The Chiropractic Care of Patients With Cancer

Abstract

Background and Significance: Cancer is the leading cause of death worldwide and accounted for 7.4 million deaths in 2004. By 2030, deaths from cancer have been estimated at 12 million with 30% being preventable. Complementary and alternative medicine remains popular among cancer patients; particularly with chiropractic services. However, the nature of the chiropractic clinical encounter and its reported benefits remains to be fully investigated. Towards these efforts, we begin with a systematic review of the literature on the chiropractic care of patients with cancer. Methods: The following electronic databases were searched: MANTIS [1965-2010]; Index to Chiropractic Literature [1984-2010]; Pubmed [1966-2010]; Medline [1965-2010] EMBASE [1974-2010], AMED [1975-2010], CINAHL Plus [1965-2010], Alt-Health Watch [1965-2010] and PsychINFO [1965-2010]. Key words used were “cancer” and “neoplasm” in Boolean combination with “chiropractic.” Primary investigation/reports in peer-reviewed English journals involving chiropractic care were reviewed. Results: Our review revealed 60 case reports, 2 case series, 21 commentaries, 2 survey studies, and 2 literature reviews. The case reports were diagnostic with commentaries highlighting the importance of recognizing the patient presenting with NMS complaints due to an underlying neoplasm. The chiropractic clinical encounter prior to cancer diagnosis and subsequent medical referral is poorly characterized in the literature. Conclusion: Patients with cancer seek the care of chiropractors. The literature does not reflect or describe the totality of the chiropractic clinical encounter. We encourage further research in this field.

Introduction

According to the World Health Organization (WHO), cancer is the leading cause of death worldwide and accounted for 7.4 million deaths (ie, approximately 13% of all deaths) in 2004. Deaths from cancer have been projected to continue to rise, with an estimated 12 million deaths globally by 2030. ¹ Sadly, more than 30% of cancer deaths can be prevented. ²

In the world of complementary and alternative medicine (CAM), the care of patients with cancer and cancer survivors remains popular.^3-11 This is despite concerns by some that dietary supplements, herbal medicine, special diets, vitamins, and other alternative therapies might be potentially harmful or carry risks.^12,13 This is not to say that these concerns are not valid, particularly if delayed diagnosis and improper care are the results. ¹⁴ Of the various CAM therapies, chiropractic is the most widely used and most regulated alternative therapy and is more often used than any other alternative.^15-17 Among patients with cancer, chiropractic is popularly used.^18-23 However, the nature of the chiropractic clinical encounter remains to be fully characterized. To begin to explore the role of chiropractors and the nature of the care provided to patients with cancer, we performed a systematic review of the literature on the chiropractic care of such patients.

Methods

A comprehensive search was performed by the authors to identify all relevant reports pertaining to the chiropractic care of patients with cancer. The following electronic databases were consulted: MANTIS (1965-2010), ICL (1984-2010), PubMed (1966-2010), MEDLINE (1965-2010), Embase (1974-2010), AMED (1975-2010), CINAHL Plus (1965-2010), Alt HealthWatch (1965-2010), and PsycINFO (1965-2010). Keywords used were cancer and neoplasm in Boolean combination with chiropractic along with related words when appropriate. Additionally, chiropractic journals (ie, Journal of Manipulative and Physiological Therapeutics, Journal of the Canadian Chiropractic Association, Clinical Chiropractic, and The Chiropractic Journal of Australia) were hand searched for the last 5 years for possible relevant materials. The bibliography lists of all retrieved articles were also searched for relevant studies. The authors independently reviewed the titles and abstracts of all articles retrieved. The full manuscripts of reports relevant to the chiropractic care of patients with cancer were retrieved by applying the following set of eligibility criteria: (1) the study should be a primary investigation/report (ie, case reports, case series, case control, randomized controlled trials, and survey or surveillance studies or commentary) published in peer-reviewed English language journals and (2) part or all of the study or study population should have involved the care of patients with cancer.

