Integrative Medicine

There are many sources of information about these complementary therapies on the internet, but most are self-serving (the source of the information stands to profit from the alternative therapy). I am convinced that modern cancer therapies can be effective and that they should not be delayed to try complementary therapies. If there are no standard therapies available, complementary therapies are reasonable. This does not mean that a lung cancer patient should not try to eat a healthy diet during therapy, but I recommend that patients do not take megadoses of any natural or alternative supplement. There are many sources of information about these complementary therapies on the internet, but most are self-serving (the source of the information stands to profit from the alternative therapy). I am convinced that modern cancer therapies can be effective and that they should not be delayed to try complementary therapies. If there are no standard therapies available, complementary therapies are reasonable. This does not mean that a lung cancer patient should not try to eat a healthy diet during therapy, but I recommend that patients do not take megadoses of any natural or alternative supplement.

Turmeric is a spice commonly used in traditional Indian cooking and medicine. It accounts for the deep yellow color of some curries. Curcumin is a chemical found in turmeric that has some activity against cancer cells in a laboratory. Turmeric is mainly used for its anti-inflammatory properties. A search of the National Cancer Institute database on clinical trials did not reveal any human trials on cancer prevention with turmeric. This is still being investigated in the lab, and if successful there, will move on to human trials. Turmeric is a spice commonly used in traditional Indian cooking and medicine. It accounts for the deep yellow color of some curries. Curcumin is a chemical found in turmeric that has some activity against cancer cells in a laboratory. Turmeric is mainly used for its anti-inflammatory properties. A search of the National Cancer Institute database on clinical trials did not reveal any human trials on cancer prevention with turmeric. This is still being investigated in the lab, and if successful there, will move on to human trials.

White flour is highly processed as compared to whole grains. White flour and other processed foods should be avoided as part of a healthy diet. White flour and white sugar have a high glycemic index/load. When you eat them their sugar is immediately absorbed and causes a spike in blood sugar followed by a spike in insulin. This can ultimately lead to insulin resistance and the development of diabetes. White flour is highly processed as compared to whole grains. White flour and other processed foods should be avoided as part of a healthy diet. White flour and white sugar have a high glycemic index/load. When you eat them their sugar is immediately absorbed and causes a spike in blood sugar followed by a spike in insulin. This can ultimately lead to insulin resistance and the development of diabetes.

For most patients, it will be safe to take a multivitamin during chemotherapy and radiation that does not contain more than 100% of the US RDA. This is certainly reasonable since it is often difficult to “eat well” during treatment. An exception might be patients who are receiving 5-FU based chemotherapy. There is an interaction between 5-FU and folic acid that can make dosing and managing side effects problematic. Check with your oncologist on that one. For most patients, it will be safe to take a multivitamin during chemotherapy and radiation that does not contain more than 100% of the US RDA. This is certainly reasonable since it is often difficult to “eat well” during treatment. An exception might be patients who are receiving 5-FU based chemotherapy. There is an interaction between 5-FU and folic acid that can make dosing and managing side effects problematic. Check with your oncologist on that one.

Vitamin D is one hot topic these days, and it’s easy to get carried away with the enthusiasm. What we know about vitamin D and cancer prevention is this: we’re not sure. The studies that have been done looking at an association of vitamin D levels and cancer incidence have been mixed with regard to whether or not vitamin D is associated with a lower risk of cancer. I stress the word “association” here. We really don’t know if there is any causal relationship between vitamin D and cancer incidence. People who have normal vitamin D levels or who are taking vitamin D supplements may have other lifestyle factors that contribute to their overall good health. A randomized controlled clinical trial would be the gold standard to establish a causal relationship and we don’t have one yet. I recommend that you have your vitamin D level checked by your primary care physician and I think it is reasonable for most people to take a vitamin D supplement. Vitamin D is one hot topic these days, and it’s easy to get carried away with the enthusiasm. What we know about vitamin D and cancer prevention is this: we’re not sure. The studies that have been done looking at an association of vitamin D levels and cancer incidence have been mixed with regard to whether or not vitamin D is associated with a lower risk of cancer. I stress the word “association” here. We really don’t know if there is any causal relationship between vitamin D and cancer incidence. People who have normal vitamin D levels or who are taking vitamin D supplements may have other lifestyle factors that contribute to their overall good health. A randomized controlled clinical trial would be the gold standard to establish a causal relationship and we don’t have one yet. I recommend that you have your vitamin D level checked by your primary care physician and I think it is reasonable for most people to take a vitamin D supplement.

