Us too io talk 2012 lawenda

Introduction to Integrative
Oncology

Brian D. Lawenda, M.D.
Radiation Oncology
Integrative Oncology
Medical Acupuncture

What is integrative oncology?
• “…the rational, evidence-based combination of
conventional therapy with complementary interventions
into an individualized therapeutic regimen that addresses
the whole person living with and beyond cancer- mind,
body and spirit.” –Donald Abrams, M.D. (Osher Center for
Integrative Medicine, UCSF)

Components of IO
• Conventional interventions (i.e., surgery, radiation,
chemotherapy, etc.)
• Non-conventional modalities “Complementary”,
“CAM” (i.e., acupuncture, massage, meditation, etc.)
• Behavioral/lifestyle education (i.e. stress, nutrition,
physical activity, sleep, etc.)
• Customized to each individual’s unique circumstances
and disease process(es)

Phases for implementing IO
• Before or during conventional therapy
– patients who have had to stop treatment due to side effects and need
to rebuild strength to resume treatment

• After conventional treatment (any time)
– Recover from side effects
– Reduce the risk of recurrence or progression
– Reduce the risk of developing other cancers/comorbidities

• When there is no conventional treatment options

Primary goals of IO
• Reduce the risks of developing/exacerbating other
medical conditions.
• Reduce or prevent treatment side effects
• Enhance tolerance of conventional therapy
• Promote relaxation & stress reduction

Secondary (potential) goal of IO
• Making the individual’s body less conducive for cancer
development and progression
– Enhancing immune function
– Decreasing inflammation
– Promoting other anti-cancer biology (anti-angiogenesis, reducing
growth factor stimulation, etc.)

IO interventions that improve survival and/or
reduce cancer recurrence/progression

• ***Conventional oncology treatments:
– Surgery
– Systemic therapies (chemotherapy, hormonal therapies, biological
agents, immune modulators, radio-labeled compounds)
– Radiation therapy, radiofrequency ablation, cryotherapy

• Complementary/CAM therapies:
– Due to poor study design/quality/rigor and conflicting data, we do
not know…
– Promising therapies: behavioral interventions - exercise, diet/
nutrition, stress reduction

Why integrate oncology?

• Patients are already using CAM treatment
– Surveys indicate that as many as 90% of individuals
with cancer are using “other therapies” while
receiving conventional treatment.


• Patients want their oncology team to be:
• well trained and credentialed
• up-to-date with the science of cancer and its treatment
• open-minded and non judgmental
• who are interested in the influence of all aspects of lifestyle
on health and illness
• understand the interactions of mind and body
• have at least a basic knowledge of botanical remedies,
dietary supplements, and commonly used CAM therapies


• Most do not tell their oncologists what else they are
doing, because they expect to be criticized, ridiculed or
told to stop.
– The oncologist should be aware of all the therapies that their
patients are using, to be able to avoid adverse interactions and
to be able to assess outcomes.
– An integrative oncologist can elicit this information and give
patients sound advice about various therapies

The IO Encounter: H&P
• Conventional details obtained
– Additional emphasis on social hx, family hx, behaviors (i.e. alcohol,
tobacco) and review of systems (assessing for side effects, symptoms of
treatment/cancer or other issues)
– Conventional therapies
– Side effects or symptoms
• IO details obtained:
– Non-conventional therapies
• What, why, when, duration
– Nutrition behaviors
• Vegetables, Fruits, Proteins, Fats, Carbohydrates
– Servings per day
– How is it prepared

The IO Encounter: H&P
• IO details obtained:
– Physical activity behaviors
• What, when, how often, duration
– Stress reduction behaviors
• What, when, how often, duration
– Spirituality
• “What are your sources of hope, strength, comfort and peace?”
• “Are you part of a religious or spiritual community?”
• “What spiritual practices do you find most helpful to you?”
• “Are there any specific practices or restrictions I should know about in
providing your healthcare?”
– Social support

The IO Encounter: Me

• Explain to my patients ‘why I went into IO’
• Discuss my role as their IO:
– Teach how to make the body less hospitable for cancer progression/
recurrence
– Prevent development/exacerbation of other medical conditions

The IO Encounter: Plan
• Help my patients increase their sense of control, QoL
and hope
– Educate: 1) how to improve the body’s innate ability to fight/prevent
cancer, 2) address and manage symptoms/side-effects, 3) prevent the
development/exacerbation of comorbidities
• Nutrition/diet
• Use of appropriate supplements
• Use of conventional and CAM approaches
• Increase physical activity
• Stress reduction techniques
• Connect with family and friends
• Engage spirituality

