How Integrative Oncology Helps Manage Cancer Side Effects
April 03, 2024
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Integrative oncology provides data-driven therapies to help with pain, insomnia, anxiety and other side effects from cancer treatment. Medical oncologist, Santosh Rao, MD, explains how managing these symptoms can not only relieve side effects, but also improve treatment and outcomes.
Pete Kenworthy
We all know someone who has gone through cancer treatment, and most likely we’re even related to someone, whether it’s a parent, a grandparent, a child. For me it was my wife, my dad, my father-in-law. And from the moment you get that call, the impact starts to happen. Stress, anxiety, sometimes depression, and then once treatment starts, side effects from that treatment can start too.
Macie Jepson
For me, in my family, grandparents on both sides of my family were diagnosed with pancreatic cancer. And of course it was years ago, horrific diagnosis. But Pete, I don’t ever recall them recovering through those horrific treatments. There just wasn’t a lot of quality life at that time. Now the good news is along with conventional western medicine, there are evidence-based complimentary treatments. Now it’s a rapidly growing world of integrative oncology. Hi everybody, I’m Macie Jepson.
Pete Kenworthy
And I’m Pete Kenworthy, and this is The Science of Health. Joining us today is Dr. Santosh Rao, Medical Director for Integrative Oncology at University Hospitals Connor Whole Health in Cleveland. He’s also the president of the Society for Integrative Oncology. Thanks for being with us.
Santosh Rao, MD
Thank you.
Pete Kenworthy
Before we take a deep dive into specifics and the research behind it, could you give us kind of a high view of what integrative oncology is, its purpose?
Santosh Rao, MD
So, integrative oncology is looking at scientific evidence for the use of complimentary therapies and really, lifestyle education for people at any stage of their cancer treatment. And it’s really about empowering people on what’s safe, what’s not safe, what’s advisable, what’s not advisable, and giving people choice. And what is it that you should be able to do for yourself? What are some of the supportive things that we can use to reduce toxicity? You mentioned side effects. That’s basically what integrative oncology is.
Macie Jepson
One of the many benefits of integrative oncology is taking care of pain. And that’s both during and after treatment, I’m assuming. So I’d like to know a little more about that. Could you explain the impact of things like acupuncture, massage, other pain relief and the research behind it?
Santosh Rao, MD
Absolutely. So, you mentioned guidelines and evidence, so we have guidelines around this. You mentioned the Society for Integrative Oncology. We put forward two years ago a guideline that we did with the American Society for Clinical Oncology on pain. Cancer and pain go together very often. It’s the most common symptom from cancer. I’m an oncologist, and first things first, we always think about why the pain is occurring. So obviously you have to first evaluate if somebody has a hip fracture. With the hip fracture, we have obviously a lot of patients who are on narcotics, and so there’s a lot of side effects from narcotics. If you can help manage somebody’s pain to the point where either they don’t need the narcotic or they need less of it, that’s a win. And patients also feel the same way. So it’s about kind of finding the right approach to the specific patient.
Macie Jepson
Obviously, there are huge benefits to controlling pain. The pain is lessened, but does it also impact the course of the treatment?
Santosh Rao, MD
It can. I So I think part of this is when you look at the data and the research around this, pain causes suffering and can lead to mood disorders and depression. It depends if somebody has got advanced cancer. Part of it is having a desire to live and feel like you have quality of life. We know that if pain is uncontrolled, then people tend to not live as long and have more stress and everything else associated with it. So we don’t want people to be in pain in terms of their treatment. It’s part of your overall quality of life and it impacts so many things. For example, if you’re in pain, you may not exercise or you may not want to do things that you find enjoyable, which ultimately does affect everything else as well. You might get more fatigued, you might have other side effects from that. We know pain can really influence sleep, so there’s just a trickle-down effect that makes you really, really want to focus on controlling pain. But most of it for me is around quality of life and reducing suffering.
