But, argued Dr Block, “while RCTs are valuable, they are by no means the only source for clinically actionable evidence.”

“The survival data speak for themselves,” Dr Block noted. “If you are going to be evidence based, our results7 represent the best available evidence to date. If a drug demonstrated a doubling in survival for advanced metastatic breast cancer patients, it would make international news. But a comprehensive, systematic, integrative and patient-tailored treatment protocol gets ignored.”

Dr Block suggested his preliminary observations could be used to determine and design future research. But Dr Abrams pointed out that it is difficult to secure grant funding for these types of nonreductionist approaches. “It is very hard to evaluate the whole intervention; the intervention is greater than the sum of the parts,” he added, and noted that he typically refers to epidemiological data as evidence-informed information.

Similarly, Dr Cohen said his team might proceed with evidence-informed data if the intervention has a high safety profile, and trying it would be in the patient’s best interest. “Getting someone to exercise is not associated with a lot of risk, other than sore muscles, compared to giving someone an unproven supplement that could result in death.”

Dr Cohen is currently conducting the follow-up stages of an RCT in breast cancer that is examining whether a comprehensive lifestyle change program for patients undergoing radiation will influence recurrence of disease, time to progression, or patient quality of life. This research will likely provide a much-needed bolster to the primarily anecdotal evidence that exists. “We hope to publish my papers from the database this year,” he said.

There are, however, evidence-based findings in lifestyle interventions and non-Western therapies supporting an integrative approach. A research group showed in a RCT that patients with early-stage prostate cancer who changed their diet and lifestyle could greatly slow down disease progression and delay the need for surgery.8

Recently, Dr Cohen and colleagues published the first randomized, placebo-controlled, phase 3 trial of 339 patients with head and neck cancer that demonstrated that true acupuncture resulted in fewer patients experiencing clinically significant (P =.009) xerostomia, or dry mouth, 1 year after radiation therapy ended compared with sham acupuncture or a standard-of-care control.9 The use of acupuncture in oncology is listed in the National Comprehensive Cancer Network (NCCN) guidelines for pain and nausea, and other integrative medicine strategies are part of this authoritative body of standard cancer treatments for other areas of symptom management.

Economic Considerations

At the Block Center, costs for conventional treatment such as chemotherapy, physician visits, blood draws, and visits with biobehavioral counselors are the same as at any medical center, like MD Anderson, for patients with Medicare, and with most insurance plans. Dietitian consultations, supplements, and nutrient infusions are generally not covered by insurance.

At the Osher Center, consultation is covered by insurance, but not necessarily acupuncture or massage. Insurance companies are not obligated to reimburse for nonconventional methods of treatment, and are not reimbursed at the same scale as pharmacological or surgical interventions. But that may begin to change, provided patients can report a benefit from these types of interventions. For example, more insurance companies are beginning to cover acupuncture, although not for indications in cancer. In fact, the Centers for Medicare and Medicaid Services (CMS) proposed to cover acupuncture for patients with Medicare who have chronic low back pain.10 As Dr Cohen noted, “insurance companies are seeing that using nonpharmacological and nonsurgical approaches to many of society’s chronic illnesses is not only cost-effective, but a huge value gained [in quality of life] for patients.”

The Future of Integrative Oncology

The American Society of Clinical Oncology’s (ASCO’s) endorsement in 2018 of the Society for Integrative Oncology (SIO) Clinical Practice guidelines in breast cancer is an important step for integrative oncology.11 To make significant progress, however, it is likely that the NCI and National Institutes of Health may need to fund integrative oncology research and make the delivery of integrative treatments part of routine practice.

References

  1. National Cancer Institute. Cancer statistics. Updated April 27, 2018. Accessed January 26, 2020.
  2. American Institute for Cancer Research. Take control of your cancer risk: Nearly fifty percent of common cancers are preventable. Published February 1, 2018. Accessed January 26, 2020.
  3. Witt CM, Balneaves LG, Cardoso MJ, et al.; A comprehensive definition for integrative oncology. J Natl Cancer Inst Monogr. 2017;52:3-8. doi: 10.1093/jncimonographs/lgx012
  4. Ambrosone CB, Zirpoli GR, Hutson AD, et al. Dietary supplement use during chemotherapy and survival outcomes of patients with breast cancer enrolled in a cooperative group clinical trial (SWOG S0221) [published online December 19, 2019]. J Clin Oncol. doi: 10.1200/JCO.19.01203
  5. National Cancer Institute. NCI-designated cancer centers. Updated June 24, 2019. Accessed January 26, 2020.
  6. Block KI. Life Over Cancer. New York, NY: Bantam Books; 2009.
  7. Block KI, Gyllenhaal C, Tripathy D, et al. Survival impact of integrative cancer care in advanced metastatic breast cancer. Breast J. 2009;15(4):357-366.
  8. Abrams DI. An integrative approach to prostate cancer. J Altern Complement Med. 2018;24(9-10):872-880.
  9. Garcia MK, Meng Z, Rosenthal DI, et al. Effect of true and sham acupuncture on radiation-induced xerostomia among patients with head and neck cancer: a randomized clinical trial. JAMA Netw Open. 2019;2(12):e1916910.
  10. Centers for Medicare and Medicaid Services. Decision memo for acupuncture for chronic low back pain (CAG-00452N). Published January 21, 2020. Accessed January 26, 2020.
  11. Society for Integrative Oncology (SIO). ASCO endorses SIO breast cancer guideline [press release]. Accessed January 26, 2020.