Programme « Améliorer la qualité de vie des personnes

Fondation du Centre
Pluridisciplinaire d’Oncologie
Centre Coordonné d’Oncologie
ambulatoire
CHUV - BH06
CHUV
Rue du Bugnon 46
CH - 1011 Lausanne
Programme « Améliorer la qualité de vie
des personnes atteintes de cancer »
« Approches complémentaires »
Bertrand Graz - novembre 2009
ANNEXES
Table des matières
Sources d'informations sur les AC en oncologie .............................................................................. 3 La recherche clinique sur les AC. L’exemple du cancer 2006-2009 ................................................ 4 1. Type de cancer ..................................................................................................... 5 2. Types de symptômes............................................................................................ 5 Douleur ........................................................................................................................... 5 Nausées........................................................................................................................... 6 Symptomes post-ménopopause ...................................................................................... 6 "Hot flashes" .................................................................................................................. 6 Psychisme – cancer ........................................................................................................ 6 Les enfants...................................................................................................................... 7 3. Types d'approches complémentaires ................................................................... 7 Massages ........................................................................................................................ 7 Le gui.............................................................................................................................. 8 Tai chi............................................................................................................................. 8 Imposition des mains ...................................................................................................... 8 4. Effets secondaires des AC ................................................................................... 8 5. Les méthodes de recherche sur les AC.............................................................. 10 Exemples de sites d'accès aux données cliniques sur les AC. ..................................................... 12 1. Site du NHS Evidence – complementary and alternative medicine ................... 12 2. Site "natural standard" http://www.naturalstandard.com/................................... 14 Institutions académiques s'occupant d'AC ...................................................................................... 16 1. 2. 3. 4. 5. 6. En Suisse ...................................................................................................... 16 Grande-Bretagne .......................................................................................... 17 Etats Unis ..................................................................................................... 18 Autres pays ................................................................................................... 20 OMS ............................................................................................................. 21 L'intégration des AC dans les systèmes de santé ......................................... 21 Bibliographie ........................................................................................................................................ 23 2/24
Annexe 1
Sources d'informations sur les AC en oncologie
Who will find
it most useful?
Name
Web site address
The National Cancer Institute
complementary and alternative
medicine summaries
www.cancer.gov/cancertopics/treatment/cam
National Center for
Complementary and Alternative
Medicine
http://nccam.nih.gov
Natural standard, the authority on
integrative medicine
http://www.naturalstandard.com/
Patients
Clinicians
Researchers
Allied and complementary
medicine database
http://www.bl.uk/collections/health/amed.html
Researchers
Clinicians
PubMed
http://pubmed.gov
Researchers
Clinicians
The Cochrane library
http://www.mrw.interscience.wiley.com/cochrane/
cochrane_search_fs.html
Researchers
Clinicians
Office of Cancer Complementary
and Alternative Medicine
(OCCAM)
http://www.cancer.gov/cam/index.html
Clinicians
Researchers
World Health Organization
(WHO): traditional medicine
http://www.who.int/topics/traditional_medicine/en/
Clinicians
Researchers
Society for Integrative Oncology
http://www.integrativeonc.org/
Patients
Researchers
Clinicians
Patients
Clinicians
Researchers
Consortium of academic health
centers for integrative medicine
http://www.imconsortium.org/
Clinicians
Researchers
International Society for
Complementary Medicine
Research
http://www.iscmr.org/index.html
Researchers
Clinicians
The Research Council for
Complementary Medicine
http://www.rccm.org.uk/
Researchers
Clinicians
Memorial Sloan-Kettering Cancer
Center
http://www.mskcc.org/mskcc/html/1979.cfm
Patients
Clinicians
MD Anderson Cancer Center
http://www.mdanderson.org/departments/cimer/
Patients
Clinicians
UK National Library for
Complementary and Alternative
Medicine Specialist
http://www.library.nhs.uk/cam/
Researchers
Clinicians
Complementary and alternative
medicine in the British Library’s
collections
http://www.bl.uk/collections/health/blcam.html
Researchers
Clinicians
Source :
Kate Boddy, Edzard Ernst: Review of Reliable Information Sources Related to Integrative
Oncology. Hematol Oncol Clin N Am 22 (2008) 619–63
3/24
Annexe 2
La recherche clinique sur les AC. L’exemple du cancer 2006-2009
Au vu de l’abondance de publications présentant des résultats de recherche clinique sur les
AC, nous nous sommes limités aux 3 dernières années et aux articles présentant une revue
de la littérature sur un sujet ayant trait aux AC. Les revues de la littérature retrouvées datant
de 2006 à mai 2009 sont au nombre de 67.
Certains de ces papiers comprennent une analyse des difficultés méthodologiques et
logistiques rencontrées dans l'étude clinique des AC (1) (2).
"There are more than 300 different topics under the term complementary and
alternative (...) . Clinical data derived from appropriately conducted clinical trials support the
use and value of complementary and alternative medicine for selected indications" (3).
"Complementary approaches in oncology that are recommended as additional to standard
cancer destructive therapies claim to optimize this therapy. A great body of data emerging
from scientifically sound clinical trials prove that defined complementary procedures are
beneficial for the patients."(4)
En commençant avec les considérations générales, les constatations suivantes ont paru
particulièrement intéressantes :
Des revues générales tentent de donner un aperçu des principaux résultats des études
cliniques d'AC en cas de cancer : "Rigorous scientific research has produced evidence that
acupuncture, massage therapy, music, and mind-body therapies effectively and safely
reduce physical and emotional symptoms. These therapies provide a favorable risk-benefit
ratio and permit cancer survivors to help manage their own care."(5)
L'intérêt pour une approche "evidence-based" envers les AC en oncologie est large, on le
retrouve en Europe (6), Amérique du nord (7) et du sud, Australie, Corée du sud (8), etc.
Voici un exemple venu du Japon :
"We review the prominent modalities in CAM <complementary and alternative medicine> in
present day cancer management and critically analyze their emerging potential into an
evidence-based oncology practice."(9)
Les méthodes de l'EBM ("essai randomisé contrôlé" - RCT en tête) ne sont cependant pas la
réponse universelle à toute question sur l'efficacité clinique. Par exemple, dans les soins
palliatifs, il peut être préférable d'utiliser des techniques mixtes: " RCTs are notoriously
difficult to conduct in palliative care, raising a variety of practical, ethical and moral dilemmas.
