Donald I. Abrams, MD, Chief of Hematology-Oncology at San Francisco General Hospital and Integrative Oncologist at the University of California, San Francisco, Osher Center for Integrative Medicine, has been investigating and incorporating integrative medicine approaches in his clinical treatment of diseases like HIV/AIDS and cancer for nearly 3 decades.
For example, while assembling information for a study of cannabis to combat AIDS-wasting syndrome in patients with HIV/AIDS, he became convinced of the medicinal potential of marijuana in relieving the side effects of conventional cancer therapy, including anorexia, nausea, vomiting, pain, and insomnia. (The use of medicinal marijuana is currently legal in 17 states, including California, and in the District of Columbia, although it remains illegal under federal law. Seven more states have pending legislation to legalize medical cannabis.)
In 2004, Dr. Abrams completed a 2-year distance-learning fellowship in Integrative Medicine from the University of Arizona and today enlists a variety of complementary therapies in his clinical practice. Among the tools and approaches he employs are nutrition, physical activity, supplements including cannabis, acupuncture, and stress-relieving methods like massage, meditation, guided imagery, and yoga.
Dr. Abrams is Past President of the Society for Integrative Oncology and is currently a member of the NCI’s PDQ Cancer Complementary and Alternative Medicine (CAM) Editorial Board. Like other integrative medicine specialists, Dr. Abrams objects to the acronym CAM and the confusion it causes for patients, since “alternative” medicine refers to treatments used in place of conventional cancer therapy, whereas “complementary” therapies are used in conjunction with conventional care.
The ASCO Post spoke with Dr. Abrams about the benefits of integrative medicine in the treatment of cancer and how the practice is slowly gaining legitimacy and greater acceptance in the field of oncology.
Foundations of Integrative Medicine
What is the definition of integrative medicine and how is the practice used in oncology?
Integrative medicine refers to more than just complementary therapies to chemotherapy, radiation therapy, and surgery. The Consortium of Academic Health Centers for Integrative Medicine defines integrative medicine as the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, health-care professionals, and disciplines to achieve optimal health and healing.
I like to say that at San Francisco General Hospital I treat cancer using conventional therapies, and at the Osher Center for Integrative Medicine I treat people living with cancer with an array of complementary interventions.
I always start my consultations by asking patients to tell me their story, so I understand how their cancer diagnosis and treatment have impacted their lives.
Clinical Focus
Are patients coming to you because they are having side effects from their treatment and are looking for some relief?
Not exclusively. I see people who are undergoing acute treatment and want to prevent or ameliorate side effects, but I also see survivors who want to know how to handle long-term side effects of treatment and, more importantly, how to reduce their risk of recurrence and prolong their survival.
My main areas of focus are lifestyle choices, especially diet and the importance of eating nutritious foods and physical activity. The World Cancer Research Fund/American Institute for Cancer Research has affirmed that preventable malignancies are caused as often by obesity, poor nutrition, and lack of physical exercise as by tobacco use. Recently, the American Cancer Society updated its lifestyle recommendations based on evidence showing a correlation between obesity, high caloric intake, and lack of physical activity and cancer incidence/recurrence. Clearly, we are in the midst of an obesity epidemic in this country, so at the beginning of my consultation I talk about nutrition and advise patients to consume—as much as possible—an organic, plant-based, antioxidant-rich, anti-inflammatory whole foods diet.
Then I talk about physical activity. Regular physical activity is something that can decrease the risk of cancer. Increasing evidence shows the benefits of exercise on reducing cancer recurrence as well.
The final topic I discuss is stress reduction through different modalities, such as massage, meditation, and yoga.
Patient Empowerment
How else is integrative medicine important in cancer care?
It empowers the patient. When people get a diagnosis of cancer, their internal locus of control is removed. Now they are at the mercy of their surgeon, their radiation oncologist, their medical oncologist, their nurse, and often a seemingly uncaring health-care system.
