Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

Use of this content is subject to the Terms and Conditions

Page 1 of 15

Rakel: Integrative Medicine, 2nd ed.

Copyright 2007 Saunders, An Imprint of Elsevier

Section 13 Cancer

chapter 75 Integrative Oncology: An Overview

Matthew P. Mumber, MD Why Integrative Oncology? 811 Expanded Domain 812 Philosophy of Integrative Oncology 813 Functional Aspects of Integrative Oncology 813 Clinical Decision-Making 816 Data on Safety and Efficacy 816 Intervention Timing Relative to Course of Cancer Experience 817 General Recommendations 818 Models of Care 818 Conclusions 818 Integrative oncology can be defined as a comprehensive, evidence-based approach to cancer care that addresses all participants at all levels of their being and experience. [1] It represents the next step in the evolution of cancer care, in that it addresses the limitations of the current system while retaining the system's successful features. Integrative oncology expands upon current practice in several ways. Integrative oncology includes the use of evidence-based tools that translate into definable outcomes in the fields of preventive, supportive, and antineoplastic care. These tools have their origin in both Western, conventional medicine and complementary and alternative medicine (CAM) traditions. In order to operate on the basis of available research, practitioners must follow decision guidelines that focus on variable levels of evidence required for recommendations based on the general and specific goals of a therapy as well as an individualized risk-to-benefit analysis. This process can include judicious use of the precautionary principle. [1]

The precautionary principle states that a lack of scientific certainty shall not be used as a reason for not acting in a way that prevents harm to human health or the environment. Integrative oncology also includes methods that can transform the lives and health of individual participants and the entire medical system. It addresses all participants involved at all levels of their beingtheir experience of body, mind, soul, and spirit within the self, within the specific culture, and in the natural world. Philosophically, integrative oncology espouses a renewed focus on the guiding principles of medicine, emphasizing healing over curing. [1]

Why Integrative Oncology?

Oncology biomedicine has resulted in important successes: The rates of cancer deaths have decreased significantly over the past 20 years. According to figures from the American Cancer Society (ACS), approximately two thirds of patients with cancer who are diagnosed today will experience 5-year survival. There are multiple reasons for this reduction in death rates, including improvements in screening, technology, and conventional therapeutic advances. Rates of disease control have risen dramatically for some malignancies in the United States, including stomach and uterine cancer, but have improved very little in others, such as lung cancer. [2] Unfortunately, these advances have come at the cost of a breakdown in the therapeutic relationship, with both patients and physicians expressing dissatisfaction

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009

Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

Page 2 of 15

with the system. [3] At the same time, a medical malpractice crisis exists in the face of sky-rocketing costs and rising cancer incidence rates. The National Institutes of Health (NIH) estimated the overall cost for cancer in the year 2003 at $189.5 billion: $64.2 billion for direct medical costs, $16.3 billion for indirect morbidity costs, and $109 billion for indirect mortality costs. It is estimated that the current lifetime risk for development of cancer in the United States is 1 in 2 for men and 1 in 3 for women. [2] In addition, there are now more than 10 million cancer survivors, who are often ill-equipped to handle their special needsmedical, psychosocial, and lifestyle issues. The majority of these patients state that their oncologists do not give them needed assistance after active antineoplastic care. [4] [5] Patients with cancer increasingly turn to practitioners of CAM while remaining high users of conventional approaches as well. [6] [7] [8] [9] [10] [11] [12] [13] [14] They spend billions of dollars per year out of their own pockets on various CAM therapies. There has been a trend away from use of CAM by specific subgroups, such as highly educated females, to a more diverse user group. [3] Physicians have scant formal education in CAM approaches and can offer little advice about these modalities. [15] The result: Beneficial CAM therapies are under-utilized in the realms of prevention and supportive care; dangerous interactions can exist between some CAM and conventional treatments; and delays in beginning conventional treatment can result in cancer dissemination and death. [16]

Expanded Domain
An integrated, evidence-based approach improves on the weaknesses of today's splintered system while building upon its strengths. A truly comprehensive integrative approach will address all participants at all levels of their being and experience. It will address all of the individuals involvedpatients, families, providers, communities, and members of societyat all levels of being (mind, body, soul, and spirit) in all levels of experience, that is, the self, the role in a specific culture, and the effects of and on the natural environment ( Fig. 75-1 ). [1]

FIGURE 75-1 Definition of a comprehensive integrative approach. (From Mumber MP: Principles of integrative oncology. In Mumber MP (ed): Integrative Oncology: Principles and Practice. London, Taylor & Francis, 2005, p 7.)

