S2E6 | Integrative care: Treating the whole cancer patient—mind, body & spirit
Pat Basu: Hi, I'm Pat Basu, President and CEO of Cancer Treatment Centers of America and the host of Focus On Cancer. On today's episode, we're going to dive into integrative care, an incredibly important aspect in the battle against cancer. My special guest today is Carolyn Lammersfeld, a registered dietician and a certified specialist in oncology nutrition who leads integrative cancer care at CTCA. Carolyn, thanks so much for being here.
Carolyn Lammersfeld: Thank you for having me today, Pat. I'm excited to be here.
Pat Basu: Well, as I said before, this is such an important topic in all of healthcare, but I would argue that it's probably... there's no other disease where integrative cancer is as important as it is in cancer care. Let's just start at the very top here. Explain to us, what is integrative care?
Carolyn Lammersfeld: If you think about being treated for cancer, you want as many tools in the toolbox as possible. So integrative care is traditional cancer care, chemotherapy, radiation, surgery, immunotherapy, and then adding supportive care services to those that can be helpful for managing side effects, maintaining or improving quality of life and helping people make lifestyle modifications for the future. Ideally under one roof and in a highly collaborative setting where everyone is communicating for the benefit of patients and to keep them safe.
Pat Basu: Fantastic. And it's such an important concept that I think intrinsically most people understand, but so often in American healthcare doesn't get delivered, that comprehensive, meaning complete, and that sort of coordinated level of care that, as I said before is a part of almost every medical disease. I mean, as a doctor, you want this in diabetes, you want this in cardiac care, but in cancer where I often say it's as much of a disease of the body as it is a disease of the mind and the spirit, this is particularly important. So, I think your definition really captures the addressing of all of that, but all of it in a coordinated fashion. And you mentioned the word side effect and side effect management. What do you mean by that?
Carolyn Lammersfeld: So what we do, or what ideally what you want is you want medical management of your side effects, right? So many, many things can be done there, but in addition to that you have services available. You mentioned emotional support, so behavioral health, naturopathic support, nutrition support, spiritual support, pain management, oncology rehabilitation, all of those individuals who have experience working with people with cancer, they're documenting in the same medical record as the patient's oncologists and oncology care team. And so it's very, very collaborative, high amount of communication to make sure individuals are using things that can potentially be helpful for what they're experiencing and also not interact with any of their traditional cancer treatments from a safety standpoint.
Pat Basu: Yeah, absolutely. And I think there can sometimes be a misconception in healthcare and in integrative cancer and cancer, that this is not a... we should be clear. This is not a replacement to unnecessary surgery or a chemotherapy or an MRI or an image guided therapy that might be required, radiation oncology in that category. This is a part, as you said before and probably worth consistently repeating, an entire package of therapy that wraps around the patient that is helping the patient. So it's not there to replace that radiation oncology treatment. It's there to help manage the side effects that may come from it, help manage a patient's ability to endure that, help ensure that through nutritional support that a patient is strong enough to endure their chemotherapy. So these things are not ors, they're not substitutes for, they're ands. They are adjunctive to each other. Can you kind of say more about that piece, because I think that is one of the misconceptions that I sometimes hear from patients.
Carolyn Lammersfeld: Absolutely. And it's an important clarification, and there are alternative medicine options out there, and this is not what we're talking about. We're talking about integrating some of these supportive care services with traditional cancer treatment. So you want the individuals providing your supportive care to know exactly what your cancer treatment plan is. So they know what you might experience, what you might be experiencing, what might be helpful and what's safe, but we're absolutely not talking about using any of these, diet, for example, any kind of diet or other approach to manage cancer, to treat cancer in lieu of traditional cancer treatment. It is a supportive role, and done in a collaborative setting where everyone is communicating and know where they can help from the evidence standpoint of what may help and not cause harm. And in many cases, some of our naturopathic support team are actually educating and counseling people and taking them off of things that they may be using that don't have any evidence of benefit for their type of cancer, or their type of treatment, or may not be safe. Herbs and other dietary supplements have the potential to interact with cancer treatments and make them less effective, which you wouldn't want, or potentially increase side effects, which is we're talking about managing, and again, potentially cause harm. So it's really having all those individuals work collaboratively, but definitely not a replacement for traditional cancer care.