Results

Our findings reveal that the overwhelming majority of the literature on the chiropractic care of patients with cancer comprises case reports/case series^24-84 followed by commentaries,^85-105 surveys,^106,107 and limited reviews of the literature.^108,109

Case Reports and Case Series

The case reports/case series published in the peer-reviewed literature reflects on the array and clinical complexity of patients with cancer presenting for chiropractic care. Often, the clinical scenario involved patients presenting with neuromusculoskeletal system (NMS) complaints, and with subsequent clinical workup on the part of the attending chiropractor, the underlying cause of the patient’s symptoms is attributed to cancer. The published literature on the chiropractic care of patients with cancer includes a diagnosis of aneurysmal bone cyst, ²⁴ astrocytoma, ²⁵ metastasis from breast cancer,^26-31 carcinoma,^32-40 chordoma,^41,42 chondroblastoma,^43,44 chondrosarcoma, ⁴⁵ enchondroma, ⁴⁶ ependymoma, ⁴⁷ Ewing sarcoma, ⁴⁸ fibrosarcoma, ⁴⁹ ganglioneuroma, ⁵⁰ hemangioma,^51-53 leukemia, ⁵⁴ lipoblastomatosis, ⁵⁵ lung cancer metastasis, ⁵⁶ lymphoma, ⁵⁷ meningioma, ⁵⁸ mesothelioma, ⁵⁹ neuroma, ⁶⁰ neurofibromatosis type I, ⁶¹ osteochondroma,^62,63 osteoid osteoma,^64,65 osteosarcoma, ⁶⁶ Pancoast tumor,^67-69 pancreatic cancer, ⁷⁰ pheochromocytoma, ⁷¹ prostate cancer,^72-75 schwannoma,^76-78 “tumor,” ⁷⁹ and teratoma. ⁸⁰ Through a case presentation, Banks ⁸¹ reviewed the literature with regard to metachondromatosis, Gaucher’s disease, and osteochondromatosis. We acknowledge that a number of imaging “case reports” have been published in various chiropractic journals, but we did not include them in our review because they did not provide descriptions of the complete clinical scenario expected of case reports.

A case series described a 46-year-old woman with ependymoma at the T12-L1 vertebral levels and a 38-year-old man at the L1-L2 vertebral bodies. ⁸² The first patient was diagnosed with fibrous dysplasia, whereas the second patient had bone metastasis. Rimmelzwaan and Bull ⁸³ presented 2 clinical cases where a tumor could have been misdiagnosed as a sporting injury.

Commentaries

With respect to commentaries, in the context of the increasing role of chiropractors as primary care providers, Defoyd ⁸⁴ reiterated that careful consideration of the patient’s history and physical examination findings along with laboratory and imaging procedures are helpful in establishing a correct diagnosis where metastasis is suspected. Augmented by a clinical case scenario involving the chiropractic care of a 46-year-old woman with a history of breast cancer, Grod and Crowther ⁸⁵ stressed the need for further diagnostic imaging, particularly when the physical examination and plain film radiographs are inconclusive or suspicious. Metastasis should be the diagnosis until proven otherwise in patients with a history of breast cancer presenting with NMS symptoms. In a 2-part series, Greenly^86,87 discussed the 3 most common forms of skin cancer (ie, basal cell carcinoma, squamous cell carcinoma, and malignant melanoma) and its prevention. A similar article was published focusing on the role of the chiropractor in early detection through careful observation of a person’s nevus and other skin lesions for changes over time that might indicate the early stages of skin cancer. ⁸⁸ Perillo et al ⁸⁹ discussed the use of a 3-phase bone scan in the differential diagnosis of osteoid osteoma versus a bony island. In the journal Topics in Clinical Chiropractic, a publication was devoted to addressing the role of chiropractors in the care of patients with cancer. Bowers ⁹⁰ commentary titled, “Breaking the Bad News” stressed the importance of the delivery of a cancer diagnosis in a manner that facilitates acceptance and understanding and minimizes the risk of provoking denial, ambivalence, unrealistic expectations, overwhelming distress, and collusion. Sembrat ⁹¹ summarized the topic of breast cancer, and Elkington ⁹² provided an overview of lung cancer for the chiropractor. Barnes ⁹³ reviewed the 5 most common forms of pediatric malignancy (ie, leukemia, central nervous system tumor, bone cancer, neuroblastoma, and lymphoma) with an emphasis on their case presentations in the chiropractic setting. Mannello ⁹⁴ reviewed skin cancers, and Jamison ⁹⁵ and Hink ⁹⁶ examined cancer prevention strategies through the use of nutritional and herbal products. Schneider and Gilford^97,98 discussed the use of spinal manipulative therapy (SMT), soft-tissue techniques, physiotherapeutic modalities, exercise, and ergonomic counseling in decreasing pain, abating the adverse effects of chemotherapy or radiation treatment, and enhancing the quality of life of patients with cancer. Edge et al ⁹⁹ explored cancer in the context of thoracolumbar syndrome, spinal metastatic disease, and carcinoma of the kidney. Persistent pelvic pain and its relation to ovarian cancers, cervical cancer, and uterine and endometrial cancer, was a topic of discussion in another article, ¹⁰⁰ whereas Wyatt ¹⁰¹ reviewed and summarized the various spine cancers that patients may present with to a chiropractic practice. Verbeeck ¹⁰² reviewed the imaging guidelines for breast cancer augmented with a case report of a 62-year-old woman with a history of breast cancer prior to chiropractic presentation. Pringle and Wyatt ¹⁰³ described the evaluation, treatment, management, and referral of 2 patients with back pain of malignant etiology. The most recent commentary was by Shaw, ¹⁰⁴ where the author described what chiropractors “need to know and do and avoid doing” for patients with cancer in their practice.

