Why Integrative Medicine?
The concept of integrative medicine is relatively new, and I often find myself needing to explain a bit about how this very in-demand medical specialty has evolved and why this is how I practice.
As background on my journey to this evolution in healthcare, I started off as a traditionally trained medical doctor (MD) with extensive training in internal medicine and molecular imaging with multiple board certifications. I have been working with cancer patients and patients with complex medical issues throughout my 27 year medical career. After several years as a assistant-clinic professor and practicing at the University of San Francisco, I was recruited to head a department at the University of Arizona medical center, focusing on molecular imaging (PET/CT imaging in particular) and targeted cancer treatments. In 2010, I branched out to form an independent facility in collaboration with industry to further the research on specialized imaging isotopes. We worked on multiple cancer imaging and therapy clinical trials, most recently completing one of the worlds largest imaging clinical trials utilizing Carbon-11 Acetate for prostate cancer imaging. Our work gave rise to a clinical base which I am proud to say has spurred industry support for the development of several other imaging agents now in clinical use or in fast track development.
My clinical approach has always been seen as somewhat unconventional for an imaging expert, and for that matter our healthcare system in general. With my background in internal medicine and molecular imaging (not a radiologist), I routinely incorporate a personalized approach. In this regard, I have been somewhat of a pioneer, sitting down in an un-rushed consultation with my patients (and family) immediately after their imaging studies to review the results, answering as many questions as needed and helping them to fully understand the imaging results and ramifications (be it good or bad). In these consultations, I also to help my patients formulate the questions to ask and to guide expectations with their subsequent appointments with medical oncologists, surgeons or radiation oncologist. In many cases, patients did not have an appropriate oncology medical team in place, and I would strive to help them establish this through my various connections with the experts in this field. As such I have been practicing a form of integrative medicine/oncology for nearly my entire career.
What followed with many of my imaging and research patients is their request for me to be the “navigator” throughout their cancer treatment process and to help with their overall health, other medical issues and lifestyle modifications. I have now been actively doing just so for several years, but more recently I evolved and dedicated my practice to be able to more fully provide this service to my clients - culminating in the creation of the a new clinic - the Center for Integrative Healing & Wellness.
There is such a tremendous need and demand for highly trained Medical Doctors to help expertly guide patients though both traditional and alternative/complimentary healthcare to achieve optimal health. The need appears to be glaringly universal in the context of our current healthcare system (whether with allopathic or naturopathic medicine), but when faced with cancer, most especially so.
Unlike the vast majority of physicians (and most allied healthcare providers), I knew much about nutrition and lifestyle for cancer and cancer prevention, but I was self trained. In an effort to more formally and diversely expanded my knowledge, I recently completed a two year fellowship in integrative medicine - this on top of my prior several years of residency and fellowship training in internal medicine and molecular imaging. I was fortunate to be able to do this at the University of Arizona Center for Integrative Medicine Program (AzCIM), under the direction of Dr. Andrew Weil, MD. As a result, I will be among some of first few physicians to undertake such dedicated training and sit for the recently established American Board of Integrative Medicine certification. To broaden my scope even further, I also completed specialize training in culinary medicine and botanical medicine, and became additionally board certified in obesity medicine. With these diverse tools added to my practice I am able to help my clients better their fight against cancer and to achieve whole-person health and wellness.
What follows is an overview of the need for Integrative Medicine & Oncology, with many reflections and observations from Dr. Weil and the AzCIM serving as an inspiration for my own practice of integrative medicine and oncology.
Integrative medicine (IM) is an established movement in North America and China. It is a developing movement in parts of the Middle East and continental Europe, especially Scandinavia. I am confident that it is the direction medicine and health care must take to address demands from patients, dissatisfaction of practitioners, and the worsening economics of health care worldwide.
Many people consider IM and alternative medicine synonymous. This is not the case. Alternative medicine comprises all those therapies not taught in conventional (allopathic) medical schools, based on ideas that range from sensible and worth including in mainstream medicine to those that are foolish and a few that are dangerous (Weil, 1998). The term alternative medicine has recently been incorporated into a broader term, complementary and alternative medicine, or “CAM,” that is used by the federal government in the United States and other institutions; the National Institutes of Health has its National Center for CAM (NCCAM).
