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Raising Awareness. Funding Research.
Supporting Patients. Achieving the DREAM!
www.DebbiesDream.org
New York Stomach Cancer Education Symposium
Integrative Medicine:
Attending to All Aspects of Health
Lecturer – Shelly Latte-Naor, MD
Assistant Attending Physician
Memorial Sloan Kettering Cancer Center
Inhabiting Our Bodies
Inhabiting Our Bodies
Optimizing the Micro- and
Macro-Environment
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Awareness/ Mindfulness
Nutrition
Exercise
Stress management
Proper sleep
Circadian cycle
Physical environment
Joy and laughter
Loving relationships
Meanings and spirituality
Wellness Considers All Aspects Of Our Life
Spiritual
Environmental
Physical
Wellness
Intellectual
Emotional
Outline
o Integrative Medicine at MSK
o The Waiting Room: Recognizing stress
o Walk in the Garden: Breathing stress away
o The Bedroom: Sleep is a healer
o The Kitchen: Food and wellbeing
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Integrative Medicine Programs in
Major Medical Centers
Memorial Sloan-Kettering Cancer Center
MD Anderson Cancer Center
Dana Farber Cancer Institute
Columbia University
Yale Cancer Center
Abramson Cancer Center
Duke Cancer Institute
University of Wisconsin
Chao Family Cancer Center UC Irvine
University of Iowa Holden
Comprehensive Cancer Center
Masonic Cancer Center
The University of Arizona
Mayo Clinic
Griffin Hospital
Oscher Center UC San Francisco
Univ of California Los Angeles
Stanford Cancer Center
Moffitt Cancer Center & Research Institute
Jefferson University Hospital
UPMC Center for Integrative Medicine
Abbott Northwestern Hospital
Northwestern Integrative Medicine
St. Francis Hartford
Huntsman Cancer Institute
VSU Massey Cancer Center
Rush University Medical Center
University of Colorado
University of Michigan Comp Cancer Care
University of New Mexico Cancer Center
Complementary Therapy Use
Percent using complementary therapies, by age
50
44.1
40
36.3
39.6
40.1
41
32.1
30
24.2
20
10
16.4
7.6
10.7
0
0-4
5-11
12-17
18-29
30-39
40-49
50-59
60-69
70-84
85+
National Health Interview Survey 2007
PubMed Publications: 1980 to present
Meditation
Acupuncture
Yoga
Herbal
450
1800
4500
450
400
1600
4000
400
350
1400
3500
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3000
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250
1000
2500
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2000
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600
1500
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100
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500
50
0
1980
1990
2000
2010
0
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2000
2010
0
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2000
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1980
1990
2000
2010
What’s In A Name?
Integrative vs Alternative
Integrative
Alternative
Good safety record
Potentially risky
Evidence-based
Unsubstantiated claims
Relatively Inexpensive
Often very costly
Used alongside conventional
treatments; complementary
Promoted for use instead of
conventional treatment
Focused on supportive care
Touted as curative
Uncertainty
Fear
Stress
Stress Is Making Everything Worse
Chronic
Stress
Chronic
Stress
Chronic
Stress
• Fight, Flight or Freeze
• Neuroendocrine
changes
• Lasting changes
Hormones and neurotransmitters
involved in our response to stress
influence
Circadian
Rhythm
Metabolism
Immune
Response
Can Chronic Stress Cause Cancer?
Stress impacts our
lifestyle
• Fast Food
• Lack of physical
activity
• Increased use of
drugs, alcohol, or
tobacco
• Social isolation
Biobehavioral Risk Factors
o Meta-analytic reviews suggest stressful life
experiences and depression are associated with
poorer survival and higher mortality across a diverse
array of cancer types.
o Meta-analysis found the influence of social
relationships on mortality comparable to risk
conferred by tobacco and alcohol use and exceeding
risks associated with physical activity (or lack
thereof) and obesity.
Chida et al., 2008; Pinquart and Duberstein, 2010; Satin et al., 2009; Holt-Lunstad et al., 2010.
Effects of Stress on Cancer
G.N. Armaiz-Pena et al. / Brain, Behavior, and Immunity 30 (2013) S19–S25
Can Stress Help Cancer Grow?
Animal studies
demonstrate:
Stress by isolation,
hypothermia, physical
distress stress may
lead to faster
metastatic spread of
cancer.
Thaker et al., Nature Medicine, 12, 939 - 944 (2006)
Chronic Stress Promotes Tumor Growth
And Angiogenesis In A Mouse Model Of
Ovarian Carcinoma
Red: endothelial cells
Green: pericytes
Thaker et al., Nature Medicine, 12, 939 - 944
(2006)
There Are Many Ways To Combat Stress
Mindfulness Based Stress Reduction (MBSR) may
improve cancer patients' psychosocial adjustment to
their disease
• Aids patients in relieving
anxiety, stress, fatigue
and
• Aids with general mood
and sleep disturbance
• Improves over all quality
of life
Ledesma et al., Psycho-Oncology 18: 571–579
(2009)
Mindfulness Meditation:
Present-centered, Nonjudgmental, Awareness
Favors
Meditation
Meditation programs for psychological stress and well-being: a systematic review and meta-analysis.
47 trials with 3515 participants, JAMA Intern Med. 2014 Mar;174(3):357-68.
