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This growing field of medicine is increasingly being referred to as integrative oncology IO. Because of their training and their licensed scope of practice, ND, FABNO are among those able to offer comprehensive whole-person integrative cancer care. IO clinics are a rich source of data for cost-effectiveness research.
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Such care consists of a whole-person-oriented approach, including a variety of evidence-based complementary and integrative medicine practices that include a diversity of nutrient and botanical natural products, diet and exercise plans, acupuncture, hyperthermia, and mind-body medicine. Many of these therapies are based on clinical evidence. Description of IO medical services is a required step toward evaluating its impact on disease-free and overall survival in breast cancer as well as measuring its cost-effectiveness.
Washington State provides an ideal environment for our study because IO providers are licensed and regulated by the Washington State Department of Health for all licensed complementary and alternative medicine CAM providers and many CAM services such as acupuncture. In Washington State, medical insurers are required to reimburse for visits to licensed CAM providers, including NDs as well as lab tests and imaging studies ordered by NDs. The scope of practice for NDs in Washington State is broad, including the oral, topical, and parenteral prescription of natural substances, including nutrients and botanicals.
To describe the costs of IO care, we selected a high-volume IO clinic in an academic setting located in the Seattle area of Washington State where there is a large population of breast cancer patients who seek integrative care. The methods used to conduct a matched comparison prospective observational study in CAM community clinics have previously been described.
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Each breast cancer patient who sought IO care at any of the participating naturopathic clinical sites between February 2, , and April 14, , was invited to participate in an observational outcomes study of quality of life and clinical outcomes associated with such care. This cohort of participants was used to describe treatments recommended by ND, FABNOs during the first year of care to women with stage 0 to 4 breast cancer. Contained within this cohort was a nested subset of women who had, at minimum, a second clinic visit within 7 months of their first office call FOC.
Stage of breast cancer at the study enrollment date was obtained from conventional medical charts. Conventional oncology medical charts were searched and abstracted for treatment plans and prescriptions. Medical records were requested at the study-defined time points of 6 months and 1 year post-FOC. Trained staff abstracted each chart for types of IO therapy, and dietary and lifestyle recommendations. Study data were collected and managed by the Bastyr research team for prospective cancer outcomes studies using REDCap Research Electronic Data Capture electronic data capture tools hosted at Bastyr University.
REDCap is a secure, web-based application designed to support data capture for research studies, providing an intuitive interface for validated data entry, audit trails for tracking data manipulation and export procedures, automated export procedures for seamless data downloads to common statistical packages, and procedures for importing data from external sources. Chart abstractors identified each IO therapy recorded in the treatment plan. The REDCap data entry form provided the abstractor a checklist of 79 commonly recommended oral and topical CAM therapies, 14 types of injectable therapies, 33 types of dietary recommendations, 10 mind-body medicine therapies, and 8 lifestyle recommendations.
This list was generated by the consensus of the lead physicians of the IO clinics. Data gathered included the type and date of physician recommendation. Standard doses and frequencies of doses for each therapy were gathered using a separate physician survey conducted concurrently. To streamline statistical analyses, some IO treatments that were recommended during conventional standard oncology treatment eg, surgery, chemotherapy, radiation and hormone, biological and immune therapies were categorized into 1 of 2 categories.
Treatment recommended concurrently with standard oncology treatments were designated as those recommended to the patient while in treatment. Treatment recommendations made to any patient during the year following diagnosis were also designated as being recommended in treatment. Treatment recommendations made during the year following standard therapy were categorized as those being made during survivorship. Results describe therapies recommended during the first year of IO care for each stage of breast cancer.
Consultations were defined as office visits, with procedure codes indicating interaction with an IO physician. Price data were gathered from commonly used internet websites for typical prices for other natural medicines prescribed to breast cancer patients enrolled in the study such as the site maintained by Emerson Ecologics, LLC. Cost data from these 4 data sources was entered into a relational database for analysis. Additionally, the percentage of cost covered by insurance and the percentage paid by the patient was also included in the analysis.
Table 2 shows the histological characteristics of the breast cancer patients who received IO care. Table 3 shows the stage of IO breast cancer patients at their first presentation to a participating IO clinic, who consented to participate on an observational outcomes study. Only 3. Intravenous IV therapies were administered mostly after completion of chemotherapy during survivorship.
The number of clinic visits per patient per year ranged widely from 1 to The mean number of visits during the first year of IO care ranged from 6.
The other commonly recommended therapies included acupuncture provided by TCM practitioners. Of these, most received acupuncture during their first year of IO care. Acupuncture was more likely to be prescribed during the year of primary oncological treatment compared with the survivorship year. TCM herbs were prescribed less frequently than acupuncture.
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Some form of exercise was the most common lifestyle recommendation. Table 5 presents details on specific types and frequencies of therapies recommended to breast cancer patients who had at least 2 visits with an ND, FABNO and who enrolled before January 1, , and had at least 2 office visits.
More than 72 specific oral or topical nutritional-, botanical-, fungal-, and bacterial-based medicines were prescribed to the cohort during their first year of IO care. Injectable therapies were used almost exclusively in stage 4 breast cancer patients data not shown. Table 6 shows the amount charged for all visits for 1 year of IO care in stages 0, 1, 2, 3, and 4 and those of unknown stage breast cancer.
Insurance reimbursement paid for The remaining The direct costs of care include medical visits naturopathic oncology consultation and mind-body medicine visits , procedures acupuncture , and pharmacy. Pharmacy includes nutritional and botanical medicines administered orally, intravenously, subcutaneously, intramuscularly, or topically. Stage 3 women had the most visits and the highest visit costs compared with women at other stages of breast cancer at diagnosis.
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Visits were subcategorized into 2 types: those made by women during the first year after diagnosis with breast cancer—that is, during the treatment year—compared with the second year after diagnosis, which is for most women the first year of postsurgical, postchemotherapy, and postradiotherapy survivorship. In Washington State most medical insurers reimburse for naturopathic and TCM medical visits and acupuncture as a medical procedure.
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We then calculated the cost of IO pharmacy for 1 year of care for a stage 4 cancer patient. Table 8 presents an IO core therapy program for 1 year of treatment for a stage 4 breast cancer patient. Parenteral therapies were the most costly of IO treatments, and few stage 4 breast cancer patients completed such an idealized treatment.
Office visits are reimbursed by medical insurance providers, including Medicaid but not Medicare. Costs are highest during the postdiagnosis period when standard oncology treatment is occurring and increases with stage at BIORC first visit. This level of institutional write off is not unusual.
Regardless of the stage of breast cancer, IO care is low cost relative to conventional oncology costs.
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