Integrative Oncology : Where we have been . . . Where we are now . - - PowerPoint PPT Presentation

Margaret A. Chesney, PhD

Cancer Support Community East TN June 1, 2019

Integrative Oncology:

Where we have been . . . Where we are now . . . Where we are headed . . .

Facing Cancer Together - a program of Cancer Support Community East Tennessee

Facing Cancer Together - a program of Cancer Support Community East Tennessee

Overview

• Define integrative oncology and describe how it

created the foundation for integrative health and medicine

• Highlight why there is a growing focus on

integrative medicine and health now

• Discuss the importance of integrative oncology

as the cornerstone for cancer wellness

Facing Cancer Together - a program of Cancer Support Community East Tennessee

Integrative Oncology -

• Patient-centered,
• Evidence-informed cancer care, that integrates

Optimal Conventional Cancer Care Healthy Lifestyles

Movement Mind, body & purpose Nutrition Social Connection Wellness Commitment

Facing Cancer Together - a program of Cancer Support Community East Tennessee

Long before integrative oncology emerged …

• Research from 1952-1960 by Arthur Sutherland and

colleagues studied the “adaptation” and “rehabilitation” of cancer patients…

• He focused on the stress of cancer care for patients and

their caregivers.

TIMELINE

Origins of “Integrative Oncology”

1952/59XXXX1964XXX…1978/79XXXX1991XX1998/99XXXXXXXXXX2019

Facing Cancer Together - a program of Cancer Support Community East Tennessee

• Dr. Arthur Sutherland: Psychological

Adaptations to Cancer

Sutherland, A., Papers, Cancer 1952-1959

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Long before integrative oncology emerged …

• Research from 1952-1960 by Arthur Sutherland and

colleagues studied the “adaptation” and “rehabilitation” of cancer patients…

 Research documented the relationship between risk behaviors and disease -

• 1964 Surgeon General’s report on cigarette smoking
• 1969 Blue Ribbon Panel drops Diet Only Study and

calls for MRFIT (Multiple Risk Factor Intervention Trial)

Origins of “Integrative Oncology”

1952/59XXXX1964 1969XXX978/79XXXX1991XX1998/99XXXXXXXXXX2019 TIMELINE

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1974

• The First Lady, Betty Ford is diagnosed with

breast cancer

1952/59XXXX1964XXX…1978/79XXXX1991XX1998/99XXXXXXXXXX2019

 Two weeks later, Happy Rockefeller, wife of the VP is diagnosed with breast cancer

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1974

• The First Lady, Betty Ford is diagnosed with

breast cancer

1952/59XXXX1964XXX…1978/79XXXX1991XX1998/99XXXXXXXXXX2019

 Two weeks later, Happy Rockefeller, wife of the VP is diagnosed with breast cancer

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Psychosocial Treatment of Patients with Breast Cancer

Spiegel, Bloom, Yalom, Arch of Gen Psychiatry, 1981

• 86 women with metastatic

breast cancer – 1 year

• Psychosocial Treatment (PT) N = 50
• weekly supportive group therapy
• self-hypnosis for pain
• routine oncological care
• Usual Care (UC) N = 36
• routine oncological care
• After 1 year, women in the PT group

had less anxiety, depression and fatigue, and more vigor than UC

Spiegel Yalom Bloom

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Psychosocial Treatment of Patients with Breast Cancer

Spiegel, Bloom, Kraemer, Gottheil, Lancet, 1989

• 86 women with metastatic

breast cancer – 1 year

• Psychosocial Treatment (PT) N = 50
• Usual Care (UC) N = 36
• Ten year survival
• PT Group: Survival 37.6 months
• UC: Survival 18.9 months

 Survival twice as long as seen in Kaplan-Meier plot

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Psychosocial Treatment of Patients with Breast Cancer

Spiegel, Bloom, Kraemer and Gottheil, Lancet, 1989

Kaplan‐Meier survival plot

B = PT Group – Psychological Treatment A = UC – Usual Care

What’s led to the difference?