Neither alternative nor complementary captures the essence of integrative medicine. The former suggests replacement of conventional therapies by others; the latter suggests adjunctive therapies, added as afterthoughts.
IM does include ideas and practices currently beyond the scope of the conventional, but it neither rejects conventional therapies nor accepts alternative ones uncritically. And it emphasizes the following principles:
The Natural Healing Power of the Organism - IM assumes that the body has an innate capacity for healing, self-diagnosis, self-repair, regeneration, and adaptation to injury or loss. The primary goal of treatment should be to support, facilitate, and augment that innate capacity.
Whole Person Medicine - IM views patients as more than physical bodies. They are also mental/ emotional beings, spiritual entities, and members of particular communities and societies. These other dimensions of human life are relevant to health and to the accurate diagnosis and effective treatment of disease.
The Importance of Lifestyle - Health and disease result from interactions between genes and all aspects of lifestyle, including diet, physical activity, rest and sleep, stress, the quality of relationships, work, and so forth. Lifestyle choices may influence disease risks more than genes and must be a focus of the medical history. Lifestyle medicine, which is one component of IM, gives physicians information and tools to enable them to prevent and treat disease more effectively.
The Critical Role of the Doctor-Patient Relationship - Throughout history, people have accorded the doctor-patient relationship special, even sacred, status. When a medically trained person sits with a patient and listens with full attention to his or her story, that alone can initiate healing before any treatment is offered. The great tragedy of contemporary medicine, especially in the United States, is that for profit, corporate systems have virtually destroyed this core aspect of practice. If practitioners have only a few minutes with each patient - the time limit set by the managed-care systems they work for - it is very unlikely they will be able to form the kind of therapeutic relationships that foster health and healing. Furthermore, this special form of human interaction has been the source of greatest emotional reward for the physician, and its disappearance in our time is a main reason for rising practitioner (and patient) discontent.
In essence, IM is conservative. It seeks to restore core values of the profession that have eroded in recent times. It honors such ancient precepts as Hippocrates’ injunctions on physicians to “first do no harm” and “to value the healing power of nature.” It is conservative in practice, favoring less invasive and drastic treatments over more invasive and drastic ones whenever possible, and it is fiscally conservative in relying less on expensive technology and more on simpler methods, as appropriate to the circumstances of illness.
The IM movement in North America is gathering momentum. And demand for training in the field is growing steadily.
To help answer that demand, the Program in Integrative Medicine (now the Arizona Center for Integrative Medicine or AzCIM) at the University of Arizona was developed. AzCIM’s focus has been the development of new educational models for training medical students, residents, physicians, nurse practitioners, pharmacists, and other health professionals. The Center has offered intensive fellowships to MDs and DOs, consisting of several hundred hours, developed to cover the philosophy of IM as well as broad subject areas currently slighted or omitted entirely from conventional medical education. These include nutritional medicine (e.g., designing an optimum diet for health and longevity; using dietary supplements appropriately; using dietary change as a primary therapeutic strategy, etc.), botanical medicine, mind-body medicine, manual medicine (such as osteopathic manipulative therapy), spirituality in health and illness, environmental medicine, and overviews of traditional systems of medicine (like Chinese medicine and Ayurveda) and CAM.
Criticism of IM has mostly focused on perceived advocacy of ideas and practices not consistent with evidence-based medicine (EBM). Training at AzCIM requires fellows to assess the evidence base for all recommended treatments, including conventional ones. The Center also trains future researchers, many of whom are working on new research designs to investigate complex systems and new outcome measures to assess the effectiveness and cost-effectiveness of integrative treatment plans (as opposed to single interventions). Practitioners are also taught to use a sliding scale of evidence in evaluating treatments: the greater the potential of an intervention to cause harm, the stricter the standard of evidence it should be held to for efficacy.
