0
Integrative Medicine/Oncology:
An Evolving Discipline
or what was called

Complementary and Alternative
Medicine
David S. ...
1. Definitions
2. Chronic Disease/Cancer Challenges
3. Integrative Therapies
4. Research
5. Integrative Medicine/Oncology ...
What’s In A Name?
Evolution Of A Discipline
•Quackery, The Practice of
•Questionable Methods of Therapy
•Unproven Therapie...
Integrative Oncology

We have come a long way
But
We still have a ways to go.
What Is CAM?
… medical and health care
practices outside the realm of
conventional medicine, which
are yet to be validated...
The CAM
Domains

NCCAM
Categories of Integrative Therapies
• Diet, OTC supplements, antioxidants, herbs
• MindBody Medicine
• Physical Activity a...
ACS Challenge Goals
1996-1998
•Reduce cancer mortality by 50% by 2015
•Reduce incidence of cancer by 25% by 2015
• Show me...
QOL Measures
• Assure appropriate care for cancer and
treatment related symptom control
• Include palliative care, end of ...
Cancer as a Chronic Disease
• With a decrease in cancer mortality and a
steady incidence of cancer, there are more
cancer ...
Integrative Medicine/Oncology
 Combines the best of both conventional and evidence-based
integrative therapies
 Emphasiz...
Why a Zakim Center for
Integrative Therapies?
• Cancer patients often have interest in or
questions about Integrative Ther...
Patient Use of CAM
• 83% of patients across broad-spectrum of chronic
diseases use CAM
• Highest use: vitamins/herbs, move...
About CAM users:
70% saw their physician concurrently with
CAM provider.

Eisenberg et al. AM Int Med 2001;135:344-51
About CAM users:
63-72% did not disclose their CAM
therapy to their physician.

Eisenberg et al. AM Int Med 2001;135:344-5...
Why haven’t patients disclosed or
shared their use of CAM with their
physician?
• 61% Not important for doctor to know
• 6...
Mission Statement
The Leonard P. Zakim Center for Integrative
Therapies at Dana-Farber Cancer Institute is
dedicated to en...
Clinical Services Offered
at Zakim Center
Individual:
• Acupuncture
• Massage
• Reiki
• Integrative Medicine Consults
• In...
Who uses Integrative Therapies at
Dana-Farber Cancer Institute ?
• Patients with:
• Pain
• Fatigue
• Anxiety
• Other Sympt...
Integrative Nutrition Consults
• Respond to pt inquiries re: diets,
supplements, herbs
• Therapies with potential benefit:...
Nutrition Guidelines
•
•
•
•
•
•

Avoid being overweight, obesity
Be physically active
Avoid sugar
Consume a phytonutrient...
Integrative Medicine Consults
Respond to questions about CAM:
• Safety
• Efficacy
Discuss role of integrative therapies al...
Mind Body Therapies
•
•
•
•
•
•
•
•
•
•
•
•

Relaxation response and biofeedback
Mindfulness meditation
Guided imagery
Sel...
Massage and Touch Therapies
•
•
•
•
•
•
•
•
•

Swedish massage
Aromatherapy massage
Reflexology
Acupressure
Shiatsu
Manual...
Acupuncture
 Benefit in QOL of cancer patients
 May be recommended:
 Chemotherapy-induced nausea and vomiting
 Cancer ...
Will patients accept
acupuncture?
Guidelines For Advising Patients:
Based on Evidence and Efficacy
Therapies that may be
recommended:

Evidence supports
eff...
Potential Concerns of
Physicians – Re Herbs and
botanicals:







Direct toxic effects
Interactions with other medi...
Drug-Herb Interactions
• Cytochrome P450 system can be stimulated
or inhibited
• Anti-inflammatory effect usually implies
...
Websites
•

•
•
•
•
•
•

Memorial Sloan-Kettering Cancer Center:
http://www.mskcc.org/mskcc/html/5707.cfm?Criteria=about+h...
Delay In Obtaining Known
Effective Therapy
 Delay seeking medical attending for symptoms suggestive
of a serious illness
...
What We Really Want To Know
Why Research
• Use of research studies & technology to
better understand acupuncture & other
integrative therapies
• Recog...
Research Issues
• Do the same rules apply as studying a new
pharmaceutical agent?
• What is the best control for massage o...
DFCI Research
•

