(Guest Lecture) October 2022 - It's Not Just About Myeloma

Okay, excellent. Oh, I'm so incredibly honored to be here today and I wish I could be with you. But I do have two daughters who are on their fall break and so we are at home staycationing and doing some camping. But I'm again so honored to be with you and to share a passion of mine, which is really integrative oncology. And so let's really jump into what do I mean by that and let's talk about some of the objectives that I hope that we can accomplish in our short time together today. And that is to really appreciate what is this emerging field of integrative oncology? What does that mean exactly? And I'd like to discover and to really investigate together what are these four pillars of health and wellness and how can the pillars and the lifestyle medicine contribution of those pillars contribute to your cancer care journey? I'd like to expand our awareness of the complementary modalities that are potentially out there to support you on your journey and to recognize the importance of spiritual care and very importantly, joy and gratitude on your journey. So let's jump in to what is the definition of integrative oncology? And this is an evidence-based form definition from the Society of Integrative Oncology. And it is a patient-centered, evidence-informed, we're still building our evidence, so it is not yet fully evidence-based, but evidence-informed field of cancer care that utilizes mind, body, practices, natural products, and lifestyle modifications along different traditions. And so it's really pulling in all of the wisdom from the different traditions around the world. And it's alongside conventional cancer treatments, and this is what I like to highlight, and this is what's different from complementary and alternative medicine and integrative medicine. It's really together, we're using our best kind of allopathic, precision-based medicine, you know, we're still recommending CAR-T or Bi-Specifix, really are the best of myeloma care, but alongside that, we can think about these integrative modalities, and that's integrative medicine. And it aims to optimize your health, quality of life, and clinical outcomes across the cancer care continuum. And what I'd like to say, and this is truly what I see as the power of integrative oncology, is it empowers you. It puts you in the driver's seat, finally, where you're not just having to show up for your doctor's appointments or your injections or your autologous stem cell transplant, but you now have something to do to focus on to really empower your journey and to affect your outcomes. And so these are the four pillars that I really go through in every patient that I have the opportunity to meet in integrative oncology clinic. We really go through these four pillars in depth, and we kind of expand them out and really talk about a personalized approach to each of these pillars. And so again, see if the central kind of core there is really that conventional medicine that anchors it all together, and everything else is kind of speckled around that. And so we'll start with the first pillar, and that's really care of the body. And when I talk about care of the body, of course it's conventional medicine, but just above that, it's really lifestyle. And I like to think of lifestyle as the backbone of integrative health, I have patients that will come in and see me and they'll have all of these supplements that they are taking. And then I say, okay, what are you eating? And they tell me, I had a triple macchiato, and I had some McDonald's yesterday. I'm like, oh, okay, let's back up a moment and let's start with the basics, the backbone of integrative health, and that's really nutrition and exercise. And that is based on really wanting to get at the heart of what's driving cancer and also symptoms. And it's really this inflammatory milieu that our Western diet and lifestyle really promotes. And so this is from Hallmarks of Cancer, which is really kind of the framework when we get new hemonk fellows, they're fresh from internal medicine and they're coming into hematology oncology training. We give them this paper and this is the Hallmarks of Cancer, what makes a cancer a cancer cell? And in that, it really talks about this tumor promoting inflammation and what causes inflammation. Let's kind of dissect that a moment. And it's really chronic infections, right? We can't really control infections, maybe we can a little bit on exposures, but obesity, smoking, alcohol consumption, environmental pollutants, high fat diets, these are all recognized as contributors to inflammation. And so our goal is to kind of take a step back and say, okay, if it's inflammation that's driving potentially cancer, my symptoms, my outcomes, other comorbidities, what can I do to intervene? What can I do to cool this inflammation that's going on? And I like to think about nutrition as really the first stepping stone towards that. And Hippocrates got it right, let food be by medicine and medicine be by food. And I love that. And I love this picture because it really, it shows the spectrum of color that's available within our foods, all of the fruits and vegetables. And so I often when I'm counseling patients, tell patients to eat the rainbow. And I say, that doesn't mean the skittles people it is eat the rainbow of fruits and vegetables. And that is because each of these colors have a color because they really represent a different phytonutrient. And they carry different vitamins, minerals, nutrients that are synergistic in this anti-inflammatory in a synergistic kind of way. And so I love to show this picture, encourage patients to eat all different kinds of fruits and vegetables and multiple different varieties to be changing up the variety seasonally. And again, that's trying to get at the heart of inflammation. And we're going to talk a little bit more about the Mediterranean diet, but inflammation can be cooled with diet. And we've seen that with a Mediterranean based diet. And we've seen that manifest and even in the bloodstream measuring markers of inflammation, such as CRP, interleukin six, tumor necrosis factor alpha, and other markers of inflammation. And so this is the one of the biggest trials ever done in a dietary intervention over 7,400 patients with high risk cardiovascular disease. This is a primary prevention trial. And they looked at those that are eating the highest quartiles of the Mediterranean diet. And you can see to the right, what is that include lots of anti-inflammatory