Evidence-Based Integrative Oncology Approaches Forge a New Path in Cancer Care

Richard T. Lee, MD

Although certain integrative oncology approaches such as acupuncture are century-old practices, many holistic approaches still lack high-level quality evidence to support their use. In response, the development of integrative oncology programs is a new focus for institutions and is aimed at helping to fill this knowledge gap, according to Richard T. Lee, MD.

“There are data on helping patients with nausea by using acupuncture and natural plant derivatives such as ginger, which has been shown to help reduce nausea in randomized controlled trials. These types of integrative therapies are a great way to complement many of the standard of care [SOC] options that we have and provide even further benefit in controlling these symptoms and allowing patients to have a better quality of life as they go through treatment and head into survivorship,” Lee explained in an interview with OncLive®.

In the randomized phase 2 IMPACT trial (NCT04095234), patients with advanced cancers received acupuncture (n = 298) for sessions spanning up to 26 weeks and experienced a reduction in worst pain score with a mean change of −2.53 points (95% CI, −2.92 to −2.15). Data from the trial also showed that patients who received massage therapy experienced a reduction in the Brief Pain Inventory worst pain score with a mean change of −3.01 points (95% CI, −3.38 to −2.63).¹

To further examine therapies such as these, the Cherng Family Center for Integrative Oncology has been established at City of Hope, with Lee and colleagues focusing on research, clinical care, and education at the first-of-its-kind national integrative oncology program.² Lee is the Cherng Family Director’s Chair at the Center for Integrative Oncology and is also the medical director of Supportive and Integrative Medicine in the Department of Supportive Care Medicine and a clinical professor of Supportive and Integrative Medicine at City of Hope in Orange County, California.

In the interview, Lee highlights different holistic integrative oncology approaches and highlights how he has seen them positively improve quality of life (QOL) for his patients. He also discusses how community practices can incorporate integrative oncology techniques into care.

OncLive: What is integrative oncology and how can it contribute to a patient’s cancer treatment?

Lee: Integrative oncology is an approach that focuses on holistic, whole-person care that pulls on diverse traditions and cultures. Specifically, [in our situation] we’re looking at traditional Chinese medicine and Eastern medicine, and how it can provide a more comprehensive, effective way for patients to receive care. We’re thinking about modalities such as acupuncture, meditation, yoga, and massage, to figure out ways to help treat patients more holistically. [Numerous] therapies today are derived from these kinds of diverse cultures—many of our chemotherapies are derived from plants, and [integrative oncology] continues that tradition of looking outside the standard box of treatments at what else we can do to help improve care for patients with cancer.

Approximately upwards of 40% of patients with cancer who are receiving treatment are using integrative therapies. A lot of patients we’re seeing right now are incorporating these areas, but very few cancer centers are focused or have a formal program to help educate and guide patients on appropriate evidence-based approaches to integrative oncology. We’re looking to do that here at City of Hope with The Cherng Family Center for Integrative Oncology.

In our research arm at the center, we are very interested in natural product drug development and continuing that tradition—it’s estimated that 30% to 40% of FDA-approved chemotherapies come from plants. We believe there’s a lot more yet to be discovered and in the laboratory we’re going to be focusing on looking at plant extracts to identify the next paclitaxel-type agent.

What guidelines are currently in place for using integrative therapies?

Recently there have been Society for Integrative Oncology [SIO] and American Society of Clinical Oncology [ASCO] practice guidelines that have focused on the evidence and how these therapies can help. For example, one of the first guidelines that came out was for pain and noted that acupuncture and acupressure can help patients with pain symptoms, as [can] mindfulness-based meditation techniques. These kinds of techniques help patients relax.

There’s also data that massage techniques or reflexology can reduce pain. More recently, the SIO/ASCO guidelines have talked about integrative approaches to anxiety and depression. They found high levels of evidence that mindfulness-based stress reduction techniques are very good at reducing anxiety and depression, as well as things like acupuncture, mind-body techniques, and yoga; there are a variety of things that we can do to help patients with their mood with all the stress that they’re experiencing [during treatment].

What integrative oncology approaches do you use most commonly in your practice?

I focus on a lot of the basics of integrative oncology, which I would consider areas like nutrition. I ask how we can optimize the foods that patients are eating to help reduce AEs and maintain their health and wellness. We talk about the role and importance of physical activity [as well]— patients often feel like because they’re going through treatment, they don’t need to be exercising, but in fact the data indicate the opposite, that they should maintain physical activity and remain active. This does not necessarily mean doing high-[intensity], vigorous activity, but even mild to moderate exercise can improve symptoms such as fatigue and improve tolerability for treatments.

