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with the system. [3] At the same time, a medical malpractice crisis exists in the face of sky-rocketing costsand rising cancer incidence rates.

The National Institutes of Health (NIH) estimated the overall cost for cancer in the year 2003 at $189.5billion: $64.2 billion for direct medical costs, $16.3 billion for indirect morbidity costs, and $109 billion forindirect mortality costs. It is estimated that the current lifetime risk for development of cancer in the UnitedStates is 1 in 2 for men and 1 in 3 for women. [2] In addition, there are now more than 10 million cancersurvivors, who are often ill-equipped to handle their special needsmedical, psychosocial, and lifestyleissues. The majority of these patients state that their oncologists do not give them needed assistanceafter active antineoplastic care. [4] [5]

Patients with cancer increasingly turn to practitioners of CAM while remaining high users of conventionalapproaches as well. [6] [7] [8] [9] [10] [11] [12] [13] [14] They spend billions of dollars per year out of their ownpockets on various CAM therapies. There has been a trend away from use of CAM by specificsubgroups, such as highly educated females, to a more diverse user group. [3] Physicians have scantformal education in CAM approaches and can offer little advice about these modalities. [15] The result:Beneficial CAM therapies are under-utilized in the realms of prevention and supportive care; dangerousinteractions can exist between some CAM and conventional treatments; and delays in beginningconventional treatment can result in cancer dissemination and death. [16]

Expanded Domain

An integrated, evidence-based approach improves on the weaknesses of today's splintered system whilebuilding upon its strengths. A truly comprehensive integrative approach will address all participants at alllevels of their being and experience. It will address all of the individuals involvedpatients, families,providers, communities, and members of societyat all levels of being (mind, body, soul, and spirit) in alllevels of experience, that is, the self, the role in a specific culture, and the effects of and on the naturalenvironment ( Fig. 75-1). [1]

FIGURE 75-1 Definition of a comprehensive integrative approach. (From Mumber MP: Principles of integrative oncology. InMumber MP (ed): Integrative Oncology: Principles and Practice. London, Taylor & Francis, 2005, p 7.)

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In order to meet the needs of this diverse group of individuals, a team approach to care is necessary.That team will require an appropriate coordinator. In the field of cancer care, the conventionally trainedoncologist would appear to be the best candidate to serve as conductor of the orchestra because his orher knowledge of conventional therapy is key to a safe and efficacious integrative approach. It wouldcertainly seem to be more efficient to educate conventional physicians about referral to appropriate CAMproviders, rather than vice versa. The main reason is the extent of biomedical information that one mustdigest in order to fully understand, recommend, and use conventional approaches to treat individuals.The majority of oncologists surveyed believe that it should be one of their responsibilities to counselcancer survivors in lifestyle and health management solutions after cancer care; however, only a minorityof oncologists provides this service. [5]

Philosophy of Integrative Oncology

Much can be learned about creating a sustainable model of cancer medicine from the philosophy of manyCAM approaches and their foundation in medicine's guiding principles. Please refer to the Part I,Integrative Medicine Philosophy, which deals with the difference between a focus on healing and afocus on curing. Oncology is recognized as a field in which high rates of burnout can occur. Examples ofinterventions that may help create a sustainable system of care include attention to the stress reductionneeds of oncologists and to improving communication skills, such as in delivering bad news. [17]

Functional Aspects of Integrative Oncology

Adherence to the philosophical underpinnings of integrative medicine provides the foundation for some ofthe specific functional aspects that further differentiate integrative oncology from a purely conventionalbiomedical approach ( Table 75-1).

TABLE 75-1 -- Defining Functional Aspects of Integrative Oncology

Tools may have transformational and translational intent.

Inclusion of preventive, supportive, and antineoplastic goals.

Use of Precautionary Principle for situations with limited data.

From Mumber MP: Principles of integrative oncology. In Mumber MP (ed): Integrative Oncology: Principles

and Practice. London, Taylor & Francis, 2005, p 10.

