ORIGINAL ARTICLE /ARTICLE ORIGINAL DOSSIER
Integrative Oncology in the United States:
Memorial Sloan-Kettering Cancer Center programme as prototype
Médecine intégrative en oncologie aux États-Unis :
le programme du Memorial Sloan-Kettering Cancer Center
B.R. Cassileth
Revised: 13 June 2011, Accepted: 15 July 2011
© Springer-Verlag France 2011
Abstract Over the last two decades, cancer treatment has become increasingly sophisticated, resulting in high cure rates. But these treatments also cause difficult-to-treat and often long-term side effects. Complementary therapies such as acupuncture, mind–body techniques, music therapy, fitness programmes and massage therapy are non-invasive, non-pharmacologic interventions that are used along with conventional treatment. These evidence-based therapies relieve symptoms and improve physical and emotional well- being. Strong clinical data indicate the value of complemen- tary therapies in controlling symptoms associated with cancer and treatment. The author has developed one of the early integrative medicine programmes in the United States, at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York City. The faculty and staff of this 60-member department provide inpatient and outpatient care, conduct research in collaboration with senior oncologists throughout the institution and produce training programmes for oncology- related professionals. Another important feature of this depart- ment is its“AboutHerbs”Web site (http://www.mskcc.org/
aboutherbs), which provides current, evidence-based informa- tion about herbs and dietary supplements used by cancer patients, as well as herb–drug interactions, at no cost. The MSKCC department continues to serve as a prototype for inte- grative oncology programmes in the United States and around the world.To cite this journal: Psycho-Oncol. 5 (2011).
KeywordsCancer care · Complementary therapies · Integrative Oncology · Acupuncture · Massage · Music therapy · Yoga · Meditation
RésuméDepuis les deux dernières décennies, les traitements en oncologie ont gagné en sophistication tout en améliorant
sérieusement les taux de guérison. Mais ces traitements ne sont pas sans difficultés particulièrement dans les effets à long terme. Les thérapies complémentaires comme l’acu- puncture, les techniques corps–esprit, la musicothérapie, les programmes de fitness et de massage sont des interventions non pharmacologiques qui sont utilisées avec les traitements conventionnels. Ces thérapies ont démontré qu’elles dimin- uaient les symptômes et amélioraient le bien-être physique et émotionnel. Des données validées indiquent la valeur de ces thérapies complémentaires dans le traitement des symp- tômes associés aux cancers et à leurs traitements. L’auteur développe l’un des premiers programmes de médecine inté- grative aux États-Unis, au Memorial Sloan-Kettering Cancer Center (MSKCC) de New York City. La faculté et l’équipe de 60 membres du service offrent des soins aux patients hospi- talisés et extérieurs, conduisent des recherches avec des onco- logues en ville et proposent des programmes de formation aux autres professionnels de l’oncologie. Un autre intérêt impor- tant de ce service concerne la phytothérapie (http://www.
mskcc.org/aboutherbs), qui fournit des informations validées sur les plantes et la diététique ainsi que sur les interactions plantes/thérapies conventionnelles. Le MSKCC continue à élaborer des prototypes de programmes aux États-Unis et dans le monde entier. Pour citer cette revue : Psycho- Oncol. 5 (2011).
Mots clésSoins en oncologie · Thérapies complémentaires · Oncologie intégrative · Acupuncture · Massage ·
Musicothérapie · Yoga · Méditation
Introduction
“Integrative oncology”is a synthesis of mainstream cancer treatment and complementary therapies. Complementary therapies are non-invasive, non-pharmacologic adjuncts to mainstream cancer treatment. These therapies do not directly
B.R. Cassileth (*)
Memorial Sloan-Kettering Cancer Center, New York e-mail : [email protected]
DOI 10.1007/s11839-011-0325-3
affect or treat the disease. Instead, they help relieve pain and distress by controlling physical and emotional symptoms associated with cancer and cancer treatment.
Optimal care for cancer patients requires a broader emphasis on an integrative approach to better manage patients’ physical and emotional needs, and it is also an important aspect of survivorship. In today’s world, successful cancer treatments cure increasing numbers of patients, but they also cause difficult, enduring physical and emotional symptoms. Oncologic care must include attention to more than the tumour. It must address those enduring problems as well.
