Oncology Association of Naturopathic Physicians: Principles of Care Guidelines

Abstract

Patient use of integrative oncology (the inclusion of nonconventional treatments alongside the conventional standard of care) continues to grow, with some studies showing its use in cancer patients to be as high as 91%. Naturopathic physicians are primary care providers who use integrative therapies to deliver patient-centred care. The Oncology Association of Naturopathic Physicians (oncanp) was formed in 2004 as a specialty association for naturopathic physicians providing integrative cancer care (nd oncs). Currently, the membership encompasses more than 400 naturopathic physicians and students, 115 of whom are board-certified Fellows of the American Board of Naturopathic Oncology.

In 2016, oncanp established a committee comprising recognized experts in the field of naturopathic oncology to develop a Principles of Care (poc) guideline. The committee first undertook a review of existing standard-of-care and best-practice guidelines in the field of oncology and then adapted those concepts into a draft document. The draft document was then reviewed by naturopathic physicians, medical and radiation oncologists, naturopathic policy experts, and finally the oncanp membership at large.

The poc document presented here provides clear guidelines for nd oncs on how best to deliver patient-centred care in the areas of assessment, treatment planning, care management, interprofessional collaboration, and survivorship care. This naturopathic oncology poc document can be a valuable resource for nd oncs and other oncology care providers to further an understanding of the naturopathic and integrative oncology care model and its potential for collaboration.

INTRODUCTION AND BACKGROUND

The Oncology Association of Naturopathic Physicians (oncanp) was formed in 2004 to advance the practice of naturopathic oncology, with the goal of improving survival and quality of life for patients with cancer. The profession of naturopathic oncology has grown: approximately 400 oncanp members are practicing in North America, 115 of whom are board-certified Fellows of the American Board of Naturopathic Oncology. That growth has been fueled by patient demand for integrative cancer treatment options and by an increase in published research documenting the safety and efficacy of natural and supportive therapies. Several studies and meta-analyses investigating the frequency of use of integrative therapies in cancer patients have shown that the prevalence of complementary and alternative medicine use in cancer patients ranges from 22% to 91%^1–5.

Naturopathic doctor oncology providers (nd oncs) play an important role in cancer care, seeking to educate, to help manage side effects of cancer treatment, to improve overall response, to help prevent recurrence, and to optimize health. To achieve positive patient outcomes, nd oncs use a wide range of natural therapeutics and supportive strategies based on clinical trials, long-standing traditional use, and patient preference. It is essential that patients receive guidance in the use of integrative therapeutic options from high-quality care providers.

The present Principles of Care document is not meant to be prescriptive nor to give providers instructive advice about therapeutic options. Instead, the intention is to ensure safe and effective care by giving clear guidance for the naturopathic management of oncology patients. The document summarizes the key elements that should be present in respect to

• ■ patient assessment,

• ■ an integrative oncology plan,

• ■ naturopathic oncology treatments,

• ■ care coordination, and

• ■ continuing care management.

The Principles of Care Guidelines can also serve as a means for other health care professionals and organizations to understand the naturopathic approach to patient care within the setting of a collaborative health care team.

This document was developed by oncanp’s Principles of Care Committee, which consists of experts in the field of naturopathic oncology who practice in a range of clinical settings from hospitals to private clinics. The guidelines were developed after a review of existing standards and guidance documents within the fields of naturopathic medicine, oncology, and other medical specialties. The Principles of Care Committee sought commentary and feedback about the document from stakeholder groups internal to oncanp and external stakeholders in the naturopathic profession and conventional oncology. The document was then reviewed and approved by the Board of Directors of oncanp.

GUIDELINE

Comprehensive Assessment as a Patient-Centred Approach

This section outlines the elements of patient assessment that could be a part of naturopathic oncology care.

To conduct a comprehensive and timely assessment of the patient’s needs for care, an nd onc will use a systematic approach that considers the whole individual, including physical, psycho-emotional, cultural, social, and spiritual dimensions. Pertinent findings will be entered into the patient’s health record.