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009

Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

Page 3 of 15

In order to meet the needs of this diverse group of individuals, a team approach to care is necessary. That team will require an appropriate coordinator. In the field of cancer care, the conventionally trained oncologist would appear to be the best candidate to serve as conductor of the orchestra because his or her knowledge of conventional therapy is key to a safe and efficacious integrative approach. It would certainly seem to be more efficient to educate conventional physicians about referral to appropriate CAM providers, rather than vice versa. The main reason is the extent of biomedical information that one must digest in order to fully understand, recommend, and use conventional approaches to treat individuals. The majority of oncologists surveyed believe that it should be one of their responsibilities to counsel cancer survivors in lifestyle and health management solutions after cancer care; however, only a minority of oncologists provides this service. [5]

Philosophy of Integrative Oncology

Much can be learned about creating a sustainable model of cancer medicine from the philosophy of many CAM approaches and their foundation in medicine's guiding principles. Please refer to the Part I, Integrative Medicine Philosophy, which deals with the difference between a focus on healing and a focus on curing. Oncology is recognized as a field in which high rates of burnout can occur. Examples of interventions that may help create a sustainable system of care include attention to the stress reduction needs of oncologists and to improving communication skills, such as in delivering bad news. [17]

Functional Aspects of Integrative Oncology

Adherence to the philosophical underpinnings of integrative medicine provides the foundation for some of the specific functional aspects that further differentiate integrative oncology from a purely conventional biomedical approach ( Table 75-1 ). TABLE 75-1 -- Defining Functional Aspects of Integrative Oncology Tools may have transformational and translational intent. Inclusion of preventive, supportive, and antineoplastic goals. Use of Precautionary Principle for situations with limited data. From Mumber MP: Principles of integrative oncology. In Mumber MP (ed): Integrative Oncology: Principles and Practice. London, Taylor & Francis, 2005, p 10.

Translation versus Transformation

The addition of CAM methods to a physician's complement of tools is quickly becoming a reality as more positive research on the benefits of these tools becomes available. Yet the addition of new tools through research and clinical application, regardless of whether they are CAM or conventional, will do little to differentiate integrative oncology from biomedicine; it will merely add new options to an already bulging toolbox. In contrast, most CAM therapies are rooted in systems that can provide an entirely new viewpoint. [3] This dual nature can be thought of as the translational and transformational aspects of CAM approaches. [18] Translation is defined as that aspect of an intervention that moves directly into a specific desired outcome. For example, two proven translations of a yoga practice might be greater flexibility and improved sleep. Transformation is defined as that aspect of an intervention that opens up the possibility of seeing the world from a new frame of reference, to see the world with new eyes. For example, the yoga practice already described may bring about a new sense of mastery, a physical, emotional, mental and spiritual opening, allowing an individual to forgive old grievances and develop comprehensive healthy lifestyle changes.

It is important to categorize any oncology intervention as translational or transformational in nature those methods that have personal transformation as a goal require mainly that the intervention is safe, and evidence concerning their efficacy is of lesser importance. There are significant differences between the translational and transformational aspects of care ( Table 75-2 ). They also share features, namely that both aspects are experiential and contextual. They are both

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009

Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

Page 4 of 15

experienced on multiple levelsphysically, mentally, emotionally, and spiritually. They are also contextual on multiple levelsas they relate to the self, the individual's culture, and the surrounding natural environment. TABLE 75-2 -- Differentiating Characteristics of Interventions with Translational and Transformational Intent TRANSLATIONAL TRANSFORMATIONAL A specific tool, technique, or instrument designed to deliver a specific measurable outcome Outcome is quantitatively measurable External locus of control Reductionistic-can be broken into parts Definable, discrete, deliverable, and replicable Understandable on a rational level Has levels of effect A highly individualized experience that involves a profound perspective shift of the essence of larger sense of purpose, meaning, and/or fulfillment Outcome is qualitative and difficult to define or measure Internal locus of control Irreducible, whole Ultimately mysterious-one can set up conditions for it but cannot force it to occur Frequently indescribable All-or-nothing effect

Adapted from Mumber MP: Principles of integrative oncology. In Mumber MP (ed): Integrative Oncology: Principles and Practice. London, Taylor & Francis, 2005, p 11.

One method of incorporating CAM is to develop logical guidelines to assist in clinical decision-making. The translational tool aspect of CAM must be judged through the use of appropriate levels of evidence, similar to those used for the majority of conventional translational approaches. When the goal of CAM is primarily transformational as a part of supportive care, however, clinical decision guidelines based in part on efficacy and safety are not as applicable, because of the rather nebulous outcomes that are intrinsically a part of a transformational experience. Outcomes are distinctly individualized and difficult to define, predict, or measure, except through a qualitative, testimonial type of feedback. Therefore, the primary concern for transformational interventions is that they are demonstrated to be safe. Safety is measured in this context with regard to cost, applicability at a specific time in the patient's care, methods used, and provider experience and skills. This is significantly different, with regard to level of evidence requirements for tools with specific outcomes, which must meet both safety and efficacy requirements. For example, in order to recommend yoga as an intervention to help improve sleep, one would need evidence concerning its safety and efficacy. If a patient were to desire to enter into a practice that could improve self-understanding, the recommendation of yoga would be based primarily on its safety, taking into account the patient's situation.

