Not all nonpharmacologic practices are the same, and some may even be detrimental to patients’ health. Patients are becoming increasingly interested in additive nonpharmacologic therapies that may reduce their treatment burden and have positive benefits for their outcome, but it will be necessary to help patients sort the real science from the pseudoscience, researchers said during the Educational Session “Integrative Oncology: The Evidence Base,” held Saturday morning.
Integrative oncology describes a relatively new movement in cancer care to incorporate complementary and adjunctive therapies with the purpose of reducing treatment-related toxicity and possibly improving the effectiveness of treatment. However, although practices like yoga, music therapy, massage, acupuncture, and diet modification have been proven to benefit some patients, the marketplace is also replete with examples of nonscientifically founded modalities that may end up doing more harm than good.
The first step in unraveling the beneficial from the detrimental may be a new understanding of the terminology used to describe these additive therapies, Barrie Cassileth, PhD, of the Memorial Sloan Kettering Cancer Center said during the session. Whereas complementary and adjunctive therapies may have beneficial therapeutic effects, it would be inappropriate to allow them to replace traditional interventions. The term ‘alternative treatments’ more aptly describes those modalities that proffer to replace medical or surgical intervention—although the word quackery may be even more fitting, Dr. Cassileth added.
“So-called alternative therapies are costly and harmful and, most importantly, they do not work and they create problems of their own,” she said. “Quackery, and people who push it, often use the term integrative medicine deliberately to confuse patients, and they do a good job of this because in the United States we spend over $40 billion a year on quack cancer products.”
Weight of the Evidence
Although the correct terminology is an important aspect of promoting integrative approaches to cancer treatment, the real question should be whether they provide any benefit or even end up doing more harm than good.
According to Dr. Cassileth, there is evidence that integrative oncology is “inexpensive, safe, effective, and evidence-based.” Several studies point to the ability of integrative oncology to help moderate pain, hot flashes, sexual dysfunction, urinary problems, fatigue, xerostomia, anxiety, depression, stress, and lymphedema.
Still, integrative oncology must be correctly applied in the right context to derive benefit. Perhaps the best example of this is in diet modification. Data from observational studies have shown a correlation between obesity at the time of diagnosis and an increased risk of mortality from breast, prostate, colorectal, and ovarian cancers. In fact, ASCO President as Clifford A. Hudis, MD, FACP, stated, “Obesity is quickly overtaking tobacco as the leading preventable cause of cancer.”
Additionally, short-term trials in randomized settings have suggested a benefit for intentional weight loss among patients with breast and prostate cancer. However, data from larger controlled trials, especially long-term data, are severely lacking, said Michelle Harvie, SRD, PhD, of the Genesis Prevention Centre and Nightingale Breast Screening Centre of the University Hospital of South Manchester. What may be more important, she said, is the quality of the diet, although here, too, data from large-scale trials are lacking.
A study by Piece et al. that was published in JAMA in 2007 comparing moderate (5-6 portions a day) and high (10-12 portions a day) levels of fruit and vegetable intake among patients with breast cancer found no difference in rates of recurrence and overall survival.1 However, studies have also found that although diet modification may not affect cancer-specific mortality, there is suggestive evidence that the quality of the diet can affect noncancer mortality (Table 1).
“A healthy diet does not seem to [have an] impact on the individual cancer mortality, but it certainly is [having an effect] on other mortalities and overall mortalities. A healthy diet, regardless of what people weigh, seems to be a very sensible thing to advise of,” Dr. Harvie said.
Although a healthy diet is beneficial to the overall health of patients with cancer, nutritional supplementation does not appear to add benefit, and in many cases, it may produce deleterious effects, including increased toxicity from treatment and greater risk to overall survival.
In a study in animals, Spindler et al. showed that the application of a specific nutraceutical containing antioxidants had no effect on survival; moreover, combining it with additional nutraceuticals actually shortened the animals’ lifespans.2
“This is an area where moderation is key. Not having enough vitamins is bad, but too much of it could be even worse,” Dr. Harvie said.
Patients are becoming increasingly interested in antioxidant supplementation under the assumption that it will reduce toxicity associated with treatment. However, a large study among patients with head and neck cancers showed quite a different effect.3-5 The study, designed to look at whether antioxidants increased the effects of radiotherapy, originally used beta-carotene but that was stopped after data emerged from other trials noting its propensity to increase mortality risk among patients with lung cancer. Data were eventually collected on the use of vitamin E supplementation, showing that it increased the risk of all-cause mortality and the development of secondary tumors versus placebo, especially among smokers.
“There was a reduction in toxicity from the radiotherapy, but it came at a price,” Dr. Harvie said. “Antioxidants, especially combined with smoking, may offset the benefit of radiation.”
Mind-body Practices, Stress Reduction
Lorenzo Cohen, PhD, Director of the Integrative Medicine Program at MD Anderson Cancer Center at the University of Texas, discussed some of the more ethereal aspects of integrative oncology aimed at controlling stress and improving patients’ mindsets, such as yoga, meditation, acupuncture, and other ancient arts that are practiced to calm one’s mind. According to Dr. Cohen, there is little doubt that life stress is detrimental to one’s health, regardless of disease activity, and that stress reduction positively affects outcomes among patients with cancer.
“A diagnosis of cancer, and frankly any life-threatening illness, comes with a lot of emotional turmoil. This is actually quite expected. What is quite disturbing is that uncontrolled depression and anxiety is a prognostic indicator of earlier death from cancer,” independent of the stage of disease,” Dr. Cohen said.
Research over the past decade indicates that the way individuals process stress at a cognitive level will have downstream implications on all nervous system functions. Epel et al.6 showed that chronic stress shortens the length of telomeres, the sequences at the end of chromosomes that protect them from deterioration. Quite literally, Dr. Cohen said, stress shortens one’s life.
“Norepinephrine and [sympathetic nervous system] pathways can actually increase tumorigenesis,” he said.
There is strong evidence, Dr. Cohen added, that reducing stress has a positive effect on cancer outcomes. In a study at his institution in which patients were randomly assigned to either a regimen of yoga, stretching exercises, or a control group with no exercise recommended, yoga was shown to improve subjective measures of health, including fatigue, perception of overall health, physical functioning, and perception of a derived benefit. Interestingly, patients in the yoga group had a greater blunting of cortisol than patients in the other groups—and this becomes important, Dr. Cohen said, in light of evidence suggesting that a greater reduction of cortisol activity is prognostic of more positive outcomes. Thus, in addition to the subjective improvement, there may be a physiologic benefit to stress reduction among patients with cancer who practice yoga.
Other studies have likewise shown that patients with cancer who practice yoga show improvements in subjective outcomes such as fatigue scores, as well as reductions in inflammatory markers. However, Dr. Cohen cautioned, “yoga is not a pill you take a few times and stop. You have to stay with it.”
Similar gains in cognitive function with reductions in inflammatory processes have been shown in conjunction with meditation, Dr. Cohen said. A study by Antoni et al.7 showed that a program of cognitive-behavioral stress management downregulated proinflammatory and metastasis-related genes while upregulating type 1 interferon-response genes.
“How people process their environment can literally get into every single cell of [their] body. It’s important for everyone to engage in mind-body practices to relieve stress on a daily basis, and of course that is true for [patients with] cancer.”