Transcript Clinical Controversies in Complementary and Alternative Medicine

Integrative Oncology
Sian Cotton, PhD
Associate Professor
Departments of Family and Community Medicine and Pediatrics
Director, UC Health Integrative Medicine
UC/CCHMC Center for Integrative Health and Wellness
John Sacco, MD
Radiation Oncologist, OHC, Inc.
Weil Fellow Integrative Medicine, University of Arizona
Adjunct Assistant Professor, Dept Medical Education
UC Health Integrative Medicine
Objectives
1. Define alternative, complementary, and
integrative medicine (IntM)
2. Describe rates and predictors of IntM use
both in general and in oncology
3. Define integrative oncology
•
Latest evidence for integrative approaches
4. Case presentation
5. UC/CCHMC IntM initiatives and resources
The History of CAM
Complementary
Medicine
1980s
Alternative
Medicine
1990s
National Center for
Complementary and
Alternative
Medicine (NCCAM)
Eisenberg
NEJM
1991
Office for the Study
of Unconventional
Medical Practices
1993
1997 1998
IntM fellowship
Dedicated to exploring CAM
Practices
Practices
not
not
generally
generally
recognized
recognizedbyby
Office
of
Alternative
in the
context
of rigorous
of Arizona
1 inUniversity
3 community;
Americans
use
CAM
medical
medical
community;
used
used
inwith
place of
Medicine
science and disseminating
conventional
conventional
medicine
medicine
research findings
Cohen et al., 2007; http://nccam.nih.gov/health/whatiscam/ Rakel, (2012). Eisenberg et al. (1993).
2000s: Integrative Medicine
“Combines
treatments from
conventional medicine and CAM
for which there is some highquality evidence of safety and
effectiveness”
http://nccam.nih.gov/health/whatiscam/; Rakel (2012).
NCCAM Classifications
• NCCAM Classifications:
1.Natural Products (e.g., herbs and supplements)
2.Mind-Body Medicine (e.g., yoga and acupuncture)
3.Manipulative and Body-Based Practices (e.g.,
chiropractic and massage)
4.Other CAM Practices (e.g., Reiki and traditional Chinese
medicine)
• Definition of CAM constantly changing
The practice of integrative medicine: A legal and operational guide, Cohen et al., 2007;
http://nccam.nih.gov/health/whatiscam/; Rakel (2012). Eisenberg et al. (1993).
Tenets of Integrative Medicine
Relationshipcentered
Optimal healing
environment
Removes barriers to
activate innate healing
response
Uses natural, less
invasive interventions
before costly, invasive
ones when possible
Engages mind, body,
spirit, and community
Healing is always
possible, even if
curing is not
Rakel (2012). Integrative Medicine. Philadelphia: Saunders Elsevier., 3rd Edition
Role of the Provider
“Research suggests that our presence as medical or
mental health clinicians, the way we bring ourselves
fully into connection with those for whom we care, is
one of the most crucial factors supporting how people
heal – how they respond to our therapeutic efforts.”
Daniel Siegel, The Mindful Therapist, 2010
Integrative Medicine Use
Rates of IntM Use in American Adults
(1990-2007)
% of Adults Using CAM
45
40
35
30
25
20
15
10
5
0
1990
1992
1994
1996
1998
2000
2002
2004
2006
Year
Barnes, PM, Bloom, B, and Nahin, R. CDC National Health Statistics Report #12. CAM use among adults and children, United
States, 2007, December 2008; Eisenberg, D., Davis, R., Ettner, S., Appel, S., Wilkey, S., Van Rompay, M. (1998). Trends in
alternative medicine use in the U.S., 1990-1997: Results of a follow-up national survey. JAMA, 280(18), 1569-1575
2008
10 Most Common IntM Therapies
Among Adults- 2007
Barnes, PM, Bloom, B, and Nahin, R. CDC National Health Statistics Report #12. CAM use among
adults and children, United States, 2007, December 2008.
Diseases/Conditions For Which IntM Is Most
Frequently Used Among Adults – 2007
Barnes, PM, Bloom, B, and Nahin, R. CDC National Health Statistics Report #12. CAM use among
adults and children, United States, 2007, December 2008.
Why Do People Use IntM?
• Relieve symptoms of diseases and chronic illnesses
• Relieve side effects associated with conventional
medical treatments
• Increase perceived control over own health
• Support a holistic health philosophy
• Improve overall health
Barnes, PM, Bloom, B, and Nahin, R. CDC National Health Statistics Report #12. CAM use among
adults and children, United States, 2007, December 2008.