Pat Basu: No, I think that's so well said, Carolyn, and you bring up such an important point that in our everyday lives are the medications we take, the diet that we ingest, even the metabolic rate due to our exercise or other things can have such an impact on how a medication gets processed and how it gets... the effect that it has in the body is influenced by so many other factors, and having an expert such as yourself, who is there ensuring that those interactions are being managed. We talk so much as physicians about drug- drug interactions, but there are drug- diet interactions. There are drug, lifestyle, habit interactions that are so important that you're managing. And in addition, one of the tough things about cancer is sometimes the therapy is just so, so hard, right? And it's about continuing that fight. There's a patient who one time, it was phenomenal, and he said to me, and he's a inaudible, " It was a fight between me and the cancer. And my goal was to fight harder until the cancer gave up, and the cancer gave up." But implicit in what he said to me and it stuck with me is that there is a duration of this fight where in his case, he had to put up with the loss of weight and the loss of strength, he had to put up with side effects like pain and nausea for some amount of time. And so much of why integrative care can be important is you're helping the patient cope with those side effects so that they can continue their fight. Can you kind of expound on that?
Carolyn Lammersfeld: Sure. And I think some people come in knowing that about cancer treatment and many come in maybe not understanding, or maybe not completely expecting the degree of, for example, sometimes pain, fatigue, nutritional issues, malnutrition, that they may be at risk for, or they may experience. So having that team of individuals that can continually be assessing for that, the whole team assessing for that and getting individuals in to see those services and learn about those modalities sooner rather than later. So that hopefully you're not losing a large amount of weight, which can delay treatment or interrupt treatment. And there are some smaller studies we look to out there, there are some studies where individuals, women who had a surgery for breast cancer were exposed to a psychologist led groups. That was the experiment. Then the control group did not have that usual care. And the individuals that had that support, that helped them with a number of different behaviors that where they could participate in their care and have some control, those individuals actually had improvements in their quality of life. And interestingly, had less ER visits, hospitalizations. And 11 years later, follow- up actually had lower risk of recurrence and lower risk of death from cancer. And then there are some newer studies that have actually looked at symptom manage monitoring, where individuals were... one group was monitored, one group received usual care. And the group that had their symptoms monitored and interventions at times when needed, not surprisingly did better too, as far as quality of life and some of those other things we look, like ability to continue cancer treatment to control their cancer.
Pat Basu: That's really powerful. You and I always approach cancer through certainly a couple of lenses. The first lens always being that human element, that mother standard of care that per individual. You absolutely hit on one of the things that makes this so powerful to me, is that there is overwhelming evidence, data driven, statistically significant evidence that doing this leads to better outcomes. Everything we're talking about here leads to greater survival, adding more years to life, greater quality of life, adding more life to years, as I like to say, and it's overwhelming. I mean, in our practice, Carolyn, I often say that one of the reasons I'm proud of the outcomes that we have in terms of survival is very much driven by the fact that we pay such close attention to symptom management. So I'm really glad that you mentioned that. And you also mentioned this idea that patients come at this with a differing level of expectation of what their treatment is going to entail. So when even if they know that there might be weight loss or hair loss or these side effects, just having that support structure, having the expertise to help them and sometimes their support to help them is so, so critical. So that is why it's important to not just offer pain management and nutritional support, which is core to what you do, but also individual counseling, treating sexual side effects, offering spiritual support. That's a big part of the comprehensive integrative care as well. Correct?
Carolyn Lammersfeld: Absolutely. And it can help with many of the things we're talking about pain, fatigue. There's a component of that. Even in managing nutritional challenges during treatment, sometimes being distressed or anxious or depressed can affect your ability to eat, some of that behavioral health. Those providers can help with different techniques, whether it be relaxation, guided imagery, meditation, hypnosis to help with that, help distract from pain. And again, group support. I mentioned the studies were it helped individuals have better outcomes. The other thing is many of these things are available for caregivers too, because we know when somebody has cancer, it affects the whole family. And you talked about relationships. So these providers can do traditional talk therapy counseling. And in addition to some of the other modalities I mentioned that can be helpful for managing side effects.
Pat Basu: Yeah. And in oncology care, we both know that I always said that the bedrock of cancer care therapy is catch it early, treat it early and treat it comprehensively. And sadly, one of the reasons that patients don't continue to treat something comprehensively is because they stopped the therapy due to side effects. And again, I keep making this parallel that it's super important in cancer, but it's relative to a whole bunch of other diseases. I know in diabetes and cardiac one of the main reasons of failure of treatment is patients don't adhere to their treatment regimen. And that's taking a handful of pills a day. This is in cancer care, just a brutal myriad of therapies sometimes that a patient has to run the gauntlet on. And it's just asking so much for patients to do that, that offering the support just dramatically increases the likelihood that they will continue treatment as opposed to delaying it, interrupting it, or stopping it. So talk about that capability, and to the extent that you can, any evidence or outcomes that you have to show that patients delay their treatment less or interrupt their treatment less or stop their treatment less because of what you and the team do.
