Jillian L. Capodice, LAc examines the background, recent research and applications for integrative oncology.

by Jillian L. Capodice, LAc

Background
Integrative oncology (IO) has been described as a science and philosophy that focuses on the complex health of people with cancer by utilizing approaches that accompany conventional oncologic treatment to facilitate health (1). Integrative oncology is an extremely large field that considers everything from molecules to mind-body interventions.

Utilizing the National Center for Complementary and Alternative Medicine categorization of Complementary and Alterative Medicine (CAM), table 1 lists only some disciplines and their application in Integrative Oncology. 

Below, I will briefly outline the practices listed in table 1 and discuss a current study for each.

Dietary Supplements
According to the National Institutes of Health Office of Dietary Supplements (2), a dietary supplement is a product that:

• Is intended to supplement the diet
• Contains one or more dietary ingredients including such substances and constituents of vitamins, minerals, herbs, botanicals, amino acids, probiotics or other substances
• Is intended to be taken by mouth a s a pill, capsule, tablet or liquid
• Is labeled on the front as being a dietary supplement

Vitamin D
Vitamin D is an essential nutrient that is synthesized in the skin following ultraviolet irradiation (exposure to sunlight) from a 7-dehydrocholesterol precursor.  The main function of vitamin D is to regulate calcium homeostasis in the body. Since vitamin D is not readily available from most food sources, many products including dairy products, grains, cereals and breads are now fortified with vitamin D.  Also supplements of pure vitamin D and multivitamin formulations containing vitamin D are readily available.

Vitamin D technically describes both ergocalciferol (D2) and cholecalciferol (D3) and the chemical nomenclature is 1-α, 25-dihydroxyvitamin D which refers to either D2 or D3 if not otherwise specified.  Evidence supporting the idea that vitamin D plays a role in protection against various cancer is both epidemiological and laboratory based and many epidemiologic studies have suggested that vitamin D deficiency may be a predictor for various cancers including prostate, breast and colon (3-5)

There is a tremendous amount of research currently being conducted on vitamin D and research is targeted in areas including:

– Epidemiology:  Cancer risk and serum vitamin D levels (6,7)- conflicting evidence of vitamin D’s predictor status
– Basic Science
o Vitamin D deficiency proliferation of cancer cell lines and in vivo models (8,9)
o Anti-growth effects of vitamin D in cancer cell lines and in vivo models (10,11)
o Genetic polymorphism, vitamin D deficiency and cancer risk (12, 13)
– Human clinical studies
o Effect of vitamin D blood levels in patients with stage IV colorectal cancer (14)
o Study of Vitamin D for Premenopausal Women at high risk for breast cancer (14)
o Vitamin D supplementation effect in Veterans with early stage Prostate Cancer (14)

Acupuncture and TCM
Acupuncture is the insertion of small needles into the body and is generally oriented in a traditional medical framework such as Traditional Chinese Medicine (TCM).  The physiologic mechanisms of acupuncture are increasingly understood and acupuncture is generally safe and proven to reduce chemotherapy induced nausea and vomiting (15).  In IO, acupuncture is also being studies for a variety of conditions including chemotherapy induced neuropathy, dyspnea, fatigue, hot flashes, pain and xerostomia (14).

Yoga and Ayurveda
Yoga refers to physical postures, mental and breathing exercises that originated in India.  Yoga also refers to concepts in Hindu and Buddhist philosophies.  With regard to the general styles of yoga, one of the most commonly practiced and studied yoga schools is Hatha yoga that emphasizes physical postures and breathing exercises (17).  Yoga is also a component of Ayurvedic Medicine (Ayurveda) which is considered a whole medical system.  Aspects and tools of Ayurveda include:

– Body, mind and spirit integration
– Products including foods, and herbs
– Practices such as yoga and meditation

Recent study of yoga in people with cancer
Chandwani KD, Thornton B, Perkins GH, Arun B, Raghuram NV, Nagendra HR, Wei Q, Cohen L. Yoga improves quality of life and benefit finding in women undergoing radiotherapy for breast cancer. J Soc Integr Oncol. 2010 Spring;8(2):43-55. This study examined the practice of six weeks of yoga versus a waiting list control on QOL in women undergoing radiation therapy for breast cancer.  QOL measures including fatigue, benefit finding, intrusive thoughts, sleep, depressive symptoms and anxiety.  Results demonstrated that the group that performed yoga had significantly better outcomes then women in the weight list control group including greater benefit finding 3 months postradiotherapay (p=0.01).