Prevention, Supportive Care, and Antineoplastic Therapy

In order to practically advise patients concerning therapeutic options, one must be able to characterize the proposed intervention as having a specific goal of prevention, supportive care, or antineoplastic therapy. Doing so allows the care team to place priorities, determine levels of evidence required for recommendations, and discuss specific risks and benefits. The three general categories of prevention are primary, secondary, and tertiary. These three general categories affect individuals with differing characteristics. Primary prevention has a goal of lowering risk in a population with normal risk level. An example would be reducing lung cancer rates in the entire population of nonsmokers. Secondary prevention tries to lower the rate of onset of disease in individuals with elevated risk or with existing precancerous changes; an example is reducing lung cancer rates in long-time smokers with premalignant changes. Tertiary prevention focuses on prevention of recurrence in individuals who have been successfully treated and are disease free. Prevention can be a very powerful approach in order to lessen the overall cost, morbidity, and mortality associated with cancer. For example, it is estimated that one third of cancers may be prevented through dietary changes alone. [2] Providing education at an early age about healthy eating and lifestyle patterns could greatly reduce lifetime risk. Counseling individuals at any level of prevention may affect other

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009

Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

Page 5 of 15

individuals on different levels. Relatives of current cancer patients may have a higher risk of disease development and represent a significant population with a vested interest in both primary and secondary prevention. Cancer recurrence may likewise be lowered in cancer survivors through a variety of lifestyle changes. Survivors can be educated about healthy lifestyle and then trained to become lay health advisors in the community. [19] Physicians who actively practice healthy lifestyle choices have a greater success rate counseling their patients to select such interventions. [20] Supportive care interventions may make cancer therapy easier to deliver by addressing physical, emotional, educational, and psychosocial needs. Major textbooks and journals are now dedicated to supportive care in oncology [21] and an entire field of study and practice known as psychooncology. [22] One major goal of these approaches is to improve the therapeutic ratioa measure that reflects the ability of patients to tolerate effective antineoplastic therapy. Treatments that will eliminate cancer from the body may be so toxic as to be intolerable for patients. Improvements in the therapeutic ratio can therefore come through improving patient tolerance to therapy or increasing the effectiveness of antineoplastic treatments so that lower doses are required. CAM therapies have significant potential as supportive care options that improve patient tolerance and compliance. [1] The most heated debate about CAM versus conventional therapies is in the field of antineoplastic care, even though the majority of CAM therapies are preventive and supportive in nature. Many current antineoplastic therapies have their origin in what some would consider CAM methods. For example, the drug paclitaxel (Taxol) was initially isolated from the Pacific yew tree. The Office of Cancer Complementary and Alternative Medicine (OCCAM) is a branch of the National Center of Complementary and Alternative Medicine (NCCAM), the National Cancer Institute (NCI)sponsored organization specifically responsible for CAM research relative to cancer. In an attempt to monitor modalities that have their primary action through measurable tumor response, the NCI Best Case Series (NCI-BCS) Program was introduced. This has resulted in several active trials of novel antineoplastic alternative approaches. Some examples are the Kelly-Gonzalez approach for the treatment of pancreatic cancer and the use of antineoplastons in brain tumors. The NCI-BCS process begins with inquiries into therapies proposed by users or developers. Case scenarios are submitted, followed by rigorous evaluation of pathology, radiographic studies, and other diagnostic and treatment aspects of specific cases. This analysis must include documented and objective assessment of tumor response, proof of a lack of concurrent conventional therapy, and documentation that the alternative treatment was delivered. Once all of the data have been reviewed, therapies that appear promising are presented to an advisory panel. If there is sufficient evidence to justify further research, the panel may decide to pursue investigation of the therapy either as part of a Practice Outcomes Monitoring and Evaluation System (POMES) or through the use of independent researchers. Over the past 5 years, three therapies have made it through to the phase of further research; they are: A homeopathy approach used at a clinic in India for nonsmall cell lung cancer Insulin potentiation therapy, which uses insulin along with low doses of conventional chemotherapy Macrobiotic diet therapy

The NCI-BCS system may be expanded in the future to include researchers in addition to those who have developed a particular therapy, in order to accomplish research in a more timely fashion. [23] In addition to these NCI-based efforts, there is an organization called the Society for Integrative Oncology (SIO). SIO is a nonprofit, multidisciplinary organization founded in 2003 for health professionals committed to the study and application of complementary therapies and botanicals for patients with cancer. It provides a forum for presentation, discussion, and peer review of evidence-based research and treatment modalities. The SIO makes a clear distinction between alternative or unproven and complementary or tested useful therapies in cancer care. More information about this organization can be found on its Web site at: www.integrativeonc.com/

It is important to categorize any oncology intervention as to its general goalprevention, supportive care, or antineoplastic therapy. Doing so helps define the level of evidence necessary to make a recommendation for or against its use.

