Integrated Medicine and Cancer
There’s a very interesting and important piece of research from the School of Social Work at the University of South Florida in Tampa.
The title of the paper is “Patient-physician communication regarding use of complementary therapies during cancer treatment,” and it discusses something with which I’ve been very involved for many years.
The paper uses the terms “complementary and alternative medicine,” though the same principles apply to the far more sophisticated and comprehensive approaches of Integrated Medicine.
Studies from the United Kingdom, Germany, Holland, France and the United States have estimated that as many as 80% of adult cancer patients use at least one form of Complementary and Alternative Medicine (CAM) during or after conventional treatment. I’ve discussed before the pitfalls of trying to use unorthodox medicine in place of conventional medicine. In Europe some of the practices of Integrated Medicine, particularly acupuncture, homeopathy and massage, are used to help people cope with the rigors of chemotherapy and radiation therapy, rather than to treat the tumors themselves. Many people claim that they can use homeopathy or some herbal remedies as the sole treatment for different types of cancer. But I won’t endorse them unless they can show me some data.
We already know that patients frequently do not tell their oncologists about their use of unorthodox medicines and physicians consistently underestimate the numbers of their patients using them. The purpose of this study was to assess newly diagnosed cancer patients’ and oncologists’ communications with regard to unorthodox medicines. They looked at people with two types of cancer: 106 had breast cancer and 82 had prostate cancer. All the patients in the study were receiving regular conventional medical treatment.
In line with previous research, 84% reported that they were using at least one unorthodox therapy. The most popular were exercise, vitamins, prayer, and nutritional supplements.
But here was the surprise for the investigators: The oncologists surveyed were generally enthusiastic and supportive of patients’ use of these therapies. In addition to those therapies popular with patients, at least half the physicians supported massage, journal writing, support groups, acupuncture, biofeedback, and art therapy.
This was no surprise to me at all. I spent most of my clinical career in tertiary referral centers, and I’ve worked with the best of the best. The vast majority was extremely supportive of anything that would help. Every one of them was a skeptic who would say, “show me.” But once they had been shown, they would be very helpful. After all, who doesn’t want to help people get better?
It has always been so noticeable that the biggest critics, not skeptics, but critics, have been people who were less secure. Often not the “Best of the best,” they would carp and complain that “we don’t do things that way,” and “I don’t see how it could work, so I’m sure that it doesn’t.”
What this new piece of research showed was that discussions the use of unorthodox medicine were relatively rare and were most likely to be initiated by the patients. When the topic was discussed, both patients and doctors said that it usually enhanced their relationship.
What do I take away from this study?
If you, a friend or loved one has cancer, or any other type of illness for that matter, consider using something else in addition to your regular medical care. Not as a replacement, but in addition. The regular treatment will be helping the physical side of the illness, but you also need help with the psychological, social, subtle and spiritual aspects of what is going on in your life.
And guess what? Chances are that if you have a good oncologist, or any other type of conventional clinician working with you, he or she will probably be very supportive of anything that you do.
I once said at a very large meeting that if I needed to put a bone through my nose and do a dance to get someone better, I’d do it.
And I’m not the only one.
What Integrated Medicine does is to put all the cards on the table from the very beginning. We tell people that we are going to be helping guide them toward physical, psychological, social, subtle and spiritual health. They need to be able to derive meaning and purpose from what’s happened to them, rather than just cussing at their misfortune.
And then using the experience to grow as individuals and to help others.
The Integrated Practitioner will also be working with the way in which this person’s challenge is changing them. If a practitioner is not changed by the person in front of him or her, they are working only as a technician and not as a healer.
There’s nothing wrong with that, but everyone needs to be clear about what the practitioner is bringing to the table, and what their expectation is for the person who has come to see them with a problem.
For now, if you are not working with an Integrated Practitioner, do tell your health care provider if your are doing something else to help yourself.
Chances are that he or she will be very supportive.
The Ethics of Complementary, Alternative and Integrated Medicine
In my recent item about ethics I mentioned that Paul Root Wolpe from the University of Pennsylvania is interested in the ethics of Complementary and Alternative Medicine (CAM), and, by extension, its offspring, Integrated Medicine. This caused some raised eyebrows, but it shouldn’t.
Using unorthodox therapies carries a number of ethical and moral responsibilities.
When I was still on faculty at the University of Pennsylvania, on one occasion I caused outrage amongst many friends using natural medicine, when I pointed out on a TV show that just because something’s natural doesn’t mean it’s safe. Think arsenic, deadly nightshade and hurricanes! But there is more to the ethics of CAM than just the safety of the treatments involved.