Mixed-methods research, which combines qualitative research and RCTs, offers a potential
solution to these problems."(10)
On trouve des revues de la littérature portant sur les AC pour un type particulier…
-
de cancer,
-
de symptômes,
-
d'AC.
4/24
Voici un résumé des publications récentes trouvées (2006-2009).
1.
Type de cancer
Une récente étude fait le point sur "Evidence-based complementary medicine in breast
cancer therapy" et réunit sur le sujet "a great body of data emerging from scientifically sound
clinical trials" (11), une autre étude sur les AC proposées en cas de cancer de l'ovaire,
conclut que dans ce domaine, on manque d'études cliniques prospectives (12), une autre
encore porte sur la sphère urinaire (13).
Dans la très grande majorité des cas, les recherches sur les AC portent sur des indications
qui ne sont pas la maladie cancéreuse en tant que telle, mais les symptômes liés à la
maladie ou aux effets secondaires des traitements conventionnels.
Il existe des revues de la littérature sur un produit particulier vanté comme traitement curatif
du cancer. De telles études, même si elles concluent à l'absence d'effet curatif, sont aussi
très utiles pour conseiller des patients qui songeraient à utiliser le produit. En voici un
exemple récent :
"Carctol is a herbal remedy that recently was widely reported to offer a cure for a
range of cancers. (...) In addition to numerous websites, we conducted systematic
searches in six electronic databases. Any factual information relating to Carctol was
considered. Results : the websites provided the composition of the herbal mixture and
numerous claims as to its effectiveness. However, not a single scientific study of any
style was found. Conclusions : the claim that Carctol is of any benefit to cancer
patients is not supported by scientific evidence."(14)
Des auteurs se sont intéressés à de possibles synergies avec le traitement anticancéreux lui-même. Voici un exemple avec le cas du cancer de la prostate :
-
2.
Pour le traitement du cancer de la prostate, une revue des AC étudiées rapporte le
"synergistic effect of Silbinin, a polyphenolic flavanoid with strong antioxidant properties,
derived from the seeds of milk thistle (Silybum marianum), when given in addition to
doxorubicin, cisplatin, and carboplatin" en précisant qu'il s'agit de résultats très
préliminaires. (15)
Types de symptômes
Les symptômes, qu'ils soient liés à la maladie ou à des effets secondaires du traitement,
sont la cible privilégiée des AC en oncologie. De façon générale, "complementary therapies
have an increasingly important role in the control of symptoms associated with cancer and
cancer treatment."(16)
Douleur
La douleur apparaît comme le cas typique où des AC ont été défendues avec vigueur et pour
laquelle existe aujourd'hui des éléments d'évidence. Un groupe d'auteurs du Sloan-Kettering
Cancer Center à New York déclare: "Pharmacologic treatment of pain does not always meet
patients' needs and may produce difficult side effects. Complementary therapies (...) may be
used adjunctively with standard pain management techniques to improve outcome and
reduce the need for prescription medication. Approaches such as acupuncture, massage
therapy, mind-body interventions, and music therapy effectively reduce pain, enhance quality
of life, and provide patients with the opportunity to participate in their own care. Such
therapies have an important role in modern pain management."(17)
5/24
"This is a systematic review of randomized controlled trials (RCTs) evaluating CAM therapies
for cancer-related pain. METHODS: RCTs using CAM interventions for cancer-related pain
were abstracted using Medline, EMBASE, CINAHL, AMED, and Cochrane database.
RESULTS: Eighteen trials were identified (eight poor, three intermediate, and seven high
quality based on Jadad score), with a total of 1,499 patients. Median sample size was 53
patients, and median intervention duration was 45 days (...) Seven trials reported significant
benefit for the following CAM therapies: acupuncture (n = 1), support groups (n = 2),
hypnosis (n = 1), relaxation/imagery (n = 2), and herbal supplement/HESA-A (n = 1, but
study was of low quality without control data). Seven studies reported immediate
postintervention or short-term benefit of the following CAM interventions: acupuncture (n =
2), music (n = 1), herbal supplement/Ai-Tong-Ping (n = 1), massage (n = 1), and healing
touch (n = 2). Four studies reported no benefit of CAM interventions (music, n = 2; massage,
n = 2) in reducing cancer pain compared with a control arm."(18)
Les douleurs lombaires ont fait l'objet d'une étude spécifique qui aboutissait à la conclusion
économique que "CAM and chiropractic often offer lower costs for comparable results
compared to conventional medicine."(19)
Nausées
Il existe des cas où une AC pourrait être efficace là où aucun traitement pharmacologique ne
semble soulager le patient.
"The use of 5-hydroxytryptamine type 3 receptor antagonists provides some relief for
chemotherapy-induced nausea and vomiting, but does not seem to control Anticipatory
nausea and vomiting (ANV). (...) Behavioral interventions, especially progressive muscle
relaxation training and systematic desensitization, should be considered important methods
for preventing and treating ANV." (20)
Symptomes post-ménopopause
Une revue de la littérature conclut à des effets modestes de thérapies complémentaires (21),
en ligne avec les conclusions de l'équipe de Ernst sur le Cimicifuga racemosa (actée à
grappes).
"Hot flashes"
L'efficacité de l'hypnose a été étudiée comme traitement des "hot-flashes" chez des
personnes traitées pour un cancer du sein. La conclusion d'une petite étude clinique
comparative était : "Significant improvements in self-reported anxiety, depression,
interference of hot flashes on daily activities, and sleep were observed for patients who
received the hypnosis intervention (P < .005) in comparison to the no treatment control
group" (22). Dans un cas comme celui-ci, on pourra arguer que, du moment que l'étude
n'était pas conduite en double-aveugle (ce qui serait sans doute difficile avec une
intervention comme l'hypnose), on ne peut pas distinguer ce qui est effet placebo (et/ou
curabo) de l'effet spécifique. On obtient en revanche une estimation de l'effet global, qui peut
aider dans la pratique clinique.
Psychisme – cancer
La question du lien entre cancer et psychisme (attitude positive, volonté de guérir, etc.) a été
quelque peu explorée. Une revue des publications sur cette question donne les conclusions
que la question reste sans réponse claire à ce jour:
"There is long history of anecdote and surmise linking psychosocial factors to cancer
incidence and survival. However, over the past three decades, an increasing number of
rigorous studies have investigated the possibility of a mind-cancer survival connection.
(...)
