Читать книгу Bridging the Gap - James Eugene Munson - Страница 11

“A doctor, like anyone else who has to deal with human beings, each of them unique, cannot be a scientist; he is either, like the surgeon, a craftsman, or, like the physician and the psychologist, an artist.”

W.H. Auden

Cancer is a complex condition encompassing hundreds of diseases within its presentation. Its characteristics are extensive, ranging from slow cellular division to fast, aggressive proliferation. The potency of this ever-evolving disease necessitates innovative and integrative therapies. The philosophy of IO was born from this awareness, a commitment to science and evidence-based medicine, while also recognizing therapeutic value in complementary modalities like traditional Chinese medicine. IO advocates conceptualize a framework of collaboration among medical paradigms to achieve a curable outcome that empowers the patient as well as the body’s ability to heal. The symbiotic energy of both the cause (cancer) and the effect (IO) harness the focus of Western and complementary medical systems due to its complex nature. This investigation is ideally done alongside patients and their loved ones to explore the capacity of healing through integrative approaches. As a result, IO practices are further empowered by the disease it seeks to manage and because of this, therapies outside the scope of conventional medicine are becoming implemented in the clinical environment.

For practitioners of Chinese medicine this is good news. At the forefront of the evolution of integrative medicine in the West, we are participants in early waves of collaborative treatment approaches that implement a range of complementary modalities alongside biomedicine. This is occurring at small public health clinics and also at large private hospitals where a range of services are valued and accepted more than ever before. Consequently, there is a momentous opportunity to bridge the gap between medicine of the West and the East. But building this bridge does not come seamlessly and without its challenges. Add in the complexity of a disease like cancer and the guidelines of integration become even more convoluted. As doctors of TCM, we honed our skills in Chinese medical oncology. It appeared only natural to lean into IO and explore its parameters, curious about the role of Chinese medicine within it.

We posed two simple questions as we embarked on this exploration. First, where does IO originate? In Chinese medicine diagnosis, the root must be examined to understand the branch. Its history would impart perspective on its evolutionary process as a prominent figure in the multitude of cancer management techniques. Secondly, what is the agreed upon definition of IO? Ideally, this clearly elucidates IO’s core mission and with equal importance, to inform complementary providers, like us, the degree to which Chinese medicine may or may not be an equal part to a greater whole. The simplicity of these queries unveiled the incredible complexity of this specialty. In a relatively brief period of time, as a result of on-site internships and doctoral research that analyzed IO programs, it became clear that the ideology of collaborative cancer care is inherently different from clinical applications at the ground level.

The Origins: Integrative Medicine

Every modality of medicine can be traced back to its historical origins, a link to the natural evolutionary processes that occur through experience, time, and sharing of information that led to its maturation. Integrative medicine is an example of this. It is an illustration of scientific advancement combined with perspectives that acknowledge the whole body, relating physical and emotional elements with disease presentation. This movement has gained significant momentum within the last few decades in the West as individuals grow increasingly frustrated with healthcare systems that appear depersonalized by doctors who have limited interaction time with patients and seem to follow medical flow-charts to reach diagnoses and treatment strategies. In our clinical experience, this is often what we hear from new patients who express their frustration stating, “My doctor can’t do anything except prescribe anti-inflammatories for the pain, so I thought I’d try acupuncture.”

Time and again we consult with individuals seeking complementary modalities to achieve health goals through more natural means and quite simply, conventional medicine struggles to meet these demands. We highly regard this patient curiosity because it empowers individuals to actively participate in their own health and wellness, from illness prevention to recovery. Thus, the limits of allopathic medicine to treat the whole person, dissatisfaction with standard medical care, and a burgeoning field of mind-body medicine shifted the healthcare paradigm. Patients created their own integrative health system by blending a myriad of disciplines: physical exams with their primary physician, access to medication and emergency services, in combination with holistic, natural medicine to address chronic, underlying conditions that encompass the whole person. Naturally, this resulted in integrative medicine (IM) designs that generated a following by larger health institutions, which incorporated mind-body modalities, like yoga or meditation. These early inroads of medical integration provided a refreshing perspective on medicine, an improved outlook on wellness and empowered individuals to do more than merely “take their medicine and call the doctor.”

