YOU DON’T HAVE TO BE DIAGNOSED WITH CANCER TO START CHANGING YOUR LIFE.
By Carla Valencia de Martinez
I SAT DOWN WITH LORENZO COHEN, FOUNDER, PROFESSOR, AND DIRECTOR OF THE INTEGRATIVE MEDICINE PROGRAM AT THE UNIVERSITY OF TEXAS MD ANDERSON CANCER CENTER, AND ALEJANDRO CHAOUL, ASSISTANT PROFESSOR AND DIRECTOR OF EDUCATION, TO TALK ABOUT THE INTEGRATIVE MEDICINE PROGRAM WHICH ENGAGES PATIENTS AND THEIR FAMILIES TO BECOME ACTIVE PARTICIPANTS IN IMPROVING THEIR PHYSICAL, PSYCHO-SPIRITUAL AND SOCIAL HEALTH. THE ULTIMATE GOALS ARE TO OPTIMIZE HEALTH, QUALITY OF LIFE AND CLINICAL OUTCOMES THROUGH PERSONALIZED, EVIDENCE-BASED CLINICAL CARE, EXCEPTIONAL RESEARCH AND EDUCATION. THE INTEGRATIVE MEDICINE CENTER WORKS COOPERATIVELY WITH THE PRIMARY ONCOLOGY TEAM TO BUILD COMPREHENSIVE AND INTEGRATIVE CARE PLANS.
What was the vision for The Integrative Medicine Program? And how has it evolved?
LC: To me, the success of integrative medicine is that it actually doesn’t exist as a separate discipline. Comprehensive integrative care should be the standard of care, part of every single clinical encounter and part of every care center. Integrative services should be available for patients at point of care delivery and not continuing the fractionation of different systems and the delivery of different modalities in different locations. Logistically that’s become somewhat complex, so we do have a separate place where people go to receive acupuncture, yoga, massage, music therapy, and dietary, exercise, and psychological counseling, etc. Incorporating integrative medicine services seamlessly within the standard of care is the ideal.
AC: Today we are not there yet, but we have moved from being spa-like service on the side of patients cancer care to being really a much more medical, evidence-based program standing alongside the other medical oncology clinical centers.
There’s not a lot of research for lay people to get their hands on readily. Why?
LC: There is, in fact, a lot of research already conducted showing the benefits of different integrative approaches. For example, extensive research shows that diet can influence cancer outcomes. The challenge is how do we translate the research changing medical and influencing policy at a national level.
I think what I meant to say, it is hard for patients and the general public to access that information.
Well, it’s hard for patients and the general public to access the benefits of conventional cancer treatments like taxol. They are scientific studies. But The New York Times and the Wall Street Journal and other lay media sources report on the studies showing the diet-cancer correlation; sedentary behavior increasing cancer risk; the harms of stress and health effects of relaxation – it’s in the lay media. Where it’s not getting picked up is by the doctors because it’s not part of the standard medical arsenal to give people dietary recommendations. It’s not part of the standard medical arsenal to tell people to be less sedentary. It’s not in their toolbox. What is in their toolbox are the conventional medical treatments like chemotherapy, pharmacological treatments, surgery and radiotherapy in the treatment of cancer.
AC: And even less, stress management tools.
LC: None of it is in their toolbox; lifestyle is not in their toolbox.
Do you think it ever will be?
LC: For sure, it will be!
Although the diet aspect is readily available, where else can patients get this information?
LC: Patients go to their doctor and they say, “Does it matter what I eat?” And the doctor will say, “No, it doesn’t matter what you eat.”
AC: I think in cardiovascular diseases doctors are more open to prescribe lifestyle changes. I don’t think in cancer yet, this is…
LC: I am not as optimistic.
LC: No! We’ll just give you a stent, keep eating the steak! We’ll just give you more stents. Don’t change your diet due to high cholesterol; we have a pill for that.
AC: I think otherwise, but anyway…
LC: I was at a banquet for the Texas Heart Institute. They paraded on the stage all the most important new high-tech treatments, gene therapies, etc. They served unhealthy food and of course McDonald’s® is in the lobby of the Texas Heart Institute. Not a single person spoke about lifestyle and heart disease. It was all about genes and the new technologies, nothing about the fact that most of heart disease cases could be prevented if people didn’t eat poorly, exercised more and managed their stress. And the link between lifestyle and disease is more definitive for heart disease than it is for cancer, and I believe it is still very much ignored. How many states offer the Ornish heart program, which has been scientifically proven to reverse heart disease?
AC: California, one.
LC: They do? All insurance covered? Medicare? I think it will happen in time. But it has to do with a culture shift and changing the financial incentives. It has to do with medicine taking more of a preventive approach and acknowledging that lifestyle factor need to be a part of the medical intervention prescription.