Some observational and quasi-experimental studies suggest the possibility that coping
and psychological factors may influence disease outcomes, but clinical trials suggest that
psychosocial interventions do not prolong survival. Methodological comment and
interpretation about the significance of these trials vary. (...) We take the position that the
question is unanswered."(23).
Les enfants
Un problème relevé est celui de la traduction des résultats obtenus chez des adultes pour un
éventuel emploi avec des enfants.
"A growing body of literature in adult oncology provides evidence for the role of CAM to help
manage symptoms and reduce distress. Translating this research to children requires studies
with new models that address family roles and include measurement of outcomes relevant to
children's developmental stages and unique responses. One of the limitations in pediatrics is
the small samples available to single institutions. Conducting clinical trials through the
cooperative group mechanism is one way of obtaining sufficient sample sizes to determine
effectiveness and safety of CAM therapies." (24).
Le problème de l'ignorance des soignants (soit par manque de formation adéquate soit par
manque de rapports d'études cliniques) se pose de la manière suivante (on retrouve
quelques analogies avec la situation avec les patients adultes): "physicians often lack basic
knowledge concerning CAM, leading to an avoidance of talking about CAM with parents. A
professional differentiation between potentially useful and potentially dangerous CAM is
necessary." (25)
Il existe cependant quelques données, comme dans le cas d'une étude allemande de
l'acupuncture comme "antiemetic rescue medication during highly emetogenic chemotherapy
in pediatric oncology" qui conclut que "The need for rescue antiemetic medication was
significantly lower in acupuncture courses compared to control courses (p=0.001) Episodes
of vomiting per course were also significantly lower in courses with acupuncture (p=0.01)"
(26) .
On a aussi utilisé les AC en Grande Bretagne pour le personnel.
"Staff in oncology hospitals experience considerable stress because of the emotional intensity
of work that involves limited clinical success, sustained contact with seriously ill/dying people,
and serial bereavement. Evidence suggests that providing complementary therapies at work
can help to reduce anxiety, depression and blood pressure and, thus, increase well-being."
(27)
3.
Types d'approches complémentaires
Massages
Une revue de 11 essais cliniques randomisés contrôlés conclut que des "positive effects on
the quality of life of cancer patients were found in most of the studies. No risk of tumor cell
spread was reported. Les effets mesurés sont : "reduction of pain and anxiety, reduction
nausea and fatigue" (28). Une autre étude a trouvé que "in isolated haematological oncology
patients, a significant reduction in cortisol could be safely achieved through massage, with
associated improvement in psychological well-being" (29). Une étude sur "Aromatherapy
massage" observait des effets à court terme seulement : "Aromatherapy massage does not
appear to confer benefit on cancer patients' anxiety and/or depression in the long-term, but is
associated with clinically important benefit up to two weeks after the intervention." (30)
7/24
Le gui
En Suisse, une AC souvent utilisée est la préparation anthroposophique à base de gui. Une
revue de la littérature clinique sur ce produit (mistletoe extracts, en anglais) à été publiée
dans le "European Journal of Medical Research". Ses conclusions pourraient être bien utiles
à connaître si des patients demandent un avis sur ce produit:
"16 randomized (RCT) and 9 non-randomized (N-RCT) controlled trials were identified
that investigated mistletoe treatment of malignant diseases (...) . Methodological quality of
the controlled trials differed substantially; some had major limitations while others were
reasonably well conducted (...).Regarding quality of studies and consistency of results, the
best evidence for efficacy of mistletoe therapy exists for improvement of Quality of Life
and reduction of side effects of cytotoxic therapies (chemotherapy, radiation). Survival
benefit has been shown but not beyond critique. (...) further properly designed trials
should be encouraged to investigate clinical efficacy and its possible dependency on the
mode of application"(31).
Tai chi
Une revue concluait, après examen de 3 RCT :
"The evidence is not convincing enough to suggest that tai chi is an effective supportive
treatment for cancer." (32)
Imposition des mains
Une étude viennoise 1 au devis original sur "laying on of hands" a évalué "a person with
self-declared "healing powers" as compared to an actor mimicking the healer. 80 patients
were registered to participate in a randomized, single-blind phase III trial (...)". Les
conclusions étaient les suivantes:" Laying on of hands" resulted in a significant improvement
of cancer-therapy-associated symptoms. The magnitude of improvement obtained was
similar whether on a self-declared-healer- or an actor-provided "treatment" (33). Autrement
dit, l'acteur faisait aussi bien que le guérisseur, ce qui est en soit un résultat à noter pour qui
s'intéresse à l'effet placebo.
4.
Effets secondaires des AC
Une revue de la littérature sur les effets secondaires des AC a été utilisée dans un
programme de "disease management" en Allemagne: " documented adverse effects of those
evidence-based complementary therapy approaches, which are integrated in the educational
curriculum of a disease management program on breast cancer" (34) .
Les dérivés de produits alimentaires sont souvent considérés comme AC. Il peut s'agir par
exemple d'extraits ou des micro-nutrients, souvent utilisés pour leur "pouvoir anti-oxidant".
Une étude sur ces derniers faisait l'observation suivante:
"There are many concerns that antioxidants might decrease the effectiveness of
chemotherapy, but increasing evidence suggests a benefit when antioxidants are added
to conventional cytotoxic therapies. However, it is imperative that physicians explore the
use of antioxidant and other micronutrient supplements with their cancer patients and
educate them about potentially negative as well as potentially beneficial effects." (35) .
On a aussi une revue très fouillée produite par le SKAK sur le sujet
1
2
.
Etude menée au "Department of Internal Medicine I, Center for Oncology and Hematology,
Wilhelminenspital, Vienna".
2
Swiss Study Group for Complementary and Alternative Methods in Cancer (SCAC)
Patronage: Swiss Society for Oncology (SGO), Swiss Society for Medical Oncology (SGMO),
Swiss Institute for Applied Cancer Research (SIAK): The Effects of Vitamins and Nutrition
on Cancer Illnesses. http://assets.krebsliga.ch/downloads/05_05_vitamine_e.pdf
8/24
Pour les suppléments alimentaires, il est proposé de les considérer sous six aspects
quand il s'agit de conseiller un patient (36) :
"Clinicians must establish if the supplement has
• antioxidant properties,
• anticoagulant or procoagulant propoerties,
• immunosuppressive or immunomodulating properties,
• hormonal properties,
• known safety issues,
• known or theoretical drug interactions "
Après quoi la stratégie suivante est recommandée :
"If the supplement is considered safe, an efficacy review must be conducted, after which the
clinicians can:
• recommend the supplement's use,
• accept the patient's decision to use the supplement if no or inconclusive evidence
exists,
• or discourage use if there is conclusive evidence supporting inefficacy"… or danger.
