Understanding the approach to integrative oncology - Curetalks

Understanding the approach to integrative oncology

Research suggests that cancer patients are interested in using additional interventions that may help improve the efficacy of conventional cancer treatments, increase their chance of survival, and/or reduce their symptom burden associated with cancer or treatments. They are also looking for complementary approaches that improve their quality of life during and following treatment, sometimes long after they are cured of their cancer.

Integrative oncology is a patient-centered, evidence-informed field of cancer care that utilizes mind and body practices, natural products, and/or lifestyle modifications from different traditions alongside conventional cancer treatments. Integrative oncology aims to optimize health, quality of life, and clinical outcomes across the cancer care continuum and to empower people to prevent cancer and become active participants before, during, and beyond cancer treatment.

We are talking to internationally renowned integrative oncologists Dr. Donald Abrams and Dr. Kavita Mishra to understand the approach used as well as when and how best to include integrative oncology into one’s cancer care. 

Panelists

Talk Recorded on Jan 07, 2022, 02:00 pm EST </> Embed
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Priya Menon Priya Menon

Priya Menon: Hello and welcome to CureTalks. A very happy new year to all of you. I’m Priya Menon, your host. Today on CureTalks we are discussing Integrative Oncology. We have with us two very well-known Integrative Medicine Specialists Dr. Donald Abrams and Dr. Kavita K. Mishra from the UCSF Osher Cancer Center for Integrative Medicine. On the patient experts panel, we have cancer advocate Cynthia Chmielewski and Jim Wickstrom. Welcome to CureTalks everyone. Thank you for joining. I know today’s topic is not a single topic, it’s actually a set of topics and I’m going to start with a question to you Dr. Abrams first, the philosophy of Integrative Medicine is to treat the entire person and not just the disease and even today in this world holistic healing is still a niche approach. Do you see a conflict with the current mainstream disease focused approach, or how do you see these two approaches coexisting in the mind of a patient?

Dr. Donald Abrams: Very good question. So, yeah, integrative medicine and Integrative Oncology is patient centered and relationship-based and it integrates the best of evidence-informed complementary therapies with conventional Cancer Care. So, at the Osher center for Integrative Medicine, I am being a consultant to patients who are being having their cancer treated by another oncologist. So, what I like to tell patients is that cancer is like a weed and someone else is taking care of their weed. And it’s my job to work with the garden and make their soil as inhospitable as possible to growth and spread of the weed. So, I’m not really focused on the weed killer per se, but on how they fertilize their garden, that is what they eat, what supplements they take, how they are physically active and how they manage stress. And so, I think that the two are quite complementary when they’re integrated appropriately.

Priya Menon: Dr. Abrams, I’m going to circle back to you. But before that I like to get Dr. Mishra on as well. Dr. Mishra, I wanted to always ask you, you are a Radiologist and Integrative Health, and Integrative Medicine is a very broad area. How did you find yourself in this discipline of medicine?

Dr. Kavita K. Mishra: Thank you for a great question. And thank you for having me join with Dr. Abrams. I’m a radiation oncologist and so for the last 27 years, I’ve been treating cancers with most recently, proton beam radiation for very rare tumours but I’ve always had an interest in integrated system, integrated health, even since I was a child, and I grew up around yoga and turmeric and meditation and some of these mind-body practices. And when I took a year off, a sabbatical year, a few years back about five years back, I travelled around the world with my family, my two kids and a husband and explored mind-body practices around the world, a lot of my own interest. And I came to re realize that I really wanted to be in this space. I have a public health background and I found that this space really brings together my medical mind, as well as my public health mind, as well as that mind-body medicine practice. So that’s a short version of how I’ve gotten here.

Priya Menon: Thank you. Dr. Mishra, can you explain I know you did mention yoga meditation, what are the various elements that are included in Integrative Oncology other than, of course, yoga meditation and probably exercise, what else?

Dr. Kavita K. Mishra: Integrative Oncology is very broad-based and Dr. Abrams gave a really nice definition of it. Obviously, we’ve talked a little bit about meditation, mind-body practices that is a whole bucket of practices including mindfulness based interventions, guided imagery, yoga, tai chi, Qigong, relaxation response, biofeedback. Some will also include nature medicine, nature therapy, art, music, dance. It’s really quite vast and variable. Then you have lifestyle modifications things like diet, exercise and manual therapy also is someone the midst of that and then you also have natural products supplements. And so the rubric generally has been natural products, lifestyle modifications and mind-body practices.

Dr. Donald Abrams: I do want to add just to that, if I could that I’m a big fan of traditional chinese medicine. And again, there’s Ayurveda, the medicine of India as well. To me, traditional chinese medicine is key for caring for patients, particularly, those who are undergoing acute treatment of their cancer with chemotherapy radiation, hormones, even the immunotherapy and targeted therapies. Traditional chinese medicine is all about expelling evil and supporting good modern western medicine really focuses on expelling evil. When people come to see me I try to support good. But when you go to traditional chinese medicine, they do both at the same time, but from a different angle, so they won’t say you have metastatic estrogen receptor positive breast cancer. They’re going to say you have decreased spleen chi, increased kidney Yang and they’ll treat that. And I just do believe that my patients particularly those getting chemo and radiation do much better if they’re concurrently getting acupuncture from a traditional chinese medicine practitioner. So, for me, that’s one of the real keys of integrating East and West if you will together.

