Talk to Your Doctor: About Integrative Medicine

Leah: 0:26
Hi, Tina.

Tina: 0:27
Hi, Leah. How are you doing?

Leah: 0:29
I'm doing great. Thanks for asking.

Tina: 0:32
Good, good, good. So, what's on our docket today?

Leah: 0:34
Oh, well, this is kind of fun. This is our first show that was a request. I had put up a little question to the folks out there, you know, what do you want to hear? What do you want us to talk about? And someone wanted to know, "how do you talk to your doctor about integrative medicine?"

Tina: 0:51
Ooh, that's a big topic. I like it.

Leah: 0:54
Yeah. So, we're going to be covering that today. Then we're going to have a couple other episodes that have to do with how do you talk to your doctor at your appointments and…and… one other subject which escapes me right now, but that's okay. It could always change.

Tina: 1:11
If it's the topic we talked about, it was genetic testing.

Leah: 1:14
Oh, there you go. That's it. Yes, that was it.

Tina: 1:18
Ah yes, I remember it well.

Leah: 1:19
Oh, yes. So that's what we'll be covering today: talking to your doctor about integrative medicine. Then, in the next couple of weeks, we'll keep the conversation going.

Tina: 1:33
Sounds good. Well, this will be an interesting topic since we have diverse experiences.

Leah: 1:40
Oh yeah. Yeah. That's true. I mean, I've mentioned before that we both were trained in integrative cancer centers, so we kind of started off very similar. And then you actually have a lot more experience talking to your patients about talking to their doctor. So, I'm going to be learning some stuff.

Tina: 2:00
Who knows… I always learn more.

Leah: 2:02
That's why we do what we do. 'Cause we're always learning. If you're not learning in a job… I don't know… I don't think it would be as much fun.

Tina: 2:12
Yeah. I'm with you. Yeah. There's definitely, a lot to know.

Leah: 2:16
Speaking of learning, our oncology residencies… that was really my first introduction to integrative oncology. Was that the same for you?

Tina: 2:27
Yes. We both were in a hospital-based residency, which also adds an element of experience that is very different than when I got out and had my own clinic.

Leah: 2:39
Right. And when I completed my training, I went on to work in another hospital, an integrative cancer center. So, I've said it before; this is really all I know. Except for when my dad was treated for his cancer, which was not in the place where I worked, and it all seemed very alien to me. The things that weren't available. I mean, it just was like, "what do you mean?" Because I assumed all cancer centers were like that. Anyways, so what would you say your transition from working in an integrative hospital to private practice was like?

Tina: 3:17
You know, it's very different to work outside community oncology clinics; as an outsider to those clinics, then it is to be under the same roof with the medical oncologists, and maybe sharing the lunchroom and getting to know them on a personal level. You develop relationships when you're under the same roof that you just don't have when you're outside of the cancer center. 

So, with that, professionally, of course, it's a lot easier to know each other and pass in the hallways if you have a question and have that kind of collegial atmosphere that helps communication. 

Communication is probably a word that will come up repeatedly today because that's the breakdown. How do you communicate as a patient and even as a provider? Even amongst conventional doctors, there is discussion about how do you continue the continuity of care after someone finishes treatment? How does that work with the medical oncologist or the main point person in the cancer center? So, this is not just a naturopathic or integrative medicine question. It's kind of a global question for ongoing continuity of care for all patients who undergo treatment. 

That said, a community cancer center is so far removed from what we trained in when you're in a hospital setting with integrative practitioners down the hallway. So, you have a nutritionist down the hallway, you might have spiritual or pastoral care down another hallway, and you have psycho neuro-immunology specialists that help with the mind-body aspects. You have classes all day helping patients learn. 

In a private practice, you provide as much of that as possible, either in-house in your practice…and many of us do that, right? Naturopathic/ functional medicine doctors will put in-house a nutritionist or other caregivers that provide complementary care. Or, we refer out to the community, and many of us in our separate practices put together a team of practitioners.

