Integrative Medicine: Adjunctive Element or Essential Ingredient in Palliative and Supportive Cancer Care?

Introduction

In the past 30 years, there has been an increased awareness that cancer care goes beyond surgery, chemotherapy, immunotherapy, and radiation treatments and, appropriately, an increased emphasis on patients' quality of life. ^{1 –3} Accordingly, the fields of palliative and supportive care have developed to address the important need to care for the whole person living with a life-limiting illness or cancer diagnosis. ^4,5 The aim of supportive cancer care, which is offered regardless of prognosis, is to actively manage patients' physical, psychologic, and spiritual concerns from the time of diagnosis through active treatment, survivorship, and the end of life. ^6,7 As cancer therapies continue to improve at extending the lives of people with advanced cancer, the meticulous assessment and management of cancer- and treatment-related symptoms have become more important components of comprehensive cancer care. ⁷ Likewise, complementary therapies are becoming an increasingly intrinsic part of comprehensive cancer care offerings and have the potential to play an essential role in the holistic care of cancer patients and their caregivers. ⁸

The European Society of Medical Oncology published a position article on supportive care and emphasized the importance of patient-centered care integrated by multidisciplinary teams from diagnosis through the entire disease process, including end-of-life and survivorship care. ⁶ Similarly, the American Society of Clinical Oncology has stated that, by 2020, all cancer services should include palliative and supportive care services as part of their standard of care. ⁹ Clinical palliative medicine programs have rapidly developed in cancer centers, academic institutions, and the community. The term “palliative care” was initially associated with end-of-life care, and referrals to such services were typically utilized late in the trajectory of illness. ¹⁰ However, with the increased availability of palliative and supportive care services worldwide, a shift in referral patterns has been seen; there is now a developing trend toward early referral for optimal management of cancer and cancer-related symptoms. For example, when the University of Texas MD Anderson Cancer Center's palliative care department (now the Department of Palliative, Rehabilitation, and Integrative Medicine) added the term “supportive care” to its name, it received increased earlier referrals in the outpatient setting. ¹¹

During the past two decades, there has been an increase in demand for supportive care and palliative care, mirroring a rise in demand for integrative oncology. This new movement of integrative oncology came mostly from patient and family demand. This movement combines complementary and integrative medicine (CIM) in cancer care. ¹² Many of today's leading oncology centers in the United States, ¹³ Europe, ¹⁴ Israel, ¹⁵ and Australia ¹⁶ now include evidence-based CIM in their supportive cancer care programs. Even in the field of surgery, personalized care and CIM in the perioperative setting are enhanced by programs supporting early recovery, in which functional status is a primary outcome and optimal prevention of nausea, vomiting, and pain enables patients to enter postoperative therapies sooner and in better clinical condition. ¹⁷

The Society for Integrative Oncology defines integrative oncology as a patient-centered, evidence-informed field utilizing CIM modalities to optimize health, quality of life, and clinical outcomes. ¹⁸ Integrative oncology and palliative care share similar philosophies and priorities, which are to improve patients' quality of life and reduce suffering, but they differ in the type of treatments being utilized. Indeed, in some comprehensive cancer centers that provide both integrative oncology and palliative care, the two often work in parallel and may actually compete with each other; in other centers, the services are integrated, although slowly. In centers that both services are being provided, the desire is to find the best option of care that can fit the individual needs of each patient. One addresses the weakness of the other, and learning the strengths and weaknesses of each approach leads to better integration and improving the health care the patient receives. However, in actuality, and despite the fact that integrative oncology and palliative care share similar values and goals, integrative oncology and CIM are rarely included in standard supportive care. Even the recent European Society of Medical Oncology position article on supportive care fails to mention integrative oncology or the integration of CIM into cancer care as options to include in supportive care. ⁶

This undercurrent competition between integrative oncology and palliative care raises the question whether CIM should be considered only as an adjunctive add-on, or perhaps even as a luxury item for the affluent, or whether it should be defined as an essential ingredient in supportive cancer care for all patients. To answer this question, the authors look at the contribution that CIM has in supportive care in each stage of the cancer trajectory.