Integrative Oncology across the United States
Virtually all cancer centres and cancer programmes in the United States have at least some components of integrative medicine. These may include only music therapy for inpati- ents, or only lectures, or only massage therapy for outpatients.
Some are involved only with research; others with a specific aspect of inpatient care, such as paediatrics or post-surgery care. The range and variety are great, but it would be difficult to find a major cancer programme in the United States that does not include at least a few complementary therapies.
Integrative Medicine at Memorial
Sloan-Kettering Cancer Center (MSKCC) as a Prototype
The author was recruited to actualize the concepts expressed above at MSKCC in 1999. Since then, we have developed an Integrative Medicine Department that was meant not only to serve our patients, but also to serve as a prototype to guide other centres around the world. This department provides inpatient and outpatient clinical care as well as research and training in collaboration with clinicians, researchers and others throughout the institution. We have also created a Web site to provide physicians and the public with evidence-based information about herbal remedies, vitamins and other dietary supplements at no cost (www.MSKCC.org/
AboutHerbs). The MSKCC Integrative Oncology Depart- ment may be more full-blown than many others, but it repre- sents the various components that produce a robust and comprehensive clinical, research and training programme.
A primary focus of our programme is to study and deploy evidence-based, rational complementary therapies to our patients, their families and staff. These approaches may be perceived as extensions of the supportive care previously associated with oncology for decades. Simultaneously, our faculty and staff work diligently to stop the use of unproved
“alternative” therapies promoted for use in lieu of main- stream cancer treatment; these are otherwise known as
quackery. The promotion and false promises of fake cancer cures is a multi-billion dollar business in the United States and in all developed countries. The use of disproved or irrational“therapies”has no place in proper cancer care.
How Patients Access Integrative (Complementary) Therapies
Patients, family members, staff and others may themselves make appointments at our outpatient centre. Inpatient con- sultations are requested by inpatient oncology professionals to reduce patient agitation, relieve pain or reduce levels of narcotics needed to maintain comfort, and manage other symptoms with complementary therapies. These therapies are cost-effective and produce no negative side effects.
They also help normalize and humanize the high-tech hospital environment. Consultations are also requested by MSKCC oncology professionals to assist them in navigating challenging interactions with patients and family members who want to use “alternative”therapies (e.g., magnet and light therapies, supplements promoted for use instead of evidence-based oncologic treatments etc.). There are no via- ble“alternatives”to modern, mainstream cancer treatment.
Integrative therapies are available to patients and their family members associated with MSKCC or other hospitals, as well as to faculty, staff and community members.
The therapies offered include massage therapy; mind–body techniques including meditation, self-hypnosis, yoga, tai chi and many other classes and private sessions; music therapy;
acupuncture treatment; nutrition and physical fitness; and advice about herbs and other dietary supplements. Each of these evidence-based approaches has an important role in cancer patient care. Most are outlined below.
Massage therapy
The main goal of massage therapy is to reduce physical pain, induce relaxation and provide comfort. Touch therapies also offer the benefits of a caring interaction and the human touch. Gentle massage or simply foot massage (reflexology) may be most appropriate, with intervention always consis- tent with the patient’s clinical status. In the hands of licensed, highly-skilled massage therapists trained to work with can- cer patients, this is a very safe and therapeutic intervention.
MSKCC has offered massage therapy at MSKCC since the inception of the Integrative Medicine Department 11 years ago. Patients’ family members and professional staff often report that just watching the therapist work with patients is comforting and relaxing for everyone. Our three-year study of 1,290 patients at MSKCC showed that massage therapy brought sustained relief from pain, fatigue, nausea and other symptoms. Symptom scores were reduced
by approximately 50%, even in patients who reported high baseline scores. Importantly, the benefits persisted in many patients throughout a 48-hour follow-up period [6]
Mind
–body techniques
Mind–body interventions, such as meditation, self-hypnosis, yoga, Qi Gong and Tai chi, use the mind’s capacity to relax the body. Conversely, massage therapies and other means of relaxing the body, conversely relax the mind. These are described below.
Meditation for Stress Reduction
Meditation training is a self-directed mental exercise to inten- tionally focus the mind on a target perception [16]. Meditation often begins with breath awareness [2]. Studies of such mindfulness-based stress reduction show that it can help treat cancer patients’symptoms [18]. In a qualitative study, patients reported that mindfulness meditation improved their quality of life and made them feel less vulnerable to stress, more tolerant of negative aspects of self and others, and more appreciative of life as meaningful [21]. A randomized study also revealed improvement in mood disturbances and decreased stress [28].