A complete and thorough assessment of the patient should be done at the initial consult, or as soon as possible afterward, and before development of a treatment plan. In situations in which a complete assessment of the patient’s entire health history is not possible (for example, an acute patient presentation), providers should undertake an appropriate assessment and history so as to develop effective initial treatment and to formulate a care plan that includes a full assessment as soon as reasonably possible. Assessments should be repeated to monitor patient response to care.

These are the constituents of a patient assessment:

• ■ An optimal health history that encompasses the following elements, recognizing that the ability to obtain certain information might be limited:

  • ▪ History and knowledge of current illness

  • ▪ Current and past conventional treatments and the patient’s response

  • ▪ Prior complementary cancer treatment and response

  • ▪ Review of pertinent pathology, laboratory, and imaging studies

  • ▪ Relevant family health history

  • ▪ Allergies (medications, dietary, environmental)

  • ▪ Lifestyle choices, including diet, sleep habits, smoking, alcohol consumption, drug use, and social history

  • ▪ Environmental factors, including occupation and work environment

  • ▪ Comorbid conditions and, if relevant, their potential effect on disease trajectory and treatment

  • ▪ Identification of key members of the patient’s health care team, including medical and radiation oncologists, surgeon, primary care provider, and so on

  • ▪ Consideration for the patient’s values and attitudes with respect to the current health situation and how they might affect therapeutic choices

• ■ A physical assessment that encompasses the following elements:

  • ▪ A physical examination that focuses on patient-reported symptoms, key systems, and common or known complications

  • ▪ A baseline performance status assessment using, preferably, although not exclusively, a validated tool (for example, Karnofsky performance status scale⁶, Eastern Cooperative Oncology Group performance status⁷, Lansky Play-Performance status⁸, Palliative Performance Scale⁹)

  • ▪ Height and weight and calculated body mass index

  • ▪ Vital signs

• ■ Laboratory assessment

  • ▪ Conventional laboratory testing should be ordered (or recommended) in addition to any laboratory testing ordered by the patient’s oncologist and should be used to inform diagnosis, response to treatment, and tolerability of treatment.

  • ▪ Nonstandard laboratory testing (tests that are considered experimental or not part of routine conventional oncology care and assessment) might also be used by the nd onc in the development of a whole-patient assessment. Such tests are not to be used alone to establish a diagnosis, determine prognosis, or decide on treatment.

• ■ Symptom assessment

  • ▪ Assess and document the patient’s symptom picture using medical terminology.

  • ▪ The use of validated, focused assessment tools for the oncology patient is encouraged (for example, the Edmonton Symptom Assessment System¹⁰, Brief Pain Inventory¹¹, Patient-Reported Outcomes Measurement Information Systems–Fatigue Short Form¹², Generalized Anxiety Disorder 7-Item-Scale¹³, the 9-item Patient Health Questionnaire¹⁴).

  • ▪ Symptom assessments should be repeated at appropriate frequencies so as to continually update the nd onc about the patient’s symptom experience.

• ■ Psychosocial, spiritual, and cultural assessment

  • ▪ Consider the impact and meaning of the illness for the patient, the family, and their support systems, with particular attention to current life circumstances and personal views on quality of life.

  • ▪ Consider the needs of the patient and family for information and their preferred or legal role in decision-making.

  • ▪ Consider cultural, spiritual, and religious influences on the patient’s view of the illness and how it affects therapeutic choices and personal ability to cope with the illness.

  • ▪ Given the prevalence of undiagnosed depression in the cancer patient population, the nd onc should screen for depression and anxiety using a clinically validated assessment tool.

• ■ Sexual health assessment

  • ▪ Consider the effect of changes in the patient’s sexual health and the effects that such changes have on the patient’s partner.

  • ▪ If relevant, explore the understandings on the part of the patient and the partner of possible changes to fertility status as a result of treatment.

