Integrative Medicine in Oncology

By Tarun Wasil, MD & Wendy Kaplan, MS, RDN, CSO, CDCES, CDN

Integrative medicine is the inclusion of some of the non-traditional medical approaches to the standard medical/oncological treatments. It differs from alternative or complementary medicine, where the users do not take traditional medications and resort to unconventional methods as the only treatment modality.  Standard medical/oncological treatments have been developed after careful studies conducted over the last several decades. We are reaping the fruits of this approach these days, and patients with several cancers are living much longer than before. Thanks to all those patients, scientists, investigators, and other health care team members who have helped us gather the evidence needed to advance in the field.

However, there are several unmet needs of our patients because cancer and almost all medications have some annoying symptoms or side effects. Patients have been doing their own research, and it is estimated that 60-80% use some sort of non-traditional approaches in order to feel better and hope to attack cancers with these methods. For the last few years, major cancer centers have realized the need to study these methods scientifically so that we can guide our patients to decrease/minimize the harm that can occur with the use of untested chemicals in supplements and non-medicinal techniques. There is evidence generated from these scientific studies to show that resorting to a healthy lifestyle can decrease the symptoms caused by cancer and the side effects of therapy. Such an approach may also prevent disease states. There is no one-size-fits-all all. There are many different ways to achieve the same goal. Various components of the complementary approaches are (there is an overlap in some cases):

• Diet – Many of us have heard quotes such as “We are what we eat” and “Let food be thy medicine and medicine be thy food,” which means food has a lot of influence on our bodies. Our Nutrition expert, Wendy Kaplan, will discuss it in detail.

• Exercise – it can be light, moderate, or vigorous – any amount of exercise is beneficial. For cancer-related fatigue, ASCO (American Society of Clinical Oncology) recommends 150 minutes of moderate aerobic exercise every week, including brisk walking, cycling, and swimming. Resisted or stretching exercises have also been shown to reduce fatigue in cancer patients undergoing chemotherapy.

• Mindful Techniques to minimize stress include yoga, Tai Chi, Reiki, Qi-Gong, acupuncture, massage, meditation, prayers, music therapy, hypnotherapy, cognitive behavioral therapy, good sleep, staying in a positive environment, avoidance of loneliness and company full of negativity, staying happy, keeping busy in some purposeful way and others.

• Avoid bad chemicals such as smoking, tobacco products, alcohol, processed foods, supplements, refined sugars, and animal fat. Unless otherwise contraindicated, consumption of plenty of electrolyte-rich fluids is recommended.

There is evidence that the above behaviors can be useful in relieving the following symptoms:

• Anxiety

• Depression

• Hot flashes

• Peripheral neuropathy

• Fatigue

• Mood alterations

• Nausea

Other than control of various symptoms, early data suggests these techniques may have deeper effects at the cellular and genome levels. A lot more work needs to be done in this area.

We have heard so much about nature vs nurture. Nature gives us our genes. We cannot change the genes we are born with, but more and more research suggests that many different practices can change the expression of the genes. The environment we stay in, the prayers, meditation, exercises (yoga, Tai Chi, Reiki, and others), diet, our beliefs and perceptions, the air we breathe, the fluids we consume, and the way we lead our lives all can influence our genes for better or worse. Stress also affects our genes at the epigenetic level and may change the expression of these genes. Genes are not active if they are not expressed. Eventually, genes make proteins, which are the building blocks for life. The role of integrative medicine is to combine the knowledge gathered by the current medical system and that from the complementary world. It may benefit healthy people or those suffering from chronic diseases in order to achieve maximal health benefits. This is in addition to and not a substitute for the recommendations made by medical professionals based on the advances made by science. 

The effects of the diet are discussed in detail by Wendy Kaplan.  There are studies to show that some diets are responsible for causing inflammation in our bodies, and others have anti-inflammatory effects. The balance between these two different types can determine the health status. 

The environment we live in is extremely important for our health. When we culture the live cells in the culture media (environment and nutrition for these cells), we see different results depending on the quantity and quality of the medium we use for these cells.  The same is true for the human body. Our cells react to the environment and the nutrition we consume. Loneliness has been associated with a marked decrease in immune responses and disease states. Those individuals who like to socialize in order to achieve happiness have changes at the genetic levels that show some health benefits. Even better genomic changes have been shown in those who lead their lives with a strong purpose and help others without a selfish motive. The company we keep is also important. If we are in a group of individuals who constantly talk about positives, there is a different type of energy created vs those where most people shed negative thoughts. This can be true even for various support groups we tell our patients to join. 

