Patients, physicians and researchers are learning that integrative therapies have a place in cancer care.
When a routine mammogram revealed Marie Jackson’s breast cancer in February 2013, she set two immediate goals. First, she wanted to spend as much time as she could behind the counter at The Flaky Tart, the Parisian bakery she owns in Atlantic Highlands, N.J. Second, she wanted to use whatever medical science she could to rid herself of the grape-size, aggressive tumor. But when the side effects of treatment started affecting every aspect of her life, she realized she needed to regain control.
Felt like I had food poisoning, a really bad hangover and the flu at the same time,” she says. “I was flat on my back.” Nauseated, worn out and more bedridden than a 47-yearold should be, she was determined to do something about it.
A New Frontier
This kind of East-meets-West approach to cancer treatment could eventually become the norm. As more research supports the use of certain complementary methods, medical centers across the country are integrating them into everyday practice in both treatment and survivorship, giving rise to one of the newest frontiers in patient care: integrative oncology.
“There’s been a sea change in the way oncology is practiced in major centers,” says Barrie Cassileth, chief of integrative medicine service at Memorial Sloan Kettering Cancer Center in New York, author of the new book Survivorship, and a member of CURE’s advisory board. “The emphasis now in oncology is not only the best possible path to cure, but how can we control the symptoms that result from cancer treatment.”
Some doctors believe that oncology has often suffered from a loss of perspective—an almost singular focus on killing the cancer, while losing sight of patients themselves. Integrative oncology is one means of restoring balance, enabling conventional treatments to remain relentless on the malignancy but as gentle as possible on the patient. Often, that involves acupuncture, massage, yoga and even some lesserknown practices, such as music therapy and the feather touch of reiki.
These practices have long been popular and patients often use them on the side without telling their doctors. Still, experts such as Cassileth say there’s been a philosophical shift: Today doctors not only give nodding acceptance to complementary care but outright encouragement.
This new approach often surprises patients. When Joan Pouch was undergoing chemotherapy at Penn Medicine’s Abramson Cancer Center in Philadelphia in mid2011, a volunteer asked if she wanted a reiki session. “I said, ‘What is it?’ ” Pouch recalls. Until then, she hadn’t known that treatment for her stage 3 breast tumor would involve anything other than the surgerychemoradiation triple play she anticipated. That day, the volunteer gently placed her hands on Pouch’s arms and head in a practice that promotes balance and stress reduction through touch. Reiki comes from Japanese terms that translate as “universal life force.” While the scientific basis for many of these practices remains unclear, the apparent benefits are starting to attract attention among conventional researchers.
The emphasis now in oncology is not only the best possible path to cure, but how can we control the symptoms that result from cancer treatment?
“It was amazing,” Pouch says. After 15 minutes, she felt her anxiety begin to lift. In its place, she felt an enhanced sense of balance she had not known since receiving her diagnosis.
Not that integrative medicine is always unfamiliar. One of its mainstays is an emphasis on diet and physical activity. Studies have found that patients who exercise during and after treatment and maintain a healthy body weight tend to recover faster, feel stronger and even live longer than their sedentary peers.
“There’s a huge amount of research on the benefits of a healthy diet, physical activity and healthy body weight,” says Heather Greenlee of Columbia University in New York, president of the Society for Integrative Oncology. “Those are some of the best things patients can do to take care of themselves. But a lot of people want quick fixes. Dietary and behavioral change takes time.”
The emphasis on diet and physical activity underscores an important distinction between integrative oncology and alternative medicine. Alternative medicine choices lack scientific validity and are used in place of conventional treatment, says Lorenzo Cohen, director of the integrative medicine program at MD Anderson Cancer Center in Houston and a member of CURE’s advisory board. “Integrative medicine is more of a philosophy of how we treat patients,” he says. It incorporates treatments that have held up under scientific challenges, with a focus largely on improving quality of life.
Why has integrative oncology finally taken hold? Partly because of demand. The rise of integrative medicine mirrors a trend in the general population, where complementary therapies have become part of the social fabric. Data show that about four in 10 adults in the U.S. use some kind of complementary or alternative medicine—but the figure is higher among people with cancer—a huge jump from just a few decades ago. For example, one 1992 study estimated that only about 9 percent of people with cancer used complementary or alternative medicine. More recent studies put the prevalence among them in a range of 40 to almost 90 percent, particularly when prayer is included.
A study of data from more than 31,000 adults, published in 2007 in the journal Complementary Therapies in Medicine, found that even after the cancer is behind them, survivors were still more likely than people without a chronic illness to seek complementary medicine and prayer.
