Integrative Oncology and the Memorial Sloan-Kettering Cancer Center Critical Care Experience

CHEST Physician Article | 08.15.11

“Integrative Oncology” is a synthesis of mainstream treatment and complementary therapies in cancer care. Complementary therapies are noninvasive and nonpharmacologic adjuncts to mainstream cancer treatment. These therapies do not directly affect or treat disease but help to relieve pain and distress by controlling physical and emotional symptoms.

In the late 1990s, the Memorial Sloan-Kettering Cancer Center (MSKCC) Board of Overseers acted on its consensus that optimal patient care requires more than expert cancer management and mandated a broader emphasis on an integrative approach to better manage patients’ physical and emotional needs. The author was recruited to actualize this concept, and MSKCC has since developed an Integrative Medicine Service (IMS) within the Department of Medicine that can serve as a prototype for other centers around the world. The IMS provides clinical care, as well as research and training in collaboration with clinicians, researchers, and others throughout the institution. The service has also created a Web site to provide physicians and the public with “solid” information about herbal remedies, vitamins, and other dietary supplements (www.MSKCC.org/AboutHerbs).

A primary focus of the IMS is to study and deploy evidence-based, rational, complementary therapies to patients, their families, and staff. These approaches may be perceived as extensions of the supportive care previously associated with oncology for decades. Simultaneously, the IMS works diligently to curtail the use of “alternative,” unproven therapies promoted for use in lieu of mainstream cancer treatments, also known as quackery.

The ICU staff requests integrative medicine consultations to reduce patient agitation, relieve pain, or reduce levels of narcotics needed to maintain comfort. These interventions are cost-effective and produce no negative side effects. Complementary therapies help normalize and humanize the high-tech ICU environment. Such consultations are also used by the ICU team to assist in navigating challenging interactions with patients and family members who insist on using “alternative” therapies (ie, magnet and light therapies, herbs, and supplements).

Integrative therapies available to IMS patients include massage therapy, mind-body techniques, music therapy, acupuncture, and herbs and supplements, as well as the provision of information about some herbal compounds and other dietary supplements. Each of these has a role in critical care.

Massage Therapy
The main goal of massage therapy in the ICU is to reduce physical pain, induce relaxation, and provide comfort. Touch therapies, such as foot massage, also offer the benefits of a caring interaction and the human touch. The type of massage intervention is determined by the patient’s clinical status and preference. In the hands of licensed massage therapists trained to work with cancer patients, this is a very safe and therapeutic intervention.

MSKCC has offered massage therapy in the ICU for many years. A 3-year study conducted at MSKCC of 1,290 study patients showed that massage therapy brought sustained relief from pain, fatigue, nausea, and other symptoms. Symptom scores were reduced by approximately 50%, even in patients who reported high baseline scores. Importantly, the benefits persisted for many patients throughout a 48-h follow-up period (Cassileth et al. J Pain Symptom Manage. 2004; 28[3]:244).

Mind-Body Techniques
Mind-body interventions, including meditation, self-hypnosis, yoga, qigong, and tai chi use the mind’s capacity to influence bodily function and symptoms.

Multiple studies demonstrate that meditation decreases pain, anxiety, stress, and insomnia in cancer patients. A 2007 study assessed the value of presurgical hypnosis for decreasing the need for intraoperative anesthesia and analgesics, as well as lowering the side effects associated with breast cancer surgery. Subjects in the hypnosis group required less propofol and lidocaine as compared with the control group. They also reported less pain intensity and unpleasantness (Montgomery et al. J Natl Cancer Inst. 2007; 99[17]: 1304). Both meditation and self-hypnosis, a deeper form of meditation, can easily be learned by patients and family members and applied, when needed, to relax and reduce stress. These stress reduction approaches are tools with which patients can help themselves, and a dose-response relationship exists, where better results are seen with more meditation practice.