Stress is not one entity. Acute stress is needed to protect us from certain dangerous experiences. Chronic stress can also be divided into at least two different kinds. Taking care of a loved one with passion and a full sense of purpose (such as taking care of a child most of the time) causes useful changes in the body at the cellular and genetic levels. However, for those individuals who consider such an experience as burdensome, their genome changes differently and may look just like those with loneliness, which can result in disease states. Chronic stress of the wrong kind is associated with inflammation. It seems logical that the reduction/elimination of stress by any method can result in reversing cellular changes and good health. 

Relief of stress by mindful techniques such as yoga, Tai Chi, Reiki, Qi-Gong, acupuncture, massage, meditation, prayers, music therapy, hypnotherapy, cognitive behavioral therapy, good sleep, staying in a positive environment, avoidance of loneliness and company full of negativity, staying happy, keeping busy in some purposeful way and others decrease inflammation and may help decrease the diseases related to such internal inflammation. These techniques have been shown to reverse some of the adverse genomic changes induced by stress into favorable profiles.

Healthy lifestyle measures, as described above, may decrease the chances of diseases related to inflammation, such as cancer, but this is not a guarantee. Some unfortunate people may do many things right in a healthy manner but may still develop some disease states, including malignancy. On the other hand, there are some rare examples of people smoking or drinking heavily for > 40 years and not having any major health issues. Most likely, interactions between the genes and environment seem to play a role. If the genetics are robust and strongly protective, bad chemicals may not be able to harm, but if the genes are mutated adversely, even small amounts of toxins may cause serious disease.

The use of supplements is very controversial, especially during chemo. These are regulated after they come to the market and when there are reports of potential harm, unlike the standard medications, which are regulated before and after their availability to the consumers. In general, single supplements have not been shown to be beneficial. The nutrition we get from whole foods has several vitamins, minerals, and supplements and is much better for attaining good long-term health benefits.

Herbal medicine is an integral part of Traditional Chinese Medicine (TCM) and Indian (Ayurvedic) Medicine. It involves the use of natural plant-based remedies to treat a wide range of conditions. Herbal formulas are typically prescribed based on the individual's unique pattern of symptoms and may be taken in the form of teas, capsules, or powders. Both disciplines use a wide range of natural herbs and plants, including roots, stems, flowers, and leaves. These herbs are used in various forms, such as teas, decoctions, powders, and pills, and are often combined in formulas to enhance their therapeutic effects. Each herb has a specific taste, "temperature," and medicinal properties, which are matched to the conditions it aims to treat. 

It is very important to note that some herbs can lead to adverse reactions and interactions with medications. Precautions need to be taken while using them.

These products seem harmless since many of these herbs are used when you’re cooking. However, some may not be safe, especially if you have certain medical conditions or take some medications that contain herbs in concentrated forms, which may negatively change the efficacy of your medication. It is important to always talk with your doctor and Registered Dietitian Nutritionist before taking any supplements.

The use of alternative “medicines” among cancer survivors is known to be high despite limited research regarding safety and efficacy. Patients like alternative practices for various reasons, including their perception that they provide them with more ways to take an active role in taking control of their care, especially while hoping to achieve symptom relief that has not responded to medical treatment or has caused significant side effects. Other patients may be averse to medications and simply want “natural therapies” due to past experiences or preferences. Many times, the patient has most likely heard anecdotal evidence from a friend or on the internet that certain herbs contain anticancer properties and that the only way to “get the amount the body needs” is via a supplement. 

As a Registered Dietitian Nutritionist, gathering additional information such as the patient’s expectations, holistic view of their issues and potential alternatives is essential for responsible practice. For example, the patient may expect symptom reduction or possibly a cure.

We need to have an honest discussion with our patients based on currently available research data. Also, let them know that there is no one-size-fits-all plan and that herbal supplements may, in fact, bring on their own side effects. Sometimes, there are large doses of the herb which may be harmful.

Popular Supplements to Be Mindful of:

St. John’s Wort: This supplement is commonly used for depression, anxiety, and sleep issues but may lead to side effects such as headache, nausea, dizziness, dry mouth, and increased sun sensitivity. Additionally, it can interact with various medications, including heart drugs, antidepressants, and birth control pills, and may reduce the effectiveness of certain chemotherapy treatments.

Kava: This is intended to alleviate anxiety and sleep issues. However, it can result in liver damage, such as hepatitis. Therefore, individuals with liver or kidney issues should avoid taking it.