Translation versus Transformation

The addition of CAM methods to a physician's complement of tools is quickly becoming a reality as morepositive research on the benefits of these tools becomes available. Yet the addition of new tools throughresearch and clinical application, regardless of whether they are CAM or conventional, will do little todifferentiate integrative oncology from biomedicine; it will merely add new options to an already bulgingtoolbox.

In contrast, most CAM therapies are rooted in systems that can provide an entirely new viewpoint.[3]

Thisdual nature can be thought of as the translational and transformational aspects of CAM approaches. [18] Translationis defined as that aspect of an intervention that moves directly into a specific desiredoutcome. For example, two proven translations of a yoga practice might be greater flexibility andimproved sleep. Transformationis defined as that aspect of an intervention that opens up the possibilityof seeing the world from a new frame of reference, to see the world with new eyes. For example, theyoga practice already described may bring about a new sense of mastery, a physical, emotional, mentaland spiritual opening, allowing an individual to forgive old grievances and develop comprehensive healthylifestyle changes.

There are significant differences between the translational and transformational aspects of care ( Table75-2). They also share features, namely that both aspects are experiential and contextual. They are both

It is important to categorize any oncology intervention as translational or transformational in naturethose methods that have personal transformation as a goal require mainly that the intervention is safe,

and evidence concerning their efficacy is of lesser importance.




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experienced on multiple levelsphysically, mentally, emotionally, and spiritually. They are alsocontextual on multiple levelsas they relate to the self, the individual's culture, and the surroundingnatural environment.

TABLE 75-2 -- Differentiating Characteristics of Interventions with Translational andTransformational Intent

TRANSLATIONAL TRANSFORMATIONALA specific tool, technique, or instrumentdesigned to deliver a specific measurableoutcome

A highly individualized experience that involves a profoundperspective shift of the essence of larger sense of purpose,meaning, and/or fulfillment

Outcome is quantitatively measurable Outcome is qualitative and difficult to define or measure

External locus of control Internal locus of control

Reductionistic-can be broken into parts Irreducible, whole

Definable, discrete, deliverable, andreplicable

Ultimately mysterious-one can set up conditions for it but cannotforce it to occur

Understandable on a rational level Frequently indescribable

Has levels of effect All-or-nothing effect

Adapted from Mumber MP: Principles of integrative oncology. In Mumber MP (ed): Integrative Oncology:

Principles and Practice. London, Taylor & Francis, 2005, p 11.

One method of incorporating CAM is to develop logical guidelines to assist in clinical decision-making.The translational tool aspect of CAM must be judged through the use of appropriate levels of evidence,similar to those used for the majority of conventional translational approaches. When the goal of CAM isprimarily transformational as a part of supportive care, however, clinical decision guidelines based in parton efficacy and safety are not as applicable, because of the rather nebulous outcomes that areintrinsically a part of a transformational experience. Outcomes are distinctly individualized and difficult todefine, predict, or measure, except through a qualitative, testimonial type of feedback. Therefore, theprimary concern for transformational interventions is that they are demonstrated to be safe. Safety ismeasured in this context with regard to cost, applicability at a specific time in the patient's care, methodsused, and provider experience and skills. This is significantly different, with regard to level of evidencerequirements for tools with specific outcomes, which must meet both safety and efficacy requirements.

For example, in order to recommend yoga as an intervention to help improve sleep, one would needevidence concerning its safety and efficacy. If a patient were to desire to enter into a practice that couldimprove self-understanding, the recommendation of yoga would be based primarily on its safety, takinginto account the patient's situation.

Prevention, Supportive Care, and Antineoplastic Therapy

In order to practically advise patients concerning therapeutic options, one must be able to characterizethe proposed intervention as having a specific goal of prevention, supportive care, or antineoplastictherapy. Doing so allows the care team to place priorities, determine levels of evidence required forrecommendations, and discuss specific risks and benefits.

