1. Integrative Medicine in Metastatic Breast Cancer
Gabriel Lopez, MD
Assistant Professor, General Oncology
Integrative Medicine Program
March 8, 2015

2. Integrative Medicine in the Media

3. The Cure for All Cancers
Cancer medicines to treat cancer aggressively with few or no side effects
100 Underground Cures for Cancer
What are your patients reading? Be prepared.

4. Objectives
To understand the terms alternative, complementary, integrative medicine and integrative oncology
To discuss our model of Integrative Medicine in Cancer Care
To discuss Integrative Medicine approaches that may benefit patients and caregivers

5. Outline Background Integrative Medicine Program
Examples of Integrative Medicine Approaches

6. Meet Jo
Jo is 52 years old.
She was first diagnosed with hormone positive breast cancer over 5 years ago.
An MRI done to evaluate her recent back pain shows metastatic breast cancer to the bone.
She sees her oncologist who discusses treatment options.
She does some research on her own and reads about alternative treatments offering her:
A chance at a cure with no side effects.
Eliminating cancer symptoms & treatment related side effects
Who can she talk to about what she has read? Is it true?
We will come back to Jo

7. Complementary and Alternative Medicine (CAM)
Definition
A group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.

8. Complementary Health Approaches Examples
Complementary Health Approaches
Examples
Natural Products
Dietary Supplements
Herbal medicines (botanicals)
Vitamins
Minerals
Probiotics
Mind and Body Practices
Meditation
Yoga
Acupuncture
Tai chi and Qi gong
Massage therapy
Relaxation Techniques
Breathing exercises
Guided imagery
Progressive muscle relaxation
Movement therapies
Feldenkrais, Pilates
Spinal manipulation
Chiropractic, Osteopathic, Physical therapy
Energy Therapies
Healing touch, Reiki, Magnet therapy
Hypnotherapy
Other Complementary Health Approaches
Whole medical systems
Traditional healers
Ayurvedic medicine
Traditional Chinese Medicine
Homeopathy
Naturopathy 
Revised Four NCCAM-CAM categories

9. How commonly is CAM used…
By the General Population (US): 38.3%
By Cancer Patients: Up to 68%
By Patients with Breast Cancer: Up to 87%
Breast cancer patients have an increased use of CIM compared to other cancer types, prevalence range of 17-87%, mean 45%.
Barnes et al., CDC Advanced Data 2008; Ernst & Cassileth Cancer

10. CAM Use Among Cancer Patients
MD Anderson Cancer Center, 2000
Survey Results of 450 patients
40-60% of patients not discussing CAM use with physicians, wide variety of cancer types
Richardson et al. JCO 2000

11. Complementary, Alternative, and Integrative Medicine
Is there a difference?

12. Difference Between Alternative, Complementary, and Integrative
Alternative medicine is used in place of conventional medicine.
Complementary medicine is used together with conventional medicine.
Integrative medicine is . . .

13. Difference Between Alternative, Complementary, and Integrative
Alternative medicine is used in place of conventional medicine.
Complementary medicine is used together with conventional medicine.
Integrative medicine is used together with conventional medicine in a deliberate manner that is personalized, evidence-based, and safe.

14. The practice of medicine that reaffirms the importance of the relationship between practitioner and patient
Focuses on the whole person
Informed by evidence
Makes use of all appropriate therapeutic approaches, providers, and disciplines to achieve optimal health and healing

15. Why? Why do patients pursuve Alternative medicine?
Pts. Want to feel better
Desire to do everything possible - To feel hopeful –
Gain control - Enhancing the immune system
Application of less toxic treatments or reducing side effects and organ toxicity –
Improve quality of life
(Stenensen1996; Fernandez1998; Rees 2000; Richardson 2000)
Why?

16. Why? Improve quality of life and prolong life Boost the immune system
Relieve symptoms
Prevent cancer recurrence
Aid conventional medical treatment
Recommendation from family or friend
Pts. Want to feel better
Desire to do everything possible - To feel hopeful –
Gain control - Enhancing the immune system
Application of less toxic treatments or reducing side effects and organ toxicity –
Improve quality of life
(Stenensen1996; Fernandez1998; Rees 2000; Richardson 2000)
Why?