Massage Therapy
Massage therapy includes a variety of practices and manipulations that affect muscle and soft tissue of the body.   In IO, massage therapy may be useful to help patients that may be experiencing pain or anxiety.  Some common forms of massage therapy include Swedish massage, Thai massage, shiatsu, and tui na.  Recent research in IO has shown that massage therapy can reduce anxiety and pain in subjects with breast and lung cancer.  Some warnings specific to cancer are listed in table 1.   

Recent study of massage therapy in people with cancer
Listing M, Krohn M, Liezmann C, Kim I, Reisshauer A, Peters E, Klapp BF, Rauchfuss M. The efficacy of classical massage on stress perception and cortisol following primary treatment of breast cancer. Arch Womens Ment Health. 2010 Apr;13(2):165-73. Epub 2010 Feb 19.

 – This study examined classical massage (30 minutes of massage with Swedish techniques) versus no treatment in women diagnosed with primary breast cancer.  Measures included a number of quantitative questionnaires, cortisol and serotonin measurement.   Compared with control group, women in the intervention group reported significantly lower mood disturbances, especially for anger (p = 0.048), anxious depression (p = 0.03) and tiredness (p = 0.01). There was a decreased level of serum cortisol from baseline to the end of the intervention period that increased after the follow up period. There were no changes in serotonin levels in either of the two groups.

Table 1.  CAM Therapies and Integrative Oncology Applications

Category

 (Subspecialty)

Integrative Oncology Application

Research notes

Clinical notes

Biologic based therapy

Dietary supplements

Extremely broad category inclusive of a variety of agents such as antioxidants, vitamins and botanical based agents potential useful as chemopreventive or synergistic.  Potentially harmful with regard to herb-drug interactions.

All categories of dietary supplements have agents that are researched.

Of these some of the most commonly studied are green tea, vitamin E, selenium and curcumin.

Important to ask your patient what dietary supplements they are taking.  Important to provide balanced guidance based on the patients treatment plan and utilization of evidence and best practices. 

Biologic based therapy

Diet and nutrition

An enormous category including epidemiologic study and data on diet and nutritional strategies, potentially preventive strategies and active nutritional therapies used during treatment and throughout survivorship.

Diet and cancer prevention research is a large category frequently studying populations consumption of various foods and beverages.

Evidence suggests that a healthy diet is a crucial lifestyle change for people that may help to reduce cancer risk.  Healthy diets during treatment and throughout survivorship are also recommended.

Whole Medical System: Traditional Medicine

Traditional Chinese Medicine (TCM) and Acupuncture

Broad category including components such as diet, acupuncture, qi gong, moxibustion, herbal medicine and tui na that may be helpful to promote health, ameliorate side effects and/or increase quality of life and survivorship issues.  

For acupuncture specifically, increasing evidence for use during conventional treatment for amelioration of a variety of side effects.

Acupuncture is likely safe. Similar recommendations and caveats for TCM based diet and herbal medicine strategies as abovelisted in dietary supplements and nutrition.

Whole Medical System: Traditional Medicine

Ayurvedic Medicine and yoga

Category includes herbs, yoga and massage oriented in Ayurvedic tenets aimed at improving the body, mind and spirit, similar overall potential as aforementioned in TCM.

Less research on traditional Ayurvedic medicinal compounds, increasing research on yoga that demonstrates help during conventional treatment and throughout survivorship

Yoga likely safe with general recommendations and caveats when learning or applying new physical/exercise routines. Same recommendation for herbs as above.

Mind-Body

Meditation

The process of focusing on mental awareness, clarity and attention in the mind.  Utilized in a variety of whole medical systems including TCM and Ayurveda.  May be useful in reducing anxiety prior to surgery and reducing worry and bother during chemo or radiation.

Mindfulness-based stress reduction is likely the most extensive form of meditation researched.

Likely safe and good recommendation as part of an integrative approach in increasing quality of life and reducing anxiety.

Manipulative Based Practice

Massage Therapy

A term that encompasses a variety of techniques that manipulate the body via pressing, rubbing and manipulating soft tissue and muscle. May provide pain relief and relaxation in people with cancer.

Research shows that various massage therapies may aid relaxation, reduce stress and may help to relieve pain in some cancer patients.

Important to note that application of deep pressure on or by cancer lesions, lymph nodes, radiation sites, or medical devices (catheters, ports etc.) is not recommended.

Conclusions
In conclusion, there are an immense number of CAM practices and products that are being studied and integrated into the oncology setting.  Moreover, the field of Integrative Oncology that combines best practices, evidence and a multidisciplinary approach is increasing.  Finally patients and clinicians alike are more aware than ever that nurturing physical, mental and spiritual well being in people with cancer is of tremendous importance.