• Social Support
• Stress Reduction

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Late 1970-1980s: Cancer Research

was the Impetus for New Studies

1952/59XXXX1964XXX…1978/79XXXX1991XX1998/99XXXXXXXXXX2017



• Research on stress and health proliferated!
• From interventions for psychological aspects of

breast cancer …

• To studies of stress as a cause of heart disease, with

Type A behavior

• Stress as a risk factor for hypertension
• The effects of stress on auto-immune diseases …



Facing Cancer Together - a program of Cancer Support Community East Tennessee

Late 1970-1980s: Cancer Research

was the Cornerstone for New Fields

1952/59XXXX1964XXX…1978/79XXXX1991XX1998/99XXXXXXXXXX2017



• From smoking cessation studies to stress triggers,

smoking and mood/weight, and relapse prevention …

• To interventions for psychological aspects of coping

with chronic conditions, such as cancer …

• To studies of stress effects on the immune system

 New fields of research were founded

founded 1978 founded 1979



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Integrative Oncology = the Foundation for Integrative Medicine

Integrative medicine programs emerged in the1990’s in Academic Health Centers

• 1991 Univ of Maryland’s Center was founded
• 1994 Univ of Arizona Center for Integrative Medicine
• 1995

Univ of Minn. Center for Spirituality and Health But wait . . . 

1952/59XXXX1964XXX…1978/79XXXX1991XX1998/99XXXXXXXXXX2019

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Integrative Oncology = the Foundation for Integrative Medicine

• 1982 !

 The Wellness Community was founded in Santa Monica

By Harold and Harriet Benjamin, and Shannon McGowan

• To provide support groups, education and other programs,
• To conducts research to quantify and document the benefits of

psychosocial support for people with cancer

1952/59XXXX1964XXX…1978/79XXXX1991XX1998/99XXXXXXXXXX2019

1982

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Integrative Oncology = the Foundation for Integrative Medicine

• 1990 !

Knoxville founds the Wellness Community, East TN

now the

Cancer Support Community

• 1995 Wellness Community offers

Mindfulness-Based Stress Reduction (MBSR)

• 1997 Rachael Patterson Young defends her dissertation

showing benefit of MBSR for people with cancer



1952/59XXXX1964XXX…1978/79XXXX1991XX1998/99XXXXXXXXXX2019

1990 1997



Facing Cancer Together - a program of Cancer Support Community East Tennessee

Integrative Oncology =

the Foundation for Integrative Medicine

Integrative medicine programs emerged in the1990’s in Academic Health Centers

• 1991 Univ of Maryland’s Center was founded
• 1994 Univ of Arizona Center for Integrative Medicine
• 1995

Univ of Minn. Center for Spirituality and Health

• 1998 Congress authorized funds for NCCIH
• 1998 Duke Integrative Medicine founded
• 1999

Osher Center at UCSF is founded

1952/59XXXX1964XXX…1978/79XXXX1991XX1998/99XXXXXXXXXX2017

Jon Kabat-Zinn Invites 8 Integrative Medicine Centers to a Meeting

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University of California, San Francisco Duke University University of Maryland University of Massachusetts University of Arizona Harvard University

1999: Consortium Formed - 8 Centers

Stanford University University of Minnesota

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Overview

• Define integrative oncology and describe how it

created the foundation for integrative health and medicine  Highlight why there is a growing focus on integrative medicine and health now

• Discuss the importance of integrative oncology

as the cornerstone for cancer wellness

Facing Cancer Together - a program of Cancer Support Community East Tennessee

2018 Data – Organization for Economic Cooperation and Development, 35 Countries US Rank 27th of 35

78.5 84.2

$10,224 $4,717

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“The disease-driven approach to care has resulted in

• spiraling costs as well as
• a fragmented health system that is
• reactive and episodic as well as
• inefficient and impersonal.”

IOM Summit, 2009 IOM - Now NAM - National Academy of Medicine

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Disease-driven care

• a fragmented health

system

• reactive and

episodic

• inefficient and

impersonal.” Integrative Oncology Integrative Medicine  an integrated patient-centered team  focuses on whole person and lifestyle  reaffirms relationship between practitioners and each patient

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Massage Yoga/Tai Chi Meditation/Breathing Acupuncture

Conventional Medicine* Complementary Medicine*

Social Support Diet/Nutrition Physical Activity Stress Management

Integrative Medicine

Radiation Medication Surgery Immunotherapy

* Examples

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Complementary / Integrative Medicine Use Increasing

• National Health Interview

Survey in 2002, 2007 & 2012

• National random sample

2002: 31,044 adults 2007: 23,393 adults XXXXXXXXX 2012 : 34,525 adults 10,218 children

Barnes et al., CDC, 2004, 2008; Black et al., CDC, 2015

36.6% 38.3% 11.8%

Similar levels

9,417 children

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Focus on Cancer Patients:

Percent who use Integrative Medicine

• National Health Interview – 38%
• Number increases to 68% in

surveys of cancer patients*

• Greater use in those with breast

cancer or advanced illness

• Goal:
• Enhance wellness,
• Improve immune function
• Relieve pain

*Lopez, Mao & Cohen, Med Clin N Am, 2017; Barnes et al., CDC, 2008

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Integrative Medicine in US Hospitals

