Complementary measures of integrative oncology

Additional Integrative Oncology Measures

Dr. Dainora Mačiulienė Oncology and Hematology Clinic of the Lithuanian University of Health Sciences Hospital Kaunas Clinics

Introduction

Integrative oncology provides reliable and effective support alongside standard cancer treatment by offering additional measures to ensure a better quality of life for the patient. It actively involves the patient and their family in the treatment plan, promoting responsibility for their health. Healthcare providers recommend these evidence-based measures for all patients facing oncological diseases. According to literature data, up to 80% of cancer patients worldwide use one or more additional measures. Today, there is more scientific literature available on reliable, effective, and patient-centered additional integrative oncology measures. The previous issue of the journal presented the principles, history, and global position of integrative oncology, as well as its prevalence among oncological patients. In this issue, we will explore some additional measures.

Integrative Oncology Worldwide

One example of an integrative oncology center and a global leader is the Memorial Sloan-Kettering Cancer Center in New York City, United States, which operates a comprehensive support system for cancer patients called horizontal care, providing holistic care to patients and their families through all departments and specialists at the center. In addition to standard treatment, they offer acupuncture, oncological massage, music therapy, meditation, dietary recommendations, physical and psychological health consultations, and individualized wellness plans (1, 2, 4). In 2003, the Society for Integrative Oncology was established in the United States, and many cancer centers have departments or separate centers dedicated to additional measures. Integrative oncology is also well developed in Canada, Australia, and many European countries.

Additional Integrative Oncology Measures

Lifestyle Management

Nutrition, physical activity, sleep hygiene, stress management techniques, and adapting to the social environment are additional measures and recommendations aimed at identifying risk factors crucial to the course and control of the disease; providing lifestyle change guidelines to improve overall health, reduce the likelihood of disease recurrence and mortality, help manage early and late disease symptoms, and treatment-related side effects (5). Scientific research has proven and it is undisputed that quality sleep and stress management significantly impact overall health. Overweight and obesity not only negatively affect the course of oncological diseases but also lead to more frequent occurrence of treatment-related side effects and harder control over them (3, 4). The principles of integrative oncology are based on key aspects of lifestyle - specific dietary and physical activity recommendations for oncology patients, stress management techniques, and quality sleep hygiene. Although there are about 200 different additional measures described in scientific literature, all of them aim to improve patients' ability to manage their lifestyle, which is inseparable from successful treatment outcomes (3). Patients who choose additional measures usually seek better well-being, ways to boost the immune system, improve quality of life, reduce disease and treatment-related side effects (nausea and vomiting, pain, anxiety, worsened sleep, emotional and mental health), enhance survival rates (4, 5).

Acupuncture – Rediscovered Ancient Healing Tradition

Western medical specialists long ignored acupuncture, but with increasing scientific evidence, traditional Chinese medicine is gaining ground in the West. Acupuncture most commonly uses needles to stimulate specific points, and the procedure's goal for oncology patients is to alleviate various disease and treatment-induced symptoms. One such example is uncontrollable episodes of heat due to hormone therapy (3). Most research on the effects of acupuncture has focused on women with breast cancer. However, as evidence supporting the benefits of acupuncture for breast cancer patients grows, more attention is being paid to other oncological diseases (4, 6, 7). The NCCN (National Comprehensive Cancer Network) guidelines recommend acupuncture for pain, fatigue, nausea, and vomiting. More studies are emerging on the effects of acupuncture in improving control of hot flashes. In 1997, the National Institutes of Health in the United States approved acupuncture as an effective measure to suppress chemotherapy-induced nausea and vomiting. Integrative oncology guidelines emphasize that acupuncture is an effective measure in controlling acute and delayed nausea caused by carboplatin and paclitaxel. Patients also reported improved sleep quality, less frequent constipation, and overall well-being improvement (8). In the United States, over 80% of national cancer centers have included acupuncture in their programs as an additional effective measure for the care of oncology patients.

