Pamela Goetz, BA, OPN-CG
Cancer care is extremely complex, and a truly holistic approach to quality care goes beyond radiation, chemotherapy, and surgery, according to Pamela Goetz, BA, OPN-CG, survivorship program manager at Johns Hopkins Kimmel Cancer Center at Sibley Memorial Hospital in Washington, DC.
Integrative health approaches, including nutritional, psychological, and physical modalities, are an important complement to a patient’s care plan. These modalities can be used in conjunction with conventional approaches to cancer treatment and serve to support patients while positively impacting health outcomes, she said at the AONN+ 13th Annual Navigation & Survivorship Conference in New Orleans.
What Is Integrative Health? Terminology and Resources
“Integrative health is evidence-based, whole-person healthcare that addresses the mind, body, and spirit, as well as their interdependence,” Ms Goetz said. “I’m passionate about integrative medicine and how it can support patients with cancer.”
Integrative practices are used along with conventional (Western) allopathic treatments, as opposed to alternative health, which employs alternative practices instead of conventional medicine. Complementary medicine refers to evidence-based practices that are used, but not necessarily in conjunction with conventional treatments. “CAM” is a term used to refer to “Complementary and Alternative Medicine.”
According to Ms Goetz, the National Center for Complementary and Integrative Health (NCCIH)—a division of the National Institutes of Health—is a source of reliable information concerning integrative health. The NCCIH states that “integrative health brings conventional and complementary approaches together in a coordinated way, with an emphasis on treating the whole person rather than, for example, one organ system.”
“One example of this in cancer care is the practice of prescribing ondansetron to patients experiencing nausea and vomiting from chemotherapy,” she explained. “If ondansetron doesn’t work, acupuncture has been shown to be highly effective at addressing nausea and vomiting. So that’s an example of 2 different modalities: 1 from Western and 1 from complementary medicine.”
Another reliable resource is the Society of Integrative Oncology (SIO), a nonprofit professional organization focused on advancing integrative health in the field of cancer care. SIO’s Clinical Practice Guidelines are referenced in Medline and on the NCCIH website, and SIO and the American Society of Clinical Oncology released a Joint Guideline on Pain Management in Oncology in 2021.
Why Should Navigators Know About Integrative Health Modalities?
According to Ms Goetz, up to 80% of patients with cancer are already using these modalities. A Pew Research Center study conducted in 2016 found that patients with chronic health conditions (not only patients with cancer) were more likely to use complementary medicine than those without chronic conditions (33% vs 24%). In addition, nearly half of the general public reports trying complementary medicine (20% instead of conventional treatment and 29% in conjunction with conventional treatments).
“The thing that’s striking to me out of this data is that nearly 50% of Americans access integrative practices,” said Ms Goetz.
Simply put, navigators should be knowledgeable about integrative medicines because they help patients. These modalities have demonstrated efficacy with side effect management, emotional impacts of cancer (ie, depression and anxiety), managing stress response, social and spiritual well-being, and self-efficacy (when patients feel that so much is out of their control).
“We like to say that patients are part of their own treatment decision-making, but I think a lot of what patients do in terms of traditional Western medicine is dictated by the science and by their provider,” she noted. “I think making a choice to participate in integrative medicine programs is something that’s in their control.”
Yet another reason for navigators to be knowledgeable about these modalities is that National Cancer Institute–designated comprehensive cancer centers are now integrating these practices into their clinics, most commonly offering acupuncture, massage, meditation, yoga, nutrition counseling, and recommendations for dietary supplements and herbs.