The three general categories of prevention are primary, secondary, and tertiary. These three generalcategories affect individuals with differing characteristics. Primary prevention has a goal of lowering risk ina population with normal risk level. An example would be reducing lung cancer rates in the entirepopulation of nonsmokers. Secondary prevention tries to lower the rate of onset of disease in individualswith elevated risk or with existing precancerous changes; an example is reducing lung cancer rates inlong-time smokers with premalignant changes. Tertiary prevention focuses on prevention of recurrence inindividuals who have been successfully treated and are disease free.

Prevention can be a very powerful approach in order to lessen the overall cost, morbidity, and mortalityassociated with cancer. For example, it is estimated that one third of cancers may be prevented throughdietary changes alone. [2] Providing education at an early age about healthy eating and lifestyle patternscould greatly reduce lifetime risk. Counseling individuals at any level of prevention may affect other




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individuals on different levels. Relatives of current cancer patients may have a higher risk of diseasedevelopment and represent a significant population with a vested interest in both primary and secondaryprevention. Cancer recurrence may likewise be lowered in cancer survivors through a variety of lifestylechanges. Survivors can be educated about healthy lifestyle and then trained to become lay healthadvisors in the community. [19] Physicians who actively practice healthy lifestyle choices have a greatersuccess rate counseling their patients to select such interventions. [20]

Supportive care interventions may make cancer therapy easier to deliver by addressing physical,emotional, educational, and psychosocial needs. Major textbooks and journals are now dedicated tosupportive care in oncology [21] and an entire field of study and practice known as psychooncology. [22] One major goal of these approaches is to improve the therapeutic ratioa measure that reflects theability of patients to tolerate effective antineoplastic therapy. Treatments that will eliminate cancer fromthe body may be so toxic as to be intolerable for patients. Improvements in the therapeutic ratio cantherefore come through improving patient tolerance to therapy or increasing the effectiveness ofantineoplastic treatments so that lower doses are required. CAM therapies have significant potential assupportive care options that improve patient tolerance and compliance. [1]

The most heated debate about CAM versus conventional therapies is in the field of antineoplastic care,even though the majority of CAM therapies are preventive and supportive in nature. Many currentantineoplastic therapies have their origin in what some would consider CAM methods. For example, the

drug paclitaxel (Taxol) was initially isolated from the Pacific yew tree. The Office of CancerComplementary and Alternative Medicine (OCCAM) is a branch of the National Center of Complementaryand Alternative Medicine (NCCAM), the National Cancer Institute (NCI)sponsored organizationspecifically responsible for CAM research relative to cancer. In an attempt to monitor modalities that havetheir primary action through measurable tumor response, the NCI Best Case Series (NCI-BCS) Programwas introduced. This has resulted in several active trials of novel antineoplastic alternative approaches.Some examples are the Kelly-Gonzalez approach for the treatment of pancreatic cancer and the use ofantineoplastons in brain tumors.

The NCI-BCS process begins with inquiries into therapies proposed by users or developers. Casescenarios are submitted, followed by rigorous evaluation of pathology, radiographic studies, and otherdiagnostic and treatment aspects of specific cases. This analysis must include documented and objectiveassessment of tumor response, proof of a lack of concurrent conventional therapy, and documentationthat the alternative treatment was delivered. Once all of the data have been reviewed, therapies thatappear promising are presented to an advisory panel. If there is sufficient evidence to justify furtherresearch, the panel may decide to pursue investigation of the therapy either as part of a PracticeOutcomes Monitoring and Evaluation System (POMES) or through the use of independent researchers.Over the past 5 years, three therapies have made it through to the phase of further research; they are:

The NCI-BCS system may be expanded in the future to include researchers in addition to those who

have developed a particular therapy, in order to accomplish research in a more timely fashion. [23]

In addition to these NCI-based efforts, there is an organization called the Society for Integrative Oncology(SIO). SIO is a nonprofit, multidisciplinary organization founded in 2003 for health professionalscommitted to the study and application of complementary therapies and botanicals for patients withcancer. It provides a forum for presentation, discussion, and peer review of evidence-based research andtreatment modalities. The SIO makes a clear distinction between alternative or unproven andcomplementary or tested useful therapies in cancer care. More information about this organization canbe found on its Web site at: www.integrativeonc.com/

The Precautionary Principle

A homeopathy approach used at a clinic in India for nonsmall cell lung cancer

Insulin potentiation therapy, which uses insulin along with low doses of conventionalchemotherapy

Macrobiotic diet therapy

It is important to categorize any oncology intervention as to its general goalprevention, supportive

care, or antineoplastic therapy. Doing so helps define the level of evidence necessary to make arecommendation for or against its use.