Integrative medicine is more of a philosophy of how we treat patients.
The trend toward integrative therapies is also due to an unmet need in conventional medicine for more comprehensive management of symptoms and side effects, says Jeffrey White, director of the Office of Cancer Complementary and Alternative Medicine, which is part of the National Cancer Institute. Not only are people with cancer beset with immediate side effects of their treatment, but also the fierceness of the symptoms can make them feel helpless in the face of disease.
“I’ve always been very healthy,” Jackson says, so her cancer diagnosis presented not only a physical challenge but a psychological one, as well. By giving people more choices and strategies for action, integrative oncology can help restore a feeling of control.
The field also tries to steer patients to methods that are most likely to bring results. Left on their own, patients might rely on advice that isn’t always correct. (In fact, experts often lament Internet sites that make either exaggerated or wholly unproven claims.) One study of patients entering clinical trials at MD Anderson found that the most common choices for complementary therapy were vitamins, herbs and prayer. Yet, in practice, acupuncture is one of the most beneficial treatments in integrative oncology for nausea and other complaints.
“Acupuncture stands out on its own to help control symptoms,” Cohen says. “There’s good evidence in the area of controlling nausea.” This past year, in the Journal of Clinical Oncology, Cohen and his colleagues reviewed all the studies published so far on the effectiveness of acupuncture for symptom management in cancer care, finding support for nausea relief and possibly pain. However, the jury is still out on its effectiveness for a host of other symptoms, such as fatigue and sleep disturbances. Nonetheless, he says, acupuncture’s moderate cost and few side effects make it an attractive option.
The same can be said for yoga: it’s cheap and has little chance of side effects. Yoga has also fared well in scientific studies of its value, at least during active treatment. A 2012 review published in the journal BMC Cancer of twelve randomized trials concluded that breast cancer patients who practiced yoga reported better short-term quality of life and improvement in other measures, such as anxiety, depression and stress.
Vitamin and herbal supplements, among the most common choices for people with cancer, are more difficult options for doctors to endorse beyond the level of a plain multivitamin. And unlike many of the mind-body approaches, supplements carry a more tangible risk of side effects due to their numerous biologic effects. “The most concerning area is that those particular agents may have a negative effect on conventional treatments,” Cohen says. “An example of this that is often used, but salient, is Saint John’s-wort.” Taking the herb, which might relieve mild or moderate depression, can reduce the effectiveness of some anti-cancer drugs. Studies of individual vitamins and herbs are inconsistent, Cohen says, and there are safety concerns about contamination and doses listed on the labels that do not reflect what is actually in the bottle.
Conventional medicine and complementary therapies are two worlds that still don't really intersect very well.
If there is one common wish among integrative oncology specialists, it is for more data on just about all the methods in their toolbox. “We don’t understand enough about the mechanism of action of these approaches,” White says. They can be difficult to study because of the complexity that has evolved over generations of use.
“Many of these interventions sound simple and can be described in a few words, like acupuncture,” he says. “There are more than 300 anatomical points that are used by acupuncturists in different combinations with different stimulation techniques. The effectiveness of an acupuncture treatment may depend on the choice of the points, the type of stimulation used, the skill of the acupuncturist and the frequency with which it’s done.”
Still, effectiveness data is needed to help achieve insurance coverage and relieve the financial barriers that could prevent patients from access. Some methods are provided as a part of cancer care, but many patients still pay for them out of their own pockets. And unless it’s covered by insurance, integrative oncology could remain confined to major cancer centers and not reach into communities. White still reserves one day each week for practice in a small hospital in suburban Washington, D.C., where, he says, a position such as a staff acupuncturist is unthinkable. Doctors in smaller hospitals must have some education, awareness and an interest in integrative medicine to pursue it; otherwise their patients remain mostly unaware. “Conventional medicine and complementary therapies are two worlds that still don’t really intersect very well,” he says.
Luckily for many patients, sometimes care is provided by volunteers, like the one who brought reiki to the bedside of Joan Pouch. Once her cancer treatments ended, she had trouble locating a practitioner near her suburban Philadelphia home. So, at age 61, she decided to learn the skill herself. Today, she volunteers at the Abramson Cancer Center every Tuesday, offering reiki to those who occupy the floors she once knew as a patient. She is not surprised to find herself delivering the care that was foreign to her just a few years ago. From the time she received her diagnosis, she looked at cancer as a journey. “I think your life is taken to the areas where you are needed.”^ TOP OF PAGE