Does hyperthermia treatment for people diagnosed with terminal cancer, allow for a better quality of life?

Written by Jemma Bower

  Introduction

Cancer is New Zealand’s single biggest cause of death and with New Zealand’s aging population rates of cancer are expected to rise (Ministry of Health, 2019). There have been many advancements in cancer treatments and many experimental treatments, one in particular called hyperthermia treatment. Many different countries are fast accepting hyperthermia treatment in addition to chemotherapy and radiation. There are currently hyperthermia treatments offered to cancer patients, however these treatments remain experimental. This essay will discuss how I came to research hyperthermia treatment, a literature review, the implications of the treatment to nursing practice and three recommendations going forward. Most importantly this essay will take you on a journey to find out if hyperthermia treatment has a place among conventional cancer treatments.

  Background of Clinical Issue

During one clinical placement in the Bachelor of Nursing programme, I was privileged to be able to work along-side a patient who had been given a terminal cancer diagnosis. This is where I first heard of hyperthermia treatment for people with cancer. The plan for the patient was to receive palliative chemotherapy, this did not sit well with the patient who had teenage children. The patient had been receiving full body hyperthermia treatment in addition to chemotherapy and radiation, the treatment was being received in New Zealand. The patient’s understanding was that, hyperthermia treatment would give the patient relief of symptoms and hope of prolonging life.

When I returned home that day, I decided I needed to know more, here I came across two newspaper articles. The articles were two different yet similar stories from New Zealanders receiving hyperthermia treatment for cancer. In June 2014, The New Zealand Herald published a story on a young mother from New Zealand, who has been diagnosed with stage 4 breast cancer (Shanksamy, 2014). The patient travelled to Germany to receive hyperthermia treatment in collaboration with chemotherapy, this was an experimental treatment. The patient’s treatment cost a total of one hundred thousand dollars and meant the patient had two months away from her children. After the treatment the patient reported feeling amazing and grateful, having better energy levels, decreased pain and less nausea. In the first year after treatment the patient’s tumour had shown no new growth

 The second article was about another young woman, also diagnosed with terminal cancer. The patient had 3 young children and was described as a wonderful mother (New Zealand Herald, 2019). The patient found a Doctor in Thailand who claimed he had a treatment that could extend the patient’s life. The treatment cost $100,000 and required a 35 day stay at a Thailand clinic. The only option the patient was given in New Zealand was palliative chemotherapy and so the patient accepted the experimental hyperthermia treatment. During the treatment the patient became extremely unwell, the patient returned home from Thailand after receiving treatment and went straight into hospice care where she passed away. The patient’s family claim she was given false hope, the cost to receive the treatment was unrealistic and the patient had lost precious time that could have been spent with her children.

 Learning of hyperthermia treatment led me to ask many questions; what is it? How does it work? Does hyperthermia treatment kill cancer cells or are people being scammed and given false hope? Is hyperthermia treatment dangerous, as I know a fever is not good for a person. I also wondered how this treatment and others like it could impact a nurse’s role.

  PECOT

 

 

 

Information relating to question.

 

Explanation

Patient

 

 

 

 

 

People in New Zealand over the age of 18 who have been diagnosed with terminal cancer.

People in this age category are more likely to be independent, make their own decisions on treatment plans as well as having more tools to access alternative treatments.

 

Intervention/ Exposure

 

Hyperthermia treatment

I will be looking for articles and research on hyperthermia treatment and the effect on cancer cells. I will also be researching the use of hyperthermia treatment in addition to chemotherapy and radiation.

Comparison

 

Patients who have a terminal cancer diagnosis and receive chemotherapy and radiation treatment, however, do not receive hyperthermia treatment.

 

I am interested to find out if hyperthermia treatment has effect on the growth of cancer cells. To investigate whether or not hyperthermia treatment can give relief of symptoms from cancer. To gain understating of barriers for people accessing alternative therapies.

 

Outcome

 

Patients receiving hyperthermia treatment in addition to chemotherapy and radiation will have reduced side effects, improved physical and emotional well-being improved quality of life and/or a more productive life

 

The outcome will identify the efficacy hyperthermia treatment has on cancer cells and quality of life for people who are terminally ill with cancer, who are having or had chemotherapy and radiation.

As a nurse to have an understanding as to why people are choosing to include alternative therapies (in particular hyperthermia treatment). To to have a base of knowledge as a nurse to be able to support patients in their choices and maintain therapeutic relationships.   To be able to provide patients with the correct information to be able to make informed decisions. To have an awareness of the danger of patients receiving hyperthermia treatment.

Timeframe

 

Each hyperthermia treatment is usually an hour.

A terminal diagnosis means the illness can no longer be cured and will lead to death.   A patient may be given a timeframe for life expectancy but this is only an estimate. Time means everything and is more precious when given terminal prognosis, however the time is unknown, therefore there is no relevant timeframe for this research.

 

Research Question: “Does hyperthermia treatment for people diagnosed with terminal cancer, allow for a better quality of life?”

  Evidence and Findings

Hyperthermia treatment is a treatment where body tissue is exposed to high temperatures between 42-45 degrees Celsius. Cancer cells are thought to not tolerate heat as well as healthy cells and may be damaged by the heat (Manaf, et.al, 2016). There are three different types of hyperthermia treatment, localised, where heat is applied directly to a tumour. The aim is to elevate the local temperature to exceed the tissue coagulation threshold, the consequence will be necrosis of the tissue therefore destroying cancerous tissue (Manaf et al., 2016).

Regional hyperthermia is more commonly being used in experimental treatments accommodating for cancerous cells in body organs, limbs or cavities. These affected areas are heated and treatment is used in conjunction with chemotherapy and radiation (Roussakow, 2019). There is potential for local and regional hyperthermia to harm patients such as burns, blisters, damage to blood vessels and the bodies immune system and organs.

Whole body hyperthermia is undertaken using a thermal chamber, warm water immersion or heated blankets, whole body hyperthermia treatment is used for metastatic cancers. It is during whole body hyperthermia where a person’s temperature becomes raised to a feverish state (Franchi et.al, 2001). A sceptical and dangerous treatment because when the human body goes into a hyperthermia state the bodies homeostasis becomes imbalanced and complications such as heat stroke and heat exhaustion can occur (Marieb, 2015). Hyperthermia can be life threatening or cause permanent brain damage and severe dehydration. (Craft et.al, 2015).

There have been studies in many countries on the use of hyperthermia treatment for cancer although none in New Zealand. A study was carried out in Korea for patients with terminal lung cancer, the experimental treatment offered was regional hyperthermia (Kim et.al, 2015). The desire was to discover if regional hyperthermia has analgesic effects on lung cancer pain. This was a case-control study consisting of two groups, group 1 (83 people) had normal opiate class drugs (oral morphine) for pain relief. Group 2 (32 people) had anti-inflammatory drugs as well as regional hyperthermia. The results showed an increase of pain in the patients in group 1 however, patients in group 2 have high levels of pain during the hyperthermia treatment. The study however had inconsistencies as only 15% of all participants in the experiment had localised cancer and the other 85% had metastases.  

In Greece hyperthermia treatment has been included in the 2013 National Comprehensive Cancer Network Guidelines as an option for the treatment of breast cancer recurrences and metastasis (Koulouias et.al2015). The change comes after many studies have shown effectiveness of hyperthermia treatment when added to chemotherapy or radiation. By raising the temperature of the tumour to 42- 45 degrees Celsius has shown control over tumour recurrence and metastasis. Treatments have only shown to being effective when correct clinical application and equipment is used. One of the biggest studies in 1996 tested over 300 lesions and five randomised trials on breast cancer that has metastasized. The results showed, treatment with hyperthermia added to radiotherapy had a 59% response rate compared to 41% response rate of radiotherapy alone (Koulouias et al., 2015). The results suggest hyperthermia treatment shows benefits for high response rates, local control rates and survival rates.

Pancreatic cancer in men and women has a low survival rate of 20% and a 5-year survival rate of 8%, modern treatment of chemotherapy and radiation show minimal tumour control. Immunotherapy has proven to be less effective due to the dense tissue surrounding the area and tumours are extremely immunosuppressant (Mahmood et.al, 2018). Experimental treatments have shown that adding regional hyperthermia to chemotherapy and radiation treatments may cause an anti-tumour response, in turn causing enhanced tumour response. Similar experimental treatments have been used for patients with bladder cancer, a cancer which has high rates of reoccurrence and risk of progression to advanced disease (Owusu, Abern, & Inman, 2013). The combined treatment of hyperthermia in addition to chemotherapy and radiation, has shown positive signs of slowing down and reducing tumour growth.

Ninety-seven participants took part in an experimental treatment for woman with mid to advanced cervical cancer (Yan Jun, Zhang Aiyun & XU Wen, 2015). The experiment offered group one (49 participants) chemotherapy and radiation and group two (48 participants) chemotherapy, radiation and pelvic hyperthermia. Group one results were 67.3% of participants were tumour free in the first year compared to group two having 91.7% tumour free in the first year. There were no complications associated with the chemotherapy, radiation and hyperthermia treatments.