There are some situations in which a cancer patient may want to be sure to drink more water than usual. Some of these situations would include having nausea or diarrhea during treatment (these can lead to dehydration), receiving treatment that makes it difficult to swallow, or getting a chemotherapy that is potentially toxic to the kidneys. The question remains, how much water is enough? That can depend on a lot of factors (physical activity, humidity in the environment, amount of perspiration) and can vary from one individual to another. The Institute of Medicine recommends about 13 cups for men and 9 cups for women as a general guideline. Logic would dictate that you certainly need enough to prevent dehydration. Some of the symptoms of dehydration include fatigue, headache, lightheadedness, dry mouth and skin, decreased urination, constipation, and of course thirst. There are some situations in which a cancer patient may want to be sure to drink more water than usual. Some of these situations would include having nausea or diarrhea during treatment (these can lead to dehydration), receiving treatment that makes it difficult to swallow, or getting a chemotherapy that is potentially toxic to the kidneys. The question remains, how much water is enough? That can depend on a lot of factors (physical activity, humidity in the environment, amount of perspiration) and can vary from one individual to another. The Institute of Medicine recommends about 13 cups for men and 9 cups for women as a general guideline. Logic would dictate that you certainly need enough to prevent dehydration. Some of the symptoms of dehydration include fatigue, headache, lightheadedness, dry mouth and skin, decreased urination, constipation, and of course thirst.

I require a very complete set of medical records for my new patients. I review these carefully. If I am unfamiliar with any aspect of their cancer or treatment, I research by reading my oncology text books, reading published studies and consulting with my naturopathic and oncologist colleagues. My first visits with new patients are typically 90 minutes so that I can learn as much as I can about each person as an individual (after all they are people with cancer, not just cancer diagnoses). I then several more hours developing my recommendations, which stem from my experience and additional research. I then provide my consultation note and my recommendations to the patient and to their other healthcare providers. I typically follow-up with patients in accordance with their treatment and disease experience on a repeated basis. I require a very complete set of medical records for my new patients. I review these carefully. If I am unfamiliar with any aspect of their cancer or treatment, I research by reading my oncology text books, reading published studies and consulting with my naturopathic and oncologist colleagues. My first visits with new patients are typically 90 minutes so that I can learn as much as I can about each person as an individual (after all they are people with cancer, not just cancer diagnoses). I then several more hours developing my recommendations, which stem from my experience and additional research. I then provide my consultation note and my recommendations to the patient and to their other healthcare providers. I typically follow-up with patients in accordance with their treatment and disease experience on a repeated basis.

Warning signs that you are dealing someone of questionable ethics when it comes to cancer care are:
• They promise you a cure that conventional treatment won’t give you
• They are asking you to spend a significant amount of money on treatment. Most complementary therapies are not covered by insurance, but watch out for those who are asking for a significant amount of money from you for their treatment.
• They recommend that you discontinue treatment with your oncologist. There may come a time when you choose to discontinue treatment with your oncologist but that’s a conversation that you should have with him or her and usually after potentially curative therapies have been exhausted or the side effects of therapy outweigh any potential benefits.
• They have a miracle cure that the FDA won’t approve.
• Ask about whether or not there are published studies on the effectiveness of the treatment they are recommending for you.
• Be careful if they tell you there are no risks or side effects
• Use your common sense…if it sounds too good to be true, it probably is. Warning signs that you are dealing someone of questionable ethics when it comes to cancer care are:
• They promise you a cure that conventional treatment won’t give you
• They are asking you to spend a significant amount of money on treatment. Most complementary therapies are not covered by insurance, but watch out for those who are asking for a significant amount of money from you for their treatment.
• They recommend that you discontinue treatment with your oncologist. There may come a time when you choose to discontinue treatment with your oncologist but that’s a conversation that you should have with him or her and usually after potentially curative therapies have been exhausted or the side effects of therapy outweigh any potential benefits.
• They have a miracle cure that the FDA won’t approve.
• Ask about whether or not there are published studies on the effectiveness of the treatment they are recommending for you.
• Be careful if they tell you there are no risks or side effects
• Use your common sense…if it sounds too good to be true, it probably is.