Physical Activity

In the American Cancer Society's dietary and physical activity guidelines, it is stated that cancer patients should engage in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity physical activity per week. However, resistance training, various flexibility, and balance exercises are also important (1). Physical activity is undoubtedly the most important tool for strengthening the bone and muscle system and helping to maintain bone mineral density, especially for patients undergoing hormone therapy for prostate or breast cancer (9, 10). It is important to note that during active cancer treatment, regular physical activity effectively reduces disease-related fatigue and improves not only physical parameters but also emotional well-being, strengthens the cardiovascular system, and acts as one of the measures to improve sleep quality. Physical activity is important as a preventive measure to reduce the frequency of postoperative complications or avoid prolonged rehabilitation periods. Physical activity has a significant impact on improving quality of life and shortening recovery time (11). Most oncology patients refuse or avoid physical activity due to fatigue or uncontrollable pain, often not receiving specific recommendations, fearing potential adverse effects, resulting in insufficient physical exertion that does not meet international recommendations. In rehabilitation guidelines, it is recommended to individually select exercises and their intensity, taking into account the patient's surgical treatment, specific treatment (e.g., chemotherapy or radiation therapy), treatment or disease consequences, overall condition. Physical activity is a necessary and appropriate measure to improve well-being, helping to restore body functions at any stage of disease treatment. Specific recommendations are also available for patients in terminal condition to improve quality of life when no other means of assistance are available. To ensure reliable and effective assistance, a physical activity specialist must be knowledgeable about oncological diseases, their treatment peculiarities, specialize in working with oncology patients. They should integrate not only theoretical knowledge and physical exercise programs into their practice but also be able to assess risk, disease progression, treatment complications, and develop a useful and enjoyable physical activity plan for cancer patients.

Yoga

Yoga is a spiritual, physical, and mental discipline based on Indian philosophy. Practicing yoga involves the unity of mind and body, the connection between here and now. Life with cancer is a major stressful challenge, regardless of the patient's age or diagnosis. Yoga is considered one of the effective physical, spiritual, and mental exercises recommended for any cancer patient (3). When practicing yoga, poses called asanas are performed - physical positions that include breathing control and often meditation. There are many different traditional styles of yoga described in the literature, but their goal is common - to strengthen physical capacity, flexibility, help relax, and feel better (12). Yoga is one of the most popular complementary measures for breast cancer patients and a good adjuvant therapy after specific treatment. As yoga gains popularity among patients and scientific evidence of its benefits, this method is increasingly recommended to improve the quality of life of oncology patients. Meta-analysis shows that yoga significantly reduces anxiety and depression symptoms in women with breast cancer, with 8 out of 10 women reporting a better quality of life attending yoga classes compared to a control group of passive patients (13). Researcher Yuanqing Pan noted that the positive effects of yoga are greater for women who have been practicing yoga for a longer time, so she recommends dedicating at least 3 months to practice. The intensity and duration of the practice are also important: attending yoga classes 1-3 times a week, with each session lasting 60-90 minutes, is recommended. When choosing the duration and intensity of the practice, discussing the exercises with a yoga specialist who understands the course and treatment of breast cancer is advisable. Including a yoga specialist in the treatment team is suggested, allowing for discussions about the treatment goals and patient expectations (12). A study with men with prostate cancer found that those who practiced yoga experienced significantly less specific fatigue, reduced stress, improved sexual health, mood, and quality of life (10).