La recherche sur des composés naturels relève souvent plutôt du domaine de "Drug
Discovery", i.e. la recherche de nouveaux composés prometteurs pour le développement de
futurs médicaments: "Botanical immunomodulators and botanical products shown to affect
pathways of angiogenesis, apoptosis and cell signaling in vitro have stimulated research
interest and may broaden the range of available cancer treatments." (37)
Les facteurs de type style de vie semblent liés aussi bien aux AC qu'aux facteurs
nutritionnels. A propos des personnes ayant été traitées pour un cancer ("cancer survivors")
la question est formulée ainsi : "is there anything that they can do beyond conventional
therapy to improve their prognosis" (38) .Les auteurs notent que "Chief among these is
interest in diet and use of complementary and alternative therapies". Les auteurs notaient
que "there are at least 5 ongoing prospective cohort studies in breast cancer survivors that
have diet as a main focus. (...) They are all aimed at examining whether differences in diet
may result in differences in recurrence and mortality rates." D'autres aspects comme l'activité
physique sont aussi abordés. (39)
Les limites entre AC et médecines conventionnelles étant floues, on trouve des articles
classés sous "médecines complémentaires" qui portent sur des interventions déjà devenues
conventionnelles ou en passe de le devenir. On trouve ainsi un papier intitulé " Colorectal
cancer and CHF - reviewing the evidence for complementary medicine" qui porte en fait sur
les bienfaits de l'activité physique, en faisant remarquer : "Benefits of physical activity in
preventing or delaying cardiovascular disease and managing obesity and arthritis have
mainstream acceptance. However, evidence is emerging of the benefits of physical activity in
other conditions such as cancer." (40)
On étudie aussi l'effet pour les patients de soins "intérgrés" per se :
"Although the evidence for safety and efficacy seems paramount for supporting the
integration of an individual complementary therapy into mainstream cancer care, the need
for evidence to support the overall practice of integrative oncology has to be considered
as well." (41)
Il existe aussi un vaste effort de recherche sur la prévention des cancers, qui portent entre
autres sur des facteurs qui sont parfois assimilés aux AC, comme les composés naturels, le
plus souvent extraits de produits alimentaires : extrais de thé vert, de raisin rouge, de
curcuma, etc. le nombre d'essais cliniques en cours dans ce domaine est important (>100).
9/24
(42) 3 . Cependant, l’essentiel des mesures préventives ont trait a des facteurs
environnementaux ou liés au style de vie (exercice, alimentation par exemple ; effet
protecteur des tomates, de l’ail, du thé vert (Ernst-Oxford handbook)).
5.
Les méthodes de recherche sur les AC
Les méthodes de recherche sur les AC font encore l'objet de débats. Une proposition
structurée classe les études de la manière suivante pour l’exemple des « médecines
orientales » (OM) (43) :
"Foundation studies (level one) establish the conceptual basis for OM research by
establishing the internal validity of its basic "truth statements."
Measurement studies (level two) determine how OM identifies and measures diagnostic
indicators, treatment outcomes, and other basic aspects of health.
Group studies (level three) describe populations in ways meaningful to their health.
Pattern/diagnosis studies (level four) identify and define OM patterns of disharmony.
Treatment technique studies (level five) describe particular techniques or principles of
treatment, their indications, and rationale.
Treatment effectiveness studies (level six) evaluate techniques of treatment, often by
comparing the results of one technique with those of another in similar patients.
Systematic reviews (level seven) draw together studies on the same topic to see if
conclusions are thereby strengthened.
Conclusion: The levels can be used to establish relationships between already published
studies, determine if sufficient background research has been done to enable a study idea
to be carried out, and generate ideas for future studies."
Il apparaît que les méthodes de recherches sur les AC ne diffèrent pas fondamentalement
des méthodes adéquates pour d'autres types de traitement. Il faut seulement utiliser parfois
des devis particuliers mais qui sont toujours sous-tendus par la même logique scientifique,
comme par exemple l'essai randomisé "N=1" ("N-of-1 randomized controlled trials") (44).
Ernst et ses collègues ont mené une série de méta-analyses selon les méthodes de la
médecine factuelle (45). Ci-dessous, quelques exemples de leurs conclusions principales sur
les preuves d'efficacité d'AC en cas de cancer :
Relaxation
The effectiveness of several relaxation therapies has been tested repeatedly. In one RCT the
programme consisted of breathing exercises, muscle relaxation and imagery. This regimen was
superior in controlling pain of cancer patients to no intervention. A similar RCT with 35 cancer
patients after stem cell transplantation found that a 6-week relaxation programme reduced
fatigue in these patients.
In another RCT, 96 women with advanced breast cancer were randomised to receive either
regular relaxation training and imagery or standard care only. The experimental group
experienced better quality of life than the control group. Other relaxation therapies supported by
similar data from RCTs or CCTs include a comprehensive coping strategy programme with
guided imagery, mindfulness meditation, stress management training, autogenic training, and
progressive muscle relaxation training.
Hypnotherapy
Several RCTs have suggested the usefulness of hypnotherapy in palliative cancer care. It was
effective in controlling pain and nausea/vomiting. In children, hypnotherapy was more effective
than attention control in reducing nausea. However, there is insufficient evidence for
hypnotherapy to control procedural pain in children with cancer and one RCT suggested its
ineffectiveness in reducing anxiety in cancer patients receiving radiotherapy.
3
On peut aussi se référer aux sites de registres d'essais cliniques en cours, comme www.clinicaltrials.gov .
10/24
Exercise
Regular physical exercise will reduce the severity of treatment-related symptoms such as
fatigue and nausea.
Aromatherapy and massage
Aromatherapy and/or massage have positive short-term effects on the well-being of cancer
patients.
Acupuncture
Systematic reviews suggest that acupuncture and acupressure reduce chemotherapy-induced
nausea. This conclusion is also supported by recent RCTs. However, an RCT (n = 80) with
adequate control for placebo-effects found no difference between real and sham acupuncture. A
systematic review of six clinical trials testing the effectiveness of acupuncture to control cancer
pain found no compelling evidence for this indication. Encouraging data suggest that
acupuncture alleviates radiation-induced xerostomia.
Homeopathy
An RCT (n = 66) of Belladonna 7cH and X-ray 15cH tested whether this homeopathic mixture
would prevent radiation-induced dermatitis. There were no differences compared with placebo.