Just a few months ago I was asked to look at a study by someone claiming to debunk one of the tapping therapies. Neither the investigator nor the practitioners and patients inveigled into the “research,” understood the principles of informed consent. This is important: one of the many consequences of the Holocaust was a re-consideration of what to do with medical “data” collected by Nazi doctors in the most unprincipled ways imaginable. Should the data be kept, so that people would not have died in vain? Or should it be destroyed, because information from unethical experiments was tainted. After a great deal of heart searching, it was decided that any information obtained under those circumstances was likely to be junk. This is one of the reasons for the absolute insistence on informed consent. I shall say something else about consent in just a moment.
Let’s have a look at the ethical issues involved in CAM, because much of the criticism of the emerging models of healthcare has come from people genuinely concerned about patient welfare.
- If we do anything with or for an individual, there has to be informed consent. Informed consent includes full disclosure not just of the chances of efficacy, but also of the possible toxicity of a treatment and an agreement of what we hope to achieve. A therapist may want to balance your Qi and stop you getting sick in the future. You may just want to be rid of your headaches. When we ask about the chances of efficacy, we all run into the problem of positive bias. I was once planning some research with a very well known practitioner in the UK, who told me that he cured every single person he saw, whether they had cancer, schizophrenia, heart disease or anything else. I was astonished, and asked him for something to backup what he said. He flew into a rage! “How dare I question him?” he said.It soon turned out that although he probably was a genuine healer who got a lot of people better, he had no evidence at all. It was like a study in the medical arena in which the investigators decided that anyone who did not come back for treatment was cured! Not a common reaction if someone fails to turn up for an appointment!
- People often say to me that there can be no harm in giving someone a homeopathic remedy. And of course, from a purely physical and psychological perspective, that’s probably true. Though I once participated in an experiment in which I took the homeopathic remedy Pulsatilla, that is prepared from the Passion Flower. I had what is known as an exacerbation, and was unable to function for several hours. But we also need to think about some of the other things that can follow from using treatments that work at the level of the subtle systems. One of our biggest objections to people who believe that they can do acupuncture after a weekend course, is that acupuncture, homeopathy and the rest are powerful medicines. Putting a needle into the wrong part of a person’s anatomy may not just cause physical harm, but can do extraordinary things to a person’s subtle systems. A fact that is exploited in some martial arts. In the Jet Li movie Kiss of the Dragon, Jet uses acupuncture needles to do some extraordinary things. The filmmakers used little artistic license: with one exception I have personally seen all of the things demonstrated in the movie.
- I mentioned that informed consent includes full disclosure about the chances of efficacy and toxicity of a treatment and agreement on therapeutic goals. We can find ourselves in a real ethical dilemma when patients have unrealistic expectations for an untested remedy. Sometimes people don’t inform their patients realistically, and they rationalize it as either choosing not to remove hope or as providing support. But we have to be sure that we are not supporting potentially dangerous or harmful decisions. The problem is not necessarily the treatment itself. Using an untested treatment in place of something that we know can be effective can also lead us into difficult ethical waters. Regular readers will remember a sad case that I highlighted a few months ago.
I’m all for holistic therapy: the less invasive the better. I’ve spent the last 35 years helping develop new and better ways of integrating treatments.
But it’s really important to be realistic, to use what we know works and if we don’t know if a thing works, then to be totally honest with the individual, and keep meticulous records of why we want to use an untested remedy in combination with the conventional.
In the 1980s, the Research Council for Complementary Medicine began to train complementary practitioners in the basics of research, so that they could be better at obtaining informed consent and monitoring the effectiveness of treatments that they were using. We had some success, and it is high time that we helped practitioners in other parts of the world do the same thing.
Using Yoga: Some Measurable Effects in People with Alcohol Dependence
I was very interested to see a quite well designed pilot study which seems to show some clear antidepressant and hormonal effects (reduction in cortisol and increase in prolactin levels) in alcohol dependent individuals who could be persuaded to practice something called Sudarshana Kriya Yoga (SKY). This technique involves rhythmic hyperventilation at different rates.
Studies like this are difficult to perform, and this one was not perfect. It only involved males, and the study will inevitably be skewed by the kinds of people participating. The study involved quite a bit of time, and so the subjects had to be motivated. Some people still dropped out of the study, and their data should have been included in the analysis. They also had more than just the breathing exercises: they got a whole treatment package. It will be interesting to see how long the effects last. We’re always interested to see how many people remain abstinent at one year.
One of the odd things was that the investigators measured the hormone prolactin. It is so named because its primary role is to promote lactation. It has at least 300 hundred other functions in the human body, and has at least ten major control systems. It is a little surprising that it should rise, since it normally goes up when people are stressed. However, I might have an explanation. As far as I can see, the techniques used in the study are pretty straightforward yogic pranayama. Hyperventilation slightly alkalinizes the blood. That would change the rate of firing in the reticular activating system of the brain stem, and could of itself be responsible for the elevated prolactin levels. Had I been designing the study, I would have measured arterial pH: it would have helped answer several questions.