The team of practitioners requires them [the patient] to travel from the community cancer center to maybe their naturopath, like me. Then they travel to their nutritionist who could be independent or at the cancer center, and then to maybe massage therapy, acupuncture, a psychologist…  

My experience putting it together on the outside of an integrative setting has been more challenging for the patient. It requires a level of communication that takes constant effort on everyone's part to put in the extra time and effort to make sure that everybody's communicating well and the patient is being served.

Leah: 6:05
Yeah. I think that's one of the things that's kind of kept me from doing private practice. I mean, having been a patient, you're tired. I would be seeing patients right after they would see the med onc (medical oncologist). They wouldn't even have to go to a different room. They'd just stay in the room. I would come in the room, and there were patients who were too tired. Mentally exhausted. And they're like, "I don't want to see you today. I am too tired for this." And I'm like, "that's fine, we'll check in next time," you know? I can't imagine having to go to so many different locations... that just seems for me, overwhelming. It's just, I didn't realize how much of a luxury it was for patients. I mean, now I realize it was a luxury to be in that sort of a facility.

Tina: 6:53
Yeah, and I think that on the flip side, the good news is large cancer centers are beginning to bring integrative oncology into the fold. So they're starting to put it under the same roof and so large cancer centers, whether it's MD Anderson, Sloan-Kettering… I'm sure Dana Farber and larger hospital settings are bringing it in under their own roof. I will say this the way they bring it in is not exactly how I practice as a naturopath because I use a lot of supplements and plants and biological agents like that. And what they'll usually bring under the roof are things that they know are the least likely to interact- understandably- with ongoing treatments. So, they'll bring in massage…

Leah: 7:44
…acupuncture and yoga I've seen.

Tina: 7:46
Acupuncture, yoga...

Leah: 7:49
And I see those as like… they're a start. Sometimes, a doctor or a nurse practitioner has done some sort of integrative medicine training that people can see. I mean, I've seen these things. It's not quite as comprehensive as the hospitals that we've worked in.

Tina: 8:07
No. And you know, what it's lacking is a quarterback, right? It's like you've got these players. Still, nobody is telling or helping the patient decide which aspect of integrative medicine is most appropriate for their particular scenario at that particular time. So I think that the advantage of having a point person of some kind and whether it's an MD, a naturopath, or a different type of practitioner doesn't matter, but somebody who knows the entire landscape well enough to say, oh, given what's going on with you, here's what I think would help. And it could be any one of the many aspects of complementary medicine that they're referring to.

Leah: 8:42
Right. We always said that the med-onc was the quarterback, but then, if it was something where he's just like, "Nope, you have to go see Dr. Sherman," you know? And then from there, I would say, okay, we need to get you into dietitian, we need to get you into physical therapy, you need acupuncture … all of these things. So, I guess we probably should define complementary medicine. Because people hear that and they hear alternative medicine, they often get interchanged, but they are different.

Tina: 9:15
Yeah. If you think about it literally, "alternative medicine" implies that you are doing something alternative from conventional. Alternative medicine means that the person is not doing conventional care, as opposed to complementary medicine, which complements the conventional. So complementary medicine is intended to get the most out of conventional care. And then integrative medicine is basically when you combine complementary medicine with the conventional and you're practicing integrating it. Right? You're integrating the two.

Leah: 9:53
And I think it's interchangeable now. I believe now "complementary" and "integrative," those two things are, are completely interchangeable.

Tina: 10:03
Yeah. I have a little preference for "integrative" because I feel like that's more true to what we're doing. We're not... we're not on the side. We're not off by 90 degrees, like a complementary angle.

Leah: 10:16
Oh, stop bringing geometry into things.

Tina: 10:19
We're not, we're not…

Leah: 10:20
No math here; there's no math involved in this podcast.

Tina: 10:24
Yeah. It's a little bit more like a braid of hair, right? Like you're overlapping it, because in time and space, you have a patient who is integrating other medicines into their conventional. I mean, "integrative" seems most descriptive to me, most true to what's happening.

