Integrative Oncology and Its Role in Cancer Care

By Stacy D’Andre, MD,
Department of Medical Oncology, Mayo Clinic, Rochester, MN

What is integrative oncology?

Integrative oncology (IO) is a patient-centered, evidence-informed field of cancer care that utilizes mind and body practices, natural products, and/or lifestyle modifications from different traditions alongside conventional cancer treatment. Patients become active participants before, during, and beyond their cancer treatment. This holistic approach is an addition to standard cancer therapy and can help patients with the side effects of therapy, as well as improve cancer outcomes. Integrative clinicians may work inside cancer centers or medical centers or have free-standing private clinics. These clinicians can be nurses, advanced practice providers (APPs), physicians, or pharmacists with additional training in integrative, functional medicine or lifestyle medicine, and they provide a complementary approach to patient care. The goals of an integrative oncology clinic are to:

  • Improve quality of life
  • Decrease the side effects of treatment Improve cancer-related outcomes
  • Ensure the safety of dietary supplements and advise on alternative treatments
  • Allow patients another space to address their emotional and psychological well-being
  • Facilitate referrals to other providers who can assist patients with these goals

Helping patients with lifestyle changes

Healthy diet, exercise, managing stress, and improving sleep quality are all fundamental lifestyle factors that play a role in quality of life and may improve some cancer outcomes. Integrative oncology addresses all these factors. Mayo Clinic IO generally recommends a Mediterranean or plant-forward, whole-food diet. This includes consuming 5-7 servings of vegetables and fruits and a high-fiber diet as tolerated (beans, peas, whole grains). For most patients, it is best to avoid alcohol. Smoking cessation is also essential. Processed meats should be limited. Added sugars and refined or processed carbohydrates should also be limited, as blood sugar control may affect cancer outcomes. Our patients are often referred to a dietitian for more detailed information. Exercise has been shown to improve fatigue and pain and can improve outcomes for some patients after treatment. This has been best studied in patients with breast cancer and colon cancer. The general recommendations are to engage in 150-300 minutes weekly of moderate aerobic activity (or half this amount if vigorous) and twice-weekly strength training. Even patients with advanced cancer can benefit from regular physical activity, improving overall function, fatigue, and quality of life. A recent study showed that only 4% of cancer survivors are meeting the American Cancer Society’s (ACS) recommendations for healthy habits, so there is a lot of work to do to help patients with lifestyle changes. Consider following the ACS recommendations:

ACS Survivorship Recommendations 2022

  1. Achieve and maintain a healthy body weight throughout life. Keep body weight within the healthy range and avoid weight gain in adult life.
  2. Be physically active. Adults should engage in 150- 330 minutes of moderate-intensity physical activity per week. Children and adolescents should engage in a least one hour of moderate to vigorous intensity each day. Everyone should move more and sit less.
  3. Follow a healthy eating pattern at all ages. A healthy eating pattern includes foods that are high in nutrients in amounts that help achieve and maintain a healthy body weight. This means eating a variety of vegetables, such as fiber-rich beans and peas, fruits, and whole grains. Red and processed meats, sugar-sweetened drinks, and highly processed foods and refined grain products should be limited or not consumed.
  4. Limit alcohol consumption to one drink per day for women and two per day for men. It is best not to drink alcohol at all.

Many patients have insomnia during or after therapy. Poor sleep is associated with increased cancer risks and worse outcomes. Cognitive behavioral therapy and mindfulness techniques can be beneficial to help patients with insomnia. Stress is also a common problem in patients with cancer and may contribute to disease progression. Many treatments are available to help, including psychological therapies, mindfulness, yoga, qigong and tai chi, progressive relaxation, and breathing techniques. Behavior change, improving diet, increasing exercise, or changing other habits can be extremely difficult. Health coaching can be very useful for patients in helping to foster an improving lifestyle. Health coaches use motivational interviewing, a technique designed to help patients find their motivation for change. These self-directed changes are aligned with the patient’s values. Coaches help patients assess challenges and potential setbacks and set goals. It’s important to set realistic goals and to follow a regular path to achieve them. See image below for five important things to consider when goal setting. Checking in with a coach regularly also helps with problem-solving and accountability.