Though not perfect, this study is a good piece of pilot data, and should stimulate further research into the use of these techniques for helping a very difficult problem.
I was interested to find out more about the technique. SKY was devised by a spiritual guru – Sri Sri Ravi Shankar – of the Art of Living Foundation in Bangalore, India. He has established a Foundation that seems to be engaged in a number of charitable activities. I have known a great many spiritual teachers; each has been criticized and controversial, and Shankar is no exception. I’m not in a position to judge whether or not it is justified.
All that I can say for now is that he has devised a technique rooted in the Indian classics, that seems to help some selected patients with an otherwise tough problem. And that is a good start.
Convergence
One of the many things differentiating complementary and alternative medicine from the more conventional type, is that complementary practitioners are not much interested in a pathological diagnosis, and instead focus far more on the whole person. There are more than 500 types of complementary and alternative medicine, and virtually all work on the principle that they want to stimulate the body to heal itself.
It is not so well-known that in recent years some of the most cutting edge academic research in medicine has been breaking down artificial organs-based barriers, and focusing instead on the whole person, and look at research in a more holistic way. So a cardiologist and liver expert may be working together on the same problem.
Someone was asking me why this blog has so many categories? The reasons is that artificial barriers between illnesses, health, wellness, consciousness and spirituality are breaking down, and this blog reflects that. I was asked, “So are you interested in self-help or health and wellness?” the answer to that one is “Yes.” All of these are inextricably linked.
A second conceptual change, that is not much known outside of research centers, is that much of the current thrust in pharmacology is based on modulating the body’s responses, rather than simply blocking diseases processes.
Despite this apparent convergence, there are still some enormous differences in approach:
1. The medical research enterprise remains profoundly reductionist, and so it tends to ignore some key aspects of what it is to be human: we are a great deal more than sets of biochemical reactions.
2. Dismissing the social and psychological aspects of health and illness remains an Achilles’ heel of most academic research. When I was working in academia, a distinguished colleague came over form the England to give a lecture. An expert in brain imaging, he spoke a lot about consciousness and free will. As one of my American friends said afterward: he sound just like you in our research meetings!
3. Complementary, alterative and now integrated medicine remains firmly focused on relationships as a key to healing. Not just the relationship of a client and their family, but the relationship between client and therapist. And there is a third arm to this. When, in the mind-1980s, we first started putting together the principles of this new Information Medicine known as Integrated Medicine in the United Kingdom or Integrative or Integral Medicine in the United States, a key component of it was the insistence that the therapeutic encounter would require the therapist to do more than just show up and do something technical. But that the therapist would also be aware of the impact of the encounter on them, and the importance for the therapist to be involved in growth work themselves. There was a time when psychotherapists would remain in therapy throughout their careers. That may not now be feasible. But it is entirely feasible for a therapist to take a bit of time each day to calm themselves; to reflect on what is going on inside them and in the subtle currents of the interactions between them, the person who has come to them for help and guidance, and all the other people involved in the situation. This is the way in which medicine is going to develop in the future.
The extraordinary advances of biomedical research can be an incredible boon to humanity, but they need to be leavened by an understanding of the context within which they are developing.
“A physicist who rejects the testimony of saints and mystics is no better than a tone-deaf man deriding the power of music.”
–Sir Sarvepalli Radhakrishnan (Indian Philosopher and, from 1962-67 President of India, 1888-1975)
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The Prince of Wales and Integrated Medicine
It is not widely known in the United States that His Royal Highness Prince Charles, the Prince of Wales, has been instrumental in the development and adoption of integrated medicine in the United Kingdom and in some parts of Europe and the Middle East. I had the privilege of working extremely closely with his Foundation for many years, and have acknowledged his personal influence in my most recent book, Healing Meaning and Purpose.
The British media is today reporting that his position on trying to integrated the best of conventional medicine with the best of traditional approaches if once again under attack, from a well-known group of critics. This time they are saying that the adoption of inadequately tested therapies is a needless drain on resources, and that regardless of what patients want, the money should be spent on treatments that are “evidence based.” This has become the new clarion cry of medicine: that everything that we do should have a defined research base. A terrific idea in theory, but sometimes disastrous in practice. As an example, there is not much in the way of an evidence base for appendectomy.
This morning, one day after the critics published their letter in the Times of London, the Prince of Wales spoke about his position and his work at a meeting of the World Health Assembly in Geneva and he had this to say:
"I believe that the proper mix of proven complementary, traditional and modern remedies, which emphasize the active participation of the patient, can help to create a powerful healing force for our world.