IntM Use in Cancer Patients
• Patients with chronic illnesses, including cancer, use
CAM more than people without chronic illness
• 70% of 365 colon, breast, or prostate cancer patients
use at least one type of CAM
– 65% dietary supplements
– 83-97% for general health vs. 8-56% for cancer Tx specifically
• 26-81% of all cancer patients use supplements
• Systematic review of 26 surveys of cancer patients from
13 countries: average prevalence 31%, highest 64%
• 48% of 250 women with gynecologic or breast cancer
– Only 54% of which informed their healthcare provider
Patterson et al., 2004; Ernst et al., 1998; Navo et al., 2004; Klempner, Bubley, 2012
Costs of IntM Use
Total = $33.9 billion
• $22 billion (64%) self-care
• $11.9 billion (35.2%)
practitioner visits
• Compared to 1997
− Increase from $20 billion
− Majority of costs from
self-care rather than
practitioners
Relaxation
therapies
0.6%
Practitioner Costs
35%
Homeopathic
Medicine
Yoga, tai chi,
9%
qigong
12%
Nahin et al. (2009). Costs of complementary and alternative medicine (CAM) and frequency of visits of CAM
practitioners: United States, 2007. National Health Statistics Report, 18, 1-16.
Natural Products
44%
Integrative Oncology
“It is more important to know
what sort of patient has a disease
than what disease a patient has.”
~Sir William Osler
What is Integrative Oncology?
The rationale, evidencebased combination of
conventional therapy
with complementary and
alternative interventions
into an individualized
therapeutic regimen that
addresses the whole
person (body, mind, and
spirit) with cancer.
Goals of Integrative Oncology
• Increase patient’s sense of control
• Increase body’s innate immunity in fight against
cancer
• Increase hope
• Decrease stress
• Decrease ongoing inflammation
Targeted Intervention
• Nutrition
• Physical Activity
• Stress Reduction
• Symptom Control
Nutrition
American Cancer Society Guidelines
• Achieve and maintain healthy weight throughout life
– Balance caloric intake with physical activity
– Avoid excessive weight gain throughout the life cycle
– Be as lean as possible without being underweight
• Adopt physically active lifestyle
– Adults: at least 150 minutes of moderate intensity or 75
minutes of vigorous intensity each week
– Children and adolescents: at least 60 minutes of moderate
to vigorous activity each day, with vigorous activity at least
3 days/week
Kushi et al., (2012). American Cancer Society Guidelines on nutrition and physical activity for
cancer prevention. CA: A Cancer Journal for Clinicians, 62, 30-67.
American Cancer Society Guidelines
• Consume healthy diet, with an emphasis on plant sources
– Choose foods and beverages in amounts that help achieve
& maintain healthy weight
– Eat at least 2 ½ cups of vegetables and fruit each day
– Choose whole grains in preference to refined
– Limit consumption of processed and red meats
• Drink no more than one alcoholic drink per day for women or
two per day for men
Kushi et al., (2012). American Cancer Society Guidelines on nutrition and physical activity for
cancer prevention. CA: A Cancer Journal for Clinicians, 62, 30-67.
Nutrition
More than 35% of all cancers in the US may be related to
diet…both what we eat and what we don’t eat
Cancer Site
% link to excess body fat
Cases Prevented Annually
Esophagus
35%
6,111
Pancreas
19%
8,345
Gallbladder
21%
2,060
Colorectum
16%
22,954
Breast (postmenopausal)
17%
38,568
Endometrium
49%
23,094
Kidney
24%
15,544
Total Estimate
21%
116,676
AICR/WRCF (2012). Policy and Action for Cancer Prevention. www.preventcancer.aicr.org
BMI in Breast and Prostate CA
• Increased BMI equated with increased breast CA risk
in postmenopausal women
– Risk up 18% for every 5 point ↑ in BMI
• Increased BMI independent predictor of treatment
failure in prostate CA s/p XRT
– Predicts biochemical and clinical failure
– Obese men two-fold increase risk of mets
Strom , 2006
Anti-Inflammatory Food Pyramid
www.drweil.com
Curcumin
Molecular Targets of Curcumin
Molecular Targets of Curcumin
Physical Activity
Physical Activity and Cancer
• International Agency for Research on Cancer
estimates 25% cases worldwide due to overweight,
obesity and a sedentary lifestyle
• Study of controlled physical activity in overweight,
sedentary, postmenopausal women
– Decreases in serum estrogen, testosterone
– Decreased serum insulin
www.dietandcancerreport.org
Exercise in Colon Cancer
• 832 pts with Stage III colon cancer s/p resection and
adjuvant chemotherapy
– 6 or more hours/wk of exercise equivalent to
moderate paced walking (2-3 mph)
– 47% greater chance of disease-free survival c/w
controls
• 573 nurses > 6mos s/p resection for Stage I-III colon
cancer
– Activity led to 61% reduction in death from
colorectal cancer
Meyerhardt, J. A. et al. (2006). Physical activity and survival after colorectal cancer diagnosis.
