Exploring Herbal Medicine Use during Palliative Cancer Care: The Integrative Physician as a Facilitator of Pharmacist–Patient–Oncologist Communication

Oncology patients frequently use herbal and other forms of complementary medicine, often without the knowledge of oncologists, pharmacists, and other healthcare professionals responsible for their care. Oncology healthcare professionals may lack the knowledge needed to guide their patients on the safe and effective use of herbal medicinal products, a number of which have potentially harmful effects, which include direct toxicity and negative herb–drug interactions. The current review addresses the prevalence and expectations of oncology patients from herbal medicine, as well as evidence for the beneficial or harmful effects of this practice (potential and actual), especially when the herbal products are used in conjunction with anticancer agents. Models of integrative oncology care are described, in which open and effective communication among oncologists, pharmacists, and integrative physicians on the use of herbal medicine by their patients occurs. This collaboration provides patients with a nonjudgmental and multidisciplinary approach to integrative medicine, echoing their own health-belief models of care during conventional cancer treatments. The role of the integrative physician is to facilitate this process, working with oncologists and pharmacists in the fostering of patient-centered palliative care, while ensuring a safe and effective treatment environment. Case scenario: W. is a 56 year old female artist who was recently diagnosed with localized hormone receptor-positive breast cancer. Following lumpectomy and sentinel node dissection, she is scheduled to begin adjuvant chemotherapy with a regimen which will include adriamycin, cyclophosphamide, and paclitaxel (AC-T protocol). She is worried about developing peripheral neuropathy and its impact on her ability to paint, and she asks about a number of dietary supplements which she heard could prevent this from happening: omega-3, vitamin E, alpha-lipoic acid, and acetyl-l-carnithine. She is concerned, however, that the supplements may negatively interact with her chemotherapy regimen.

Vascular Pseudoinvasion: A Case Report and Review of Literature

In the era of minimally invasive procedures, laparoscopic hysterectomy is preferred over total abdominal hysterectomy as the primary treatment of endometrioid cancer limited to the uterus. Lymphovascular invasion (LVSI) is an important prognostic indicator for this tumor. Studies have observed presence of vascular pseudoinvasion in the surgical specimen excised via laparoscopic hysterectomy. Some studies have reported no increase in LVSI after minimally invasive surgery, implying that there is no vascular pseudoinvasion. Here, we present a 59-year-old female with history of obesity, hypertension, diabetes mellitus, asthma, and biopsy-proven well-differentiated endometrioid adenocarcinoma who underwent total laparoscopic hysterectomy with bilateral salpingo-oophorectomy and sentinel node dissection. An ill-defined friable mass (2.1 cm in maximum dimension) was present in the posterior lower uterine segment and had the morphology of endometrioid adenocarcinoma, grade 1 out of 3, invasive into the outer half of myometrium. There was no true vessel invasion but rather abundant contamination—smearing of tumor into vascular spaces. An immunostain for D2-40 identified no lymphatic invasion. Immunostains for CD31 and CD34 highlighted tumor cells present in vascular spaces consistent with pseudoinvasion. No regional lymph node metastasis was seen. Peritoneal fluid did not show malignant cells. After surgery, the patient received radiotherapy and had no evidence of recurrent disease. It has been proposed that the artifact of vascular invasion as seen in our case could be associated with the technique of laparoscopic hysterectomy. Substantial LVSI, in contrast to focal or no LVSI, has been shown to be the strongest independent prognostic factor for pelvic regional recurrence, distant metastasis, and overall survival. Its presence is a deciding factor for the type of adjuvant therapy. Therefore, it is important to recognize vascular pseudoinvasion to avoid misdiagnosis of LVSI.

Surgical management of axilla: controversy and care

Background: Surgical staging of the axilla has traditionally provided the best prognostic information about breast cancer. However, the morbidity of a complete axillary clearance outweighs the therapeutic and prognostic benefits of the procedure. Authors observed the types of axillary lymph node dissection (ALND) performed in authors’ institute and the magnitude of morbidities of a complete ALND.Methods: This observational study was conducted at the Cancer Institute of Himalayan Institute of Medical Sciences for a period of one year. Sequelae of ALND was observed at 1, 3 and 6 months in all female patients undergoing axillary dissection as part of surgery for breast cancer.Results: Out of 150 patients 53 (35.33%) presented with locally advanced disease, and 84 (56%) had palpable axillary nodes. All patients with palpable nodes underwent level II-III dissection. 32 patients underwent sentinel node dissection using blue dye only. Tumour size correlated positively with grade of tumour (r =0.36, P <0.001) and number of positive lymph nodes (r = 0.34; P <0.001). There was significant difference in incidence of lymphedema at 6 months in patients who underwent level III dissection (27.38%) as opposed to those who did not (8.92 %) (p <0.05). The incidence of seroma was also more at 1 month in these patients (57.14%) vs (39.28%), (p <0.05). Post-operative pain/ wound infection/Restriction of motion were not statistically significant.Conclusions: Higher stages of presentation require higher levels of axillary dissection. Unwarranted dissection can be avoided by tailoring the surgery during initial clinical assessment.