Protocol for treating patients who have been given a cancer diagnosis

Although a large proportion of the respondents tended to agree on their approach regarding engagement with the medical team, there were some interesting differences within the group.

Many of the respondents (11/13) would not consider contacting the medical team of the patient to request permission to treat. However, one panellist stated they would contact the clinical team regardless of whether the patient was diagnosed with cancer, in chemo- or radio-therapy or in remission.

Approximately half of the respondents (7/13) considered that a clinical relationship between the chiropractor and the oncologist was not necessary, while six of 13 considered it to be necessary. Comments within the responses to this question showed some differences in terms of type of interaction. Two of nine who commented directly, stated that either oncologists are not open to chiropractic care in the country of practice (n= 1), or that the oncologist does not know what a chiropractor is or could do (n= 1).

Comments supportive of a multidisciplinary approach came from six of the 13 panel members. These are best encapsulated in the following statement: all healthcare practitioners working on a patient should have some clinical relationship for the benefit of the patient and that the patients’ optimal management is based on a mutual understanding of each practitioners’ role. Finally, 11/13 of the actively engaged panel agreed that a chiropractor should offer treatment to a patient who has a current diagnosis of cancer; however, two disagreed.

Discussion

There was unanimous agreement of the panel regarding the perception that patients with cancer can benefit from chiropractic treatment. Interestingly, the main reasons that a patient with cancer seeks chiropractic treatment were considered by the panel to be no different from those of any other patient, namely MSK pain and associated disorders. A better quality of life, pain relief and improved function were reported to be the most common perceived benefits of chiropractic in relation to the panels’ experience with cancer patients.

The panel agreed that a cancer diagnosis should make a difference to a chiropractic treatment plan, even if the patient seeks care when in remission. Spinal manipulative therapy was not reported as being used on all cancer patients, with exclusion criteria including the location of the tumour as well as presence of metastases or concurrent osteoporosis. Type of cancer was not mentioned as a factor by any of the panel, however, this might relate to the lack of a specific question.

One of the obvious limitations was that the panellists only had restricted clinical experience of patients with cancer, having only encountered them through their own practices. The potential lack of diversity in terms of the cancer types seen requires consideration when interpreting the comments reported here. The fact that these chiropractors have seen sufficient patients with these conditions to be comfortable discussing their treatment, however, does indicate that chiropractors should expect to see these patients in general practice.

The authors had initially considered a general questionnaire to the profession; however, a Delphi method was considered an appropriate starting place to gain some insight into the issue.

The Delphi method maximizes the benefits of using an expert/knowledgeable panel while minimizing potential disadvantages by implementing anonymity.^49–51 Furthermore, this method allows everything to be performed by email and does not require the participants to meet or interact directly. The presence of anonymity allowed those participating, the room to air their views without the inhibition that might result when discussing potentially contentious issues in a direct (face-to-face) social interaction. This was an important consideration in relation to approaching this topic area within members of the chiropractic profession, in order to gather a wide range of views. Furthermore, anonymity allows decisions to be evaluated on their merit, rather than being influenced by the strength of personality (i.e. of the person who had proposed the idea). Anonymity and confidentiality of participants are central to ethical research practice in social research.^50–53

Using the Delphi methodology rather than focus groups allowed information exchange between numerous geographically (and temporarily) dispersed individuals in an iterative process. The belief is that there could be benefits from the exchange of information while retaining a low cost and convenience of accessing the questionnaires. In this case, the method allowed chiropractors from across Europe to answer the questionnaires in their own time and without awareness of other panel members’ views. Supplying their responses to a central point and not sharing them prevented any adverse personal interaction. This approach has been criticized for limiting the potentially positive aspects of interaction found in any face-to-face exchange of information, as these often help identify the reasons for any disagreements.⁵⁰ The preliminary basis of this study accepted this minor disadvantage in relation to the major advantage of determining the nature of the issues.

Consensus development methods are being used to help clinical guidelines, which define key aspects of the quality of health care.⁵² However, particularly appropriate indications/suggestions for interventions, such as those revealed in this Delphi study, do not represent any clinical guidelines. Instead, these results should only be considered as a representation of a consensus between members of a small panel of European chiropractors regarding their perspective on chiropractic management of patients with cancer.

Although 23 potential participants were invited, only one actively decided to opt out. Of the remaining 22 who indicated they were interested in participating, slightly more than half (n=13) actively participated in the first round. Reassuringly, this level of participation continued into the second round, however due to the success of the anonymization process we were not in a position to determine whether participation was by the same 13 chiropractors in both rounds. The low response rate during the verification stages could be considered as reflecting a general agreement with the conclusions, however as this was not an active agreement, this can only be considered tacit approval at best.