Cancer programs may vary depending on the size of your medical center and the services that are available to you. Academic medical centers that are involved in cancer research often have the NCI designation “Comprehensive Cancer Center”. Just because a cancer center calls itself “comprehensive” does not necessarily mean it has this NCI designation. Smaller community cancer programs have often been accredited by the American College of Surgeons and this would be something you should ask about. A radiation oncology program should be accredited by the American College of Radiology.

There are no defined criteria for an “integrative” cancer care program. There are several things you should look for, however. One would be a physician, preferably an oncologist, who has done additional training in integrative medicine. There is an associate fellowship program in integrative medicine at the University of Arizona which was developed by Dr. Andrew Weil and is the one I have completed. A few other universities offer fellowship programs in integrative medicine so you should ask the integrative medicine physician what his or her additional training has been. In two to three years there will hopefully be a national board certification for integrative medicine physicians which will make the task of finding one infinitely easier. An integrative cancer program should emphasize evidence-based therapies that are combined with conventional therapies.
Cancer programs may vary depending on the size of your medical center and the services that are available to you. Academic medical centers that are involved in cancer research often have the NCI designation “Comprehensive Cancer Center”. Just because a cancer center calls itself “comprehensive” does not necessarily mean it has this NCI designation. Smaller community cancer programs have often been accredited by the American College of Surgeons and this would be something you should ask about. A radiation oncology program should be accredited by the American College of Radiology.

There are no defined criteria for an “integrative” cancer care program. There are several things you should look for, however. One would be a physician, preferably an oncologist, who has done additional training in integrative medicine. There is an associate fellowship program in integrative medicine at the University of Arizona which was developed by Dr. Andrew Weil and is the one I have completed. A few other universities offer fellowship programs in integrative medicine so you should ask the integrative medicine physician what his or her additional training has been. In two to three years there will hopefully be a national board certification for integrative medicine physicians which will make the task of finding one infinitely easier. An integrative cancer program should emphasize evidence-based therapies that are combined with conventional therapies.

As soon as possible. Check in with an integrative oncologist so that you understand the potential interactions between any of your complementary therapies and conventional treatment. Also you should get some information on things you can be doing to help with side effects and get on to living a healthier life. Why wouldn’t you want to do that as soon as possible? As soon as possible. Check in with an integrative oncologist so that you understand the potential interactions between any of your complementary therapies and conventional treatment. Also you should get some information on things you can be doing to help with side effects and get on to living a healthier life. Why wouldn’t you want to do that as soon as possible?

EmbodiWorks provides an educational website with integrative cancer care resources about whole person health and healing in five areas–body, mind, spirit, social, and environmental. We also have a Resources section to help cancer patients and caregivers navigate their cancer journey. Our goals are to reduce cancer risk and improve cancer-related survival, quality of life, and whole person health care.