Journal of Clinical Oncology, 24, 3527-3534.
Exercise in Breast Cancer
• Exercise improves energy level
• Exercise may decrease weight gain associated with
chemotherapy
• Exercise may reduce risk of post-surgical
lymphedema
• Elevated endorphin levels relieve tension and
depression
• Walking 3 hrs/wk at moderate pace reduces the risk
of death from all causes for breast cancer survivors
Mind-Body Therapies for
Stress Reduction
Hypnosis Before Breast Cancer Surgery
• N=200 women
• Scripted 15 minute hypnosis session within 1 hour of
surgery by trained psychologist
• Control group spent 15 minutes w/psychologist
talking and receiving emotional support
• All others blinded to patient group
Montgomery et al,. 2007
Hypnosis Before Surgery
• Women in the hypnosis group:
– Required less anesthesia
– Reported less pain, nausea, fatigue
– Spent 10.5 minutes less in the OR, saving $770
Montgomery et al,. 2007
Symptom Control
Acupuncture in Cancer
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Antiemetic during chemotherapy
Pain control, including neuropathy
Anxiety/Depression
Xerostomia after radiation therapy
Hot flashes secondary to hormonal therapy
Chronic post-chemotherapy fatigue
Constipation/diarrhea
Sleep disturbance
Acupuncture for Xerostomia
• Randomized Swedish Trial
– 24 tx, 2 groups, placebo controlled (sham)
– 68% vs. 50%, p=.05
• Johnstone, n=50; historical control
– 70% w/ significant improvement using 3-4 weekly Tx
• Fudan Univ/MDACC
– PREVENT xerostomia in patients with nasopharyngeal
cancer
– 3x/wk for duration of XRT, benefit up to 6 mo
Johnstone; Meng, 2011
Acupuncture for
Chemo-Induced Nausea
• Cochrane review of 11 RCTs (N = 1247) of acupuncture combined with
pharmacologic antiemetics
•
Reduced incidence of acute vomiting across all acupuncture methods (RR = .82,
95% CI = .69 to .99, p = .04), but not nausea severity
•
Only acupressure reduced nausea severity (SMD = -0.19, 95% CI = -.37 to -0.01)
•
Noninvasive electrostimulation showed no benefit for any outcome
• Randomized study of needle or laser acupuncture combined with
pharmacologic antiemetics for pediatric oncology patients (N = 11)
•
Acupuncture reduced antiemetic mediccation use (p = .02)
•
No difference in episodes of vomiting (p = .37) or level of nausea (p > .10)
•
One patient reported side effect of pain from needling
• Review of literature, NIH consensus statement, and federal regulations
• Concluded that acupuncture and acupressure are safe and effective for
chemotherapy-induced nausea and vomiting
Ezzo et al., 2010; Reindel et al., 2006; Melchart et al., 2006; Collins & Thomas, 2004
Benefits of Acupuncture
• Equal to velafaxine in relief of hot flashes
• Effective in hot flashes in men undergoing ADT for prostate
cancer
• Safe in children with cancer Rx related thrombocytopenia
• Effective for cancer-related fatigue in breast cancer
• Decreases chronic xerostomia symptoms
Walker et al., 2010; Beer et al., 2010; Ladas et al., 2010; Molassiotis e tal., 2012; Simcock et al., 2013
P-Stim
• Pulse stimulation treatment for pain management
• FDA-approved device sends continuous flow of
intermittent low frequency electrical pulses to nerves
in the ear
• RCTs show safety and significant pain reduction for up to 50% of
patients with a range of pain conditions
• Cochrane review of two RCTs for cancer pain (N = 64) reported
no significant difference than placebo but need for controlled,
adequately-powered studies
• Successful case study for pain reduction in patient with cancer
bone pain
Rushton, 2002; Robb et al., 2008; Searle et al., 2009
Massage Therapy for Cancer
• Psychological Changes
–
–
–
–
–
Increase mood
Reduce anxiety
Relaxation of the mind
Increase pain threshold
Decrease stress
Corbin 2005; Kanitz 2012
• Physiological Changes
– Improved blood and lymph
flow
– Reduce muscle tension
– Reduce blood pressure
– Helps promote