It is not surprising that subspecialties were born from the foundation of IM. It is even less astonishing that integrative approaches surfaced in the field of oncology. While there are no exact origins of integrative medicine, nor can we link its popularity to a particular individual or institution, there are certainly major influencers, such as Dr. Andrew Weil. Dr. Weil is a classically trained Western medical doctor who pioneered early efforts to align allopathic and holistic medicine. One of the earliest publications on the topic of integrated cancer treatment is co-authored with IO proponent Dr. Donald Abrams. In their book entitled, Integrative Oncology, Dr. Weil outlines the fundamental components that embody an ideal relationship between medical paradigms. He states, “Integrative medicine does include ideas and practices currently beyond the scope of the conventional, but it neither accepts conventional therapies nor accept alternative ones uncritically. And it emphasizes principles that may or may not be associated with CAM (complementary and alternative medicine).”¹¹ Four major tenets are proposed as part of the integrative medical model proposed by Dr. Weil:

•The natural healing power of the organism

•Whole person medicine

•The importance of lifestyle

•The critical role of the doctor-patient relationship¹²

This viewpoint delineates central characteristics of IM and essentially sets the stage for Western trained physicians to approach patient healthcare and the treatment of disease with strategies that extend beyond linear medicine. These core values illuminate the future landscape of integrated healthcare. It recognizes the individual as a whole system, beyond quantitative measurements based in reductionist biomedical theory to diagnose and treat illness.

The IM principles noted above are embedded in the rich clinical history of Chinese medicine, which was developed thousands of years ago. These core values are not new to those trained in Chinese medicine. They are as inherent to the practice as yin-yang theory. The TCM physician observes disease as a result of imbalance through any combination of vital substances, energy and physiology. The ability to discern the cause of illness results from diagnostic skills that take into account the entire constitution, the whole person. There is no separation within the living organism, and through specialized skill and techniques, TCM optimizes the organism to heal itself. In order to support the body to restore health, the physician utilizes multiple pillars and techniques of the medicine to advise the patient on diet, lifestyle and emotional wellness. Thus, integrative medicine was happening long before modern definitions of it. And yet, because our medical philosophy aligns with Eastern traditions in a Western dominated medical system, Chinese medicine remains heavily scrutinized as researchers seek definitive scientific explanations for how it works, instead of trusting its empirical research and dynamic medical scope.

This reluctance provides insight into Chinese medicine’s limited position in the IO specialty. Is it science or merely an esoteric medical art? It is a great question, some say debate, in our profession as to whether TCM is art or science. If it is the former, the likelihood the entire system of Chinese medicine is ever entirely welcomed into open, allopathic arms is slim. Within the spectrum of Western standards, TCM is not a science, given a deficiency of evidence-based results that indicate clear measurements of success. In a seminal book about Chinese medicine, The Web That Has No Weaver, Dr. Ted Kaptchuk aptly addresses this idea stating, “If we mean by science the relatively recent intellectual and technological development in the West, Chinese medicine is not scientific. It is instead a prescientific tradition that has survived into the modern age and remains another way of doing things. But it does resemble science in that it is grounded in conscientious observation, of phenomena, guided by rational, logically consistent, and communicable thought process.”¹³ In this construct Chinese medicine, true to its nature, weaves among philosophies of medicine as art and among the confines of medicine rooted in science.

Whichever perception of TCM, science-based medicine leads the charge in the West. Double-blind, randomized studies determine standards of medical intervention, but Chinese medicine is a system that cannot be measured according to these rigid scientific criteria. While there are numerous studies that demonstrate its potential (namely acupuncture), it remains under the microscope, cautiously accepted and subject to Western clinical guidelines. The outcome has resulted in treatments that employ only technical methods of acupuncture therapy for acute patterns or with respect to oncology, palliative care. This is evident in integrative medical facilities that hire licensed acupuncturists and only permit needle-based treatments to address nausea, fatigue or cancer-related pain and prohibit the range of diagnostic methods or techniques integral to TCM. This grossly limits the capacity of Chinese medicine. These barriers will be further explored in this chapter, but first we follow the path from the foundation of IM philosophy into the vast realm of integrative oncology.