17. Outline Background Integrative Medicine Program
Examples of Integrative Medicine Approaches

18. Clinical Program Philosophy
“The Integrative Medicine Center aims to work collaboratively with the oncology team to build a comprehensive and integrative care plan that is personalized, evidence-based, and safe with the goal of improving clinical outcomes.”
Based on this definition, we’ve developed a philosophy here -

19. The Integrative Medicine Program at MD Anderson Cancer Center
Clinic
Research
Education
Goal of improving patient care and advancing knowledge in the area of integrative medicine

20. Integrative Medicine Center Model
“the physician’s basic professional knowledge and
skills must span the social, psychological, and biological, for his decisions and actions on the patient’s behalf involve all three.”
Physical
Our integrative model is based upon Dr. George Engel’s paper in Science from Illness and Disease as separate entities.
Health
Psycho-Spiritual
Social

21. Integrative Medicine Center Model
● Integrative Oncology Consultation
Physical
● Nutrition
● Acupuncture
● Massage
● Exercise
● Rehabilitation
● Smoking
Cessation
●Environmental
Exposures
● Rest/Sleep
● Pharmacy
●Chemotherapy
● Surgery
● Radiation
Psycho-Spiritual
● Chaplaincy
● Psychiatry
● Tai Chi
● Meditation
● Yoga
Optimal Health & Healing
Social
● Music Therapy
● Family/Friends
● Patient
Advocacy
● Social Work
● Education
● Support Groups
= Improved Clinical Outcomes
● Psychology
For cancer patients, how can we optimize their cancer care – can we improve upon chemotherapy, surgery and radiation? We believe we can by addressing all dimensions of their health…
This option is not for everyone and some patients may be perfectly happy taking prozac for mood.

22. Back to Jo Jo is 52 years old.
She was first diagnosed with hormone Positive breast cancer over 5 years ago.
An MRI done to evaluate her recent back pain shows metastatic breast cancer to the bone.
She sees her oncologist who discusses treatment options.
She does some research on her own and reads about Alternative treatments offering her:
A chance at a cure with no side effects.
Eliminating cancer symptoms & treatment related side effects
Who can she talk to about what she has read? Is it true?
We will come back to Jill

23. Back to Jo Ask oncology team about Integrative Medicine
Jo is 52 years old.
She was first diagnosed with hormone Positive breast cancer over 5 years ago.
An MRI done to evaluate her recent back pain shows metastatic breast cancer to the bone.
She sees her oncologist who discusses treatment options.
She does some research on her own and reads about Alternative treatments offering her:
A chance at a cure with no side effects.
Eliminating cancer symptoms & treatment related side effects
Who can she talk to about what she has read? Is it true?
We will come back to Jill
Ask oncology team about Integrative Medicine

24. Integrative Oncology Consultation
Educate
Provide personalized therapeutic recommendations
Interdisciplinary Approach
Weekly team meeting to discuss patient cases
Communication with the primary team
Integrative Medicine
Herbs & Supplements
Nutrition
Exercise
Acupuncture
Oncology Massage
Music Therapy
Meditation
Consultation clinic focuses a lot of time educating patients about our approach
Our recommendations are becoming more therapeutically driven
Other changes include our IDT, increased communication and more frequent f/u

25. Herbs & Supplements
Product label from Isotonix product

26. Toxicity
Thirty-four cases of hepatitis following the consumption of preparations containing green tea were retrieved from Medline between 1999 and October Hepatoxoicity likely secondary to EGCG.

27. Toxicity Immune Factor Change from Baseline
34 postmenopausal breast cancer patients who had completed therapy and were free of disease; enhance-boost some, depressed other parameters of immune function; dose escalation study; maiake liquid extract twice per day for 3 weeks
J Cancer Res Clin Oncol (2009) 135:1215–1221

28. Quality
Arch Intern Med. 2003;163(6):
Arch Internal Med 2003

29. Interactions Green Tea Echinacea Mushroom extracts (maitake)
One of the most common methods in the field of alternative medicine has been to pursue the use of herbs and supplements

30. Catharanthus roseus (Periwinkle) Vinblastine
Taxus brevifolia (Yew Tree)
Paclitaxel
Camptotheca acuminata (Happy Tree)
Irinotecan
Podophyllum pelatum (Mayapple)
Etoposide

31. ATBC trial
Lung cancer prevention trial Results: Smokers taking beta-carotene supplement had higher incidence of lung cancer
ATBC (alpha tocopherol and betacarotene trial
NEJM 1994

