By Monica Smith, Clinical Oncology News

The use of integrative care in oncology has become somewhat standard at large academic centers. Now it’s gaining ground in smaller treatment centers, where physicians recognize that for many cancer patients, holistic support throughout the course of their treatment and in survivorship is of increasing importance.

“The use of herbs and supplements in general is growing in the U.S., and the use of integrative medicine is increasing as more people are interested in supporting their standard treatment, whether it’s for cancer, diabetes or other health issues,” said Michelle Niesley, ND, MS, FABNO, a naturopathic physician with the Clinic of Natural Medicine, in Eugene, Ore.

“They’re looking for things they can do that will give them the best chance to live the highest-quality life they can.”

The Gundersen Health System in La Crosse, Wis., for example, has offered integrative medical services for the better part of a decade. Its integrative care services has especially grown in the last couple of years, and is now offered at six of the health center’s locations.

“We have traditional healing and herbal therapists who have agreed to work with our clinic, and they’ve agreed we share the patient,” said Jeffrey Landercasper, MD, a general and breast surgeon affiliated with Gundersen. “We’ve been able to keep patients who said they were leaving.”

In some centers, such as Northwest Surgical Specialists (NWSS) in Eugene/Springfield, Ore., naturopathic doctors participate at tumor board meetings, an approach for involving integrative care providers that was discussed during a panel session at the 2017 annual meeting of the American Society of Breast Surgeons by Winnie Henderson, MD, a general and breast surgeon at NWSS.

“I’ve never heard of anyone else doing that. It’s a novel idea that I think ought to be investigated,” Dr. Landercasper said.

Naturopathic Provider Participation At Tumor Boards

Heather Wright, ND, FABNO, president of the Oncology Association of Naturopathic Physicians (OncANP), has participated on tumor boards in both community hospital settings and at larger treatment centers. “This is an excellent model, because a tumor board is where the physicians and others working together in cancer care come together to talk about cases,” she said.

Tumor boards provide an educational platform, giving integrative care providers an opportunity to explain their background and training, and how their care supports the work of the surgeons and oncologists.

A lot of people have no idea what a naturopath is,” Dr. Niesley said. “Many doctors aren’t aware that we go through a four-year postgraduate program, and that there are hospital-based residencies in integrative medicine for naturopathic doctors.”

At these multidisciplinary meetings, integrative care providers can present research in their area, which “allows other team members caring for the patient to hear the rational and evidence base for the supportive care offered by naturopathic doctors,” Dr. Wright said.

Often though, Dr. Niesley said, integrative care providers usually are simply there to answer questions. “We listen to the cases and provide clarification. For example, if a patient has asked an oncologist about some sort of alternative treatment that the oncologist is not familiar with, we can provide evidence-based information.”

But the educational aspect goes both ways. Dr. Henderson and her colleagues began inviting local naturopathic oncology providers to tumor boards in an effort to form an alliance with the integrative care providers they knew their patients were seeing or thinking about seeing.

“We want the naturopathic providers to know what happens when patients follow, or don’t follow, a certain path of care—or instance, what happens as a result of delayed treatment,” she said.

There were numerous situations, Dr. Henderson said, in which newly diagnosed patients who turned to alternative therapies as a primary treatment returned with tumors that had grown to the point of requiring a salvation mastectomy or had metastasized.

“So the Oregon Cancer Alliance (OCA), a local network of cancer specialists from different disciplines and specialties including breast and plastic surgeons, medical and radiation oncologists, pathologists and radiologists, decided to collaborate and provide coordinated care for our patients,” said Dr. Henderson, who is on the board of directors of the OCA.

“Instead of shutting out integrative care providers, we want them to know why we might suggest one treatment plan over another,” Dr. Henderson said. “For patients with triple-negative breast cancers, time is of the essence. These are situations in which it’s important for the naturopaths to refer patients back to us for the aggressive treatment some patients need.”

Dr. Wright agrees. “OncANP is a specialty group of licensed naturopathic doctors who work with cancer patients in sync with conventional oncology care and we understand that when an advantageous cancer treatment is delayed, poor outcomes can result. Naturopathic doctors often refer patients who are otherwise not pursuing conventional care to do so.”