Leah: 10:39
I like "integrative" too. We should probably define the modalities used in all integrative, complementary, and alternative medicine. The similarity is that they are all utilizing what's been divided into five categories: (1) mind-body therapies, which would be meditation, Tai Chi, yoga, music therapy, and art therapy. There are (2) biologically based practices: your vitamins and herbs, diet, nutrition service-type things, (3) manipulative and body-based practices chiropractic, massage, and reflexology. (4) Biofield therapy includes Reiki and therapeutic touch. And then (5) the whole medical systems, like Ayurveda or traditional Chinese medicine, naturopathic medicine is included in there as is homeopathy.

Tina: 11:44
Okay. And I know that this is something that… here we are sitting in the United States, we have one kind of way of thinking about it, and I know it changes around the world. So, whether people are in Europe or in Asia, or, whether it's, Ayurvedic medicine, Chinese medicine, Korean traditional medicines, they are of course offered in their respective countries as complementary care as well.

Leah: 12:14

Yeah. I was surprised because I had put up a post introducing that this might be coming up maybe in an episode. And I learned that in the Netherlands there aren't integrative cancer centers. I guess it's just not a thing outside of the US. I don't know if it's a thing in Canada. I'm not familiar with cancer centers outside of the US, and I'm not really familiar with a lot of them inside somewhat, but I kind of get how they, how they operate, Yeah, I thought that was fascinating. So, I'm not quite sure if somebody wanted to get acupuncture or, take herbs or something, like, I'm not quite sure how that's received overseas.

Tina: 12:58
Yeah, a paper a few years ago in Integrative Cancer Therapies looked at integrative oncology in several different countries. And the ones that they put in a chart-probably because it's the ones where its most used- traditional complementary or integrative medicine, was 50 to 60% use in the United States. Canada was 47 to 61%, Australia about the same 43 to 65%, Italy 22% of people, and Western Europe varied between 22 and 45%. But that's probably because Western Europe has a lot of different cultures. So, it looks like roughly more than a third… let's just say a third to a half of all people going through cancer care. And this paper was interesting because it talked about funding. Who was it offered by? Because a lot of these countries have socialized medicine. Was it provided for patients? How was it given? What was the culture? Was it acceptable? So, it was an interesting paper that we can link to on our website.

Leah: 14:06
Yeah, if you send me the link, I can post that. I have a friend who was treated in New Zealand and she said that her oncologist was pretty open to things, and he would tell her when to stop. And when you just hold this during this treatment. For her, it was a different experience. I think it's fascinating.

Tina: 14:30
Yeah. You know, I have found that it's safe and usually well received by the medical oncology community when people are doing mind-body techniques or acupuncture or, like I said, non-biological therapies in general. There was a time… 'cause we've been doing this for a while… right? There was a time when medical oncologists literally said to people, "It's your money. You can waste it if you want to." 

Leah: 15:08
Oh, for sure. So that would be a really good thing for us to talk about. What are the concerns from a conventional care team about using integrative medicine along with conventional cancer care? And that's one of them. I know that my patients would express to me that they were fearful of, being ridiculed/dismissed. We're not just saying this happens with oncologists. This happens with conventional medicine. In general, you'll have someone say, "don't try that it might hurt you." And then other people say, "do whatever you want, try it; it's not going to work anyways." So, there are patients who just… they don't know how to, how to communicate [the use of complementary therapies]. Still, there should be an awareness of the potential for interaction. And that's a huge concern, especially in oncology.

Tina: 16:16
Yes.

Leah: 16:17
And I guess the case study that we always talk about is the St. John's Wort.

Tina: 16:24
Yes.

Leah: 16:25
Because that's one thing that is familiar to pretty much everyone in oncology.

Tina: 16:30
You're referring specifically to how St. John's Wort can perhaps change the metabolism of various drugs to make them ineffective? 

Leah: 
So, for people out there who aren't familiar with St. John's Wort, it is an herb often taken by people in general for a low-level depression, like we talked about before. We used the word melancholy. You got the blues, you take St John's Wort.