Integrative Oncology Plan

The nd onc’s comprehensive evaluation of each patient, combined with the provider’s broad understanding of conventional and complementary treatment options, enables the development of a rational set of therapies appropriate to each patient. Specific recommendations might vary between practitioners, but all nd oncs should give attention to a common set of components in developing any program. In this subsection, we review key principles involved in developing a naturopathic oncology plan, including how the provider expects to involve other referring providers, social support networks, and the documentation of clinical decisions.

Coordinating Medical Care

Throughout the evaluation process, the nd onc comes to a full understanding of the health needs of the oncology patient. When referral of the patient for other services or evaluation is indicated, the nd onc initiates and coordinates the referral and acts to facilitate communication between all practitioners associated with the patient’s care.

In North America, nd oncs practice within widely diverse licensure and regulatory environments. It is incumbent upon each nd onc to communicate both the scope and the limitations of the nd onc’s clinical work with each patient as it pertains to the treatment program that is being recommended. Specific areas that might need to be addressed include, but are not limited to

• ■ naturopathic oncology treatment,

• ■ prescriptive authority,

• ■ parenteral therapy authorization, and

• ■ authority for ordering laboratory testing and diagnostic imaging.

Continuity of care through appropriate coordination is a critical aspect of high-quality patient care. The Care Coordination subsection provides greater detail about core principles for ensuring continuity of care.

Providing Therapeutic Options

A primary role of the nd onc is to assure that the patient makes fully informed decisions about treatment. That assurance includes providing full information about conventional oncology treatment and the inclusion of naturopathic care. Although no individual nd onc can reasonably know all relevant information about all treatment options, it is critical that the nd onc provide comprehensive information about the potential risks and benefits of the various strategies they are recommending and, where relevant, reasonable alternatives. In addition, nd oncs also enhance the patient’s understanding of the risks and benefits of conventional therapies. To solidify that education, the nd onc should refer the patient to an oncologist for a complete review of their conventional treatment options if the patient has not already received an oncology consultation. When necessary and possible, the nd onc will refer to other practitioners who can contribute productively to the patient’s comprehensive education and health care.

The nd onc ultimately provides each patient with a comprehensive and coherent treatment program, detailing a set of therapies based on the personalized evaluation of the patient. The treatment program considers not only the clinician’s best-practice recommendations (given the body of published evidence), but also the patient’s diagnosis and individual circumstances. It also incorporates the patient’s personal preferences, values, and existential inclinations. The nd onc’s treatment recommendations seek to balance those components in a patient-centred manner that optimizes all elements to the greatest extent possible.

Once the plan is formulated and presented, the nd onc completes and documents a full Procedures, Alternatives, Risks, and Questions (parq) or comparable process with the patient for the established program (see the Naturopathic Oncology Treatment subsection).

Informed Consent

Patients have the right to receive information from the doctor about the benefits of any procedure, the alternative treatment options, and the associated risks. Patients also have the right to receive answers to any questions they might have about treatment recommendations that might be complex or might carry a more significant possibility of short- or long-term risk. That process is often called a “parq discussion” or “parq conference.” The parq conference should be documented in writing in the patient record and should consider patient preferences.

It is important that the nd onc provide a clear explanation of the logical relationships between alternative care options and health outcomes, and a summary (where possible and appropriate) of both the quality of the evidence and the strength of the recommendations.

Evaluating Safety

The nd onc is responsible for the safety of the patient with respect to the treatment recommendations. As the patient progresses through both the conventional and naturopathic treatment program, adjustments to the program are commonplace. It is the responsibility of the nd onc to assure that each change in complementary therapies is compatible with any concurrent conventional therapies. If the state of knowledge about the use of the nd onc’s recommended treatment or treatments and their potential effects on the patient’s conventional treatments is incomplete, the nd onc should disclose that lack of completeness to the patient.

Addressing Comorbidity

The nd onc understands that the cancer diagnosis happens within the larger context of the patient’s overall health. As such, the plan is not exclusively focused on eradication of the cancer, but on re-establishing health in all bodily systems that are assessed to be dysfunctional or contributory to the patient’s predilection for malignancy, ability to tolerate conventional treatment, and overall wellness.