32. Anti-Oxidants During Treatment
Decreased survival taking Vitamin E or Vitamin E and Beta-carotene supplements
Reduction in severity of acute side effects, but decreased survival on alpha tocopherol and beta carotene or alpha tocopherol alone

33. Outline Background Integrative Medicine Program
Examples of Integrative Medicine Approaches

34. Nutrition & Exercise

35. Healthy body weight (normal BMI)
Exercise regularly – 150 minutes/week of moderate intensity or 75 minutes of vigorous activity
5 servings of fruits and vegetables per day
Limit processed meat, red meat, and refined grains
Limit alcohol
American cancer society guidelines are for cancer risk reduction and for survivors but still apply to patients with breast cancer; most important in patients with metastatic breast cancer to develop an individualized plan of nutrition and exercise to maximize safety.
McCullough et al. Cancer Epidemiol Biomarkers Prev; 20(6); 1089–

36. Nutrition Emphasize Whole Foods Dietician referral Whole Fruits
Whole Vegetables
Whole Grains
Lean Meats
Dietician referral

37. Organic versus Natural

38. Exercise Multiple benefits to exercise Goal of safe exercise
Improved Mood
Decreased Fatigue
Goal of safe exercise
Referral to:
Physical Medicine and Rehabilitation
Physical Therapy and Occupational Therapy

39. Acupuncture Traditional Chinese Medicine practice
Insertion of needles at specific points to help relieve cancer or treatment related symptoms.
How can Acupuncture help?
Pain
Nausea
Dry Mouth
Hot Flashes
Fatigue
Neuropathy

40. Oncology Massage Therapy
Oncology massage therapists have special training to provide safe and optimal massage through awareness of the unique needs of cancer patients.
How can Oncology Massage help?
Relieve Anxiety & Stress
Decrease Pain
Relieve Constipation
Relieve Neuropathy

41. Mind-Body Practices
Practices that enhance self-awareness through increased focus on the connection between mind and body using sound, breath, movement, or other approaches.
How can Mind-Body practices help?
Relieve Anxiety & Stress
Improve Quality of Life
Improve Sleep
Yoga
Meditation
Tai Chi
Qi Gong

42. Music Therapy
Music therapists help those affected by cancer learn how to use music (songwriting, listening, etc.) for non-musical goals.
How can Music Therapy help?
Relieve Anxiety & Stress
Improve Quality of Life

43. Integrative Medicine, when? Continuum of Cancer Care
Surgery
Radiation
Diagnosis
Chemotherapy
Recurrence / Metastasis
Advanced Cancer
Active Treatment
Prevention
Prevention
Active Treatment
Survivors
Survivorship
When to refer – for patients with interest and needs then having patients come early in the cancer continuum would be ideal; no time is too soon
Meditation
Music Therapy
Massage
Acupuncture

44. Integrative Medicine Resources
Organization/Web Site
Address/URL
University of Texas MD Anderson Cancer Center Complementary/Integrative Medicine Education Resources
Memorial Sloan-Kettering Cancer Center Integrative Medicine Service
NIH National Center for Complementary and Alternative Medicine (NCCAM)
NCI Office of Cancer Complementary and Alternative Medicine (OCCAM)

46. Our Team
Lorenzo Cohen Richard Lee Peiying Yang Alejandro Chaoul Kay Garcia Amy Spelman Jane Williams Stephanie Maxson Roma Polanska Kira Taniguchi Curtiss Beinhorn Sat-Siri Sumler Ingrid Moeller Michael Richardson Jill Flury Sanober Ajani Catherine Powers-James
Kathrin Milbury
Michael Spano
Donna Capps
Sarah Prinsloo
Qi Wei
Rosalinda Engle
Smitha Mallaiah
Charles Mikeska
Devin Bigler
Zinat Taiwo
Sarah Nguyen
Stephanie Gabel
Suki Cheema
Chelsea Gilts
Robin Haddad
Marilyn Kenebrew
Anne Marie Alcala
Patrea Rhea
Edrea Gonzales
Xiao-Ping Ding
Carrie Cartwright
Xanthia Baptiste-Gordon
Tanier Williams
Ekem Efuet
Yong Pan
Carol Eddy
Susan Underwood
Patrick Hwu
Robert Wolff
Wendy Austin
Andrea Armstrong
Thank you!

47. Thank You