Common Symptoms in Oncology
• Cancer pain & neuropathy:
– Conventional therapies (pain medications, focused tumor
treatments: radiation, surgery, etc)
– Acupuncture, massage therapy, healing touch
– Botanicals, alpha-lipoic acid
– Mind-body interventions
• cognitive behavior therapy, Hypnosis, Support groups (supportive
expressive therapy), Guided Imagery, Music therapy, Progressive
muscle relaxation

• Fatigue:
– Aerobic exercise
– Minimal data, but promising therapies:
• yoga, massage therapy, cognitive behavior therapy, healing touch,
acupuncture, guided imagery, relaxation breathing exercises,
levocarnitine, Ginseng, Astragalus (anti-tumor effects)

• Poor appetite and weight loss:
– Cannabinoids
• Creatine, melatonin (anti-tumor effects)

• Nausea and vomiting:
– Mind-body interventions:
• Cognitive behavioral therapy, Progressive muscle relaxation, Music
therapy, Guided imagery
– Acupuncture
– Cannabinoids

• Insomnia:
• Cognitive behavioral therapy, Progressive muscle relaxation
– Yoga
– Cannabinoids
• Valerian, Melatonin

• Anxiety and Mood:
• Cognitive behavioral therapy, Progressive muscle relaxation,
Massage therapy, Music therapy, Healing touch
– St. John’s Wort
– S-adenosyl methionine (SAMe)
– Cannabinoids
– Minimal data, but promising:
• Acupuncture, Passion flower

• Hot flashes:
• Paced breathing, flaxseed, Vitamin E

• Genitourinary symptoms:
– Urinary hesitancy & Frequent urination
• Alpha-adrenergic blockers (Flomax): prevent adrenaline from acting on
adrenaline receptors in prostate tissue that contribute to BPH. (markedly
decreased ejaculation volume).
– Flax seed lignan extract (phytoestrogen) produces equivalent
improvements in BPH symptoms, while also lowering plasma
cholesterol and glucose concentrations.
• 5-Alpha Reductase Inhibitors (Proscar, Avodart): inhibit the enzyme
that converts testosterone into its active dihydrotestosterone (DHT) form.
Effective at reducing lower urinary tract symptoms in BPH. (causes erectile
dysfunction, ejaculatory dysfunction, decreased libido, and breast
enlargement.)
– Saw palmetto extracts work by the same mechanism, without the
side effects of prescription drugs.
– Nettle root extract is also effective in reducing BPH symptoms,
without side effects.

The IO Encounter: Cancer 101

• Steps 1-3 of carcinogenesis:
– Exposure of normal DNA to damaging effects:
• Chemicals (environment, tobacco, etc.), Radiation, Viruses, Free radicals
• DNA mutations occur (Lifestyle and behavioral changes may prevent/reduce DNA
damage)
– Cells continue to develop key mutations
• activation of reproduction and growth genes, inactivation of suppressor
genes, deactivation of cell death genes
• can take 1-40 years for a sufficient number of these changes to occur
(**long time available to intervene at this stage)
• Lifestyle and behavioral changes can influence the effects/outcomes
– Increasing free radical damage, inflammation, immune response, blood levels of substances
that promote tumor growth and angiogenesis

– DNA damaged cells become cancer cells


• Causes of cancer:
– 15% hereditary
– 2% air/water pollution
– 2% UV-ray exposure
– 5% obesity & lack of exercise
– 3% alcohol
– 5% workplace-related exposure
– 5% infection
– 30% smoking
– 30% poor dietary habits

70% are related to lifestyle choices

What is inflammation?


• Inflammation 101
– When increased, it is associated with cancer development and
progression.
– When decreased, it is associated with reduced risk of cancer
development and decreased aggressiveness


• Inflammation 101: (offenders)
– Smoking
– Alcohol consumption (>1 women, >2 men)
– Obesity (adipose tissue produces proteins that increase inflammation:
IL-6 and arachidonic acid)
– Sleep deficit (<6hours per night increases proteins that cause
inflammation:IL-6, TNF-alpha and CRP)
– Pollutants (air, water, food)
– Unhealthy dietary fats (overconsumption of omega-6s and saturated
fats)
– Unhealthy carbohydrates (overconsumption of high-glycemic index
foods)
– Unhealthy cooking methods (high-flames or high-heat methods, such as
charcoal grilling and deep frying)

The IO Encounter: Obesity

– Obesity and cancer mechanisms:
• suppresses immune response
• contributes to inactivity.