The nd onc gives attention to all comorbidities, addresses them as indicated within the context of the treatment program, and monitors their change, as appropriate.

Involving Social Support Networks

Naturopathic doctor oncology providers recognize that supportive social networks are an integral component of each patient’s overall health and contribute substantially to an optimal treatment outcome. Therefore, the nd onc, to the extent of each patient’s comfort and agreement, seeks to incorporate family and friends in discussions about patient care and treatment. For mental and emotional support, nd oncs assist patients with referrals to resources in the community such as counsellors or support groups.

Involvement in Clinical Research

Clinical research is critically important to advancing knowledge in any field. Good correlation has been observed between clinical trial systems that increase clinical trial enrolment and more rapid advances in treatment and clinical outcomes. All nd oncs are encouraged to participate in research and to support patient involvement in clinical trials. In situations in which the patient of an nd onc is participating in a clinical trial, the nd onc should communicate with the clinical trial coordinator or coordinators about any proposed interventions so as to ensure that those interventions are not excluded in the study protocol.

Naturopathic Oncology Treatment

This subsection presents principles relating to the responsibilities of the nd onc for ensuring the delivery of high-quality patient care throughout the care pathway. Where legally sanctioned, nd oncs are primary care providers or specialty providers, who, through continuing patient assessment and care, can play an important role in ensuring whole-person care for the cancer patient. In other jurisdictions, nd oncs provide lifestyle-based support based on continuing patient evaluation. To provide continuing high-quality and professionally appropriate care, the principles described here should be followed.

Consent

Consent is an evolving process during the treatment of a patient. Although the initial informed consent based on a detailed parq discussion with the patient is important in treatment planning, provision of that consent should be understood not to preclude the need for future discussions to obtain patient consent as treatment progresses. The nd onc should continue to obtain consent as meaningful changes occur in the conventional and nonconventional treatment of the patient and in the expected effects and prognosis. Those discussions should be adequately documented in the patient’s record.

If a patient decides to refuse conventional oncologic care during their care pathway, the nd onc should make an appropriate referral (as outlined in the Providing Therapeutic Options and Care Coordination subsections) for a discussion of the implications of that choice with an oncologist. The reason for treatment refusal, together with steps taken to ensure that the patient was adequately informed about the potential consequences of refusal and the nd onc’s specific recommendations with respect to treatment refusal, should be well documented in the patient’s record.

Treatment Documentation

A written treatment plan or set of recommendations should be included in the patient record and given to the patient. The plan should be

• ■ rationally based on identified patient needs and realistic treatment goals.

• ■ based on a proper assessment, including ruling out or identifying life-threatening or hidden conditions with appropriate history, examination, and testing (including referral for specialized evaluation, when appropriate) and allowing for timely ongoing reassessment.

• ■ practical, in light of the patient’s condition and situation, including the physical, psycho-emotional, social, and financial spheres.

• ■ in the best interest of the patient and prioritized to the patient’s most pressing conditions.

• ■ logical in sequence and internally consistent.

• ■ compatible with other therapies that the patient might be undergoing (especially conventional oncology treatments).

• ■ cost-effective (estimates of the value-for-expenditure returned to the patient based on available evidence and clinical experience of the procedures or treatments—for example, longer life, better quality of life, or both).

• ■ flexible so as to accommodate new developments and findings.

• ■ experimental only with informed consent and only in areas of nd onc’s expertise.