What percentage of patients here at MD Anderson takes advantage of this program?
LC: It’s a small number. This is partly due to the fact that we have only two doctors, one and half acupuncturists and two massage therapists. MD Anderson sees over 30,000 new patients every year, with over 1 million patient visits.
Is it because people can’t get in to see these oncologists? Or is it that there just isn’t enough interest?
LC: We are busy – our wait time isn’t that long and we don’t want to have a long wait time to get into our clinic because that causes frustrations – but not enough patients know about us. And it’s not because the doctors and staff think what we do is not important. It’s just that people are so overwhelmed with their own area and they focus on that.
What needs to happen from a preventative standpoint? If funding and politics weren’t an issue, what would be the first thing you would do to integrate this program into modern day medical practice?
AC: Education is a key factor. Through our website, anyone can come to our website and get education on integrative medicine. We are trying to expand our educational efforts and reach more people, and partly, it is through people like you sharing the word about this program.
LC: Where there really needs to be a cultural shift is in medical school. Because if we expect this message to be coming from health care professionals – whether it’s the doctors or the nurses or anyone on the healthcare team – they need to know the role of lifestyle factors on disease. And receive a minimum education in that area and some training on how to help patients to modify their behaviors and then incorporating the professionals on the team whose job it is to work with patients to change unhealthy behaviors that we know are linked with disease risk and worse outcomes for those with disease. So, Medicare/Medicaid has agreed for the first time ever (and this was about two years ago) to do what they call intensive counseling for patients who are classified as obese. But the only people who were going to get paid to do that were doctors and nurses. But doctor and nurses aren’t trained on how to do lifestyle counseling. Dieticians weren’t included in that, PT people weren’t included in that and clinical psychologists weren’t included to be reimbursed for their obesity counseling. So of course everyone is up in arms and writing letters, and so in theory that will change as well. The ideal is a society that has more of a focus on prevention. A society that doesn’t give incentives to organizations and big businesses that are essentially poisoning our society, whether that business is a building supply chain making wood flooring or BIG food exposing our society to unhealthy levels of sugar. We need to have financial incentives for prevention and wellness. But there is now much more of a cultural awareness that lifestyle factors, that also includes the environment, modifies our risk factors for many diseases including cancers.
AC: I couldn’t agree more about medical school. I think there is a trend. I have a joint appointment here at UT Medical School and we have a course called Medical Humanities, which is both about the human care and the doctor/patient relationship but also bringing things in such as integrative medicine. Today, even though after 10 years it’s still what they call a blue book elective, we are still somewhat part the curriculum. However, that means that the future doctors that choose to know about this are just a minority. It should be mandatory. For many medical schools around the country integrative medicine has become more a part of the formal curriculum. We still have a bit of work here in Houston.
LC: I heard from a current oncology fellow that on the board exams for oncologists there is a question about acupuncture and the role of acupuncture in symptom control. So changes are starting to happen. If it’s on the exam it will be in the curriculum. A big effort for the Academic Consortium for Integrative Medicine and Health has been to change the board exams and that’s not an easy process.
Where did the value of life get lost?
LC: Are you kidding? When capitalism started to flourish in the world. When the incentives are for wealth and not health. Free enterprise, survival of the fittest, and the fittest now are the people with more toys and money.
CV: Who die of cancer too!
LC: Sure, right. Or of anything else. There is irrefutable evidence from every major governmental and nongovernmental organization that acknowledges that the majority of noncommunicable diseases could be prevented. The main noncommunicable include lung disease, cardiovascular disease, cancer, and diabetes – together accounting for the majority of deaths in our world. And at least 60% of them could be prevented.
CV: And by easy switches!
LC: By easy switches, no tobacco, more exercise/less sedentary behavior, healthy diet and moderate alcohol consumption. Those essentially four behaviors would remove the majority of noncommunicable diseases in our world. That’s data from the WHO (World Health Organization) and the CDC, which are regarded as pretty reputable sources for our health.
AC: And stress reduction.
LC: Well, stress isn’t a part of it yet because it hasn’t been acknowledged. Stress research is more challenging than say measuring what someone eats, but we know stress is linked with behavior and also influences physiological and biological processes associated with health and disease.
So what is the point of conducting all of this research if it’s not being applied?
LC: To change the standard of care it is essential to have the evidence on what matters to prevent disease and increase health of out nation. But the evidence is not sufficient to create change. We need to change the incentives of the system, because preventing disease doesn’t make money.
But at the end of the day it would?
LC: But who’s incentivized to do it? The incentives in this country are to treat disease once it has developed. But it looks like the incentives are finally changing. The folkloric history from traditional Chinese medicine was that the Chinese medicine doctor was paid when the patient stayed well. If the patient got sick, he wasn’t paid anymore. So the incentive was to keep the patient healthy. Our system is an illness model. And doctors are paid when someone comes in and they are sick and they fix them or try to fix them.