Priya Menon: That’s very interesting Dr. Abrams. In fact here in India, we actually do pack a lot about your day that we do take a lot of ayurvedic medicines, that’s usually our first go to. So, it’s like really great that East meets west. I think it’s a really great for cancer and other diseases. So, Dr. Abrams, I know last time you came we had an entire show on supplements and nutrients and the interest is really huge among our audience. So, I’d like to have asked a few questions on those. We know that there’s a lot of interest regarding vitamins and supplements, as I said, and this is, of course a big business also? Can you advise people how to approach the sort of area in terms of Cancer Care? What are some of the commonly relevant, supplements or vitamins that patient with cancer should be taking, or what are some of the questions they should be asking the nutritionist or their doctor regarding this?

Dr. Donald Abrams: Yeah, that’s a great question. I think, I would say that people should approach this carefully because the oncologist, the traditional oncologist is very fearful of patients, taking things that they are not prescribing, and their concerns are twofold really, number one that the supplements, particularly some of the Botanicals may interfere with the enzyme system in the liver that breaks down pharmaceuticals and it could either ramp up that enzyme system. So, it breaks down drugs too quickly, making them less effective or it could inhibit the system so that it doesn’t break down the drugs that the oncologist is prescribing as quickly as they think, making them more toxic. So that’s one thing. The other thing that’s always of concern is that radiation therapy and some chemotherapy drugs work by creating free radicals of oxygen. Oxygen, normally exist as two molecules linked together but when I separate, they create so called free radicals, or reactive oxygen species, which knock into our DNA leading to aging or cancer. Antioxidants take those free radicals out of circulation, so they don’t do damn it. So, if patients are taking antioxidant supplements, vitamin C, vitamin A, vitamin E, coenzyme, Q10, even melatonin while they’re getting radiation, which is generating those free radicals or the chemotherapeutic agents to do that, taking those out, of circulation is defeating the purpose of the treatment. So, one needs to be careful and that’s why most oncologists a stop everything while I’m giving you radiation or chemo, but that’s not really necessary. My main go-to supplements, I like vitamin D. I think low vitamin D levels put people at greater risk for cancer and people with cancer whose vitamin D levels are low, don’t do as well as people whose vitamin D levels are normal. So, the only blood test I measure on patients, I see at our center for integrated medicine is a 25 hydroxy Vitamin D to see where they stand, and I aim for a level between 40 and 50. Other people aim higher, I think that could be dangerous because it could lead to deposition of calcium in the coronary arteries or the aorta. Calcium is something I also recommend for people because I asked people to stop consuming dairy products. And so dairy is the major source of nutritional calcium. So, I think a little calcium supplementation, especially for patients, who are on hormonal therapies for breast cancer, prostate cancer, where their bones might be put at risk, they need a little calcium supplement. I say a little because for men, too much calcium can increase the risk of particularly aggressive prostate cancer. Calcium also decreases the risk of colorectal cancer. So, I like vitamin D, calcium, calcium constipates, magnesium does the opposite. So, I usually ask people to get a calcium magnesium supplement where they’re both together, so that you get that balance. And magnesium is also calming and magnesium like, calcium is also good for bones. The other supplement that I like for most people is fish oil or Omega 3 fatty acids because those are anti-inflammatory and a little bit, maybe antidepressant. Although the evidence is somewhat mixed on that all together. And then finally the one I mean, I like turmeric from ayurveda for inflammation and decrease in colorectal cancer, but I’m a big fan of medicinal mushrooms. And this is one where my oncology colleagues are always fearful patients, taking mushrooms, because we live in fungal phobic society, we’re fearful of mushrooms. Whereas Asia and Eastern Europe are much more loving of mushrooms, but we’re always afraid that mushrooms are going to damage the liver or kill people. But the cell wall of the mushroom resembles, the cell wall of the bacterium. So, when people ingest medicinal mushrooms, particularly, my favorite is turkey tail or Trametes versicolor, their body thinks they’re being invaded by a bacteria and it mounts a non-specific immune response which we also hope will attack cancer. So, I often recommend mushrooms. I don’t for people with lymphoproliferative malignancies lymphoma, myeloma, chronic lymphocytic leukemia, because I feel their immune system is already stimulated and I don’t want to stimulate it anymore. And I don’t recommend mushrooms currently for patients, who are on immunotherapy for a similar reason because the new checkpoint inhibitor immune therapies, can really potentially have such great therapeutic benefit. I don’t want the mushrooms to compete. And chemotherapy is generally a pretty potent antibiotic. So, I do recommend for patients who have had chemotherapy that they consider taking a probiotic and this is all a lot of information, I’m now a Scientific Advisor to a company called Wellcasa and Wellcasa has a website that both physicians and patients can utilize to look at potential interactions between supplements, as well as their cancer treatment. So that’s a resource that I think people might find valuable. I do have to disclose that I am again, a paid consultant to the company, but I think it’s something that people might find it quite useful.