The IO Encounter: Physical activity

• Numerous studies support the association between
physical activity and improved outcomes in individuals
prior to and after a diagnosis of cancer:
– Decreased risk for cancer development
– Slower cancer progression rates
– Reduced recurrence rates
– Improved survival rates


UCSF 2011 (Journal of Clinical Oncology)
•Followed 2705 men diagnosed with nonmetastatic prostate cancer for 8 years.
•Men who reported that they undertook vigorous physical activity for 3 hours per week
or more were found to have a 49% lower risk for all-cause mortality and a 61% lower
risk for prostate-cancer-specific mortality than those who exercised for less than 1 hour
per week.

UCSF 2011 (Cancer Research)
•1455 men with clinically localized prostate cancer.
•Men who reported a brisk walking pace (>3 mph), compared with an easy walking pace
(<2 mph), had a 48% lower risk for prostate cancer progression. The walking pace was
associated with a decreased risk for progression, independent of duration, the
researchers note.


• Exercise causes physiologic and psychologic changes:
– Genetic expression changes (increased expression of tumor suppressor
genes and DNA repair genes)
– Reduction in tumor stimulating growth factors (estrogen, insulin, IGF-1)
– Helps to maintain muscle and bone mass
• Muscle contains glutamine (an important AA that supports the immune
system)
– Reduction in free radical formation
– Increase in immune function parameters
– Reduction in pro-inflammatory & increase in anti-inflammatory
molecules
– Improvements in sleep function and fatigue
– Reduction in anxiety and depression


• Exercise must be individualized:
– Underweight or overweight
– Symptoms
– Side effects
– Limitations
– Motivation level
– Cardiac fitness
– Access

• Recommend physical trainers or therapists who have
undergone training in working with cancer patients

The IO Encounter: Psychosocial stress

• Although many epidemiologic studies identify
psychosocial stressors as potential risk factors in the
development, progression and recurrence of
malignancies, this remains an area of controversy.
– There is little doubt that stress management and reduction
interventions greatly improve quality of life.

• As many as 33% of cancer patients stop chemotherapy
prematurely due to physical and psychological distress,
decreasing efficacy of therapy.


• Stress increases cortisol and epinephrine:
– Increases free radical formation
– Increases inflammation
– Decreases the immune response
– Decreases tumor cell death
– Decreases the activity of DNA repair
– Increases production of IGF-1 and other growth factors
– Increases angiogenesis proteins (VEGF)


• Numerous studies have demonstrated the beneficial
effects of CAM interventions in relieving anticipatory
nausea and vomiting, anxiety, depression, fatigue and
pain:
– Hypnosis, Guided imagery
– Meditation, Progressive muscle relaxation
– Cognitive behavioral techniques
– Acupuncture, Massage therapy

The IO Encounter: Spirituality

• A spiritual crisis is commonly provoked in cancer patients
and their families:
– Anger, grief, loss, despair and hopelessness
– Questions: “why me?”, “why now?”, “what is the meaning of
this?”


• Definition:
– Related to but distinct from religiosity.
– Focuses on purpose, meaning and connectedness with self,
others and a higher power.


• Contribution to health:
– Studies demonstrate:
• Increased QoL (reduction in stress, increased sense of well-being, less
depression, increased autonomy, increased sense of hope, increased sense
of personal growth and life satisfaction)
• Increased odds of survival (meta-analysis of 29 studies: comparing higher
religious involvement vs. lower)


• Addressing Spirituality:
– Prayer- many forms
– Meditation/mindfulness
– Music, art and nature
– Journaling
– Spiritual direction or counseling

What is the current integrative oncology
model?
Medical, surgical, radiation oncologists

Spiritual advisors Support groups
• Compartmentalized services
that are not coordinated or
aware of the entire picture
(clinically, socially, culturally, Patient/family care services Psychosocial oncologists
etc.)

• Too time demanding for most Nutritionist PATIENT Pain and palliative care
oncologists to coordinate the
complex multi-disciplinary care
…and multiple options may be
confusing for the patient
Physical trainers Social workers

• Minimal educational (MD/RN)
training about other therapies
and resources CAM practitioners Nurse specialists

Geneticist

• Most services are not
reimbursed (self-pay)

The future of integrative oncology
Medical, surgical, radiation oncologists

Spiritual advisors Support groups
• Multidisciplinary oncology team
that focuses on the relationship
of the patient and a “primary
Patient/family care services Psychosocial oncologists
care oncologist”

• Establishing individualized PATIENT
care-plans (& empower the Nutritionist Primary care oncologist Pain and palliative care
patient to take charge) Coach/navigator

• Establish patient coaches/
navigators (i.e. nurse Physical trainers Social workers
specialist) to assist the patient
and oncologist in coordinating
the care plan and assessing CAM practitioners Nurse specialists
progress
Geneticist

• Reimbursed by insurers

IntegrativeOncology-Essentials.com

Us too io talk 2012 lawenda

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