Music Therapy
Music therapists, musicians with graduate training in music therapy, use music to reach patients. Music therapy is felt to encourage healing and promote well-being. Benefits from music therapy may be derived passively (patient listens) or interactively (patient participates). The music can be tailored to the patient’s preference in terms of the music selected and the instruments used. Typically, we bring portable instruments to the ICU, ie, guitar, keyboard, and harp. Percussion instruments are available for the patient to play as appropriate. Music therapy also permits caregiver and family member participation.

Music therapy is valuable for patients in the ICU, especially for those who are noncommunicative or withdrawn. It reduces the sense of isolation often experienced. Music therapy also offers gentle stimulation for patients who are being weaned off sedatives and helps patients relax during procedures, such as extubation. In a serendipitous result of a music therapy study designed for patients, the attendant physicians and nurses unexpectedly experienced helpful emotional, cognitive, and team effects (O’Callaghan and Magill. Palliat Support Care. 2009;7[2]:219).

Acupuncture
Acupuncture is a 3,000-year-old component of traditional Chinese medicine. It involves stimulating one or more predetermined points on the body with sterile, filiform needles, which are approximately the width of human hair. The needles target specific acupuncture points on the body that are dense with sensory receptors. These acupoints have lower electrical resistance and are closer to superficial nerve junctions (Ma. J Altern Complement Med. 2003;9[2]:207).

Acupuncture reduces many symptoms experienced by cancer patients in all stages of treatment, including dyspnea, fatigue, hot flashes, sexual dysfunction, urinary problems, osteoarthritis, neuropathy, xerostomia, and more. Most relevant to patients in the ICU, acupuncture can relieve anxiety, depression, stress, and pain, and it can reduce the amount of opioids required to maintain patient comfort. Randomized clinical trials show that relief offered by acupuncture is not a placebo effect. A phase III MSKCC trial reported that acupuncture reduced pain and dysfunction in cancer patients with a history of neck dissection. In addition, acupuncture relieved xerostomia in this population (Pfister et al. J Clin Oncol. 2010;28[15]:2565). A companion functional MRI (fMRI) study illustrated that true vs sham acupuncture produced neuronal activation associated with increased saliva production. Signal changes on neuroimaging were correlated with changes in the appropriate cortical areas (Deng et al. BMC Complement Altern Med. 2008; 8:37).

Herbs and Supplements
Many cancer patients turn to herbs in the misperception that, because the products are “natural,” they are safe. Herbal and most other dietary supplements are not recommended for cancer patients under-going treatment or for people receiving prescription medications. In fact, MSKCC recommends that no herbs, high-dose vitamins, or antioxidants be taken during cancer treatment. This prohibition stems from the fact that herbal remedies, which are biologically active, may interact negatively with mainstream oncologic treatments or induce toxicities. Moreover, most dietary supplements are not standardized, many are contaminated, and there are often major discrepancies between ingredients listed on the label and the supplement’s actual components.

Problems caused by herbs include:

Garlic, gingko, ginseng, vitamin E: interfere with blood coagulation
Ephedra: lowers blood sugar
St. John’s Wort, valerian: may affect blood levels of chemotherapy
Kava: can cause kidney failure

Herb-drug interactions represent an important problem. The MSKCC AboutHerbs Web site (www.mskcc.org/ AboutHerbs) offers routinely updated and comprehensive, evidence-based data on more than 250 herbs, botanicals, antioxidants, vitamins, bogus therapies, and more, at no charge. Portals are available for patients and physicians. In conclusion, integrative oncology can benefit patients, family members, and staff in the ICU by relieving symptoms of physical pain and emotional distress and maximizing the serenity of critically ill patients throughout their ICU stay.

Barrie R. Cassileth, PhD
Chief, Integrative Medicine Service
Laurance S. Rockefeller Chair in
Integrative Medicine
Department of Medicine
Memorial Sloan-Kettering Cancer Center
New York, NY