Priya Menon: Thank you, Dr. Abrams. I think you answered almost all my questions there with touching upon antioxidant supplements, and not having diary, and vitamin D and calcium supplements, so thanks a lot for that. Dr. Mishra, can you talk a little bit of the adaptability of Yoga mind-body practices for cancer and how it is being integrated into the mainstream medicine?

Dr. Kavita K. Mishra: Yes, again, great question and a lot of interesting pieces so let me just break that down. Yoga mind-body practices are really complicated concept, a bucket that holds a lot of things as we’ve talked about. One of the definitions that has resonated for me over the years is like we exercise our body these mind-body practices are exercises or trainings for our mind to really develop that connection between our mind and body to increase awareness, to deepen wisdom within and potentially help in our healing process. And going back to your question earlier, the beauty I feel about Integrative Oncology is you are really trying to bring together your own inner wisdom of healing as well as outer wisdom of healing and that can come in so many forms. So, mind-body medicine really tries to grab into that space and you may know this but for others who are listening in yoga, the concept of yoga as I have learned it traditionally one of the definitions that really resonates for me is connection, whether that means to connection to your body connection between mind and body connection between self and other. But again, coming back to that idea of sort of deepening our wisdom, understanding the Mind-Body complex, which is honestly, the most complicated thing out there. I work with a really complicated machine, but this mind-body complex is a bazillion times more complicated. So, because it’s such a complicated field, it’s also really hard to study it because in medicine, what we try to do today is you have an intervention, and you have an outcome. So, we may have a chemotherapy drug or a radiation protocol, we either give it or we don’t and we follow those patients and we get an outcome. In mind-body practices there are so many types of interventions and so many types of outcomes and those outcomes may be physical changes in our body, pain, fatigue, sleep difficulty, they may be psychosocial differences, around depression, anxiety, fear of recurrence. It may be cognitive, kind of or existential questions as we go through the cancer journey, it may be interpersonal. And so, what makes this a challenging area to adapt to cancer is, how do you really study it? What type do you intervene on and what are the outcomes you’re measuring? Having said that we over the last few decades as a nation, and as a world have really in the language of our current medicine, been able to study, these mind-body practices via randomized control trials, via meta-analyses, via systematic reviews. And so, we find that now, based on really good data in our current language of medicine we can actually add to our national guidelines saying, hey, we now know that mindfulness based practices, movement based practices, like yoga, Tai-chi, Qigong, meditational practices do have benefit for cancer-related, depression, anxiety, fatigue, quality of life, stress management, sleep. So, for example, breast cancer, the ASCO- the American Society for Clinical Oncology just came out in the last few years with recommendations for anxiety, stress reduction, depression, quality of life to utilize things like music therapy, meditation, stress management, yoga mindfulness based interventions, like MBSR-Mindfulness-based Stress Reduction, which generally is taught as an eight week course, has been recommended for chronic pain as has individualized exercise, programs and relaxation techniques. So, we now know that though this is a really difficult area to study. We have been able to study it in some form. And now we’re actually adapting it into our cancer guidelines based on the evidence. And the last part of your question, in terms of, how do we really integrate it into current practice. It’s complicated and Dr. Abrams has been a real pioneer in the field of you sort of seen it grow from a real baby to maybe a toddler now, but we’re still in the youthful phases of growing in the field. I feel. And so… there are a whole lot of resources both at the hospitals, in the clinics, courses online, live yoga classes, etc. In my own practice, I really like to focus in on all the things that we’ve talked about, but particularly mind-body practices. And I think the challenges are really trying to understand what are the barriers, what are the needs and managing expectations because mind-body practices are very variable, may be different for any individual from another patient and can be very different day-to-day. So, what resonates with me one day may not the next day and that’s challenging about mind-body practices, but that’s how I think about this field and how it’s coming into our mainstream.

Priya Menon: Very interesting.

Dr. Donald Abrams: Can I just add something like, the importance of stress management as Dr. Mishra was mentioning I used to start my consultation with a new patient by saying, tell me your story. I actually stopped doing that because I got low grades on doctor knew my history but when I did do that patient often read their stories as a stress caused their cancer. I don’t think stress in and of itself causes cancer. But stress is not good for cancer or anything else. Stress is adrenaline or epinephrine, which kills our lymphocytes, the building block cells of the immune system and stresses the cortisol, a steroid hormone, which is an immunosuppressant. So, decreasing stress is really, really important. And Dr. Mishra is I think, being a little humble and not saying that she’s initiating a program of group visits now for patients at the UCSF Helen Diller Family Comprehensive Cancer Center to teach them interventions, mind-body interventions to help decrease stress.