Ginkgo: Many individuals take this to address chemo-brain-related memory issues. Some believe that ginkgo biloba also aids in circulation, mental function, and alleviates altitude sickness, among other health conditions. However, it's important to note that it can also thin your blood and cause bleeding.

Ginger: Individuals take this to alleviate nausea resulting from surgery, chemotherapy, or motion sickness, and sometimes for treating arthritis or joint pain. However, ginger may pose issues with blood clotting, heart rhythms, blood pressure, and blood sugar levels. 

Goldenseal: This remedy is utilized for constipation, colds, eye infections, and even cancer. However, goldenseal can impact your heart's rhythm, blood clotting, and lower blood pressure.

Black Cohosh: This supplement is frequently used by cancer patients to suppress menopausal symptoms such as hot flashes and night sweats. Some women also use it to manage PMS. However, individuals with liver issues should avoid it, as it may potentially cause inflammation or failure. Additionally, women with breast cancer should abstain from using it until more research establishes its impact on their condition. Currently, there is insufficient evidence to support the use of black cohosh in cancer treatment. It may also interfere with the biological activity of other medications as well.  

Every day, our bodies face oxidative stress, leading to the generation of free radicals that can cause damage to cells, tissues, and DNA. A free radical is an unpaired electron, which is not good. This unpaired electron seeks to form a pair by taking a partner from another atom or molecule, resulting in a process called oxidation.

Various sources contribute to this damage, including a poor diet, environmental pollution, radiation, UV light, smoking, alcohol consumption, exercise, and even normal bodily processes such as the conversion of food into energy within cells. This daily onslaught of oxidative damage can be repaired by the body in many instances, but some damage may persist. Prolonged oxidative damage can lead to chronic inflammation, which in turn increases the risk of developing diseases such as cancer, heart disease, and diabetes.

Certain dietary habits have been linked to a reduced risk of inflammation, with some studies suggesting that specific food choices could potentially enhance the body's ability to combat and reduce chronic inflammation. Increasing the intake of foods with potential anti-inflammatory properties appears to provide notable health benefits. Antioxidants are substances that delay or inhibit oxidative damage to target molecules. For example, putting lemon juice on a cut-up apple will delay browning and oxidative damage. They protect our cells from free radical damage. 

Phytochemicals derived from plants act as antioxidants and anti-inflammatory agents to reduce inflammation levels and counteract the detrimental effects of chronic inflammation.

Diet can significantly impact our health and well-being. By including foods with anti-inflammatory properties, we can aid our bodies in combating the effects of oxidative stress and reduce the risk of chronic inflammation and related diseases. Incorporating antioxidant and phytochemical-rich foods and foods, along with other anti-inflammatory foods (such as fatty fish like salmon), plus engaging in an active lifestyle, is a proactive step in promoting long-term health and vitality. 

Some phytochemicals are antioxidants that exert scavenge free radicals. Others may affect cell differentiation, increase the activity of enzymes that detoxify carcinogens, block the formation of carcinogens, preserve the integrity of intracellular matrices, promote maintenance of normal DNA repair, increase apoptosis (spontaneous death of cancer cells) and decrease cell proliferation.  

Fruit, vegetables, whole grains, beans, legumes, nuts and seeds have hundreds of different antioxidants and phytonutrients that synergize to increase disease-fighting potential. This also includes herbs and spices, as they contain numerous phytonutrients. Research studies that have focused on whole foods solidly back this up, whereas research that focused on individual antioxidants (or phytonutrients) has shown mixed results and has not proved protective against cancer.  

Numerous dietary patterns embody this style of eating, collectively known as a plant-forward diet. One example is the Mediterranean dietary pattern, distinguished by its incorporation of a social component and an exercise component. In addition to emphasizing the consumption of fruits and vegetables, olive oil, nuts and seeds, pulses, and fish rich in omega-3s EPA and DHA, this diet also promotes regular exercise and encourages spending time and dining with loved ones.

To sum up, we recommend that standard medical care must be adhered to. The use of CAM alone is harmful to treat a disease such as cancer. However, the addition of these complementary approaches can help patients counter several symptoms and make them feel better, as described above. For those who have indolent diseases and are on watchful waiting/monitoring, as well as those who are otherwise healthy, resorting to beneficial lifestyle methods may keep them in that relatively healthier state.

The following sources are helpful in getting more information:

1. Cancer therapy interactions with foods and dietary supplements by the National Cancer Institute

2.  Society of Integrative Oncology

3. Natural Medicines, Therapeutic Research 

4. Memorial Sloan Kettering Cancer Center – About Herbs

5. Other references are available upon request.