Plants and plant extracts
Black cohosh (Actaea racemosa), administered for 60 days, was not superior to placebo in
controlling hot flushes after conventional therapy for breast cancer in an RCT (n = 85). In
another RCT for tamoxifen-induced hot flushes, black cohosh was administered for 1 year. The
results show a reduction in the number and severity of hot flushes.
Calendula officinalis cream was compared with trolamine cream in an RCT (n = 254) testing
their usefulness in preventing radiation-induced dermatitis in breast cancer patients. The
occurrence of grade 2 dermatitis was 41% with calendula and 63% with trolamine. Calcium
(supplement).
11/24
Annexe 3
Exemples de sites d'accès aux données cliniques sur les AC.
1.
Site du NHS Evidence – complementary and alternative medicine
Par exemple, le site donne les informations suivantes sur la douleur liée au cancer
(adresse : http://www.library.nhs.uk/cam).
Total records: 52
export
•
•
•
Control of pain in adults with cancer
Publisher: SIGN
Publication Type: Care Guideline
Publication Date: 01 Nov 2008
•
•
View detail
Link to full text here, Portable Document File/ PDF
export
Guidance on cancer services: improving supportive and
palliative care for adults with cancer - the manual
•
•
•
Publisher: NICE
Publication Type: Service Guidance
Publication Date: 24 Mar 2004
•
•
View detail
Link to full text here, Portable Document File / PDF
export
Guidelines for providing acupuncture treatment for cancer
patients--a peer-reviewed sample policy document
•
•
•
Publisher: British Medical Acupuncture Society
Publication Type: Care Guideline
Publication Date: 01 Dec 2006
Les liens donnent accès aux documents complets.
12/24
Autre exemple : sur le même site, en cherchant sous "nausea", on accède au "Guideline for
the Management of Postoperative Nausea and Vomiting" (PONV), du "Executive and Council
of the Society of Obstetricians and Gynaecologists of Canada" dans lequel on trouve un
paragraphe sur les traitement non-pharmacologiques :
Non-pharmacologic Prophylaxis
Acupuncture has been shown to be effective in the management of PONV. Coloma et al.
(2002) compared acustimulation with ondansetron for the treatment of established PONV in
outpatient laparoscopic surgery patients. They concluded that acustimulation may be a
satisfactory alternative to ondansetron for established PONV, and that ondansetron seems to
enhance the efficacy of acustimulation for treatment of established PONV.
[Coloma M, White PF, Ogunnaike BO, Markowitz SD, Brown PM, Lee AQ,
et al. Comparison of acustimulation and ondansetron for the treatment of
established postoperative nausea and vomiting. Anesthesiology
2002;97:1387–92.]
Dernier exemple : métanalyse trouvée sur ce site: La question de l'effet du calcium sur le
cancer du colon:
Shaukat A, Scouras N, Schunemann HJ. Role of supplemental calcium in the recurrence of
colorectal adenomas: A meta-analysis of randomized controlled trials. Am J Gastroenterol
2005;100:390-394.
Department of Medicine, School of Medicine and Biomedical Sciences, State University of New
York, 462 Grider Street, Buffalo, NY 14215, USA.
Abstract: BACKGROUND: Colorectal adenomas are neoplastic growths that are important
targets for chemoprevention. Dietary calcium is thought to play an important role in
chemoprevention. However, the role of calcium supplementation for preventing recurrence of
adenomas is controversial. We performed a systematic review and meta-analysis to study the
role of calcium supplementation in preventing recurrence of adenomas. METHODS: We
searched electronic bibliographic databases (Cochrane Database of Systematic Reviews,
Cochrane Controlled Trials Register, CINAHL, EMBASE, and MEDLINE) and contacted authors
to identify potentially eligible studies. RESULTS: We identified three trials including 1,485
subjects with previously removed adenomas who were randomized to calcium versus placebo
supplementation. The study endpoint was recurrence of adenomas at the end of 3-4 yr in 1,279
patients who completed the trials. We found that the recurrence of adenomas was significantly
lower in subjects randomized to calcium supplementation (RR: 0.80, CI: 0.68, 0.93; p-value =
0.004). CONCLUSIONS: This systematic review and meta-analysis suggest that calcium
supplementation prevents recurrent colorectal adenomas.
13/24
2.
Site "natural standard" http://www.naturalstandard.com/
Cancer pain and related conditions
Levels of scientific evidence for specific therapies
Grade: A (Strong Scientific Evidence)
Therapy
Specific therapeutic Use(s)
Acupuncture
Pain (chronic)
Acupuncture
Post-operative pain
Grade: B (Good Scientific Evidence)
Therapy
Specific therapeutic Use(s)
Acupressure, shiatsu, tuina
Pain (general)
Acupuncture
Endoscopy procedure pain
Bromelain
Inflammation
Clove
Dental pain
Comfrey
Inflammation
Comfrey
Pain
Guided imagery
Pain
Hypnotherapy, hypnosis
Pain (various causes)
Music therapy
Pain (general/chronic/surgery/osteoarthritis)
Physical therapy
Pain
Therapeutic touch
Pain
Grade A (Strong Scientific Evidence)
Statistically significant evidence of benefit from >2 properly randomized trials (RCTs), OR
evidence from one properly conducted RCT AND one properly conducted meta-analysis, OR
evidence from multiple RCTs with a clear majority of the properly conducted trials showing
statistically significant evidence of benefit AND with supporting evidence in basic science,
animal studies, or theory.
Grade B (Good Scientific Evidence)
Statistically significant evidence of benefit from 1-2 properly randomized trials, OR evidence
of benefit from >1 properly conducted meta-analysis OR evidence of benefit from >1
cohort/case-control/non-randomized trials AND with supporting evidence in basic science,
animal studies, or theory. This grade applies to situations in which a well designed
randomized controlled trial reports negative results but stands in contrast to the positive
efficacy results of multiple other less well designed trials or a well designed meta-analysis,
while awaiting confirmatory evidence from an additional well designed randomized controlled
trial.
14/24
Pour chaque AC, on peut obtenir une "professional monograph" avec les références, un
tableau comparatif et accès aux abstracts. On peut aussi y trouver les informations relatives
aux interactions.
Exemple: "Acupuncture for chronic pain":
Pain (chronic): Ten 30-minute sessions, generally two sessions per week, of verum
acupuncture according to principles of traditional Chinese medicine has been used (1). A
four-week course of acupuncture, twice weekly, has been used (2). Five to fifteen sessions
over three weeks to three months has been used (3;4;5;6).