Leah: 17:04

And cancer patients were taking it because they had cancer, and yeah, they were kind of feeling a little blue, to put it mildly. And there were, there were interactions. Because some cancer drugs need to be converted. Once they're inside your body, they need to be converted to the active form, and it interfered with Irinotecan. Right?

Tina: 17:30
Yeah, that was the one. That's the one that we have the evidence for. There's reason to believe that St. John's Wort, maybe Kava, some other plants, could change the way we metabolize the drugs to make it so that the drug is not therapeutic. So, with chemo drugs, in particular, there's that very, very small range of dosing in which they are effective, right? You need a certain amount to be circulating. And you know, we're talking about toxic agents, let's be honest, right? So these are toxic compounds that are titrated down to a very specific range. And that small therapeutic window means that you have to get a certain amount in your bloodstream to kill the cancer cells. But if you get too much, it could kill your normal cells as well. And you could actually take in a fatal dose if they gave you too much of a chemotherapeutic. Right? So this is called a therapeutic window or a therapeutic dose. And what we don't want to do with a narrow therapeutic window or dose where you need just enough, but not too much of something is change it. How the body metabolizes that drug is the last thing anyone wants to do. 

On that note, we have to also say that not just plants, but also other medications can change that dosing. So, I'll say this in probably many episodes, always use one pharmacist for all of your needs and make sure that that pharmacist knows that you're doing a certain chemotherapy or another drug. So that one pharmacist knows all of your drugs, and they're all in one system. So if there is anything that changes or interacts with your therapeutic agents, it'll get flagged. You know, it's automated in most places, that's on a computer and it, red. 

Leah:
As long as they have the list of what you're taking that is natural, because people aren't necessarily buying their herbs and supplements from you. 

Tina:
Yes, I'm not talking about the natural stuff. I'm saying that the interaction between medications ... It's much higher for drugs. The med to med interactions are much more likely than medication to supplement or medication to plants.

Leah: 19:32
And that was it. I mean, that was a huge part of, of what I did. And I don't even know if it was in—I'm sure it was—in my job description. Before seeing a patient, I would review their chart, and then we would make sure that they were still taking the medications that were in there, that were in their chart. And often, I was like, are you taking these two things because there is a potential [for interaction] and it wouldn't even be a supplement. So I was constantly monitoring not only their supplements but also their prescription medications to make sure. Every visit I was reviewing it.

Tina: 20:07
Yeah. The risk of drug-drug interaction goes up with every drug you add until, I think, I don't remember if it was four or five drugs. The risk is nearly a hundred percent that they're going to interact in some way. It may not be that you have to discontinue them, but they're going to start interacting. 

Leah: 20:21
Right. And other concerns would be not being familiar with what they're taking too. I would say the general public hears about herbs and supplements that might help. A lot of it's in the news, maybe, or social media or something. And often, doctors are getting information because there is something in their newsfeed and in their realm that might be a negative story.

Tina: 20:55
That reminds me, that paper made the rounds a few years ago. It was from 2017, I believe. Yes, 2017. And it talked about how.... All the headlines said those who take cancer treatments that are alternative treatments had an increased risk of death. And that was actually what the headline said. The headline said, 

Leah:
I think they said complementary medicine, 

Tina: 
Oh yeah. That's the inaccurate ones because it wasn't complementary medicine [since by definition complementary means they were also receiving conventional treatment].

Leah: 21:32
But that's what made it sensational, you had to read the story to see that they were talking about patients who are diagnosed with early-stage cancer, who opted for alternative therapies in place of conventional therapy. So they never received standard of care, but you didn't know that until you read the article. And if you just got that popping up you know, in your newsfeed...

Tina: 21:57
Well, yes. How many people go to the primary...You know, no one goes to the citation.

Leah: 22:01
No, it wasn't even in the citation. It was in the news... the news body actually told you what it was about, but the headline, which is what I think, majority of people read, they were like, oh my gosh.

Tina: 22:12
Well, and even the bodies of some of the articles at that time, because everyone's in a rush to make sure they splash that up really quickly while you get the 30 seconds of attention out there. 