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The development of clinical guidelines requires that providers make appropriate recommendations, evenin situations for which data are limited. Categorizing the intent of supportive care treatment astranslational or transformational in nature is one example of differentiating the level of evidence requiredto make a recommendation, as does defining the specific therapeutic goal as prevention, supportive care,or antineoplastic therapy. The precautionary principle can help with decision-making as well.

The precautionary principle was originally formulated as a way of making environmental policy in

situations for which data were limited. The Rio Declaration on Environment and Development, adopted ata 1992 United Nations conference held in Rio de Janeiro, defined the principle as a precautionaryapproach that is used to protect the environment when there are threats of serious or irreversible damageand scientific uncertainty should not be used to postpone cost-effective measures. [24]

This principle was developed in medicine in order to address situations in which the collection of data thatwould absolutely prove efficacy and safety of a particular treatment or approach is prohibitive. As anextreme example, it is not practical to do a randomized trial of dumping sewage into the water supply inorder to measure health effects. The precautionary principle (among other things) would tell us that onthe basis of the limited data available, such dumping would have significant health hazards and would beinadvisable. A more subtle example is the difficulty of prospectively measuring the health effects ofxenoestrogens from pesticides used on foods meant for humans. The precautionary principle would tell

us to avoid them, if possible, until further data are available.

This principle has been expanded for use in health care situations, specifically for breast cancerprevention. [25] [26] [27] It can be applied to preventive and supportive interventions, in which the usual toolsof biomedical research are impractical. Using the precautionary principle should not be seen as anexcuse to advance one's hypotheses without evidence, but can allow physicians and other providers toact in situations in which limited data are available, if that action is almost certainly safe and deemed

necessary.

Another aspect of the precautionary principle deems that significant risk of adverse outcomes be presentin order to justify going forward with limited data. This is inherently a judgment call and may be difficult toquantify, especially in the realms of supportive care and prevention. For example, the use of antioxidantvitamins during radiation therapy has been debated for years. Proponents say that it may lessen sideeffects, whereas detractors say that it could protect the tumor from being destroyed by treatments. Theprecautionary principle in this situation could result in recommending against the use of antioxidantsupplements during treatments because of the possibility that it could protect tumor cells from lethaldamage and thereby affect disease controla significant and irreversible risk. After treatment, patientsmay be interested in taking antioxidants for general supportive care and prevention of recurrence, despitethe fact that data in support of their use for either purpose are limited. In this situation, the precautionary

principle may lead one to recommend supplementation because of the significant risk of recurrence,persistent fatigue, and so on. In this case, the risk of adverse outcomes and the presence of preliminarydata on safety and efficacy could tip the scales in favor of recommendation.

These types of decisions are not to be taken lightly. A significant caveat of the precautionary principle isthat future data may show that we have made a mistake and recommended something that wasdetrimental. Therefore, an analysis of the entire clinical situation, with appropriate informed consent, isalways necessary. As one climbs up the ladder of intervention from prevention to supportive care and,ultimately antineoplastic therapy, the use of the precautionary principle becomes more difficult torationalize.

Clinical Decision-Making

The precautionary principle can be used for treatments or interventions in situations in which limiteddata are available, as long as there is a complete discussion of the risks and benefits and informedconsent. The precautionary principle is best used for preventive and supportive interventions; it isdifficult to justify its use for antineoplastic therapies, unless the options available are extremely limited.

The precautionary principle would recommend against using antioxidant supplements during radiation

therapy treatment because of the possibility that they could protect tumor cells from lethal damageand thereby affect disease control.




