Integrative Medicine: Attending to all aspects of health

Shelly Latte-Naor, MDDirector Mind Body MedicineAssistant Attending Physician Integrative Medicine Service July 14th, 2018

Ovarian Cancer National Conference 2018

Inhabiting our bodies

Inhabiting our bodies

Optimizing the Micro- and Macro-Environment

•  Awareness/ Mindfulness

•  Nutrition•  Exercise•  Stress management•  Proper sleep•  Circadian cycle•  Physical environment•  Joy and laughter•  Loving relationships•  Meanings and

spirituality

Wellness considers all aspects of our life

Wellness

Spiritual

Physical

Emo5onal Intellectual

Environmental

Outline

• Integrative Medicine at MSK• The Waiting Room: Recognizing Stress• Walk in the Garden: Breathing Stress away• The Bedroom: Sleep is a healer• The Kitchen: Food and wellbeing

•  Cancerpatientsareveryinterestedincomplementarytherapies.Whenusedproperly,theyimprovepatient’slifeandalsohelphealthcareproviders.

•  Alothashappenedinthelastdecadeintermofresearch.Iwillgiveasummaryofthestateofthescience.

•  Themainquestionisnolonger“doesitwork”,butmulti-dimentional:howitworks,forwhomitworks,andhowtoapplytheminclinicalpractice.Iwilluseexamplestoshowthat,esp.howitrelatestohospitaloperations.

•  Thebiggerpictureoftheroleintegrativemedicineplaysinenhancequalityofcancercare.Callforactions.

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Oscher Center UC San Francisco Univ of California Los Angeles Stanford Cancer Center Moffitt Cancer Center & Research Institute Jefferson University Hospital UPMC Center for Integrative Medicine Abbott Northwestern Hospital Northwestern Integrative Medicine St. Francis Hartford Huntsman Cancer Institute VSU Massey Cancer Center Rush University Medical Center University of Colorado University of Michigan Comp Cancer Care University of New Mexico Cancer Center

Memorial Sloan-Kettering Cancer Center MD Anderson Cancer Center Dana Farber Cancer Institute Columbia University Yale Cancer Center Abramson Cancer Center Duke Cancer Institute University of Wisconsin Chao Family Cancer Center UC Irvine University of Iowa Holden Comprehensive Cancer Center Masonic Cancer Center The University of Arizona Mayo Clinic Griffin Hospital

Integrative Medicine Programs in Major Medical Centers

Complementary Therapy Use

National Health Interview Survey 2007

Percent using complementary therapies, by age

PubMed Publications: 1980 to present

What’s In A Name? Integrative vs Alternative

Integra5ve Alterna5ve

Goodsafetyrecord Poten0allyrisky

Evidence-based Unsubstan0atedclaims

Rela0velyInexpensive O@enverycostly

Usedalongsideconven0onaltreatments;complementary

Promotedforuseinsteadofconven0onaltreatment

Focusedonsuppor0vecare Toutedascura0ve

Stress

Fear

Uncertainty

Stress is a making everything worse

Circadian Rhythm

Metabolism

Immune Response

Hormones and neurotransmitters involved in our response to stress influence

Chronic Stress

• Fight, Flight or Freeze

Chronic Stress

• Neuroendocrin changes

Chronic Stress

• Lasting changes

Can chronic stress cause cancer?

Stress impacts our lifestyle

•  Fast Food•  Lack of physical

activity•  Increased use of

drugs, alcohol, tobacco

• Social isolation

Effects of Stress on Cancer

G.N.Armaiz-Penaetal./Brain,Behavior,andImmunity30(2013)S19–S25

Can stress help cancer grow?

Chronic stress promotes tumor growth and angiogenesis in a mouse model of ovarian carcinoma

Red:endothelialcells Green:pericytes

Thaker et al., Nature Medicine, 12, 939 - 944 (2006)

Are you responding or are you reacting?

•  Aidspatientsinrelievinganxiety,stress,fatigueand

•  Aidswithgeneralmoodandsleepdisturbance

•  Improvesoverallqualityoflife

Ledesma et al., Psycho-Oncology 18: 571–579 (2009)

Mindfulness Based Stress Reduction (MBSR) may improve cancer patients' psychosocial adjustment to their disease

Favors Meditation

Mindfulness Meditation: Present-centered, nonjudgmental, awareness

Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. 47 trials with 3515 participants, JAMA Intern Med. 2014 Mar;174(3):357-68.

Mindfulness Meditation: Present-centered, nonjudgmental, awareness

• “Mindfulness meditation programs can reduce the negative dimensions of psychological stress”

•  Improvements in anxiety, depression, and pain with moderate evidence

Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. 47 trials with 3515 participants, JAMA Intern Med. 2014 Mar;174(3):357-68.