Surveys

To examine the health promotion strategies of chiropractic patients, Jamison ¹⁰⁵ surveyed Australian chiropractic patients (n = 102) and found that most were nonsmokers, did not abuse alcohol, exercised regularly, had a diverse diet, made sensible dietary choices, and did not overmedicate. The majority of women had been screened for the early detection of cervical and breast cancer. Brown, ¹⁰⁶ in a retrospective file review, randomly selected 500 files of patients older than 50 years with lumbar radiographs at the Anglo European College of Chiropractic in Bournemouth, England. Brown found that only 3.4% of the files had radiographs with findings for absolute contraindication to SMT (ie, the presence of spinal lytic metastasis), whereas findings of relative contraindications to SMT were high, such as osteopenia (31.6%), calcified abdominal aorta (33%), Paget’s disease (1%), and ankylosing spondylitis (0.6%).

Reviews of the Literature

With respect to reviews of the literature, Simon ¹⁰⁷ examined the possible link between certain nutrients and their inhibitive effect on cancer. Simon concluded that certain vitamins, minerals, and bioactive phytonutrients can be used as a first-line therapeutic defense against cancer before chemotherapy or radiation treatment is started. Evans and Rosner ¹⁰⁸ addressed the topic by examining the chiropractic services offered to patients with cancer for pain management. According to the authors, the judicious use of chiropractic services may offer economical and effective strategies for reducing pain and suffering, with the potential to improve overall patient health.

Discussion

The breadth and width of cancer care are enormous and complex, even in the world of CAM therapies. It has been estimated that between 9% to 91% of adults with cancer use CAM therapies.109,110 The popularity of CAM use among cancer patients is reflected in an examination of the CAM content of 66 comprehensive cancer control (CCC) programs in the US territories and tribes. Lo et al ¹¹¹ found that almost 60% of the CCC plans included CAM content. These involved patient education on the CAM practices (46.2%), use of CAM therapies (28.2%), CAM research (18%), encouraging patient and orthodox provider communication about CAM use (18%), and characterization of CAM as a barrier to treatment (10.3%).

To determine the predictors of CAM use by patients with cancer, Fouladbakhsh et al ¹¹² surveyed patients (n = 968) with lung, breast, colon, or prostate cancer using a self-administered questionnaire. The investigators found that predictors of CAM use were gender, marital status, cancer stage, cancer treatment, and number of severe symptoms experienced. Enabling variables such as higher income, education, and marital status (ie, married) were associated with CAM use. Individuals with breast cancer, those having chemotherapy or surgery, or those in the late-stage diagnosis of cancer were more likely to use CAM therapies. Interestingly, dissatisfaction with medical care, pain, emotional distress and concerns about cancer, and expectation of recurrence were not related to CAM use. According to Rosenthal et al, ¹¹³ the expectations of cancer patients are that CAM offers symptom management, improved quality of life, and in some cases, the hope of lessening the disease process and potential cure.

