(Guest Lecture) November 2022 - Integrative Medicine: Ideas for Myeloma Treatment

Good afternoon and thank you to Greg and Heltry and well as well to Dr. Krishnan for inviting me. It's great to be here. I want to talk about something a little bit different than probably your usual multiple myeloma toxin and thinking about a little bit out of the box which is something we call integrative medicine and how that might really help you as a patient. Is it okay if I walk around? Okay. Let me run up there and then I'm just going to walk around a little bit. We'll try to do some audience participation here if that's all right. You probably weren't prepared for any quizzes or questions right? Okay, can you hear me okay? Great. A little bit closer. Okay, can you hear me okay? All right. So no disclosures, not going to be selling any supplements or products. Dr. Lee's cure all. So the outline is really talking about integrative medicine and oftentimes we use the terms integrative complementary alternatives and we'll talk about what that all means and then in the second half of the talk we'll talk about specifically areas such as pain, stress, sleep and how we can find other ways to help you other than say maybe another prescription. Okay, we'll talk about the evidence. So when I tell people I do integrative medicine I think I got a lot of funny looks like what is this guy doing and I get a lot of things from my patients for consults. So people bring me books and you know you're hiding the cure for cancer and these kind of things and so it's a wide variety of things that happen out there in the field and Barry Castellith who created the integrative medicine program at Moral Stone Kettering she used to say there's a lot of quackery happening in the field. So then I would say yes unfortunately there is some quackery out there so it smells like a duck and quacks like a duck be careful. Okay. Well Frank got us started to get a funny feeling that his doctor was a quack. So what is the difference? Who's heard about integrative medicine? Most people some people have some people haven't. What do you think about integrative medicine versus alternative medicine versus complementary medicine? What does that mean to you? You can just shout it out. Everybody? All the same to you or? Okay so more directed by a physician and thinking about the whole body the holistic approach. Anyone else? Just yell it out. It's okay. Don't be shy. Yes that's a good question. So let's talk about that. So when I think about alternative exactly right so I do have patients who say well I'm a GI medical oncologist and they'll say I'm going to try to do acupuncture and treat my cancer. So okay that's that's alternative that's out of the box but there are people you know I know people who've done this. I'm going to try that and then there's some people who say well I'm going to you know I'm going to get chemotherapy get a stem cell transplant and I'm going to try acupuncture to cure my cancer. I would say well that's like a complementary structure kind of a little bit of everything but integrative is really kind of what someone mentioned earlier is really thinking more carefully and deliberately about these different approaches. So if someone said I'm you know myeloma I'm going to get treatment chemotherapy go through stem cell transplant and I'm going to use acupuncture as a way to help manage my nausea. I would say that's an integrative approach and because there's actually data there has been randomized controlled trial showing that acupuncture can improve nausea symptoms. So that that to me is an integrative approach is really think about acupuncture and what is it useful for based on the science that's out there as part of your treatment plan. So that's really you know thinking about it together with conventional medicine is it personalized as in space and is it safe for that individual patient. Now there there is the NCCIH National Center for Complementary Integrative Health which is part of NIH. It actually started in the 1990s 91 it was Office of Alternative Medicine. It was a new field no one knew what to call it. Then later on they renamed it as the National Center for Complementary Alternative Medicine NCAM and then more recently they changed it to Complementary Integrative Health because the terminology is really changing. We want to get away from alternative approaches and really move more towards complementary integrative approaches overall. So they define as health care approaches that have been developed outside of modern or western medicine. So it's a very broad definition. It can include things from Arabic medicine and Chinese medicine Native American approaches as well. So if you look at the NCCIH categories there's a variety of different categories that we think about one being natural products or supplements that you see at your grocery store or vitamin store. Mind body interventions things like meditation. Then you have body based so kind of massage therapy osteopathic manipulation and then they kind of have this other which is your catch all. But this is where you might see these kind of entire medical