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A comprehensive approach to decision-making in integrative oncology will address multiple issues in allparticipants at all levels of their being and experience ( Table 75-3). It will take into account prevention,supportive care, and antineoplastic treatment. It will make rational recommendations based on thespecific situation of the patient, the general and specific goals of therapy, the levels of evidenceconcerning safety and efficacy for specific interventions, and a resulting risk-to-benefit analysis.

TABLE 75-3 -- Factors to Consider in Clinical Decision Making for Integrative Oncology

FACTOR DEFINITION

Patient clinical situation Acute versus subacute presentation and need for intervention Disease stageand type Prognosis

Specific treatment goals PreventionSupportive careAntineoplastic care

General preventive approach PrimarySecondaryTertiary

General supportive careapproach

Translational versus transformational utility:Improve tolerance of antineoplastic therapySymptom controlGeneral quality of lifeEnd-of-life care

General antineoplasticapproach

Curative versus palliative

Level of evidence for therapy Data levels I-IV, for both safety and efficacyRisk-to-benefit ratio-including cost, toxicity, and chances of beneficial andharmful outcomes

From Mumber MP: Clinical decision analysis. In Mumber MP (ed): Integrative Oncology: Principles and

Practice. London, Taylor & Francis, 2005, p 146.

Levels of Evidence

Reviewing the research on a particular therapy requires an understanding of the weight of the findings. Ascheme that ranks the importance of research is the concept of levels of evidence, which is based on thestudy design and sample size. Two organizations, the National Cancer Institute (NCI) and the U.S.Agency for Health Care Policy and Research (AHCPR), have developed ranking criteria for levels ofevidence. A schema has been proposed for the use of such criteria in integrative oncology on the basis ofthese classification systems. [28] This proposed system functions well for both CAM clinical trials andbasic science trials reporting a therapeutic outcome such as tumor response, improved survival, or qualityof life. It also allows for some weight of evidence from expert committee opinions and traditional uses.

The schema consists of levels I through IV, with I representing the highest level of evidence, and IV thelowest ( Table 75-4).

TABLE 75-4 -- Schema for Levels of Evidence in Integrative Oncology

Level I Well-designed randomized controlled clinical trial(s)

Level II Prospective and retrospective nonrandomized clinical trials and analyses

Level III Opinions of expert committees, best case series

Level IV Preclinical in vitro and in vivo studies, and traditional uses

From Stark N, Hess S, Shaw E: Clinical research and evidence. In Mumber MP (ed): Integrative Oncology:

Principles and Practice. London, Taylor & Francis, 2005, p 22.

It is important to note that some CAM therapies do not allow for the highest level of evidence to be




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accomplished because randomized controlled trials of the therapies are not feasible. In this situation, it isvery important for the clinician to weigh all the decision-making factors before making a recommendationbased on informed consent.

Data on Safety and Efficacy

An integrative approach to oncology cannot be founded on the indiscriminate addition of new methods,tools, and providers to our biomedical system. Such an approach must involve a critical appraisal of

modalities that may enhance response to biomedical therapies or improve the quality of life for patientswith cancer, their families, and providers of care. For oncologists and medical providers caring forpatients with cancer, the growing interest in CAM therapies raises concerns about efficacy and safety aswell as appropriate ways to counsel patients about their use. The deaths of patients with prostate cancerwho were taking PC-SPES, a botanical supplement that had shown some preliminary antineoplasticefficacy, reinforce the importance of ensuring that therapies are safe as well as efficacious. [29]

It is necessary not only to ensure the safety of a therapy taken as a single agent but also to know thepotential adverse effects if it is combined with other medications or therapeutic regimens. This concern isof particular importance in cancer treatment, in which patients may be receiving multiple concurrent orcontinuous forms of therapy for extended periods. Oncologists and other practitioners treating patientswith cancer or counseling them about treatment options face significant challenges in deciding both how

to approach recommending the use of CAM therapies and how to determine the value of incorporatingCAM therapies into clinical practice. The ability to understand research findings on CAM therapies anddetermine the applicability of findings to practice is essential. [28]

A full understanding of safety and efficacy data is a major component in decision-making. Please seeFigure 75-2for a tabular presentation of recommendations for or against a specific therapy based onavailable data.