The Precautionary Principle

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009

Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

Page 6 of 15

The development of clinical guidelines requires that providers make appropriate recommendations, even in situations for which data are limited. Categorizing the intent of supportive care treatment as translational or transformational in nature is one example of differentiating the level of evidence required to make a recommendation, as does defining the specific therapeutic goal as prevention, supportive care, or antineoplastic therapy. The precautionary principle can help with decision-making as well. The precautionary principle was originally formulated as a way of making environmental policy in situations for which data were limited. The Rio Declaration on Environment and Development, adopted at a 1992 United Nations conference held in Rio de Janeiro, defined the principle as a precautionary approach that is used to protect the environment when there are threats of serious or irreversible damage and scientific uncertainty should not be used to postpone cost-effective measures. [24] This principle was developed in medicine in order to address situations in which the collection of data that would absolutely prove efficacy and safety of a particular treatment or approach is prohibitive. As an extreme example, it is not practical to do a randomized trial of dumping sewage into the water supply in order to measure health effects. The precautionary principle (among other things) would tell us that on the basis of the limited data available, such dumping would have significant health hazards and would be inadvisable. A more subtle example is the difficulty of prospectively measuring the health effects of xenoestrogens from pesticides used on foods meant for humans. The precautionary principle would tell us to avoid them, if possible, until further data are available.

The precautionary principle can be used for treatments or interventions in situations in which limited data are available, as long as there is a complete discussion of the risks and benefits and informed consent. The precautionary principle is best used for preventive and supportive interventions; it is difficult to justify its use for antineoplastic therapies, unless the options available are extremely limited. This principle has been expanded for use in health care situations, specifically for breast cancer prevention. [25] [26] [27] It can be applied to preventive and supportive interventions, in which the usual tools of biomedical research are impractical. Using the precautionary principle should not be seen as an excuse to advance one's hypotheses without evidence, but can allow physicians and other providers to act in situations in which limited data are available, if that action is almost certainly safe and deemed necessary. Another aspect of the precautionary principle deems that significant risk of adverse outcomes be present in order to justify going forward with limited data. This is inherently a judgment call and may be difficult to quantify, especially in the realms of supportive care and prevention. For example, the use of antioxidant vitamins during radiation therapy has been debated for years. Proponents say that it may lessen side effects, whereas detractors say that it could protect the tumor from being destroyed by treatments. The precautionary principle in this situation could result in recommending against the use of antioxidant supplements during treatments because of the possibility that it could protect tumor cells from lethal damage and thereby affect disease controla significant and irreversible risk. After treatment, patients may be interested in taking antioxidants for general supportive care and prevention of recurrence, despite the fact that data in support of their use for either purpose are limited. In this situation, the precautionary principle may lead one to recommend supplementation because of the significant risk of recurrence, persistent fatigue, and so on. In this case, the risk of adverse outcomes and the presence of preliminary data on safety and efficacy could tip the scales in favor of recommendation. These types of decisions are not to be taken lightly. A significant caveat of the precautionary principle is that future data may show that we have made a mistake and recommended something that was detrimental. Therefore, an analysis of the entire clinical situation, with appropriate informed consent, is always necessary. As one climbs up the ladder of intervention from prevention to supportive care and, ultimately antineoplastic therapy, the use of the precautionary principle becomes more difficult to rationalize.

The precautionary principle would recommend against using antioxidant supplements during radiation therapy treatment because of the possibility that they could protect tumor cells from lethal damage and thereby affect disease control.

Clinical Decision-Making

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009

Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

Page 7 of 15

A comprehensive approach to decision-making in integrative oncology will address multiple issues in all participants at all levels of their being and experience ( Table 75-3 ). It will take into account prevention, supportive care, and antineoplastic treatment. It will make rational recommendations based on the specific situation of the patient, the general and specific goals of therapy, the levels of evidence concerning safety and efficacy for specific interventions, and a resulting risk-to-benefit analysis. TABLE 75-3 -- Factors to Consider in Clinical Decision Making for Integrative Oncology FACTOR DEFINITION Patient clinical situation Specific treatment goals Acute versus subacute presentation and need for intervention Disease stage and type Prognosis Prevention Supportive care Antineoplastic care

General preventive approach Primary Secondary Tertiary General supportive care approach Translational versus transformational utility: Improve tolerance of antineoplastic therapy Symptom control General quality of life End-of-life care Curative versus palliative

General antineoplastic approach

Level of evidence for therapy Data levels I-IV, for both safety and efficacy Risk-to-benefit ratio-including cost, toxicity, and chances of beneficial and harmful outcomes From Mumber MP: Clinical decision analysis. In Mumber MP (ed): Integrative Oncology: Principles and Practice. London, Taylor & Francis, 2005, p 146.