Carolyn Lammersfeld: Yeah. I mean the studies I mentioned with a psychology led support, I mean, that showed it helped people stay on treatment, symptom monitoring and interventions when needed helped people stay on treatment. There's this concept, I think you're alluding to it, called patient activation and the more the care team, really everybody on the care team, but specifically behavioral health providers can help individuals participate in their care and deal with distress, pain. Anything they may be impacting their ability to be compliant to, if it's an oral medication, or be able to come in and have the recommended amount of cancer treatment at the right time, having all those resources is incredibly important. And as you said, the research is there, there are practice guidelines now that are coming out from organizations like the Society for Integrative Oncology that have been adopted by the American Society of Clinical Oncology that really show how these services, if you will, and these modalities can help individuals with those side effects or symptoms that may impede their ability to continue care.
Pat Basu: Fantastic. And on previous episodes of the show, Carolyn, I've spoken to doctors about important topics that I think are to be brought to light for patients and caregivers and other listeners. What I love to do is just kind of drill down into a kind of a specific example, because I think probably as people have heard you talk, they think, " Well, yeah, I get it. That makes a lot of sense," but let's really explore kind of how this works. So let's say a patient develops malnutrition while they're on chemotherapy, or they develop chronic nausea. Walk through the patient experience or exactly how does this work for a patient who might be experiencing one of those side effects?
Carolyn Lammersfeld: Yeah. Yeah. That's a great example. And malnutrition, you may not think of it as being something where you need an interdisciplinary approach or an integrative approach, but it's a really good example where again, having more tools in the toolbox is better. So the obvious things, again in addition to medical management, so there are times when the supportive care team is collaborating with the oncology care team. Even sometimes suggesting a medication, if you will, if other things aren't working or you're helping individuals be compliant with medications. But so with my nutrition background, I'll start there, there are things that can be done to help people modify maybe foods they're taking in, modify meal schedules. Sometimes it's actually adding up oral nutritional supplement or liquid nutritional supplement. Many times it's easier to drink nutrients or drink your nutrition at various times during the journey, it could be adding other supplements. I think you mentioned treating nutrient deficiencies, so there may be supplements. Ginger products, so ginger tea, ginger ale that actually has ginger in it. Many of the things on the shelves do not, but there are some where just an ounce can give an amount of ginger that can be helpful. And then in addition to that, oncology rehabilitation, so having physical therapist, for example, help make sure individuals are exercising in a way they can, given their situation to maintain muscle mass, even occupational therapy. So individuals can do their daily activities of life, like prepare food. And then you layer on, I think I mentioned earlier behavioral health to deal with any anxiety, distress, depression that's impacting eating or distraction techniques for nausea, pain. And then naturopathic support, so there may be other natural products that can be added that can help with what we call nutrition impact symptoms or symptoms that are making it difficult to eat, and even address some of the underlying metabolic changes that can happen from cancer and cancer treatments. So that's an example, and I said behavioral health, but it could just as easily be spiritual support. So some individuals would prefer to maybe have some of that support from a chaplain. So that's an example of really where everyone on that supportive care team we mentioned is important for managing nutritional issues and specifically malnutrition during treatment.
Pat Basu: Well, that's a great example, Carolyn, and not only are they all working on the same problem for the patient, but unlike so many other aspects of the American healthcare system where maybe it's a provider seeing a patient in a vacuum, these members of the team are not only working directly with the patient. They're also staying in close coordination with each other. Right?
Carolyn Lammersfeld: Right. Absolutely. Many times working in the same general area, sharing consultation rooms, if you will, there are often huddles, rounds where the team is, again, talking about patient care together and understanding what's happening and suggesting where they might be helpful or where someone else might be helpful that isn't present at that moment. And the fact that everybody's working in close proximity, documenting the same medical records, so that information would be there, but more real time, you could share some concerns what was discussed. It also can prevent somebody having to answer the same questions, " That person that was in here just asking me the same questions." And so being able to relay some of that saves some time repeating questions for individuals.