As one climbs up the pyramid of therapeutic goals ( Fig. 75-3), the evidence level required torecommend a therapy increases. Antineoplastic therapies must have definitive level I evidence of bothsafety and efficacy. Preventive and supportive therapies that can be tested in a randomized fashion mustalso meet this criterion, especially when recommended for use during treatment with antineoplasticinterventions proven to be effective.

FIGURE 75-2 Relationships among safety, efficacy, and recommendation of treatments. Light gray indicates that clinician

should recommend the use of a treatment; black indicates that the clinician should recommend against the use of a

treatment. Medium gray indicates that the clinician should recommend caution about using a treatment and should follow the

patient closely; the precautionary principle may tip toward or against the use of a particular treatment, depending on the

particular situation. (Adapted from Cohen MH, Rosenthal D: Legal issues. In Mumber MP (ed): Integrative Oncology:

Principles and Practice. London, Taylor & Francis, 2005, pp 101-120.)




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Intervention Timing Relative to Course of Cancer Experience

Another important aspect of developing an approach to integrative oncology is the wide range of needs ofall the individuals involved in the process and the fact that needs vary over the course of time. Forexample, Cunningham and Edmonds [30] have identified a hierarchy of different types of mind-bodytherapy based on increasingly active participation by the patient with cancer at different phases of his/herclinical course. [30] These five intervention types are providing information, emotional support, behavioraltraining in coping skills, psychotherapy, and spiritual/existential therapy ( Table 75-5). Carlson hassuggested therapeutic possibilities for patients with cancer based on the needs that generally arise atspecific times in the course of the cancer experience ( Table 75-6). [31]

TABLE 75-5 -- Suggested Psychosocial Interventions for Clinical Stages of Cancer Experience

FIGURE 75-3 The pyramid of therapeutic goals. Level of evidence for both safety and efficacy increases as one rises up thepyramid. Maximally effective antineoplastic therapy depends on the solid foundation of prevention and supportive care.

(From Stark N, Hess S, Shaw E: Clinical research and evidence. In Mumber MP (ed): Integrative Oncology: Principles and

Practice. London, Taylor & Francis, 2005, p 35.)

CLINICAL

STAGE

PSYCHOSOCIAL

PICTURE

SUGGESTED PSYCHOSOCIAL

INTERVENTION

LEVEL OF

INVOLVEMENT

Diagnosis AnxietyInformation seekingDepression

PsychoeducationInformation provisionEmotional support

LowLowMedium

Treatment AnxietyTreatment side effects

Coping skills trainingEmotional support

MediumMedium

Recovery Reintegration Emotional support Medium




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Depression Psychotherapy High

Recurrence DepressionDeath and dying

PsychotherapySpiritual/existential therapy

HighHigh

Data from Cunningham AJ, Edmonds CV: Group psychological therapy for cancer patients: A point of view,

and discussion of the hierarchy of options. Int J Psychiatry Med 26:51-82, 1996.

TABLE 75-6 -- Therapeutic Possibilities for Patients with Cancer

SITUATION NEEDS THERAPEUTIC POSSIBILITIES

Diagnosis Information, addressing ofanxiety levels

Psychoeducation, relaxation

Activetreatment

Treatment tolerance Cognitive behavioral therapy with focus on active copingstrategies, imagery, hypnosis, relaxation, creative arts

Recovery Regain strength, existentialissues (meaning, purpose)

Meditation, yoga, creative arts therapies

Survivorship Promote health, address fear of

recurrence

Support groups, retreats

Palliation Symptom control, quality of life Coping strategies, imagery, hypnosis

End-of-lifecare

Transition, transcendence Address spirituality and symptom control, meditation,creative therapies

From Carlson LE, Shapiro SL: Mind-body interventions. In Mumber MP (ed): Integrative Oncology: Principles

and Practice. London, Taylor & Francis, 2005, p 187.