Dr. Kavita K. Mishra: Thank you for bringing that up. Two things just to add on there. One is, we are starting to understand scientifically how these practices may be helping and so, Dr. Abrams very nicely is talking about some of the hormonal differences where are we in terms of our fight-or-flight sympathetic system versus our parasympathetics. There’s also really interesting data around the immune system, cardiovascular, what’s happening to our telomeres, which are our protective caps on our chromosomes. What is happening in our brain with MRI imaging. And so, there’s some really interesting data around why these mind-body practices may be helping as well as the fact that yes, they’re helping with these symptoms and then just to comment on what Dr. Abrams is adding about the course. Yes. I’m really excited about a course that we’ve piloted myself and a colleague, Dr. Atreya at UCSF, and it’s a four-week version, and it’s for active cancer patients because it can be really hard to sign up for an eight-week class and actually be expected to show up each week when you’re actively going through cancer treatment, surgery, chemo radiation. And so, this is a four-week version where we talk about mindfulness in the context of mindful eating, mindful movement, mindful sleep, mindful emotional regulation, and try to give some practical tips that can actually be used during the cancer journey. And to be honest I am a learner as much as a teacher in those courses, which I love because the patients actually help each other understand what might be working for them, what may not in terms of practical things. And I think also just knowing that others are going through some of the same things that you might be going through, is really wonderful for patients, have that connection, which is hard sometimes when you’re going through the cancer journey. So yeah, it’s been a really wonderful experience.

Priya Menon: Thank you, Kavita. Thanks for sharing that. I have more question, but going to move to Cindy and Jim ask theirs. They also have a bunch of questions for both of you. So, Cynthia, please go ahead and ask your questions, all yours.

Cynthia Chmielewski: Okay. Well, thank you so much. This is so exciting to hear about this integrative medicine is something patients, really want to learn more about it because it is something that we as patients has control over and we could feel like we are helping fight our cancer. But there are so many words, I mean like and for people who are listening in, for new patients and hearing those terms, Dr. Abrams, can you just talk a little bit about like, what conventional medicine is, is that the same as Western medicine and you mentioned something about Eastern medicine and what’s that? And this is a complimentary meaning that you are saying in addition to as, opposed to alternative. Like, all these terms, that patients should just maybe confused about because they are hearing it, but they really don’t understand it. Yeah.

Dr. Donald Abrams: So, we used to call this CAM, which I think is very bad word and it’s Complementary and Alternative Medicine. And the reason that it’s a nice acronym, you can say CAM easily but something cannot be complementary, which as you say means, in addition to an alternative, which means instead of at the same time. So, integrative medicine, as again, as I mentioned is combining conventional medicine, which is since we are in the west, I guess you could call it Western medicine. It’s your conventional anti-cancer therapies with complementary therapies, which include the broad spectrum of lifestyle medicine, nutrition, physical activity, plus supplements, plus mind-body interventions, stress reduction and then the Eastern modalities that we’ve mentioned traditional Chinese medicine and ayurveda. So yeah, there are a lot of terms but integrative is what we like to say now because we’re integrating those complementary therapies with conventional care. You might also say holistic, because again, we’re looking at the whole person and not just their malignant tumor. And so holistic is another word for the type of approach that we’re using. And your point about control, exactly, that’s what I say when I lecture about Integrative Oncology that I am giving to the patient back control because when you hear the words, you have cancer, your locus of control has been ripped out from underneath you. You’re now at the mercy of the surgeon, the radiation oncologists, medical oncologists, even the chemotherapy nurse. So, in my one-hour new patient consultation we discuss the things that the person can control; their weight, their diet, their physical activity, their use of supplements, their mind body, stress reduction, and obtaining traditional Chinese medicine evaluation. I also like to ask my patients at the end of my history three questions: what brings you joy? what are your hopes? and where does your strength come from? And that makes people really think about what’s important to them and sort of gets into this element of spirituality, which I also think is really important in cancer care.

Cynthia Chmielewski: Great. Yeah, I’m so glad that you guys are starting to do this because I’ve been living with myeloma now since 2008. I do a lot of mentoring to newly diagnosed myeloma patients and the very first thing any new patient wants to know, should I eat a special diet, are there supplements I could take, maybe I need to exercise more and when they talk to their myeloma doctor or their general oncologist, I say, oh, just follow the guidelines or do this and they want more, they really do. Because they feel that something that they can take part of and be actively involved in their care in that way. So, I’m glad now we’re seeing some of because I’m also a science geek, some of the science behind it. It’s not just tell ya that may help it won’t hurt but it may help. But really saying it’s going to help and so but integrative medicine is even more than just lifestyle medicine from what I’m hearing you’re speaking. But my next question is do all Cancer Centers have an integrative oncologist there? I mean, I think it’s so important that if you’re really interested in this that you talk to someone who really understands what they’re saying like, Dr. Abrams was telling me like, okay. This is what I do for people but not for patients that had blood cancers because these mushrooms may cause something else. So, it’s important that the person you’re talking to knows that kind of information. So, how do I as a patient find someone that I can trust because it’s going to be variable from cancer to cancer. So, Dr. Mishra, how do I find someone, like you guys are in San Francisco or in the New Jersey? I can’t go visit you, wait a couple weeks to have a consultation. So, how does that happen?