Studies of breast and prostate cancer patients showed improved immune profiles in the form of a shift from TH1 (pro-inflammatory) to TH2 (anti-inflammatory) environ- ment [3]. In a one-year follow-up study, the same authors reported that participation in the programme continued to enhance patients’ quality of life, decrease stress, alter cortisol and immune patterns consistent with less stress and less mood disturbance, and decrease blood pressure [2].
The procedure’s relaxation benefits may contribute to this effect. A meta-analysis demonstrated the effectiveness of mindfulness-based meditation in helping cancer patients manage psychosocial stress. Patients experienced relief of anxiety, stress, fatigue, and general mood and sleep distur- bances, and reported improved psychological well-being and quality of life [17].
Similarly, a study of 115 cancer-survivors showed improve- ments in depression, anxiety, distress, and mindfulness. These effects were maintained at a three-month post-intervention follow-up [13]. Overall, the medical literature points to signif- icant benefits of mindfulness-based meditation for cancer patients. This intervention is generally easy to learn and well accepted by patients.
Self-Hypnosis
Both meditation and self-hypnosis, a deeper form of medita- tion, can be self-applied by patients as needed to promote
relaxation and reduce stress. The additional value of these stress reduction approaches is that they are tools with which patients can help themselves. Hypnosis is a highly relaxed state in which the conscious and unconscious mind is open to therapeutic suggestion. It may be defined as an altered state of consciousness, awareness or perception.
Hypnosis has been studied in a number of health problems including pain, smoking cessation, migraine headaches, allergies, childbirth, dermatology, wart removal, dentistry, haematology, hypertension, obesity, tinnitus, colonoscopy and more recently as a treatment for hot flashes [11,30].
Hypnotic relaxation is the most frequently cited form of non-pharmacologic cognitive pain control. It may also reduce dependency on analgesics and has no harmful side effects [23]. In a randomized study of advanced-stage cancer patients, hypnosis was shown to effectively reduce pain [12].
A National Institutes of Health Technology Assessment panel in the United States showed that evidence for the use of clinical hypnosis in alleviating chronic cancer pain was conclusive [14].
Hypnosis has also been employed for the relief of nausea and vomiting secondary to chemotherapy in children as well as adults [30]. A randomized study in children receiving chemotherapy found that hypnosis decreased anticipatory nausea and vomiting, and decreased vomiting overall com- pared to controls [31]. This finding was replicated in another paediatric study, which also showed decreased need for anti-emetic medications with hypnosis [15]. Hypnosis was also shown to be associated with the relief of acute and chronic cancer pain in children [19]. Breast cancer patients utilizing self-hypnosis reported less pain and showed increased length of survival [29].
Hot flashes, a difficult symptom of the climacteric and a common problem for cancer survivors on chemotherapy, may respond to clinical hypnosis. A randomized study of 60 breast cancer survivors with hot flashes showed that hot flash scores (frequency times average severity) decreased 68% from baseline utilizing clinical hypnosis [11]. This find- ing led to an ongoing large, randomized NIH-funded study.
A randomized clinical trial demonstrated that as little as one session of self-hypnosis training lasting only 15–20 minutes can reduce pain, fatigue, and discomfort in breast cancer patients who underwent surgery. In a well-designed study, patients undergoing excisional breast biopsy or lump- ectomy received either a 15-minute pre-surgery hypnosis session or empathic listening for the same amount of time.
Those receiving the brief hypnosis session reported signifi- cantly lower pain, discomfort, fatigue and emotional distress post-surgery. In addition, they required less time in recovery and earlier hospital discharge, resulting in decreased institu- tional costs. This study provides persuasive evidence for integrating self-hypnosis for symptom management in breast cancer patients following surgery [22].
Yoga
Yoga, an ancient tradition from India, is popular also in the West and around the world. There are many different styles of yoga, but virtually all incorporate controlled breathing and visualization, relaxation techniques such as meditation, and postures. The practice of yoga encompasses ethical prin- ciples such as avoiding harm in actions and words, physical postures and spiritual practices, all with the goal of uniting mind and body [27].