Here's what happened: There was over 1.6 million people that they tracked in the National Cancer Database, and it was between the years of 2004-2013. Guess how many people out of almost 1.7 million people who had breast colorectal, prostate, and I believe lung was in there as well. Guess how many people refused conventional treatments in favor of one or more alternative therapies? 

Leah:
Out of 1.6 million?

Tina:
Yeah. In this particular study. I'll tell you, it was 281 people.

Leah: 22:57
Wow.

Tina: 22:58
Yeah. Okay. So percentage-wise, I don't even know what that calculates out to be, but it's not that much. So out of these 281 people who refused conventional treatment in favor of alternative therapies, alternative therapies for the purposes of this publication were defined as- I am laughing a little bit because this is ridiculous, and it was ridiculous at the time- I'm reading this right off their website, the NIH website, National Institutes of Health, the definition of alternative therapy used by the database included any "unproven therapies from a non-medical provider." That was their definition. So, it's not what we're defining here, just for the record.

Leah: 23:33
Okay.

Tina: 23:34
And it had nothing to do with the alternative therapy. It had to do with the fact that some people put off the conventional medicine... these 281 people. They put off doing the conventional medicine, whether it be surgery, I'm sure for many of them it was surgery. And then, of course, their cancer advanced in that time. And whether they did alternative cancer treatments or not didn't matter; any delay of conventional treatment led to worse outcomes. So, it didn't matter if they did alternative or if they just went home and pretended it wasn't happening. Any delay of actual conventional treatment is what led to the outcome of more deaths. 

That paper… I don't know how they even got that paper through with 281 cases out of 1.7 million people. 

Leah: 24:20
1.6 million. Sorry. Don't be adding some people onto that. 

Tina:
1.68 to be exact. So, I was rounding up. True. It was a silly and fairly useless paper, because if they had said the truth, the truth was delay of treatment leads to worse outcomes, which I don't think would have shocked anybody.

Leah: 24:53
Right.

Tina: 24:55
When that paper came out, I was in my private practice. There was a lot of damage control that I had to do to explain both to medical oncologists and my fellow colleagues and to my patients to say, okay, this is what happened. It's nothing that we need to be really concerned with because we're not doing alternative medicine, first of all. And second of all, I gave them the spiel on what they really found in that particular study.

Leah: 25:23
Can I tell you that I was working at the hospital, and we all read the headlines and everything. I don't think it ever came up. I don't think I ever heard anything from my med onc about it. I think people, when they read it, they were like, oh, delay of treatment. But also, they had an understanding of what we did in this integrative setting. You know, the naturopathic doctors there, they were the safety checks. We're making sure that patients are doing things. Often, I was the one talking to patients about.... you need to be taking your aromatase inhibitor daily. We were often the ones counseling patients about how to take their medications. So, I remember having that like panicky thought, like I'm going to be answering these questions hour after hour with each appointment, and it really didn't come up. So such different environments

Tina: 26:22
Yes.

Leah: 26:23
Another point is that oncologists are so busy. They're so busy staying on top of their own fields that learning about all of the natural things and all of the other options out there.... I mean, they're probably familiar with acupuncture, especially if they've had it themselves, massage, chiropractic, those kinds of things. But in terms of supplements, they don't have that background. I don't know if it's being offered in schools now. Traditionally, they don't, unless it's their own personal interest. 

And to have that time to sit down with someone, I think that's probably another issue why sometimes it's just not dealt with. As the naturopathic doctor, I would have patients wanting to take certain supplements. They would show up with printouts of studies or what they thought were studies, articles on the benefits of these different herbs or vitamins, or whatever. I'm sure they went to their oncologists with them too. I know that actually, I know that they went to the oncologist because then he would say, ‘oh no, show that to Dr. Sherman.’ And then I would, you know, have to go through it. And it is time-consuming. 

Tina: 27:37
Well, in community clinics, oncologists see around 25 patients. That is, you know, 20 to 25, somewhere in that region. All the medical oncologists and the community clinics where I was... and when I say community clinics, that's separate from academia, and it's separate from private hospitals or integrative settings. And so, yeah, there's no time between patients to go brush up on, you know, curcumin's interactions with their 5-FU or whatever drug they're giving. But it needs to be done, right, at the same time somebody needs to do it. 