Dr. Kavita K. Mishra: Again, great questions, I really appreciate the thoughtfulness of it. It’s a complicated thing. So, we’ll talk about a few parts of it. First, you’re totally right, a lot of patients are interested and either trying it on their own from something they heard from their neighbor or family or friend, and often a non-medical source and very often they are not reporting it to their cancer teams. And so, there are some numbers that are out there but something like 80% of patients may be using some form of Integrative Oncology practice, but only about 15% actually reported to their teams. So, one step is for the folks to be able to feel comfortable to say hey, this is something I’m interested in, or want to try or I’m doing so that their cancer team is aware. Then the question of, how do you find integrative oncology? How do you find the specialist? It is really difficult, obviously, a lot of the major Cancer Centers now do have some sort of Integrative Oncology team or symptom management team. Most places will have a nutritionist, exercise counsellor, physical therapy and maybe some mind-body practices or courses. And then there are obviously online services, our webpage at UCSF also has a lot of information around nutrition, the American Cancer Society there’s other National organizations, like the American College of Sports medicine has some really neat information around exercise, as medicine. Dr. Abrams is talking about some of the sites around supplements. But it’s complicated, it’s hard and sometimes it takes a little bit of manoeuvring to find your way. I’ve heard from patients that there are various Facebook groups where they might be able to access, get some information on who might be good to connect with. And Dr. Abrams, I don’t know if there are other things that you’re thinking about in addition to that.

Dr. Donald Abrams: Yeah, the Society for Integrative Oncology has a website where people can access and look for an integrative oncologist. You’re in New Jersey, Memorial Sloan-Kettering in New York City has a whole integrated medicine Department. In fact, our last few presidents of the Society for Integrative Oncology have been from that program in Memorial Sloan-Kettering. Many Cancer Centers have Integrative Medicine attached to them or an Integrative Medicine Center, especially if you’re an academic Medical Center, most academic medical centers in the United States now have integrative medicine programs attached to them. And many of those places are equipped to see patients living with and beyond cancer diagnosis.

Cynthia Chmielewski: That’s good to know. I guess the message out to the patients out listening is to ask because it seems like everything else if you don’t ask sometimes you’re not told that. We have this wonderful program here that you’d be part of and that brings me up to another question of access to these programs. Are these programs covered by Insurance and if they’re not or how about the people who have cancer they suffer from so much financial toxicity to begin with that enrolling in some program that’s going to cost more money that they’re not even sure is going to help them, it’s a big decision. So can you address that issue of access to Insurance, so we’re not creating disparities in these programs? Anything on that either of you, I don’t know, both of you.

Dr. Donald Abrams: Well, the Osher Center for Integrative Medicine accepts insurance. So, every patient I see is covered by their insurer. If I recommend that they get massage, for example, that might not be covered. If I recommend acupuncture many insurers, do cover acupuncture, but not all do. At our Center as Dr. Mishra said we have nutritionist, we also have a personal trainer, all of those are free or covered by the insurance. So, it really depends on the center and how they’re set up. But, we do accept insurance for all of our services.

Dr. Kavita K. Mishra: That’s right. And I’ll just add that there are sometimes for example for acupuncture, sliding scales, that may be available with different manual therapy like massage. And for example, the pilot that we’re doing in group medical visits, that’s all through insurance covering mind-body practices learning. So yeah, we’re trying. It’s an excellent question. I think insurance companies the more that we as a Medical Group and patient advocacy group can show the insurance companies that hey, this helps for these symptoms more and more I think will make headway in that. For example, Dr. Abrams actually just last night, sent me a paper, which was excellent around exercise, and focuses survival for cancer and almost a 5x difference for folks who are sitting more exercising less versus folks who are sitting less exercising more, and that is a massive difference in terms of risk and survival, recurrence risk and survival. So, it takes time, and it takes manoeuvring but there are resources today and we hope that we will continue to push the science forward to make headway there.

Cynthia Chmielewski: Sure. Thank you for that. That leads me to my last question is a paper that Dr. Abrams sent you. Can you just talk about is this evidence-based decisions just because you have a hunch that this works and is the evidence based like in cancer in general or specific cancers or yeah, just anything about research backing up with your finding?

