Enhancing Cancer Care With Integrative Oncology

Richard Lee, MD

Integrative oncology is a growing field with the goal of improving cancer treatment through the incorporation of holistic approaches alongside conventional medical care. These therapies have also proved to be effective in reducing adverse effects like anxiety and depression in patients with cancer.^1,2

This approach includes therapies rooted in traditional practices, such as traditional Chinese medicine, Arabic medicine, and other culturally based treatments, given in combination with evidence-based complementary treatments like acupuncture and aromatherapy.¹

Recently, updated guidelines for integrative oncology were developed through a collaborative effort between the Society for Integrative Oncology (SIO) and the American Society for Clinical Oncology (ASCO).² This process ensures that the guidelines reflect a wide range of expertise and are tailored to address specific symptoms, such as anxiety and depression, within cancer care.

However, implementing an integrative oncology approach presents several challenges for patients and clinicians, including ensuring accessibility and affordability. While therapies such as mindfulness meditation, yoga, and acupuncture exist and are often beneficial for patients, they might not be available at all cancer centers or covered by insurance. Overcoming these barriers is essential for wider adoption.

In an interview with Targeted Oncology^TM, Richard Lee, MD, clinical professor and director's chair of the Cherng Family Center for Integrative Oncology at City of Hope in the Department of Supportive Care Medicine and Medical Oncology, discussed what integrative oncology encompasses and its significance in modern cancer care.

Can you give a big picture look about what integrative oncology is?

Lee: Many patients may wonder what integrative oncology is, as well as many clinicians. Integrative oncology is a new field of medicine and cancer was focused on bringing in more holistic approaches together with modern medicine to provide the best care for cancer patients. Many of these may come from more traditional approaches like traditional Chinese medicine or Arabic medicine, as well as other more culturally based therapies. The key to integrative oncology is that it has to be delivered in a way that is evidence based. There needs to be clinical research within specific cancer populations that demonstrates both the benefits and value of how these can help cancer patients. Here at City of Hope, we recently established the Cheng Family Center for Integrative Oncology. We are focused on not only delivering clinical care for patients in an evidence-based way, but also addressing the knowledge gap that exists for many integrative therapies that are available today. Many patients and clinicians are not aware of the evidence base that does exist for some but not all [therapies]. Where there is a gap in knowledge, we want to be addressing that and building up the scientific rigor and evidence base to show that many of these holistic approaches like acupuncture, massage, meditation, and music therapy are helpful for patients and can be effectively delivered in a way that is valuable for patients, clinicians, and the health care system.

Another key area for the Cherng Family Center for Integrative Oncology is also addressing the educational needs of patients, clinicians, and the cancer community at large. We understand that many individuals, both patients and clinicians, do not know about these integrative therapies, and the realization that there is clinical research that exists and some of it is what we would consider high-level evidence or in other cases more intermediate. We want to be providing educational opportunities, including a clinical fellowship, so that those who are training already in oncology, whether that be surgical, radiation,medical oncology, or hematology, we want to be providing an opportunity for them to also learn how they can incorporate these integrative therapies in their own practice in an evidence-based way to improve outcomes for our patients

DNA helix enlarged model in bright colors and spots, generative AI: © Radomir Jovanovic - stock.adobe.com

Can you explain the process for developing these updated guidelines?

The process is a joint process together with the Society for Integrative Oncology and American Society for Clinical Oncology. The 2 organizations have representation from both organizations, and we looked for a wide, diverse panel of individuals with expertise related to the guidelines at hand. In this case, we were looking for expertise in anxiety, depression, and integrative therapies.

What are the key areas where previous guidelines needed revision based on new evidence or evolving practices?

This guideline is really the first guideline by SIO and ASCO to focus on integrative approaches to anxiety and depression. There have been other guidelines but they have focused on other symptoms. It is great to see a more generalized approach focusing on 2 important symptoms of anxiety and depression. This guideline also looked at both integrative therapies during active treatment, as well as those who have finished treatment into survivorship, and covered a broad array of integrative therapies that have been studied and have some level of evidence.

How did the updated guidelines address the integration of patient preferences and shared decision making in managing anxiety and depression?

This is important for any guidelines that are related to clinical care or patient preference. In the discussion, it is reviewed about some of these options for which there is a good level of evidence. Then, with this specific guideline, there is high-level evidence for mindfulness-based interventions, as well as intermediate-level evidence for things like yoga, acupuncture, and relaxation therapies. Patient preference is always key to any discussion about therapies. There should also be a discussion about all the appropriate options that might exist that are more standard-of-care options, like medications, as well as integrative therapies. I think this guideline adds value in the sense that many patients are interested in integrative therapies but do not realize there is a strong evidence base for many of these therapies.

What are some of the biggest challenges in implementing these approaches?

There are several major challenges as we think about the field of integrative oncology and incorporating some of these recommendations from the guidelines on anxiety and depression. One of them is that these therapies are available at different cancer centers [but not all]. Things like mindfulness-based meditation or yoga may or may not be available at the cancer center but may be available in the community. So how do we best provide these therapies for patients, especially if they are undergoing active treatment? I think that is 1 of the major challenges.

Another challenge would be how do we best provide these, as many of these do have an out-of-pocket cost. Most of these therapies may or may not be covered by insurance companies. Thus, we will have to think about access even though patients may desire to have these therapies, and it may be accessible. Can they afford these types of therapies? That is another major area that we need to address. I think insurance companies need to realize that there is an evidence base that these can be quite cost effective for patients. Hopefully, we will see more insurance companies begin to allow coverage of these types of interventions, which have few [adverse] effects that have great value and benefits.

Could you elaborate on the specific recommendations and what is most important for a community oncologist to know?

The guidelines cover 2 important areas. One is anxiety and the second is depression. If we look at the period of active treatment, there is a high level of evidence to suggest that mindfulness-based interventions should be recommended for patients. That is a strong recommendation, the highest level from the SIO's guidelines. That is true for posttreatment for anxiety, as well as depression during active treatment and posttreatment. That is 1 of the most important takeaways. There are several therapies that have intermediate levels of evidence and also moderate levels of strength and recommendation. That includes yoga, both during and after treatment for anxiety symptoms. This is also true for depression; we also see that relaxation therapies like meditation can be recommended. We also find that hypnosis can be used during specific procedures to help patients relax. There are also data that indicates acupuncture, tai chi, and qigong can be recommended with intermediate-level evidence for patients with anxiety posttreatment, as well as posttreatment for depression. I think these are some of the most important takeaways, that patients have several integrative options, in addition to the standard-of-care options that might exist for anxiety and depression that include medication. Oftentimes, we might be able to utilize both of these therapies for patients for optimal benefit.

How can oncologists effectively collaborate with mental health professionals to ensure comprehensive care for their patients that might be experiencing anxiety and depression?

It is important for both oncologists and mental health professionals to be working together to think about the most appropriate options for any individual patient. We have guidelines, but of course, we always have to think about the patient context and what might be the best fit for that patient, including patient preference. And so having that important dialogue between health care professionals in the primary oncology team is so important. And thinking about what would be most appropriate and optimal for that patient and continuing the monitoring and assessing what is working and maybe what is not working. And so, if medications do not work, maybe we need to incorporate some of these mindfulness-based interventions, yoga, acupuncture, or hypnosis.

Are there any specific areas of research that you find particularly important for improving the management of anxiety and depression?

I think there are several areas that require more research. There are many therapies which were listed as intermediate- to low-level evidence, including things like lavender aromatherapy, or different situations such as music therapy, reflexology, and other relaxation-type therapies. So I think there is still a lot of work to be done and a lot of therapies that still might provide a substantial benefit but just need more research to really understand how to best utilize them and grow the evidence base. Probably 1 key area is how do we optimize these therapies for patients who are very busy, especially during active treatment? They have so many appointments and other things they are thinking about and might still be working. How do we best deliver these therapies in a way that is very efficient and effective, given their limited time and energy during treatment?

How can we encourage wider adoption of these integrative approaches within the oncology community?

Unfortunately, there is still low adoption in many places regarding integrative approaches for thingslike anxiety and depression. Part of it is around education, both for the patients and for the clinical team, so that they understand there is good evidence that exists to support the use of these therapies for cancer patients. I think that is 1 of the key areas for adoption that need to be addressed is education. Another which we briefly mentioned is how do we best pay for these types of services and have insurance companies cover them as well, given that there are some cases of moderate- to high-level evidence to support their use to help patients?

REFERENCES:

1. Witt CM, Balneaves LG, Cardoso MJ, et al. A comprehensive definition for integrative oncology. J Natl Cancer Inst Monogr. 2017;2017(52):10.1093/jncimonographs/lgx012. doi:10.1093/jncimonographs/lgx012

2. Carlson LE, Ismaila N, Addington EL, et al. Integrative oncology care of symptoms of anxiety and depression in adults with cancer: Society for Integrative Oncology–ASCO guideline. J Clin Oncol. 2023;41(28):4562-4591. doi:10.1200/JCO.23.00857