Us too io talk 2012 lawenda

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Dr. Brian Lawenda provided us this terrific presentation on integrative approaches to preventing and treating cancer. Dr. Lawenda is a Harvard trained radiation oncologist working in las Vegas for 21st Century Oncology. It certainly helps to have him lecture along with this presentation because this can be a complicated discussion.

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  • Us too io talk 2012 lawenda

    1. 1. Introduction to Integrative Oncology Brian D. Lawenda, M.D. Radiation Oncology Integrative Oncology Medical Acupuncture
    2. 2. 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)
    3. 3. 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)
    4. 4. 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
    5. 5. 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
    6. 6. 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.)
    7. 7. IO interventions that improve survival and/orreduce 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
    8. 8. 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.
    9. 9. Why integrate oncology?• 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
    10. 10. Why integrate oncology?• 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
    11. 11. 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
    12. 12. 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
    13. 13. 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
    14. 14. 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
    15. 15. 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
    16. 16. Common Symptoms in Oncology• 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 – Minimal data, but promising therapies: • Creatine, melatonin (anti-tumor effects)
    17. 17. Common Symptoms in Oncology• Nausea and vomiting: – Mind-body interventions: • Cognitive behavioral therapy, Progressive muscle relaxation, Music therapy, Guided imagery – Acupuncture – Cannabinoids• Insomnia: – Mind-body interventions: • Cognitive behavioral therapy, Progressive muscle relaxation – Yoga – Cannabinoids – Minimal data, but promising therapies: • Valerian, Melatonin
    18. 18. Common Symptoms in Oncology• Anxiety and Mood: – Mind-body interventions: • 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: – Minimal data, but promising therapies: • Paced breathing, flaxseed, Vitamin E
    19. 19. Common Symptoms in Oncology• 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.
    20. 20. 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
    21. 21. The IO Encounter: Cancer 101• 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
    22. 22. The IO Encounter: Cancer 101
    23. 23. The IO Encounter: Cancer 101 What is inflammation?
    24. 24. The IO Encounter: Cancer 101
    25. 25. The IO Encounter: Cancer 101• 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
    26. 26. The IO Encounter: Cancer 101• 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)
    27. 27. The IO Encounter: Nutrition
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    46. 46. The IO Encounter: Obesity
    47. 47. The IO Encounter: Obesity
    48. 48. The IO Encounter: Obesity
    49. 49. The IO Encounter: Obesity
    50. 50. The IO Encounter: Obesity– Obesity and cancer mechanisms: • suppresses immune response • contributes to inactivity.
    51. 51. 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
    52. 52. The IO Encounter: Physical activityUCSF 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 weekor more were found to have a 49% lower risk for all-cause mortality and a 61% lowerrisk for prostate-cancer-specific mortality than those who exercised for less than 1 hourper 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 wasassociated with a decreased risk for progression, independent of duration, theresearchers note.
    53. 53. The IO Encounter: Physical activity• 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
    54. 54. The IO Encounter: Physical activity• 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
    55. 55. 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.
    56. 56. The IO Encounter: Psychosocial stress• 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)
    57. 57. The IO Encounter: Psychosocial stress• 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
    58. 58. 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?”
    59. 59. The IO Encounter: Spirituality• Definition: – Related to but distinct from religiosity. – Focuses on purpose, meaning and connectedness with self, others and a higher power.
    60. 60. The IO Encounter: Spirituality• 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)
    61. 61. The IO Encounter: Spirituality• Addressing Spirituality: – Prayer- many forms – Meditation/mindfulness – Music, art and nature – Journaling – Spiritual direction or counseling
    62. 62. 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)
    63. 63. 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
    64. 64. IntegrativeOncology-Essentials.com
    65. 65. b.lawenda@gmail.com

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