Pete Kenworthy
A side effect that is common when receiving chemotherapy is what you talked about. Peripheral neuropathy, right? When nerves are damaged, which causes weakness, numbness, pain, especially in the arms, legs, hands and feet. But it can also impact other things like digestion and urination. So what can be done through integrative oncology and how does that help with chemotherapy treatment?
Santosh Rao, MD
Good question. So, it’s a really common side effect of a number of different types of chemotherapy, and it’s something that can be what we call a dose-limiting side effect. So for some people, we have a plan of six months of chemo, and if somebody is starting to get these symptoms two months into it, you have to make decisions about whether you’re going to reduce the dose or ultimately for some people whether they can continue. So it’s a huge issue. It’s also one of the main symptoms that somebody can be left with when they’re done with all their treatment. So many times we’re successful with treating the cancer, but then afterwards you may have chronic symptoms that can be really awful. It can affect how you function. Some people are on ongoing medications and it can become a really chronic, terrible symptom. When I think about how we manage neuropathy, again, the story is building.
So traditionally there are certain medications that we use and that’s about it. Now we’re getting more and more evidence that acupuncture can be helpful specifically for treatment of neuropathy. There’s some evidence for prevention of neuropathy. I have myself seen that experience in the past, but the research in that particular area is still building. It’s very important. And then we know that there are other approaches to neuropathy as well. So it’s been shown that stress management is helpful. There’s some evidence for yoga for people who have neuropathy and then in a different approach. We also at University Hospitals have started using something called scrambler therapy. What that entails is putting some probes on the hands and feet and literally scrambling the message that’s being sent to your brain. And that’s also really, really effective. So a lot of times we will take a personalized approach. Some people need medication, often we’ll try acupuncture, if it’s helpful, great. And if it’s not working, then we might try scrambler therapy.
Pete Kenworthy
I want to be really clear before we move on from this. Your example was we prescribe a six week course of chemotherapy and they can only handle two weeks because of the pain. That’s enormous, right? Because if they can’t handle the dosage that they were prescribed, which will do the best for their clinical outcomes, you need to be able to control the pain. It has a huge impact on how they’re treated.
Santosh Rao, MD
And to be clear, I mean we need to do more research. So I think that the more programs like ours that exist, you can talk to people and patients and physicians who use these strategies will tell you, I really do think this helps. I think we need to get more precise with the magnitude of the effect. Is this really lengthening how long somebody can take chemo? I think it does, and these are just some of the exciting opportunities we have with research to show not only are you helping somebody with their symptoms, but if you can help somebody stay on their chemo, ultimately that improves outcomes as well.
Macie Jepson
I would imagine that insomnia is a major issue with cancer treatment, just the worry or even maybe a physical side effect. Is that the case and do you have something to help that?
Santosh Rao, MD
Absolutely. So, insomnia is this kind of catchall symptom because it’s very common. First of all, in the US in general, it’s increasing. So a lot of people have sleep disturbances. First of all, it’s not just how much you sleep, it’s the quality of sleep as well, and it gets by everything. So everybody who gets diagnosed with cancer obviously has that as a stress, and most people have other stresses as well, so it doesn’t help. And so stress is a major part of that. If somebody has anxiety, which is super common with cancer, whether you’re anxious about the treatment, anxious about the outcome, or even when people have positive outcomes, there’s still a lot of fear of recurrence. So these things are very common. And then on top of that, you mentioned pain. There are other symptoms that can kind of cluster with sleep disturbance and anxiety. So if somebody’s in pain or they have hot flashes, a lot of times that’s why they have trouble sleeping or if they have to get up to urinate, all sorts of things. So we see it all the time.
Pete Kenworthy
What specifically do you do to treat those though? If we’re talking about insomnia and you mentioned stress and anxiety, those things, all three of those things can be treated. How are they treated from that integrative oncology approach?