Levels of Evidence
Reviewing the research on a particular therapy requires an understanding of the weight of the findings. A scheme that ranks the importance of research is the concept of levels of evidence, which is based on the study design and sample size. Two organizations, the National Cancer Institute (NCI) and the U.S. Agency for Health Care Policy and Research (AHCPR), have developed ranking criteria for levels of evidence. A schema has been proposed for the use of such criteria in integrative oncology on the basis of these classification systems. [28] This proposed system functions well for both CAM clinical trials and basic science trials reporting a therapeutic outcome such as tumor response, improved survival, or quality of life. It also allows for some weight of evidence from expert committee opinions and traditional uses. The schema consists of levels I through IV, with I representing the highest level of evidence, and IV the lowest ( Table 75-4 ). TABLE 75-4 -- Schema for Levels of Evidence in Integrative Oncology Level I Well-designed randomized controlled clinical trial(s) Level II Prospective and retrospective nonrandomized clinical trials and analyses Level III Opinions of expert committees, best case series Level IV Preclinical in vitro and in vivo studies, and traditional uses From Stark N, Hess S, Shaw E: Clinical research and evidence. In Mumber MP (ed): Integrative Oncology: Principles and Practice. London, Taylor & Francis, 2005, p 22.

It is important to note that some CAM therapies do not allow for the highest level of evidence to be

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009

Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

Page 8 of 15

accomplished because randomized controlled trials of the therapies are not feasible. In this situation, it is very important for the clinician to weigh all the decision-making factors before making a recommendation based on informed consent.

Data on Safety and Efficacy

An integrative approach to oncology cannot be founded on the indiscriminate addition of new methods, tools, and providers to our biomedical system. Such an approach must involve a critical appraisal of modalities that may enhance response to biomedical therapies or improve the quality of life for patients with cancer, their families, and providers of care. For oncologists and medical providers caring for patients with cancer, the growing interest in CAM therapies raises concerns about efficacy and safety as well as appropriate ways to counsel patients about their use. The deaths of patients with prostate cancer who were taking PC-SPES, a botanical supplement that had shown some preliminary antineoplastic efficacy, reinforce the importance of ensuring that therapies are safe as well as efficacious. [29] It is necessary not only to ensure the safety of a therapy taken as a single agent but also to know the potential adverse effects if it is combined with other medications or therapeutic regimens. This concern is of particular importance in cancer treatment, in which patients may be receiving multiple concurrent or continuous forms of therapy for extended periods. Oncologists and other practitioners treating patients with cancer or counseling them about treatment options face significant challenges in deciding both how to approach recommending the use of CAM therapies and how to determine the value of incorporating CAM therapies into clinical practice. The ability to understand research findings on CAM therapies and determine the applicability of findings to practice is essential. [28] A full understanding of safety and efficacy data is a major component in decision-making. Please see Figure 75-2 for a tabular presentation of recommendations for or against a specific therapy based on available data.

FIGURE 75-2 Relationships among safety, efficacy, and recommendation of treatments. Light gray indicates that clinician should recommend the use of a treatment; black indicates that the clinician should recommend against the use of a treatment. Medium gray indicates that the clinician should recommend caution about using a treatment and should follow the patient closely; the precautionary principle may tip toward or against the use of a particular treatment, depending on the particular situation. (Adapted from Cohen MH, Rosenthal D: Legal issues. In Mumber MP (ed): Integrative Oncology: Principles and Practice. London, Taylor & Francis, 2005, pp 101-120.)

As one climbs up the pyramid of therapeutic goals ( Fig. 75-3 ), the evidence level required to recommend a therapy increases. Antineoplastic therapies must have definitive level I evidence of both safety and efficacy. Preventive and supportive therapies that can be tested in a randomized fashion must also meet this criterion, especially when recommended for use during treatment with antineoplastic interventions proven to be effective.

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009

Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

Page 9 of 15

FIGURE 75-3 The pyramid of therapeutic goals. Level of evidence for both safety and efficacy increases as one rises up the pyramid. Maximally effective antineoplastic therapy depends on the solid foundation of prevention and supportive care. (From Stark N, Hess S, Shaw E: Clinical research and evidence. In Mumber MP (ed): Integrative Oncology: Principles and Practice. London, Taylor & Francis, 2005, p 35.)

Intervention Timing Relative to Course of Cancer Experience

Another important aspect of developing an approach to integrative oncology is the wide range of needs of all the individuals involved in the process and the fact that needs vary over the course of time. For example, Cunningham and Edmonds [30] have identified a hierarchy of different types of mind-body therapy based on increasingly active participation by the patient with cancer at different phases of his/her clinical course. [30] These five intervention types are providing information, emotional support, behavioral training in coping skills, psychotherapy, and spiritual/existential therapy ( Table 75-5 ). Carlson has suggested therapeutic possibilities for patients with cancer based on the needs that generally arise at specific times in the course of the cancer experience ( Table 75-6 ). [31] TABLE 75-5 -- Suggested Psychosocial Interventions for Clinical Stages of Cancer Experience CLINICAL PSYCHOSOCIAL SUGGESTED PSYCHOSOCIAL LEVEL OF STAGE PICTURE INTERVENTION INVOLVEMENT Diagnosis Anxiety Information seeking Depression Anxiety Treatment side effects Reintegration Psychoeducation Information provision Emotional support Coping skills training Emotional support Emotional support Low Low Medium Medium Medium Medium

Treatment Recovery

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009

Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

Depression Recurrence Depression Death and dying Psychotherapy Psychotherapy Spiritual/existential therapy High High High

Page 10 of 15

Data from Cunningham AJ, Edmonds CV: Group psychological therapy for cancer patients: A point of view, and discussion of the hierarchy of options. Int J Psychiatry Med 26:51-82, 1996.