From Integrative Medicine, To Integrative Oncology

The endeavor to explore the culture of IO began in 2013 as a byproduct of doctoral research in Chinese medical oncology and a growing specialty in cancer. Even before pursuing a doctorate in TCM, there was a palpable energy emanating from our cancer patients who used the buzzword “integrative oncology” with hope and expectation. While much can be assumed from the terminology and inferred through professional experience, it still required closer analysis. Thus, having focused entirely on the history, evolution, principles and treatment of cancer from a TCM viewpoint, it was only natural to juxtapose this same data to conventional oncology. This examination reviewed the parameters of this multidisciplinary medical approach, carefully peeling the layers away from the ideology of collaborative medicine in order to glimpse at actual practices where the role of Chinese medicine was more closely scrutinized.

The process of discovering a unified definition of IO unveiled extensive interpretations that spanned from prominent cancer hospitals to private clinics. A proponent of collaborative medicine, Dr. Stephen Sagar explains the discipline as, “…both a science and a philosophy that focuses on the complexity of the health of cancer patients and proposes a multitude of approaches to accompany the conventional therapies of surgery, chemotherapy, molecular therapeutics, and radiotherapy to facilitate health.”¹⁴ In addition, Dr. Sagar points out that IO philosophy encompasses socio-cultural components to care, recognizing such implications that influence decision-making, as well as access to self-empowering resources that are financially stable, safe and that improve outcomes. This reflects a very real concern in the spectrum of oncology familiar to allopathic and complementary doctors alike: cancer patients are seeking curative outcomes and the diagnosis has the potential to lead vulnerable patients toward therapies that are possibly dangerous, ineffective and carry a hefty price tag.

For example, we consulted with a patient diagnosed with stage III colon cancer actively seeking a multitude of opinions following a surgical resection. His oncologist prescribed chemotherapy to treat the remaining cancer cells, but this patient refused, expressing a deep, visceral response to allowing “toxic medicine” into his body. Point blank, he asked if Chinese medicine could cure his cancer. This question provides the TCM doctor with an immense opportunity that benefits the patient in two ways. First, recognize that in this specific case the patient was seeking a fast, straightforward cure. Medical ethics override any discourse that insinuates Chinese medicine as a singular therapy to quickly eradicate his cancer cells. But this also opened a dialogue that informed him about the principles of Chinese medicine oncology for cancer management, and how it integrates with conventional treatments from acupuncture and moxibustion to herbal medicine. At the follow-up appointment, he shared his decision to opt for an alternative therapy at an “integrative cancer center” even though it was extremely costly and not covered by insurance. His understanding of the treatment was vague, but he was compelled by the case manager who reviewed his diagnosis and proposed the course of treatment. He was told “in two months you’ll be cured.” We asked questions about this protocol to determine its potential harm or efficacy and explore its parameters. However, he was uncertain as to what medicine, vitamins or supplements he would be treated with for those two months.

The outcome of this case is unknown, as the patient proceeded with the alternative therapy and did not follow-up. These interactions occur in TCM cancer management, and patients should feel empowered to ask questions, seek multiple opinions and ultimately make the best choice for themselves. Of equal regard, however, is the integrity of the clinician to listen and inform the patient within their scope of practice. The clinician’s role should never be to exploit or promise a healing outcome. An integral strength of Chinese medicine is its duality to observe the whole person, diagnose according to constitution and deliver medicine through skilled treatment protocols, which optimize the healing process. And in some cases, this aligns with curable outcomes as a result of balanced integration. This is the message we share with cancer patients.

This patient’s interaction provides insight as to why a singular, agreed upon definition of IO did not exist for many years. Countless medical disciplines and providers in cancer care had the autonomy to label a particular therapy or practice as “integrative” regardless of proven, therapeutic efficacy. Thus, the merge of a multitude of modalities interconnected to the framework of conventional medicine lead to variable interpretations of IO. What ensued was an ambiguous medical melting pot that ultimately impacts those navigating collaborative treatments. In response to this confusion, as well as an apparent demand by cancer patients seeking complementary therapies, the Society of Integrative Oncology (SIO) was established in 2003.