Nutrition

More and more scientific studies confirm the negative impact of obesity and other harmful lifestyle factors on the development and aggressiveness of oncological diseases, as well as the course of the disease. Upon hearing a cancer diagnosis, people often seek miraculous remedies, one of them being diet (alkaline, ketogenic, macrobiotic, Paleo, and other scientifically unfounded extremes). Beneficial nutrition for oncological diseases is one that suppresses systemic inflammation, does not cause hormonal disruption or peaks of hyperinsulinemia, while ensuring an adequate intake of calories, vitamins, and micronutrients. This is an ecological, plant-based, rich in antioxidants and anti-inflammatory food and its products (3, 9).An important part of integrative oncology is a consultation with a nutrition specialist and individual dietary recommendations. Traditional medicine emphasizes that nutrition is important not only for the prevention of oncological and other diseases but also for the course of the disease, aiming to reduce the likelihood of recurrence, improve the quality of life during treatment. It is undeniable that a diet causing systemic inflammation (high total fat content, trans fats, saturated fats, consumption of products with sugar and a high glycemic index) influences the pathogenesis of ovarian cancer. Diet rich in cow's milk and lactose links to the development of ovarian cancer, while higher calcium intake reduces this risk. Green tea reduces the risk of endometrial cancer. A study conducted in Australia noted that even when diagnosed with cancer, higher serum vitamin D concentrations associate with better disease outcomes compared to low serum vitamin D concentrations. When diagnosed with cancer or experiencing progression, patients tend to follow dietary recommendations more carefully and attentively, but often gravitate towards extreme measures by choosing various diets without scientific basis (4, 6, 7). General principles of beneficial nutrition apply to patients with any oncological disease. Dietary guidelines emphasize different and important aspects that need to be known, assessed, and recommended.

Sleep - an important but often overlooked factor

Various sleep disorders are one of the most common complaints among patients with oncological diseases both during active treatment and after its completion, or when suspicions of cancer are heard. There can be various reasons for this. The most common ones are several - psychological, emotional, social, and even physical challenges, unwanted effects of medications, disruption of the circadian sleep rhythm due to treatment-related fatigue (3). Disruption of the circadian rhythm leads to an imbalance of rest and activity phases, chronic uncontrollable fatigue, loss of appetite, sleep problems. It has been found that the disruption of the usual rest and activity regimen has a negative impact on the course of lung, kidney, breast, and colon cancer, significantly worsening survival. Various chemotherapy regimens often disrupt the circadian sleep rhythm (8). The first-choice measures for managing sleep disorders are not medications, but cognitive-behavioral therapy (the gold standard), sleep hygiene, sleep diaries, and other measures that patients and doctors often lack information about. Acupuncture, stress management techniques, relaxation exercises, which reduce symptoms of depression, anxiety, and direct disease-related discomfort, are also mentioned in randomized clinical trials.

Oncological Massage

Oncological massage is a specific massage therapy tailored to the individual, taking into account the treatment and consequences of the disease, specific expectations. It is performed by a specialist who can assess the oncological situation. This is not lymphatic drainage massage. Research has proven the positive effects of massage in improving not only mood but also reducing pain, cancer-related fatigue, lymphedema, nausea, psychological stress. Massage recommendations are included in clinical treatment guidelines for oncology patients (14, 15). The massage technique is chosen individually, taking into account the course of the disease, the treatment applied, previous surgical interventions. According to international practice, the benefits of massage are felt immediately after the procedure, although the effect is short-term compared to other additional measures. Nevertheless, massage is popular for its reliability and relaxation it provides, significantly improving the quality of life for patients. Randomized clinical trials have found that massage increases the levels of CD4, CD8, NK cells. Although the results were not statistically significant, there is no doubt that oncological massage improves the emotional and physical health of patients. More research is needed to provide a scientific basis for these statements (16).