Improvements in quality of life, pain relief and function were the most commonly reported perceived benefits of chiropractic in regard to patients with cancer. Importantly making potential patients more aware of these benefits was not considered appropriate. The debate in the profession regarding the “philosophy of chiropractic” seems to have made some chiropractors apprehensive regarding who they will talk to about chiropractic treatment in these patients, with the motivation apparently being a fear of possible misunderstanding about what the chiropractor could do. Indeed, when presenting our preliminary analysis at a major European chiropractic meeting one of the authors found that a number of chiropractic scientists misinterpreted the aim of the research. A small number of the panel expressed concerns about advertising any perceived benefits. Apart from local advertising restrictions and lack of evidence base, the main concern was that these patients should not be considered any differently from patients without a history of cancer, due to the treatment focus being neuro-musculoskeletal.

The panel agreed that chiropractors should view the patient as a “whole person” with needs reaching beyond the management of the disease entity. Indeed, the chiropractic profession has, ever since its inception, embraced such a “holistic” approach toward patient care. The generally accepted primary role of the chiropractor is to assist the patient with pain management and help the patient to increase mobility and function beyond a disease diagnosis.^9,47 The panel did consider that the use of spinal manipulation might be contraindicated or require careful consideration when treating patients with cancer. When challenged regarding alternative management/treatment tools, the panel reported using a variety of tools, but only a few of them appeared to be chiropractic specific. The key feature was that each patient must be evaluated thoroughly to determine which methods (chiropractic or other) will provide the greatest benefit in the particular case. In some instances, treatment may call for non-force techniques, whereas other situations could be better addressed through use of more standard manipulative procedures.⁸ Interestingly, most of the techniques mentioned by the panel did not appear specific to chiropractic; as a variety of physical therapists, physiotherapists, osteopaths and sport massage therapists would also consider them part of their toolbox. It was agreed by all the panel who expressed an opinion (n=13) that more evidence would be needed in order for chiropractic adjustments and chiropractic specific techniques to be considered safe to use with such patients.

Although the attitude of health care providers and regulators to chiropractic has been historically negative, the opinion of the consumers has always been positive. It appears the public’s opinion of chiropractors does not suffer because of advertising,⁴⁸ however it has been suggested that approval of the majority of clients can be helped by using a professionally designed and well-conceived advertising campaign. It has been reported that almost 77% of the general public seek and want information regarding the services a chiropractor provides.⁴⁸ This supports the need for clarity and transparency when communicating the identity for chiropractic: as we found here, what a chiropractor considers specific to chiropractic, may not be considered to be specific to chiropractors by those outside the profession.

The vast majority of the panel agreed that chiropractors should treat patients with cancer, which provides a positive answer to the initial question. However, there was a recognition of the need for evidence to indicate whether chiropractic treatment is safe for these patients which was one of the main concerns of the panel. In addition, the panel struggled to find chiropractic specific management techniques, which could raise an issue for further research.

Although anecdotal, there has been the perception of both fear and confusion in the profession regarding the role of the chiropractor in the management of patients with cancer. This was strongly reflected in the comments made by the panel. Therefore, going forward it is apparent that evidence will be needed in order to both allay fears, define roles and facilitate in the engagement of chiropractic as part of an integrated care package for these patients. This suggests there may be a need, at least initially, to create consensus based guidelines (as there is no research available to currently inform such guidelines) that support currently considered best practice and prevent more dubious and unhelpful claims of efficacy.

This research does not present evidence supporting benefits for patients with cancer from chiropractic care, or whether spinal manipulative therapy should be used on the management of patients with a diagnosis of cancer. However, it does give evidence that experienced chiropractors both treat such patients and recognize a potential role for chiropractic in this population of patients.

Conclusions

Chiropractors treat patients who have cancer, seeking care mainly for neuro-musculoskeletal complaints. Advertising is not considered viable due to potential for adverse interpretation.

Further research is necessary regarding initially how chiropractic could gather data about the relative safety and risks of chiropractic care in such patients. Chiropractors need to establish better inter-professional relationships with the patient’s medical and rehabilitation team.

It is important to send a clear message that chiropractors do not cure cancer but only aim to help with the neuromusculoskeletal signs and symptoms. Therefore, construction and publication of consensus-based guidelines of best practice should be considered a priority.

Acknowledgements