The SIO platform promotes communication among cancer providers, including classically-trained Western physicians, practitioners of Eastern medicine, naturopathic doctors, massage therapists, herbalists, social workers and professionals committed to cancer management and recovery. It is instrumental in the advancement of multidisciplinary systems of care. Regardless of discipline, members share a common goal that promotes evidence-based standards of integrative oncology. It proposes an awareness and sensitivity of the patient’s mental, emotional and spiritual wellness, while combining mainstream care and complementary therapies to treat the whole person.

The management of cancer requires a delicate balance of interventions focusing on two simple principles of equal measure: eradication of the disease and optimizing the body’s innate ability to heal. Biomedicine takes the role of “attack therapy” directed at the cancer cells, while complementary modalities aim to strengthen the cancer patient and potentiate healing. Illustrating these methods of integration are renowned cancer hospitals, such as Memorial Sloan Kettering Cancer Center (MSKCC), MD Anderson Cancer Center, Mayo Clinic, and Cancer Treatment Centers of America (CTCA). Each facility has implemented IO programs that encompass these elements of care reflected in its language, distinctive structure and tone, which are demonstrated by a wide variety of therapies and how they are defined. The most common modalities include acupuncture, mind-body medicine, yoga, Qigong, massage therapy, and nutritional and dietary advice. Despite the myriad differences among them, the philosophy of IO weaves through a system that is centralized around conventional medicine protocols, such as chemotherapy, radiation and surgery, which all may be supported by adjunctive therapies. With equal, if not greater value, is the premise that IO practices are founded in evidence-based medicine and scientific findings.

This philosophy is evident in a growing number of hospitals implementing IO practices. Program features display a variety of therapies and services that demonstrate the aspects of the integrative oncology paradigm. For example, the University of Texas MD Anderson Cancer Center offers therapeutic modalities such as acupuncture stating, “The Integrative Medicine Program engages patients and their families to become active participants in improving their physical, psycho-spiritual and social health. The ultimate goals are to optimize health, quality of life and clinical outcomes through personalized evidence-based clinical care, exceptional research and education. We provide access to multiple databases of authoritative, up-to-date reviews on the evidence and safety for the use of herbs, supplements, vitamins, and minerals, as well as other complementary medicine modalities.”¹⁵

The MD Anderson IM program was established in 1998 and is one of the earliest models of collaborative cancer care. A brief overview of their program characteristics will demonstrate standard clinical integration common to IO centers. The gateway to adjunctive therapy options begins with a consultation led by a Western-trained doctor who outlines various modalities, reviewing the benefits and risks. Nutritional counseling, oncology massage, exercise therapy, meditation, health psychology, music therapy and acupuncture are examples of services cancer patients may access upon physician approval. The primary function of these supportive modalities is to reduce side-effects of conventional medicine, improve quality of life, mental outlook, and optimize outcomes. IM practitioners collaborate weekly to review cases, devise treatment plans and maintain shared access to patient records.¹⁶ Its framework offers elements of integrative, patient-centered care in the management of cancer.

Closer examination of Chinese medicine’s role within this structure indicates vast therapeutic limitations. First, acupuncture is the only modality of TCM offered at MD Anderson. The literature explains its function is to reduce side-effects related to conventional medicine, such as neuropathy, hot flashes or dry mouth, and it also can promote well-being to alleviate stress.¹⁷ While acupuncture is effective for those ailments and should not be discounted, there is a significant lack of detail about the system of Chinese medicine. Yes, acupuncture addresses acute physical side-effects, but this occurs as the therapeutic outcome after diagnostic assessment of the whole person. The insertion of needles according to simple point indications grossly undermines the capacity of the medicine. A comprehensive diagnosis enables the practitioner to treat the symptoms, what is referred to as the branch in TCM, and simultaneously address the root, or underlying condition.