Dr. Kavita K. Mishra: I can start and I’m sure Dr. Abrams will add on this is as scientist or Integrative Oncology in general is really trying to have evidence-based or evidence-informed data to support these recommendations. And so, for example with Dr. Abrams was mentioning earlier around acupuncture that has been shown by multiple studies in multiple cancers to help with for example, chemotherapy induced, nausea, and vomiting. Such that now, it is part of the national guidelines for care. And so, that is kind of the sort of steps that we want to take, which is, we see a benefit anecdotally perhaps, we do studies, we get to a place where we actually get it into the national guidelines. The paper around exercises is really excellent survey done by the NHANES study that’s been running for decades through the U.S. I think affiliated with NIH, basically looking at 1500 cancer survivors and looking at a folks who are sitting more than eight hours a day, exercising less than 150 minutes a week. How did they do compared to folks who are sitting less than four hours a day and exercising 150 or more minutes a week. So, very scientific looking at a broad spectrum of cancers across the US and found this very significant difference, this 5x difference and that is in line with other data that’s come out prior in meta-analyses, other smaller randomized trials. So, this is good data in our current language of medicine that shows certainty around benefit. So yes, the aim is for Integrative Oncology to really based our recommendations on evidence, safety, efficacy to make those recommendations for patients. Dr. Abrams you want to add.

Dr. Donald Abrams: Yeah, I do. You bring up exercise and physical activity. So, when I have my conversation with patients about nutrition, I follow the American Institute for Cancer Research, World Cancer Research Fund guidelines. And those are ten guidelines for reducing the risk of cancer. Although number 10 says, for cancer survivors, follow the nine guidelines above and the number one guideline is to be a healthy weight. We now believe that 40 percent of all cancer in the United States, is related to overweight or obesity. It’s has surpassed tobacco smoking as a avoidable cause of cancer. And the number two recommendation is to be physically active. And that’s one way to maintain a healthy weight. They changed the guideline in 2018, when they updated it from 2007 to just move more sit less, which I don’t like because in 2007 it said be physically active for at least 30 minutes a day. And I think that prescription of time is a better guideline than move more, sit less. What does that mean? Yeah, again the paper that Dr. Mishra just mentioned, did talk about people sitting for more than eight hours a day. I couldn’t even picture doing that myself. I’m a little bit hyper, but physical activity has been shown to decrease the risk of breast, colon and prostate cancer are three most common cancers and people with cancer who implement a program of physical activity after their diagnosis also have survival benefits and that even not only breast, colon and prostate but even pancreatic cancer, which is one of my most difficult challenges. So physical activity, the number two guideline is key and the paper that we just shared really emphasize that. Now, when you talk about evidence-based, that’s what your oncologist really wants is evidence-based because we’re dealing with a bad disease and we use toxic medications, but your Integrative Oncology wants evidence-informed because I can’t do a randomized placebo-controlled trial of massage. What is Placebo massage or tofu, what is Placebo tofu, many people think tofu is already Placebo. So, we do a lot of sort of evidence informed, as opposed to evidence-based from randomized placebo-controlled clinical trials.

Cynthia Chmielewski: Okay. Well, that’s good too. Because as a patient advocate, I feel that if I’m starting to gather this evidence informed information, I could start talking to my insurance companies or things to help pay for these interventions that are going to possibly help me live longer or not, relapse as quickly and cost their company a lot more. So, thank you so much and that’s enough for me. I let someone else talk.

Priya Menon: Thank you, Cindy. Jim, you can ask yours.

Jim Wickstrom: My questions are going out the door right now. You guys have opened the window a little bit too much for me. I had prostate cancer about 10 years ago and I was kind of frosted by misinformation, by doctors, by urologist, who were proprietarily suggesting surgery or radiation, when they own the radiation clinic. And we saw evidence of this in New York, blah, blah blah. I did HIFU where I left the country to do it, cost me a little bit of money, but I’m OK. And now, I have people finding what I publish online and they call me up from all over the country and they are guys and guys just suck at doing their own research and trying to find out solutions. They want to know, just tell me the answer, who do I go to? So, I give them a list of questions. Here’s what to ask your doctors. See more than one doctor and my doctor, Dr Scionti in Florida is a fabulous resource. He will talk to anybody but guys aren’t good at this part. For me, when I had cancer my son is in a coma with epilepsy and my mother is dying. I can’t fix it. And I am sort of downloading music but I didn’t know, I’m downloading dance music. I’m downloading music about love, but I didn’t know it. So, I’m going to work out heavy. I’m a surfer, I’m surfing. I come home and turn this music on again. This music therapy for me that I didn’t know I was doing was right to her, but I didn’t see it. I’m trying to share this with your friends of mine who ever get cancer, but you can’t tell you have to allow and so that’s what I’m kind of done on my level. But now I’m okay. My son is okay, but the challenge is when you’re okay, it’s easy to look at someone else who has cancer. And I have friends who have cancer now, but when it’s you who has this cancer and you’re looking for alternative treatments, it’s a blur. There’re too many things to look at that Joe public cannot desegregate. All of these choices. They are heading out to Tecate to spend fifteen thousand dollars for a cancer therapy that doesn’t work. And we’ve all seen these treatments that are just abusive in my mind. And we’ve seen people enabling these ridiculous, fake solutions. I feel bad there’s not a push back by the medical community because there is really not you were living our own little bubble as a medical profession and patients, don’t know how to segregate anything. They try their best to get through each piece. But it’s hard and I look at patients who call me and I’ll give them the choices. One of my close friends who was a top athlete. He’s still nerd going through each step to try to figure out things. He doesn’t want to look at alternative therapies. He’s going to go right into radiation in two weeks because that’s what he feels comfortable with. But I think as a Joe public, how do we use integrative thoughts with oncology to get the word out. There is no avenue. There is no pathway. Harvard Medical School has great publications on diet, Mediterranean diet and dash and stuff that are really fabulous, my diet is a killer. But you can’t get people to do that because once they start, they don’t keep it going. Exercise, oh yeah, going to exercise now and they don’t exercise. You guys know what I’m talking about. So, I think the message I have is, how do you get from point A to point B in the medical community? So, Joe public, hears’ what is being said here. Sorry for my diatribe, but I don’t know how else to share it. Any ideas of how to integrate Joe public?

