Holistic Cancer Therapy and Symptom Management

Today Cancer Network is discussing complementary approaches to cancer care that are meant to supplement effective cancer treatments and improve patients outcomes and quality of life with Professor Judi M. Fouladbakhsh, PhD, RN, PHCNS-BC, AHN-BC, CHTP, an associate professor at Oakland University’s School of Nursing in Rochester Michigan. Fouladbakhsh studies and teaches evidence-based holistic and complementary therapy approaches and symptom management including yoga for cancer survivors, natural products, and mind and body practices.

-Interviewed by Anna Azvolinsky

Cancer Network: There are likely many misconceptions out there on what exactly constitutes evidence-based complementary and alternative medicine and symptom management therapies. Could you define these therpaies, particularly in the context of cancer patients and survivor care, and why you think they are so important?

Professor Fouladbakhsh: Thank you for having me. As we look toward complementary therapies and moving these into integrative healthcare, what we mean by that is establishing the evidence for therapies through research to then integrate them into conventional care as support for patients as they go through treatment and through survivorship. That means we want to do more and more research studies to accumulate evidence [on complimentary therapies].

Recently, the Society for Integrative Oncology (SIO) and the American Society for Clinical Oncology (ASCO) provided endorsement for certain integrative, complementary therapies during and after breast cancer treatments. There are grading systems of these therapies that are rated based on the amount of research evidence available.

These grading systems provide patients with recommendations with what to use or not to use. There are a lot of misconceptions for patients. For example, if I add ginger or something else, that would help my fatigue and nausea or vomiting. We are working on recommendations for other cancers as well. There is also a category for contraindications of what not to use because some things could be harmful at some points during treatment.

Cancer Network: You’ve done a lot of studies on how incorporating yoga practice can help both those patients currently receiving cancer therapy and cancer survivors coping with symptoms to improve their quality of life. Could you highlight what your research has shown as far as what works and how patients can best incorporate yoga into their everyday life?

Professor Fouladbakhsh: That is an excellent question. Although yoga has been around for thousands of years, we are at the beginning stages of studies with yoga and how it can help cancer patients. Study evidence has been accumulating and we have been fortunate to receive funds from the National Institutes of Health (NIH) on a yoga protocol, which is a program of classes for non-small cell lung cancer patients.

What we find with accumulating evidence, is that yoga can be recommended at this point for patients with some cancers. We can say that there is a moderate level of evidence for decreasing anxiety and improving mood and symptoms including post-treatment fatigue and improving quality of life and sleep. Most of that evidence applies to patients with breast cancer.

We did a preliminary lung cancer patient study and found changes in sleep and that overall, when we compared the effect of yoga and exercise, both improved sleep. 

We saw an improvement in breathing with yoga in lung cancer patients. We studied the effect of these physical interventions and if they could help with symptom management in this population of patients that has had surgery within the past year. We are also doing additional yoga therapy studies of specific protocols, to study how this could affect pain in breast cancer patients who suffer from a lot of pain during treatment and survivorship. We know that yoga can help with sleep, but are building these additional studies to see how yoga could help with pain and perceived control of pain in breast cancer patients.

Cancer Network: What about incorporating herbal supplements and vitamins? Are there good sources for how patients can do this? How their clinicians can help?  What are the important precautions to consider since there are many contraindications for certain supplements and vitamins with certain treatment regimens?

Professor Fouladbakhsh: On herbal supplements, botanicals, vitamins, and other kinds of products that we include as supplements, it gets tricky. There are literally thousands of products that some patients use and patients approach me often and say 'I've heard that this might be good for my fatigue as I am going through treatment or for managing my nausea.'

Patients want to try different things and what I have found in working with patients is that there are potential hazards and many times, just by word of mouth, they are searching for solutions to the problems they are experiencing in good faith.

But for many of these methods, we are lacking evidence. So, again, evidence needs to be built for complementary, integrative therapies. This is why we are moving towards guidelines based upon research that exists. A few key points for patients is one, speak to your physician. There is still debate for use of anti-oxidants for example, during chemotherapy and these are not recommended because chemotherapy is an oxidative process and anti-oxidants counter that but we don't have solid proof as far as where we go with that. The best advice is to talk to your physician, understand, and be sure what evidence based guidelines have been published.

We know that what came out with this Integrative Therapies During and After Breast Cancer Treatment ASCO Endorsement of the SIO Clinical Practice Guideline, the first to be endorsed by ASCO and SIO, is that there is not enough evidence of using soy for hot flashes, for example.

Patients can’t just stop what their doctor prescribed and take something else. Patients could be misguided and get into hazardous territory. Something like glutamine is not recommended, so as we pull the data together, the key as it is for many supplements, is that there have been no studies. So, we go forth with what evidence is available for a supplement to support what to recommend.

The importance thing is not to go with what is recommended by friends but to go to the literature, databases like Natural Standard that anyone can access, to find the level of evidence, whether A–I or 1–5, which ranks the current research literature. But the best thing to do is for patients to discuss this with their clinician and nurse practitioner, oncologist, and primary care provider before embarking on the use of any herbal supplements or vitamins.

Cancer Network: Lastly, you’ve worked on an integrative oncology nursing model for person-centered cancer patient care. Can you talk about what that means and how oncologists and oncology nurses can learn more about this and incorporate more holistic patient care into their practice?

Professor Fouladbakhsh: That is an excellent question. Integrative nursing compared with integrative oncology, is a newly-emerging model published just a few years ago in a book by Mary Jo Kreitzer and Mary Koithan in which we have a chapter. It is a model of clinically focused professional nursing practice based on the theoretical premise and principles of integrative healthcare to promote health and healing, to prevent illness, and to improve quality of life which is really what it is all about.

The model is based on the components that affect a person and where they are going, pulling evidence-based complementary therapies and joining them, for support, with conventional oncology care and treatments during survivorship. For example, to address symptoms of fatigue which can continue for a long time, or pain, especially joint pain, to increase quality of life.

At Oakland University, we are developing programs for nurses and nurse practitioners to understand how to and the scientific rationale and the evidence for putting these therapies together with conventional practice. We're giving confidence to nurse practitioners to recommend certain integrative therapies for pain to their patients.

We have also developed a program at Wayne State University on complementary therapies in healthcare so that we can look at how to research, how to study the evidence, find what works and what doesn’t, and how to integrate these within our nursing practice.

This means we could have a nurse practitioner write prescriptions for integrative therapies and actually, we just did that a few weeks ago. I am working with a program for the Integrative Oncology Scholars at the University of Michigan, an NIH-funded program, in which we are training and educating oncologists and nurses to become scholars in integrative medicine. This type of model will pull in the data and evidence that is necessary to support the use of complementary approaches to then guide patients correctly. The ultimate goal is to manage cancer patients’ symptoms and to improve their quality of life.

Cancer Network: Thank you so much professor Fouladbakhsh for joining us today.

Professor Fouladbakhsh: You are welcome, it’s been a pleasure. I appreciate the time to speak with you all.