Unfortunately, this does not appear to be happening at the ground level. In October 2018, a news source for all things TCM, Acupuncture Today interviewed a licensed acupuncturist employed at the integrative medical center of MD Anderson. On the periphery, the picture of acupuncture as part of the integrative oncology model appears collaborative. Each practitioner treats 30–50 cancer patients per week, and clinical staff participates in interdisciplinary meetings to review cases. According to the source, “At these meetings, as an acupuncturist, I can openly discuss the pathology of cancer in Eastern medicine terms and share different ways we can intervene.”¹⁸ When acupuncture therapy is the only modality at the disposal of a trained Chinese medicine physician, what are the remaining interventions possible? The interview proudly highlights this union of disciplines, but in doing so, it also unveils definitive boundaries within its integration. These are evident in the following ways:

•Acupuncture therapy first requires pre-authorization by a medical doctor

•Development of the integrated treatment plan does not include the licensed acupuncturist’s presence and professional input

•Herbal recommendations or formulas are not permitted

•Moxibustion therapy is not allowed

The guidelines and procedures set forth demonstrate how the Chinese medicine practitioner is merely a technician. Such facts, again, illustrate a real discrepancy in the integrative paradigm. The merge of disciplines is also made clear by the practitioner’s approach to the language of medicine. The practitioner in the interview asserts that acupuncturists must consider their role in integrative hospitals as providers responsible for acclimating to the Western medical environment. It is upon us to bridge the gap, communicate on their terms and weave into conventional standards. As an example, he suggests, “…instead of discussing Qi with a medical team, we should speak more of how acupuncture can affect the production of endogenous opioids or reduce inflammation. Instead of relying solely on pulse and tongue, looking through MRI/CT or PET scan to gain intimate knowledge of tumor location or surgical changes is essential.”¹⁹

Chinese medicine doctors should be familiar with Western biomedicine, cancer diagnosis, tumor pathology and treatments. The ability to dialogue with an oncologist is necessary, and providers must become well-versed in the medical vocabulary associated with neoplastic disease. In modern medicine, there is always an opportunity to translate our terminology in order to clarify its purpose. We argue, however, that if the ideology of integrative oncology relies upon collaboration and equal regard for other disciplines, then Western physicians must also learn our language as well. This goes beyond palliative care referrals. We are inviting our colleagues into the medical acumen of Chinese medicine.

The program at MD Anderson Cancer Center is one example of an integrative oncology model. From this established perspective, we present a brief comparative analysis of an equally renowned cancer hospital, Memorial Sloan Kettering Cancer Center (MSKCC). Between the two reputable facilities, there are obvious overlaps and similar philosophy toward integrative practices. MSKCC has designed a broad integrative department that promotes multidisciplinary avenues in cancer management. In addition to program offerings, it is a leading research institution. As such, it has carved a pathway enabling greater access to complementary therapies alongside conventional treatments. Cancer patients consult with a physician or nurse specialist to coordinate an “integrative care plan,”²⁰ and patient records are shared among disciplines. The IM model is well-designed with a multitude of classes, workshops and services available to cancer patients. Individual therapies include acupuncture, both private and community style, as well as Swedish, deep tissue, or lymphedema massage. Mind-body therapies, medical Qigong, Reiki and Shiatsu are also available. All of these are fee-for-service, on-site at the IM facility.

The indications promoting the use of acupuncture for cancer and its related symptoms align with those previously noted at MD Anderson. They emphasize palliative care protocols to reduce side-effects that correlate to the disease or conventional treatment. An equally short description of acupuncture, MSKCC notes it is a form of traditional Chinese medicine validated by science through its ability to “…stimulate the nervous system to release certain chemicals in the brain.”²¹ This highlights a challenge Chinese medicine contends with in modern medicine. It gains relevance when validated by scientific methods, ushered into programs only after having determined its efficacy as safe and nonthreatening. However, this message does not encompass an integrated viewpoint. It leans West and into scientific interpretations. This discounts thousands of years of empirical research and methodology engraved in TCM. So, the Chinese medicine profession is caught between both paradigms, science and art. While this may appear to be self-limiting and an undesirable position for the profession, it actually illustrates the flexible nature of Eastern medicine to evolve alongside our conventional colleagues, as well as the disease itself.

How does this flexibility occur? Quite simply, the field of TCM has the benefit of an extremely well-rounded education. Practitioners adhere to classical texts, relying upon empirical research of physicians more than three-thousand years ago to detect and prevent disease. But this philosophy and method is not accepted in modern medicine paradigms. We cannot casually reference the classical interpretation of tumors from the Nei Jing when discussing a case with an oncologist. Fortunately, at least half the didactic coursework for licensed acupuncturists is biomedicine. Medical terminology, anatomy, physiology, physical exam, lab analysis, red flag/emergency cases are all included in the curriculum to an almost equal measure. This means, we have an unseen advantage because of this comprehensive training. TCM doctors review and interpret pathology, physiology, and allopathic treatments and then (sometimes immediately) shift these findings into Chinese medicine concepts to create an individual treatment plan. Essentially, simultaneously translating from one medical language to another.

