Many oncologists may not frequently advise their cancer patients to
control their breathing, meditate or eat more fruits and vegetables to manage
cancer symptoms and adverse effects of cancer treatment. Yet, these are a few
of the integrative medicine modalities slowly being adopted by oncologists and
other health care professionals as part of an all-encompassing approach to
The National Center for Complementary and Alternative Medicine defines
integrative medicine as treatment that combines conventional medicine with
complementary and alternative therapies that have been reported to be safe and
effective after being studied in patients.
Lorenzo Cohen, PhD, of M.D. Anderson
Cancer Center is conducting a phase 3 trial of the effects of yoga on women
with breast cancer.
Photo by John Everett
Integrative medicine is a philosophy based on treating patients by
focusing on the whole person and using both conventional and complementary
therapies in a multidisciplinary care fashion, Lorenzo Cohen, PhD, director and professor of the Integrative Medicine Program at The
University of Texas M.D. Anderson Cancer Center, told HemOnc
It is similar to complementary medicine, but one key difference is
that there is an open communication between practitioners of the different
traditions, he said.
According to Melinda Ring, MD, medical director of the Center for
Integrative Medicine and Wellness at Northwestern Memorial Hospital, Chicago,
more patients with cancer are turning to integrative medicine or integrative
oncology methods. In addition, an increasing number of institutions have
established integrative medicine centers within the last decade.
There has been growth in awareness of the value of integrative oncology
therapies, particularly on the part of oncologists and oncology teams,
according to Ring.
There is definitely interest in these varied approaches, and there
is ongoing research to try to validate some of the products and therapies
patients are interested in using, she said.
Between 30% and 80% of patients use some form of integrative or
complementary medicine, and they are probably spending a lot of money,
according to Diljeet Singh, MD, assistant professor of obstetrics and
gynecology, Robert H. Lurie Comprehensive Care Center of Northwestern
If physicians feel that they cannot guide the patient in an
educated way, it is important to know, that just like in any other specialty,
there are experts in integrative oncology, Singh said.
Integrative oncology incorporates various methods to reduce cancer risk,
improve quality of life, and decrease cancer symptoms, as well as symptoms from
chemotherapy and radiation, according to the experts interviewed by
According to Cohen, integrative medicine includes a plethora of
therapies and methods but can be most easily classified into five categories:
biologically based therapies, mind/body medicine, manipulative body-based
practices, energy medicine and whole medical systems.
Biologically based therapies include ingestibles such as herbs and
supplements, megadoses of vitamins or specialized diets. Mind/body medicine
consists of techniques that typically help with stress management. These
techniques include meditation, yoga, guided imagery and other forms of
relaxation, according to Cohen. Manipulative body-based practices include
therapies such as massage, medical acupuncture and chiropractic work.
The most controversial area of integrative medicine, according to Cohen,
is energy medicine, which includes techniques such as healing touch, Reiki, a
Japanese form of energy healing, or the use of magnets for healing. Healing
touch techniques such as Reiki and Qigong, an ancient Chinese healing therapy,
are based on the theory that human beings are energetic bodies and certain
individuals with specific training can emit energy into another person for
The final category of integrative medicine is called whole medical
systems. This is an overarching area and not necessarily a separate domain from
the other integrative medicine categories, according to Cohen.
Whole medical systems are medical systems typically from other
cultures, such as Ayurvedic medicine from India and traditional Chinese
medicine from China, he said. These systems have their own methods
and techniques for diagnosing patients, prescribing treatments and following
patients over time.
Integrative oncology uses complementary therapies that are commonly used
in Eastern countries, which are not taken advantage of in the United States,
according to David S. Rosenthal, MD, medical director of the Leonard P.
Zakim Center for Integrated Therapies at Dana Farber Cancer Institute in
At the Leonard P. Zakim Center, the best of Eastern medicine is combined
with the best of Western medicine, according to Rosenthal.
While major cancer centers have modern, advanced treatments for
cancer, sometimes there is not sufficient time to spend with a patient
discussing important things like quality of life and how to deal with the
symptoms of cancer and symptoms resulting from cancer treatments,
Rosenthal said during an interview.
Integrative oncology combines conventional and complementary therapies
into a regimen that speaks to the whole person living with cancer: body, mind
and spirit, according to Donald I. Abrams, MD, director of the
Integrative Oncology Research Program, Osher Center for Integrative Medicine,
University of California, San Francisco. Abrams is also chief of
hematology/oncology at San Francisco General Hospital.
