Overview. Overview. Integrative Oncology: The Catalyst and Bellwether for Integrative Medicine and Health

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1 Integrative Oncology: The Catalyst and Bellwether for Integrative Medicine and Health Margaret A. Chesney, PhD Society for Integrative Oncology Chicago, Illinois November 12, 2017 Overview Overview Describe how integrative oncology was been a catalyst for integrative medicine Highlight why there is a growing focus on integrative medicine and oncology now Discuss the importance of integrative oncology as a bellwether for the future of integrative medicine and health Describe how integrative oncology was been a catalyst for integrative medicine Highlight why there is a growing focus on integrative medicine and oncology now Discuss the importance of integrative oncology as a bellwether for the future of integrative medicine and health Integrative Oncology = The Catalyst? Go back in time. Integrative medicine emerged in the 1990s 1991 Univ of Maryland s Center was founded 1994 Univ of Arizona Center for Integrative Medicine 1995 Univ of Minnesota Center for Spirituality and Health 1998 Congress authorized funds for NCCIH 1998 Duke Integrative Medicine founded 1999 Osher Center at UCSF is founded 1999 Meeting? 1952/59XXXX1964XXX 1978/79XXXX11991XXX1998/99XXXXXXXXXX2017 The Catalyst: Early work on the Impact of Cancer Long before integrative medicine emerged Research from by Arthur Sutherland and colleagues studied the adaptation and rehabilitation of cancer patients this foreshadowed the field of Health Psychology (Braun, M) 1

2 Dr. Arthur Sutherland: Psychological Adaptations to Cancer The Catalyst? Long before integrative medicine emerged Research from by Arthur Sutherland and colleagues studied the adaptation and rehabilitation of cancer patients this foreshadowed the field of Health Psychology (Braun, M) Research documented the relationship between risk behaviors and disease Surgeon General s Report on Cigarette Smoking 1969 Blue Ribbon Panel drops Diet Only Study and calls for MRFIT (Multiple Risk Factor Intervention Trial) Sutherland, A., Papers, Cancer Two The weeks First Lady, later, Betty Happy Ford Rockefeller, is diagnosed wife with of the VP is breast diagnosed cancer with breast cancer Two The weeks First Lady, later, Betty Happy Ford Rockefeller, is diagnosed wife with of the VP is breast diagnosed cancer with breast cancer Psychosocial Treatment of Patients with Breast Cancer Psychosocial Treatment of Patients with Breast Cancer 86 women with metastatic breast cancer Psychosocial Treatment 1 year of weekly supportive group therapy and self-hypnosis for pain and routine oncological care (n = 50) Usual Care Routine oncological care (n = 36) Outcome Survival at 10 year follow-up Primary outcome: Survival from randomization and onset of intervention Treatment Group: Survival 37.6 months (SD = 37.6 mos) Usual Care Control: Survival 18.9 months (SD = 10.8 mos) Survival twice as long as seen in Kaplan-Meier plot Spiegel, Bloom, Kraemer and Gottheil, Lancet, 1998 Spiegel, Bloom, Kraemer and Gottheil, Lancet,

3 Psychosocial Treatment of Patients with Breast Cancer Cancer Research Cornerstone of New Fields late s B = Treatment Group A = Usual Care What s the mechanism? From smoking cessation studies stress triggers, smoking and mood, relapse prevention, smoking and weight, primary prevention. To interventions to address psychological aspects of breast cancer, and studies of the impact of stress on immune system. founded 1978 founded 1979 Kaplan Meier survival plot Spiegel, Bloom, Kraemer and Gottheil, Lancet, 1989 Public interest in healthy lifestyles included concerns about stress and its effects on health The Catalyst? 1990s Integrative medicine emerges in the 1990s 1991 Univ of Maryland s Center was founded 1994 Univ of Arizona Center for Integrative Medicine 1995 Univ of Minnesota Center for Spirituality and Health 1998 Congress authorized funds for NCCIH 1998 Duke Integrative Medicine founded 1999 Osher Center at UCSF is founded 1999 Jon Meeting? Kabat-Zinn Invites 8 Integrative Medicine Centers to a Meeting 1999: Consortium Formed - 8 Centers 1999: Consortium Formed - 8 Centers University of Minnesota University of Minnesota University of California, San Francisco Stanford University University of Massachusetts Harvard University University of Maryland University of California, San Francisco Stanford University University of Massachusetts Harvard University University of Maryland Duke University Duke University University of Arizona University of Arizona 3