foods, fruits, veggies, nuts, olive oil, fatty fish, and look at the bottom, not too much of those fried foods, sodas, refined carbs, processed meats. And so if you look at these survival curves, it's really incidents of cardiovascular endpoints, a major cardiovascular event or death. And those that were eating the highest quartiles of the good foods, of the Mediterranean foods, which you see in the green curve had a much lower incidence of this cardiovascular endpoints. Well, how does that translate into cancer? This is not a randomized controlled trial. So that is the disclaimer, but they did do a sub analysis looking at incidents in this trial. And those that again, were eating highest quartiles of Mediterranean diet, plus extra virgin olive oil rather than nuts, which I didn't mention in the trial trial, but it really is the olive oil really is a potent anti-inflammatory. But here you can see that the incidence of breast cancer was much lower with this kind of dietary strategy. In myeloma, we don't have a randomized controlled phase three trial yet. I think that will come, but this was a really interesting study looking at a pre diagnosis dietary pattern and survival in patients with myeloma. So there's 423 multiple myeloma patients and they looked at what kind of foods were they eating? And they did food questionnaires. And then they looked at their myeloma specific mortality and it was significantly lower with the healthier dietary patterns, 15 to 24%. So when we're thinking about diet, some patients will say, well, there's not enough evidence. And I say, well, that's probably true. We don't have our big, strong, randomized phase three interventional Mediterranean diet yet, but what is the risk? What are we risking with undertaking a Mediterranean based diet? We see from large cardiovascular studies that it's modulating inflammation and we know inflammation drives symptoms and cancer. So why not? Right? Why not? And so I definitely recommend a Mediterranean diet. And this is the Center of Integrative Medicine at the Andrew Weil Center at the University of Arizona. They're anti-inflammatory diet food pyramid. And there's a few tweaks within here, which I think are really interesting in that there's highlighting a few components. So it's basically Mediterranean, but they're really highlighting cruciferous family. And so lots of cruciferous vegetables. And why is that? Well, we know that cruciferous vegetables have something called sephorophane. And sephorophane is a very potent antioxidant protein activator. And so we're actually studying this here at the University of Arizona as a chemopreventative in head and neck cancer. And so, you know, maybe a half cup to a cup per day of the crucifers. And when I say that, that's broccoli, cauliflower, bok choy, kale, brussels sprouts, anything that's kind of in this floret. Lots of berries, tons of flavonoids in berries, antioxidants in berries, but very low sugar content. Healthy fats, certainly the extra virgin olive oil. I like to highlight lots of omega threes. Omega threes most potently are in fatty fish, however, can also be obtained within fat sources such as chia, hemp, walnuts, ground flaxseed, which I encourage patients to use. Whole soy foods in my alone are less of a controversial issue for endocrine positive tumors, such as breast cancer, prostate cancer. There's some controversy out there, but in general, large observational studies actually say that there's a lower incidence with the consumption of whole soy foods. And so things like soy milk, tofu, tempeh, edamame certainly can be consumed as a part of a healthy diet. Asian mushrooms are really interesting. They have something in their cell wall called beta D-glucan, which actually is a potent stimulus for the immune system. And a potent stimulus for the tumor response. And so there's many supplements out there. Some patients choose to take supplements. I am a food as medicine person, so I love the idea of just consuming this mushroom. Things like shiitake, maitake, oyster mushrooms potentially can give you this benefit with low risk. Plentiful herbs and spices, particularly turmeric, cinnamon, ginger, garlic. If a hormone positive tumor rosemary can be consumed with good medicinal benefit. Green tea, EGCG. This is another controversial issue because there is that lovely blood paper that looked at their interaction with bortezomib and green tea. If you do the math though, that poor mouse would have consumed 100 cups of green tea that day. And so whether that really translates into something, an interaction that occurs within a human, I am not convinced of. And so I think, you know, in moderation, green tea can be consumed as a part of a healthy diet. I could probably spend our whole time talking about nutrition. So let's move on because I love nutrition and I love recipes, but let's move on to physical activity. So I like to share this study. This is a systematic review and meta-analysis looking at many different physical activity, interventions and mortality in breast and colorectal cancer because that's where we have the most data. This is a forest plot and this is the relative risk of cancer specific mortality. And you can see everything is falling on the left of that forest plot saying reduction of that risk. And so it really, independent of what the intervention was looking at, and these cancer survivors thought their mortality actually was lower with an exercise intervention. Not only cancer specific mortality, but also all cause for mortality. And so again, when we're talking about interventions, we're weighing risks and we're weighing benefits in any therapeutic, whether that be a new bi-specific or it is a integrative oncology intervention. And when it comes to diet and when it comes to exercise, undertaking meta-training and diet and an exercise program, which is safe and monitored and really intuitive for the patient, right? You don't want to overdo, you want to listen to your body, you want to talk to your doctor, but something to enhance movement there's very low risk and potential benefit. Here is a study in multiple myeloma. So physical activity is associated with less comorbidity, better treatment tolerance and improved response in patients with myeloma undergoing autologous stem cell transplant. And so they defined 150 minutes and some strength training and they found that there was improvement of the tea treatment, tolerance, decreased hospital stay, and even overall and progression free survival. This was actually a retrospective