Goal Setting Chart

Symptom management
Patients have many symptoms from cancer or their cancer treatments. Aside from medications, there are several other approaches to help patients. Acupuncture is one of the most valuable tools to help patients with a variety of symptoms, such as pain, neuropathy, nausea, and hot flashes. It is an ancient practice of placing tiny needles in the skin that may interrupt specific nervous system pathways. Acupressure (therapeutic pressure from hands, elbows, or other body parts) may also be helpful for nausea. Mindfulness-based techniques (which can include deep breathing, progressive relaxation, meditation, and qigong) are highly recommended for anxiety and depression symptoms. These therapies may also help with pain management and insomnia. Medical cannabis can be considered for patients in some states and may help with pain, nausea, and possibly sleep. Most of the studies on medical cannabis that have been published are not of high quality, and much more research needs to be done. However, cannabis does have side effects, can be expensive, and is not available to all patients. Cannabidiol (CBD) alone has not been shown to be very helpful for patients with cancer.

Fatigue
Fatigue is the most common symptom that cancer patients face. This can be from treatments, such as surgery, chemotherapy, or radiation; cancer itself can cause fatigue. It is important to look for reversible causes of fatigue, such as improving a nutritional deficiency (iron or B12 deficiency anemia) or low thyroid or adrenal gland function. Many medications can also contribute to fatigue. Integrative methods can help, including exercise, qigong or tai chi, cognitive behavioral therapies, hypnosis, and mindfulness-based interventions. Wisconsin ginseng has been shown to help patients with fatigue, and Mayo Clinic is currently conducting a final larger clinical trial to study this in a broad group of patients.

Neuropathy
Many patients with Waldenstrom macroglobulinemia suffer from neuropathy from their disease or treatments for it. This can be a challenging symptom to treat. There are prescription medications, such as duloxetine, which may help. At Mayo Clinic, we will often check for any underlying nutritional deficiencies or high blood sugar that could worsen the neuropathy. Many patients will take vitamin B complex to help with neuropathy, but unless a patient is low in those vitamins, overdosing on B vitamins won’t help. Also, too much vitamin B6 can cause neuropathy. Acupuncture and medical cannabis may help with painful neuropathy. We conducted a clinical trial to test a low-dose CBD cream to help neuropathic symptoms and found that it did not help when compared to a placebo cream. More studies are needed on the different types and strengths of topical medications for neuropathy. Some patients use light therapy, but this has not been well-tested. Scrambler therapy administers electrical stimulation through the skin above and below areas of chronic pain and was approved by the FDA in 2009. The goal is to scramble the signals to the brain, so that the brain is retrained to think there is no pain in the treated area. Sessions are usually 30 minutes, and 3-12 sessions may be needed; this may not be widely available or covered by insurance.

Distress and mood disorders
Many patients with cancer experience distress, anxiety, or symptoms of depression. Psychological therapies such as cognitive behavioral therapy (CBT) and other supportive therapies can be helpful. There is currently insufficient evidence to recommend therapies such as psilocybin, Reiki, massage, light therapies, and other alternative therapies, but participating in clinical trials is always encouraged when available. Treating distress improves quality of life and can improve outcomes for patients with cancer. Social support is also essential to help with well-being, reduce the side effects of treatments, and improve cancer outcomes.