4 The Catalyst Cancer Patients Overview Cancer patients were vocal about wanting complementary medicine Provided critical financial support to centers Bravewell Philathropic Collaborative Supported the Consortium Created Bravenet Duke Leadership Program Promoted integrative medicine to public PBS Special The New Medicine Describe how integrative oncology was been a catalyst for integrative medicine Highlight why there is a growing focus on integrative medicine and health now Discuss the importance of integrative oncology as a bellwether for the future of integrative medicine and health Bravewell: $4,500 $4,500 $9,892 $2,000 $2,000 $4, yrs yrs yrs yrs Data from 2000, UC Atlas of Global Inequality, 2014 New 2017 Data Organization for Economic Cooperation and Development, 35 Countries US Rank 27 th of 35 Healthcare Facts 35 Countries United States Ranks #1 on obesity Ranks #33/35 on prevalence of diabetes Ranks #1 in pharmaceutical spending Ranks #1 in drug related deaths Opioid epidemic Organization for Economic Cooperation and Development 2017 (Bloomberg News, August 2,2017) The disease-driven approach to care has resulted in - spiraling costs as well as - a fragmented health system that is - reactive and episodic as well as - inefficient and impersonal. IOM Summit, 2009 IOM - Now - National Academy of Medicine 4

5 Integrative Medicine? The disease-driven approach to care has resulted in - spiraling costs as well as - a fragmented health system that is - reactive and episodic as well as - inefficient and impersonal. IOM Summit, 2009 IOM - Now National Academy of Medicine The field of integrative medicine and health Reaffirms the importance of the relationship between practitioners and patients, Focuses on the whole person, Is informed by evidence, and 2014 Makes use of all therapeutic and lifestyle approaches, health care professionals and disciplines to achieve optimal health and healing. Complementary Medicine* Conventional Medicine* Disease-driven care o a fragmented health system o reactive and episodic o inefficient and impersonal. Integrative Healthcare an integrated patient-centered team focuses on lifestyle and health promotion reaffirms relationship between practitioners and each patient Acupuncture Yoga/Tai Chi Meditation/Breathing Massage Surgery Medication Radiation Immunotherapy * Examples Complementary Medicine* Integrative Medicine Conventional Medicine* Complementary / Integrative Medicine Use Increasing National Health Interview Survey in 2002, 2007 & 2012 Acupuncture Stress Management Yoga/Tai Chi Physical Activity Meditation/Breathing Diet/Nutrition Massage Weight Loss Biofeedback * Examples Surgery Medication Radiation Immunotherapy National random sample 2002: 31,044 adults 2007: 23,393 adults XXXXXXXXX 9,417 children 2012 : 34,525 adults 10,218 children 36.6% 38.3% 11.8% Similar levels Barnes et al., CDC, 2004, 2008; Black et al., CDC,

6 Focus on Cancer Patients National Health Interview 38% Number increases to 68% in surveys of cancer patients* Greater use in those with breast cancer or advanced illness Goal: - Enhance wellness, - Improve immune function - Relieve pain *Lopez, Mao & Cohen, Med Clin N Am, 2017; Barnes et al., CDC, 2008 Integrative Medicine in US Hospitals Hospitals offering Integrative Medicine services 8% in % in % in % in % in 2011 Key reasons Patient demand 85% Clinical evidence 74% AHA Health Forum, Sept University of California, San Francisco Stanford University University of Arizona 1999: Consortium Formed - 8 Centers University of Minnesota University of Massachusetts Harvard University University of Maryland Duke University Albert Einstein/Yeshiva University Allina Health Systems Aurora Health Care Beaumont Health System Boston University Central Maine Healthcare Cleveland Clinic Columbia University Connor Integrative Health Cornell University Duke University Emory University Georgetown University George Washington University Harvard Medical School INOVA Health Johns Hopkins University Mayo Clinic McMaster University, Ontario MD Anderson MedStar Health Memorial Sloan Kettering Meridian Health Mount Sinai Medical Center Northwestern University Ohio State University Oregon Health & Science University Pennsylvania State Univ., Hershey Members Rutgers New Jersey Medial School Scripps Health Sutter Health Stanford University Temple University Tecnológico de Monterrey, Mexico Texas Tech University Medical Center Thomas Jefferson University Tufts University University of Alberta University of Arizona University of Calgary University of California, Irvine University of California, Los Angeles University of California, San Diego University of California, San Francisco University of Chicago University of Cincinnati. University of Colorado University of Connecticut Univ. of Hawaii at Manoa University of Kansas University of Kentucky University of Maryland University of Massachusetts University of Miami University of Michigan University of Minnesota University of New Mexico University of North Carolina University of Pennsylvania University of Pittsburgh University of Saskatchewan University of Southern Ca. University of Texas, MB University of Utah University of Vermont University of Washington University of Wisconsin, Vanderbilt University Veterans Administration Wake Forest University Yale University Albert Einstein/Yeshiva University Allina Health Systems Aurora Health Care Beaumont Health System Boston University Central Maine Healthcare Cleveland Clinic Columbia University Connor Integrative Health Cornell University Duke University Emory University Georgetown University George Washington University Harvard Medical School INOVA Health Johns Hopkins University Mayo Clinic McMaster University, Ontario MD Anderson Medstar Health Memorial Sloan Kettering Meridian Health Mount Sinai Medical Center Northwestern University Ohio State University Oregon Health & Science University Pennsylvania State Univ., Hershey Members Rutgers New Jersey Medial School Scripps Health Sutter Health Stanford University Temple University Tecnológico de Monterrey, Mexico Texas Tech University Medical Center Thomas Jefferson University Tufts University University of Alberta University of Arizona University of Calgary University of California, Irvine University of California, Los Angeles University of California, San Diego University of California, San Francisco University of Chicago University of Cincinnati. University of Colorado University of Connecticut Univ. of Hawaii at Manoa University of Kansas University of Kentucky University of Maryland University of Massachusetts University of Miami University of Michigan University of Minnesota University of New Mexico University of North Carolina University of Pennsylvania University of Pittsburgh University of Saskatchewan University of Southern Ca. University of Texas, MB University of Utah University of Vermont University of Washington University of Wisconsin, Vanderbilt University Veterans Administration Wake Forest University Yale University Overview Describe how integrative oncology was been a catalyst for integrative medicine Highlight why there is a growing focus on integrative medicine and health now Discuss the importance of integrative oncology as a bellwether for the future of integrative medicine and health 6