It is estimated that 15 million adults have used yoga, with almost half specifically applying it to manage health conditions [27]. Randomized clinical trials and other studies of cancer patients show that yoga improves sleep [8] and reduces stress, fatigue, negative mood, and pain [1,4,5,9].
A multi-site, phase II/III randomized clinical trial examined the efficacy of yoga for improving sleep quality, fatigue and quality of life in 410 early-stage cancer survivors.
Significant improvements in sleep quality, fatigue and quality of life were demonstrated [24].
Music Therapy
Music therapists are musicians with graduate training in using music as therapy. Music therapy is offered to encour- age healing and promote well-being. Benefits from music therapy may be derived passively (patient listens) or interac- tively (patient participates). The music can be tailored to patient preference in terms of the music selected and the instruments used. Typically, we bring portable instruments into the Intensive Care Unit, the isolation units, and through- out the hospital to work with inpatients. Instruments include guitar, keyboard, harp and percussion instruments for the patients to use, as appropriate. The level of patients’involve- ment varies by their clinical status. Music therapy also permits the participation of caregivers and family members.
Music therapy is valuable for patients in isolation, especially for those who are non-communicative or with- drawn. It reduces the sense of isolation often experienced by such patients. Music therapy also offers gentle stimula- tion for patients who are being weaned off sedatives, and helps patients relax during procedures such as extubation.
In a serendipitous result of a music therapy study designed to benefit patients, the attendant physicians and nurses unexpectedly experienced helpful emotional, cognitive and team effects [25].
Acupuncture
Acupuncture is a 3,000-year-old component of traditional Chinese medicine. It involves stimulating one or more pre-
determined points on the body with sterile, filiform, dispos- able needles, which are approximately the width of a human hair. The needles target specific acupuncture points on the body that are dense with sensory receptors. These acupoints have lower electrical resistance and are close to superficial nerve junctions [20].
Acupuncture reduces many symptoms experienced by can- cer patients at all stages of treatment, including dyspnoea, fatigue, hot flashes, sexual dysfunction, urinary problems, osteoarthritis, neuropathy and xerostomia. Acupuncture also can relieve anxiety, depression, stress and pain, and it can reduce the amount of opioids required to maintain patient comfort. Randomized clinical trials show that relief offered by acupuncture is not a placebo effect. A phase III MSKCC trial reported that acupuncture reduced pain and dysfunction in cancer patients with a history of neck dissection. In addi- tion, acupuncture relieved xerostomia in this population [26].
A companion functional MRI (fMRI) study illustrated that true versus sham acupuncture produced neuronal activation associated with increased saliva production. Signal changes on neuroimaging correlated with changes in the appropriate cortical areas [10].
Herbs and supplements
Many cancer patients turn to herbs in the misperception that, because the products are“natural,”they are safe. Herbal and most other dietary supplements are not recommended for cancer patients undergoing treatment, or for people taking any prescription medication. MSKCC recommends no herbs, high-dose vitamins, or antioxidants during cancer treatment. This prohibition stems from the fact that herbal remedies, which are biologically active, may interact nega- tively with mainstream cancer treatment or induce toxicities.
Moreover, most dietary supplements are not standardized, many are contaminated, and there are often major discrepan- cies between ingredients listed on the package label and the actual components of the supplement.
Examples of problems caused by herbs include:
•
Garlic, gingko, ginseng, vitamin E: can interfere with blood coagulation;•
Ephedra: may lower blood sugar;•
St. John’s Wort, valerian: may affect blood levels of chemotherapy;•
Kava: can cause liver toxicity.Herb–drug interactions represent an important problem.
The MSKCC AboutHerbs Web site (www.mskcc.org/
AboutHerbs) offers routinely updated and comprehensive, evidence-based data on more than 250 herbs, botanicals, antioxidants, vitamins, bogus therapies, etc., at no charge.
Separate entry portals are available for patients and
physicians; anyone can enter either portal. Additionally, our group recently published the second edition of our book, entitled Herb-Drug Interactions in Oncology [7].
Conclusion
Integrative Oncology can benefit patients, family members and staff by relieving symptoms of physical pain and emotional distress, and by maximizing the serenity and comfort of patients at diagnosis, throughout their inpatient stay, and following treatment into Survivorship.
Conflict of interest :The author doesn’t have any conflict of interest to declare.
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