systems like traditional Chinese medicine or Arabic medicine. Also energy therapies would be included in there as well. So there is a consortium of academic centers for integrative medicine and health and it really talks about what is the definition of integrative medicine. One reaffirms the relationship between the patient and the provider. Two really should be the whole person care holistic care. And I think the third and fourth are really what differentiated. It has to be informed by evidence. There has to be some data to indicate why we're maybe recommending a therapy. And then utilizing all appropriate therapeutic options. So acupuncture is not good for everybody. Just like mind body medicine might not be the right approach for everyone. So really think about that person and personalized approach to achieve optimal health and healing. So I like this definition by the consortium. It includes over 50 academic centers including Harvard, Mayo Clinic, Duke, other organizations. So when I think about the whole picture and you have the patient, you have the cancer and you have the two sides of the coin, the yin yang. And then you have all your traditional therapies. Surgery, chemotherapy, radiation. Of course, stem cell transplant, immunotherapy, as Dr. Krishna was talking about. And then we also want to support the patient through the whole journey. So thinking about key dimensions, your physical, psychological, spiritual and social dimensions. And what are all the pieces of the puzzle that we need to put together to really have a comprehensive holistic approach to your cancer care? And so what does that look like? So on the physical dimension, you're going to hear about physical therapy from Dr. Chang, but palliative care, nutrition, exercise, psychiatrists, psychologists, chaplains. And then, of course, we have to support you things like health coaches that we heard about earlier, health tree organizations, support groups, education navigators. These are all important part of your entire treatment plan. How do we get you through from diagnosis through survivorship and really integrated medicine is like another piece of the puzzle. It's another part of your toolkit to think about how how else can I have a more comprehensive, complete treatment plan? Now, what's happening in the United States? If we look at the CDC most recent data, people are using natural products, one, what is that one in six, one in seven or so deep breathing techniques, mind, body techniques, meditation, massage, special diets, acupuncture. So this is just adults in the general population in the past 12 months. Now, actually, I did the survey when I was in Cleveland, where I came from before coming here. We're looking at patients level of interest in different therapies. And you can see massage is one of the most interesting, has the highest level of interest among patients. So over 50 percent of patients are interested in that. But there's also interest in meditation, acupuncture, music therapy, yoga therapy. What's interesting to me, we also ask, well, what if your physician recommended it? You can see in the red bar, actually, the interest goes up quite a bit. And then we also said, well, what was it? Well, what would your interest level be? We ran a clinical trial and interest level also goes up. So we just wanted to get a sense of how do people think about it in different scenarios. So this is the kind of model I've been using most recently in my own clinic when I see patients for integrative oncology consultation. And so you have the patient in the center, the family, their culture. Then we have all the important therapies that we're providing. This is an integrative approach, not an alternative approach. And then we want to surround that with all the supportive and integrative therapies that are really important to get that patient, your family through the whole process. And we also want to help support the clinicians. We want to help support Dr. Christian and what she's doing as well. And then there are specific integrative therapies in each domain. We talk about integrative medicine, acupuncture, massage, music and art therapy in the psychological domain, healing spaces. So we have a garden in the back of the new Orange County Lennar Foundation Cancer Center, also at Duarte has very beautiful gardens. So all these are really important. If you've come visit the Lennar Foundation Cancer Center, you'll see it's very intentional in terms of how it looks and how it feels. It doesn't feel like a typical cancer. And I'm sure some of you have probably visited, right? It doesn't it doesn't feel like, you know, if it wasn't a sign out, so you may not even know that it's a cancer center. And that was intentional. We really want the environment to be very different. We didn't want that sterile kind of non-healing environment. So what are some differences between integrative medicine, similarities and differences between integrative medicine and supportive care? But they're both about holistic care, focused on your quality of life, symptom management. But integrative medicine also thinks about your overall health and