Welcome to Fight Colorectal Cancer’s Webinar:FAD or FACT. How to determine if

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Today’s Webinar:1. Today’s Speaker: Lisa W. Corbin, MD, FACP

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SpeakerLisa W. Corbin, MD, FACPDr. Corbin is a board-certified internist, Associate Professor in the Department of Internal Medicine at the University of Colorado School of Medicine. In 2001, she helped the University of Colorado Hospital establish the Center for Integrative Medicine (TCFIM) and has served as the Medical Director ever since. Dr. Corbin works closely with oncologists in the community and from the University of Colorado Comprehensive Cancer Center to help their patients manage side effects of treatment, reduce chance of recurrence, and improve quality of life using lifestyle approaches and complementary / alternative medicine therapies that align with the patient’s values and interests.

Fad or Fact?Complementary and Integrative

Medicine

Lisa W. Corbin, MD, FACPMedical Director, Integrative MedicineUniversity of Colorado HospitalAssociate Professor, Internal MedicineUniversity of Colorado School of Medicine

Definitions CAM Complementary / Alternative

Medicine Therapies not historically part of

conventional medicine Chiropractic, acupuncture, massage,

herbals…

Lifestyle medicine Use of stress reduction, exercise,

nutrition for health benefits

Integrative medicine CAM therapies and lifestyle

approaches coordinated with conventional medical treatments

Who’s Using CAM? Nearly 50% of general public uses CAM 70 – 85% of patients with cancer used at least one

CAM treatment 80% used spiritual practices 63% used herbs / supplements 60% used movement / physical therapies

Reasons for use: Feel hopeful (73%) Boost immune system (63%) Want control (38 - 44%) Prevent recurrence (43%) Aid conventional therapy / treat cancer (28 – 38%)

Case Vignettes• MS, a 54 year old woman with metastatic

colon cancer. Was able to keep it “in check” with chemotherapy, but was so sick every 3 weeks for 1.5 weeks that she had to quit work as a medical technician. She came to us stating it was a last resort, she was planning to take a “last hurrah” trip to Greece. After discussion, she agreed to try acupuncture before chemotherapy, and this worked so well for her that she was able to continue getting the life sustaining chemo and even went back to work for four years

Case Vignettes• MK, a 60 year old female runner, had colon

cancer treated with chemotherapy, radiation, and surgery. Was dismayed that after treatment she was still fatigued and could “only” run 3 miles (prior 10+). We discussed exercise and local programs for cancer survivors, she worked with a dietician to improve diet, she worked with a psychologist on mind/body strategies for fatigue management. Gradually she was able to increase her tolerance and was back to running half-marathons within 18 months.

Case Vignettes• SS, a 62 year old male with rectal cancer just

starting treatment with chemotherapy. Family insisted that he take herbs and change his diet; some told him the chemotherapy was toxic and “would kill him, not the cancer”. He was understandably anxious about treatment and by family recommendations. He had persistent pain at the site of a surgical procedure. We suggested working with the psychologist for anxiety reduction and how to respond to well-meaning family. He began massage therapy for anxiety and pain reduction. He discussed supplements and diet with a dietician. He used acupuncture during chemotherapy and came through his treatment better than he had expected.

Using an Integrative Approach Avoid harmful practices Don’t overlook lifestyle / self-

care Sleep Exercise Mind / body techniques Nutrition

Consider safe, plausible CAM therapies Herbs / supplements Acupuncture Massage

Harmful Therapies• Colonic hydrotherapy• Chelation therapy• Ionic foot baths• Restrictive diets• Some supplements• Financial toxicity!• Anything used IN PLACE OF a

curative conventional treatment

Ionic Foot Baths

Ionic Foot Baths

http://www.wikihow.com/Test-a-Detox-Foot-Bath

Detoxification Human body is evolved to get rid of

toxins Skin Lungs Colon Kidney Liver

Be natural – let the body do what it’s good at! Support the processes: Drink plenty of fluids Exercise Don’t put a lot of toxins in in the first

place!

Helpful Therapies

• LIFESTYLE– Sleep – Exercise– Mind / body techniques– Nutrition

• CAM APPROACHES– Supplements– Acupuncture– Massage

Why Lifestyle Approaches?