I think working with a pharmacist, a naturopath, a medical practitioner of any kind who is versed in both plant and supplement medicine, as well as the conventional side- because let's be clear, anyone who's doing natural medicine during treatment in particular needs to work with someone who understands the mechanisms of action of the conventional treatments. If the practitioner that you're seeing of any stripe is using biological agents of any kind. By that, I mean physical, right? Like supplements, something you swallow, something that has a chemical action in your body- plants, whatever- they have to understand the drugs or the radiation. So, if they can't answer how that is working, then they shouldn't be combining them. That means that they don't have enough knowledge to really understand how to blend them together and to integrate them.

Leah: 28:52
So, I have an interesting story. When I would see them at their first appointment, I had several patients who I'd go through their supplements. And they were taking alpha-lipoic acid. They had already started treatment somewhere else. They were seeing an integrative doctor and that doctor had recommended a whole list of supplements, including alpha-lipoic acid. In my training, I was told never to recommend that to somebody in active treatment, if they're getting radiation or chemotherapy. And these are integrative medical doctors who were prescribing it. And I used to tell my patients, first of all, the dose that they're prescribing is not a therapeutic dose, but it is, it's still, it's an antioxidant. So, I don't recommend it at all. I would recommend holding that until we're done with treatment.

Tina: 29:42
Yeah. And lipoic acid or any of those sulfur-containing antioxidants are something that I always have people put aside, especially during radiation, which I think is easier to undo. 

Leah:
Right. 

Tina: 
Antioxidants might be more likely to undo the effects of radiation. Radiation works by oxidizing cells to the point where the cell succumbs to the damage. So, it kills itself basically because it's so damaged. 

One of the things during chemotherapy that I always had people do was talk to the pharmacist. Usually a pharmacist who is well acquainted with the drug itself. So maybe the one that's even dispensing it at the center and ask them about the drug. If it's a drug, like 5-FU is a very short-acting drug, (which is why people get a continuous pump of 5-FU for colorectal cancer, for example,) don't take it while the drug is going in and don't take it when there's any active chemotherapeutic time. But if it's a chemo that only works for a day or a few hours, you can talk to a pharmacist, you can talk to the medical oncologist and say, how long is the action of this drug?

There's something called the area under the curve (AUC), which is a pharmacy phrase for how long does it take to leave my body? And when is it safe for me to do something? 

Let's just say you're taking a plant (herb) that works really well for your sleep, but you don't want to take that plant during treatment. You can ask your medical oncologist when it would it be safe to take. Is there a time period between my treatments that I can resume taking that? Where you're not worried about interacting with the drug because the drugs no longer have an active effect on killing cancer cells? There are some times you can dance in between, especially when you have a three-week or four-week period between chemotherapy infusions. 

Leah: 31:21
So, that's a really good segue for us to start talking about how do you talk to your doctor about getting integrative therapies? And I mean, we're, we're talking about more than just taking supplements and herbs and vitamins. I mean, acupuncture is one, you know, I've had patients who've come to me who are also seeing Ayurvedic practitioners. Can you go to a chiropractor? You know, all of these, these kinds of modalities and yeah, I think people do kind of stick to the safe ones. You know, like the meditation, like you're saying the mind-body things, but even yoga. I mean, my training doing Yoga4Cancer. I mean, there are things that we do not do with our patients that I have seen other yoga practitioners doing with their clients.

Tina: 32:11
Well, and that brings up the point that this is really opinions that we're looking at. Right? So, I think one of the things that we need to discuss is how each person feels about the doctor they're seeing. When you talk to your medical oncologist, or surgical oncologist, radiation oncologist, whomever you're talking with, of course, you want to have a hundred percent trust in that person. And you do need to find people that you can talk to in a peer-to-peer fashion. It shouldn't be feeling afraid to say something or getting a look that you don't want to get from your doctor. I've had this happen with patients who are like, "Well, I'd bring it up, but the doctor gives me a certain face that it's clearly disapproving."

