Issue: July 25, 2010
July 25, 2010
10 min read

Integrative oncology combines conventional, CAM therapies

This growing medical discipline incorporates methods such as yoga, acupuncture and stress management.

Issue: July 25, 2010
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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 cancer treatment.

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
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 Today.

“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 University.

“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 HemOnc Today.

Integrative medicine categories

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 therapeutic purpose.

Melinda Ring, MD
Melinda Ring

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.”

Treating cancer and the patient

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 Boston.

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 cancer.

“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 integrative therapies.”

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 Northwestern’s Singh.

“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; they’re just not using every available tool and intervention, which is what integrative oncology is about.”

Lifestyle affects risk

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 don’t 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.

Diljeet Singh, MD
Diljeet Singh

“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 said.

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.

Acupuncture alleviates symptoms

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 sessions.

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 treatment.

“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.

Donald I. Abrams, MD
Donald I. Abrams

“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.

Resistance exists

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 supplements.”

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. John’s wort, a frequently used herb, stimulates an enzyme in the liver that degrades chemotherapy.

“If St. John’s 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.

Educating physicians, patients

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.

Fast Facts

“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 medicine-related practices.

“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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