Santosh Rao, MD
Yeah, so again, the integrative approach is really first and foremost getting to know the patient. So that process is really about working with that specific patient and ascertaining what is it that’s going on. And I spend a lot of time just understanding what are the stressors you have to get to know that first, what are the symptoms somebody’s going through? So, sometimes you have to deal with the symptom first. If somebody’s having hot flashes and they’re not sleeping because of that, if you don’t treat the hot flashes, they’re not going to sleep. So I first focus on that if it’s really around stress and anxiety. I think we have many things that we can try and it really is about what works for which person. So acupuncture is something that is on the list, but a lot of times we will use massage therapy, we will use expressive arts.
We have a fantastic music therapy department, for example, and I am a big believer in yoga breathing exercises as well as mindfulness meditation and different types of meditation. When you start talking about how does somebody process their own stress, it has to be very personalized. We want to give people choice. Some people have their own routine. There are other people who have never really thought about it. And so that can be anywhere from expressing yourself in a variety of manners, doing some kind of exercise which helps as well, or doing some kind of a mind body approach where you learn to regulate your breathing and you learn something like mindfulness. And there’s a lot of evidence around this. And then sometimes we have to include people outside of our department. One of the most effective treatments and probably the most effective treatment for insomnia is what we call cognitive behavioral therapy, which is usually something that a psychologist employs. So it’s really important to be collaborative and just being part of the team. Part of it is to think beyond just this particular approach. What is it that’s right for which patient? And sometimes it might be us, sometimes it might be a psychologist.
Macie Jepson
A big fear for cancer patients is that the cancer will come back. So even people who have been deemed cancer free, obviously worried in the back of their minds about recurrence. Are there proven methods that actually lower that risk?
Santosh Rao, MD
There are, and it’s really so understandable for those who’ve been diagnosed with cancer, it probably is just a very natural feeling. So, I always try to first be understanding. We do know that mindfulness, and there are different types of mindfulness programs. There’s a program called Mindfulness Based Cancer Recovery. There’s another program called Mindfulness Oriented Recovery. And there are different types of programs that really focus on staying in the moment, trying not to think ahead, very difficult thinking about what triggers your anxiety and fear. And those things have been shown to be very effective. I think ultimately, again, I am very collaborative and I think alongside asking somebody to manage their own anxiety, it’s on us as a field to improve our treatment. I mean, the thing that would make somebody less anxious is if I say it’s not going to come back and we’ve done everything we can, so it goes hand in hand.
I don’t sugarcoat it. So it’s normal to be afraid if you really think it’s going to come back. So as the treatment gets better, part of it is explaining to people why you feel optimistic. And I think the empowerment part is really important because part of why I even do this is this idea of feeling helpless. So you go through all this treatment and suddenly you feel like, okay, what can I do? I just feel like this happened and now I’ve gone through all this treatment and part of it is what is it I can do for myself? So I feel like I have some control over this. I’m part of this team.
Pete Kenworthy
You kind of mentioned this, but I think it’s important to mention that integrative oncology isn’t a one size fits all approach. And you talked about this, and this is important for this integrative oncology side of things to figure out what works for each patient because the anxiety in that patient isn’t the same or isn’t the same treatment necessarily than the anxiety in another treatment or the pain from that same kind of treatment isn’t the same for the pain in someone else. So, if you have any specifics about how does that become individualized, some people might say, well, I can’t be helped by this. I know my friend was, but it wouldn’t work for me.
Santosh Rao, MD
And again, part of it is just being a good healthcare provider. I think it’s no different than any other doctor in our cancer center. So part of it is just listening and listening to that person and then thinking about what we add is just maybe some more options, maybe focusing a little bit more on somebody’s self-stress management techniques, having those resources like music therapy and massage and those things. So I think part of it is just giving a little bit more in terms of the menu, and then a lot of it is giving patients choice. So a lot of times people will already know what helps them and you’re just making it easier for them to utilize that. For somebody who doesn’t have those tools that they’ve used before, they’ve never dealt with something like this or whatever, then I think it’s really walking them through and giving them, many of the patients that I see, they’re looking for some direction. So I’m not going to tell you that you have to do X, Y, or Z, but this is what I think will help. Most people are very open to that. You are giving them guidance, but you’re also giving them choice, and that’s how you do the personalization part of it.