I think that breaking down that hierarchy in the room is important. It's important that the patient be heard. Approaching the doctor in such a way, and I hate to make generalizations, but I think this one is fairly; that respects the fact that they are an expert in what they're doing, and they probably have a pretty good ego that you need to be gentle with; to not go abruptly. You know, it's kind of like how you approach a dog. You don't go straight up to a dog and expect it to take kindly to you, you turn your shoulders a little bit, and you come at it and angle. So, kind of pave the way to be gentle and not be abrupt. I think sometimes trying to go straight on receives a lot of resistance.

Leah: 33:38
Oh, I've experienced that because I've had those kinds of interactions with my doctors, not my oncologist, but definitely my other doctors. Yeah, because I'm so used to having certain conversations. And then when I'm given a look... yeah, I come out swinging, so I get it. I do get it.

Tina: 34:00
Basically, think of it like this: you don't want to go toe to toe and have a standoff of any kind. You want to let your own ego go as well. You don't need to go in there with an agenda, just with an open mind and understand that you are getting an opinion. You're still in control of your own body and your destiny. So you get the opinion. You see if it was a thoughtful opinion or if it was just a snap, knee-jerk reaction. "Don't do anything if it's not in my toolbox." You know those are two very different reactions. You can tell if it's a thoughtful reaction. Or if it's based on just an abrupt ego-based, "don't tell me what's good for you" reaction, which unfortunately is not uncommon still. 

I mean, I'd love to say that everyone just goes out and gets along, but a lot of times it's not like that. The hierarchy in the room is real. Right? So, just being mindful and respectful and expecting to be respected back is very important because no one should be disrespected. Ultimately, I think this is really empowering to think about before you walk in the room. The oncologist is working for you. You're the one paying them. You're one of their 25 people for the day, or 20 people for the day, or however many they're seeing. They are working. You are the patient. In some ways the hierarchy should be reversed, but of course it's not because they have their expertise that you certainly need to listen to. In any case, I do find that telling yourself, reminding yourself that you deserve respect and that should happen when you walk in the room. 

To be honest, I've actually counseled patients in changing their doctor when they weren't respected. I think that that has to happen. I don't think it's good medicine unless they're on the receiving end of a respectful interaction with your oncologist or any other doctor, for that matter.

Leah: 35:47
I think that it's also important that the patient does research on their side. So let's say they want to get acupuncture or massage or chiropractic. I remember there was a time when people - and then maybe it still is this way - people were told not to get a massage if they had cancer because it could spread the cancer. I mean, I remember massage therapists learning that at one time. So if you're interested in getting chiropractic or massage or acupuncture, finding someone who works with cancer patients, I think, would be reassuring. That way, your med onc [medical oncologist] doesn't have to vet anyone. You can say, "I found this acupuncturist who works with cancer patients, and I'm interested in getting acupuncture for this, this and this." 

Often, the integrative providers can have consults with your doctor as well. They can talk to them and if there's any concern, they can reach out and say, "I've been working with this patient for this many months, and I'm not seeing any changes." So having that open dialogue between integrative providers is important, and finding integrative providers who have experience with cancer patients.

Tina: 37:02
Yes, I totally agree. If it's someone doing an alternative- complementary, we should say complementary therapy- like acupuncture or massage, whatever... they should have experience working within oncology for sure.

Leah: 37:14
Especially chiropractic, they have to be familiar with what's going on with you and your bone health.

Tina: 37:26
Yes, completely. 

Leah: 37:28
Crucial. I mean, that's crucial for anyone, but for cancer patients, they really need to have that additional experience.

Tina: 37:39
I want to say something about when someone goes to their oncologist and wants their opinion on something. Often, the most they're going to get is an "okay." They might not say, "Yeah, that's a great idea!", but they might say, "that's fine if that's what you want to do." 