• Hospitals offering Integrative

Medicine services

– 8% in 1998 – 17% in 2002 – 27% in 2005 – 37% in 2008 – 42% in 2011

• Key reasons

– Patient demand 85% – Clinical evidence 74%

AHA Health Forum, Sept. 2011

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University of California, San Francisco Duke University University of Maryland University of Massachusetts University of Arizona Harvard University

1999: Consortium Formed - 8 Centers

Stanford University University of Minnesota

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2019 - 76 Members*

Albert Einstein/Yeshiva University Allina Health Systems Aurora Health Care Beaumont Health System Boston University Cedars Sinai Los Angeles Central Maine Healthcare Cleveland Clinic Columbia University Connor Integrative Health Cornell University Duke University Emory University Georgetown University George Washington University Harvard Medical School INOVA Health Johns Hopkins University Mayo Clinic McMaster University, Ontario MD Anderson Medstar Health Memorial Sloan Kettering Meridian Health Mount Sinai Medical Center New York University Northwestern University Ohio State University Oregon Health & Science University Pennsylvania State Univ., Hershey Rutgers New Jersey Medial School Scripps Health Sutter Health Stanford University Temple University Tecnológico de Monterrey, Mexico Texas Tech University Medical Center Thomas Jefferson University University of Chicago University of Cincinnati University of Colorado University of Connecticut

• Univ. of Florida

University of Hawaii University of Kansas University of Kentucky University of Maryland University of Massachusetts University of Miami University of Michigan University of Minnesota University of New Mexico University of North Carolina University of Pennsylvania University of Pittsburgh University of Saskatchewan University of Southern Ca. University of TN, Knoxville University of Texas, MB University of Utah University of Vermont University of Washington University of Wisconsin, Vanderbilt University Veterans Administration Wake Forest University Yale University Tufts University of Alberta University of Arizona University of Calgary University of California (UC) Irvine UCLA, UCSF, UCSD University of Chicago * Apologies to Canada & Mexico

Overview

• Define integrative oncology and describe how it

created the foundation for integrative health and medicine

• Highlight why there is a growing focus on

integrative medicine and health now  Discuss the importance of integrative oncology as the cornerstone for cancer wellness

Facing Cancer Together - a program of Cancer Support Community East Tennessee

• Efficacy
• Mechanism
• Intervention

Integrative Oncology has often led the effort to build the integrative medicine evidence base

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Stress & Cancer Progression Research Evidence Mounts

*e.g., Chida et al, Nat Clin Pract Oncol, 2008, **Andersen et al, Cancer, 2008

• Stress-related factors were found to be associated

with higher cancer incidence and, according to the Spiegel’s and other studies, to be associated with poorer survival in people with cancer diagnoses*

• Dr. Barbara Andersen conducted a randomized

study to test whether a comprehensive or multimodal group program to reduce stress and improve lifestyle could impact survival**

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Stress & Cancer Progression

Design of Andersen’s Study

Andersen et al, Cancer, 2008

• Recruited breast cancer patients N = 227

Stage IIA, IIIB

• Assessment Only –

N = 113 Year 1: Baseline, month 4 and 12 Years 2 – 5: Observed every 6 months Years 6 – 10: Observed every year

• Intervention* and Assessment –

N = 114 Year 1: Weekly sessions for 4 months, small groups Followed by 8 monthly sessions

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Stress & Cancer Progression

Intervention Program

Andersen et al, Cancer, 2008

• Progressive Muscle

Relaxation for Stress

• Problem Solving

Optimal Conventional Cancer Care Healthy Lifestyles

Mind, body & purpose Movement

• Walking
• Exercise
• Improving Diet Habits
• Lowering Fat Intake

Nutrition Social Connection

• Support of the Group
• Family and Friends

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Stress & Cancer Progression

Results

Andersen et al, Cancer, 2008

Recurrence free survival Breast cancer Overall survival specific survival

Intervention Assessment Only

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Opportunities & Challenges

e.g., Greenlee et al., J of NCI Monographs, 50, 2014; SIO Website

• Research has led to Clinical Practice Guidelines*

– General practice for integrative therapies – 2007, 2009

–

Integrative therapies for lung cancer – 2007, 2013

–

Integrative therapies for breast cancer – 2014, 2017

• Model for Integrative Medicine
• Research presents a challenge

– Guidelines rely on studies with high rigor, that focus

• n specific modalities

– While multimodal interventions may have more impact on patient health.

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Multimodal Intervention & Telomeres

• Telomeres are protective DNA-

protein complexes which stabilize the ends of chromosomes

 Like the aglets at the end of shoelaces

• Telomeres shorten in response to

age, disease, poor sleep, and stress

• But do they lengthen in response to

healthy lifestyles and stress management?