Every medical doctor should know basics of nutrition and health, mind-body interactions, and botanical medicine as well as the difference between an osteopathic physician and a chiropractor and have at least some sense of important traditional systems, like Chinese medicine and Ayurveda. Every medical professional should understand the influence of lifestyle on health. Unfortunately very few do, and specialized board certification in IM has now been established through the American Board of Integrative Medicine, a sign of maturity of the field and a way to help patients identify those practitioners properly trained in it.
AzCIM’s graduates now include more than a thousand physicians from many specialties, including growing numbers of those with special interest in oncology. I am happy about this, although the demand for integrative oncology is overwhelming and practitioners trained to provide it remain very few. To cater to public demand, some leading cancer centers advertise that they offer “integrative treatment”, but these claims are misleading. They offer selected CAM therapies, mostly the safest, least controversial ones, such as massage, stress reduction, and very basic nutritional counseling but advise patients to shun botanical remedies that might ameliorate the toxic effects of chemotherapy and radiation as well as most dietary supplements, and they have no informed advice to give about more complex therapies. One chain of private cancer-treatment centers that builds its reputation on an “integrative” philosophy employs conventional oncologists completely untrained in IM while using naturopaths (NDs) to supervise CAM therapies as adjuncts. A disjointed process that is hardly integrative or effective.
how does integrative medicine apply to cancer care?
The truth is that most patients with cancer want integrative care. The great majority - as many as 90% in some surveys - are using other therapies while receiving conventional treatment. Most of those do not tell their oncologists what else they are doing, because they expect to be criticized, ridiculed, or told to stop. In any medical situation, whatever the disease, the physician in charge ought to know all therapies that the patients are using, both to be able to avoid adverse interactions and to be able to assess outcomes. An integrative oncologist can elicit this information and give patients sound advice about CAM therapies.
Because nutrition, including the use of dietary supplements, is a core competency of IM education, integrative oncologists can answer some of the most common and urgent questions of cancer patients starting chemotherapy and radiotherapy, such as, “Are there any foods I should or shouldn’t eat during treatment?” and “Can I continue to take my vitamins?”
Here is a glaring example of the present paucity of training about nutrition and cancer: The daughter of a man undergoing chemotherapy for metastatic prostate cancer consulted me in distress, because the medical oncologist told her mother to “eat only white foods” during the entire course of treatment. She wanted permission to encourage her father to eat more wholesome meals. Many cancer patients tell me they are advised not to eat fruits and vegetables while receiving chemotherapy or radiotherapy, because the antioxidants in them would compromise the efficacy of those treatments. Countless others express dismay that their oncologists are unable to talk to them about best nutritional strategies for reducing risks of recurrence. “Just eat a balanced diet,” or “Whatever you feel like eating,” are common responses they get, leaving them frustrated and unsure about where to turn for better advice and information.
If a patient undergoing cancer treatment asks a conventionally trained oncologist about the value of the herb astragalus (from the root of Astragalus membranceous) to protect the bone marrow and white cell populations from some of the toxicity of some chemotherapeutic agents or the use of Asian mushrooms like maitake (Grifola frondosa), enoki (Flammulina velutipes), or turkey tail (Trametes versicolor) to “boost immunity,” it is likely the physician will be entirely unfamiliar with these natural products. The reflexive response will be, “Do not take anything other than what we give you,” again leaving patients frustrated and often angry about their doctors’ limited knowledge, hence the tendency to conceal the use of such products, which may have been recommended by friends, by books, by CAM providers, or by Internet sites. A major component of patients’ frustration with these interactions is a strong sense of dis-empowerment and inability to have any partnership in shaping their medical destiny.
Given the fact that so few integrative oncologists exist and that cancer patients in our part of the world have such difficulty putting together sound and safe integrative treatment plans, it is surprising to learn that their counterparts in China are much luckier. At least in large Chinese cities, most cancer patients who undergo surgery, chemotherapy, and radiotherapy also get Chinese herbal therapy to increase efficacy and reduce toxicity of the conventional treatments, as well as acupuncture, massage, energy work (such as Qi gong), and dietary recommendations to support general health and manage symptoms.
Of the various specialties of medicine, oncology has been much slower to embrace IM than most. Family medicine, pediatrics, and psychiatry are quite open to IM philosophy and training, and there is receptivity in internal medicine as well, especially from cardiologists. Integrative oncology seems so sensible and so needed. What are the sources of resistance that have slowed its development?
