INTEGRATIVE ONCOLOGY

INTEGRATIVE ONCOLOGY Shauna Birdsall, ND, FABNO Director of Naturopathic Medicine and Integrative Oncology Cancer Treatment Centers of America Learning Objectives: Describe Integrative Oncology. Discuss specific therapies that may be beneficial to elderly patients and rationale for use. Recognize risks for interactions and contra-indications, specifically with dietary supplements. DISCLOSURE OF COMMERCIAL SUPPORT Shauna Birdsall, ND, FABNO, does have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and /or provider(s) of commercial services discussed in this presentation. Speaker s Bureau Employment, Cancer Treatment Centers of America 1

Integrative Oncology Shauna Birdsall, ND, FABNO Director of Naturopathic Medicine and Integrative Oncology Cancer Treatment Centers of America at Western Regional Medical Center Disclosures I am an employed physician of Cancer Treatment Centers of America Learning Objectives 1. Describe Integrative Oncology 2. Discuss specific therapies that may be beneficial to elderly patients and rationale for use 3. Recognize risks for interactions and contra-indications, specifically with dietary supplements 2

Terminology Alternative Medicine Complementary Medicine Complementary and Alternative Medicine (CAM) Integrative Medicine Integrative Oncology Integrative Oncology is an emerging field of evidencedbased complementary approaches to support patients receiving conventional cancer care. This presentation will review common, cost effective therapies to support patients during and after cancer treatment. Prevalence of Alternative and Complementary Medicine Use How frequently do oncology patients use complementary or alternative therapies? 3

How Often Are Patients Using Complementary or Alternative Medicine? Richardson MA, Sanders T, Palmer JL, et al. Complementary/Alternative Medicine Use in a Comprehensive Cancer Center and the Implications for Oncology. 453 participants surveyed regarding Complementary and/or Alternative Medicine use (CAM) J Clin Oncol 2000 Jul;18(13):2505-14 Complementary and Alternative Medicine Usage 83.3 percent had used at least one CAM therapy When psychotherapy and spiritual practices were excluded, 68.7 percent had used at least one CAM therapy 40 percent of these had not discussed CAM usage with their physician 24.7 percent of participants used seven or more CAM therapies J Clin Oncol 2000 Jul;18(13):2505-14 Supplement Usage Gupta D, Lis CG, Birdsall TC, Grutsch, JF. The use of dietary supplements in a community hospital comprehensive cancer center: implications for conventional cancer care. 227 new CTCA patients surveyed regarding dietary supplement use within the previous 30 days Support Cancer Care 2005 Nov;13(11):912-919 4

Supplement Usage 73 percent had used at least one dietary supplement within the previous 30 days Of patients who had received chemotherapy within the previous 30 days 71 percent had also used dietary supplements during the same timeframe 25 percent had used one or more herbal products suspected to have adverse interactions with chemotherapy Of patients combining chemotherapy with dietary supplements, 53 percent had not consulted any healthcare professional about their supplement use Support Cancer Care 2005 Nov;13(11):912-919 Breast cancer patients' perspectives on Complementary and Alternative Medicine The rates of Complementary and Alternative Medicine (CAM) use varies from 17 to 75%, with a mean of 45%. Vitamins, minerals, and herbs are the most frequently used Many CAM therapies focus on symptom management, improving quality of life, and enhancing immune function. Although women rely on a variety of resources for information, they frequently experience frustration owing to the absence or conflicting nature of such information. J Soc Integr Oncol. 2006;4(4):157-69 11 Breast cancer patients' perspectives on Complementary and Alternative Medicine Communication with conventional providers about CAM is frequently experienced as either unsupportive or not helpful by many patients. There is a need to develop better evidence-based informational resources related to CAM and cancer There is also a need for physicians to become better educated about CAM and how to communicate more effectively with their breast cancer patients about it. J Soc Integr Oncol. 2006;4(4):157-69 5