Mindfulness Meditation:
Present-centered, Nonjudgmental Awareness
o “Mindfulness meditation programs can
reduce the negative dimensions of
psychological stress.”
o Improvements in anxiety, depression, and
pain with moderate evidence
Meditation programs for psychological stress and well-being: a systematic review and meta-analysis.
47 trials with 3515 participants, JAMA Intern Med. 2014 Mar;174(3):357-68.
Neuro-imaging Studies of Meditation
Emotional Detox
On Paper
Expressive writing can help
with physical and emotional symptoms.
277 patients with kidney cancer were asked
o to write about their deepest emotions and
thoughts
or
o to write about the following four neutral
topics
Milbury et al., J Clin Oncol. 2014 Mar 1;32(7):663-70
Writing Improved
Symptoms, Fatigue
and Physical Function
Guided
Imagery
Improves putative anti-cancer immune-defense
markers in
- Breast cancer patients undergoing treatment
- Prostate cancer pre-surgically
Eremin et al., Breast. 2009 Feb;18(1):17-25
Cohen et al., Psychosom Med. 2011 Apr;73(3):218-25
Guided
Imagery
NK Cell cytotoxicity
measured by
chromium release assay:
Measuring how well
the immune system is
destroying foreign cells
Cohen et al., Psychosom Med. 2011 Apr;73(3):21825
Insomnia
Stress
Isolation
Fatigue
Irritability
Sleep is a Powerful Healer
o Sleep deprivation results in poorer
immune function.
o Sleeping less than 7 hours is
associated with a three time
higher risk of developing a cold
compared with > 8 hours of sleep.
o Sleep durations of ≤5 hours per night
are associated with a significantly
increased risk of hypertension and
heart disease.
Gangwish et al., Hypertension. 2006; 47: 833-839,
Cohen et al., Arch Intern Med. 2009;169(1):62-67
Cancer Patients And Survivors Often
Struggle With Sleep
o 25 to 59% of cancer patients
have sleep disturbances.
o Increased daytime fatigue
o Impaired cognition
o Negative consequences on
employment, relationships,
quality of life
Howell et al., Annals of Oncology 25: 791–800, 2014
Sleep Hygiene:
Cleaning Up Your Sleep Habits In 7 Steps
o Mind the clock
o Work out
o Wind down
o Dim the lights
o Skip the coffee/alcohol/nicotine
o Avoid naps
o Relax
Howell et al., Annals of Oncology 25: 791–800, 2014
Harsora et al., Am Fam Physician 279(2):125-130, 2009
Relax? …But How?
o Mindfulness meditation
o Guided Imagery/ Visualization
o Hypnotherapy and Self-hypnosis
o Progressive Muscle Relaxation
o Gentle Yoga
o Expressive Writing
o Massage
o Acupuncture
Howell et al., Annals of Oncology 25: 791–800, 2014
Black et al., JAMA Intern Med. ;175(4):494-501; 2015
How To Maintain Weight and
Address Indigestion
o Small but frequent meals
o Making every bite count
o Staying active
o Abdominal massage
o Acupuncture
o Appetite stimulants
How to Choose Natural Supplements
Filtering the
information on
nutritional
supplements and
herbal medicines
can be difficult,
Graviola or Paw Paw
• In the laboratory: Leafs contain compounds that inhibit
cancer cells in-vitro and in animal models.
• Inhibits P-glycoprotein - thus influencing drug metabolism
• Neurotoxicity has been reported.
https://www.mskcc.org/cancer-care/integrative-medicine/herbs/graviola
Turmeric and Curcumin
o In the laboratory: inhibit tumor growth on cell culture and in
animal models
o Possible clinical anti-cancer effect seen in pancreatic cancer
o Curcumin inhibits cytochrome 3A4 enzyme.
https://www.mskcc.org/cancer-care/integrative-medicine/herbs/turmeric
Vitamin D
o Deficiency is very
prevalent in the US
(~41%).
o May be protective
against breast
cancer, colorectal
cancer, prostate
cancer.
o Check levels
o Be careful in case of
kidney disease.
Coriolus Vesicolor (Yun Zhi, Turkey Tail)
o Possible immunostimulatory properties
o Possible improved survival
rates when given in
conjunction with
chemotherapy
o Not standardized
o Certain preparations
enhanced cancer growth in
mice.
Nakazato et al, Lancet 1994; 343(8906): 1122-6
Niimoto , et al, Jpn J Surg 1988; 18(6): 681-6
Integrative Services
How Can Integrative Medicine Help?
o Acupuncture
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Pain
Hot flashes
Dry mouth
Neuropathy
Lymphedema
Nausea & vomiting
o Massage
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Postsurgical recovery
Lymphedema
Anxiety & stress
Fatigue
o Nutrition
– Supplement safety
– Weight loss/gain
– Digestive health
o Exercise
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Weight loss/gain
Dyspnea
Muscle tightness
Improve body image
Fracture prevention
o Mind Body
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Anxiety & stress
Depression
Fatigue
Nausea
More Patient Benefits
o Actively participating in one’s own care
o Learning tools to care for self
o Receiving nurturing therapies that release
endorphins
o Feeling safe and cared for
We help patients feel empowered by helping them
participate in their own recovery.
Thank You