required providing the study commenced Page 10 of 61

after September 1st 2011 as participants were professionals. The NHS Research and Ethics Committee agreed with the NHS Ethics committee that approval was not required see appendix 4 & 5. Confidentiality & Anonymity The participant information form asked participants to avoid names or details that may lead to identification. Interviews were transcribed excluding names and identifiable details to protect identity. Participants were allocated a reference number so anonymous quotes by the participants could be used in the study. Name, contact details and digital recordings were securely stored by the author for the duration of the study then in a locked cabinet at the BSO on completion of the study for a period of six years after which they will be destroyed. Bias Selection bias is likely as participants chose to take part in the study. To minimise misunderstanding questions which might lead to bias, questions were checked with the research supervisor, a professor of oncology and piloted with an Oncology consultant. Open questions were used to minimise question leading question bias. There may be researcher bias as the author was studying to become an osteopath. To minimise reporting bias 16.7% of the interview data was transcribed and analysed by another final year osteopathy student then discussed and compared for inter-rater reliability.

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Results

Data analysis identified five themes: understanding of osteopathy, referral route, time constraints, manual therapy effects (see figure 2.0)

Participants details Participant details Occupation Oncology consultant Oncology nurse Palliative care registrar Gender Males Females Age