AC: And the sicker they are, the more things they have to do, the more money the medical system makes.
LC: I am somewhat optimistic for our country and the role of prevention and real integrative care, because there is hope that the incentives are changing. MD Anderson, not necessarily today, but in a very near future is going to be incentivized to try and do less. To try and get the same medical return on less intensive interventions. We are already in some sense testing this with head and neck cancer patients. They are experimenting with essentially a bundle payment (this was written up in the Wall Street Journal because we are one of the few hospitals that are doing this kind of experiment right now in the area of cancer), the head and neck group have mapped out in the last five years, down to the dollar, what is spent on different things and came up with what they think is the appropriate target for what we should be paid for treating a head and neck cancer patient. And if it costs us a lot more money to treat a specific patient, then we are going to lose money and there won’t be profits. But if we can do it for less, we are going to save money and put some money in the bank.
For example, we’ve known for a long time that people who smoke up until the time of their surgery have far more complications due to surgery. Doctors actually refuse to do surgery on a patient who acknowledges not quitting smoking due to having worse outcomes. Soon there will be financial incentives for making this behavior change. Because surgery can be done for less money which we know is the case if they are a nonsmoker. If you do surgery on an obese person it takes a lot longer, there are far more complications and the probability of reoccurrence of disease is a lot higher, so we need to be incentivized to help that person lose weight.
Has the whole eating clean, juicing, organic movement helped the IM area?
AC: It has helped and hurt. On one hand, yes, there is more interest in IM. But on the other hand, there are a lot of things that are under IM that are not evidence-based and so in fact there are probably more non-evidence-based things out there that people are doing than evidence-based. I think there needs to be more research. You just can’t make claims.
LC: Ultimately the science is going to speak for itself. Literally every couple of weeks there is a high impact publication showing the role of lifestyle factors and disease. I have a email blog that I send out 5 days a week highlighting new research in the news. I don’t have to dig very deep to find a scientific study to send 5 days a week, 50 weeks out of the year on an article that shows the link behbetween lifestyle and halth, whether that’s sleep, stress/mind-body, environmental factors, social connection, diet, or exercise. Those six factors are what I focus on, and the data just keeps mounting and mounting and mounting that it cannot be ignored.
AC: The other area that I think is helping is that businesses are realizing the importance of this with fewer absentees, by having a more productive workforce, etc. So when they are able to provide better food, offer time for exercise or put a gym in the facility, bring them meditation, do yoga – offer these things – businesses are noticing that it helps the financial bottom line. This is a way of reaching the general public and getting our message out.
Have you seen any surprising results in your clinical research?
LC: The outcomes of our research haven’t been surprising and a lot of them have been positive. The studies that have been negative are because the patients haven’t done their prescription, so to speak. So meditation, yoga, exercise and a healthy diet, for that matter – it’s not going to work, if you don’t do it. You can do six weeks of meditation and then you stop. We assess you a year later; you are not going to be different. We are not talking about treating an infection with a course of antibiotics and it’s gone forever. We are talking about trying to make permanent lifestyle changes in an individual that’s going to impact their risk of disease down the road, recurrence of disease, etc., treating a symptom that is chronic. What’s challenging is trying to figure out what buttons to push to motivate people to create long-term behavior change.
What has been somewhat surprising is what we are starting to see from a comprehensive lifestyle study that we are doing which is really delivering the integrative medicine prescription. The study is being done with stage III breast cancer patients who are at high risk for recurrence of disease. Around 50% are predicted to have a recurrence on average within 4 years. So pretty bad odds, because they have advanced disease. In the study we are providing very intensive counseling in the area of diet, exercise and stress management. They have a behavioral counselor they work with for six months. And the response that these women are having anecdotally to this team of women who are there to coach and counsel and to help modify their lifestyles, has been beyond expectations. And importantly, many of the women are from minority groups and underserved patients living with challenging financial means. Even with all the challenges they are facing, there has been an excellent uptake of yoga and meditation, healthful eating and increasing vegetable intake (some who had never eaten vegetables before and they are eating vegetables daily), practicing yoga with their friends and meditating with their children and husband. They are sharing this new lifestyke with their friends. One person in Midland, TX, has brought a yoga instructor into the office to teach other people because she feels the benefits – and knows and wants to share it with her staff. It’s been quite remarkable so far. The study is ongoing with the main goal of trying to decrease recurrence of disease through lifestyle, so this will take some time to complete.
AC: But it is important to know – You don’t have to be diagnosed with cancer to start changing your life. That’s the bottom line for me.