Please visit our site at www.embodiworks.org. There are several great ones (unfortunately there are many more to be avoided!)
MSK Cancer Center Integrative Medicine: http://www.mskcc.org/cancer-care/integrative-medicine
MD Anderson Cancer Center (CIMER):http://www.mdanderson.org/education-and-research/resources-for-professionals/clinical-tools-and-resources/cimer/index.html
Pub Med (National Library of Medicine): http://www.ncbi.nlm.nih.gov/pubmed/
National Cancer Institute: http://www.cancer.gov/cancertopics/pdq/cam/cam-cancer-treatment/patient/page2

Meditation has been shown to reduce stress, improve mood, and affect immune function, but studies have not yet established whether it prevents cancer recurrence. However, just because a study hasn’t been done yet to prove meditation prevents recurrence, does not mean it won’t be helpful. Stress and depression are often associated with higher morbidity and mortality rates among people with chronic disease in general, so anything you can do to manage your stress will be good for your health. In terms of the type of meditation, I suggest selecting the one you like the best and feels the most right to you. People vary a lot in their response to various forms of meditation and stress reduction. If you are in or around Massachusetts, for classes I highly recommend the UMass Center for Mindfulness http://www.umassmed.edu/Content.aspx?id=41252 originally founded by Jon Kabat-Zinn. Meditation has been shown to reduce stress, improve mood, and affect immune function, but studies have not yet established whether it prevents cancer recurrence. However, just because a study hasn’t been done yet to prove meditation prevents recurrence, does not mean it won’t be helpful. Stress and depression are often associated with higher morbidity and mortality rates among people with chronic disease in general, so anything you can do to manage your stress will be good for your health. In terms of the type of meditation, I suggest selecting the one you like the best and feels the most right to you. People vary a lot in their response to various forms of meditation and stress reduction. If you are in or around Massachusetts, for classes I highly recommend the UMass Center for Mindfulness http://www.umassmed.edu/Content.aspx?id=41252 originally founded by Jon Kabat-Zinn.

Insomnia is a really common problem for cancer patients. Although there are very effective prescription medications out there, most have some unwanted side effects. Effective nonprescription treatments for insomnia include regular exercise (preferably not just before bedtime), a balanced diet, meditation, acupuncture, and yoga just to name a few. For those of you who are still intent on taking a little something at bedtime to help you sleep, I usually recommend some combination of hops, valerian, lemon balm, and/or passion flower. Chamomile tea is helpful as well. Insomnia is a really common problem for cancer patients. Although there are very effective prescription medications out there, most have some unwanted side effects. Effective nonprescription treatments for insomnia include regular exercise (preferably not just before bedtime), a balanced diet, meditation, acupuncture, and yoga just to name a few. For those of you who are still intent on taking a little something at bedtime to help you sleep, I usually recommend some combination of hops, valerian, lemon balm, and/or passion flower. Chamomile tea is helpful as well.

This is really a common side effect with Tamoxifen treatment and all too frequently leads to discontinuation of a really helpful drug. Recommendations that are at the top of the list include regular exercise and a Mediterranean diet. Do those first. Next I would consider acupuncture. There was a study in the Journal of Clinical Oncology a couple of years ago that compared acupuncture to an antidepressant drug commonly used for hot flashes called Effexor. Acupuncture was just as effective in decreasing hot flashes and patients reported increased libido, and improvements in energy, clarity of thought, and sense of well-being with acupuncture. Side effects for the Effexor group included dry mouth, nausea, constipation,and decreased appetite. Black cohosh is another option. I won’t go into all the weaknesses of the big studies that have been done on black cohosh and hot flashes but I’ll summarize by saying the preponderance of the evidence shows that black cohosh is effective in treating hot flashes. It is not a phytoestrogen as some have believed in the past. Many of the common herbal preparations used for hot flashes do contain phytoestrogens so I would avoid those and stick with plain black cohosh. This is really a common side effect with Tamoxifen treatment and all too frequently leads to discontinuation of a really helpful drug. Recommendations that are at the top of the list include regular exercise and a Mediterranean diet. Do those first. Next I would consider acupuncture. There was a study in the Journal of Clinical Oncology a couple of years ago that compared acupuncture to an antidepressant drug commonly used for hot flashes called Effexor. Acupuncture was just as effective in decreasing hot flashes and patients reported increased libido, and improvements in energy, clarity of thought, and sense of well-being with acupuncture. Side effects for the Effexor group included dry mouth, nausea, constipation,and decreased appetite. Black cohosh is another option. I won’t go into all the weaknesses of the big studies that have been done on black cohosh and hot flashes but I’ll summarize by saying the preponderance of the evidence shows that black cohosh is effective in treating hot flashes. It is not a phytoestrogen as some have believed in the past. Many of the common herbal preparations used for hot flashes do contain phytoestrogens so I would avoid those and stick with plain black cohosh.