analysis. So we need an actual study looking at more physical activity interventions, which is true in all of the hematologic diseases, not only multiple myeloma. I have an ongoing Tai Chi trial for myeloma for patients undergoing autologous stem cell transplant. And we're actually looking at markers of the immune system being modulated within that trial. So what are the recommendations? I recommend that again, physical activity be undertaken in an intuitive and communicative way. Talk with your doctor, talk with your team, get a buddy, try to figure out what it is that makes you joyful when you're moving. How can you make it as fun as possible? And listen to your body and try to, if possible, incorporate cardiovascular strength and flexibility. And I love meditative movements such as yoga, Qigong or Tai Chi, because that is engaging the mind and decreasing stress at the same time. So we've already, we spent the bulk of our time in the body and I'm going to try to tie in the mind, joy and meaning and complimentary therapies as well. Stress triggers inflammation. Going back to that idea, we need to cool inflammation and how do we do that? And we know that our mind and stress is a potent, potent stimulus for inflammation in our body. The fear response, the stress response releases cortisol epinephrine, norepinephrine, which goes into the bloodstream and it actually modifies the tumor microenvironment. And so what happens is we know that there is more blood vessels around the tumor microenvironment. There's less migration of our immune cells. There's more migration of cancer cells. If there's viral replication, there's enhanced viral replication. And so stress truly manifests in a very physiologic way in the body and in specific the tumor microenvironment. And so anti-stress medicine is good medicine. And the first key is to recognize it, right? And we all hold more stress than we give ourselves credit for, or maybe not credit. We all have more stress that we need to release. And so I encourage you all to, however the mechanism works for you, whether it's a smartphone or in stickies throughout the house, to say, wait, take a moment. Where am I in this moment? Am I in a stress response or am I in a relaxation response? And if you find yourself in a stress response, if you're hunched over, your palms are sweaty, you're tense, you're planning, planning, planning or ruminating and not in the present moment, then take a moment, step back, do some deep breathing. I love to teach force. And we don't have time today to talk about that, but essentially it's as intuitive as it sounds. You breathe in for the count of four, you hold that for the count of seven and you breathe out for the count of eight. You do that for cycles. That's a YouTube video as well if you want to see Dr. Andrew Wilde doing that on his couch with his dog. It's quite friendly. And I recommend patients start that at the beginning of the day and the end of the day because it is like a muscle. It gets stronger the more you use it. And so when you most need it in that stress response, it's a sharpen tool. So I also recommend tons of different modalities to engage in growth work or meditation. There's calm, headspace, insight timer, all of these applications that are out there. Mindfulness based stress reduction programs that are out there. Probably the most evidence based mind-body intervention form to date is mindfulness based stress reduction. What about spiritual care? And we know that those that are engaging in something that connects them outside of themselves, whether that be nature, spirituality, religion, do better. Do better with their chemotherapy, with their treatment tolerance, have lower rates of alcohol and drug abuse, lower rates of depression, anxiety. And so really focusing in on what it is that you're connecting to and having that relationship every day is also powerful medicine. So I recommend a 10 minute intervention in that domain. And then joy. Joy is probably the most fun pillar and it's overlooked. And joy really has the capacity to transform our experience and our lives and focusing on what brings us gratitude and happiness every day makes it more accessible as you're moving forward to claim it in the moment. So I tell patients to do a joy practice where they name something joyful, they do it, and then they reflect back and say, oh, that was really rich and beautiful and wonderful. So once per day, enjoy practice. And then a gratitude exercise, whether that be a gratitude journal, a gratitude practice in the morning before getting up, or there's an app out there called Three Good Things. And that's been correlated to higher happiness scores. So really having this practice of gratitude is potent medicine and is evidence-based medicine. So that's really body, mind, joy, meaning, kind of done at the speed of light. And here's a ton of complementary care modalities. And we certainly don't have time to jump into all of these, but I would say acupuncture is probably my go-to. I personally do acupuncture. I refer almost all my patients for a trial of it. It's good for fatigue, neuropathy, psychosocial issues, depression. And so I find it very helpful. Botanicals is usually a big topic of discussion. And I will refer you to Memorial Sloan Kettering website about herbs, as well as the Natural Medicines Database, where you can get evidence-based information about all botanicals. But I think that the biggest key is communication. You want to be talking to their team about what are the botanicals you're taking, if you're taking them, and if they're safe. And we did an integrative medicine survey with the help of Health Tree. Thank you so much, which hopefully will be published soon. It's under review. But notice how many patients were actually undertaking some sort of supplements. 50% of those surveyed, and this 178 patients that were surveyed were taking curcumin. And a significant portion were not disclosing that to their providers. So again, underscores the need for communication within the population. So to end our talk today is really to eat intentionally, eat beautifully with lots of colorful foods, lots of omega-3 fatty acids, to move often, to breathe, manage stress, sleep well, cultivate joy, and be open to new and innovative modalities for healing. So thank you so much for your kind, kind attention. That's my email. If you want to get a hold of me and ask me any questions, you're welcome to. And again, thank you so much to the organizers for inviting me. It's really an honor.