TABLE 75-6 -- Therapeutic Possibilities for Patients with Cancer SITUATION NEEDS THERAPEUTIC POSSIBILITIES Diagnosis Active treatment Recovery Survivorship Palliation End-of-life care Information, addressing of anxiety levels Treatment tolerance Regain strength, existential issues (meaning, purpose) Psychoeducation, relaxation Cognitive behavioral therapy with focus on active coping strategies, imagery, hypnosis, relaxation, creative arts Meditation, yoga, creative arts therapies

Promote health, address fear of Support groups, retreats recurrence Symptom control, quality of life Transition, transcendence Coping strategies, imagery, hypnosis Address spirituality and symptom control, meditation, creative therapies

From Carlson LE, Shapiro SL: Mind-body interventions. In Mumber MP (ed): Integrative Oncology: Principles and Practice. London, Taylor & Francis, 2005, p 187.

Other patient-related variables that the clinician may find helpful to take into account when assessing which interventions may be appropriate are the patient's personality characteristics, spiritual/religious beliefs, physical limitations, readiness to make changes, as well as simple preference for and comfort with different modalities. Further research is necessary to define the needs of other participants in the process as well. [32]

General Recommendations
Multiple considerations go into decision-making and recommendations in the formulation of a treatment plan for a specific individual. Despite this complex set of factors, concise recommendations can be made that are evidence-based. Tables 75-7 through 75-9 [7] [8] [9] delineate general treatment options for prevention, supportive care, and antineoplastic therapy interventions and their clinical settings, as well as levels of evidence. They contain a partial list of the most common interventions. For a more comprehensive review, please consult a dedicated text on integrative oncology. TABLE 75-7 -- General Cancer: Primary, Secondary, and Tertiary Prevention INTERVENTION CLINICAL INDICATION Nutrition: Plant-based diet Individual foods: Green tea Soy Omega-3 fats from fish, walnuts, flaxseed (including flax lignans) Lycopene-containing foods-esp. tomato sauce High fiber intake Individual phytochemicals: Antioxidant vitamins (A, C, E, selenium) Mushroom extracts Multiple cancer types Multiple cancer types Multiple cancer types Multiple cancer types Multiple cancer types Multiple cancer types Multiple cancer types Unknown Multiple cancer types

LEVEL OF EVIDENCE II, III, IV II, III, IV II, III, IV II, III, IV III, IV II, III, IV II, III, IV None III, IV

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009

Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

Curcumin Physical activity Mind-body: Stress reduction Botanicals: Milk thistle Scutellaria baicalensis (prostate cancer) Tobacco cessation Multiple cancer types Unknown, possible positive effect Multiple cancer types Prostate cancer Multiple cancer types

Page 11 of 15

II, III, IV IV IV IV

II, III, IV

TABLE 75-8 -- General Cancer: Supportive Care MODALITY/INTERVENTION BENEFIT Physical activity: Mild/moderate Nutrition: Diet Individual foods: soy [*] Individual phytochemicals: [*] coenzyme Q10 [*] Supplementation MVI and antioxidants [*] Mind-body: Yoga Hypnosis Meditation Support groups Manual therapy: Massage and manual Lymphatic drainage Botanicals: Black cohosh [*] Panax ginseng [*] Calendula cream Energy medicine: Biofield techniques Alternative systems: Acupuncture Spirituality and prayer Improved fatigue, quality of life (QOL) Decreased hot flashes Possible cardiac protection, improved fatigue (breast cancer) Improved tolerance of conventional therapies (may also protect tumor)

LEVEL OF EVIDENCE II, III Conflicting level II, III IV Conflicting II, III, IV

Improved QOL, sleep, anxiety Improved anxiety Improved anxiety, sleep Improved QOL Improved lymphedema Improved anxiety, sleep Improved hot flashes Improved fatigue Improved skin reaction to radiation Improved fatigue and QOL Nausea prevention Social support Improved anxiety, QOL

II, III II, III II, III I, II, III I, II, III II, III Conflicting level I, II, III II, III I, II, III, IV II, III I, II, III I, II, III

* May interact unfavorably with conventional treatments or cause tumor protection/stimulation for certain tumor types.