Advance Care Planning and End-of-Life Issues

During naturopathic oncology care, patients could require planning for end-of-life care. The role of the nd onc in that part of care will vary depending on the jurisdiction of practice and the associated scope of practice. Although this discussion can be very challenging for the clinician, involving not only the mechanics of care, but also the patient’s social dynamics and spiritual beliefs, it has been shown that early discussion and planning for end-of-life care issues is associated with better quality of life during the patient’s last months and could be associated with a better chance of the patient experiencing a “good death.” The nd onc should ensure that these essential issues relating to end-of-life care are at least discussed with the patient:

• ■ Personal goals of treatment and a discussion of what is important to the patient

• ■ Advance directives (for example, desire to limit conventional or nonconventional treatment together with life-sustaining treatment)

• ■ Identification of substitute decision-makers and the granting of power of attorney

• ■ Creation of a will

• ■ Place of care, including authority for referral to hospice care and collaboration with hospice care

Ethical Issues in Practice Management

Management and disclosure by the nd onc of any potential, perceived, or real conflict of interest is important—for example, financial interest in products or services offered to patients. In addition, any health care provider is assumed to have a position of power in the context of a therapeutic relationship, and with that in mind, the nd onc should not enter into a therapeutic relationship with or accept a patient with whom they already have a personal relationship (as defined by the nd onc’s state or provincial regulatory authority) and with whom professional boundaries might not be sustained.

Timely Delivery of Care

Timely delivery of care is critical to effective patient care management in the oncology treatment setting. The requirements for timely care will be governed, in part, by the nd onc’s jurisdictional regulatory environment and corresponding scope of practice. The care management principles for timely care delivery set out here should be applied in nd onc practice as appropriate based on the individual scope of practice as set out in the regulatory and practice settings¹⁵.

• ■ The nd onc should review with the patient, in a timely manner, the results of ordered tests and consultations. The nd onc should explain, where appropriate, how results might affect care decisions and prognosis.

• ■ The nd onc should arrange for any necessary follow-up care or should notify the patient of any necessary follow-up care relating to assessment findings and responses to treatment.

• ■ The nd onc should document all contacts with a patient, including failed attempts to notify a patient about follow-up care.

• ■ In jurisdictions and practice settings that require it, the nd onc should directly provide or arrange for continuous afterhours care to be provided through an appropriate health care provider, providers, or service with the capacity to assess and triage care needs. The nd onc will ensure handover of relevant patient information to the afterhours health care provider, providers, or service when the patient’s need for afterhours care is reasonably foreseeable.

• ■ As a part of ongoing practice-based quality assurance, the nd onc should provide a basis for measuring, evaluating, and improving provider performance and timely delivery of quality care based on the provider’s jurisdictional requirements.

• ■ For effective case management, it is essential that the nd onc provide timely and ongoing assessment of patient’s subjective and objective progress with the recommended treatment. The nd onc should use laboratory and imaging results, together with the aforementioned functional assessments, to track and document in the patient record, at appropriate intervals, the patient’s response.

• ■ All assessments performed by the nd onc and other providers in the patient’s care team should be considered at regular intervals and used to evolve the patient’s treatment plan.

Care Coordination

Collaborative, coordinated care is a key attribute of high-quality care, and it is the responsibility of the nd onc who directly provides specialty care or supervises and manages specialty care provided by other clinicians. Studies have shown that systematic sharing of information between primary care providers in oncology settings is an important factor in the delivery of high-quality, patient-centred care; however, that sharing is often lacking^{16– 18}. The nd onc is in a unique role to advocate for health care collaboration, which ideally includes multiple professionals, together with family and community members, and to assist patients as they maneuver through often complex multicomponent systems of care.

Role in Collaborative Health Care for Cancer Patients

The nd onc plays an integral role in the multidisciplinary care of a cancer patient. The nd onc performs a detailed assessment and develops deep contextual knowledge about the patient and their overall health that allows the nd onc to take a key role in ensuring effective continuity of care in a collaborative team of providers. Continuity of care is rooted in a long-term patient–physician partnership in which the physician knows the patient’s history from experience and can integrate new information and decisions from a whole-person perspective efficiently without extensive investigation or record review. The nd onc, together with the rest of the patient’s health care team, should have the shared goal of providing the highest-quality cost-effective medical care. The nd onc should cultivate positive health care team relationships by identifying shared treatment goals and developing interprofessional trust through effective, clear communication^19,20.