Gives you more control over your health and an active role in your care

Low / no cost Can help current cancer-related

concerns, also to help prevent future illness

Get Some Sleep! Restorative sleep improves pain,

fatigue, mood Sleep deprived “normals” develop

chronic pain Links: breast cancer, weight gain

Behavioral approaches: Don’t eat, drink, exercise just before bed Avoid late day caffeine, too much alcohol Get consistent exercise earlier in the day Pay attention to room environment Establish consistent sleep times Get out of bed if not tired Don’t nap

Exercise for Prevention

• Primary prevention– Most versus least active = 27%

reduction in colon cancer– Being generally active likely helps, too

Exercise for Prevention

Exercise During Treatment

• Prevents weight gain • Decreases fatigue• Improves stamina• Helps balance• Decreases anemia

during radiation • What to “take” for my

immune system? EXERCISE!

Exercise Can Help Symptoms

• Improves pain in general• Helps memory and concentration• Improves sleep, depression• Good for the rest of life, too:

– Helps high blood pressure, diabetes, cholesterol, improves bone mass

Unlike late night TV claims, this product CAN help you lose 20 pounds and improve your sex life!

Simple Exercise Prescription: FIT

F requency Exercise every day

I ntensity Break a sweat; increase difficulty of

exercise T ime

Start with 5 minutes daily, increase by 1 minute daily each week; goal 30 minutes

(Final goal - 30 min vigorous or 60 min moderate activity daily)

Why Mind-body? Help restore locus of control Mind-body therapies are generally

safe Perception of symptoms requires

processing by the mind; mind-body therapies can alter perception

Decrease pain, stress, anxiety Often covered by insurance

Mind-body Therapies Cognitive Behavioral Tx Relaxation techniques Breathing techniques Biofeedback / heart math Art, music, pet therapy Mindfulness / Meditation Imagery / visualization Yoga / tai chi Hypnosis

Mindfulness-Based Stress Reduction• Promotes relaxation through

nonjudgmental awareness of sensations, experiences, and reactions: being “present”, “in the moment”

• Randomized wait-list vs MBSR in 107 cancer patients– Improvement in mood and stress– Effect maintained 6 months after program

ended

Yoga

• Combines physical movement, breath control, and meditation

• Promoted for patients with cancer• Studied in breast cancer; recent

study in Germany just completed for colon cancer

Support Groups

• Andersen and colleagues RCT– psychologist-led group support

resulted in improvements in QoL, in aspects of immune function, and in life expectancy.

Cancer 2008; 113: 3450 – 8.

Diet / Nutrition

Estimated percentages of cancer due to selected factors:

• Diet* 35-60%• Tobacco 30%• Air & water pollution 1-5%• Alcohol 3%• Radiation 3%• Medications 2%* Primarily obesity

Body Weight and Cancer

Specific Dietary Factors

• Fruits/ vegetables• Inconsistency in studies showing protection

• 50% reduction in one study, no association in another

• If valuable, probably most of risk reduction is in increasing over 100 g / day (easily get this in reasonably well balanced diet – apple is 200 g!)

• Red meat / animal fat / cholesterol• Increased risk 3x for highest intake vs

lowest intact• Fiber

• 4 large studies show decreased risk, 2 no association

Nutrition: Summary• Plant based diet, less

meat and dairy • 5 + fruits / vegetables• 7 + high fiber complex

carbohydrates • Low saturated/trans fat• Less n-6, more n-3 FA• Limited alcohol

Excellent resource: AICR

Real Nutrition Questions

Should I take

supplements?

Does “sugar feed the tumor”?

Do I have to eat

organic?Is soy good for

me?

Herbs and Supplements Three types of medicines:

Prescription (Rx) Over-the-counter (OTC) Dietary Supplements

Unlike Rx and OTC, supplements: Are not required to prove safety, efficacy Are not required to enforce quality control Can vary in concentration of ingredients

Over 60% of cancer patients use supplements

General Advice: Supplements

• Natural safe• Use extra caution with prescriptions• Use trustworthy resources for information

– Health food store, internet notoriously suspect– Good: NMCD, ODS

• If you choose to take a supplement:– Look for a well-labeled brand– Avoid combination products, MLM sales– Watch for red flags:

– Direct mail, infomercial, ads disguised as news articles, back of the magazine ads, testimonials