Epel, et al. PNAS 2004;101:17312 Prather, et al. Brain, Behavior & Immunity, 2015; 147:155 Ornish D et al. Lancet Oncol., 2008; 9:1048

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A Case in Point: Healthy Lifestyle Treatment for Cancer

• Biopsy proven, low-risk prostate cancer
• 35 men agreed to active surveillance (2003-07)
• 25 received only active surveillance
• 10 received an integrative treatment plan
• Dr. Peter Carroll, Chair, UCSF Dept. of Urology
• Integrative treatment (3 mon intensive)
• Stress management, yoga, breath, progressive

muscle relaxation training, exercise, diet, and support group

Ornish, et al., New England J of Med, 2013

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Ornish et al. Lancet Oncology, September 2013

A Case in Point: Healthy Lifestyle Treatment for Cancer

Courtesy of Dr. Lorenzo Cohen

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Arun, Austin…Cohen, Integrative Cancer Therapies, 2017

• First 6 weeks in person
• 6 weekly individual counseling
• 12 exercise sessions
• 12 dietary classes
• 12 mind-body classes
• 6 months of monthly

“video counseling” via FaceTime

New: Comprehensive Lifestyle Trial for Breast Cancer

Facing Cancer Together - a program of Cancer Support Community East Tennessee

Integrative Oncology -

• Patient-centered,
• Evidence-informed cancer care, that integrates

Optimal Conventional Cancer Care Healthy Lifestyles

Movement Mind, body & purpose Nutrition Social Connection Wellness Commitment

Facing Cancer Together - a program of Cancer Support Community East Tennessee

Healthy Lifestyles

Movement Nutrition Social Connection Wellness Commitment

Optimal Conventional Cancer Care

Mind, body & purpose

MBSR Spirit of Healing Wellness Workout Yoga Qigong Quick & Tasty Nutrition Ammunition Weekly Support Creativity Socials

“ Cancer can be a catalyst for change”

Family Fun

Offering Comprehensive, Multimodal Healthy Lifestyle Interventions

Integrative Oncology

Facing Cancer Together - a program of Cancer Support Community East Tennessee

Now: The Challenge!

• Almost all of the studies I have cited have a “secret”

 People drop out!

• Often only “60% complete, 6 or more of 8 sessions”

and this is with reminders and sometimes incentives

• “Home practice,” often even lower, rarely reported
• Same problem is seen in the best clinics and

centers with great programs, groups and classes

• People lose their motivation
• However, research shows that engagement and

practice are associated with better outcomes!

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We Need to Address This With: Steps to Greater Adherence

“Every journey begins with a single step!”

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Steps to Greater Adherence

Every journey begins with a single step!

• Start by focusing on answering this question?

What is your personal goal? “You want your health in order to . . do . . ______.

• There are a lot of options (mind-body, diet, etc.).

What are you really likely to do and “stick to the plan?”

• Change is hard. Old habits were created over years.

New habits are fragile . . . like seedlings . . .

• Almost everyone slips . . .
• What do you need to do?

“What defines us is how well we rise after falling.” *

*Summit Gupta

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Steps to Greater Adherence

Every journey begins with a single step!

• Make a commitment to yourself – write it down!

Share it with others

• Integrate the new behavior into your life schedule.

Plan to do the new behavior just before something you enjoy

• Reward yourself as you meet a milestone –

Make the first milestone an easy one!

• Measure your progress
• If you slip?

Return to the commitment you made.

• Does anyone have a story to share?

Facing Cancer Together - a program of Cancer Support Community East Tennessee

Overview

• Defined integrative oncology and described

how it created the foundation for integrative health and medicine

• Highlighted why there is a growing focus on

integrative medicine and health now

• Discussed the importance of integrative oncology

as the cornerstone for cancer wellness

 And how it is happening

right here at the

Facing Cancer Together - a program of Cancer Support Community East Tennessee

Optimal Health

Resilience Reduced vulnerability to daily stress

Ill-health Health “Neutral”

When we think of health care… The goal of Integrative Oncology go the distance, to achieve optimal health

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The Goal of Integrative Oncology

To create support communities

• Where individuals, families, and groups
• Have access to healthy choices that

build resilience

• Promote wellness
• And enhance the quality of their lives

… and, I know you are a part of a support community that is making this possible!

Facing Cancer Together - a program of Cancer Support Community East Tennessee

Thank you!

Debra Sullivan Beth Hamil Kathleen Williams Denise Stillman Sherry Lomax Katherine Chyka

Facing Cancer Together - a program of Cancer Support Community East Tennessee