TABLE 75-9 -- General Cancer: Antineoplastic Therapy MODALITY/INTERVENTION BENEFIT Physical activity: Mild-moderate Nutrition Diet: Plant-based Fiber Specific diets (macrobiotic, Gerson) Individual foods: Green tea None None None Cell kill Cell kill Cell kill Cell kill Cytostatic Improved survival

LEVEL OF EVIDENCE None none none Conflicting III, IV IV IV IV IV Preliminary II, III, IV

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009

Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

Soy Grapeseed extract (proanthocyanidin) Curcumin Avemar (fermented wheat germ) Mushroom extracts Individual phytochemicals: Individual vitamins (A, C, E, selenium) Mind-body: Yoga Hypnosis Meditation Support groups Manual therapy: Massage, chiropractic, straincounterstrain Botanicals: Panax ginseng, flax lignans, red clover
[*]

Page 12 of 15
IV Conflicting level I, II, III, IV

Cell kill None (may have tumor protective effect)

Possible positive (decreased PSA in one study) None None Improved overall survival None

Preliminary level I None None Conflicting Level I, II, III None

Iscador (mistletoe) Essiac tea Energy medicine Alternative systems: Chinese herbs Spirituality Prayer

Estrogen like activity- AVOID with breast cancer Anti-tumor efficacy None None Cell kill Increased cell kill Improved overall survival

IV Conflicting I, II, III, IV I, II

None IV IV II

* May interact unfavorably with conventional treatments or cause tumor protection/stimulation for certain tumor types.

Models of Care
For administrators and/or physicians engaged in the startup phase of an integrative oncology program, one place to turn for guidance is to those who have gone before. The number of integrative oncology centers in North America is growing, according to a 2002 American Hospital Association survey. [33] These centers, which are being developed both in association with hospital systems and as free-standing ventures, tend to add CAM services to existing conventional carethat is, medical care in such centers remains a priority. Most are directed by a physician, and those that are directed by naturopaths, osteopaths, or persons with PhDs most often have a physician on staff. [33] For the reader's ease of reference and contact, Table 75-10 lists several of these centers. TABLE 75-10 -- Examples of Models of Care Consult-based integrative oncology: Academic centers Leonard P. Zakim Center for Integrated Therapies Dana-Farber Cancer Institute Boston, Massachusetts www.dana-farber.org/pat/support/zakim_default.asp Place of wellness M. D. Anderson Cancer Center Houston, Texas www.mdanderson.org/departments/wellness Multidisciplinary Group Practice: California Hematology Oncology Medical Group Los Angeles and Torrance, California www.CHOMG.com Informed, Networking, CAM-Trained Clinicians:Harbin Clinic Cancer Services Rome, Georgia Contact: mmumber@harbinclinic.com Interdisciplinary Group Practice: Center for Integrated Healing Vancouver, BC, Canada www.healing.bc.ca

Freestanding centers

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009

Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

Hospital-based integrative oncology Hospital-based pediatric integrative oncology Cancer Treatment Centers of America Zion, IL and Tulsa, Oklahoma www.cancercenter.com Children's Hospital and Clinics Minneapolis, Minnesota www.childrenshc.org/communities/integrativemed.asp

Page 13 of 15

Adapted from Boyce J: Models of care. In Mumber MP (ed): Integrative Oncology: Principles and Practice. London, Taylor & Francis, 2005, p 84.

Conclusions
Integrative oncology has the potential to transform both individuals and the system of cancer care. In the process, a more sustainable approach to health care can emerge, grounded in the guiding principles of medicine and focusing on all participants at all levels of their experience. Integrative oncology also has the potential to improve outcomes with regard to prevention, supportive care, and antineoplastic therapy. We are at a critical juncture in the evolution of health care. In order for the development of an integrative approach to oncology to be successful, the efforts of researchers, clinicians, patient advocate groups, corporate health care workers, and policymakers must be combined. Such a process will allow for rational planning, development, and implementation in the setting of diminishing resources.

Acknowledgements
The author would like to acknowledge the contributing authors of Integrative Oncology: Principles and Practice, whose critical thinking have influenced this chapter, especially Judy Boyce, Linda Carlson, Michael Cohen, and Nancy Stark.

REFERENCES
1. Mumber MP: Principles of integrative oncology. In: Mumber MP, ed. Integrative Oncology: Principles and Practice, London: Taylor & Francis; 2005:3-15. 2. American Cancer Society: Cancer Facts and Figures 2004, Atlanta: American Cancer Society; 2004. 3. Barrett B, Marchand L, Scheder J, et al: Themes of holism, empowerment, access, and legitimacy define complementary, alternative, and integrative medicine in relation to conventional biomedicine. J Altern Complement Med 2003; 9:937-947. 4. Ganz PA: A teachable moment for oncologists: Cancer survivors, 10 million strong and growing!. J Clin Oncol 2005; 23:5458-5460. 5. Denmark-Wahnefried W, Aziz NM, Rowland JH, Pinto BM: Riding the crest of the teachable moment: Promoting long-term health after the diagnosis of cancer. J Clin Oncol 2005; 23:5814-5830. 6. Angen MJ, MacRae JH, Simpson JS, Hundleby M: Tapestry: A retreat program of support for persons living with cancer. Cancer Pract 2002; 10:297-304. 7. Burden B, Herron-Marx S, Clifford C: The increasing use of reiki as a complementary therapy in specialist palliative care. Int J Palliat Nurs 2005; 11:48-253. 8. Chartterjee AK, Ganguluy S, Pal Sk, et al: Attitudes of patients to alternative medicine for cancer treatment. Asian Pac J Cancer Prev 2005; 6:125-129. 9. Deng G, Cassileth BR: Integrative oncology: Complementary therapies for pain, anxiety, and mood disturbance. CA Cancer J Clin 2005; 55:109-116. 10. Ernst E: The current position of complementary/alternative medicine in cancer. Eur J Cancer 2003; 39:2273-2277. 11. Jones HA, Metz JM, Devine P, et al: Rates of unconventional medical therapy use in patients with prostate cancer: Standard history versus directed questions. Urology 2002; 59:272-276.