– Claims a “cure”– “Secret ingredients”, “one manufacturer”

Manufacturers More Likely to Produce Quality Products

Nature’s Way Nature’s Made Nature’s Bounty Costco (Kirkland) Walmart (Equiline) Phytopharmica Puritan’s Pride

In General: Avoid Supplements During

Treatment• Antioxidants may decrease effect

of some chemo, radiation• Some supplements directly

inhibit some chemotherapy (St. John’s wort)

• Some supplements may increase risk of bleeding during surgery or interfere with anesthesia

Specific Supplements• Consider:

– Omega 3 fatty acids (fish oils): anti-inflammatory

– Glutamine– Probiotics (decrease diarrhea, may

break down carcinogens)– Ginger (for nausea)– Melatonin (consider if also sleep

deprived!)– Other chinese herbals may improve

response rate according to 2012 Cochrane review

AcupunctureChinese Medicine Background

Health = balance of yin and yang Qi = energy force created by interaction of yin and yang Meridians = channels that carry qi throughout

the body; each corresponds with a specific organ

Excess, deficiency, or stagnant flow of qi results in disease

Examples of TCM diagnoses: Yin deficiency and yang predominance with reduced

kidney qi Stomach qi rebelling

AcupunctureWestern Medicine Background

Osler, 19th century “best treatment for lumbago”

James Reston, China, 1971 Biological effects

Local nerve activation Endorphins, ACTH, endogenous opioids

(reversal of analgesia with naloxone) SPECT scanning: increased activity and

reversal of asymmetry in chronic pain patients in thalamic and prefrontal cortex during acupuncture over baseline

General Advice: Acupuncture

Acupuncture is generally safe Adverse events: minor or rare (pain,

bleeding, fatigue) Disposable needles, alcohol wipes avoid

infection Practitioners

Must have a license in CO (LAc); scope of practice for MD, DO, DC

TCM: National Certification Commission for Acupuncture and Oriental Medicine (www.nccaom.org)

MD: American Academy of Medical Acupuncture (www.medicalacupuncture.org)

Costs Initial / follow up: $100 / $55 for LAc Covered by some insurances

Benefits: Acupuncture• Reduces nausea / vomiting due to

chemo• May help return of bowel function

post-op• Decreases neuropathy• Pain control• Helps depression• May stimulate immune system • Recommended for dry mouth

Massage Therapy Developed by

almost all cultures Many different

forms Emphasis on

improving circulation, releasing muscle tension, calming and relaxing patient

Massage Therapy: Facts Over 20% of patients with cancer use

massage therapy Many patients remain unaware of the

potential benefits of massage Some patients are mistakenly told to avoid

massage if they have cancer

General Advice: Massage Generally safe. Use caution with:

Congestive heart failure Infections Blood clots / bleeding disorders Osteoporosis or bone metastases Pregnancy Does NOT spread tumor

Requirements for licensure or registration vary by state

Look for involvement in AMTA (www.amtamassage.org)

Extra training for oncology available $60 - $120 / hour, occasionally covered

Massage Therapy: Benefits Relaxation, improved QOL Depression, anxiety, sleep Post-operative wound healing Lymphedema treatment Pain management

Finding a Good Provider

Training and licensure Experience with cancer Expected benefits Risks

Direct risks or side effects, interactions?

Costs / reimbursement Time frame / progress assessment Ability to work with conventional

providers

Summary• CAM treatments can be safely

integrated with conventional treatments– Don’t use harmful therapies – Use therapies shown to be beneficial

• Lifestyle approaches often overlooked• If it sounds too good to be true…

– Consider safe, plausible therapies • If they help you, they are beneficial!

• Find good practitioners, use good resources

“Be open minded, but not so open minded that your brains fall out”

Widely attributed

Internet Resources• CU Integrative Medicine: www.uch.edu/integrativemed• NCI (follow links for CAM):

www.cancer.gov/cancer_information/ or http://occam.nci.nih.gov

• ACS: www.cancer.org• ASCO patient information:

www.PeopleLivingWithCancer.org• Nutrition - AICR: www.aicr.org• Supplements: http://ods.od.nih.gov/• Consortium of Academic Health Centers for Integrative

Medicine: www.imconsortium.org• NCCAM: http://nccam.nih.gov/

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