Integrative Care Into Practice

Another model for alignment with integrative care is to bring those providers into the practice setting, giving patients the opportunity to meet with both their standard care providers—their surgeon and oncologist—as well as naturopathic doctors.

“In the tumor board setting, you have the naturopathic doctor explaining the patient’s reported symptoms and condition along with their desire for a natural or holistic approach to the conventional treatment team. In the practice setting, the integrative provider can explain and reinforce to the patient the benefit of the treatment offered by the surgeon, medical oncologist and other providers,” Dr. Wright said.

“This gives patients, who might be fearful of those treatments and may not fully understand them, a chance to get more comfortable with the conventional approach and feel listened to and heard in their choice to use an integrative or combined approach,” she added. “It’s a really nice way of bridging both sides of the picture.”

Willamette Valley Cancer Institute (WVCI), in Eugene, formally began offering integrative care to its patients about five years ago. Although the institute does not have integrative care providers on-site, it has established relationships with local naturopathic providers who can be recommended to patients.

“Part of this is the culture. Oregon legalized medical marijuana 13 years ago, and a lot of the 1960s has stayed in Eugene. People are very environmentally conscious and interested in more natural ways to either treat or complement their care,” said Benjamin L. Cho, MD, a medical oncologist with WVCI and member of the board of directors of the OCA.

“When I finished residency and moved to Eugene, I realized that a lot of patients were seeking integrative and complementary care on the side and not telling us.”

Patients weren’t necessarily turning their backs on standard treatment, but they wanted to supplement that treatment. “We decided working together would be best for our patients,” Dr. Cho said.

Most of the integrative care providers affiliated with WVCI are naturopathic oncology providers, who are fellows of the American Board of Naturopathic Oncology (FABNO), and acupuncturists. The institute also has dietitians, social workers and psychologists. Dr. Cho estimates about 20% of WVCI’s patients make use of the integrative care services.

“I think it’s a relief to those patients to see facilitation between us and integrative care. When the patients visit their integrative providers and see my notes and lab results, they don’t feel like they’re doing it in secret anymore,” he said.

Dr. Niesley has been working with physicians at WVCI, the OCA and NWSS for about a year and a half. “Any of the physicians there will note that integrative medicine is not their expertise, so I think it’s a comfort to them to know they have someone whose job it is, all day every day, to keep on top of the studies that back up our recommendations,” she said.

Finding and Vetting Integrative Providers

When WVCI decided to work collaboratively with local integrative care providers, patients were asked who they were seeing. “We asked around the community, and a few names bubbled up, so we reached out to those providers and formed a group,” Dr. Cho said. “Anyone who wants to join the group has to be vetted by the group.”

And vetting is a good idea. Although naturopathic doctors go through extensive training and carry malpractice insurance, licensure is another issue. “Naturopathic doctors are currently licensed in 20 states, including Oregon. In states where there is no licensure, it can be a significant issue to find an ND who is appropriately trained,” Dr. Niesley said.

In addition to those 20 states, the territory of Puerto Rico, the District of Columbia, and the U.S. Virgin Islands, and five Canadian provinces license or regulate NDs.

But in those states that do not require licensure, “if you want to hang a sign on your door that says ‘naturopathic doctor,’ given that there’s no law that says one way or the other, there’s nothing stopping you,” Dr. Niesley said. “It’s a significant public safety issue.”

Dr. Wright and Dr. Niesley recommend practices searching for a naturopathic oncology provider consult the OncANP, which has a list of licensed NDs with specialty training in oncology care listed by location. “It’s not a complete list of doctors who practice integratively, or for other integrative providers, but it’s a great place to start,” Dr. Niesley said.

Having a naturopathic provider on board can open up many integrative care doors, Dr. Wright explained. “We have training in massage, acupuncture, herbal and botanical medicine, and we also understand the training, board exams and regulatory information needed from state to state,” she said.

“Naturopathic doctors can help create the integrative model in a clinic because of their understanding of those competencies and skill sets needed for other integrative providers to participate.”