In the last column section editor Dr. Stephen Sagar provided an overview of some of the defining characteristics of Integrative Oncology (IO) programs. One statement that leapt out at me is that IO “is not alternative medicine, but evidence-based therapies that are complementary to the medical cancer treatments. It is part of a supportive care program that enhances coping and well-being.” With this definition in mind we’ve been working hard in Alberta, beginning at the Tom Baker Cancer Centre (TBCC), to create a truly integrated IO program. Dr. Sagar was kind to single out our work as an example of efforts in Canada to make IO part and parcel of comprehensive cancer care. I’d like to take this opportunity now to tell you more about our services, plans and overall vision.
Our vision is to develop a truly integrated program that will provide whole-person comprehensive care to patients at one centre, seamlessly combining conventional and complementary therapies. But what would that really look like? First of all, the program incorporates research, clinical service and education throughout. We learn from every patient seen, conduct cutting-edge clinical trials on promising therapies, and train students along the way, thereby ensuring the next generation of health care providers is knowledgeable in these areas.
The program incorporates the following four elements.
Patient and provider education programs: In 2012 we conducted surveys with about 500 patients and 100 health-care providers at the TBCC (http://www.ncbi.nlm.nih.gov/pubmed/26069277). Almost half of all patients surveyed said they were using some form of complementary therapy (CT) such as vitamins, herbs, meditation, acupuncture and more. Yet only 20 per cent said their health-care providers asked if they were using, or considering using, any CTs. For their part, the health-care providers said they had very little education about the efficacy and safety of CTs and wanted to learn more. Meanwhile, patients felt their oncology care team should be knowledgeable about CTs.
In response to this need, we developed monthly patient education seminars based on comprehensive literature reviews conducted in 2012 and 2013, teaching patients about evidence-based CTs and how to find and evaluate evidence to support making their own decisions about which therapies to use and when. These have been well-attended since 2012.
This year we began a study training health-care providers on CTs to help improve their knowledge base and communication skills, using the Complementary Medicine Education and Outcomes (CAMEO) program materials that are available online (http://cameoprogram.org/). We’ve signed up over 100 cancer care professionals to date.
Down the road we plan to provide evidence-based training materials and workshops, perhaps in-person, on the web, or through educational videos and seminars. These would help ensure people know which therapies are proven to be helpful, who they’re meant for and under what circumstances. Programs will be tailored to different groups of patients and providers.
Individual IO consultation: Patients are using CTs to help optimize their cancer treatments, decrease symptoms and improve overall quality of life. However, the evidence about which therapies to use when, for which symptoms and types of cancer, in combination with conventional treatments, is daunting. Policies are largely not in effect guiding the use of natural health products or other CTs during treatment. We conducted a survey of cancer centres around Canada and the USA about policies and guidelines for the use of antioxidants specifically during cancer treatments, and found few centres have consistent policies, and these are often lagging behind the research evidence-base (http://www.ncbi.nlm.nih.gov/pubmed/25716350).
Beyond generalized education, especially during cancer treatments people need individualized guidance around the use of natural health products and other CTs, since recommendations depend on their specific medical history, their current diagnosis, treatments they will be undergoing, side-effects, medications and a host of other individual factors. Individualized consultations will be the heart of our IO programs, run by trained oncologists or oncology nurses, naturopathic and conventional doctors, counsellors and CT providers. This piece of the puzzle is the most costly and we are still working to fund these positions.
Service provision: In a truly integrated program, provision of recommended CT services would be available at the cancer centre for patients along with their conventional treatments. These would include a full range of evidence-based CTs, such as mind-body therapies like meditation and yoga, advice on nutrition and natural health products (herbs, vitamins, foods), energy medicine like acupuncture and Tai Chi, and body-based modalities like massage and exercise programs. We already offer many of these services free of charge at the TBCC, but would like to expand to offer more evidence-based therapies to patients in need.
IO Clinical trials: Finally, where treatments show promise but evidence is inconclusive, development of a fully functional integrative oncology clinical trials unit qualified and equipped to conduct research on a range of CTs, including natural health products, is the cornerstone of the program. Where evidence doesn’t exist but treatments are promising or in-demand, our job is to create the evidence and learn not only which treatments are helpful, but also if some are potentially harmful and should be avoided.
While this program in its entirety is a vision for the future, many of the pieces are already in place. With the new Calgary cancer centre in development, IO has been included as a key component of bringing truly integrated whole-person care to Alberta, and can serve as a model for interested centres in the rest of Canada.
Dr. Linda Carlson holds the Enbridge Research Chair in Psychosocial Oncology, is an Alberta Innovates-Health Solutions Health Scholar, Full Professor in Psychosocial Oncology in the Department of Oncology, Cumming School of Medicine at the University of Calgary, and Adjunct Professor in the Department of Psychology. She is the Director of Research and works as a Clinical Psychologist at the Department of Psychosocial Resources at the Tom Baker Cancer Centre.
Dr. Carlson trained as a Clinical Health Psychologist at McGill University in Montreal, researching the area of psychoneuroendocrinology. She worked as a post-doctoral fellow at the Tom Baker Cancer Centre in Calgary, sponsored by a Terry Fox Postdoctoral Research Fellowship from the National Cancer Institute of Canada/Canadian Cancer Society and subsequently received a Canadian Institutes of Health Research New Investigator award from 2002-2007.
Dr. Carlson received the Kawano New Investigator Award from the International Psycho-Oncology Society in 2006; the William E. Rawls Prize in cancer control from the National Cancer Institute of Canada/Canadian Cancer Society in 2007; a New Investigator Award from the Canadian Psychological Association Health Section in 2009, the inaugural Research Excellence award from the Canadian Association of Psychosocial Oncology in 2010, the Arete Award for Research Excellence from the Department of Oncology at the University of Calgary in 2012, and was shortlisted for the Dr. Rogers Prize in Complementary and Alternative Medicine in 2013.
She is a fellow of the Society for Behavioral Medicine and the Mind and Life Institute.
Dr. Carlson’s research in Mindfulness-Based Cancer Recovery has been published in many high-impact journals and book chapters, and she published a patient manual in 2010 with Michael Speca entitled: Mindfulness-Based Cancer Recovery: A step-by-step MBSR approach to help you cope with treatment and reclaim your life, in addition to a professional training manual in 2009 with Shauna Shapiro entitled The Art and Science of Mindfulness: Integrating mindfulness into psychology and the helping professions. She has published over 150 research papers and book chapters in the area of psycho-oncology, holds several millions of dollars in grant funding and is regularly invited to present her work at international conferences.