Integrative Oncology Program

The Cancer Advances podcast is joined by the Chair of the Palliative and Supportive Care Department, Laura Shoemaker, DO, and Integrative Medicine Specialist, Naoki Umeda, MD, to talk about Cleveland Clinic’s Integrative Oncology Program. Listen as they share how combining evidence-based complementary therapies, such as acupuncture and lifestyle medicine, with conventional cancer treatment can help alleviate symptoms, enhance patients' quality of life, and improve outcomes.

Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals exploring the latest innovative research and clinical advances in the field of oncology. 

Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a Medical Oncologist, Director of International Programs for the Cancer Institute and Co-Director of the Sarcoma Program here at Cleveland Clinic. 

Today I'm happy to be joined by Drs. Laura Shoemaker and Naoki Umeda. Dr. Shoemaker is the Chair of the Department of Palliative Medicine and Supportive Care, and Dr. Umeda is a Specialist in the Center of Integrative Medicine. Dr. Shoemaker was previously a guest on the podcast to discuss navigating difficult conversations, and this episode is still available for you to listen to. They're here today to discuss integrative oncology program. So welcome.

Laura Shoemaker, DO: Thank you. Great to be here.

Naoki Umeda, MD: Thank you.

Dale Shepard, MD, PhD: Yeah. So maybe just as a start, you could remind us what you do here at Cleveland Clinic, Laura.

Laura Shoemaker, DO: Sure. Nice to be with you. Thanks for inviting me back. I'm a Palliative Medicine Specialist and currently Chair and leader of our Palliative and Supportive Care Department, which encompasses, of course, our palliative care program and also our psycho-oncology program and our evolving and emerging integrative oncology program.

Dale Shepard, MD, PhD: Excellent. And Naoki, what do you do here at Cleveland Clinic?

Naoki Umeda, MD: Yeah, so again, thank you for having me today. I work as an Integrative Medicine Specialist at Department of Wellness and Preventive Medicine, which is part of the Primary Care Institute. I see a variety of patients such as fibromyalgia, irritable bowel syndrome, migraine, anxiety, depression, chronic joint pain, muscle pain, and also post-COVID long haul syndrome, really variety of symptoms and condition, and also cancer patient. Especially I have a strong interest in providing integrative and holistic care for cancer patient and survivors.

Dale Shepard, MD, PhD: Excellent. We're going to learn a little bit more about that. And so we're going to be talking about this integrative oncology program and maybe Naoki can start off, give us an idea what exactly is integrative oncology?

Naoki Umeda, MD: Yes, certainly. So the integrative oncology is a practice where we are using dietary modifications, lifestyle medicine, including exercise and also acupuncture, massage therapy, yoga, stress reduction, meditation and mindfulness activities. We combine those modalities to help patients not only with quality of life, but also to hopefully improve treatment outcome as well. So this should be considered as an add-on care or support for those who are about to start conventional cancer treatment or those who already started cancer care.

Dale Shepard, MD, PhD: And Laura, maybe give us an idea. So most people may be more familiar with palliative medicine services and sort of integrating those into cancer care. Give us a little bit of an idea of sort of the intersections where they diverge.

Laura Shoemaker, DO: Sure. So I think these are all supportive care pieces. So we give patients an opportunity to become more active participants in their care and really focus on assessing each unique cancer experience. So as palliative specialists, we're going to do a detailed symptom assessment, assessing for common symptoms like nausea, vomiting, bowel disruptions, pain, those sleep disturbances. And we also really want to take the temperature on the emotional impact of cancer symptoms. And understandably, people's symptoms are interrelated. So the integrative oncology piece gives us additional methods and modalities to holistically approach a person's unique cancer experience.

Dale Shepard, MD, PhD: And so, I guess when we think about integrative oncology, what are some of the misconceptions people might have about what is involved with a program like this?

Naoki Umeda, MD: Yeah, so sometime I hear the integrative oncology and ultimate medicine are same, but I like to emphasize that these two are different. Alternative medicine is to provide natural medicine or natural therapy instead of conventional or traditional cancer care. And we do not provide that. Cancer patients should consider conventional treatment first, and we, integrative medicine provider will add additional support trying to decrease the side effects. If they have questions about diet and supplements, we'll provide a guidance for that. And we always make sure to stop any supplements or vitamins which would interfere with your cancer treatment.

Dale Shepard, MD, PhD: And I guess you mentioned alternative medicine. Is that along the similar lines for functional medicine?

Naoki Umeda, MD: Right. So functional medicine is also different from alternative medicine. So this is actually a bit confusing for many people because different medical institution have a different style. So for example, Cleveland Clinic has a Department of Wellness and Preventive Medicine, and there are two team, which is functional medicine team and integrative medicine team. I am in the integrative medicine team. We have a very similar concept and a philosophy trying to work on a whole body system, which is holistic approach, but approach is a little bit different. Simply speaking, integrative medicine is more like a symptom-based approach. We listen to your patient's symptoms, their conditions, and provide or suggest, "How about this treatment? How about this modality?"