While this process can be straightforward for the common cold, when it comes to cancer, nothing is easy. Communication is imperative among providers of different training with equal regard for education, skill and expertise despite these known differences. Perhaps the acupuncturist at MD Anderson is accurate, and this duality assumes that the TCM profession is responsible for dialoguing with collaborative medical partners because we speak both languages. If that is what it takes, then ultimately the onus is on Chinese medicine doctors to introduce our medical vernacular as a valuable construct into the conversation with our IO colleagues. This is certainly the end goal. Until that time, however, the significant obstacles that create barriers to integration must be recognized and averted.

Dr. Di Giulio had the unique privilege to intern at a prominent IO facility during her doctoral program. It provided an opportunity to observe IO model of care and the promise of a collaborative healthcare network. What became most evident was the routine logistical barriers imposed on the Chinese medicine practitioners that overshadowed the healthcare team’s potential for collaboration. The Cancer Treatment Centers of America (CTCA) in Tulsa, Oklahoma is a well-established cancer hospital. This is a reputable facility, which was founded in the late 1980s by Richard J. Stephenson who envisioned a cancer center with comprehensive medical oncology. Disillusioned by the treatment his mother received during her cancer diagnosis, he developed a multidisciplinary facility with all services under one roof. The philosophy of patient-empowerment and patient-centered care is embedded in the CTCA mission. It is appropriately referred to as the “Mother Standard” of care.

CTCA is considered a destination hospital. Every step of treatment from initial consultation to imaging, labs, chemotherapy, radiation, surgery and extended stays occurs onsite. This is appealing for patients and caregivers who can rely on complete supervision and quick access to medical care. Conventional medicine is the cornerstone of treatment at CTCA, but complementary therapies are numerous and extensively available. Physical therapy, cold-laser therapy, nutritional counseling, mind-body services, pastoral care, naturopathy, and acupuncture are on the menu of services. There is also entertainment and activities, such as bingo, movie nights, daily exercise groups and transportation to events in the community. This exemplifies an approach that considers psychosocial wellness, quality of life, and acknowledges the needs of the patients beyond biomedical parameters of care.

At CTCA, acupuncturists fall under the umbrella of “Naturopathic Therapies.” This department is led by a naturopathic physician and is comprised of licensed acupuncturists, naturopathic residents and doctors, most of whom are dual-trained in acupuncture therapy as well. This influences the structure of the department accordingly. In the hierarchy of this particular component of complementary medicine, naturopathy comes first and then Chinese. As such, the disconnect among the disciplines is apparent. Furthering this divisiveness was the fact that naturopaths shared offices in one area of the hospital while Chinese medicine was in another. Paths only crossed in corridors and hallways unless there were meetings. Communication about shared patients occurred by way of electronic charts. Thus, there were clear indications that the separate scopes of practice remained precisely that, separate.

A more integrative collaboration appeared in a process called grand rounds. Oncologists, nurses, social workers, therapists, pastors and naturopathic doctors (ND) are invited to attend and check-in with their shared patients. At the time of this internship, the licensed acupuncturists were not included in these collaborative rounds. The understanding was that the naturopaths represented the department. This process illustrated a significant discrepancy in the ideology of IO. In this example, there are two distinct features. Firstly, naturopathic medicine is an entirely different discipline, compared to TCM, not better or worse. It is likely more respected because of its scientific methodology as an evidence-based medicine, which better aligns with the West. Secondly, this particular environment results in minimal regard for TCM, which inherently implies that acupuncture is simply a technical modality. The clinical observations showed just that: short intakes, needles in, needles out, and repeat. The practitioners were very busy and stated they were strongly encouraged to treat even more patients per day. Considering the demands, the acupuncturists remained focused and provided immeasurable concern, compassion and care for their patients.