Research References
National Cancer Institute
National Cancer Institute- Office of Cancer Complementary and Alternative Medicine
National Center for Complementary and Alternative Medicine
Professional Organizations
Society for Integrative Oncology

References
1.  Sagar SM. The integrative oncology supplement—a paradigm for both patient care and communication. Curr Oncol 2008; 15: 166 – 7.
2.  Office of Dietary Supplements:  http://ods.od.nih.gov/
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4. Khan QJ, Kimler BF, Fabian CJ.The relationship between vitamin D and breast cancer incidence and natural history. Curr Oncol Rep. 2010 Mar;12(2):136-42.
5. Dong LM, Ulrich CM, Hsu L, Duggan DJ, Benitez DS, White E, Slattery ML, Farin FM, Makar KW, Carlson CS, Caan BJ, Potter JD, Peters U. Vitamin D related genes, CYP24A1 and CYP27B1, and colon cancer risk. Cancer Epidemiol Biomarkers Prev. 2009 Sep;18(9):2540-8. Epub 2009 Aug 25.
6. Toriola AT, Surcel HM, Calypse A, Grankvist K, Luostarinen T, Lukanova A, Pukkala E, Lehtinen M. Independent and joint effects of serum 25-hydroxyvitamin D and calcium on ovarian cancer risk: A prospective nested case-control study. Eur J Cancer. 2010 Jun 18. [Epub ahead of print]
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8. Ooi LL, Zheng Y, Zhou H, Trivedi T, Conigrave AD, Seibel MJ, Dunstan CR. Vitamin D deficiency promotes growth of MCF-7 human breast cancer in a rodent model of osteosclerotic bone metastasis. Bone. 2010 Jul 15.
9. Ooi LL, Zhou H, Kalak R, Zheng Y, Conigrave AD, Seibel MJ, Dunstan CR. Vitamin D deficiency promotes human breast cancer growth in a murine model of bone metastasis. Cancer Res. 2010 Mar 1;70(5):1835-44. Epub 2010 Feb 16.
10. Persons KS, Eddy VJ, Chadid S, Deoliveira R, Saha AK, Ray R. Anti-growth Effect of 1,25-Dihydroxyvitamin D3-3-bromoacetate Alone or in Combination with 5-Amino-imidazole-4-carboxamide-1-{beta}-4-ribofuranoside in Pancreatic Cancer Cells. Anticancer Res. 2010 Jun;30(6):1875-80.
11. Washington MN, Kim JS, Weigel NL. 1alpha,25-dihydroxyvitamin D(3) inhibits C4-2 prostate cancer cell growth via a retinoblastoma protein (Rb)-independent G(1) arrest. Prostate. 2010 Jul 14.
12.  Slattery ML, Wolff RK, Herrick JS, Caan BJ, Samowitz W. Calcium, vitamin D, VDR genotypes, and epigenetic and genetic changes in rectal tumors. Nutr Cancer. 2010 May;62(4):436-42. Cancer Epidemiol Biomarkers Prev. 2009 Sep;18(9):2540-8. Epub 2009 Aug 25.
13. Dong LM, Ulrich CM, Hsu L, Duggan DJ, Benitez DS, White E, Slattery ML, Farin FM, Makar KW, Carlson CS, Caan BJ, Potter JD, Peters U. Vitamin D related genes, CYP24A1 and CYP27B1, and colon cancer risk. Cancer Epidemiol Biomarkers Prev. 2009 Sep;18(9):2540-8.
14.  ClinicalTrials.gov:  http://clinicaltrials.gov/ct2/home
15. Sharma R, Tobin P, Clarke SJ. Management of chemotherapy induced nausea, vomiting, oral mucositis, and diarrhoea. Lancet Oncol 2005;6:93–102
16.  Gary Deng, Moshe Frenkel, Lorenzo Cohen, Barrie R. Cassileth, Donald I. Abrams, Jillian L. Capodice, Kerry S. Courneya, Trish Dryden, Suzanne Hanser, Nagi Kumar, Dan Labriola, Diane W. Wardell, and Stephen Sagar. Evidence-Based Clinical Practice Guidelines for Integrative Oncology: Complementary Therapies and Botanicals. Journal of the Society for Integrative Oncology, Vol 7, No 3 (Summer), 2009: pp 85–120.
17. National Cancer Institute-Office of Cancer Complementary and Alternative Medicine