•
•
•
•

Immunologic Activity, Physical Status, and QOL in Connection with Two
Exercise Programs (Modifie...
Pain Severity And Interference
Pain Severity

Pain Interference

3.0

Mean

2.5
2.0
1.5
1.0
0.5
0.0
0

4

8

Week

9

12
History of
Federal Involvement
• Office of Alternative Medicine
• NCCAM
• NCI – OCCAM
• Affordable Care Act
Funding Appropriations for IM
National Center for
Complementary and
Alternative Medicine

NCI / OCCAM

FY 2011:

$127.7 mi...
Integrative Oncology
The Future
GENOMICS
Cancer is now defined
more by a genetic defect and
less by site of origin
GENOMICS
Gene Profiling
• Individualizing cancer risk
• Individualizing cancer therapy
• Individualizing integrative thera...
Services Available To Cancer Patients And Their
Primary Care Oncologists, Often Operating In Silos
Specialty Consultants
P...
Coach/Navigator Assists Patient, Primary
Care Physician In Individualizing Care.

Patient – Primary Care Physician
Coach/N...
SAVE THE DATE

10th International Conference of the Society for
Integrative Oncology

Oct. 20-22, 2013
The Fairmont
Hotel ...
“It only takes one person to start a revolution of thought and spirit.”
Lenny Zakim
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  1. 1. Integrative Medicine/Oncology: An Evolving Discipline or what was called Complementary and Alternative Medicine David S. Rosenthal, MD Leonard P. Zakim Center for Integrative Therapies Dana-Farber Cancer Institute May 29, 2013 NewBridge on the Charles
  2. 2. 1. Definitions 2. Chronic Disease/Cancer Challenges 3. Integrative Therapies 4. Research 5. Integrative Medicine/Oncology - The Future
  3. 3. What’s In A Name? Evolution Of A Discipline •Quackery, The Practice of •Questionable Methods of Therapy •Unproven Therapies •Complementary and Alternative Methods of Therapy •Integrative Medicine
  4. 4. Integrative Oncology We have come a long way But We still have a ways to go.
  5. 5. What Is CAM? … medical and health care practices outside the realm of conventional medicine, which are yet to be validated using scientific methods Complementary: together with conventional practices Alternative: in place of conventional practices NCCAM
  6. 6. The CAM Domains NCCAM
  7. 7. Categories of Integrative Therapies • Diet, OTC supplements, antioxidants, herbs • MindBody Medicine • Physical Activity and Modified Exercise Programs • Massage and Touch Therapies • Acupuncture
  8. 8. ACS Challenge Goals 1996-1998 •Reduce cancer mortality by 50% by 2015 •Reduce incidence of cancer by 25% by 2015 • Show measurable improvement in the quality of life; physical, psychological, social and spiritual
  9. 9. QOL Measures • Assure appropriate care for cancer and treatment related symptom control • Include palliative care, end of life care and survivorship issues
  10. 10. Cancer as a Chronic Disease • With a decrease in cancer mortality and a steady incidence of cancer, there are more cancer survivors • Result is that QOL issues become more important and Integrative Oncology becomes more significant
  11. 11. Integrative Medicine/Oncology  Combines the best of both conventional and evidence-based integrative therapies  Emphasizes patient participation (e.g. exercise, diet, stress management) in maximizing health  Emphasizes the primacy of the patient provider relationship and the importance of shared decision making  Emphasizes the contribution of the therapeutic encounter itself  Seeks to optimize and individuals’ innate healing capacity Snyderman R, Weil AT, Arch Inter Med; 2002;162:395-397
  12. 12. Why a Zakim Center for Integrative Therapies? • Cancer patients often have interest in or questions about Integrative Therapies e.g., acupuncture, massage, herbs • Many patients benefit from Complementary Therapies in conjunction with conventional cancer care • Patients need advice from clinicians about contraindicated therapies e.g., “alternative” medicine clinics, drug-herb interactions