Other patient-related variables that the clinician may find helpful to take into account when assessingwhich interventions may be appropriate are the patient's personality characteristics, spiritual/religiousbeliefs, physical limitations, readiness to make changes, as well as simple preference for and comfort

with different modalities. Further research is necessary to define the needs of other participants in theprocess as well. [32]

General Recommendations

Multiple considerations go into decision-making and recommendations in the formulation of a treatmentplan for a specific individual. Despite this complex set of factors, concise recommendations can be madethat are evidence-based. Tables 75-7 through 75-9 [7] [8] [9] delineate general treatment options forprevention, supportive care, and antineoplastic therapy interventions and their clinical settings, as well aslevels of evidence. They contain a partial list of the most common interventions. For a morecomprehensive review, please consult a dedicated text on integrative oncology.

TABLE 75-7 -- General Cancer: Primary, Secondary, and Tertiary Prevention

INTERVENTION CLINICAL INDICATION LEVEL OF

EVIDENCE

Nutrition:Plant-based dietIndividual foods:Green teaSoyOmega-3 fats from fish, walnuts, flaxseed (including

flax lignans)Lycopene-containing foods-esp. tomato sauceHigh fiber intakeIndividual phytochemicals:

Antioxidant vitamins (A, C, E, selenium)Mushroom extracts

Multiple cancer typesMultiple cancer typesMultiple cancer typesMultiple cancer typesMultiple cancer typesMultiple cancer typesMultiple cancer typesUnknownMultiple cancer types

II, III, IVII, III, IV II, III, IV II,III, IVIII, IVII, III, IVII, III, IVNoneIII, IV




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TABLE 75-8 -- General Cancer: Supportive Care

TABLE 75-9 -- General Cancer: Antineoplastic Therapy

Curcumin

Physical activity Multiple cancer types II, III, IV

Mind-body:Stress reduction

Unknown, possible positiveeffect

IV

Botanicals:Milk thistle

Scutellaria baicalensis(prostate cancer)

Multiple cancer typesProstate cancer

IV IV

Tobacco cessation Multiple cancer types II, III, IV

MODALITY/INTERVENTION BENEFIT LEVEL OF

EVIDENCE

Physical activity:Mild/moderate

Improved fatigue, quality of life (QOL) II, III

Nutrition:

DietIndividual foods: soy [*] Individual phytochemicals: [*]

coenzyme Q10[*]

SupplementationMVI and antioxidants [*]

Decreased hot flashes

Possible cardiac protection, improved fatigue(breast cancer)Improved tolerance of conventional therapies(may also protect tumor)

Conflicting level

II, IIIIVConflictingII, III, IV

Mind-body:YogaHypnosisMeditationSupport groups

Improved QOL, sleep, anxietyImproved anxietyImproved anxiety, sleepImproved QOL

II, IIIII, IIIII, IIII, II, III

Manual therapy:

Massage and manualLymphatic drainage

Improved lymphedema

Improved anxiety, sleep

I, II, III

II, III

Botanicals:Black cohosh [*] Panax ginseng [*] Calendula cream

Improved hot flashesImproved fatigueImproved skin reaction to radiation

Conflicting levelI, II, IIIII, IIII, II, III, IV

Energy medicine:Biofield techniques

Improved fatigue and QOL II, III

Alternative systems:Acupuncture

Nausea prevention I, II, III

Spirituality and prayer Social support Improved anxiety, QOL I, II, III* May interact unfavorably with conventional treatments or cause tumor protection/stimulation for certain tumor types.

MODALITY/INTERVENTION BENEFIT LEVEL OF EVIDENCE

Physical activity: Mild-moderate None None

NutritionDiet:Plant-basedFiberSpecific diets (macrobiotic, Gerson)Individual foods:Green tea

NoneNoneCell killCell killCell killCell killCytostatic Improved survival

none noneConflicting III, IVIVIVIVIVPreliminary II, III, IV




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Models of Care

For administrators and/or physicians engaged in the startup phase of an integrative oncology program,one place to turn for guidance is to those who have gone before. The number of integrative oncologycenters in North America is growing, according to a 2002 American Hospital Association survey. [33] These centers, which are being developed both in association with hospital systems and as free-standingventures, tend to add CAM services to existing conventional carethat is, medical care in such centersremains a priority. Most are directed by a physician, and those that are directed by naturopaths,osteopaths, or persons with PhDs most often have a physician on staff. [33] For the reader's ease ofreference and contact, Table 75-10lists several of these centers.

