15 May How Integrative Oncology Services Can Help Those Affected by Head and Neck Cancers
Written by Santosh Rao, MD
Head and neck cancers, occurring in such a sensitive area of the body, can pose a number of issues for those undergoing treatment. The mainstays of curative treatment are surgery and/or radiation, both of which can cause many symptoms during and after treatment. Surgical treatment can result in loss of function or disfigurement. Radiation can result in pain, swallowing dysfunction, and xerostomia (dry mouth). Chemotherapy with cisplatin, a mainstay of head and neck cancer treatment, often causes nausea and vomiting and can sometimes result in long-standing neuropathy and fatigue. Adequate nutrition and weight maintenance can plague individuals during and after treatment as well. While some of these are more difficult to fix than others, we must try whatever we can using a multi-disciplinary approach and all available options. It is with this spirit that we look to integrative oncology for help.
“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 become active participants, before, during and beyond cancer treatment.” From: A Comprehensive Definition for Integrative Oncology
Integrative oncology is growing in popularity and support within the oncology community. Recent guidelines have been established for the use of integrative oncology in breast cancer and survivorship, and research is giving us a better understanding of the impact of different strategies and approaches on those affected by cancer. The importance of including lifestyle and complementary approaches, which we would call integrative approaches, identifies patients at the center of their care and active partners in their treatment and follow up. Too often, the focus on helping cancer patients, in this case head and neck cancer patients, revolves around the important decisions regarding systemic therapy and local therapy options (surgery or radiation). These decisions are central in the care of head and neck cancer patients. However, the experience and short and long term tolerability and outcomes from these treatments can be modified using integrative approaches and keeping patients engaged and active in the plan of their care.
During an integrative oncology consult, recommendations are individualized depending on where in the course of treatment the patient stands and what he or she needs at the time. These recommendations can change with different stages of treatment. Symptoms are first considered and how to address them. Many people come to integrative oncology just to see what’s safe and what they should avoid in terms of supplements, exercise, or diet choices. Diet, exercise routines, stressors and how one relieves stress, sleep, supplements, spiritual concerns and other miscellaneous items are discussed.
One of the great aspects about integrative oncology is the team approach that is employed. It is an opportunity to involve a range of health practitioners to work together and answer questions to really help people where they are in their journey. These include dietitians, health psychologists, acupuncturists, yoga therapists, chaplains, exercise physiologists and physical therapists, massage therapists and Reiki practitioners among others. The key is to coordinate our recommendations and use all the skills and knowledge of the team to help; that is one of the special things about integrative oncology, bringing people together that previously were not part of a conventional cancer center.
Integrative Care Before or After Surgery
For those who undergo surgery for head and neck cancer, often losing part of the palate, tongue, or other disfiguring surgeries, there are many steps towards healing that integrative oncology can assist. One important consideration up front is tobacco cessation. Head and neck cancer is often related to smoking, and current smoking is a contraindication to surgery. We use acupuncture, hypnosis, essential oils, medications and counseling to assist those who want to quit.
Otherwise, pain with cancer and with surgery is common. Relaxation techniques such as guided imagery, Reiki and other energy healing modalities, music therapy, massage and acupuncture can all help with pain and anticipation of surgery. Anxiety over surgery and functional impairment can be aided through meditation, yoga, guided imagery, massage and aromatherapy. What better way to transcend physical changes through treatment than with prayer and meditation?
As mentioned earlier, part of the involvement of integrative practitioners is to help answer questions. Frequently, those newly diagnosed with cancer will read on the internet or go to groups and then start supplements or changes in behavior that may not be helpful, especially before surgery. It is important to guide in the use of supplements, especially those that might increase the risk of bleeding prior to surgery. So many questions come up, ideas about alkaline and ketogenic diets, hyperbaric oxygen, vitamin c, things people often entertain on the side of conventional care but don’t involve their doctors. Integrative practitioners try to keep it simple, especially in sensitive times such as pre-op periods and post-op periods, where it’s not wise to experiment.
Integrative Care During Chemotherapy
Systemic therapy options used to treat head and neck cancer depend on the stage of disease and other concurrent therapies such as radiation. Cisplatin, taxanes, 5FU, cetuximab, and now immunotherapy all have their place depending on other clinical factors. Cisplatin in particular is one of the most commonly used chemotherapy agents in head and neck cancer treatment. Nausea and vomiting can be reduced with acupuncture, which can be offered during chemotherapy. Ginger tablets or fresh ginger with tea is also commonly used. There is also some evidence for certain acupressure points to reduce nausea from chemotherapy. Acupuncture for neuropathy prevention and treatment can also be considered. Our patients notice if they get acupuncture or not during chemotherapy.
For fatigue, physical activity is recommended. That can mean 10 minutes a day for those with severe fatigue from chemotherapy, but otherwise 30 minutes a day is recommended. Getting sunlight in the morning helps not only with energy but to train the circadian rhythm. American ginseng can be used during chemotherapy to increase energy. Not a lot of other supplements during chemotherapy are recommended. There is interesting research suggesting the importance of the microbiome and even probiotics with those receiving immunotherapy (in advanced head and neck cancer for example).