One is surely the emotionalism that surrounds cancer— a frighteningly common, mysterious, and serious group of diseases. We can argue about whether the incidence of cancer is increasing or not, but most people I know feel that cancer now touches their lives more directly than it used to, affecting them, their immediate families, their friends, and neighbors. The possibility of developing cancer or having to care for or help someone who has it is very great. Moreover, conventional cancer treatments are also frightening, because they can be painful, debilitating, disfiguring, and not always as successful as those who perform them represent them to be. Many people have a strongly negative perception of chemotherapy and radiotherapy because of their obvious toxicity and known potential to cause mutations and malignant transformation.
Progress in the diagnosis and management of cancer has been significant. A dramatic example is that it is now possible to envision the management of metastatic breast cancer as a chronic disease, much like AIDS, rather than as an inevitable and premature death sentence. At the same time, the incidence of breast cancer is at an all-time high. The prospect of individualized and targeted therapies is already being realized, with significant reduction in toxicity. Still, I and many others look forward to the advent of new and better treatments— gene therapy, immunotherapy, antiangiogenesis therapy, ligand based targeted radiotherapy— that may render many of our current strategies obsolete and reduce some of the emotionalism that now fuels the debate about other ways of managing cancer.
Over the years at the request of my patients, I have looked at a number of alternative cancer treatments - those offered (mainly by naturopaths and other non-medical doctors) instead of surgery, chemotherapy, and radiotherapy. I have seen and performed detailed imaging on many patients who used them as primary therapies, others who tried them after recurrences or when they were terminal. Although I have known a few individual patients who responded to one or another of these diverse therapies, none of them in isolation, in my experience, has produced reliably good outcomes in significant numbers of patients. Some of these therapies are based on utterly unscientific and unsound ideas: that cancer is caused by infection with parasites or other germs that can be seen by developers of proprietary vaccines but not by mainstream microbiologists; that cancer results [solely] from nutritional deficiencies or excesses and can be cured by dietary change alone; and so forth. A prominent and disturbing message from the alternative-cancer-treatment community [most often in order to promote their own career, agenda and financial gain] is that a conspiracy of pharmaceutical companies and medical organizations profits handsomely from conventional treatment and has suppressed effective natural and alternative therapies. There may be some truth in that pharmaceutical companies are not interested in natural treatments that can not be patented and profited from, but most any therapy that is actually proven to be effective for cancer care is typically quickly embraced by the conventional medical community. A good example is how fasting or calorie restriction during chemotherapy is now more routinely supported by most conventional oncologists (though many of them yet do not know how to properly instruct patients how to actually implement this).
I also have encountered elements of alternative cancer treatments that seem possibly useful, worthy of investigation and implementation. A broad example is the use of botanical remedies and supplements along with chemotherapy and radiotherapy to increase their efficacy, reduce toxicity and side effects. One example is the use of a topical extract of bloodroot (Sanguinaria canadensis) to provoke an immune reaction against and kill some skin cancers. Mistletoe therapy is another intriguing immuno-modulating and cancer suppression therapy, in fairly wide use in Europe and gaining ground in the US. Practitioners of integrative oncology should be informed about alternative cancer treatments and able to answer patients’ questions about them factually. They should also encourage research on those that show any evidence of efficacy.
No integrative oncologist would ever advise a patient to forego evidence-based treatment in favor of unproved therapy of unknown safety and efficacy. However, a major role for such a practitioner would be to help patients make difficult choices about standard therapeutic options. Often cancer patients must decide among different courses of treatment, such as whether to use chemotherapy after surgery or radiation, whether to submit to aggressive chemotherapy in the event of a recurrence, whether to try an experimental vaccine or stem-cell transplant. They must gamble— with their lives— on making the right choices.
In most medical situations that involve serious disease, both doctors and patients are forced to deal with uncertainty. To the dismay of many patients, rarely do we have all the information we need to make decisions that will guarantee desired outcomes. Instead we must use incomplete information to estimate probabilities and place the wisest bets we can. Ultimately, patients must take responsibility for this, but doctors can and should help them understand the possible therapeutic options and their probable consequences.