A small study was carried out on adding hyperthermia treatment to chemotherapy and radiation for palliative treatment on head and neck cancer. Head and neck cancer have disheartening conclusions and do not respond strongly to standard care of chemo and radiation (Huigol, 2016). The study treated 6 participants with the chemotherapy (cetuximab) and 6 patients with the same treatment except adding hyperthermia treatment in addition. Two participants did not finish the treatment and the participants who received hyperthermia treatment showed less tumour progression than those without the hyperthermia treatment. As a side effect from the treatment all participants acquired mucositis and acneiform rashes. The study advocates combined treatments improve clinical outcome. However the study was very small and bigger studies need to be carried out to support the desired outcome (Schneider & Whitehead, 2013).

An experimental treatment was carried out on people who had soft tissue sarcoma (which is prone to recurring or metastases), using Neoadjuvant chemotherapy with regional hyperthermia for treatment (Roussakow, 2019). The aspiration was to find out if adding regional hyperthermia to the chemotherapy treatment offered better survival rates. The experiment utilised men and woman over the age of 18 from Germany, Norway, Austria and America. There were 670 people in the study, half received chemotherapy alone and half received the experimental treatment, this was randomised. The experimental treatment was carried out from 1997 through to 2006 and follow up ended in 2014. By 2014, 220 people had experienced relapse and 180 of those people had died (Roussakow, 2019). The results of the study showed an absolute difference of 5 years of 11.4% and at 10 years of 9.9% compared with the chemo alone. Therefore suggesting hyperthermia treatment in addition to chemotherapy for people who have soft tissue sarcoma may show promise of progression free survival.

A study was carried out on people who were terminally ill with cancer and had denied standard intrusive treatment, looking for better quality of life. Whole body hyperthermia was given along-side low doses of palliative chemotherapy and radiation (Franchi et al., 2001). People from the study reported having improved mood, relief from depression, improved fatigue and a better quality of life in general. The study however is easily contested due to lack of information, being non- measurable and reliable on subjective information. While it is positive people have reported improved quality of life, it is hard to pinpoint the attribution on hyperthermia treatment alone.

Modern advancements backed by positive clinical outcome give assurance that hyperthermia treatment could be included in the future as a safe and effective addition to current oncological treatments (Owusu et al., 2013). Whilst hyperthermia treatment has shown to have less effect on larger tumours, when used in addition to chemotherapy and radiation the combined treatment may aid in lowering pain levels (Datta et al., 2015). Hyperthermia treatment has a forthright and immune-mediated cytotoxic effect on tumour cells that can affect tumour growth. Combined treatment could possibly add to a better quality of life for patients who have inoperable tumours, by reducing pain and slowing tumour progression (Datta et al., 2015).

  Implications for practice

With Hyperthermia treatment available in New Zealand and the continuation of experimental treatments overseas, the concern for health professionals is patients choosing the alternative treatment. One implication of patients seeking the alternative treatment is loss of conventional cancer treatments, including surgery, chemotherapy and radiation (New Zealand herald, 2016). Conventional cancer treatments are evidence-based treatments scientifically validated and underpin nursing practice for prevention, diagnosis and treatment of cancer. Nurses have education on evidence-based practices to guide practice and need to have awareness of patient’s health literacy.

Low health literacy around a cancer diagnosis, disease progression and conventional cancer treatments may be an instigator contributing to patients’ decisions to have treatments such as hyperthermia treatment (Dempsey, Hillege & Hill, 2014). Low health literacy may contribute to a person’s confidence levels, attitudes, values and beliefs towards conventional cancer treatments. Low health literacy also makes people more vulnerable to make choices based on emotion, hear ‘say and false hope rather than facts and lead to inequalities. The increase in social media and internet use allows patients to gather unreliable information on treatments from the internet rather than discussing with health professionals. A patient’s health literacy is not solely the responsibility of a patient yet a tremendous moment for nurses to educate patients. Nurses assist cancer patients in palliative care to make decisions about health because patients require information and it is nurses who are providing the information as well as other health professionals. Competency 2.7 of the New Zealand Nursing Council competencies for registered nurses’ states nurses have a professional responsibility to provide health education appropriate to patient’s health needs (Nursing Council of New Zealand, 2007). Nurses can educate patients and raise patient’s health literacy so they can assess the information and make informed choices. Nurses need to educate patients in a non-shaming way showing compassion as this is a key factor to palliative care and building therapeutic relationships (Chang & Johnson, 2011).