7 Bellwether? Bellwether? In a flock, one sheep must lead the way The bellwether - Middle English bell & sheep noun person or thing that assumes the leadership or forefront In a flock, one sheep must lead the way The bellwether - Middle English bell & sheep noun person or thing that assumes the leadership or forefront Integrative Oncology has often led the effort to build the integrative medicine evidence base Efficacy Mechanism Intervention Stress, Lifestyle & Cancer Progression Stress-related factors are associated with higher cancer incidence in those who are healthy, and poorer survival in those with cancer diagnosis* Dr. Barbara Andersen conducted an RCT designed to test the hypothesis that stress accompanying a cancer diagnosis would trigger psychologic and behavioral responses, as well as biologic responses that would influence disease outcomes survival.** *e.g., Chida et al, Nat Clin Pract Oncol, 2008, **Andersen et al, Cancer, 2008 Stress, Lifestyle & Cancer Progression Andersen et al. Stress, Lifestyle & Cancer Progression B. Andersen et al. 227 breast cancer patients, stage IIA, IIIB Assessment Only At baseline and months 4 and 12, Observed with 6 mon assessments from Years 2 5, and annually thereafter (N = 113) Intervention* and Assessment 4 month of weekly small groups sessions, followed by 8 monthly sessions (n = 114) *Psychosocial/behavioral support intervention, also addressed diet, exercise, smoking and adherence Andersen et al, Cancer, 2008 Recurrence free survival Breast cancer Overall survival specific survival Intervention Assessment Only Andersen et al, Cancer,

8 Opportunities & Challenges Opportunities & Challenges Applaud: Clinical Practice Guidelines* General practice for integrative therapies 2007, 2009 Integrative therapies for lung cancer 2007, 2013 Integrative therapies for breast cancer 2014, 2017 Opportunity: Model for Integrative Medicine May present a challenge Guidelines rely on studies with high rigor, that focus on specific modalities While multi-modal interventions may have more impact on patient health. Multimodal Interventions may have more impact How do we balance Evidence Base vs. Health Impact Consider survivorship programs. There is likely to be public demand from baby boomers as more evidence shows value Challenge Integrative oncology is up to it e.g., Greenlee et al., J of NCI Monographs, 50, 2014; SIO Website Multimodal Intervention & Telomeres A Case in Point: Healthy Lifestyle Treatment for Cancer Telomeres are protective DNAprotein complexes which stabilize the ends of chromosomes Like the aglets at the end of shoelaces Telomeres shorten in response to age, disease, poor sleep, and stress But may lengthen in response to healthy lifestyles and stress management! Biopsy proven, low-risk prostate cancer 35 men agreed to active surveillance ( ) - 25 received only active surveillance - 10 received an integrative treatment plan - Dr. Peter Carroll, Chair, UCSF Dept. of Urology Epel ES et al. PNAS 2004;101:17312 Prather, et al. Brain, Behavior & Immunity, 2015; 147:155 Ornish D et al. Lancet Oncol., 2008; 9:1048 Ornish, et al., New England J of Med, 2013 Outcomes: Standard Active Surveillance Regular visits... Telomere Length?? VS Integrative Care Exercise Healthy Diet Stress Reduction Social Support A Case in Point: Healthy Lifestyle Treatment for Cancer Shorter p<.03 Longer! Courtesy of Dr. Lorenzo Cohen Ornish, et al., New England J of Med, 2013 Ornish et al. Lancet Oncology, September