During care transitions, nd oncs should ensure that their information about the patient’s health status, current treatment plan, treatment adherence, and treatment progress is shared with current and subsequent providers. Examples of interprofessional communication that could be used include copies of consult notes or treatment forms, formal referral letters, and e-mail communications with respect to the patient’s naturopathic oncology treatment progress, among others. Before sharing information with other health care providers in the patient’s care team, the nd onc should, where appropriate and necessary, ensure that proper authorizations for release of information are obtained.

The nd onc should ensure patient privacy when transmitting information to other care providers and should use methods of communication that guarantee secure private data transmission according to jurisdiction-specific regulation— for example, the Health Insurance Portability and Accountability Act in the United States and the Personal Information Protection and Electronic Documents Act in Canada. If the patient asserts personal privilege to block the sharing of confidential naturopathic treatment information with other providers, the nd onc should educate the patient about the health and safety risks inherent in poorly coordinated care.

Referral Recommendations

A patient meeting any of the following criteria should be referred to the appropriate specialty:

• ■ Suspected oncology diagnosis in either a primary or recurrent setting

• ■ Oncology diagnosis not currently under the care of the appropriate conventional oncology specialty, unless the patient refuses conventional oncology care (such a refusal should be well documented, and a second or third opinion should be strongly encouraged; see the section on refusal of standard of care in the Consent subsection within the Naturopathic Oncology Treatment subsection)

• ■ Suspected oncologic emergency

• ■ Any symptoms or diagnosis that the naturopathic physician does not have the knowledge, skills, or judgment to manage, or is outside the scope of practice to manage in the practice jurisdiction.

Survivorship Care Management, Screening and Surveillance, and Prevention of Recurrence

A cancer patient is a survivor from the moment of diagnosis through the rest of life. From the perspective of naturopathic oncology patient management, survivorship care begins once active conventional treatment (surgery, radiation, chemotherapy) ceases and clinical remission is achieved. Care plans should involve not only the patient, but also the patient’s family, friends, and caregivers per the patient’s request. In this portion of the treatment pathway, nd oncs play an important role for patients because of the provider’s unique understanding of the interplay between long-term health and environmental factors, diet and lifestyle, and psychosocial and other factors.

Patients should receive a detailed summary of their individualized naturopathic cancer survivorship plan from their nd onc. Discussion of the therapeutic options outlined in the plan should be conducted in a way similar to that outlined in the Providing Therapeutic Options subsection within the Integrative Oncology Plan subsection.

A naturopathic cancer survivorship plan should include

• ■ support for rapid and effective recovery to maximal functioning, including resolving or minimizing, wherever possible, lingering side effects of disease and treatment, including physical, psycho-emotional, and social functioning.

• ■ interventions that reduce the risks of long-term side effects of care and provide appropriate screening to monitor potential long-term or future side effects of treatment.

• ■ support for the prevention of recurrence, assurance of adequate surveillance for cancer recurrence, and provision of continued appropriate primary cancer screening where the nd onc is acting as the patient’s primary care provider.

SUMMARY

Changing patient demographics, cultural attitudes, and increased access to health and related information are causing a massive transformation in health care today²¹. Those transformational forces have led to the burgeoning field of naturopathic oncology. Because of their training as primary care providers delivering whole-person care, in concert with expertise in integrative oncology treatment approaches, nd oncs can play an important role in the care of cancer patients. Guiding principles of care are needed if nd oncs are to be effective players in the larger care team for cancer patients.

In the present document, we have set out clear guidelines covering areas of patient assessment, treatment planning and management, care coordination, and survivorship. The guidelines were developed in a comprehensive process that brought together experts in the field, extended invitations for internal and external stakeholder review and commentary, and culminated with final dissemination, whose goal was broad adoption by nd oncs. The oncanp Principles of Care Guidelines constitute a tool not only for ensuring consistent, high-quality care delivery by nd oncs, but also for cultivating a greater understanding of naturopathic oncology practice with other oncology care professionals.