  13. 13. Patient Use of CAM • 83% of patients across broad-spectrum of chronic diseases use CAM • Highest use: vitamins/herbs, movement & physical therapies (excluding spiritual practices) • Expectations were: improve QOL, alleviate symptoms, prolong life, cure their disease, boost their immune system • Why did patients use CAM: hopefulness, lack of toxicity, and more control Richardson et al, JCO 2000;18:2505-14
  14. 14. About CAM users: 70% saw their physician concurrently with CAM provider. Eisenberg et al. AM Int Med 2001;135:344-51
  15. 15. About CAM users: 63-72% did not disclose their CAM therapy to their physician. Eisenberg et al. AM Int Med 2001;135:344-51
  16. 16. Why haven’t patients disclosed or shared their use of CAM with their physician? • 61% Not important for doctor to know • 60% Doctor never asked • 31% “None of the doctor’s business” • 20% Doctor would not understand • 14% Thought doctor would disapprove and discourage use Eisenberg et al. Ann Int Med 2001;135:344-51
  17. 17. Mission Statement The Leonard P. Zakim Center for Integrative Therapies at Dana-Farber Cancer Institute is dedicated to enhancing the quality of life for cancer patients and families by incorporating complementary medicine into traditional cancer care. The Center provides affordable clinical services for pediatric and adult patients and their families, educates and empowers patients about their use, and conducts peer-reviewed research.
  18. 18. Clinical Services Offered at Zakim Center Individual: • Acupuncture • Massage • Reiki • Integrative Medicine Consults • Integrative Nutritional Consults Group: • Music Therapy • Expressive Arts Therapy • QiGong • Meditation • yoga
  19. 19. Who uses Integrative Therapies at Dana-Farber Cancer Institute ? • Patients with: • Pain • Fatigue • Anxiety • Other Symptoms (e.g., nausea; neuropathy) • Interest in nutrition counseling for special diets or supplements or other therapies
  20. 20. Integrative Nutrition Consults • Respond to pt inquiries re: diets, supplements, herbs • Therapies with potential benefit: – – – – Fish oil for cachexia Probiotics for bowel irregularities Glutamine for chronic diarrhea Various dietary manipulations for symptom control • Ex: a low fiber/residue diet for patients with acute or chronic diarrhea
  21. 21. Nutrition Guidelines • • • • • • Avoid being overweight, obesity Be physically active Avoid sugar Consume a phytonutrient rich diet Limit red meats, avoid processed foods Limit alcohol ACS, AICR
  22. 22. Integrative Medicine Consults Respond to questions about CAM: • Safety • Efficacy Discuss role of integrative therapies alongside conventional therapy
  23. 23. Mind Body Therapies • • • • • • • • • • • • Relaxation response and biofeedback Mindfulness meditation Guided imagery Self-hypnosis Self-expression in words Music therapy Expressive arts therapy Dance Yoga Tai chi Qi gong Support groups
  24. 24. Massage and Touch Therapies • • • • • • • • • Swedish massage Aromatherapy massage Reflexology Acupressure Shiatsu Manual lymphatic drainage Reiki Deep tissue massage Rolfing
  25. 25. Acupuncture  Benefit in QOL of cancer patients  May be recommended:  Chemotherapy-induced nausea and vomiting  Cancer pain  May be acceptable:  Post-chemotherapy fatigue  Radiation-induced xerostomia  Insomnia  Anxiety
  26. 26. Will patients accept acupuncture?
  27. 27. Guidelines For Advising Patients: Based on Evidence and Efficacy Therapies that may be recommended: Evidence supports efficacy and Evidence supports safety Therapies that may be accepted: Evidence regarding efficacy is inconclusive but Evidence supports safety Therapies that should be Discouraged or unacceptable: Evidence indicates inefficacy or Evidence indicates serious risk Weiger et al, Ann Int Med, Dec.
  28. 28. Potential Concerns of Physicians – Re Herbs and botanicals:       Direct toxic effects Interactions with other medicine Reduced effectiveness of “standard therapy” Toxicity not related to cancer Impairment in overall “quality-of-life” Delay in obtaining known effective therapy
  29. 29. Drug-Herb Interactions • Cytochrome P450 system can be stimulated or inhibited • Anti-inflammatory effect usually implies antiplatelet effect