9 Yoga for Chronic Low Back Pain (clbp) Design of Saper et al. CompLife RCT of a comprehensive lifestyle intervention Occurs during the 4-6 wks of radiotherapy for women with stage III breast cancer Follow-up to yr with Facetime Captures the synergy of combining healthy behaviors 320 patients, clbp randomized Yoga - 12 weekly, 75-min group classes, 30-min home practice, followed to 1 year with classes (n = 127) PT- 15, 60-min individual appts. over 12 weeks, followed to 1 year, half randomized to 5 boosters (n = 129) Education The Back Pain Helpbook with newsletter and support calls (n = 64) Outcomes Non-inferiority Trial Roland Morris Disability Questionnaire (RMDQ) Saper et al., Annals of Internal Med, Yoga for Chronic Low Back Pain (clbp) Results Yoga for Chronic Low Back Pain (clbp) Results Primary Outcome: Improvement in RMDQ by those in Yoga was not inferior to improvement by those in PT Yoga Decrease in disability: -3.8 PT Decrease in disability: -3.5 Compared to Education: Yoga and PT less likely to use medications Yoga and PT more satisfied with the intervention Saper et al., Annals of Internal Med, Primary Outcome: Improvement in RMDQ by those in Yoga was not inferior to Clinically improvement meaningful by those improvement in PT PT: 57% Yoga Decrease in disability: Yoga: 56% -3.8 PT Decrease in disability: Education: % Given the low adherence (36-44%) Compared to Education: between-group comparisons are highly susceptible to Yoga and PT less likely to use medications bias. Yoga and PT more satisfied with the intervention Saper et al., Annals of Internal Med, Chronic Low Back Pain MBSR vs CBT vs Usual Care - Results Outcomes Group MBSR CBT UC Roland RDQ 60.5% 57.7% 44.1% Less Bothersome 43.6% 44.9% 26.6% MBSR = CBT, both superior to UC These finding indicate that either MBSR or CBT are effective treatment options for chronic low back pain. Cherkin, Sherman et al., JAMA, 315, 2016 Chronic Low Back Pain MBSR vs CBT vs Usual Care - Adherence Participants Mean age % female Adherence 53.7% attended 6 or more of the 8 weekly sessions 86% completed 26 wk follow-up 85% completed 52 wk follow-up Low Adherence? and only to sessions What about home practice? Cherkin, Sherman et al., JAMA, 315,

10 Chronic Low Back Pain MBSR vs CBT vs Usual Care - Adherence Participants Mean age % female Adherence 53.7% attended 6 or more of the 8 weekly sessions 86% completed 26 wk follow-up 85% completed 52 wk follow-up Low Adherence? and only to sessions What about home practice? Cherkin, Sherman et al., JAMA, 315, 2016 Potential Opportunities to Increase Impact of IM The evidence-base for integrative medicine is growing Early research compared integrative approaches to effective treatments, in studies with small Ns - Designs tested for superiority with insufficient power - Included active controls and no usual care - Set a high bar and often showed equivocal results Non-inferiority designs (Saper Yoga vs PT) are a step forward Adding the cost-effectiveness is very helpful While these better designs are helpful, they are unlikely to be sufficient to change policy Checklist to Increase Impact for Integrative Medicine Checklist to Increase Impact for Integrative Medicine Integrative approaches have evidence-base Integrative approaches have evidence-base Integrative approaches result in cost saving Integrative approaches result in cost saving Publicize findings (professional journals, meetings) Publicize findings (professional journals, meetings) Watch for windows of opportunity Betty Ford & Happy Rockefeller Baby Boomers aging Opioid Epidemic Calling for non-pharmacological interventions Get the word out to professionals and the public Watch for windows of opportunity Opiate Crisis Get the word out to professionals and to the public Engage Congress, NIH, Natl Academy of Medicine, highlighting the 72 health centers and work together to build public advocacy! Academic Consortium for Integrative Medicine and Health New Official Journal of Consortium 10

11 Review Described how integrative oncology was been a catalyst for integrative medicine Highlighted there is a growing focus on integrative medicine and health ~ the time is NOW Discussed the importance of integrative oncology as a bellwether for the future of integrative medicine and health ~ you are in the lead When we think of health care Health Ill-health Neutral Waiting When we think of health care Health Ill-health Optimal Health for those affected by Cancer Resilience, Reduced vulnerability to recurrence, Quality of life Neutral Waiting My Hope is that Integrative Oncology will continue to lead the field of Integrative Medicine so that we can go the distance, to achieve optimal health and wellbeing Thank you! Acknowledgments I wish to thank my many mentors and colleagues, including many who are in this room, the Academic Consortium for Integrative Medicine and Health, UCSF, and NIH for helping me stretch my boundaries. margaret.chesney@ucsf.edu 11