postoperative wound
healing and reduction of
scar tissue formation by
increased circulation
– Abdominal massage has
been advocated to reduce
constipation
Manual Lymphedema Drainage
PRE TREATMENT
POST TREATMENT
Manual Lymphedema Drainage
PRE TREATMENT
POST TREATMENT
Targeted Supplements
• CoQ 10
– Chemotherapy-induced myocardial dysfunction
– Fatigue
– Concurrent statin therapy
• L-Glutamine
– Treatment-induced mucositis
– CIPN
• Black Cohosh
– Vasomotor instability
Hot Topics in Integrative Oncology
• Epigenetic expression
• Naturally occurring chemopreventive
substances
• Naturally occurring molecular target modifiers
• Oncometabolic milieu
• Controlling inflammation
Epigenetics in Action:
The Agouti Mouse
Epigenetics and Prostate Cancer
• Men with prostate cancer not electing
treatment (surgery, radiation, hormone
therapy) enrolled
• Gene expression compared after 3 months on
diet
• Expression of 500+ genes changed
• Oncogenes were down-regulated
Ornish D. et al: Changes in prostate gene expression in men undergoing an intensive
nutrition and lifestyle intervention. Proc Natl Acad Sci USA. 2008 Jun
17:105(24):8369-79
Examples of Natural Molecular
Target Modifiers
Marker
Nutraceuticals
COX-2
Curcumin, fish oil, ginger, Scutellaria baicalenis
IGF-I
Lycopene, genistein, quercetin
MDR
Rosemary extract, fish oil, indole-3-carbinol
VEGF
Luteolin, apigenin, milk thistle
P53
Green tea (EGCG), genistein
EGFR
Curcumin, resveratrol, grape seed extract
Ras
Garlic, limonene, tocotrienols
HER2/neu
Green tea, olive oil
PTEN
Indole-3-carbinol, soy isoflavones
Rakel (2012) Integrative Medicine, 3rd edition
Blood
Glucose
and
Cancer
Survival
Blood Glucose & Cancer Survival
Survival in Mice with
Injected Breast Cancer Cells
Survival of
Brain Tumor Patients
% surviving
70 days
Survival
in months
100
15
75
90%
50
11
67%
25
0
8
33%
3.7%
60
4.7%
88
14.5 mo
5.4%
108
9.1 mo
4
A1c
Approx. Blood Glucose (mg/ dl)
SOURCE: Santisteban GA, et al: Glycemic modulation
of tumor tolerance in a mouse model of br east cancer.
Biochem Biophys Res Commun, Nov 1985;132(3):1174-9.
0
65-93
94-137
138
Mean Blood Glucose Lev el (mg/ dl)
SOURCE: Derr R, et al., Association between hyperglycemia
and survival in patients with newly diagnosed
glioblastoma. J Clin Oncol, Mar 1, 2009;27(7):1082-6.
10
Integrative Oncology Consults
“The role of the physician is to cure
sometimes, heal often, support always”
Integrative Oncology Evaluation
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Reason for visit
Recent and past history
Social history - snapshots of personal, professional life
Family history – with an eye on epigenetics
ROS including environmental exposure
Stressors and antecedents
Nutritional history
Exercise history
Spirituality
Prior experience with IM – supplements, meditation,
massage, etc
• PE
• A and P
Commonly Used Integrative Modalities
• Nutritional Counseling
• Exercise Assessment and Prescription
• Sleep Assessment and Recommendations
• Stress Assessment
• Motivational Interviewing
• Acupuncture
• Massage
• Meditation and Breathwork
• Guided-imagery
• Metabolic Evaluation, Particularly Post Treatment
Case Presentation
• 78 y.o. African American gentleman with
a history of prostate cancer
• 1994 - Adenocarcinoma cT1cN0M0
Gleason 7 (4+3), Pre-treatment 11.4
• Rx – neo adjuvant depolupron (3 mos)
Followed by definitive XRT (7200cGy)
PSA curve
2005: added flax,
pom, Zyflamend
2006:
corrected
Vit D level
2004: declined
lupron; added
green tea
Integrative Medicine at
UC/CCHMC
Consortium of Academic Health Centers for
Integrative Medicine
1999 - Duke Univ, Harvard Univ, Stanford Univ,
UCSF, Univ Arizona, Univ Maryland, Univ Mass,
Univ Minnesota.
60
2000 - Albert Einstein/Yeshiva Univ,
Georgetown, Thomas Jefferson Univ.
2002 - UTMB, Univ Pittsburgh, Univ Washington,
Univ Pennsylvania, Univ Hawaii, UMDNJ, Univ
50
Michigan, Columbia.