Neuro-imaging Studies of Meditation

Emotional detox on paper

Expressive writing can help with physical and emotional symptoms 277 patients with kidney cancer were

asked•  write about their deepest emotions and

thoughtsor •  write about the following four neutral

topics

Milbury et al., J Clin Oncol. 2014 Mar 1;32(7):663-70

Writing improved symptoms, fatigue and physical function

Guided Imagery

Improves putative anti-cancer immune-defense markers in- Breast cancer patients undergoing treatment- Prostate cancer pre-surgically

Eremin et al., Breast. 2009 Feb;18(1):17-25 Cohen et al., Psychosom Med. 2011 Apr;73(3):218-25

Guided Imagery

NK Cell cytotoxicitymeasured by chromium release essay: Measuring how well the immune system is destroying foreign cells Cohen et al., Psychosom Med. 2011 Apr;73(3):

218-25

Insomnia

Fatigue

Irritability Isolation

Stress Chasing Sleep

Sleep is a Powerful Healer

• Sleep deprivation results in poorer immune function

• Sleeping less then 7 hours is associated with a three time higher risk of developing a cold compared with > 8 hours of sleep

• Sleep durations of ≤5 hours per night are associated with a significantly increased risk of hypertension and heart disease

Gangwish et al., Hypertension. 2006; 47: 833-839, Cohen et al., Arch Intern Med. 2009;169(1):62-67

Cancer patients and survivors often struggle with sleep

• 25 to 59% of cancer patients have sleep disturbances

•  Increase daytime fatigue•  Impaired cognition• Negative consequences

on employment, relationships, quality of life

Howell et al., Annals of Oncology 25: 791–800, 2014

Sleep Hygiene

• Recommended

• Not single intervention

Exercise

• Likely beneficial • Inconclusive evidence

Mind Body

• Likely beneficial • Low quality evidence

Howell, Ann Onc, 2014

Sleep Hygiene: Cleaning up your sleep habits in 7 steps

• Mind the clock• Be active• Wind down• Dim the lights• Skip the coffee/ alcohol/ nicotin • Avoid naps• Relax

Howell et al., Annals of Oncology 25: 791–800, 2014Harsora et al., Am Fam Physician 279(2):125-130, 2009

Are you active enough?

Relax? …but how?

• Mindfulness meditation• Guided Imagery/ Visualization • Hypnotherapy and Self-hypnosis• Progressive Muscle Relaxation• Gentle Yoga• Expressive Writing• Massage• Acupuncture Howell et al., Annals of Oncology 25: 791–800, 2014 Black et al., JAMA Intern Med. ;175(4):494-501; 2015

How to choose natural supplements?

Filtering the information on nutritional supplements and herbal medicines can be difficult

Papaya Leaves

•  Touted for increasing platelet counts

•  No human studies

•  Evidence based one case report

Graviola or Paw Paw • In the laboratory: Leafs contain compounds that inhibit cancer cells in vitro and in animal models•  Inhibits P-glycoprotein - thus inf luence drug

metabolism•  Neurotoxicity has been reported

https://www.mskcc.org/cancer-care/integrative-medicine/herbs/graviola

Turmeric and Curcumin

• In the laboratory: inhibits tumor growth on cell culture and in animal models•  Possible clinical anti-cancer effect seen in pancreatic

cancer•  Curcumin inhibits cytochrome 3A4 enzyme

https://www.mskcc.org/cancer-care/integrative-medicine/herbs/turmeric

Vitamin D

• Deficiency is very prevalent in the US (~41%)

• May be protective against breast cancer, colorectal cancer, prostate cancer

• Check levels• Careful in case of

kidney disease

How to make self-care a habit?

Integrative Services

How Can Integrative Medicine Help? •  Acupuncture

–  Pain–  Hot flashes–  Dry Mouth–  Neuropathy–  Lymphedema–  Nausea & vomiting

•  Massage–  Postsurgical recovery–  Lymphedema–  Anxiety & stress–  Fatigue

•  Nutrition–  Supplement safety–  Weight loss/gain–  Digestive health

•  Exercise–  Weight loss/gain–  Dyspnea –  Muscle tightness–  Improve body image–  Fracture prevention

•  Mind Body–  Anxiety & stress–  Depression–  Fatigue–  Nausea

More Patient Benefits • Actively participating in one’s own care•  Learning tools to care for self• Receiving nurturing therapies that release

endorphins•  Feeling safe and cared for

We help patients feel empowered by helping them participate in their own recovery

Integrative Medicine Appointments

•  Meet with our doctors and leave with a plan•  Our door is open – We do not require referrals•  Bendheim Integrative Medicine Center

— 1429 First Avenue at East 74th Street— 646-888-0800

Thank You

Questions?