Pat Basu: Well, Carolyn, I think that's just such a great walk through and an example on an incredibly common issue or side effect that patients deal with in the nutritional realm or in the nausea and vomiting realm. Another one that is just incredibly common in cancer patients that a study by the National Cancer Institute shows, that maybe up to 50% of patients deal with pain as a major side effect, and up to 80% with advanced stage cancer. So pain is certainly one of those areas that is, it can be debilitating for patients. It can be a reason why they stop or interrupt their treatment. Oftentimes it can be a metastatic disease. It can be mass effect. It can be just other, sometimes harder to diagnose sources of pain. And so there's a variety of medical techniques that we use to try and address a patient's pain. In addition to that, tell us how the integrative care approach works to handling a cancer patient's symptoms of pain.
Carolyn Lammersfeld: Sure. So yeah, in addition to the medical management, which you mentioned, and many times we will get consults or referrals from that team. So as you can imagine, oncology rehabilitation would be very much involved with somebody with pain. So you may have a physical therapist working on range of motion exercises, an occupational therapist helping individuals be able to do their activities of daily living shower, prepare food, go to work, speech therapy if there's pain with swallowing. So there might be texture modifications for food. Then of course the nutritionist or dietician can help with that as well. And then swallowing exercises that can help. Behavioral health, we talked a little bit about that. So there's, in addition to counseling and talk therapy about how distressing pain can be, there also are some modalities like relaxation training, guided imagery, meditation, hypnosis, a number of techniques that can be taught that individuals can do on their own that has been shown to help at least distract from pain in combination with some of the other therapies and medical management. So those are a couple examples of how pain might be addressed. And again, spiritual pain so individuals may want to talk with the spiritual care team about those types of issues, whatever they may be. Some of those questions we have when we have pain and we're dealing with a serious illness.
Pat Basu: Absolutely. I mean, the very definition of a symptom that all of us as human beings acknowledge and look to seek relief from. But as I mentioned before, is such a common occurrence in cancer patients, but such a powerful integrative therapy that you and the team help lead. So I think we've talked about a really common example and in the nutritional arena, in the pain arena, just there's a couple of more that I think are very common. Sadly, emotional and behavioral conditions are very, very common during the course of treating cancer. And studies show that at least a third of patients experience some emotional or behavioral distress, just personally speaking. My personal opinion is that it's probably way higher than that in talking to patients. I think it's almost ubiquitous that patients struggle with some behavioral challenge during this time, and integrative care is a very powerful therapy for that. Let's transition to... we've talked a lot about the active therapy, but one of the bright spots in cancer care, something that I know we're very proud of, is survivorship. The idea that we have more cancer survivors today than at any other point in human history. I certainly believe it's due to the advances in cancer care, including integrative care. As the effect on survivorship is more positive, the better we get at treating it, we have now up to 17 million, 18 million survivors in the United States. And integrative care is not just useful in the active disease of cancer, but also in the survivorship phase. Isn't that right?
Carolyn Lammersfeld: That's correct. Yes. In fact, survivorship care plans have a lifestyle modification included in them. And so that can include diet, exercise, smoking cessation. So for example, and I mentioned these services, one of the benefits is helping people with lifestyle modification for the future, survivorship, which can be started during treatment. So diet is an important component of that. Obesity is one of the risk factors for cancer, cancer recurrence that many people are not aware of. Next to smoking, it is the leading modifiable risk factor for 13 cancers. And there's some projections that by 2030, it may overtake tobacco as a risk factor. So working with diet and exercise, if people have extra body weight, helping them lose that, and the diet recommendations for all cancer survivors can help with that. So moving towards more of a plant- based diet with less meat, less processed foods, refined food, sugars, and maybe smaller portions for individuals who have extra weight. Exercise, the current recommendations are 150 to 300 minutes of moderate activity per week. It could be 75 to 150 if you're vigorously exercising, and many people don't reach those targets. So helping individuals find a plan in survivorship where they can move that amount, smoking cessation, being careful with alcohol, if consumed at all. So those are some of the lifestyle modifications that can be started during treatment and continue after treatment. And then that information is shared with individuals, hometown physicians, primary care providers. Then also part of that survivorship care plan is what tests, what screening, surveillance need to be done in the future to watch for a potential recurrence in other cancer or another chronic disease that may need to be managed.