2003 - UCLA, OHSU, Univ Calgary (Canada),
George Washington Univ.
2004 - Univ Connecticut, Univ New Mexico, UCI,
40
Wake Forest, Univ Alberta (Canada).
2005 - Laval Univ (Canada), UNC-Chapel Hill,
Univ Wisconsin.
2006 - Univ Colorado, Univ Kansas, Univ
30
Vermont, Mayo Clinic, Yale.
2007 - Vanderbilt, McMaster (Canada), Johns
Hopkins.
2008 - Boston Univ, Northwestern Univ, Ohio
20
State.
2009 – Univ Cincinnati, Univ IL-Chicago.
2010 – Univ Chicago, UCSD.
10
2011 – Mount Sinai, UT MD Anderson, Aurora
Health Care*, Cleveland Clinic, Tufts University;
Laval Univ. withdrawn.
2012 – Allina Health*, Univ of Southern
0
California, Universidad Autónoma de
Guadalajara, Scripps Center for Integrative Medicine*.
2013 – Temple , Texas Tech, Univ of Miami,
Univ IL-Chicago withdrawn
*affiliate institutional member
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CAHCIM
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28
39
56
50
42
44
46
31
23
19
8
11 11
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
www.imconsortium.org
Current Initiatives at UC COM
• To develop and sustain a premier Center for Integrative Health
and Wellness at the UC COM
• Horizontal integration with Centers for Excellence / Programs
Clinical
• Interdisciplinary, focus
on optimizing wellness
• Multiple clinical locations
with IntM physicians,
psychologists, therapists;
group space
•Women’s Health Ctr
• Barrett Ctr
• Collaborate with CCHMC;
community IntM
practitioners
Education
• Curriculum integration;
4th year elective
• Develop Medical Student
Scholars Program in IntM
• Eventual resident and
fellowship IntM training
• Faculty IntM grand
rounds/ seminars
Research
• Develop strong portfolio
of federal and foundation
sponsored IntM projects
• Comparativeness
effectiveness studies of
IntM model to usual care
with national CAHCIM
PBRN
• Examine sustainable
models of IntM care
Clinical Services
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Integrative physician consult (most insur accepted)
Acupuncture (auricular/ear)
Massage therapy
Reflexology/Acupressure
Mindful coping with cancer group
Nutrition evaluation and support
Health and wellness coaching
Yoga for cancer and Pilates therapy
Tai Chi and medical QiGong
475-WLNS (9567)
UC Integrative Medicine Research
• Multi-site RCT examining Progressive Muscle Relaxation (PMR)
for seizure frequency reduction in adults with stress-related
epilepsy (Privitera/Cotton)
• Neurofunctional Changes Associated with Mindfulness Based
Cognitive Therapy (MBCT-C) for Anxiety Symptoms in Youth at
Risk for Bipolar Disorder (Delbello/Cotton/Sears)
• School-based RCT examining feasibility and efficacy of a
breathing retraining intervention, as compared to an
education control, in African-American adolescents with
asthma (Cotton)
• Omega-3 FA vs placebo for 12 weeks in children/adolescents
with depression and at least one bipolar I parent, fMRI pre/post (Delbello/McNamara)
How to Refer to Integrative Medicine?
• Call (you or your patient) 475-WLNS (9567)
• Women’s health center schedulers
• We DO see male patients at this location…
• Barrett Center second site Jan 2014
• We WILL see non-cancer patients at this location…
• In EPIC
• Meds and Orders
• Under Orders search Acupuncture (Wellness for MD)
• Or Search by Integrative Medicine
http://uchealth.com/services/integrative/
Resources
Finding the Evidence
• www.pubmed.org
• www.nccam.nih.gov
• http://nccam.nih.gov/health/providers
• Medline Plus Complementary and Alternative Medicine
www.nlm.nih.gov/medlineplus/complementaryandalternative
medicine.html
• http://ods.od.nih.gov/
Books
Thanks!
[email protected]
[email protected]
LACE Study
• Life After Cancer Epidemiology Study followed 1954
breast cancer survivors diagnosed 1997-2000 for 6.3
years
• 282 breast cancer recurrences ascertained
• Isoflavone intake assessed
• Soy intake levels comparable to those consumed in Asian
population
• May reduce the risk of recurrence in women who have been treated with
tamoxifen
• In postmenopausal women (HR -.48, 0.21-.79, p = .008)
• Does not appear to negate the effects of tamoxifen
• Further confirmation required before recommendations issued
Guha et al., Breast Cancer Researfch and Treatment, 2009