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009

Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

Page 14 of 15

12. Molassiotis A, Pantali V, Patiraki E, et al: Complementary and alternative medicine use in patients with haematological malignancies in Europe. Complement Ther Clin Pract 2005; 11:105-110. 13. O'Beirne M, Verhoef M, Paluck E, Herbert C: Complementary therapy use by cancer patients: Physicians' perceptions, attitudes, and ideas. Can Fam Physician 2004; 50:882-888. 14. Risberg T, Lund E, Wist E, et al: Cancer patients use of nonproven therapy: A 5-year follow-up study. J Clin Oncol 1998; 16:6-12. 15. Ben-Arye E, Frenkel M: An approach to teaching physicians about complementary medicine in the treatment of cancer. Integr Cancer Ther 2004; 3:208-213. 16. Weiger WA, Smith M, Boon H, et al: Advising patients who seek complementary and alternative medical therapies for cancer. Ann Intern Med 2002; 137:889-903. 17. Abeloff MD: Burnout in oncology physician heal thyself. J Clin Oncol 1991; 9:1721-1722. 18. Jobst KA, Shostak D, Whitehouse PJ: Diseases of meaning, manifestations of health, and metaphor. J Altern Complement Med 1999; 5:495-502. 19. Herdman R, Lichtenfeld L; National Cancer Policy Board (U.S.): Fulfilling the potential of cancer prevention and early detection: An American Cancer Society and Institute of Medicine Symposium, Washington, DC: National Academies Press; 2004. 20. Frank E, Rothenberg R, Lewis C, Belodoff BF: Correlates of physicians' prevention-related practices: Findings from the Women Physicians' Health Study. Arch Fam Med 2000; 9:359-367. 21. Berger A, Portenoy RK, Weissman DE: Principles and Practice of Palliative Care and Supportive Oncology, Philadelphia: Lippincott Williams & Wilkins; 2002. 22. Holland JC, Rowland JH: Handbook of Psychooncology: Psychological Care of the Patient with Cancer, New York: Oxford University Press; 1989. 23. Mumber MP: Modalities antineoplastic therapy. In: Mumber MP, ed. Integrative Oncology: Principles and Practice, London: Taylor & Francis; 2005:pp 377-378. 24. Richter ED, Laster R: The precautionary principle: epidemiology and the ethics of delay. Int J Occup Med Environ Health 2004; 17:9-16. 25. Brody JG, Tickner J, Rudel RA: Community-initiated breast cancer and environment studies and the precautionary principle. Environ Health Perspect 2005; 113:920-925. 26. Davis DL, Axelrod D, Bailey L, et al: Rethinking breast cancer risk and the environment: The case for the precautionary principle. Environ Health Perspect 1998; 106:523-529. 27. Resnik DB: The precautionary principle and medical decision making. J Med Philos 2004; 29:281-299. 28. Stark N, Hess S, Shaw E: Clinical research and evidence. In: Mumber MP, ed. Integrative Oncology: Principles and Practice, London: Taylor & Francis; 2005:pp 17-42. 29. Davis NB, Nahlik L, Vogelzang NJ: Does PC-SPEs interact with warfarin?. J Urol 2002; 167:1793. 30. Cunningham AJ, Edmonds CV: Group psychological therapy for cancer patients: A point of view, and discussion of the hierarchy of options. Int J Psychiatry Med 1996; 26:51-82. 31. Carlson LE, Shapiro SL: Modalities supportive care: Mind-body interventions. In: Mumber MP, ed. Integrative Oncology: Principles and Practice, London: Taylor & Francis; 2005:pp 319330. 32. Carlson LE, Shapiro SL: Modalities overview: Mind-body interventions. In: Mumber MP, ed. Integrative Oncology: Principles and Practice, London: Taylor & Francis; 2005:pp 183-190. 33. Boyce J: Models of care. In: Mumber MP, ed. Integrative Oncology: Principles and Practice,

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009

Section 13 - Cancer from Rakel: Integrative Medicine on MD Consult

London: Taylor & Francis; 2005:pp 77-100.

Page 15 of 15

Copyright 2009 Elsevier Inc. All rights reserved. - www.mdconsult.com

Bookmark URL: /das/book/0/view/1494/122.html

http://0-www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619-2/0/149... 06/09/2009