Equal Access for Cancer Patients

The Charlotte Maxwell Complementary Clinic (CMCC), located in Oakland, Calif, opened its doors in 1991 offering free state-of-the-art complementary medicine services to uninsured or under-insured women with cancer. Founders were guided by the belief that everyone should have access to the full range of evidence-based treatments, programs and resources that could potentially benefit those diagnosed with cancer. Furthermore, they were committed to providing education so that women could make informed choices about their health care and their lives. CMCC's vision of health care was based on ensuring equal access as a matter of social justice.

CMCC offers a variety of integrative treatments, including acupuncture, herbs, massage therapy and other holistic approaches. Because chemotherapy or radiation treatment for cancer is often associated with disabling side effects, acupuncture and these other modalities are ideally suited to help women manage their symptoms of nausea, vomiting, pain, debilitating fatigue or anxiety. CMCC leaders feel that providing these adjuvant approaches contribute to timely completion of chemotherapy which can, in turn, reduce the risk of cancer recurrence or progression. Thus, ensuring access to complementary and integrative approaches to underserved women is both medically and ethically sound.

More than 750 women are currently being served by CMCC; all have incomes at or below the federal poverty level. Most are women of color and 40 percent speak little or no English. Many live in shelters or sleep in their cars. Most of the women who are seen at the clinic (85 percent) have primary or metastatic breast cancer, and more than half have been diagnosed with advanced or aggressive cancer. Lacking the resources to have routine health screenings or early intervention, most are diagnosed after cancer has spread. With later diagnosis, options for treatment dwindle and survival rates drop precipitously. Patients have likely experienced extensive surgeries as well as aggressive chemotherapy and radiation, and typically arrive at CMCC with extensive post-surgical scarring or lymphedema.

This column discussed the work of CMCC in January 2009 ("AOM a Highlight of APHA Annual Conference"). Since that time, the clinic has continued to survive despite the enormous strain of the U.S. economy. Linda Wardlaw, DrPH, the Grants and Program Administrator for CMCC, spoke with us about how the challenges of the economic down-turn have affected CMCC. Wardlaw stated, "With no federal funding and the California state budget in crisis, the shaky safety net for women has been drastically reduced."

Wardlaw and her colleagues offered this story about how comprehensive, holistic care can lead to unanticipated and unexpected outcomes. Five years ago, Client A was diagnosed with advanced cancer that required surgical removal of her stomach. Despite surgical reconstruction, eating was virtually impossible, and her physicians had exhausted all treatment options. Her oncologist advised her to put her affairs in order. She began to give away her possessions, holding on to only a few articles of clothing and household items. In the meanwhile, she discovered CMCC and began to come weekly for acupuncture and specialized Chinese herbs to address her fatigue and loss of appetite. As the months went by, she began to realize that not only was she not dying, she felt better than she had in some time. As winter approached, she missed the warm sweaters she had given away. She went shopping at the same thrift store that had received her donations many months back. To her amazement, one of her beloved sweaters was still there and she bought it back. For her, that sweater symbolized her cancer journey; the uncertainty, the letting go, and the mystery of the life force. To this day, she goes to CMCC for care, outliving all expectations for survival.

Chinese and Western herbs and appropriate supplements have been critical for CMCC's capacity to address the complex symptoms and side effects that emanate from advanced cancer and the powerful chemotherapy agents and radiation required to treat it. Ensuring a well-stocked pharmacy is essential due to the physical challenges of dealing with more invasive cancers. Chemotherapy and radiation treatments are given more frequently, the courses are prolonged, and the damage to immune function is significant. Clients often experience mouth and throat blisters that make eating and drinking virtually impossible. Others have radiation burns so severe that the touch of fabric is nearly unbearable. Relief can be possible, however, through the range of CAM interventions, from nutritional supplements to topical burn ointments to essential herbs that are offered at no cost. Having an optimally stocked herbal pharmacy allows CMCC's practitioners to address pain, fatigue, neuropathy, nausea, dry mouth, and a host of other disabling symptoms. Throughout 2009, CMCC practitioners were able to mix personalized herbal formulas for clients when medications were either out of reach due to cost, or were simply not bringing the relief they needed.

As part of a comprehensive approach to care for women with cancer, CMCC provides on-site social services that address issues of housing, hunger, and other socioeconomic difficulties. It also collaborates with medical, legal, and social service providers to ensure basic needs for clients. CMCC offers Survivorship Programs that offer free organic produce and other food staples. On-site exercise and stretching groups are provided that contribute to women's quality of life. For clients with end-stage cancer, CMCC designed an in-home comfort care program to address needs of symptom management and palliative care.

Acupuncturists at CMCC work as part of a care team with patient navigators, case managers and other providers. Teams meet routinely to discuss cases and to design plans for care that emphasize quality of life and respect for women's individual choices. Putting a priority on education, CMCC even offers continuing-education opportunities to acupuncturists and other practitioners that include background on cancer biology and current treatment options.

The connection between public health and complementary, integrative care is clear to Wardlaw and her colleagues: "The emphasis of mind, body, and spirit intrinsic to integrative care is one way of interpreting the comprehensive nature of public health. We've created a collaborative model that promotes health and wellbeing for our clients; as a community that cares deeply about social justice, everyone at CMCC understands that critical role they play in providing a comprehensive approach to addressing cancer for women living in poverty."

Further information on the vital work of CMCC can be accessed at www.charlottemaxwell.org. They have one office in San Francisco and a second one in Oakland. We encourage readers to support CCMC's efforts.