Studies on the use of chiropractic services in the United States and other industrialized countries point to the popularity of NMS conditions, in both the adult and pediatric population, as motivation for attending the care of a chiropractor.^114-116 There exists a strong relationship between NMS symptoms and the possible underlying pathology of cancer.^117-119 In a study of insured patients with cancer, musculoskeletal signs and symptoms (ie, acute sprains and strains, cervical pain syndromes, low back pain, and bursitis, synovitis, and tenosynovitis) were commonly diagnosed. ¹²⁰ Furthermore, the study found that chiropractic use among cancer patients was substantial and ranged from 7.2% for men with bladder cancer to 15.1% for women with skin cancer. As alluded to earlier, studies examining the use of CAM therapies by cancer patients consistently document the popularity of chiropractic when compared with all the various practitioner-based CAM therapies.^18-23 For example, the recent publication by Habermann et al ²³ found that chiropractic was the most popular CAM therapy among long-term lymphoma survivors. In pediatric care, chiropractic’s popularity as the most commonly used practitioner-based CAM therapy also extended to those children with cancer.^114,121 As part of their education in the care of patients with NMS symptoms, chiropractors receive extensive training in the diagnosis of various cancers.^122,123 The failure to diagnose and make the appropriate referral or the delivery of SMT when contraindicated can have potentially dire consequences for the patient. Our review found 4 reports in the scientific literature describing adverse events (ie, delayed diagnosis and care in addition to iatrogenesis) associated with chiropractic and in patients with cancer. They highlight the importance of a thorough history and clinical examination and the need for constant vigilance for the possibility that a patient’s presenting symptoms may be caused by cancer. In a medicolegal abstract published in JAMA ¹²⁴ in 1952, a female patient presented to a chiropractor with complaints of a stiff neck, headaches, and a “sore spot” behind the right ear. Radiographic examination of the cervical spine revealed that 2 vertebrae were “out of place,” and subsequent “adjustments” were performed. Shortly thereafter, the patient experienced inability to walk, vision impairment, vomiting and pain, and paralysis of the throat and vocal cords. The patient was taken to the hospital with the eventual diagnosis of “brain tumor.” The unknown authors claimed “rupture of the brain tumor” as a result of chiropractic care. Another case described a 53-year-old man with complaints of neck pain attending chiropractic care. Following the third visit, swelling of the neck occurred. Physical examination by a medical physician revealed a continuous bruit over the left neck mass along with numerous café-au-lait spots and cutaneous neurofibromatosis. Cervical spine radiological examination revealed dysplasia and kyphosis consistent with neurofibromatosis. There was a fracture of the T1 vertebral body transverse process. Angiography revealed a cervical fibroma in the left external carotid artery. Left subclavian artery injection to the thyrocervical trunk revealed an enlarged and irregular trunk. Contrast filling revealed a false aneurysm but an enlarged cervical neurofibroma. ¹²⁵ Lennington et al ¹²⁵ speculated that the mechanism of injury was similar to a traumatic dissection of the high extracranial internal carotid artery with the SMT causing stress of the thyrocervical trunk, since enlarged and tethered to the neurofibroma. The third article was a letter to the editor describing a 40-year-old man with numbness of the right fourth and fifth digits. ¹²⁶ Medical physical examination revealed atrophy and weakness of the ulnar-innervated hand muscles with generalized hyperreflexia. The patient did not return for medical care for 8 months but did attend treatments over a period of 2 weeks consisting of 6 treatments. The patient developed gradual weakness over the entire right upper extremity, unsteady gait, and numbness of the entire left side of his body. Clonus and spastic hemiparesis were also detected. Eventually, a fibroblastic meningioma was surgically removed with claims on the part of the author that the meningioma had been “activated” by chiropractic manipulation. The last article described the chiropractic care of an infant with congenital torticollis resulting in respiratory insufficiency, seizures, and quadriplegia. Shafrir and Kaufman ¹²⁷ placed the blame on the chiropractor because of a temporal association with the infant’s adverse symptoms despite the findings of a holocord astrocytoma, with extensive acute necrosis requiring resection.