Dr. Donald Abrams: I’m thinking of one of those listserv sent me this physician someplace talking about people dying of covid, and the tendency for people to be overweight and obese, and how Boris Johnson, this is what the guy said in the Prime Minister of England has now appreciated that and is banning sales of all sorts of toxic foods in England. Now whether or not, this is true. I don’t know. But the answer to your question is we as a country need to stop supporting advertising of junk food to people, because this is what’s causing dietary issues are the number one cause of both morbidity and mortality in the United States today. And we’re at the mercy of companies that have a lot of money that advertise particularly to the children, the obesity epidemic in children is alarming. And it’s I don’t know how to get to Joe public other than modifying, the system that we currently use of disseminating information about health because it’s broken. I agree with you.

Jim Wickstrom: In my profession, I was in education. We created a physical program for schools all over California. We spoke at the Caper conference. I taught inner-city. Those kids have no choice of what food comes to them. There are so many food deserts. You can drive through miles of LA, you can go miles and you can’t find any place that has food. They people don’t have transportation there, cheap food, is bad food if it is too cheap and we educated children and students in that educational setting but they have no help because their parents bring home food they can afford not the food, that’s necessarily good for them. And the food desert thing is a huge issue that it goes along with obesity. Because when you become obese, you don’t exercise. And it’s a mixed bag right there on both ends of this and having worked in the city, I don’t know the answer because you can’t. There is no infrastructure in America or California, or we are to fix this, as I could see it. So, I’m not asking a question, I’m just stating my opinion.

Dr. Donald Abrams: But you’re right. I mean you’re right again, when I use the lecture to the third year medical students at San Francisco General which is our safety at hospital about nutrition and cancer they would always raise their hand at the end and say well what about our patients here? And I would say yes, my organic apple costs as much as a double cheeseburger, fries and shake. And that’s unfortunate and we do subsidize the wrong information. Now, I just read talk about evidence-based, an article about the sulfur promoting microbiome, leading to increased risk of colon cancer. So, I said what is a sulfur promoting microbiome and its diet soft drinks, French fries and processed meats. How much of America lives on that. It’s a problem.

Jim Wickstrom: Let me ask you this, there’s a man, I’ve travelled with the first name is Bob Wales. And he is the new California, medical association director. He’s a great man. I’m going to see him next month. I want to ask him questions. So, what are you doing? How are you linking big pharma with the California Legislature with a medical community create positive change. This guy doesn’t have to work. He’s into this job. He’s doing 15-hour days. I respect him a lot, but I wanted him to create positive change because he can do it. He is in a spot there but he told me recently, he’s overwhelmed by it. He spends 15 hours a day is trying to link stakeholders together and it’s not easy for obvious reasons we’ve talked about earlier today. So, if you guys have any thoughts for me to ask him because he’s just a good guy who’s into it

Dr. Donald Abrams: It’s not impossible. I don’t know how many viewers are as old as I am. But I remember ashtrays on airplanes. Remember you used to be able to smoke on air. There was a non-smoking in a smoking section, how ridiculous is that. Now tobacco is pretty much unheard of. If we could do the same thing with poor nutrition in this country that we did with tobacco. I think it would be a huge step forward. Why don’t you mention that to your buddy when you meet with?

Jim Wickstrom: Okay.

Priya Menon: Thank you, Jim. Thank you for sharing that with us. Dr. Abrams and Kavita, I have a couple of more questions before we wrap up today’s session. Okay, Dr. Abrams, what daily habits can help healing through any cancer staging. And how do you help patients from this process?

Dr. Donald Abrams: Kavita, I missed the question.

Priya Menon: Some recommendations on daily habits that will help people through their entire cancer staging and healing process? And how would you help them with this?