1. Liang, S. Y. [Observation on therapeutic effect of tendon-muscle picking therapy on
myofascitis of back]. Zhongguo Zhen.Jiu. 2008;28(8):621-622. View Abstract
2. Wang, L. Q. [Observation on therapeutic effects of scraping therapy and warming
acupuncture-moxibustion on 50 cases of fasciitis of back muscles]. Zhongguo Zhen.Jiu.
2006;26(7):478-480. View Abstract
3. Kim, Y. S., Lee, S. H., Jung, W. S., Park, S. U., Moon, S. K., Ko, C. N., Cho, K. H., and Bae,
H. S. Intradermal acupuncture on shen-men and nei-kuan acupoints in patients with insomnia
after stroke. Am J Chin Med 2004;32(5):771-778. View Abstract
4. Nir, Y., Huang, M. I., Schnyer, R., Chen, B., and Manber, R. Acupuncture for postmenopausal
hot flashes. Maturitas 4-20-2007;56(4):383-395. View Abstract
5. Huang, M. I., Nir, Y., Chen, B., Schnyer, R., and Manber, R. A randomized controlled pilot
study of acupuncture for postmenopausal hot flashes: effect on nocturnal hot flashes and
sleep quality. Fertil.Steril. 2006;86(3):700-710. View Abstract
6. Vincent, A., Barton, D. L., Mandrekar, J. N., Cha, S. S., Zais, T., Wahner-Roedler, D. L.,
Keppler, M. A., Kreitzer, M. J., and Loprinzi, C. Acupuncture for hot flashes: a randomized,
sham-controlled clinical study. Menopause. 2007;14(1):45-52. View Abstract
15/24
Annexe 4
Institutions académiques s'occupant d'AC
Quelques exemples :
1.
En Suisse
Enseignement à l’Université et Hôpital de l'Île, Berne
[email protected]
www.kikom.unibe.ch
Kollegiale Instanz für Komplementärmedizin KIKOM
Imhoof-Pavillon
Inselspital - CH-3010 Bern
(source: http://www.kikom.unibe.ch/unibe/medizin/kikom/ )
Lehrangebot Herbstsemester 2008
Interdisziplinäre öffentliche Vorlesung „Erkenntnisgrenzen in Medizin und Wissenschaft sind sie überwindbar?“
Donnerstag, 20.00 - 21.00 Uhr, Beginn: 02. Oktober 2007
Dr. B. Ausfeld-Hafter, Dr. L. Fischer, Dr. M. Frei-Erb, Dr. P. Heusser, Dr. U. Wolf
Seminar:
„Anthroposophisch
orientierte
Medizin.
Einführung
in
ihre
erkenntniswissenschaftlichen, natur- und menschenkundlichen Grundlagen“. Wöchentlich,
fortlaufender Jahreskurs. Dr. P. Heusser
Wahlpraktikum: „Homöopathisch potenzierte Substanzen: Placebos oder wirksam?“
(Medizinstudierende 2. und 3. Jahr). 10 Doppellektionen.
Dr. S. Baumgartner, Dr. U. Wolf, Dr. K. von Ammon, Dr. M. Frei-Erb
Doktorandenkolloquium. Mittwoch, 05. November 2008, ab 17 Uhr.
Dr. B. Ausfeld-Hafter, Dr. S. Baumgartner, Dr. L. Fischer, Dr. M. Frei-Erb,
Dr. M. Pfister, Dr. U. Wolf
Lehrangebot Frühjahrssemester 2009
Wahlpraktikum Komplementärmedizin: Vorlesung und Praktikum
(Medizinstudierende 2. und 3. Jahr gemäss Studienplanung, 20 Stunden)
Dr. B. Ausfeld-Hafter, Dr. L. Fischer, Dr. M. Frei-Erb, Dr. U. Wolf und AssistentInnen
Komplementärmedizin im Schlusskurs Blockunterricht SKBU
(Medizinstudierende 5. Jahr)
Dr. B. Ausfeld-Hafter, Dr. L. Fischer, Dr. M. Frei-Erb, Dr. U. Wolf
Seminar:
„Anthroposophisch
orientierte
Medizin.
Einführung
in
ihre
erkenntniswissenschaftlichen, natur- und menschenkundlichen Grundlagen“. Fortlaufender
Jahreskurs.
Dr. P. Heusser
Wahlpraktikum: „Homöopathisch potenzierte Substanzen: Placebos oder wirksam?“
(Medizinstudierende 2. und 3. Jahr). 10 Doppellektionen
Dr. S. Baumgartner, Dr. U. Wolf, Dr. K. von Ammon, Dr. M. Frei-Erb
A Zurich: Institut für Naturheilkunde (à l’hôpital universitaire)
« Auswertung von Primärdaten (…) im Sinne der Evidenz Based Medicine (EBM) »
http://www.naturheilkunde.usz.ch
A Bâle : "Schul- und Komplementärmedizin: gestern und heute“ (Dr. Hubert Steinke)
http://209.85.129.132/u/basel?q=cache:yYXXMy-YmpUJ:medizin.unibas.ch/studium/
16/24
bachelor/2-jahr/majors/clinical-medicine/wahlmodul/schul-und-komplementaermedizingestern-und-heute-modul-2.html+komplementarmedizin&cd=1&hl=fr&ct=clnk&ie=UTF-8
A St-Gall
« Integrative Medizin in der Palliative Care »
A Genève
- Hypnose en anesthésie
- Toucher-massage® en soins palliatifs-douleurs
A la Ligue suisse contre le cancer
- La „helpline“ ([email protected], 0800 11 88 11) donne réponses à toutes
sortes de questions, y compris sur les AC.
2.
Grande-Bretagne
L'unité la plus connue est sans doute l’Université d'Exeter :
Complementary Medicine, Universities of Exeter & Plymouth
http://www.pms.ac.uk/compmed/
Voici un auto-portrait de cette institution:
Ours is the first University Chair of complementary medicine in the UK. It was established in
1993 (...). To date, we have published more than 700 articles in peer-reviewed journals.
Our aims:
- to conduct rigorous, inter-disciplinary and international collaborative research into the
efficacy, safety and costs of complementary and alternative medicine
- to promote analytical thinking in this area.
- to be neither promotional nor derogatory but to struggle for objectivity.