Most of our cancer treatments have significant risks as well as benefits. Patients must understand the risk/benefit ratio for any treatment offered, especially impact on quality of life versus quantity of life. If a patient opts to forego chemotherapy following surgical removal of a breast or lung tumor, choosing instead to make all the right lifestyle choices to reduce risk of recurrence and to use various herbs and dietary supplements as insurance, is this an informed and wise decision? It may be— if he or she has been able to estimate the probabilities of outcomes. The individual will be guessing in the midst of uncertainty, but if they can get and can understand the best available data on their particular type and stage of cancer and on the risks and benefits of the therapeutic options under consideration, they can select wisely. As the provider and interpreter of medical information, the integrative oncologist is indispensable to this process.
There is an urgent need for this service. Most cancer patients I know are desperately seeking the advice and counsel of oncologists who are well trained and credentialed; up-to-date with the science of cancer and its treatment; open-minded and nonjudgmental, who are interested in the influence of all aspects of lifestyle on health and illness; understand the interactions of mind and body; and have at least basic knowledge of botanical remedies, dietary supplements, and commonly used CAM therapies. Most often, patients (and their loved ones and friends) cannot find such practitioners, as few currently exist.
In addition, because IM puts emphasis on total lifestyle, it is in a better position than conventional medicine to offer true holistic and preventive care. Preventive medicine as a field has accomplished much, but it has focused narrowly on public-health measures like sanitation, eradication of insect vectors of disease, diagnostic screening, and immunization rather than on the choices people make about how to eat, get physical activity, play, and handle stress. Most of the chronic diseases that kill and disable people prematurely are diseases of lifestyle that could be avoided or postponed by making better choices and developing better habits of living. Because the treatment of cancer is difficult and costly, especially if it has spread from its primary site, risk reduction should be a high priority - not only by means of diagnostic screenings but primarily by counseling patients and educating society about the details of lifestyles associated with lower risk.
In the case of the hormonally driven cancers, for example of the breast and prostate, we know a great deal about dietary and other influences that both raise and lower risk, but much of this information is not yet common knowledge; nor are there societal incentives to encourage people to change behavior. For example, the chemistry of the formation of carcinogens as animal tissue cooks is well known: the higher the temperature and the longer the time of cooking, the higher the dose of carcinogens in the meat (or poultry or fish) that comes to the table. We also have clinical data indicating that a preference for meat cooked “well done” is a significant risk factor for breast cancer in women (Steck et al., 2007). Most women I know, including some with family histories of breast cancer, are totally unaware of these facts; certainly, no physician has made them aware of the danger.
There is good evidence that moderate, regular consumption of whole soy foods, beginning early in life, affects the development of the female breast in ways that make it resistant to malignant growth (Cabanes et al., 2004). It is also believed to offer significant protection against prostate cancer in men. Integrative oncology should develop strategies for helping people, to access, understand, and implement this information.
As one of the first generation of integrative oncologists I find myself most in demand as a consultant, with these main areas where I provide an advisory role:
Helping clients with difficult decisions about conventional treatment options.
Helping clients put together integrative treatment plans that use dietary strategies, physical fitness, mind-body therapies, and selected CAM therapies during and after conventional cancer treatment.
Helping clients review and select clinical trials that may provide benefit.
Advising clients about possible risks and benefits of conventional and alternative cancer treatments.
Informing clients about strategies for increasing efficacy and reducing side effects of chemotherapy and radiotherapy.
Advising clients about nutritional and other lifestyle strategies for reducing risks of recurrence.
Teaching those at risk for cancer about lifestyle strategies for reducing risk.
Helping clients with incurable cancer to get the best palliative care, drawing on all therapeutic options.
Helping terminal patients and families with issues around death and dying.
“Integrative medicine is not revolutionary, but it is radical in the literal sense of that word (from Latin radix: “root”) in that it aims to reconnect medicine to its roots, to restore its core values. Integrative oncology simply means doing the best we can to prevent and treat cancer and support those affected by it on all levels: body, mind, and spirit. ”