well-being. So really more importance on nutrition and exercise, lifestyle medicine, optimizing kind of the whole person and then thinking about integrative therapies as appropriate when they have evidence base for symptom management. All right, so this is a small group, so if you have questions, feel free to stop me. I know we're going to do some question and answer at the end as well. So so when I see patients, these are probably the most common reasons I see patients in clinic. One, patients are interested in an integrative or holistic approach to their cancer care. So we do a lot focusing on things like lifestyle medicine. I have patients who are kind of interested, you know, when I imagine when you get diagnosed, you know, your your neighbor, your cousin, does everyone telling you, hey, you got to do this, you got to do this. And so they come with a list of questions and things they've been sent. And so I kind of go through that list and say, hey, does this make sense? You know, they might have seen Dr. And he recommended another supplement. So they're like, do I take this to? And so we kind of go through all those lists. And then I have patients who have a lot of chronic symptoms, who are already on high dose opioids, who may not want they're already getting sleepy or constipated. You want something that's non prescription to help them with their symptoms like pain. And then I do see patients who, for a variety of reasons, they may be going to Mexico or seen an alternative clinic and they want some guidance. And I think our traditional approach has been if patients were kind of choosing alternative therapies and said, well, good luck and we'll see you later. So what I try to do is talk to them and guide them. We we don't always see eye to eye. And that's that's their choice. But at least I follow along with them. So if they go to Tijuana, Mexico, want to do alternative therapies, I don't I don't close the door. I say, hey, let's keep in touch every three months. Let's see what's happening. In my experience over the past 10 years, unfortunately, ninety nine percent of these patients come back in worse condition. But we want to catch them early. We don't want to catch them when it's too late before an emergency happens. So we say, hey, what's happening? Is it working? It's not working. Hey, let's let's talk again. And maybe it's worth another opinion with Dr. Christian or your physician about is that alternative therapy really the right approach? So we try to help keep in touch with people and provide a way back if things aren't going well. Monitor them. You'd be surprised how many of these alternative clinics don't check basic labs. They don't get CT scans. I'll see patients and they'll say, well, when's the last time they checked your kidney function, your liver, no, they haven't checked it. And so it's surprising what some of these clinics might do. So I just want to spend one slide on the real importance of lifestyle medicine. And sometimes patients will jump to herbs and supplements before they really focus on what they're doing on a day to day basis. And so I really emphasize the American Cancer Society guidelines on survivorship around nutrition and exercise, really keeping yourself healthy. That's really the foundation of an integrative approach. So for a lot of patients, I'm focusing on this area. I remember I had one patient one time, I feel what kind of cancer she had, but she was smoking and she said, Dr. Lee, I need a supplement to negate the effects of smoking. I was like, I'm sorry, that's a tall order. And maybe you should just stop smoking. But she's like, I love it. I know. But you know, you have cancer. And so, you know, we have to be realistic. But I focus on this because it's so important. But I think people often forget that their own health is really a foundation from which you can go from. Right. So keeping that in mind. Now, this just came out like a couple of months ago, the Society for Integrative Oncology with the American Society for Clinical Oncology, will put out guidelines for integrative medicine and pain. So and it's out there available. It's free access for all of you where we really looked at the evidence. I was part of this panel over it took us about a year, year and a half, actually, to look at through all the data and look at the research in terms of how can we help pain among cancer patients with integrative therapies. And so these were the six major findings for which there was a moderate level of evidence to say this is worthwhile to think about. So acupuncture for patients experiencing what we call rheumatidase, I'll throw out just so there's some certain medicines of breast cancer that cause a lot of joint aches. And so acupuncture was shown to be helpful. Those also experiencing general pain or musculoskeletal pain would benefit from acupuncture. Surprisingly, reflexology and acupressure can also be offered for patients who are experiencing pain during treatment. So if your platelet count is too low or you don't like needles, you can still get reflexology or you could get acupressure. It doesn't mean you can't use those therapies. There's