TABLE 75-10 -- Examples of Models of Care

SoyGrapeseed extract (proanthocyanidin)CurcuminAvemar (fermented wheat germ)Mushroom extractsIndividual phytochemicals:Individual vitamins (A, C, E, selenium)

Cell killNone (may have tumor protective effect)

IVConflicting level I, II, III,IV

Mind-body:YogaHypnosisMeditationSupport groups

Possible positive (decreased PSA in onestudy)NoneNoneImproved overall survival

Preliminary level INoneNoneConflicting Level I, II, III

Manual therapy:Massage, chiropractic, strain-

counterstrain

None None

Botanicals:Panax ginseng, flax lignans, red clover[*]

Iscador (mistletoe)Essiac tea

Estrogen like activity- AVOID with breastcancerAnti-tumor efficacy

None

IVConflicting I, II, III, IVI, II

Energy medicine None None

Alternative systems:Chinese herbs Cell kill IV

Spirituality Prayer Increased cell killImproved overall survival

IVII

* May interact unfavorably with conventional treatments or cause tumor protection/stimulation for certain tumor types.

Consult-basedintegrative oncology:

Academic centers Leonard P. Zakim Center for Integrated TherapiesDana-Farber Cancer InstituteBoston, Massachusettswww.dana-farber.org/pat/support/zakim_default.asp

Place of wellnessM. D. Anderson Cancer Center Houston, Texaswww.mdanderson.org/departments/wellness

Freestanding centers Multidisciplinary Group Practice: California Hematology Oncology Medical GroupLos Angeles and Torrance, California www.CHOMG.com

Informed, Networking, CAM-Trained Clinicians:Harbin Clinic Cancer Services

Rome, Georgia Contact: [email protected] Group Practice: Center for Integrated Healing Vancouver, BC,Canada www.healing.bc.ca


http://www.dana-farber.org/pat/support/zakim_default.asphttp://www.mdanderson.org/departments/wellnesshttp://www.chomg.com/mailto:[email protected]://www.healing.bc.ca/http://www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619http://www.mdconsult.com.millenium.itesm.mx/das/book/body/158401619http://www.healing.bc.ca/mailto:[email protected]://www.chomg.com/http://www.mdanderson.org/departments/wellnesshttp://www.dana-farber.org/pat/support/zakim_default.asp


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Hospital-basedintegrative oncology

Cancer Treatment Centers of America Zion, IL and Tulsa, Oklahomawww.cancercenter.com

Hospital-basedpediatric integrativeoncology

Children's Hospital and Clinics Minneapolis, Minnesotawww.childrenshc.org/communities/integrativemed.asp

Adapted from Boyce J: Models of care. In Mumber MP (ed): Integrative Oncology: Principles and Practice.

London, Taylor & Francis, 2005, p 84.

Conclusions

Integrative oncology has the potential to transform both individuals and the system of cancer care. In theprocess, a more sustainable approach to health care can emerge, grounded in the guiding principles ofmedicine and focusing on all participants at all levels of their experience. Integrative oncology also hasthe potential to improve outcomes with regard to prevention, supportive care, and antineoplastic therapy.

We are at a critical juncture in the evolution of health care. In order for the development of an integrativeapproach to oncology to be successful, the efforts of researchers, clinicians, patient advocate groups,corporate health care workers, and policymakers must be combined. Such a process will allow for rational

planning, development, and implementation in the setting of diminishing resources.

Acknowledgements

The author would like to acknowledge the contributing authors of Integrative Oncology: Principles andPractice, whose critical thinking have influenced this chapter, especially Judy Boyce, Linda Carlson,Michael Cohen, and Nancy Stark.

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