During an interview with HemOnc Today, Abrams drew an
important distinction between treating cancer and treating patients with
At San Francisco General, many of my patients with cancer are
homeless, psychotic, addicted and undocumented; it is not suitable to talk to
them about eating organic and doing yoga, as they have much more essential
needs, he said. Patients at The Osher Center, however, are
typically highly functional people for whom it may be appropriate to offer
The Osher Center, similar to many of the more recently established
integrative medicine centers throughout the country, has a staff of varied
practitioners such as integrative oncologists, integrative psychiatrists,
integrative family practice doctors, traditional Chinese medicine doctors,
massage therapists and yoga instructors.
The idea is to address all aspects of the patient. An important goal of
integrative oncology is also to return some sense of active participation to
the patient, according to Abrams.
Once you get a diagnosis of cancer, you are at the mercy of your
surgeon, your radiation therapist, your medical oncologist and even your
chemotherapy nurse; integrative oncology therapies help patients regain some
sense of control, he said. We try to offer services in an
integrative fashion that address the needs of the whole person.
This is not to suggest that physicians who do not use integrative
approaches are not treating the whole patient, according to Northwesterns
Many physicians who practice conventional medicine talk to their
patients about pain and spirituality, she said during an interview with
HemOnc Today. They are still taking care of the whole
patient; theyre just not using every available tool and intervention,
which is what integrative oncology is about.
Lifestyle changes, a part of integrative medicine, such as increasing
physical activity and eating a more healthful diet, may not prevent cancer, but
physicians can advise patients to modify certain behaviors to reduce cancer
risk, according to Abrams.
Most people are aware that tobacco use accounts for about 30% of
all malignant disease in the developed world, but fewer people are aware that
what we eat and what we dont eat accounts for about another 30% of
avoidable malignancies, he said.
Because nutrition is difficult to study, and it can be hard to pinpoint
exactly what is causing an effect, researchers must rely mostly on
epidemiological data, according to Abrams.
There is substantial evidence, however, showing trends that, in
the United States, the standard American diet, aptly abbreviated SAD, is making
Americans more prone to a number of malignancies, he said.
Some oncologists and internists might not be aware of the
importance of focusing on things like nutrition, even though study findings,
like the one conducted by Jeffrey Meyerhardt, MD, at Dana-Farber Cancer
Institute, showed that people who eat a more Western diet have an increased
risk for recurrence and death from cancer compared with patients who eat a more
prudent diet, Abrams said.
Meyerhardt and colleagues conducted a prospective observational study of
1,009 patients with stage III colon cancer. During a median follow-up of 5.3
years, patients in the highest quintile of Western dietary pattern had an
adjusted HR of 3.25 (95% CI, 2.04-5.19) for DFS. Patients eating a Western diet
also demonstrated a poor HR for recurrence-free survival (HR=2.85; 95% CI,
1.75-4.63) and OS (HR=2.32; 95% CI, 1.36-3.96).
Even though we know obesity is one of the biggest risk factors for
developing cancer, and in certain cancer populations, it is clearly predicting
worse outcomes, you would be hard-pressed to find a cancer center that has a
full-blown physical activity counseling program that advises patients to
exercise as the standard of care, Abrams said.
Physical activity is not considered standard of care, nor is it
reimbursed by Medicare, and we have not seen a definitive study showing that
the modification of obesity will impact outcomes; so, research is going in the
direction of looking at comprehensive lifestyle and behavior change, he
Another important area for research in integrative medicine is viewing
the potential benefits as a whole. Cohen said integrative medicine as a
comprehensive program has not been researched much in the past.
It is important to examine a more personalized medicine technique
combining appropriate diet and physical activity, appropriate forms of stress
management and symptom management, using both conventional and complementary
medicine treatment modalities, according to Cohen.
Although the benefits of integrative medicine therapies as a whole have
been difficult to prove in a scientific, evidence-based manner, some therapies,
such as acupuncture and yoga, have been validated and tend to be more accepted
within the allopathic medicine community, according to Ring.
There is especially good evidence in regard to acupuncture and reduced
nausea and vomiting related to chemotherapy, she said.
Similarly, there is good evidence that acupuncture alleviates
xerostomia, or dryness of the mouth, after radiation therapy for head and neck
cancers, she told HemOnc Today.
About 60% to 70% of people have proven benefit from acupuncture, yet it
is one of the most underutilized adjunctive therapies in cancer in the United
States today, Rosenthal said.
Acupuncture can reduce cancer-related pain, and there are also
trends toward decreased anxiety, stress, fatigue and insomnia, he said.
According to Rosenthal, yoga has also been shown to provide significant
beneficial effects in patients with cancer.
Karen Mustian, PhD, MPH, assistant professor of radiation
oncology and preventive medicine at the University of Rochester Medical Center,
discussed the findings of a yoga study at the 2010 ASCO Annual Meeting, held in
Chicago in June.