Working alongside patients who choose to have hyperthermia treatment presents an ethical issue for nurses because the treatment sits outside the biomedical model of care. Nurses have a professional responsibility to educate patients on evidence-based care yet, nursing is also based on holistic care (Boston, Bradstock & David, 2011). Holistic care is an enabler for patients maintaining autonomy and for nursing in a culturally safe way. Holistic care allows nurses to expand practice to meet patient needs and improve quality of care. However, nurses have a responsibility to be aware of implications of hyperthermia treatment. Nurses can discuss evidence-based care in a way that does not shame or push patients away breaking down therapeutic relationships (Rodgers & Niven, 2003).

Patients travelling overseas to receive hyperthermia treatment has a huge implication on communication and therapeutic relationships between nurse and patients. Nurses provide essential nursing support in palliative care through palliative nurses, district nurses and hospital nurses (Chang & Johnson, 2011).   If a patient travels overseas to participate in treatment communication and relationships with the normal health providers can be compromised. If patients are being offered hope of prolonging life and possible cure from overseas treatments, patients can lose trust in the New Zealand health professionals because they do not offer the same desired outcome. Maintaining a therapeutic relationship enable nurses to give patients good knowledge about experimental treatments and reducing risks of experimental treatments and wrong use (Dempsey, Hillege & Hill, 2014). An example of this is if a patient receives hyperthermia treatment and then radiation treatment soon after without disclosing the information to health professionals. The patient is at higher risk of physical harm such as burns and blisters from the radiation (Marieb, 2015).

  Recommendations
  1. Further research into hyperthermia treatment

First recommendation is more studies on a larger scale need to be undertaken to show if there is a link between hyperthermia treatment and a better quality of life. The studies need to include full body hyperthermia to be able to discover if hyperthermia treatment works alone or only enhances the effect of chemotherapy and radiation (Golib, 2019). Further studies can also indicate if hyperthermia treatment has analgesia properties that can give patient’s relief from cancer pain.

 

  1. Nurses have a base knowledge of hyperthermia treatment

Second recommendation is that nurses working in oncology care or other settings working along-side cancer patients gain a base knowledge of hyperthermia treatment as well as other complimentary therapies. Nurses need to be aware of the growing trend of hyperthermia treatment and the increasing number of patients travelling overseas for the treatment. Nurse need to address the gap in knowledge regarding the treatments for both patients and nurses. By closing the gap in knowledge opens the door for honest conversations in an environment that safeguards the patient and their needs (Wepa, 2015). Nurses need to have compassion and empathy to be able to understand a person’s needs to seek alternative therapies yet to have enough knowledge so nurses can support patients to make fully informed choices (Dempsey, Hillege & Hill, 2014).   If nurses are open to discussion and have a base of knowledge, nurse are able to fully inform patients that this treatment is not evidence based and comes with risks and can potentially harm patients. Having a base knowledge on complimentary therapies, especially hyperthermia treatment, is not for the nurse to recommend or advise for these treatments. Having knowledge however allows a nurse to educate patients and advocate for patient’s safety and ensuring patients who choose alternative treatments are not ostracized from health services.

 

  1. Implementation of hyperthermia treatment and how to maintain strong therapeutic relationships with patients seeking alternative treatments

The third recommendation is for the Bachelor of Nursing degree to educate students on how to work with patients who use therapies that sit outside of the biomedical model approach to treatment. As cancer rates increase and the trend for hyperthermia treatment grows, likeliness of nurses working with patients who are seeking the treatment is high. Knowledge is needed on the treatment, the risks involved, the growing trend and how to handle these conversations with patients as they arise. Education around hyperthermia treatment, patients seeking complimentary therapies and patients who refuse any treatment is needed. Education will give nurses a skill set on how to still work alongside patients and maintain good communication and therapeutic relationships whilst upholding professional and ethical responsibility.

  Conclusion

Some terminally ill health consumers are making decisions that see themselves travelling overseas for hyperthermia treatment in addition to other therapies. These treatments are costing patients hundreds of thousands of dollars, the treatment is experimental, risky and cannot claim to prolong life or cure cancer. Whilst the literature search shows positive signs of analgesic properties and tumour regression, studies are small. There is not yet enough evidence to prove hyperthermia treatments can improve a person’s quality of life. Nurses need to have honest conversations with patients, to find out what quality of life means to the individual. Hyperthermia treatment has implications for practice including, patients choosing hyperthermia treatment over conventional cancer treatments, health literacy, ethical dilemmas and compromised therapeutic relationships. The recommendations are for nurses to have enough knowledge to work alongside patients choosing alternative treatment. Nurses can educate patients to making informed choices. Education enables nurses to advocate for patients needs and against false hope, money making schemes and for a better quality of life for the individual.

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