data around massage can be offered for patients or breast cancer also generally through symptom management. And then hypnosis has also been shown to be helpful for patients undergoing procedures like biopsy. OK, we can really do and I'll talk about some of the data in a little bit here. OK, how are you doing on time? OK, OK, I just want to make sure we're on time. So this is a recent study published in JAMA Oncology. This is from Ju Mao's group at Memorial Sloan Kettering where he had a large randomized trial looking at electrical acupuncture versus auricular acupuncture versus routine care. And what you can see here, those blue and kind of the dark blue lines did much better than usual care in terms of their musculoskeletal pain. So, again, showing the data that there is real evidence that these acupuncture type therapies can be quite helpful and you don't have to rely on more medicines necessarily. And actually, you know, it has, you know, the effect last beyond just the treatment. So I think they have like 12 or 16 weeks and they still had benefit at 24 weeks. This is another one where they just use ear acupuncture. So I don't know. Anyone here uses acupuncture? A couple of people. Have you had ear acupuncture as well? Yeah, OK. So if you don't want the needles in your body, you can just put little seeds or little beads in your ear as ear acupuncture. And in this study, what you see on the left hand side is real ear acupuncture. And then in the two right columns, let me see here, you can see here, this is actually placebo. So they kind of put it in fake points or they, you know, these are placebo points. So compared to the real acupuncture, you can see the score went down from the mid fifties to mid thirties versus in the fake acupuncture. It was still in the fifties. Just to demonstrate, it's not just a placebo effect. There's a real effect to some of these therapies. This is a large randomized trial run by Gene Kutner out of Colorado, where you look at massage techniques for patients with cancer. And what you see is that both the knowledge that their pain, this is the massage group versus just simple touch, had significant improvements in their pain and mood overall. Again, this is a large randomized clinical trial phase three. Now, when I talk about massage, especially for the multiple myelo group, remember that when we do oncology massage, we don't generally use deep pressure massage, right? Because there could be a lot of bony lesions. And so generally the massage tends to be, it needs to be modified and probably more level one through three. This is a Walton scale. And so if you see massage therapists, hopefully they've been trained to how to work with cancer patients. They, you know, sometimes we call it oncology massage. There is an organization out there that focuses on oncology patients. And so they need to be using some kind of pressure scale. Generally we use one through three. We don't generally use four or five for patients, especially if they have known bone metastasis. Then it's more of a light touch so that we don't have any risks there. And then, you know, there was a pilot study we did at MD Anderson. I was one of the authors on this with K. Garcia, looking at just about 19 patients who had chronic neuropathy through their treatment with vellium. And we did demonstrate that at, I think it was week nine, you almost see a reduction of half of their neuropathy symptoms. So a significant drop in neuropathy just using acupuncture over a two month period. Again, so there's growing data that they're looking at it in breast cancer. And now there's a large randomized clinical trial going on with team Val at Memorial where they're looking at it for breast cancer patients with neuropathy as well. And so if you look at national guidelines now, this is the National Comprehensive Cancer Network guidelines, NCCN, which commonly is utilized by insurance companies as such. You can see they have a whole thing in the adult cancer pain guidelines where they talk about things like mindfulness based stress reduction, things like massage, acupuncture. And so what you're seeing is that national guidelines are starting to include integrative therapies because the evidence is growing and it's worthwhile to think about. This is actually from the American College of Physicians. This came out just about five years ago where they're talking about back pain. And I think because of the opioid epidemic, there's been a real push to look for non-pharmacologic approaches to pain. And you can see here they talk about there's a level of evidence to consider acupuncture and meditation techniques, moderate level quality evidence. So I think there's a lot of benefit. So let's switch gears to from pain. Let's go to stress. So does anybody occasionally have stress in this audience? Yeah. And so, of course, when you get a stress test, you're probably stressing out because you have to do a stress test, right? The cardiac stress test. So but then I'm sure some of us also feel anxious and can't sleep at night. Right. And oftentimes they're related. So if you're stressed, you probably can't sleep. And