Functional medicine will focus on how to find the underlying cause of the chronic illness. It could be inflammatory or body inflammation or other metabolic syndrome or a variety of symptoms. And they may do some extensive tests like blood work, checking the variety of vitamins, hormones for the thyroid, adrenal, and also sometimes the microbiome, the stool test, and they make a treatment plan. So approaches are different, but we try to do something natural things. So that's the difference. So alternative medicine is really to use the treatment, these natural things instead of this. So it really depends on the condition. For example, irritable bowel syndrome or migraine. Yes, patient may want to try something natural instead of the pharmaceutical medicine. Depending on the cases, it might be appropriate to try. But a cancer is completely different situation. So we are against to use the alternative medicine for the cancer patients.

Dale Shepard, MD, PhD: So, Laura, as we think about these, about incorporation of integrative medicine, as you put together a program within your palliative medicine department, what kind of groups do you engage? Who exactly is involved in the program itself?

Laura Shoemaker, DO: Great question. Thank you for that. First and foremost, we're listening to patients and families wanting to understand their experiences and then assessing what resources we have and how good of a job we're doing in addressing those needs. As I mentioned earlier, patients and their families want to become more active participants in their cancer care and they want to explore all available modalities. The other thing that we're really hearing from patients is they want to do it in a way that's safe and aligned and improving the outcomes they're getting with their overall cancer treatment plans from their oncology teams. So to Naoki's point, we're really trying to align the conventional cancer treatment and add these integrative oncology options to improve the cancer experience and to improve the cancer outcomes. We all want people to live as long and as well as possible during their cancer experiences and hopefully for a long time after.

You asked a little bit about partnership. I think part of assessing what we have available to patients, what we did at Cleveland Clinic was we looked outside the walls of the cancer center. We were offering several things already when it comes to symptom management and cancer experience. And there were many places in our institution like the Wellness and Preventive Medicine Department. And so we've partnered very, very closely with Dr. Umeda, Dr. Rob Saper, to say this is what's already available. Maybe it's an issue of access. How can we make what's already available more accessible to cancer patients? And of course, certainly align it with their cancer treatments.

And then the other piece is to assess if there are any gaps in what we're offering. Are there services that would be beneficial to patients that we don't have anywhere in our institution? How do we get the expertise and the resources to patients? And then finally, I would say the other great partnership is really around philanthropy and our cancer space in particular, many of the services that we're alluding to are offered free of charge to cancer patients and their caregivers, and that's really based on the generosity of our donors to the Cleveland Clinic Cancer Center.

Dale Shepard, MD, PhD: Dr. Umeda, Laura said something about accessibility, being able to have patients get these therapies. Tell us a little bit about some of the successes and truly being able to bring those therapies to patients as they're getting treatment, for instance.

Naoki Umeda, MD: I think there are two ways. We've been getting the referral from the medical oncologist and the surgeon, radiation oncologist, and also definitely palliative medicine doctor. And we appreciate that. Also, we accept a self-referral from the patient and we'll start reviewing the patient's current conditions and what treatment they are currently receiving as to these conventional treatments. And we would choose the most suitable integrative oncology modalities. So this could be different from time to time, depending on patient condition and the cancer treatments. We always make a recommendation based on the evidence, and very importantly, we'll recommend modalities which would not interfere the patient treatment plan. So we'll always communicate with the patient, existing care teams, oncology professional, whenever necessary.

Dale Shepard, MD, PhD: And I guess in terms of some of these modalities, oftentimes cancer patients have very long days. They'll see their provider, they'll have labs, they'll be getting treatment. Have you been able to incorporate some of these modalities into seeing patients even while they're getting treatments?

Naoki Umeda, MD: Yes. So for example, acupuncture, I think it is very beneficial to tackle or decrease the chemotherapy side effects, such as could be nausea, headache, peripheral neuropathy. Yeah. So we always try to choose what is the most suitable, and it could be different time to time.

Dale Shepard, MD, PhD: Dr. Shoemaker, what would you consider some successes in this ability to get patients therapies in a most convenient way?

Laura Shoemaker, DO: Well, Dr. Umeda referred to using acupuncture during infusion, and we've actually done a really exciting pilot at Cleveland Clinic over the last several months. We've offered acupuncture free of charge to patients during their infusion treatments, and we're collecting information from patients about their experience of this treatment. They're brief treatments, about 20 to 25 minutes, comfortably administered while they're sitting in their infusion chair in the infusion suite. And we're asking patients if they're interested, a high percentage of patients are very interested in trying acupuncture in this way. And then after the experience, we're asking them how it went, and we're excited that we've had an overwhelmingly positive response. So just a unique way to bring the treatments to patients while they're already at the cancer center trying to improve their experience.

Dale Shepard, MD, PhD: So when you think about these sort of services, certainly is a wide range of different symptoms and experiences cancer patients have, is there an ideal patient that you've come across? Maybe some sort of symptoms or issues that some of our cancer patients have that make them better suited for this integrated approach?