Dr. Donald Abrams: Daily habits, so I think we should consume in organic plant-based antioxidant rich, anti-inflammatory whole foods diet. We should be physically active for at least 30 minutes each day. We should take appropriate supplements get most of our nutrients from our foods, but if we don’t, then some supplementation would be good, and we should work to do some mind-body interventions to decrease our stress. We currently live in a very stressful environment with this ongoing two-year pandemic, that we’ve been dealing with. But you really need to do what you can to decrease your stress so that you can sleep well, because we haven’t talked much about sleep today. But sleep is really important for us as people. And I think getting a good night’s sleep, going to sleep at the same time waking up at the same time is recommended. And again, we didn’t talk about fasting. Fasting seems to be the new sort of ketogenic or paleo diet. I think we should eat three meals a day personally and I’m not a big fan of fasting intermittent or otherwise, to be honest. So, I don’t know. Dr. Mishra, what do you think?

Dr. Kavita K. Mishra: I’ll add a couple of thoughts there. That’s wonderful. In terms of fasting, in speaking with our exercise specialist or exercise oncologist, the issue with intermittent fasting when you’re doing 16:8 sort of the version that maybe you’re talking about for cancer patients in particular, one can lose muscle mass and we don’t want that. And so generally what I’m hearing from the folks in nutrition and exercise oncology is that around 12 or 13 hours where you eat 7 p.m, you eat again, 7 a.m. or 8 a.m., that is a sustainable potentially healthier way to go especially as you’re going through a cancer journey. So, I’ll just add that piece and then there are so many things that we’ve talked about the one comment I’ll make for patients, is it can feel overwhelming to try to think Oh, my gosh, I need to go do this with my nutrition I need to go do this in terms of exercise and a little bit of what Jim you were talking about, which is you might start something but then how do you actually maintain it? These are potentially transformational practices, and it requires your own input into it, right? Your time, your effort. And so, starting with one or two priorities is something that I often talk to patients about, which is, there are 30 things, that might be on the list of things to think about. Then let’s start with one or two items. Let’s try that for a few weeks or a month or whatever, whenever I see you next. Let me know how that goes. That will add on something else depending on what their greatest need is. And what is their greatest barrier? So, yes, I’ll just add that in terms of habit-forming. Habit-forming is really difficult. So, taking it step by step.

Priya Menon: This one last question to both of you. I don’t know if this question is right, but could you kind of name three side effects of cancer treatment that mind-body practices or eating right has actually helped and we know about it. I know you did mention acupuncture and nausea. Is there anything else that we are sure that would help with?

Dr. Kavita K. Mishra: Well, I’ll start and Dr. Abrams, please add in. For every single one of the things that we’ve talked about there have been evidence, informed evidence-based data that’s come out, showing benefits of, for example, everything from physical symptoms, like sleep, fatigue, pain, something that we didn’t talk about was xerostomia or dry mouth, where acupuncture has really shown that it can reduce not only during the radiation period that even up to a year out some of these symptoms. And so, these are very practical physical symptoms that mind-body practices, acupuncture, etc can help. On an emotional level, we’ve definitely seen that. For example, mindfulness-based interventions help with depression, cancer-related anxiety, cancer-related, fear of recurrence and then I’d say that for example, the exercise people that we talked about was very clear and some of actually the dietary information that Dr. Abrams is sharing is very clear in terms of risk reduction. So, less chance of recurrence of cancer, and now we have fairly clear evidence of survival benefit. So, it really spans the physical, the psychosocial, as well as the recurrence of the survival risk. Dr. Abrams.

Dr. Donald Abrams: Yeah, the question was mind-body interventions are good for what symptoms that we haven’t talked about pain much. But I think that many of the things that we do are dealing with pain because cancer patients often or dealing with painful issues. And I think acupuncture for one is something I like for pain. Mind-body interventions, I guess you can get some control over, I’m not aware of all that evidence. Some of the supplements may be useful, turmeric, for example, maybe something that’s useful for pain as well. So, I think that the symptoms that we deal with the most are pain, insomnia, nausea, vomiting, and loss of appetite. And that one thing that we haven’t talked about and we’re right at the end of the day, of course is cannabis, which is something that I studied, and which I recommend to patients, because it’s one thing that can really deal with all of those symptoms that I just mentioned. So, I’m a big proponent of cannabis for symptom management. Although, I don’t see it as something that cures cancer as many of my patients, believe it might.

Jim Wickstrom: You know what, you said in a previous show on cannabis, so you said one of your patients said to you I heard cannabis can cure cancer. And you paused in my recollection, you said the only people who believe that are dead. I think that is how you worded it.

Dr. Donald Abrams: Not exactly, I said I’ve been an oncologist in San Francisco for 39 years. And if I would venture to say that most of the patients that I’ve taken care of have used cannabis and if cannabis cured cancer, I probably have a lot more survivors. So, I’m rephrasing of what you said.

Jim Wickstrom: Sorry.

Priya Menon: Thank you. Thank you, Doctors. So, with that I think we can wrap up today’s discussion. Dr. Abrams, Dr. Mishra, thank you very much for taking time to join us on CureTalks today. Cindy, and Jim, I hope the discussion would prove useful for the cancer community and thanks for joining and asking these great questions. We also thank UCSF- Helen Diller Family Comprehensive Cancer Center. This talk will be available on curetalks.com. Thank you, everyone and have a great day


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