then if you can't sleep, of course, you're more stressed. Right. And if you put pain in here, then if you have pain, you're more stressed and you can't sleep. I mean, it all cycles together. Sometimes we call the symptom clusters. Right. But they're very related. And so mind body practices are probably one of the best well studied integrative therapies out there. I don't know if anyone's heard of Herbert Benson. Herbert Benson recently passed away. He came up with the phrase we call relaxation response. And he really understood the science of why things like meditation help patients. And so he was one of the first in the 70s to really look into this. There's a Herb Benson Mind Body Institute at Harvard named for his work. And so there's really good evidence around stress, mood disturbance, quality of life and helping the sleep as well. Looking at mind body techniques. So this is a study by Ovalrood Lang where they were looking at patients who were getting biopsies. And so they had three groups. One group got hypnosis during the procedure. Another group got attention control. So it's kind of like a placebo arm and then standard of care. And what you can see is that the hypnosis group in circles here, solid line circle, they had the lowest pain scores and the lowest anxiety scores going through the procedure. And you might say, well, why do these lines keep going? Because they actually finish the procedure faster. If your patient's less anxious and has less pain, you kind of get the procedure done more efficiently. And so what they found is that these procedures without the hypnosis lasted an extra 30 minutes. So this is a nicely done randomized controlled trial by Ovalrood Lang. This is Karen Mustean's work from Rochester, where they randomized patients to a yoga technique. And what they found is that patients slept much better when they practiced a yoga meditation. You can see their overall sleep quality improved quite a bit on the blue line. That's a large phase three randomized trial. Even in children, there's benefits for like art therapies, like music and art therapy. You can see here where patients undergoing lumbar puncture, if you had them do some kind of music, their pain and anxiety scores were much lower than the control group. It's a simple music therapy intervention. You don't have to give them Benadryl and Ativan and kind of knock them out. You can just use something like this. This is one of my favorite studies. So anyone use it? I mean, I'm sure I'll come across Lavender and it's like sold in every soap product. But is there any science behind Lavender? Well, there's a Japanese group. They published this in 2018. Oh, actually, no, I think maybe two years, 2020. And so there's a couple of ingredients in Lavender. I love this study. So they extracted the different ingredients and they found that there's a compound called Linolule. And when you give Linolule to these mice, they relax. You know, you can put mice in an open room or put them in water and then you see how long they stay. And so the mice were much better relaxed when they just smelled Linolule. OK, the specific compound of Lavender. And then they compared it to things like Ativan. You can give mice Ativan and had the same effect. And then if you block a receptor with Flumazenil, which reverses things like Ativan, it had no effect. And so they actually demonstrated the actual compound that causes the relaxation due to Lavender. And so, you know, there have been studies and this one's in bone marrow biopsy, but there are multiple studies. This is a randomized study where they had half the patients smell Lavender oil for 15 minutes before a bone marrow biopsy versus a control group. And you can see that mean anxiety between the two groups, the group that got Lavender aromatherapy for 15 minutes, had 40 percent decreased anxiety after procedure. So simple intervention, very low toxicity. I'm actually very interested in trying to do this at Lennar to do a similar study. So you might be asked to participate in a Lavender study if you show up at Lennar. But, you know, again, NCC and guidelines talks about integrative therapies for pain, nausea, dyspnea. And so the evidence base is really growing. So with that, you know, let me summarize that integrative oncology is part of the supportive care spectrum and can really help optimize your cancer care. True integrative oncology has to be evidence based and really personalized to your care plan. And it's really important for you if you want to think about integrative approaches, talk to your oncologists, your treating team to say, hey, I'm interested in this. I want to just jump into it because you want to make sure it doesn't interfere or interact. It's safe for you. And you know, you have to think about the timing. When is it appropriate to use one of these therapies? And then there's growing data on acupuncture, mind-body therapies, massage, music therapy to help manage pain, anxiety, stress and sleep. So I think with that, I will finish and then I'll look forward to your questions at the Q&A session later on. Thank you. Thank you. Thank you. Thank you. Thank you.