My goal is to return some sense of control to patients by giving them things during their treatment or in their survivorship that they can do themselves. They can eat better, they can be physically active, they can take judicious supplements, and they can learn how to cope with and manage their stress.
Increasing Evidence of Efficacy
How much scientific evidence is there that complementary medicine enhances conventional cancer care?
There is an increasing amount of data from controlled clinical trials supporting the use of complementary interventions, especially in symptom management. For example, studies suggest that acupuncture is useful for chemotherapy-induced nausea and vomiting, as well as in reducing hot flashes in both men and women taking hormonal therapy and may relieve xerostomia in patients undergoing radiation for head and neck cancer.
My patients who are getting acupuncture while undergoing conventional chemotherapy or radiation therapy seem to have an easier time coping with symptoms than my patients who aren’t getting acupuncture. Can I prove that my integrative intervention is better than conventional care alone? That is difficult to do.
As an oncologist, when I prescribe a specific chemotherapy agent to a patient, I can cite the evidence showing risk and benefit. But I can’t show scientific proof of the health benefits of getting a massage once or twice a month or of eating more blueberries and broccoli. How do I do a placebo-controlled, randomized trial to study the effects of broccoli and blueberries or even physical activity in cancer care? Some of these strategies are just not amenable to our gold standard modality of investigation: the randomized double-blind, placebo-controlled trial that evidenced-based medicine requires.
Marijuana as Medicine
How effective is medicinal marijuana in the treatment of people with cancer?
Medical cannabis has been legal in California since 1996, and I have conducted clinical trials using cannabis in patients with HIV/AIDS and in patients with chronic pain. I’m also an editor of the NCI’s website on Cannabis and Cannabinoids (cancer.gov/cancertopics/pdq/cam/cannabis/healthprofessional), which outlines information available on the use of cannabis in symptom management. In addition to clinical trials, an increasing body of evidence from in vitro studies and animal models suggests that cannabinoids might have direct anticancer activity.
I believe that cannabis is a medicine and that this medicine has significant utility in addressing a number of concerns of patients with cancer, including nausea related to chemotherapy, anorexia, pain, insomnia, and depression. Those are five common side effects from cancer and its treatments, and instead of writing prescriptions for five drugs that may all interact with each other or with the chemotherapy that my patient is receiving, I can recommend one medicine that won’t adversely interfere with my patient’s cancer treatment.
Incorporating Integrative Care
Are you seeing an increase in the number of oncologists incorporating integrative medicine into their practices?
A number of my colleagues at the UCSF Helen Diller Comprehensive Cancer Center have worked with me over the years and have learned some of my methods. They can answer their patients’ questions and make recommendations regarding integrative care. But the reality is, if oncologists have only 20 minutes during an office visit to examine their patients, hear how they are doing on their chemotherapy regimen, and discuss plans for the next phase of treatment, it’s a lot to ask that they also talk to patients about their diet or which supplements they take, or whether they are practicing yoga for stress reduction. Moreover, many conventional organ-based oncologists might not have the knowledge to do that, so the default reflex is to say to patients, “Don’t take any supplements” or “Eat whatever you want; it doesn’t matter.”
Mainstreaming Integrative Oncology
What has to happen to increase the inclusion of complementary modalities in traditional cancer care? What standards have to be met?
The field of integrative oncology is not as mainstreamed as we want it to be. I conducted a workshop at the Ninth International Conference of the Society for Integrative Oncology (SIO) in October on Integrative Oncology Education for the Physician, to begin the dialogue to establish better guidelines for recognizing and accrediting physicians who want to practice integrative oncology.
In the meantime, the SIO has published clinical practice guidelines for conventional oncologists interested in increasing their knowledge base of this promising field (integrativeonc.org/sio-publishes-2009-practice-guidelines). ■
Disclosure: Dr. Abrams reported no potential conflicts of interest.