Pat Basu: Well. Absolutely. I think that's right on. I think it's such a powerful solution for survivorship. And you mentioned surveillance for recurrence, the risk factor for a survivor, a cancer survivor, developing another type is a significant, something that happens to one in six cancer patients. So to put that number in context, if there are, let's call it 18 million cancer survivors in the US right now, then 1/ 6th of that could be approximately 3 million secondary cancers in those patients. So a huge, huge number, and speak a little bit more about the role of integrative care and in helping surveil and prevent a secondary cancer recurrence.
Carolyn Lammersfeld: Yeah. So I think it's what's part of that care plan. So it's diet, it's activity, it's helping individuals find smoking cessation programs if they're still smoking. It may be working with our behavioral health providers here. If somebody needs help with alcohol consumption, we start that during treatment and then help coordinate with individuals, providers at home, help them find resources at home to continue that lifestyle modification plan, if you will, into survivorship. And I think what's encouraging if... one thing that's come out of the COVID pandemic is the emergence of more tele-health and virtual options. And so I'm encouraged too... we're finding resources and there will be more, helping individuals have access to those types of options to help reinforce these lifestyle modifications in survivorship.
Pat Basu: Well, that might be a great place to conclude. I think you've done such an amazing job of showing us what integrative care is, the evidence behind how powerful it is in preventing and treating and allowing greater survivorship and greater thriver-ship, as I like to call it, in cancer care. But paint for us your vision, how will integrative care evolve and change over the next five to 10 years? What can we, what can we expect and look forward to?
Carolyn Lammersfeld: Yeah, so I mentioned earlier that the Society for Integrative Oncology, the American Society for Clinical Oncology are collaborating to develop more practice guidelines that incorporate these supportive services based on evidence and safety. And so I think we will see the more of these guidelines, the more these support services, if you will, will be included into standard of care or clinical pathways, so that more people have access to this during cancer treatment. And we're talking about cancer, but as you've mentioned, other chronic diseases, the emergence of telehealth and virtual care, so that will help with access too. I think individuals will be able to access these services in their home when they need it. We always say, you want to provide the right service for the right patient at the right time. And that enables that. Yoga, I mean, all of these things can be done virtually, so they don't have to be done where somebody is having their care. And then hopefully we will have more information with personalized medicine, genetics and genomics and the microbiome, things in your gut that may influence treatment side effects, have more of that available to actually personalize all of these services and modalities, if you will, that we've discussed. Because it's not a one size fits all solution. And what works for me may not work for you. And hopefully we will have more than information at our fingertips 5, 10 years from now to be able to further personalize these options as well.
Pat Basu: Absolutely. Well, so much to look forward there. And finally, Carolyn, just I know you personally as a colleague, and I know how amazing you are with patients. What advice might you have for any of our listeners who may have heard this episode or things that you'd want to leave them with?
Carolyn Lammersfeld: Yeah, I think it's important to consider having these options. Again, the more tools in your toolbox, the better, so consider having these options available to you. And one of the things we didn't discuss is it's really important that... some people will try and do some of these things on their own, and making sure that if you are trying to... because access can be challenging, trying to do some of this on your own, that you are at least running it by your care team and individuals who know your cancer, know your treatment to make sure it has the potential to help and not harm and it's safe. I think access is improving and it will continue to improve. Don't be afraid to ask your care team, if these things are available where you're being treated. They may be and you just haven't been oriented to them. And if not, can they help you find these types of providers that have background in cancer and will communicate with your oncology care team to make sure you're safe.
Pat Basu: Well, thank you. Thank you so much for ending with that advice. Thank you so much, Carolyn, for taking the time. I think this has been just a really fantastic dive into, as I said before, a remarkably powerful area of fighting and treating cancer. So thank you for all that you do. Thank you for taking the time for being here and really appreciate it. We'll talk to you soon.
Carolyn Lammersfeld: Thank you. Thank you for having me.
When you’ve been diagnosed with cancer, you quickly learn that fighting the disease itself is only half the battle. There are also other impacts on your life—from side effects like pain and nausea to changes in your relationships to learning to manage long-term effects as a survivor after treatment. That’s why it’s important to have an integrative care plan that incorporates side-effect management, social support, and survivorship into your cancer treatment regimen. On this episode of Focus on Cancer, our host, Pat Basu, MD, MBA, President & CEO of Cancer Treatment Centers of America® (CTCA), welcomes Carolyn Lammersfeld, Vice President of Integrative Care Services at CTCA®, for a robust discussion on integrative care and its important role in the cancer journey.