Dietary supplements
According to the US Food and Drug Administration (FDA), dietary supplements are intended to add to or supplement the diet and are different from conventional food. If a supplement is used to treat, diagnose, cure, or prevent diseases, the FDA considers it a drug, even if it is labeled as a supplement. Supplements are taken by mouth and come in many forms, including tablets, capsules, soft gels, gel caps, powders, bars, gummies, and liquids. Common supplements include the following:

  • Vitamins (such as multivitamins or individual vitamins like vitamin D and biotin)
  • Minerals (such as calcium, magnesium, and iron)
  • Botanicals or herbs (such as echinacea and ginger)
  • Botanical compounds (such as caffeine and curcumin)
  • Amino acids (such as tryptophan and glutamine)
  • Live microbials (commonly referred to as
    “probiotics”)

Up to 70% or more of patients with cancer are using supplements. Some of these, such as vitamin D or calcium, are recommended by their care teams. Supplements are not meant to “treat” or “prevent” cancer. However, many patients are using them for this reason. Many botanicals interact with cancer treatments and other common medications like blood thinners. Mayo Clinic will use supplements to correct deficiencies (such as vitamin D, B12, or iron) or help treat symptoms. One example is using Wisconsin ginseng for fatigue in patients on or off chemotherapy. It is essential for patients to let their care team know if they are taking or plan to take any supplements so that safety can be ensured. Also, supplements are not routinely tested or regulated, so it is important for patients to do their homework and look for products that have passed specific testing regulations (GMP, USP label).

Organizations like Consumer Labs test products and recommend the highest quality and most affordable supplements.

Alternative therapies
Some patients seek out alternative therapies to treat their cancer, rather than combine a standard cancer therapy with integrative methods that have been studied in clinical trials. These alternative therapies have not been well-tested in clinical trials or have not shown any benefits. One example of an alternative treatment is laetrile or apricot pits. This is a popular supplement on the internet and support groups. However, it has already been shown in clinical trials to have no activity against cancer and carries a severe risk of cyanide poisoning. Other alternative therapies include intravenous vitamin C, ozone therapies, coffee enemas, juicing, and hyperbaric oxygen chambers. One study looked at patients with curable cancers who chose alternative therapies and compared outcomes with those who chose standard therapies. The group that chose alternative medicines for the treatment of breast, colon, and lung cancers was 2-5 times more likely to die of cancer. The Mayo Clinic IO does not recommend these types of therapies unless in the context of a clinical trial. Integrative therapies
Many integrative therapies are available to help patients manage symptoms and improve their quality of life. For example, clinical trials of acupuncture have shown that it can help patients with pain, nausea, hot flashes, and sleep. Other types of integrative therapies are listed in the table below.

Integrative Modality Benefit
Acupuncture Improves pain, nausea, hot flashes, sleep
Acupressure/reflexology Improves anxiety/depressive symptoms (breast cancer)
Yoga Improves anxiety/depressive symptoms (breast cancer)
Tai chi/qigong Improves anxiety, balance, and lung function
Hypnosis Stress reduction
Reiki Relaxation, stress reduction, general healing (Note: not as well studied)
Mindfulness-based interventions Reduces anxiety/depressive symptoms, pain, insomnia
Massage Relaxation/stress reduction, improved muscle/joint pain
Aromatherapy Reduces anxiety, nausea

Summary
Integrative/lifestyle medicine can benefit patients navigating diagnosis, treatment, and survivorship. Improving diet, increasing exercise, reducing stress, and improving sleep quality are fundamental to enhanced well-being and health. Many integrative methods are also available to help with symptom management. A growing number of integrative and lifestyle clinicians focus on the care of patients with cancer, so ask your care team for a referral!

Dr. DeAndre

Stacy D’Andre, MD, is a senior associate consultant in the Division of Medical Oncology, Department of Oncology at Mayo Clinic in Rochester, Minnesota, with a joint appointment in the Division of General Internal Medicine, Department of Medicine. She joined the staff of Mayo Clinic in 2021 and holds the academic rank of assistant professor of oncology, Mayo Clinic College of Medicine and Science. Dr. D’Andre started a new Integrative Oncology Clinic at Mayo Clinic, with a clinical focus on helping cancer patients with lifestyle changes, including improving diet, exercise, sleep, and reducing stress.