Expert Review: Integrative Cancer Management session by Kim Hobbs, Clinical Specialist Social Worker, Department of Gynaecological Cancer, Westmead Hospital.
COSA Annual Scientific Meeting, Melbourne, Australia
Paul Katris chaired a dynamic and diverse session in which four speakers presented various aspects of integrating a range of services and interventions to properly address patient-centred care.
Integrative cancer care: Who, what, why, when and how by Donald Abrams
Donald Abrams, a haematologist/oncologist from the University of California San Francisco Cancer Centre and the Osher Centre for Integrative Medicine, asked how best to offer integrative cancer care: questions of who, what, what, when and how to provide truly integrated care.
A poignant quote attributed to William Osler set the tone of this presentation- “it is more important to know what sort of patient has a disease than what disease he has”.
“Do we treat cancer, or treat people who have cancer?”
This was the key question posed by Donald. At the Osher Centre Donald delivers patient-centred care in a 60 minute consultation in which he integrates conventional and complementary medicines to engage mind, body, spirit and community providers to model healthy lifestyles for patients. Donald’s philosophy is that healing is always possible, even when cure is not.
At the Osher Centre a broad range of therapies are offered:
- mind/body interventions
- energy-based therapies
- manipulation and body-based therapies
- biologically-based therapies
- culturally-based therapies
Integrative cancer management of people with an existing cancer diagnosis has the potential to reduce the risks of second cancer diagnoses by focussing on lifestyle issues; such as maintenance of a healthy BMI, aerobic and resistance exercise training, encouraging physical activity, providing information about dietary guidelines and smoking cessation.
Responsible integrative cancer care practitioners do not support the use of unproven complementary and alternative therapies; but rather recommend the use of CAM treatments in support of conventional therapies. CAM therapies have an important role to play in symptom management of treatment side-effects and continue to be useful in the management of the palliative stages of illness.
It’s known that a high proportion of people with cancer seek out complementary therapies whilst on treatment, but many do not disclose this to their oncologists for fear of being ridiculed or requested to cease use of CAM’s. Oncologists need to increase their knowledge about integrative cancer management in the interests of providing better patient care.
The goals of integrative oncology are to increase the patient’s sense of control, to manage ongoing inflammation, to improve the body’s innate immunity in fighting cancer and to lower patient stress and improve hope. As well as providing education about the benefits of healthy lifestyle, the integrative oncologist may prescribe appropriate supplements, offer information about breathing techniques, guided self-imagery and self-hypnosis, encourage connection with family and friends and engage with spirituality and religion.
The elements of the 60 minute consultation are:
- Tell me your story
- Examine the patient- the power of touch
- Tell them my story (how I came to be an integrative practitioner)
- Review how they “fertilise their soil”- how diets and supplements can tend the body’s “garden” while the cancer treatments eradicate the “weed” (cancer)
- Recommend modes of stress-reduction
- Refer (most) patients to traditional Chinese medicines
- Provide a resource package to take home
- Finish with a hug
Thirty minute follow up consultations are offered on a schedule determined by the needs of the patient.
Truly integrative cancer care is about the oncologist treating the cancer and performing or recommending complementary interventions. It’s about supporting the “good” while traditional cancer treatments remove the “evil”; and working with the “soil” rather than the “weeds”. So called integrative models that offer cure of cancer without conventional therapies are NOT integrative, and are not supported by Donald.
- What brings you joy?
- What are your hopes?
- Where do you derive your strength?
So, what are the essential elements of an integrative cancer care program?
- that it is located within or adjacent to an oncology service, with endorsement from that service
- that referrals to integrative oncology are initiated by oncologists; thus affirming the endorsement of conventional treatment providers
- that adequate time is allocated for integrative oncology consultations
- that integrative practice is evidence-informed
- that integrative practitioners are professionally competent medical practitioners
- that the cost of integrative consultations are covered
Further information about the practice of integrative cancer care can be found in the “Textbook of Integrative Oncology” published by Oxford University Press.
Donald concluded his presentation with a quote from Ambroise Parer: “the role of the physician is to cure sometimes, heal often, support always”.
Focusing on coping with a diagnosis of gynaecological cancer – and improving outcomes for women by Lynette Joubert
Professor Lynette Joubert, a Social Worker from the University of Melbourne and Peter MacCallum Cancer Centre, addressed the issue of integrating a social science paradigm into medicine and research methodology to improve our understanding of the benefits of supportive care interventions. Calling upon several recent small studies of women with gynaecological cancer in Melbourne, Lynette found that there were modifiable risks in women who didn’t start treatment or failed to complete treatment. Interventions that target the broader social networks in which women live their lives can modify risks to enable more effective engagement with the cancer treatment process.
Lynette’s group has developed and validated the soNET intervention. This model works as a single session of strategic counselling, with proactive linkage with primary care providers and community services. This is an evidence informed model based on identified need, targeted to those who meet criteria of high distress levels on psychosocial screening tools. Ongoing secondary consultations of up to six telephone contacts reinforces the single face to face contact. This style of intervention may be an efficient and effective use of scarce and over-stretched psychosocial support services. It has the potential to be offered by frontline staff as part of routine supportive care.
Patient rated outcomes in an RCT of immediate versus delayed exercise programs in patients with haematological malignancies; and to assess use of complementary therapies at SolarisCare centres in Western Australia by David Joske
David Joske is the founder of Solaris Care which now has four integrative cancer care centres in Western Australia; two in Perth (Sir Charles Gairdner and St. John of God hospitals), and in Bunbury and Albany. Solaris Care centres offer a wide range of complementary therapies. In this presentation David discussed the results of an RCT of immediate versus delayed exercise programs from the point of view of patient rated outcomes.
The Thriving Exercise Intervention Study found that a structured exercise program improved cancer related fatigue and health related quality of life, and reduced anxiety and depression (as measured by the HADS); no matter when the exercise intervention is instigated. This is important because it is known that cancer patients have low physical activity levels and impaired quality of life during and after treatment
Patient reported outcomes can inform us of the patient experience of cancer, rather than a narrower focus on treatment, remission and cure. The top three patient reported outcomes for patients accessing the Solaris programs were relaxation, empowerment and support. Most reported that they would continue to use complementary therapies after ceasing cancer treatment. A challenge for Solaris Care, as for many supportive care services is how to engage more men in accessing these services. In a 2012 “Snapshot Survey” of Solaris users, only one-third were men.
Acupuncture for cancer patients by Xiaoshu Zhu
Dr Xiaoshu Zhu from the School of Science and Health at University of Western Sydney, presented on the use of acupuncture and traditional Chinese medicines as cancer treatments.
There is good evidence for the benefits of acupuncture in managing chemotherapy induced nausea and vomiting, using either needles, acupressure or electrical stimulation. Treatment related, neuropathic and post-operative pain also respond well to acupuncture. Anecdotally, patients also report improvements in cancer related fatigue with acupuncture.
There is emerging (but sometimes conflicting and not yet robust) evidence for other conditions:
- endocrine therapy induced hot flushes
- peripheral neuropathy
- stress management
- radiation induced xerostomia
Acupuncture is a safe procedure in the hands of competent practitioners, and can be a useful as an adjunct to usual cancer treatments.
Dr Zhu discussed the use of traditional Chinese medicines in improving physical and emotional well-being, boosting the immune system and decreasing treatment side-effects. The challenges for practitioners of these therapies lie in their acceptability to both patients and medical practitioners, and the practicality of delivering these therapies.
Dr Zhu called for better implementation, adaptation and integration of acupuncture and traditional Chinese medicine into Australian health systems.
Kim has previously contributed expert commentary for OncologyNews: