A Clinician’s Guide to Integrative Oncology What You Should Be Talking About with Cancer Patients and Why Kylie O’Brien Avni Sali 123 ’ A Clinician s Guide to Integrative Oncology ’ Kylie O Brien Avni Sali (cid:129) ’ A Clinician s Guide to Integrative Oncology What You Should Be Talking About with Cancer Patients and Why 123 KylieO’Brien, BSc(Optom), BAppSc AvniSali, MBBS,PhD,FRACS, FACS, (ChinMEd), MPH,PhD (Chinese FACNEM Medicine), GradCert TertEd National Institute ofIntegrative Medicine Department ofEducation Hawthorn, VIC National Institute ofIntegrative Medicine Australia Hawthorn, VIC Australia ISBN978-3-319-56631-3 ISBN978-3-319-56632-0 (eBook) DOI 10.1007/978-3-319-56632-0 LibraryofCongressControlNumber:2017937721 ©SpringerInternationalPublishingAG2017 Thisworkissubjecttocopyright.AllrightsarereservedbythePublisher,whetherthewholeorpart of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission orinformationstorageandretrieval,electronicadaptation,computersoftware,orbysimilarordissimilar methodologynowknownorhereafterdeveloped. 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Printedonacid-freepaper ThisSpringerimprintispublishedbySpringerNature TheregisteredcompanyisSpringerInternationalPublishingAG Theregisteredcompanyaddressis:Gewerbestrasse11,6330Cham,Switzerland Foreword O’Brienand Sali have done an outstanding jobputting together a book which will beusefultoanyonewhoisinterestedinintegrativemedicine.Thebookprovidesa newandpracticalapproachtointegrativemedicinepractice.Integrativemedicineis a relatively new field of medicine. Most health care providers, patients and even academicians are unaware of the importance of this new way of delivering health care. This requires a new way of thinking about heath and having a holistic approach to the patient. Integrative medicine is patient-centric, individualised preventive patient care focusing on achieving and maintaining health with sus- tainableeverydayinterventionsanddevelopinghealthyhabits.Thephysician’srole is tomake the patientaware of the factors that result inloss of health and give the patient and his/her family the tools to prevent disease. This book offers practical advice on conducting a comprehensive integrative medicine consultation. Professor Sali’s “Ultimate Consultation” and “Ultimate Patient”ideasarerightontargetandemphasisetheimportanceofspendingtimeto understand the patient as a whole and putting the patient in the driver's seat in making treatment decisions and living a healthy life to prevent chronic diseases. It is very important to empower the patient and give him/her the necessary tools to make decisions and live a healthy and happylife.The book iswellorganisedwith chapters on stress, nutrition, sleep, vitamin D and sunshine, exercise, additional therapies and the last chapter brings it all together. Importance of stress reduction, physical activity, healthy diet, sleep as well as nutritional supplements and botanicals are emphasised. Each chapter provides detailed information and a very good summary of the subject area with plenty of references. Thebookiseasytoreadandfullofusefulinformationforprofessionalsandlay people alike. I would highly recommend this book to all health care providers as wellastostudentsinthefieldofhealthsciences,andthepublicingeneral.Healthy living and disease prevention is essential for a happy and productive life. v vi Foreword By implementing the knowledge and strategies in this book, the whole society could become healthier and more productive. This would also reduce health care expenditure and save governments large amounts of money. Ömer Küçük, MD Professor of Hematology-Oncology and Urology Director, Integrative Oncology Center, Director, Multidisciplinary Genitourinary Oncology Group, Chief, Genitourinary Medical Oncology Service, Leader, Prostate Cancer Research Program Georgia Research Alliance Distinguished Scientist Winship Cancer Institute of Emory University, Atlanta, GA, USA Preface The idea for this book came about afterI sat inon oneof Prof. Avni Sali’s patient consultations in 2015. The person had cancer, as many of Prof. Sali’s patients do. This is not surprising with the ‘one in three women and one in two men will be diagnosedwithcancerintheirlifetime’figuresthatareregularlysplashedaround— a rather bleak outlook for the western world to say the least. As a new member of the National Institute of Integrative Medicine (NIIM) consulting in the NIIM Clinic, the largest integrative medicine clinic in Australia, and a Chinese medicine practitioner, I was keen to understand more about Prof. Sali’s approach to cancer management.Asthe‘FoundingFatherofIntegrativeMedicine’inAustralia,surely I could learn something from this fellow? And learn I have. What struck me first is that Prof. Sali’s consultations are typically two to three hours long. The patient is listened to and their story is heard. The atmosphere is relaxed but does not detract from the seriousness of what these people face when confronted with a cancer diagnosis. The patient is not told what to do. Their intelligence is respected. They have come for advice on what they can do. In that two- to three-hour period, Prof. Sali walks the patient and, typically, their support person or persons who accompany them, through the steps that they can take to become‘theUltimatePatient’.TheUltimatePatientissomeonewhotakesanactive roleinbecomingashealthyastheycan.Inhisconsultation,whichwehavetermed ‘theUltimateConsultation’,thewholepersonisconsidered—howstress,diet,lack ofexerciseandsunlightexposureplusotherlifestylefactorscanimpactonthebody inrathercomplexwaystocreateillness,andhowsuchfactors,whenaddressed,can assistthepatientinachievingahealthierstateofbeing.Thefocusisontheperson, thehumanbeing,notjustthedisease,itspathogenesisandthecancercellsthatneed to be stopped from replicating. Integrative Medicine, which combines conventional medicine with evidence-based complementary medicine, therapies and lifestyle interventions for the treatment and prevention of disease, provides the foundation of Prof. Sali’s approach. Integrative Medicine empowers patients and health practitioners with a wider range of treatment, screening and prevention options, is actioned via a col- laborative relationship and emphasises the promotion of health and well-being. vii viii Preface Atthistimeinhistory,patientsinthewesternworldarevotingwiththeirfeet— they are choosing to practise their own form of integrative medicine, even if their orthodox medical doctor isn’t. A systematic review of complementary and alter- nativemedicine(CAM)usefoundthatprevalenceincountriesincludingtheUnited States, Australia, Great Britain, Germany, Italy, Austria, Switzerland, Canada, South Korea, Denmark and othersranges between 5 and 74.5% [4]. Data from the (then-named) National Centre for Complementary and Alternative Medicine in the US (the name has changed to the National Centre for Complementary and IntegrativeHealth)indicatedthatapproximately38%ofadultsand12%ofchildren use some form of CAM [9], whilst in Australia this figure is almost 70% of the population [16]. Studies indicate that people with cancer are high users of CAM. For example, amongst European countries, the prevalence was approximately 36% (range 14.8– 73.1%) [6], and data from the 2007 National Health Interview Survey (NHIS) indicatethat65%ofthosesurveyedwhohadeverbeendiagnosedwithcancerhad used ‘complementary health’ (CAM) approaches [10]. And of course, it is well known that many patients don’t tell their medical doctor about their CAM use, for all sortsofreasons.Often, itissimply fear ofdisapproval.From ourexperienceas clinicians, there are still too many medical practitioners not supporting their patients’ choice to do something pro-active and look at a range of options. This behaviour may simply be due to mainstream doctors’ lack of knowledge about evidence-basedintegrativemedicine, butit might also havetodowith turf warsin some cases too. Orthodox medicine is, for the most part, dominated by pharmacological and biochemical medicine. This is also true in oncology, with its focus on surgery, chemotherapyandradiationtherapy,alsoknownas‘slash,poisonandburn’.Whilst there havebeensome successeswithorthodoxapproachesineffecting a cure from certaincancers,overallthesuccessrateisnotspectacular.Forexample,thebenefit of cytotoxic chemotherapy is called into serious question by studies such as one conducted by Morgan and colleagues: a literature search of clinical trials reporting the5-yearsurvivalbenefitattributabletochemotherapyaloneinadultmalignancies foundthattheoverallcontributionofcurativeandadjuvantcytotoxicchemotherapy was 2.1% in the US and 2.3% in Australia [7]. Orthodoxwesternmedicineis,ingeneral,inherentlyreductionistinitsapproach. That’snottosaythatsuchanapproachhasnotbeentremendouslyvaluableinmany respects.Andit’snottosayitisn’tchanging,forexamplewiththevariousfieldsof omics like metabolomics opening up. However, the danger is that in focussing on thecancercells,wemisswhatweknowarethemanyotherfactors,includingstress, diet, exercise, and the mind, that all impact on the immune system, the gut microbiome, the endocrine system and other systems. Orthodox oncology focuses on the disease, in particular eradicating the cells that are out of control, with chemotherapy, radiation therapy and surgery. Scant attention has been paid in orthodoxoncologytothefactors that broughtthehuman being into suchastateof imbalance that cancer could begin to manifest in the first place. Little attention is paid to treating the whole person, mind and body, nor to helping the patient with Preface ix cancer achieve a healthier general state. A healthy person has a better chance of beatingcancerthananunhealthyone.Theadventofimmune-stimulatingdrugshas causedalevelofconfusionamongstoncologistsbecauseforthefirsttime,thereisa need to think about the whole person, and not just the cancer. This is because immunityisabouttheperson.It’snotenoughtosimplyremovethecancer,poison it or radiate it. Asfarbackas1931itwasrecognisedbyNobelPrizewinnerOttoWarburgthat cancercellshaveadifferentenergymetabolismcomparedwithhealthycells[3].He found that cancer cells utilised aerobic fermentation, producing lactate in the presence of oxygen, and believed this was due to respiratory insufficiency [3, 11, 12].Pederson,Seyfriedandothersfoundthatcancercellshaveabnormalitiesinthe contentandcompositionoftheirmitochondria,andareseverelyreducedinnumber in some cancers [3, 11, 12]. The ‘Metabolic Theory of Cancer’, developed from Warburg’s original discoveries, posits that mitochondrial damage is the primary eventincancer,notgeneticmutation,whichmayoccurafterwards[3,11,12].This theory,ofcourse,isunlikelytobepopularasitchallengesthepredominantlineof