Similar to the other IO hospitals researched, neither moxibustion or Chinese herbal medicine was permitted. A request for an air filter or secluded space for moxa was denied. The reasons included available space and according to the acupuncturist who made the request, moxibustion was not science-based and was therefore not a proven, useful modality to integrate. Despite a conversation with a medical oncologist who condoned Chinese herbs and made attempts to introduce them on-site, he was met with skepticism and concern by colleagues and administration. Thus, basic herbal therapy was recommended by naturopaths and only what was available for purchase at the pharmacy.

The most distinctive feature of this internship reflected the aspect of “the language of medicine.” In a small meeting led by an ND, attended by one acupuncturist, medical oncologist and research analyst, the idea of a scientific study on the merits of a particular acupuncture protocol for a pain-related condition was discussed. The first impression of this subject matter was encouraging. This discussion was a true picture of integration, and an opportunity to create a clinical study that warrants acupuncture for a particular condition as a result of cancer treatment. The barrier was evident within moments. The ND and medical oncologist were merely focused on the point combinations based on their individual indications to treat the pain syndrome. In an attempt to contribute and describe the theory and principles of TCM, the acupuncturist explained that there is more depth to be measured. Diagnosis, pattern differentiation, tongue, pulse — all of these elements contribute to the selection of acupuncture points to treat any condition. Protocols cannot be haphazardly applied without considering the constitution supported by the current presentation. This would essentially compromise the efficacy of the study.

The information was not met with a willingness to understand, and communication quickly faltered. There was no open discussion that considered alternative approaches for the study. The meeting ended abruptly with no resolution. While this is just a mere moment and glimpse into an honest attempt at integrative partnership, it appeared to reflect the larger issue of the IO paradigm. Conventional medicine along with disciplines that are scientifically affiliated and evidence-based, to a significant extent, control how complementary therapies, such as TCM, are accessed and studied. The range of application is grossly limited, relying upon a singular pillar to do all the work. This contradicts the nature of integration. It not only diminishes the capacity to build upon medical skills, but it also limits the ability to embed them into new paradigms, and most importantly, to heal patients.

The internship at CTCA was invaluable on many counts. It created a tangible, visual overview of an IO hospital that emphasized compassionate cancer care. While the components of integration were lacking, there was a genuine intention to that end. Following this experience, the doctoral research continued, and the investigation for the nebulous definition of integrative oncology went on. However, it became apparent that the concept and its application were indeed left up to interpretation. This was illustrated in a meta-analysis survey study performed by the Journal of the National Cancer Institute (JNCI). The conducted research reviewed 20 extensive definitions of IO. Predominant themes revolved around concepts of evidence-based medicine, management of symptoms, improving quality of life and complementary medicine in conjunction with conventional methods.

The compilation of terms and defining characteristics of IO overlap extensively. They are ingredients to a larger recipe, some parts unique and other elements predictable. Nonetheless, these formed a grouping that allowed deeper analysis toward a unified definition. The following statements are examples discovered by JNCI that highlight the varied components that encompass this growing specialty. Statements include:²²

“Integrative oncology is the term being increasingly adopted to embrace complementary and alternative medicine (CAM), but integrated with conventional cancer treatment as opposed to being considered a rival or true ‘alternative’.”

“In the United States, the term ‘integrative oncology’ may be variably defined, but most definitions would include the idea and practice of adding complementary and alternative medicine (CAM) approaches to the range of therapeutic options provided to cancer patients in previously strictly conventional medical environments.”

“…comprehensive, evidence-based approach to cancer care that address all participants at all levels of their being and experience.”

This definition adapts current notions of “integrative medicine” — the judicious integration of CAM and conventional therapies in the best interest of patient — to oncology, with emphasis on aspects of patient care including attention to “body, mind, soul and spirit within the self, and within the specific culture and the natural world.”²³

The analysis of 20 definitions identifies characteristics, philosophies and themes that reflect a cohesive whole. With deliberation, a reliable foundation emerges upon which the definition is clearly derived in order to delineate clear guidelines within this specialty. Of the entire list, the shortest quote in length and description, stood out as a simple, approachable, all-encompassing framework, “Integrative oncology aims to combine the best practices of conventional and complementary oncological therapy (the ‘best of both worlds’).”²⁴ Indeed, it is often the remarkable features and strengths that an individual entity can bring that contribute to a greater whole. Equal balance optimizes better integration.