Macie Jepson
You talked a lot about integrative oncology during your treatment. What about after and what advice do you have for patients who don’t have access to a Dr. Rao and a symptom clinic and how they could navigate that with their oncologist to get these treatments?
Santosh Rao, MD
That’s a really good question. You did mention I’m president of the Society for Integrative Oncology. Part of it is building the story as to whether this should be a standard approach. And right now it’s not available everywhere. So I think that as the evidence is building and we’re finding that, okay, you can do acupuncture and massage for pain and you can do all these great things, and then there’s a positive outcome from that. If somebody who utilizes these modalities gets to have less pain or isn’t taking as many narcotics, that’s a real win. So what about somebody who doesn’t have access? And a lot of my focus is, at least in this Cleveland area, is how do we make it accessible? We don’t want to broaden the gap between people who can pay out of pocket and those who can’t. I don’t think that’s fair.
And so, we’ve tried to design a lot of our programs that are based on insurance as much as possible. I think that these programs are building around the country, certainly around the world. There’s different forms that it takes, but generally it’s not available everywhere. And so there are online resources. There’s actually programs specifically for women. There are at least a couple programs that help people raise money for integrative care or it can give you ideas about how to utilize it. So those things are kind of building. There’s a lot of online approaches as well when it comes to diet, lifestyle, stress management, what you can’t really replicate from that standpoint is the hands-on interventions. And I think we just have to keep doing the work when it comes to research to get to the point where there’s more insurance coverage. That’s how our healthcare is done, and I think it is building. But once we get to that point, then it’ll be about how more providers can be trained.
Macie Jepson
Are there any treatments that we haven’t discussed, and if so, how would they be used?
Santosh Rao, MD
Well, I get a lot of questions about natural products. So we’ve talked a lot about symptom management. Certainly I talk a lot about diet and exercise, but then natural products have, their supplements have their own place in this. And a lot of it is answering questions nowadays. A lot of people go on the internet. We know that they may not be all patients, but many patients will on their own take supplements and often do not talk about it with their oncologist. And that can potentially have negative consequences if there’s interactions, if there’s side effects, et cetera. So part of it is kind of helping someone really navigate that whole situation. And then there are times where some supplements I have found help with some of these symptoms. So taking a very targeted approach. I’m a fan of aromatherapy, for example, and essential oils. There’s a whole bunch of these kind of things that are easy to employ and that ultimately do make people feel better.
Pete Kenworthy
So bottom line here is this is a quality-of-life issue, and that’s huge for people dealing with cancer. Can you tie a bow on this discussion? What’s the takeaway? Who would benefit most from seeking out this kind of care?
Santosh Rao, MD
I think you can make the argument that everybody can benefit. Certainly everybody has stress. And so part of it is my goal is to use this approach at every stage and really in as many locations as possible. And we have only so much capacity, but that’s the goal. And everybody can utilize stress management. A lot of our patients are in survivorship. So, after they’re done with treatment, many people can use education on lifestyle, and that may come from other sources. It doesn’t always have to be integrative oncology, but I think most people could benefit from that. And then anybody who has symptoms, at least think about how we can incorporate that, specifically pain, anxiety, depression, fatigue, those kinds of things. And there are others as well that we’ve touched on some of them, but I think anybody could utilize our services and see if it helps them. And then if it does, great.
Macie Jepson
Thank you, doctor, for your time and for giving us hope today.
Santosh Rao, MD
Thank you. And I think hope is part of this is allowing people to feel like they can do something for themselves and do it in a way that they feel comfortable. It’s giving people some choice and some empowerment.