Natural Products

According to the definition of the United States National Center for Complementary and Integrative Health, natural products include: herbs, vitamins, minerals, probiotics, which are usually sold as dietary supplements and are easily accessible. More than 30% of patients over 50 years old use various dietary supplements, hoping to better control the course of the disease or unwanted effects of prescribed treatment (4). The use of herbal preparations (herbs) is very popular in many countries, including Europe: even 67% of German patients with gynecological tumors use mistletoe (Viscum album) supplements (5). In vitro studies have shown that curcumin induces apoptosis of ovarian cancer cells, increases the sensitivity of cervical cancer cells to cisplatin and paclitaxel, but inhibits the therapeutic effect of vinblastine. Ginger has anticancer effects, increases sensitivity to carboplatin. Bilberry activates apoptosis of ovarian cancer cells but interacts negatively with paclitaxel (5, 7). Although only a small part of various active natural biological substances used as dietary supplements, their effects are often underestimated and/or unknown due to a lack of knowledge about efficacy and interactions. For example, selenium, commonly used in all oncological diseases, reduces the risk of ovarian cancer, but a high amount increases the risk of prostate cancer. It is particularly important to note that thoughtlessly selected dietary supplements and their interaction with prescribed medications can be dangerous: high doses of antioxidants can inhibit the cytotoxic effects of chemotherapy drugs or radiation therapy on cancer cells; plant-based preparations affecting blood clotting can reduce platelet count and negatively affect the action of blood clotting-regulating drugs; preparations containing phytoestrogens can interact with hormone therapy; immune system stimulating preparations can reduce the effect of immune system-suppressing drugs. Such interactions can be very diverse, often unpredictable in advance, so in order to provide effective assistance, it is necessary to evaluate narrow indications for the use of natural products, taking into account possible adverse interactions with specific treatment components.

Selection of Health Measures

Integrative oncology worldwide has already accumulated clinical practice and scientific knowledge, based on which the most effective additional measures can be selected to achieve the best results, taking into account the individual condition and needs of the patient. The goal of these measures is to help control early and late disease and treatment-related adverse events, help initiate and establish necessary lifestyle changes, and improve the quality of life of patients. Oncology patients use various additional measures to improve their health, but often remain silent about these measures when talking to their oncologist. The goal of consultations with integrative oncology specialists is a specialized, comprehensive conversation that discusses not only standard treatment methods, disease progression, but also pays great attention to additional measures, respecting the thoughts, expectations, plans, opinions of the patient and their relatives regarding the discussion of dietary supplements or other potentially beneficial measures. The essential difference between integrative oncology and alternative medicine involves evidence-based recommendations and practices. Alternative medicine aims to replace standard treatments with alternative measures, often presented not only as health-promoting but also as treatment measures. Although many so-called alternative medicine specialists operate worldwide, scientific research refutes the possible positive effects of specific measures. Health and treatment guidelines emphasize the need for a comprehensive approach based on evidence-based measures. Evidence-based medicine, which began to develop only in 1980, undoubtedly changes clinical practice today. The goal of scientific research is to evaluate and support reliable and effective additional measures, critically assess literature data, and based on the latest research results, develop clinical practice guidelines. This provides doctors and specialists with the opportunity to expand the arsenal of treatment and support measures and achieve not only a more open dialogue with the patient but also better treatment outcomes. However, many studies need to be conducted and treatment standards need to be developed so that clear criteria are followed in all situations and evidence-based recommendations are applied, while maintaining an individualized, patient-centered approach. The most important factors to consider when selecting additional measures are: 1) the level and strength of evidence; 2) cost; 3) reliability and effectiveness. The main goals of applying additional measures are to enhance patient and family involvement in the treatment and health plan, giving them responsibility and tools to help themselves. Involving the patient in the team is important at any stage of treatment and after active specific treatment, when transitioning to long-term monitoring.

Summary

Integrative oncology is a discipline based on a holistic medical approach, where a person is valued as a whole, without dividing into separate organs or organ systems. The goal of integrative oncology measures is to ensure mental, physical, emotional, and spiritual health. Integrative oncology is a relatively new discipline, the development of new programs and protocols requires not only scientific knowledge but also clinical practice, often facing challenges that are often solved through collaboration between multiple centers and sharing experiences of good clinical practice.