thinkinginthisfield,thatis,thatcancerisessentiallycausedbygeneticmutations. In more recent times, medical oncologist and prostate cancer survivor, Dr. Charles Myers found evidence that prostate cancer utilises LDL cholesterol as a major source of energy, but if LDL cholesterol is lowered, the cancer cell is able to alter its metabolism to use glucose instead as fuel. These findings obviously present some opportunities for the pharmaceutical industry to manipulate metabolism. There are also many other possible ways in which metabolism might be manipu- lated, without detrimental side effects, for example with diet, stress reduction and exercise. The gloves have metaphorically come off years ago in the battle to suppress or discredit various forms of CAM. Ralph Moss’s book, ‘The Cancer Syndrome’ [8] detailsthe‘outlawing’ofnon-conventionalmedicinesincludinglaetrile,vitaminC, and immune therapy. The BristolCancerHelp Centre (BCHC) was set up decades agointheUK,ataroundthesametimeastheGawlerFoundationinAustraliawas established by Dr. Ian Gawler. These were the first major centres to establish supportsystemsforpatientswithcancer,offeringCAMtherapies,andtheywereset upoutsideconventionalcancerorganisations.Astudywasconductedtoinvestigate patient outcomes at the BCHC centre in comparison to those at two specialist hospitals and one district general hospital [1], soon after Spiegel’s study in San Francisco that showed that an integrative programme of social support with hyp- notherapyalmostdoubledthesurvivaltimeofpatientswithmetastaticbreastcancer in comparison to routine oncological care [14]. The BCHC study was funded by two major UK cancer charities, the Cancer Research Campaign and the Imperial Cancer Research Fund [2, 13]. The BCHC study, published in the prestigious Lancet, found what could only be described as an astounding result that patient outcomes were actually worse if they got additional support at the BCHC [1]. However, it transpired that the study was severely flawed in several ways and was widely criticised by medical research experts [15]. For example, some of the crit- icismswerethatthestudywasn’trandomisedandtheBCHCincludedpatientswho x Preface were much sicker than those who went to the London Hospital at baseline. The researchers eventually admitted that it was much more likely that the differences between the two groups could be explained by the increased severity of disease in the BCHC group [15]. In 1992 a formal complaint against the study was made to theUKCharityCommissionbyagroupofpatientswhowerepartofthestudy,who formed the Bristol Survey Support Group [2, 13].Somenineteenmonthslater,the UK government’s Charity Commission that oversees charities all British charities hadcompleteditsinvestigationandseverelyreprimandedthetwocharitiesthathad fundedthestudyforpoorsupervision[2,13].However,bythistimemuchdamage hadbeendonetotheBCHCanditnearlywentintoreceivership.Thisunderpinsthe necessity of rigorous research methodology and highlights the damage that can be done when erroneous results reach the press. Pharmaceuticals equal big money. In contrast, you can’t patent complementary medicines easily and you can’t bottle meditation. The recent savagery of homoeopathy in Australia is an example of an attempt to discredit the practice, despiteitsverywideuseinEuropeancountries,onthebasisof,purportedly,alack of scientific evidence. Forthoseinvolvedinresearch,itiswellknownthatitisverydifficulttoprocure governmentfundingforresearchintootheraspectsofpatientcare,becausethereare often no products to sell that are patentable. Governments have a responsibility to become more informed and fund a broader range of research. Governments also havearesponsibilitytoexaminetheirhealthfundingmodels.Atthelevelofhealth systems, doctor reimbursement is biased towards short consultations and selling products (via a prescription pad) rather than selling health. Despitethedominanceofthepharmaceuticalindustryandvariouseffortstodis- creditformsofCAM,governmentsarestartingtorecognisethevalueofIntegrative Medicine. For example, the National Center for Complementary and Integrative Health (previously the National Center for Complementary and Alternative Medicine,NCCAM)ispartoftheNationalInstitutesofHealth(NIH)intheUnited States(US).TheUSNationalCancerInstitute’sOfficeofCancerComplementaryand AlternativeMedicine(OCCAM)andtheCancerInstituteoftheChineseAcademyof Chinese Medical Sciences jointly held planning meetings to establish the InternationalConsortiumforChineseMedicineandCancerin2014and2015,clear recognition of the need to integrate knowledge across medical systems. Orthodox cancerorganisationsarerecognisingthatcancersuffererswillusedifferentformsof CAM andareproviding information ontheirwebsites.Forexample,theAmerican CancerSocietywebsitehasa‘ComplementaryandAlternativeMethodsandCancer’ sectiondevotedtoinformationaboutCAMandprovidesquitebalancedinformation. The Australian Cancer Council’s website provides slightly more conservative information about various alternative therapies. The Clinical Oncology Society of Australia(COSA)isthepeaknationalbodyrepresentinghealthprofessionalsfromall disciplineswhoworkwithcancerpatients.COSAhasaPositionStatementontheuse of CAM by cancer patients. This is evidence of some acknowledgement from orthodoxstructuresofaroleofCAMinsupportingcancerpatients.