Benefits of Integrative Oncology Can help manage the physical, emotional, and psychological symptoms experienced by cancer survivors Evidence-based therapies can help improve quality of life, speed recovery, and optimize patient and caregiver support Achieves three important objectives: Care is received from therapists experienced in working with cancer patients Visits become part of the medical record, allowing treatment teams to guide individuals in maximizing benefit Patients are diverted from useless or harmful alternatives. Int Rev Psychiatry 2014 Feb;26(1):114-27 What might be included in an Integrative Oncology Plan? Diet/Nutrition Exercise Lifestyle changes Massage Acupuncture Mind/Body Medicine Naturopathic Medicine Vitamins, minerals, herbal supplements Yoga Spiritual support Physical Therapy, Occupational Therapy, Speech Therapy Chiropractic care Evidence-based medicine: applications for integrative oncology Three major factors to consider in evaluating natural therapies: 1) the level of scientific evidence supporting the effectiveness of the treatment and what other options exist 2) the cost of the therapy 3) its safety, as well as the existence of potential side effects, contra-indications or interactions. 15 6

Diet/Nutrition Diet is associated with breast cancer risk; associations appear more pronounced for women with postmenopausal disease. Healthy choices after diagnosis and treatment likely support longevity more so than reduced risk for recurrent disease. Reduced risk is associated with higher vegetable and fruit consumption, increased physical activity, and a body mass index that was neither low weight nor obese. Eating a diet rich in whole foods, including fruits and vegetables, provides vitamins, minerals, and phytonutrients that are the basis to build a healthy immune system. Nutr Clin Pract October 2012 vol. 27 no. 5 636-650 JCO June 10, 2007 vol. 25 no. 17 2345-235 16 Exercise Lifestyle Behaviors in Elderly Cancer Survivors: A Comparison With Middle-Age Cancer Survivors: Elderly cancer survivors are less likely to meet exercise goals compared with younger survivors. J Oncol Pract. 2015 Jun 9 Exercise interventions on health-related quality of life for people with cancer during active treatment: Exercise may have beneficial effects on Health Related Quality of Life, including physical functioning, role function, social functioning, and fatigue. Positive effects of exercise interventions are more pronounced with moderate- or vigorous-intensity versus mild-intensity exercise programs Cochrane Database Syst. 2012 Aug 15;8 Exercise Prevention: Women who engaged in 2-3 hours of brisk walking per week the year before they were diagnosed with breast cancer showed increased survival after diagnosis. After Diagnosis: Women who increase physical activity after diagnosis had significantly increased survival as well. How much and what Type: 3-5 hours per week of walking at an average pace gave the greatest benefit. J Clin Oncol. 2008 Aug 20;26(24):3958-64. 18 7

Combination Counts Improving both diet and exercise can significantly improve survival with breast cancer (regardless of obesity): Walking 30 minutes a day Eat at least five servings of vegetables and fruits daily J Clin Oncol. 2007 June 10;25(17):2345-2351 19 Yoga The effects of yoga on the quality of life and depression in elderly breast cancer patients: Yoga is valuable in helping: Depression Pain Fatigue Cancer patients to perform daily and routine activities Increases the quality of life Complement Ther Clin Pract. 2015 Feb;21(1):7-10 Acupuncture Research has shown Acupuncture may be helpful for: Xerostomia Lymphedema Pain Research is conflicting for: Hot Flashes Fatigue Chemotherapy-induced nausea J Acupunct Meridian Stud. 2015 Jun;8(3):115-21 J Clin Oncol. 2013 Mar 1;31(7):952-60 21 8

What are the real risks with supplements? Self-diagnosing and self-medicating Lack of monitoring for interactions or adverse effects Prioritizing supplements with little research over medications that would provide significant benefit Patients may be taken advantage of financially or spending their health care financial resources in a way that is not going to provide them with the most benefit 22 Vitamins, minerals, herbal supplements and other natural products need to be evaluated for: Appropriateness Dose Interactions with medications Contra-indications with the medical conditions Cost Patients feel most empowered when they are informed of the evidence and rationale (or lack thereof) for potential supplements and why they might not be indicated 23 Supplements-when might they be most beneficial? When a supplement has scientific evidence supporting its use to: Replete deficiency Prevent chronic disease Prevent a potential drug-induced deficiency Co-manage a medical condition by a health care provider along with other treatment Safely treat a low risk medical condition Manage symptoms of an established medical condition Decrease side effects Help improve quality of life 24 9