However, simplicity is not well received in the field of oncology. This has been demonstrated for hundreds of years as doctors, researchers, scientists, patients and caregivers strive toward a cure. It is evident that this nefarious disease demands complex, innovative treatments that eradicate the cancer cells and not the whole organism. To this end, the agreed upon definition of integrative oncology, finally unveiled in 2017 at the international conference led by SIO, reflects this inherent complexity:²⁵

“Integrative oncology 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 treatments. Integrative oncology aims to optimize health, quality of life, and clinical outcomes across the cancer care continuum and to empower people to prevent cancer and become active participants before, during, and beyond cancer treatment.”

When we encountered this long-awaited definition, it was encouraging. It references mind-body medicine and natural therapies that occur in conjunction with allopathic methods. But, closer examination reveals the concept and ideology grossly differ from the practical application evident in analyses of IO facilities. It exemplifies a harmonious balance among disciplines, that does not easily exist. This suggests that practitioners of all backgrounds, skills and education collaborate alongside one another without a medical hierarchy. However, current systems do not reflect these standards. This standard of integration is inherently compromised by a myriad of logistical challenges, impaired by differing therapeutic views and practices, and then further hindered by an inability to communicate in one medical language.

The definition is a starting point, but it is not the ultimate guide. A window of opportunity is open to establish proper integrative dynamics that recognize the value of each medical modality. This fluidity aligns with the nature of the disease itself. As it evolves, so too must the providers and patients. Within that construct, there is an ebb and flow of interpretive understanding and from this evolution, improved application. This is what we aim to do by exploring the therapeutic capacity of traditional Chinese medicine for cancer. Peering beyond the romanticized version of acupuncture therapy and demonstrating the refined approaches and inherent value of this ancient medicine.

References

Abrams, D. I., & Weil, A. (2009). Integrative Oncology. New York, NY: Oxford University Press.

Balneaves, L. (2018). President’s Message. SIO NewsWire August 2018, 1–2.

Kaptchuk, T. J. (2008). The Web That Has No Weaver: Understanding Chinese Medicine. New York, NY: McGraw-Hill.

MD Anderson Cancer Center. (2018). Acupuncture. Retrieved September, 7, 2018, from MD Anderson Cancer Center: https://www.mdanderson.org/patients-family/diagnosis-treatment/care-centers-clinics/integrative-medicine-center/clinical-services.html

MD Anderson Cancer Center. (2018). Integrative Medicine Program. Retrieved October 1, 2018, from MD Anderson Cancer Center: https://www.mdanderson.org/research/departments-labs-institutes/programs-centers/integrative-medicine-program.html

Memorial Sloan Kettering Cancer Center. (2018). Developing Your Personal Care Plan. Retrieved September 14, 2018, from https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-medicine/expertise

Memorial Sloan Kettering Cancer Center. (2018). Individual Therapies. Retrieved October 18, 2018, from https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-medicine/therapies/individual-therapies Video

Reddy, B. (2018). Acupuncture in an Integrative Oncology Center. Acupuncture Today.

Sagar, S. (2008). The integrative oncology supplement: A paradigm for both patient care and communication. Current Oncology, 166–167.

Seely, D., & Young, S. (2012). A Systematic Review of Integrative Oncology Programs. Retrieved September 10, 2018, from http://www.current-oncology.com/index.php/oncology/article/view/1182/1078

Witt, C., Balneaves, L., Cardoso, M., et al. (2017). Comprehensive Definition for Integrative Oncology | JNCI Monographs | Oxford Academic. Retrieved October 14, 2018, from https://academic.oup.com/jncimono/article/2017/52/lgx012/4617827

¹¹ Weil, Abrams

¹² ibid

¹³ Kaptchuck, 2008

¹⁴ Sagar, 2008

¹⁵ MD Anderson Cancer Center, 2018

¹⁶ Seely, 2012

¹⁷ MD Anderson, Acupuncture, 2018

¹⁸ Reddy, 2018

¹⁹ Reddy, 2018

²⁰ MSKCC, 2018

²¹ MSKCC, 2018

²² Witt, 2017

²³ Balneaves, 2018

²⁴ Witt, 2017

²⁵ Balneaves, 2018