We also talk a lot about how to help manage the stress and emotional changes that occur with a cancer diagnosis and going through treatment. Thinking about stress management techniques—guided imagery, hypnosis, yoga, and meditation—there’s a variety of these mind-body techniques that can be very beneficial for patients to help reduce the stress and anxiety that comes through the cancer journey, and we don’t have to depend on a prescription to help them sleep better at night. If patients come in with symptoms such as pain, I may talk to them about acupuncture as well as using techniques such as massage or music therapy to help reduce symptoms. These are some of the common integrative therapies and it’s a personalized approach depending on their needs and what they’re experiencing.

Now that you’ve established this program at City of Hope, how can other institutions follow suit? How can community oncologists implement integrative oncology approaches into practice?

We hope that eventually [our work will] lead to large randomized controlled trials that then inform guidelines, such as the SIO/ASCO guidelines, so that in the future when they update those guidelines, they’ll see there’s more research demonstrating there’s now high-quality instead of intermediate- or low-quality evidence that demonstrates the value of these types of programs.

Many cancer centers out there, both big and small, are interested in integrative oncology programs] but don’t know how to practically [establish] them. In addition to driving the research and demonstrating the value, we need to demonstrate a sustainable clinical model that others can use [to] then start their own program. That’s oftentimes a criticism of large academic cancer centers as they have these programs, but [they are] hard to replicate because of their unique situation. We want to figure out a model that can be continued at other locations and is not unique to just City of Hope.

For smaller programs, it might be a matter of identifying staff within your own institution that might have some integrative training. There might be a nurse who has been trained in massage therapy or acupuncture, and [physicians can determine whether] there are any community practitioners with whom they may want to collaborate; if patients are interested in acupuncture or massage, [physicians can identify] somebody who is appropriately certified, trained, and they can work with them closely.

We want to stick to the evidence. Where does the clinical research indicate that these types of integrative therapies are beneficial? [We also want to] avoid things that aren’t proven. What’s key about integrative oncology is it is an evidence-based approach, and not every therapy is appropriate for every patient. We have to tailor it and make sure it’s personalized for both patient safety and efficacy issues.

In your experience, what integrative approaches have had the most impact for patients?

The integrative therapies that we will be providing [at the City of Hope center] for which there’s good evidence will include acupuncture, massage, mind-body medicine, music therapy, and art therapy. I have seen that all these therapies have had a major impact on patient care in different ways.

I found that patients who might have refractory or chronic pain or refractory nausea for which SOC therapies may not be helping enough will often come back [following acupuncture] and say, ‘Wow, my nausea is 50% decreased.’ Or patients who can’t sleep at night who have stress and anxiety and have already been on 2 or 3 sleep aids that are not helping [have expressed they experienced benefit with integrative oncology]. I say, ‘Let’s try some stress management with deep-breathing exercises or meditation,’ and patients come back a month later and say, ‘I don’t need those prescription sleep medicines anymore because I’m meditating at night for 10 minutes and I’m getting much better sleep. I don’t have any of the AEs.’

I’ve found that patients are already using a lot of SOC therapies but [when] they start incorporating these integrative therapies, they’re able to come down on other treatments and get [good] if not better control of symptoms and improvement in QOL. Oftentimes, patients also forget some of the basics of nutrition and exercise. It’s surprising how often patients may want a new herb or supplement to try, and I say, ‘Let’s just focus on your nutrition and start exercising,’ and suddenly their energy levels are up and they can do things that they haven’t been able to do in the past 6 months. All these integrative therapies have great value and some of them are so simple, they’re often overlooked. Now that the evidence is growing about how we can use them safely and appropriately, I hope more patients as well as more oncologists will be open-minded and think about integrative approaches.

References

1. Epstein AS, Liou KT, Romero SAD, et al. Acupuncture vs massage for pain in patients living with advanced cancer: the IMPACT randomized clinical trial. JAMA Netw Open. 2023;6(11):e2342482. doi:10.1001/jamanetworkopen.2023.42482
2. Logsdon Z. City of Hope receives $100 million gift to create first-of-its-kind national integrative oncology program. News release. City of Hope. September 12, 2023. Accessed March 8, 2024. https://www.cityofhope.org/city-hope-receives-100-million-gift-create-first-its-kind-national-integrative-oncology-program