Categories of Integrative Health Modalities
According to Ms Goetz, integrative health modalities can include the following individual or combination approaches:
- Manipulative and body-based therapies
- Oncology massage
- Mind–body techniques
- Mindfulness-based stress reduction (MBSR), biofeedback, expressive arts (music, writing, etc), guided imagery, meditation and mindfulness, tai chi, Qigong, and yoga
- Whole medical systems
- Traditional Chinese medicine, Kampo medicine (Japanese), Ayurvedic (Indian) medicine, and naturopathy
- Energy therapies
- Reiki, biofield, and healing touch
- Biologically based practices
- Nutrition, natural products, and medical marijuana
She also pointed out some of the specific benefits associated with these approaches:
- Acupuncture
- The National Comprehensive Cancer Network (NCCN) guidelines recommend acupuncture for pain, fatigue, nausea, vomiting, and hot flashes, and for palliative and survivorship care
- Massage Therapy
- Recommended by NCCN for cancer-related fatigue, pain, mood disturbance, and lymphedema
Ms Goetz noted that oncology massage therapists are specially trained to work with patients using a distinctive touch scale, the lightest touch being akin to the way one would touch a newborn infant. “It’s not like these patients are going in for deep tissue massage,” she said. “These people are trained in knowing if they need to avoid a surgical site, and in what’s safe in terms of working someone with metastatic cancer.”
- MBSR
- A formalized 8-week training combining yoga and meditation practices has been shown to decrease fatigue, depression, distress, anxiety, and fear of recurrence and is associated with improvements in sleep, quality of life, mood, and cancer-related cognitive impairment
- Yoga
- Benefits quality of life, emotional health, sleep, balance, strength-building, and joint pain
- Qigong and tai chi
- Improve balance and reduce the risk for falls; improve symptoms of fatigue, and improve sleep quality
She noted that natural products (including herbs/botanicals, vitamins/minerals, and probiotics) can potentially interact with active cancer treatment, and quality control issues pose other concerns with these supplements. The SIO states that little or no evidence exists for using supplements, and also cites potential harms. However, Ms Goetz noted that this is still an evolving field, and future research could change the way in which these natural products are used.
Finally, she emphasized the importance of physical activity and the well-documented positive effects of exercise on quality of life. The American Cancer Society guidelines recommend 150 minutes of aerobic exercise and 2 strength training sessions per week to address loss of muscle, cachexia, or weight gain resulting from cancer treatment.
Resources are plentiful, but tai chi and yoga might be more palatable for those in recovery from certain types of treatment, she noted, and the Cancer Exercise Training Institute offers a directory of trainers certified in working with patients with cancer, searchable by zip code.
It’s important to note that adhering to some of these practices constitutes a lifestyle change for patients, and that can become a barrier. This, coupled with cost/insurance coverage issues and a demanding treatment schedule, can deter a patient from adherence to these healthy changes.
According to Ms Goetz, one-on-one training with a health coach can offer patients realistic strategies for maintaining these new practices in their life.
“We don’t charge our patients for any of these services, so funding has been imperative,” she said. “So, talk with your foundation and find out if there are funds to support these kinds of programs.”
How Can Navigators Facilitate Patient Access to Integrative Health Services?
Ms Goetz offered tips for navigators in helping their patients to access these integrative health modalities. First, try some of these practices for self-care, so that you can effectively explain and refer patients to these resources, she suggested.
“How can you tell a patient about the benefits of acupuncture, yoga, or Reiki unless you know about them firsthand?” she pointed out. “And, maybe more importantly, it’s beneficial to practice these things for your own health and well-being, particularly with the stressors of working in healthcare.”
Create integrative health resource lists to share with your care team and patients, research what’s already available locally and online, and identify and vet reputable practitioners, she advised.
Ask patients who have participated in integrative practices for feedback on preferred practitioners/modalities, and seek out colleagues who are champions for integrative health (ie, rehab departments, palliative care teams, community organizations). Practice educating patients on integrative health, and assess their interest in the topic, whether it’s in regard to side effect management, lifestyle behaviors, social connection, finding purpose, or any other potential benefit.
Finally, it is important that navigators serve as the liaison between a patient and their care team when it comes to the use of integrative health modalities.
“As navigators, you’re a trusted person holding everything together for everybody on your team,” she said. “If you know that your patient is using herbs or trying acupuncture, that’s important information for the oncologist and clinical team to know.”