LITERATURE 1. C.A.Buckner, R. Lafrenie, J.Denommee, et al. Complementary and alternative medicine use in patients before and after a cancer diagnosis. Current Oncology, 2018; 25:275-281. 2. S.Latte-Noar, J.Mao. Putting Integrative Oncology Into Pratice: Concepts and Approaches. Journal of Oncology Practice, 2019:15:7-14. 3. K. O‘Brien, A.Sali. A Clinician‘s Guide to Integrative Oncology. Springer, 2017. 4. G.J.Dobos, P. Voiss, I.Schwidde, et al. Integrative oncology for breast cancer patients: introduction of an epert-based model. BMC Cancer, 2012:12:1-9. 5. G.Deng, B.Cassileth, L.Cohen, et al. Integrative Oncology Practice Guidelines. Journal of the Society for Integrative Oncology, 2007:5:65-84. 6. E.Ben-Arye, N.Samuels, O.Lavie. Integrative Medicine for Female Patients with Gynecologic Cancer. The Journal of Alternative and complementary medicine, 2018:9-10:881-889. 7. D.I.Abrams. An Integrative Approach to Prostate Cancer. The Journal of Alternative and Complementary Medicine, 2018:9-10:872-880. 8. P.Fasching, F.Thiel, K.Nicolaisen-Murmann, et al. Association of complementary methods with quality of lie and life satisfaction in patients with gynecologic and breast malignancies. Support Care Cancer, 2007:15; 1277-1284. 9. C.L.Rock, C.Doyle, W.Demark-Wahnefried, et al. Nutrition and Physical Activity Guidelines for Cancer Survivors. CA Cancer Journal, 2012:62:242-274. 10. W. Divino Nilo dos Santos, A.Vieira, C.A.Barbosa de Lira, et al. Once a Week Resistance Training Imporves Muscular Strength in Breast Cancer Survivors: A Randomized Controlled Trial. Integrative Cancer Therapies, 2019:18:1-9. 11. B.Hayes, L.Brady, M.Pollak, et al. Exercise and Prostate Cancer: Evidence and Proposed Mechanism for Disease Modification. Journal of American Association for Cancer Research, 2016;10:1281-1288. 12. D.El-Hashimi, K.M.Gorey. Yoga- Specific Enhancement of Quality of Life Among Women With Breast Cancer:Systematic Review and Exploratory Metaanalysis of Randomized Controlled Trials. Journal of Evidence-Based Integrative Medicine, 2019:24:1-9. 13. H.Greenlee, M.DuPont-Reyes, L.Balneaves, et al. Clinical Practice Guidelines on the Evidence-Based Use of Integrative Therapies During and After Breast Cancer Treatment. CA Cancer, 2017:67:14-232. 14. D.Gentile, D.Boselli, G. O‘Neill. Cancer Pain Relief After Healing Touch and Massage. The Journal of Alternative and complementary medicine, 2018:9-10:968-973. 15. S.M.Sagar, T.Dryden, R.K.Wong. Massage therapy for cancer patients: a reciprocal relationchip between body and mind. Current Oncology, 2019;14(2):45-56. 16. S.Bober, C.Recklitis, A.Michaud. Improvement in sexual function after ovarian cancer: Effects of sexual therapy and rehabilitation after treatment for ovarian cancer. Cancer Cytopathology, 2018:124:176-182. 17. E.Klein, I.Thompson, C.Tangen, et al. Vitamin E and the risk of prostate cancer: TheSelenium and Vitamin E Cancer Prevention Trial (SELECT). JAM, 2011:306:1549-1556. 18. K.Block, P.Block, Ch. Gyllenhaal. Integrative Treatment for Colorectal Cancer: A Comprehensive Approach. The Journal of Alternative and Complementary Medicine, 2018:9-10:890-901. 19. C.Zollman, A.Walther, H.E.Seers, et al. Integrative Whole-Person Oncology Care in the UK. J Natl Cancer Inst Monogr,2017;52:26-28. 20. C.A.Buckner, R.M.Lafrenie, J.A.Denommee, et al. Complementary and alternative medicine use in patiens before and after a cancer diagnosis. Current Oncology, 2018;25(4)-275-281.

Publication "Internist" 2019, No. 7