The importance of recognizing that chiropractic patients presenting with NMS complaints may have an underlying neoplasm is reflected in the findings of our systematic review. Comprising mostly case reports, the typical case scenario described the presentation of a patient with NMS symptoms as a motivation for attending chiropractic care. Some presented with a history of cancer (ie, breast cancer) but by far, the majority of patients were not aware of the underlying cause of their NMS symptoms. The diagnosis of cancer was made through a careful history and physical examination or because the patient was nonresponsive to a trial of chiropractic care (ie, persistence or worsening of symptoms and/or presence of unrelenting pain). The use of radiographic imaging as an essential tool in this regard is highlighted, given that it is the cornerstone of diagnostic imaging for patients presenting with NMS conditions. ¹²⁸ Insofar as the totality of the chiropractic clinical encounter is concerned (ie, reasons for seeking care, the chiropractic SMT and adjunctive therapies rendered, effectiveness of care, etc), we found these to be poorly documented or not at all. One reason for this could be the focus of the case reports themselves as one of diagnosis rather than a description of the clinical encounter to document the benefits of chiropractic care (ie, alleviating NMS symptoms, improve the overall quality of life, etc). As mentioned previously, studies examining the CAM therapies used by patients with cancer document the popularity of chiropractic.^18-23 Our systematic review of the literature does not reflect this. As described in the case reports/case series, once the diagnosis of cancer and medical referral is made, the care rendered to the patient is not described, nor is the care rendered prior to the diagnosis. If, indeed, chiropractic care provides symptomatic relief, provides supportive care to conventional cancer care, and improves the overall quality of life in this patient population, as some have commented, these are poorly described or not at all. Only 1 case describes the totality of the chiropractic clinical encounter throughout the course of the patient’s cancer diagnosis. Lee and Jenson ³⁶ described a 60-year-old man with medically diagnosed hepatocellular carcinoma and benign hemangioma. Following 9 percutaneous ethanol injections, remission occurred. The patient was also under concurrent chiropractic care during this time period. Then, 2 years later, the carcinoma reappeared with elevated levels of α-fetal protein. A computer axial tomography (CAT) scan revealed a cluster of small lesions, collectively 2 cm wide and 4 cm long. Surgery was ruled out, and the patient declined a second course of percutaneous ethanol injections or any further medical treatment. The patient elected to remain under chiropractic care. After 8 months, the patient’s α-fetal protein levels dropped to “safe” levels, and a follow-up CAT scan revealed no lesions. The patient received the Palmer Specific Hole-In-One Technique. Long-term follow-up has revealed that the patient continues to enjoy his life of retirement and remains under chiropractic care. Despite the lack of characterization in the scientific literature of the chiropractic clinical encounter “beyond diagnosis” in patients with cancer, there are indications that patients (in general) are presenting to chiropractors for “wellness care.”^116,129 The chiropractic patient-centered paradigm of health care, incorporating the principles of vitalism, holism, humanism, conservatism, naturalism, and rationalism ¹³⁰ may be what patients with cancer are seeking. The nature of this clinical encounter between chiropractors and their patients with cancer remains to be investigated in future studies.

We acknowledge that controversy and ethical breach exists with claims of “cancer cure” by various “alternative therapies.” In a survey of pediatric oncologists to assess barriers to CAM communication in pediatric oncology, Roth et al ¹³¹ found that the majority were of the opinion that it was important to know what CAM therapies their patients use; yet less than half inquired about CAM use. Many thought some forms of CAM may improve quality of life such as massage and yoga, whereas more than half of the responders thought that dietary supplements, herbal medicine, special diets, vitamins, and chiropractic might be harmful to patients. Understandably, then, chiropractors may be hesitant to describe their care approach with patients with cancer for fear of being misunderstood—that the chiropractic care of patients with cancer is not equivalent to the treatment of cancer in a patient.

Integrative Medicine (IM)

According to Geffen, ¹³² a number of factors (ie, changing patient demographics, heightened awareness of alternative products and services, advances in medical science and technology, and expanding access to the Internet and health information) have contributed to a “wave of transformation” in the entire health care system to fuel the emerging fields of IM and oncology. According to Rosenthal and Dean-Clower, ¹¹³ in the context of oncology, IM emphasizes the incorporation of complementary therapies into conventional treatments, such that patients and their medical and CAM providers are working together to improve the patient’s overall well-being. Chiropractic’s theoretical and clinical framework of vitalism, holism, humanism, and so on and its established effectiveness in the care of patients with NMS conditions positions the profession for a significant role in the care of patients with cancer in an integrative setting.

Conclusion

Our systematic review revealed that the published literature does not provide much insight into the chiropractic care of patients with cancer. We encourage further research in this field to investigate the nature of the clinical encounter between patients with cancer and their chiropractors.