Researchers enrolled 410 survivors of non-metastatic disease who
participated in the Yoga for Cancer Survivors program. Survivors reported
suffering from moderate or severe sleep disruption 2 months to 24 months after
completing adjuvant therapy.
The participants were assigned to breathing exercises, 18 gentle Hatha
and restorative yoga postures and meditation for 4 weeks with twice-weekly
Patients practicing yoga had greater improved sleep quality (22% vs.
12%), decreased incidence of clinically impaired sleep (31% vs. 16%) and less
daytime sleepiness (29% vs. 5%) compared with those who did not practice yoga.
Adding to these findings, a study of the effects of yoga on women with
breast cancer is also in the works. In April, Cohen received a $4.5 million
grant to conduct a phase 3 trial in women with breast cancer to determine the
improvement in physical function and quality of life during and after radiation
Research has shown that yoga and other types of mind/body
practices incorporated into the standard of care can help improve patient
outcomes, particularly quality of life, Cohen said in a press release.
However, none have become standard of care or are on the clinical
care pathway for cancer patients; this funding will allow us to definitively
determine the benefit of incorporating yoga into a treatment plan for women
with breast cancer, he said.
Although therapies such as yoga and acupuncture have demonstrated
efficacy in clinical trials and, therefore, are often accepted in the
conventional medicine community, other therapies are met with more resistance,
according to the experts interviewed.
Given that certain integrative medicine modalities lack evidence-based
data and that there is unfamiliarity with various therapies, some physicians
are hesitant to employ integrative oncology techniques, according to Rosenthal.
Many oncologists said patients with cancer may use certain integrative
medicines without consulting an integrative medicine professional, putting
themselves in danger. In addition, many integrative therapies are difficult to
assess in randomized, controlled studies, according to Rosenthal.
Over-the-counter products, including herbal supplements, for
example, can be problematic. They are unregulated, and what you buy today might
not have the same ingredients as what you buy next month, he said.
This is a difficulty that we as scientists face in trying to study herbal
Rosenthal cited a trial that examined the use of PC-SPES, a combination
of eight herbs, in the treatment of patients with prostate cancer. Eventually,
the researchers began to see complications.
They saw breast swelling, which may occur with estrogen
[exposure], and bruising and bleeding. It turned out that there were
phytoestrogens and [warfarin], an anticoagulant, in the product, so they had to
cancel the study, Rosenthal said. A substantial amount of money was
lost, and there were many unhappy patients and unhappy investigators.
Another issue with studying herbs and botanicals is the risk of
potential drug interactions that may occur in patients being treated with
chemotherapy, Rosenthal said. For example, St. Johns wort, a frequently
used herb, stimulates an enzyme in the liver that degrades chemotherapy.
If St. Johns wort is taken concurrently with agents like
cyclosporine, Cytoxan or cyclophosphamide, those agents can be rapidly cleared
from the blood stream, jeopardizing the efficacy of chemotherapy,
Rosenthal said. Similarly, there are herbs and botanicals that may
inhibit the effects of chemotherapy. The levels of the chemotherapy drugs can
become too high, resulting in more toxicity.
Regardless of the possible dangers of using integrative therapies
without the guidance of an expert, patients with cancer will still use them,
according to Ring.
Findings show that up to 80% or more of patients are using some
sort of integrative therapy, many of which are supplements. They often get
information from the Internet or from a friend, who is most likely not
adequately educated in this area, she said.
Because at least half of all patients with cancer will take biologically
based therapies without telling their oncologist, physicians should be aware
and concerned about drug-herb interactions, for example, just as there may be
benefits with certain therapies as well, according to Cohen.
Patients are often fearful of telling their oncologists that they are
using dietary supplements because they think they are going to be told not to
take them or be ridiculed in some way, according to Ring.
Oncologists need to ask their patients if they are using any of
these therapies, and then educate and refer them to knowledgeable
sources, she said. Patients often use supplements without
necessarily thinking about the potential for interaction.
Communication and education are crucial, Cohen said. There are many
things that patients with cancer can do to help improve their quality of life
and, possibly, clinical outcomes.
When patients turn to complementary medicine, it is important that
they do so under the guidance of their health care team, he said.
Good communication starts with medical oncologists, nurses and health
care professionals, by asking patients if they are interested in integrative
medicine and by asking if they are engaged in any of the complementary
At a minimum, certain integrative medicine therapies, like
getting patients to engage in physical activity, eat an appropriate diet, and
manage their stress will at the least make them feel
better, Cohen said. by Christen Cona
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