The most basic would be a metabolic panel (sometimes called a chem 7 or basic chemistry). It basically is a picture of the electrolyte balance in your body and kidney function. With this test the bicarbonate level will give your doctor an idea of any acid-base problems. The other way to directly measure blood pH is an arterial blood gas. Here blood is taken directly from the artery (usually the radial artery in the wrist) and information about the level of oxygen and carbon dioxide in your blood helps direct your care—usually ventilator settings (yep, this is the “in the intensive care unit” scenario). The most basic would be a metabolic panel (sometimes called a chem 7 or basic chemistry). It basically is a picture of the electrolyte balance in your body and kidney function. With this test the bicarbonate level will give your doctor an idea of any acid-base problems. The other way to directly measure blood pH is an arterial blood gas. Here blood is taken directly from the artery (usually the radial artery in the wrist) and information about the level of oxygen and carbon dioxide in your blood helps direct your care—usually ventilator settings (yep, this is the “in the intensive care unit” scenario).

No, please save your money. For a more detailed answer please see (http://talkabouthealth.com/how-are-ph-and-the-acid-alkaline-balance-related-to-cancer).

Make sure you understand tests that actually measure acid-base balance. It must be a blood test. Salivary or urinary tests will not completely measure acid-base balance in your blood. No, please save your money. For a more detailed answer please see (http://talkabouthealth.com/how-are-ph-and-the-acid-alkaline-balance-related-to-cancer).

Make sure you understand tests that actually measure acid-base balance. It must be a blood test. Salivary or urinary tests will not completely measure acid-base balance in your blood.

This is one of the more common questions I get since there are folks out there selling alkaline water supposedly to combat acid problems related to cancer. Basically there are many half-truths out there on the internet. The half-truth behind alkaline water is that tumors exist in an acidic environment. The problem is that it is an acidic environment created by the tumor. Acid in the body is largely created by cellular metabolism and tumor cells are metabolizing at an accelerated rate. They produce more acid than the body can clear away and therefore live in an acidic environment. They outgrow their blood supply and hence their oxygen supply which also contributes to the acidity. So acid is not a cause of the tumor, it is a byproduct. Secondly there is no amount of alkaline water that you can drink that will change your body's pH. Your body has thousands of chemical reactions and mechanisms to keep your body's pH at 7.4. If you stray too far from that number then you end up in the Intensive Care Unit. Your kidneys and lungs are well equipped to help your body with acid/base balance. Drinking alkaline water will alkalinize your urine (because it is getting rid of excess base). It will do nothing for your cancer. This is one of the more common questions I get since there are folks out there selling alkaline water supposedly to combat acid problems related to cancer. Basically there are many half-truths out there on the internet. The half-truth behind alkaline water is that tumors exist in an acidic environment. The problem is that it is an acidic environment created by the tumor. Acid in the body is largely created by cellular metabolism and tumor cells are metabolizing at an accelerated rate. They produce more acid than the body can clear away and therefore live in an acidic environment. They outgrow their blood supply and hence their oxygen supply which also contributes to the acidity. So acid is not a cause of the tumor, it is a byproduct. Secondly there is no amount of alkaline water that you can drink that will change your body's pH. Your body has thousands of chemical reactions and mechanisms to keep your body's pH at 7.4. If you stray too far from that number then you end up in the Intensive Care Unit. Your kidneys and lungs are well equipped to help your body with acid/base balance. Drinking alkaline water will alkalinize your urine (because it is getting rid of excess base). It will do nothing for your cancer.