From a dietary perspective, integrative providers work with dietitians to try to maintain nutritional needs, which is often difficult. It is advisable to limit sugar if at all possible (meaning that someone is getting plenty of nutrition). What really should be a focus is maintaining a positive attitude, expressing concern and emotion in a healthy way, and helping patients stay in the moment. Meditation, including mindfulness meditation, can be very helpful to help ground people during this turbulent time. Health psychologists can help with sleep through cognitive behavioral therapy. Trying to maintain a routine and sleep enough is also important. Diet, stress, and sleep all can modify tumor behavior, so why not try to focus on these things rather than the anxieties that come with treatment.
Integrative Therapies During Radiation
The use of supplements during radiation should be limited. There is controversy regarding strong antioxidants such as melatonin, and whether it’s helpful or harmful during radiation. Sometimes radiation oncologists feel strongly one way or another. Many discussions such as these are theoretical, with less than definitive studies supporting one claim or another. That makes offering strong recommendations difficult in integrative oncology. Many of the same issues with pain and anxiety occur during and after radiation, and integrative approaches are often similar.
There is really limited evidence on what to do post radiation. Some treatments commonly used for radiation burns are aloe and other lotions, topical vitamin E, etc. Hyperbaric oxygen does have a place post radiation for healing as well. The use of frankincense oil topically has been suggested to improve healing but studies are still preliminary.
For oral ulcerations and loss of appetite, medical honey (Manuka), which has the secondary benefit of giving some calories, is sometimes recommended. Taste issues are common and difficult to manage, though sometimes oral zinc will help.
Another troubling symptom is dry mouth (xerostomia). Studies have shown that acupuncture can reduce dry mouth and increase salivary flow when done post radiation. It is probably the most important reason to involve integrative oncology in head and neck cancer patients treated with radiation. Treatment can be given once to twice per week on an ongoing basis.
Integrative Approaches in Advanced Disease
Most people with metastatic head and neck cancer will be treated with chemotherapy, immunotherapy, or be on some kind of clinical trial. The primary focus will be on symptoms such as pain, anxiety and fatigue, working alongside other specialists such as palliative care many times. Many of the recommendations above hold true for pain and anxiety in the advanced setting, utilizing specialists in mind/body medicine (yoga therapists, health psychologists, Reiki and other energy healers) along with integrative approaches to pain such as acupuncture, massage and aromatherapy. In the metastatic setting, it is important to also help patients with their personal and treatment goals. It is easy to lose motivation and purpose; having a purpose, expressing yourself in these situations often helps people continue the battle through bad news and suffering. Spiritual counseling, focusing on purpose and goals and hope, lifting resentments and fears, can really aid. All of us are involved in some way or another in this counseling, not just the chaplains, but the integrative practitioner, the psychologist, the yoga therapist and the massage therapist.
In those who have advanced stages of cancer, it may be ok to be more liberal with some supplements and other integrative therapies. This needs to be coordinated with other doctors of course, and one should be certain to identify supplements that are more helpful than harmful. These are controversial topics and many do not agree with this approach, especially since we do not have precise information regarding benefit, harm, dosing etc. But research doesn’t move fast enough to answer some of these questions in real time, and many people need help with symptoms and rightfully want to try something they are optimistic will help. Some favored supplements in this setting are turmeric, an anti-inflammatory spice from India which has many anti-cancer properties, and melatonin, a very safe immune-modulating hormone that helps with sleep and has been shown to have some clinical activity in the advanced cancer setting. The evidence is weak but these supplements are relatively safe. If there are other supplements someone wants to use, caregivers should go through them individually, and also consider some supplements or other modalities of treatment for specific symptoms. Whatever helps and doesn’t interfere with therapy at all.
It is clear that no two people practice Integrative Oncology the same way. While that may sound intriguing, in reality it is because we do not have enough evidence to be precise in our recommendations, we do not have the same algorithmic approach we do in other areas of cancer care. It’s messy right now in terms of where the research is and understanding the mechanisms behind some of the therapies that have been discussed. Hopefully, in time that will change, and we can really integrate acupuncture, the use of natural supplements, and dietary recommendations, in a way that right now is very subjective.
Editors Note: Dr. Rao is the Medical Director of Integrative Medicine for Banner MD Anderson. His interest in Integrative Medicine began in college and was a significant influence on his decision to pursue a career in the medical field. After studying biophysics at the University of Michigan, he went on to obtain his medical degree at the University of Michigan as well. Dr. Rao then completed his internship and residency in Internal Medicine at the University of California, San Diego. Dr. Rao has studied Hematology and Oncology at University Hospitals Case Medical Center. He previously was employed at Scripps Green Hospital in San Diego, where he observed the practice of Integrative Medicine and developed strong relationships with leaders in the field.
Dr. Rao is passionate about incorporating Integrative Oncology and Cancer Prevention in cancer care. He completed an Associate Fellowship in Integrative Medicine at the University of Arizona in 2006 as a Bravewell Fellow. Dr. Rao is on the board of trustees for the Society of Integrative Oncology, where he has chaired the 2018 annual conference in Scottsdale and is co-chair of this year’s conference in New York. He also teaches Integrative Medicine fellows at the University of Arizona, and has been a leading contributor to education modules for the cancer curriculum. Dr. Rao has a strong interest in Ayurveda; he has travelled to India multiple times studying Ayurveda, and he is currently enrolled in an Ayurveda courses with a goal of offering Ayurvedic services.