  30. 30. Websites • • • • • • • Memorial Sloan-Kettering Cancer Center: http://www.mskcc.org/mskcc/html/5707.cfm?Criteria=about+herbs&x =13&y= The University of Texas MD Anderson Cancer Center: http:// www.mdanderson.org/departments/CIMER American Cancer Society: http://www.cancer.org/docroot/ETO/ETO_5.asp National Center for Complementary and Alternative Medicine: http:// nccam.hih.gov/ National Cancer Institute’s Office of Cancer Complementary and Alternative Medicine: http://www.cancer.gov/cam/ Natural Medicines Comprehensive Database: http:// www.naturaldatabase.com Natural Standard: http://www.naturalstandard.com
  31. 31. Delay In Obtaining Known Effective Therapy  Delay seeking medical attending for symptoms suggestive of a serious illness Brienza RS, et al. J Women’s Health & Gender- Based Medicine 2002; 11:79  Delay initiation of “standard effective treatment” for a malignancy Coppes MJ, et al. NEJM 1998; 339-846. Ernst E. JCO 2001; 19:2365
  32. 32. What We Really Want To Know
  33. 33. Why Research • Use of research studies & technology to better understand acupuncture & other integrative therapies • Recognition that patients are continuing to use these therapies, so that questions of dose, synergy, and potential interactions can be investigated through established & refined research methods
  34. 34. Research Issues • Do the same rules apply as studying a new pharmaceutical agent? • What is the best control for massage or a mind/body intervention? • Sham acupuncture • Whole systems vs reductionist research
  35. 35. DFCI Research • • • • • Immunologic Activity, Physical Status, and QOL in Connection with Two Exercise Programs (Modified Exercise and Qigong) PI: Paul Richardson Acupuncture on Pain, Nausea and Quality of Life in Advanced Cancer PI: David S. Rosenthal, MD Acupuncture and Neutropenia in Ovarian Cancer Co-PIs: Ursula Matulonis, MD, Weidong Lu, MB, MPH, Lic.Ac. QiGong on Mood and Cortisol in Breast Cancer PI: Ursula Matulonis, MD Use of Music Therapy with Metastatic Breast Cancer Co-PIs: Susan Bauer-Wu, D.N Sc., Suzanne Hanser, Ed.D., MT-BC • Reiki and Relaxation Response in Prostate Cancer Pts Receiving Radiation PI: Clair Beard, M.D.
  36. 36. Pain Severity And Interference Pain Severity Pain Interference 3.0 Mean 2.5 2.0 1.5 1.0 0.5 0.0 0 4 8 Week 9 12
  37. 37. History of Federal Involvement • Office of Alternative Medicine • NCCAM • NCI – OCCAM • Affordable Care Act
  38. 38. Funding Appropriations for IM National Center for Complementary and Alternative Medicine NCI / OCCAM FY 2011: $127.7 million $122.5 ( includes Recovery act) FY 2005: $123.1 million FY 2004: $117.7 million FY 1998: $19.5 million (OAM) $28 million $129 million
  39. 39. Integrative Oncology The Future
  40. 40. GENOMICS Cancer is now defined more by a genetic defect and less by site of origin
  41. 41. GENOMICS Gene Profiling • Individualizing cancer risk • Individualizing cancer therapy • Individualizing integrative therapies
  42. 42. Services Available To Cancer Patients And Their Primary Care Oncologists, Often Operating In Silos Specialty Consultants Physical Trainers Psychosocial Oncology Support Groups Spiritual Patient & Family Care Services Patient – Primary Care Physician Nutritionist CAM Practitioners Nurse Specialists Social Workers Ethicist Pain and Palliative Care
  43. 43. Coach/Navigator Assists Patient, Primary Care Physician In Individualizing Care. Patient – Primary Care Physician Coach/Navigator Proposed Model
  44. 44. SAVE THE DATE 10th International Conference of the Society for Integrative Oncology Oct. 20-22, 2013 The Fairmont Hotel Vancouver Vancouver, BC integrativeonc.org Co-Chairs: Lynda Balneaves, RN, PhD Associate Professor, Nursing Faculty of Applied Science University of British Columbia Emma Guns, PhD Associate Professor, Dept. Urology Faculty of Medicine University of British Columbia Richard Lee, MD Assistant Professor, General Oncology MD Anderson Cancer Centre University of Texas
  45. 45. “It only takes one person to start a revolution of thought and spirit.” Lenny Zakim
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