Inflammation is heat or fire in the body. This includes a distinction between acute and chronic inflammation. Think about when you've had a cut or wound. Your skin is red, flamed, and perhaps uncomfortable. That's acute inflammation. But in chronic inflammation, the "flare" does not stop. It continues on and on for months and years where the body acts with immune and other processes to heal a "wound" and yet there isn't one. The chronic inflammation then begins to support health conditions such as cancer.

To reduce inflammation, eat organic vegetables, some fruits, spices such as turmeric, and consider specific supplements. Inflammation levels can also be tested. The most common blood test is called c-reactive protein (CRP) high sensitivity available through mainstream blood laboratories. A healthy level is below 1.0 mg/L.

You can learn more about inflammation and cancer, including a more in depth explanation about inflammation and how to reduce it, in an article on the EmbodiWorks integrative cancer care resources website at http://www.embodiworks.org/cancertreatments/bodymindspirit/inflammation/. Why is there so much excitement these days about inflammation? It’s preventable, treatable (both to a degree), and it has been associated with several chronic health conditions that exert a tremendous cost on our society.

Specifically with regard to cancer, there is mounting evidence that elevated levels of markers of chronic inflammation are associated with a higher incidence of cancer. As an example, there was a really interesting study from Denmark where researchers took blood samples from 10,000 random people beginning in 1976 and then followed these folks for years to assess their health problems. Those who had an elevated c-reactive protein level (a marker of chronic inflammation), had a greater incidence of developing cancer years later, and the higher your CRP level, the worse your survival (Allin, et al. Journal of Clinical Oncology, 2009).

There is also evidence that elevated levels of inflammatory markers are associated with poorer survival in breast cancer (Pierce, et al. Journal of Clinical Oncology, 2009), and pre-treatment levels of c-reactive protein are associated with a worse prognosis in breast cancer (Allin, et al. Breast Cancer Research, 2011).

Integrative medicine comes in to play with lifestyle changes and supplements that can decrease levels of inflammation.

There is a lot you can do….and most of it does not require a prescription of any kind. Regular exercise reduces chronic inflammation. Perhaps this is why exercise has been helpful in controlling things like high blood pressure and heart disease and has been associated with better survival in cancer patients. Eating a Mediterranean diet also decreases inflammation (in fact another name for this diet is the anti-inflammatory diet). Omega-3 fatty acids (fish oil) are anti-inflammatory. Getting enough sleep, meditation, fiber, red wine (in moderation), aspirin and other non-steroidal anti-inflammatory drugs, and prescription cholesterol lowering drugs called statins all lower measures of chronic inflammation. There is a lot you can do….and most of it does not require a prescription of any kind. Regular exercise reduces chronic inflammation. Perhaps this is why exercise has been helpful in controlling things like high blood pressure and heart disease and has been associated with better survival in cancer patients. Eating a Mediterranean diet also decreases inflammation (in fact another name for this diet is the anti-inflammatory diet). Omega-3 fatty acids (fish oil) are anti-inflammatory. Getting enough sleep, meditation, fiber, red wine (in moderation), aspirin and other non-steroidal anti-inflammatory drugs, and prescription cholesterol lowering drugs called statins all lower measures of chronic inflammation.

Elevated levels of markers of chronic inflammation are associated with an increased risk of cancer (for more details: http://talkabouthealth.com/what-is-meant-by-the-term-inflammation-in-the-context-of-cancer-and-integrative-medicine). There is a difference between association and causation. While chronic inflammation and many diseases occur together, the exact mechanisms as to how inflammation might cause illness have not yet been worked out—but what an exciting area of research! Elevated levels of markers of chronic inflammation are associated with an increased risk of cancer (for more details: http://talkabouthealth.com/what-is-meant-by-the-term-inflammation-in-the-context-of-cancer-and-integrative-medicine). There is a difference between association and causation. While chronic inflammation and many diseases occur together, the exact mechanisms as to how inflammation might cause illness have not yet been worked out—but what an exciting area of research!