Nausea: Potential Interventions 25 Ginger (J Clin Oncol 27:15s, 2009 (suppl; abstr 9511) Sea Bands (Br J Community Nurs. 2004 Sep;9(9):383-8) Aromatherapy: for example, peppermint essential oil) (research is conflicting as to effectiveness) Acupuncture (Proc (Bayl Univ Med Cent). 2009 Apr;22(2):138-41) Educate patient to take supplements with food and hold certain supplements if nausea persists until it is resolved Reinforce appropriate use of anti-emetics Cancer Related Fatigue: Potential Interventions Address any known underlying causes of fatigue (insomnia, iron deficiency anemia, etc.) Mild to moderate exercise has the most promising evidence for cancer-related fatigue Yoga may be helpful (Complement Ther Clin Pract. 2015 Feb;21(1):7-10) Adequate protein intake is essential (J Nutr. 2012 Aug;18(2):173-84) Cancer Related Fatigue: Potential Interventions Panax quinquefolius (Wisconsin/American Ginseng) at 2000 mg/day x 8weeks has shown benefit (J Natl Cancer Inst. 2013 Aug 21;105(16):1230-8) Caution: American Ginseng should not be used with patients with hormonally related cancers (breast cancer) as there is some evidence of potential for estrogenic activity in some products May also have risk for drug interactions, so caution with medications metabolized through CYP3A4) 10

Insomnia: Potential Interventions Ensure adequate assessment and treatment of underlying disorders (for example: pain, depression, anxiety, vasomotor symptoms) The following may be helpful: Cognitive behavioral therapy with sleep hygiene Exercise Yoga Melatonin Cancer J. 2014 Sep-Oct;20(5):330-44 Hot Flashes/Night Sweats: Potential Interventions Can be experienced by both men and women who are on hormonal therapy The following may be helpful: Magnesium oxide (Support Cancer Care. 2011 Jun;19(6):859-63) EPA (omega 3 in fish oil) (Menopause. 2009 Mar-Apr;16(2):357-66) Acupuncture (Cancer Nurs. 2015 Jun 3) Yoga (Am J Obstet Gynecol. 2014 Mar;210(3):244) Exercise(research is conflicting) Resources for Integrative Oncology Memorial Sloan-Kettering Cancer Center About Herbs Database (provides evidence-based information about herbs, botanicals, and supplements): www.mskcc.org/cancer-care/integrative-medicine/about-herbsbotanicals-other-products American Cancer Society-Complementary and Alternative Therapies (evidence-based reviews): www.cancer.org/treatment/treatmentsandsideeffects/complementar yandalternativemedicine/index The Society for Integrative Oncology: www.integrativeonc.org 30 11

Dietary Supplement Interaction Resources NCCAM Herbs at a Glance : www.nccam.nih.gov/health/herbsataglance.htm Natural Medicines Comprehensive Database: created by PharmD s. Evidenced-based website that is constantly updated and very user-friendly for healthcare professionals. Paid subscription. www.naturaldatabase.therapeuticresearch.com/home Examine.com: an independent organization that presents unbiased research on supplements and includes citations: http://examine.com/supplements/ Consumer Labs: Independent source on supplement quality. Paid Subscription. www.consumerlab.com 31 Overall Resources Oncology Association of Naturopathic Physicians (for a listing of naturopathic physicians board certified in naturopathic oncology): www.oncanp.org National Comprehensive Cancer Network (NCCN) Guidelines for Supportive Care (for Cancer-related Fatigue, Pain, Symptom management, and Survivorship): http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#su pportive 32 Questions? 12

Integrative Oncology Shauna Birdsall, ND, FABNO Director of Naturopathic Medicine and Integrative Oncology Cancer Treatment Centers of America at Western Regional Medical Center 13