This is where orthodox practice can learn from complementary medicine, the West can learn from the East and new from old traditions."
It will not surprise you to hear that I strongly agree with the Prince’s views. If you glance through a few of my blog entries, you will see that I am a huge advocate of good research: I analyze dozens of studies every week and present you with the best. I have also had to spend a great deal of time making decisions based upon cost. But it would be a big mistake for us to declare that any therapy that does not have a biological basis, or conform to the medical model should be excluded from health care. After all, patients also have a say, and they are clearly deriving benefit from complementary medical therapies. And as I have reported before, we are slowly collecting more and more data indicating that at least some of the 500 different schools of complementary and alternative medicine do have research to support their use.
“In scientific work, those who refuse to go beyond fact rarely get as far as fact.”
–Thomas Henry Huxley (English Biologist and Educator, 1825-1895)
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How Not to Use Complementary Medicine
There is a report in the British Medical Journal that the Amsterdam Medical Disciplinary Tribunal has struck one doctor from the medical register and suspended two others for their exclusive use of unorthodox approaches in the treatment of a famous Dutch actor and comedian named Sylvia Millecam, who sadly died of breast cancer in 2001 at the age of 45.
After being diagnosed, the patient was recommended to have surgery and chemotherapy, but instead sought unorthodox treatment. Although the patient wanted this type of treatment, the legal case was that the doctors failed to give a reasonable assessment of the chance that their treatments would help, or made it clear that the only treatment that had been proven to help the course of the illness is the conventional route. One of the doctors was also judged to have caused her unnecessary suffering by withholding conventional palliative care as she deteriorated.
Not surprisingly, this case has attracted a lot of interest in Europe, where alternative, complementary and integrated approaches to health care are far more commonly used than in the United States. Many alternative practitioners feel that conventional medicine simply “suppresses” the underlying cause of the illness, and that there is no need to use orthodox and unorthodox together.
The approach that I have been advocating for many years is that if the individual warrants it, to use conventional and unconventional approaches together. But to see them as working on different dimensions of the person: what I call integrated medicine, though the term “integrative” is more popular in the United States. There is nothing very integrated about using St. John’s Wort instead of Prozac. That is just an alternative, which may be appropriate for certain individuals. And everything gets tailored to the individual: a man came to see more for acupuncture, but left with a prescription for a medicine. Once the medicine had done its part, some acupuncture was a very helpful adjunct. And there have been many folk where we have worked the other way round: acupuncture or homeopathy, and sometimes also a medicine. Whatever it takes to help people get to where they need to be.
In an ideal world, Ms. Millecam would probably have had surgery, but also psychological and energetic work, and perhaps some other remedies and spiritual counseling to support her through the process. Would it have enabled her to live longer? Perhaps, but the point is that the integrated approach would have aimed to help her quality of life and to help her to find the meaning and purpose of what she was going through.
She may have declined all this, but the problem was that enthusiastic doctors were using their approaches in place of regular evidence based medicine, without making it clear to Ms. Millecam what she was letting herself in for. Yes, a mentally competent individual has the right to decide whether or not to have a course of treatment, but he or she must be given all the options, so that he or she can make an informed decision. It was all rather sad and probably avoidable.
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Adjunctive Homeopathy in an Intensive Care Unit
Although we normally try to get articles quickly, we are sometimes thwarted and they can be delayed in arriving. I have only just got my hands on a study abstract that was published by a research team from Graz in Austria last October. The investigators from the Ludwig Boltzmann Institute for Homeopathy examined the use of homeopathy in a group of severely ill people in an Intensive Care Unit.
This was a double-blind, placebo-controlled trial to see whether homeopathy would be able to influence the outcome of critically ill people with severe sepsis. Seventy people entered the study, and 35 received homeopathic treatment and 35 received placebo, in addition to their regular treatment. The main outcome measure was survival. At day 30 there was no difference between the survival rates of the people receiving homeopathy and placebo. But at day 180, the survival rate in the homeopathy group was 75.8% compared to 50% in the placebo group.
One study does not make a revolution, and it is still early days for this kind of experimental work. Yet two things stand out from this small investigation:
1. The homeopathy was being used as an adjunct to conventional medical care. I sometimes get worried when practitioners of unorthodox medicine say that they would ONLY use herbs or homeopathy. The best approach has to be to combine conventional treatments with those unorthodox ones that can be shown to be helpful.
2. Trained homeopathic physicians did the prescribing. This is important: some studies have foundered because the studies tried to test just one remedy. Yet homeopaths individualize each treatment. So two people may have the same infection, but because they have different personalities and constitutional make-ups, they will receive different treatments.
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