Naoki Umeda, MD: So I would say anyone is really welcome to come to our integrated oncology program, but especially those who already started the, let's say chemotherapy or immunotherapy or endocrine therapy, if they are experiencing some chronic bothering symptoms, yes, definitely we like to hear that. And I think there are some way we can help. And again, we always trying to choose the options or modality which would not interfere their cancer treatment.

Dale Shepard, MD, PhD: So Laura, when we think about putting a program like this together, people might be listening in and maybe want to think about incorporating this into their practices. What were some of the things you learned along the way that you could offer as advice?

Laura Shoemaker, DO: Well, your greatest informants and partners are your patients. So again, I can't say strongly enough how important it is to engage patients and not only to listen, but to ask questions and listen. People are very willing to share their experience, and sometimes it's just a matter of getting the conversation started. So asking and listening to patients is first. And then I think that assessment piece of what's already available is really important and to really leverage those partners, it's not something that's easily done alone. And it does take resources. So engaging partners who are experts in the work already, it's much easier to make something that's already available accessible than to reinvent a new wheel. So we're doing both, of course, but leveraging those partnerships is really important. Gaining support from philanthropic partners is also helpful. There is a limit to what conventional payment systems' insurances will sometimes pay for these treatments, even though there is significant data and growing data about the benefit of integrative oncology modalities in cancer experience and outcomes.

Despite that though, sometimes we have issues with payment and reimbursement. So if you can offset with philanthropic support, that's really helpful. And then finally I would say keep learning. Stay open-minded and use experts like Dr. Umeda, Dr. Saper to teach you about what's out there. The professional society, the American Society for Integrative Oncology is another great treasure trove of information and resource.

Dale Shepard, MD, PhD: That's great. When you think about someone that sort of comes into this program, how do coordinate sort of the services? Who sort of serves as the quarterback, if you will, to make sure that people have access to what oftentimes patients may not even know what's available? Who sort of quarterbacks that process?

Laura Shoemaker, DO: I'll start and then I'll definitely hand it over to Dr. Umeda. In our cancer space, we have a wonderful health educator named Bria Heifetz. Bria actually has a prescription pad that lists all the different resources, and we have cards that list all the resources, kind of like a menu for patients. And Bria is very well versed in all the different services that we offer. So she can sit down with a patient in person or frequently contacts people over the phone to review the menu of available services, explain what the services are if people are not familiar with them, and then match them up to the service and the practitioner that provides it. And when patients are interested in a more comprehensive medical assessment in the integrative oncology space, that's when we make the referral over to Dr. Umeda and his group.

Dale Shepard, MD, PhD: So Dr. Umeda, what would you like to see as you look forward in terms of further growth of the program, further access for patients? What do you see the future look like?

Naoki Umeda, MD: Yeah, so I feel, or I believe more and more patients are getting interested in and wants to learn about the integrative oncology. Especially, lots of people really have a morally variety of question, multiple question regarding the diet and also supplements. For example, some people heard about the acupuncture, but they don't know what it is. So they want to learn about the benefit of the acupuncture and also many people feeling so stressed because it could be potentially life-threatening disease. So mindful activity, yoga. These are very really variety of questions. So I see lots of opportunities to grow together hopefully. And also by answering those questions the cancer patient have, because the appointment time with the cancer provider, oncology professional might be limited. So by answering those questions regarding the integral oncology lifestyle medicine, I hope patient satisfaction gets better.

Dale Shepard, MD, PhD: Laura, are there any other services that you find particularly unique and exciting within your program?

Laura Shoemaker, DO: Yes, definitely. One of the things that patients frequently ask about is how to optimize their nutrition. I think nutrition is a unique challenge and it's variable depending on what kind of cancer people have and what their conventional treatments are. You can imagine that patients have issues not only with appetite, sometimes functional issues with chewing, swallowing, bowel dysfunction. So we are developing a culinary medicine program in consultation with a professional chef to not only optimize the nutrient part, the nutrition part of the food that we eat, but sometimes altering the consistency or types of food that people are able to eat based on their cancer experience. So our culinary medicine program is actually delivered in a kitchen and with active participants, we project that online as well and record these. We're developing a library of offerings around culinary medicine options. The next thing that people often ask about is activity.

And at Cleveland Clinic we've engaged Dr. Eileen Slavin, she's been with us for over a year now. She is a physical medicine and rehab physician with expertise in cancer rehab and cancer prehab. So that was kind of a newer concept to me a couple of years ago. This idea though, that one of the things that can really help with cancer outcomes is to get into the best shape possible before and during your cancer treatment so that you can experience the best outcomes. So Dr. Slavin has unique expertise around cancer prehab and rehab in the survivorship period as well.

Dale Shepard, MD, PhD: Well, you're doing a fantastic job taking on a holistic view of patients and providing the best care possible, and I appreciate your insights today.

Laura Shoemaker, DO: Thanks for the invitation.

Naoki Umeda, MD: Thank you very much.

Dale Shepard, MD, PhD: To make a direct online referral to our Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You will receive confirmation once the appointment is scheduled.

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