The Role of CIM for Patients with Newly Diagnosed Cancer

Receiving a cancer diagnosis may cause an existential crisis and major distress in patients with newly diagnosed cancer and their families. Patients with cancer face completely different internalization processes than those with other chronic conditions, such as cardiac disorders, even when the survival expectations are similar. ¹⁹ For example, patients with cancer may experience extreme fear worsened by the uncertainty of recovery and may face a heightened awareness of their mortality that becomes more pronounced as their disease progresses. ²⁰

The time shortly after diagnosis is often a time of confusion during which patients are consumed with thoughts and discussions about conventional disease-directed therapies with the goal-of-life prolongation. It requires time to process information, emotions, and the prognosis and to develop a plan of action. Despite research that supports stress reduction as a means of ameliorating emotional distress, most people are unable to think about CIM at this early stage. ¹⁹ It may be weeks or months later that they learn about the options for and benefits of integrating CIM stress-reduction offerings, such as touch therapies, mindfulness, yoga, acupuncture, and others. Had they known about these offerings, they might have benefited from them earlier in their disease trajectories. ²¹

Patients ambivalent about conventional treatments have a very high level of anxiety. ²² An empathic approach, consultation with an integrative oncologist combined with utilization of CIM methods, is often effective in reducing this anxiety and improving patients' attitudes regarding the acceptability and tolerability of cancer treatments. ²¹ A small minority of patients with newly diagnosed cancer, fearful of the risks and side effects of conventional cancer care, explore and utilize alternative medicine options of care that are not safe or clinically effective. ²³ Referrals to an integrative oncology service, therapeutic listening, followed by a discussion of strengths, weaknesses, and evidence-based alternatives, may help reduce patients' fears and anxieties, and encourage patients to make more educated, informed, and empowered decisions. ²⁴

The Role of CIM for Patients Undergoing Treatment

Treatment options today are expanding. Immunotherapy and targeted and biologic treatments have become major additions to conventional chemotherapy, radiation, and surgery, and for many types of cancer, survival is improving, sometimes dramatically. Even with advanced disease, prognosis is improving and cancer treatment requires prolonged care with extended follow-up. ²⁵ Unfortunately, however, both old and new therapies may come with a physical and psychologic cost. For example, some treatments are associated with adverse reactions that are life-threatening or that affect quality of life to varying degrees. ²⁶ As a result, patients undergoing treatment and their families seek ways to reduce the side effects from both cancer and its treatment and to improve the patient's quality of life. It is during the treatment stage that most patients visit integrative oncology clinics in comprehensive cancer centers to request information on CIM. ^21,27

In the past two decades, an increasing number of reports have documented the benefits of integrating CIM during treatment. ^{12 –14,18,21,27} These benefits include reducing the burden of illness, addressing unmet needs and unresolved concerns expressed by patients and their families, and decreasing the distress associated with treatment side effects, which commonly include pain, ^28,29 anxiety and emotional distress, ³⁰ insomnia, ^30,31 fatigue, ³⁰ neuropathy, ^29,32 change in taste, and reduced appetite. ³³ Integrating CIM as part of a holistic supportive care program can result in improved adherence to treatment protocols, which, in turn, can lead to improved survival. ³³ Some studies also suggest that integrating CIM can be beneficial in reducing the need for supportive cancer care-related medications, such as anxiolytics, analgesics, and antiemetics. ³³ This effect alone can substantially improve patient well-being.