The overriding aim of all our research is to maximise benefit, and minimise risk for patients and
consumers of complementary medicine.
Areas of interest:
Our research covers a wide range of complementary and alternative medicine modalities, but
we focus primarily upon the most commonly used complementary therapies in the UK :
- herbal medicines (phytotherapy)
- acupuncture
- homoeopathy
- manipulative therapies (osteopathy and chiropractic)
- mind / body modalities
Research tools :
The main research tools used within the unit are:
- systematic reviews and meta-analyses
- clinical trials
- surveys
- laboratory investigations
Cet institution a aussi un journal: Focus on Alternative and Complementary Therapies
(FACT) " that aims to present the evidence on complementary and alternative medicine
(CAM) in an analytical and impartial manner".
On trouve aussi un centre de recherche et d'enseignement important à l'Université de
Northampton :
Division of Psychology, notamment l'équipe de Harald Walach, qui est par ailleurs président
de la "International Society for Complementary Medical Research", fondée en 2003
17/24
(http://www.iscmr.org/ ) , qui a un des journaux majeurs dans le domaine: The Journal of
Alternative and Complementary Medicine.
Citons à ce propos d'autres grands journaux réunissant dans leurs comités éditoriaux les
principaux chercheurs académiques du domaine:
3.
•
eCAM - Evidence Based Complementary Complementary Therapies and Alternative
Medicine
•
FACT - Focus on Alternative and Complementary Therapies
•
Forschende Komplementarmedizin / Research in Complementary Medicine
•
Research Council for Complementary Medicine (RCCM) - www.rccm.org.uk . The
RCCM was founded in 1983 by a group of enthusiastic practitioners and researchers
from both orthodox and complementary medicine.
Etats Unis
Le "National Center for Complementary and Alternative Medicine" (NCCAM) soutient la
recherché dans le domaine des AC. Il a aussi proposé une classification des AC en cinq
domaines:
-
-
alternative medical systems,
mind-body interventions,
biologic-based therapies,
manipulative and body-based methods,
energy therapies
Le "Osher center" de San Francisco, qui dépend de UCSF, est présenté ainsi:
(http://www.osher.ucsf.edu/index.html )
"The UCSF Osher Center integrates modern medicine with established practices from around
the world. Our clinical programs focus on prevention, patient-empowerment and whole person
healing.
The Clinical Practice at the UCSF Osher Center offers a variety of integrative medicine
services, treatments and therapies. Our practitioners are trained in both conventional and
complementary therapies and offer a professionally guided complete approach to your health
care. “
The Osher Center for Integrative Medicine offers a variety of groundbreaking lectures, classes,
workshops, and therapeutic programs for the public. Our programs emphasize patient
empowerment, prevention, and whole person healing, and are designed to provide the public
with the opportunity to see and hear what is going on with integrative medicine at UCSF inside
the worlds of research, education and clinical programs. Featured Programs :
- New Yoga Program at the UCSF Osher Center
- Upcoming Lecture on Clinical Hypnosis in Children and Adolescents
- Upcoming Info Session for MBSR
- Lunchtime Lecture on Massage Therapy Benefits
"An important focus of our research is mind-body health approaches. We are the recipients of
two Center of Excellence grants from the National Center for Complementary and Alternative
Medicine of the National Institutes of Health. The first Center of Excellence grant (2004-2009)
is investigating the effects of a meditation based stress reduction intervention in HIV infection,
including the impact on disease course, neuroendocrine function, and the immune system.
The second Center of Excellence grant (2008 – 2014) involves a clinical trial investigating
long-term weight loss and maintenance in obesity."
“The Integrative Medicine Network (IMN) at the University of California, San Francisco
believes that bridging the gap between alternative and allopathic medicine will lead to the
18/24
improvement of patient care and choices. As future health care professional committed to
providing the best care for our patients, we aim to utilize all possible resources to address our
patients’ needs. Thus, we advocate research and education in the safe, effective use of
alternative therapies in conjunction with conventional medicine.
We hope to create a network of students and professionals who seek to continuously improve
their understanding of alternative therapies and to incorporate an integrative approach to
health care.”
D’autres Osher Centers existent, par exemple à Harvard University :
Osher Research Center at Harvard Medical School and the Division for Research and
Education in Complementary and Integrative Medical Therapies and the Director of the
Program in Integrative Medicine at Brigham & Women’s Hospital.
Le "UCLA Collaborative Centers for Integrative Medicine" (CCIM) "is a campus-wide
program committed to the study and application of integrative medicine.
The CCIM sponsors public and professional education, facilitates research and promotes
appropriate practice of complementary, alternative, and mind-body medicine."
http://www.ccim.med.ucla.edu/:
Center for East West Medicine
Center for Excellence in Pancreatic Diseases
Center for Human Nutrition
Center for Neurobiology of Stress
Cousins Center for Psychoneuroimmunology
eCAM (le journal "evidence-based complementary medicine")
Mindful Awareness Research Center
Pediatric Pain Program
Stiles Program in Integrative Oncology
Simms/Mann - UCLA Center for Integrative Oncology
UCLArts and Healing
A la Johns Hopkins University:
Complementary and Alternative Medicine
BIMAL H. ASHAR, M.D., F.A.C.P.,
Assistant Professor of Medicine, Johns Hopkins
University School of Medicine
Le Memorial Sloan-Kettering Cancer Center à New York est un des 39 National Cancer
Institute-designated Comprehensive Cancer Centers. “ Information resource, presented by
our Integrative Medicine Service, provides evidence-based information about herbs,
botanicals, supplements, and more.” http://www.mskcc.org/mskcc/html/11570.cfm
Le "Program in Integrative Medicine, University of Arizona", Tucson, Arizona, USA.
"has two clinical locations at the University of Arizona: our physicians act as consultants,
providing patients with a wide range of therapeutic options from the best of conventional and
complementary therapies. Our physicians care for patients with medical conditions ranging
from cancer to chronic conditions such as diabetes and heart disease, as well as offering
preventive care recommendations." […] "majority of the Center's educational offerings are
online, including our flagship program: The Fellowship in Integrative Medicine"
"to contribute rigorous scientific research on the integration of complementary and alternative
therapies with conventional medicine. We focus on three areas: educational research,
corporate health research, and methods to study clinical outcomes in integrative medicine"
[email protected] et http://integrativemedicine.arizona.edu/
19/24
4.
