Original Research PapersEffects of a holistic, patient-centered approach on breast cancer relative dose intensity
Introduction
With over 246,000 new breast cancer (BC) cases in the United States during the year 2016, the number of women affected is second only to skin cancer [1]. Thankfully, there are increased survival rates [2,3], including American Cancer Society-reported 5-year survival changing from 63% in the 1960's to 90% in 2012 [2]. Improved outcomes are generally attributed to improved early detection and treatment [2,3]. To be effective, chemotherapy must achieve >85% relative dose intensity (RDI; intended versus received dose) [[2], [3], [4], [5]]; an RDI < 85% may have limited or nonexistent efficacy [[2], [3], [4], [5]]. For example, 80% RDI compromises remission/cure by ∼50%, and patients with <65% RDI have a survival expectancy similar to no treatment [[2], [3], [4], [5]].
Although RDI’s importance is documented, up to half of BC patients have <85% RDI [2,6]. Receiving less than the intended dose and/or having treatment delays is problematic because every chemotherapy dose kills cancer cells [3]; treatment delays allow cell growth, increasing the chance of negative outcomes. In many cases, delayed appointments are not rescheduled quickly, or the oncologist is unaware and does not adjust the treatment plan [3,5]. Treatment reductions and delays occur for many reasons, withnon-treatment-related delays possibly due to: lacking transportation, patient/family illness, fear, and/or caring for family member [3,5]. Treatment-related delay reasons include: (1) lower socioeconomic status (e.g., inflexible work schedules); (2) body mass (i.e., surface area >2m2); (3) therapy toxicity; (4) treatment length (≥28 days); (5) neutropenia (low white blood cell count); (6) side effects (e.g., fatigue,); and/or (7) age (i.e., >65 years) [[2], [3], [4], [5]].
There is no current standard of care for improving RDI for BC, but strategies may include: patient and caregiver education, assessing neutropenia risk pre-treatment, using G-CSF (granulocyte-colony-stimulating factor, a supportive care agent), and/or strict cancellation protocols [5]. Additionally, nutritional counseling may help [7], especially people with a high body mass index (BMI) or body surface area (BSA) since chemotherapy maximums may restrict heavier individuals from receiving a full dose [6]. Finally, non-pharmacologic, holistic approaches are used with increasing frequency to decrease treatment-limiting side effects (e.g., fatigue) and improve quality of life [[1], [2], [3],8]. Yoga improves quality of life and psychological well-being, thus is recommended during and after treatment [9,10]. Reiki (light touch to stimulate healing) also improves physical and psychological cancer symptoms [11]. Indeed, according to Maslow’s Humanistic Hierarchy of Needs Theory [12], humans have a myriad of needs (e.g., physical, emotional, social, spiritual), and benefit from holistic approaches. Maslow’s theory is consistent with the concerns and needs of women with BC, as indicated by the Institute of Medicine and NCCS Breast Cancer Survivorship Program [[13], [14], [15]]. Ng et al. [16] eloquently applied Maslow’s Theory to BC, arguing that cancer care should be individualized, comprehensive, and address patients’ holistic needs to promote healing (Fig. 1).
Despite evidence supporting holistic cancer approaches, no known studies examined whether a patient-centered, non-pharmacologic approach improves RDI. To address this gap, this descriptive study’s objective is to examine RDI rates in a BC sample from a clinic emphasizing the patient experience and high quality, individualized, compassionate care. Given the lack of research on patient-specific variables and RDI, secondary analyses will include patient/clinical factors (e.g., age, hormone status, cancer stage). This clinic was chosen because it offers a unique, holistic approach, including continuous communication and education, and allowing patients to be active decision-makers. Also included at no cost to the patient are: chair yoga, Reiki, and nutritional counseling. If this patient-centered, holistic approach improves RDI rates for BC, other clinics may benefit from similar practices.
Section snippets
Study design
After obtaining approval from the Mount Mercy University Institutional Review Board (IRB), medical records from the Ghosh Center (Cedar Rapids, IA) were retrospectively evaluated and de-identified before coding and analysis.
Participants were 161 consecutive BC patients between 1/15/1998 and 7/18/2013. This cohort was selected at random, and included every single adult (18 + years) BC patient diagnosed at the Ghosh Clinic over this 5-year-period. Inclusion criteria consisted of: (1) BC diagnosis;
Participants
A total of 180 medical records were initially reviewed. Fourteen were excluded due to missing/incomplete initial prescribed dose records, and five had missing/incomplete received dose records (started or completed treatment at a different clinic). The remaining 161 patients’ data were included in the analyses (Table 1), with a mean age of 56.0 years (SD = 13.0; range 23 to 93). The majority of the sample was Caucasian (96.7%, n = 146), not Hispanic or Latino (99.3%, n = 150), married (62.9%; n = 95),
Discussion
This patient-centered, holistic approach contributed to BC patients achieving an impressive, overall RDI of 96%, which is over 10% higher than the recommended 85% RDI for optimal BC treatment outcomes. In fact, 92% of patients met or exceeded 85% RDI. Every treatment regimen had an RDI above 91.5% (highest RDI = 99.8% for FEC), with the exception of FAC, which had an RDI of 76.7%. Relative dose intensity was significantly higher in women who: (1) had a low BMI (<25); (2) were ER+; and/or (3)
Limitations
Contains missing data, limiting the ability to determine. The patient medical charts did not include detailed data on complementary therapy participation (e.g., exact minutes per sessoin, frequency per patient), disallowing assessment of dose-response relationships in patient outcomes. It was also challenging to analyze certain demographic and clinical characteristics due to small samples sizes within groups (e.g., n = 6 receiving FAC), limiting the ability to evaluate the effects of patient
Conclusions
A non-pharmacologic, holistic BC approach led to an RDI 11% higher (i.e., 96%) than the recommended 85% RDI for optimal treatment outcomes (92% of patients' RDI exceeded 85%). RDI was significantly associated with BMI and being ER+ and HER2+ . Additionally, this patient-centered approach led to 83.9% of patients receiving treatment on time. While a retrospective analysis disallows examination of the specific effects of each complementary approaches, this study provides preliminary evidence of its
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