Cancer-directed treatment options are continually expanding and concerns that are usually not discussed with the oncology team can be discussed in the supportive setting of integrative oncology. For example, one of the leading concerns expressed by a high percentage of patients in integrative oncology settings, but not usually expressed in conventional oncology settings, is the desire to integrate holistic, patient-centered care in the disease trajectory. ^21,27,34 Unmet needs, unresolved concerns, and questions such as “What else can I do?” are also quite common in integrative oncology settings, where solutions, such as nutrition plans, nutritional supplements (including botanical medicines), lifestyle changes, mind/body/spirit programs, and stress management techniques, can be incorporated into patient care. Such approaches are received favorably by patients undergoing treatment and their families. ^{12 –14,21,27,33,34}

A high number of patients suffer from a large range of various treatment side effects, at times to the point that they cannot complete the suggested therapy. In certain situations, CIM has the potential to reduce symptom severity allowing the patient to better comply and continue the suggested treatment. ^21,27,33,34

The Role of CIM During Survivorship

Because of improved and increasingly successful treatment regimens, the numbers of cancer survivors are increasing. ^35,36 Unfortunately, up to a third of these cancer survivors suffer from prolonged adverse reactions to treatments after treatment ends. ²⁶ These long-term effects might include fatigue, hot flashes, depression or other mood disturbances, sleep disruption, pain, cognitive dysfunction, infertility, neuropathy, heart failure, and others. These residual symptoms, which sometimes do not have an adequate conventional solution, have a significant impact on quality of life and are associated with disability and health care utilization. ^37,38 Fortunately, CIM integration has the potential to decrease the intensity of some of these symptoms and improve quality of life. ^12,39,40

Most survivorship care plans invest substantial effort in surveillance for cancer recurrence or the development of second cancers. ^{41 –44} Increasingly, patients in the survivorship stage want to know what they can do on their own to prevent cancer recurrence or spread, to avoid late treatment side effects, and to extend the length and quality of their lives. ^45,46 There is a growing body of evidence that supports integrating CIM during this stage in the cancer trajectory and actually addresses some of those unmet needs and the desire to be more involved in their own care. ^39,40 Incorporating CIM into the survivorship period can also empower cancer survivors, improve their symptom burden, reduce their psychosocial distress, and enhance their quality of life, and it may potentially improve their survival by reducing the risk of recurrence. ³⁹

The Role of CIM at the End of Life

For many people with a cancer diagnosis, a cure is not possible and disease control is temporary. The reality in these situations is that patients and their families need to confront critical issues associated with the end of life. Palliative care programs can improve end-of-life care for these patients. ⁴⁷ In addition, patients with advanced cancer commonly experience symptoms and concerns, including stress, anxiety, pain, dyspnea, fatigue, depression, and a slowly deteriorating quality of life. The utilization of CIM modalities, such as acupuncture, touch therapy, stress reduction, and biofield therapy, can improve the management of some of these symptoms for patients in palliative, hospice, and home-based care; reduce pain, anxiety, and physical limitations; improve ease of breathing, self-awareness, and comfort; help address unmet needs; and enhance the psychologic and spiritual well-being of patients and families at this critical stage in patients' lives. In short, the incorporation of noninvasive CIM therapies into end-of-life care can have profound benefits. ^{48 –50}

It is also noteworthy that the sense of isolation that patients at the end of life may experience can be reduced by the utilization of interpersonal touch, which has physiologic and psychologic effects. Specifically, touch can reduce stress, improve pain, and ultimately promote comfort and well-being. Many of the CIM modalities can be taught to caregivers for incorporation into their loved ones' daily routines. Utilizing these simple measures can further improve the quality of care for both patients and their families during the end-of-life period. ^51,52

Conclusion

There is increasing evidence that utilizing CIM in supportive cancer care throughout the whole cancer trajectory is gaining greater acceptance and support. The utilization of CIM early in the cancer trajectory, during treatment, and during survivorship periods, as well as during end of life, addresses unmet needs experienced by cancer patients. Utilization of CIM has a role in reducing suffering and distress and enhancing well-being in patients with cancer and their families. CIM is seen not only as an adjunctive add-on treatment but actually as an important component in supportive cancer care for all patients. It addresses aspects of care ignored by conventional treatments. With the increase in CIM-related research, as well as the increased clinical experience in oncology programs worldwide, CIM is gradually becoming an essential ingredient in supportive and palliative cancer care. It is recommended that cancer institutions should consider increasing additional research, education, and clinical programming in this area of care, which actually addresses many unmet needs of patients and their families during the cancer trajectory.