Autres pays
En Italie
A Milan, le "Centro di Ricerche in Bioclimatologia Medica, Biotecnologie e Medicine
Naturali dell'Università degli Studi di Milano" est un centre collaborateur de l'OMS pour
les AC. Il a , par exemple, une participation dans le "WHO Working Group on Clinical Studies
on Phytotherapy (2009) . Les activités de ce centre sont présentées comme suit
(http://www.naturmed.unimi.it/10_ist_atti.html) :
"Le attività del Centro sono a carattere :
-
Scientifico: ricerche in campo bioclimatologico, studi e ricerche nel campo delle tecnologie
biomediche e delle medicine naturali, con collaborazioni internazionali.
Didattico: Corsi di Formazione e di Perfezionamento universitari per medici.
Organizzativo: promozione, realizzazione dei Seminari, Simposi e Convegni.
En Norvège
L'autre centre collaborateur OMS en Europe est en Norvège. Il s'agit du Norway National
Research Center in Complementary and Alternative Medicine (NAFKAM), à l'Université
de Tromso, (cf: http://uit.no/nafkam/omnafkam/ )
En Australie
Australasian Integrative Medicine Association http://www.aima.net.au/index.jsp (site avec
panorama critique des ressources d'information, y compris sur les interactions et les effets
secondaires rares, mais sérieux des AC)
En Allemagne
Les sites universitaires sont nombreux. Un des plus grands est celui de la Charité à Berlin.
Qui est décrit ainsi (http://www.charite.de/epidemiologie/german/ueberblick.htm):
Charité Ambulanz für Prävention und Integrative Medizin (CHAMP):
Œ
Œ
Œ
Œ
Œ
Œ
Œ
CHAMP wurde im Frühjahr 2007 vom Institut für Sozialmedizin, Epidemiologie und
Gesundheitsökonomie der Berliner Charité als Forschungsambulanz gegründet.
In der Ambulanz werden Brücken zwischen Wissenschaft und Praxis sowie Schul- und
Alternativmedizin gebaut:
Wissenschaftler,
Ärzte,
Psychologen
und
Gesundheitstrainer
setzen
Forschungsergebnisse aus der Prävention in die Praxis um. Ziel ist es, gesunde und
kranke Bürger durch moderne Beratungskonzepte wie das Gesundheitscoaching zu
nachhaltigen gesunden Lebensstilveränderungen zu befähigen.
Im Sinne der Integrativen Medizin erweitern wir konventionelle Medizin um
komplementäre Methoden wie Akupunktur, Naturheilverfahren und Homöopathie, um
Patienten die jeweils bestmögliche Therapie(kombination) anzubieten.
Alle CHAMP-Projekte werden wissenschaftlich evaluiert.
CHAMP-Präventionsprogramme werden auch als "Community-Interventionen" z.B. in
Schulen und Betrieben implementiert und evaluiert.
Für das innovative Konzept wurde CHAMP im Innovationswettbewerb "Deutschland -
Land der Ideen" zum "Ort im Land der Ideen 2008" prämiert.
Cet organisme a aussi été l’organisateur de la Conférence « European Congress of
Integrative Medicine" en novembre 2009 à Berlin (http://www.ecim-congress.org/).
20/24
En France
-
5.
A Marseille, un enseignement de l'homéopathie intégré à la Faculté de Médecine.
A Paris, un diplôme universitaire d'hypnose médicale (Paris VI - Pitié Salpêtrière) et une
formation à l'Hôpital Ambroise Paré à Boulogne.
cf: http://pagesperso-orange.fr/afehm.hypnose.medicale/presentation-formation.html
OMS
Au niveau des institutions internationales, l'OMS a une unité dédiée aux AC, y compris les
médecines traditionnelles des différents pays :
Dr Xiaorui Zhang
HSS/EMP/TRM
WHO/Geneva
…a organisé le "WHO Congress on Traditional Medicine", 7-9 Novembre 2008, à Beijing.
La "Beijing Declaration" a été adoptée, dont voici un extrait:
"It calls on WHO Member States and other stakeholders to take steps to integrate traditional
medicine (TM) / complementary and alternative medicine (CAM) into national health
systems.
WHO: (Fact Sheet - mise à jour 2008) http://www.who.int/mediacentre/factsheets/fs134/en/
6.
L'intégration des AC dans les systèmes de santé
C’est un sujet de recherche en soi.
The integration of complementary and alternative medicine (CAM) into cancer services is
increasingly discussed as a potential part of UK health policy (...) The integration of CAM
should not be conceptualised as a mere challenge to biomedicine, or, as resulting in a linear
process of de-professionalization. Rather, it should be seen as producing a complex array of
processes, including strategic adaptation on the part of medical specialists and NHS
organisations" (46).
Un exemple a déjà été mentionné: la CAM unit within a NHS cancer treatment centre, ce
qui s'appelle dès lors "intergrated care". Une des surprises de cette expérience a été que
relativement peu de patients utilisaient cette offre d'AC au sein de l'hôpital :
"Of all outpatients attending the cancer centre, 498 (15.8%) visited the CAM unit, 290 (9.2%)
accessed therapies. (...) Despite easy access to CAM therapies, a relatively small number of
people regularly used them (...). More research is needed on why people do not use
integrated CAM services and how charges affect demand.
Après 20 ans d'expérience d'intégration du "therapeutic touch" (TT) dans les soins
conventionnels dans une province du Canada, les auteurs retenaient les leçons suivantes :
"Lessons gleaned include (1) positioning TT within the context of research and evidencebased practice, (2) developing and adhering to standards of practice and professionalism,
and (3) maintaining a nonpartisan attitude and communicating a plausible rationale" (47).
Il existe des National guidelines for the use of complementary therapies in supportive
and palliative care, développées par "The Prince of Wales's foundation for Integrated
Health & The National Council for Hospice and Specialist Palliative Care Services" à Londres
-- et aussi un "Complementary Therapies Program" au St. Vincent's Comprehensive Cancer
Center à New York.
21/24
" a coordinated approach to integrate CAM therapies safely into conventional
medicine. This article describes how an integrative CAM program in an outpatient
oncology center addresses some of the clinical issues" (48) .
Des pharmaciens ont développé un approche structurée de conseil des patients en rapports
avec une catégorie d'AC, les produits naturels :
"... evaluation of evidence, assessment of efficacy, assessment of toxicity, monitoring
parameters, and provision of a closure. A patient counseling approach was developed based
on this information. (...) . A structured, step-by-step approach to counseling patients was
developed" (49) .
22/24
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