I want to be clear that I would say that the majority of time, that is the reaction that I got. Over time, when oncologists got to know me- or other practitioners in the community- well enough to know that they shouldn't be threatened, that we're not talking people out of doing their conventional medicine, I actually got referrals from certain doctors. But there were select doctors. Out of 18 oncologists, I got referrals from two or three.

Leah: 38:26
That's another question. "Do you know of an acupuncturist or do you know of a provider that I could see?" Asking nurses, asking other people at the cancer center, if it's not offered at the cancer center where you are. 

Tina: 38:43
That's a really good point because they might have an idea of who's done well from their perspective.

Leah: 38:47
We're talking about staff at the cancer center.

Tina: 38:49
Yes. Not the person in the waiting room, which is fine too, because you know, word of mouth works. But if you're talking to the nurse or the doctor or whoever sees 20 patients a day or more. In that case, they're going to see a trend in who's doing well that wouldn't be visible to a single person out in the waiting room, sitting in a chair who had a good experience. And they might know the credentials of that person and make sure that they're not just someone who hung a shingle and was self-proclaimed as whatever type of healer, which happens a lot more in other states. 

In the United States, naturopathic medicine, for example, is regulated in many states—18 or 20 at this point—but the majority of states don't have any licensure for naturopaths. So you literally could just put the word or the letters after your name, hang a shingle outside a door at a plaza and call yourself one. So that's an issue. We can also put more details about that on our website: how to figure out where to find a licensed or at least a well-trained as in four-year post-graduate school, perhaps a residency. 

Leah: 39:52
Or just oncology-trained because there are requirements to get board certified in naturopathic oncology.

Tina: 40:04
And in this post COVID era...I know it's not truly post-COVID, e still have some covid around... but in this era of remote medicine, there's plenty of practitioners who are willing to do remote consultations. And they are specialized in naturopathic oncology. So we'll put a link up so that people can find them in their area. 

Leah: 40:23
So, any other tips for people in talking to their provider, their med onc about incorporating integrative therapies?

Tina: 40:33
You know, I think the conversation people should have with their oncologist is similar to the one I have, and that is to stick to the common ground first. Like what do you have as a common ground? It might be nutrition for example, or exercise or sleep. Establishing that your doctor also believes that a nutritious diet that's largely plant-based is an important component of health in general, whether you're going through treatment or not. Even if you know nothing about the medical literature, you would still say, "oh, you should eat well and have all the macronutrients and micronutrients in your diet." "You should sleep well. You should move your body." And, of course, "stress doesn't do anyone any favors." Sometimes you are just breaking ground and making sure the common ground is there with the person. Because I can tell you now, if a doctor looks at me and pooh-poohed any of that, I would be out. I'd be like, okay, I'm going to find someone else who's at least reasonable. Because you don't need to be up on medical literature to agree on good health and going in the right direction.

Leah: 41:35
And I think that was another thing that I kind of took for granted where I was working; there were dietitians on hand. So, if patients came to us and they said, "I read this book and I want to do this diet." Or, "I'm seeing someone outside of here, and they told me I need to be eating this certain way." I immediately put in a referral and our dietitians knew about many alternative diets and knew their pros and cons. That was another advantage. Having these oncology-trained, registered dietitians. 

I know I've discussed with you before, maybe it was offline, but I didn't realize that there are so few of those out there. Again, I'm spoiled. So just making sure that if you are seeing a registered dietitian, that they are oncology trained. There are some awesome ones out there on... on the Instagram. So I'll put some links to where people can find them. 

Tina: 42:43
Yeah, I bet there is.

Leah: 42:44
Yeah.

Tina: 42:45
I'm open to putting that up on our website because I think that's really important. I can think right off the top of my head of times that I disagreed with people who weren't oncology-trained and they were dietitians and you're like, "hmm... that's not quite appropriate for what's going on." So yeah, I would think that anyone who's specifically certified as oncology specialized nutritionist would be ideal and dietitians I know are RDs. It's registered dietitians (RDs)_ and then there are nutritionists, which again is a less regulated term, often outside hospital floors.

Leah: 43:23
Just the fact that there aren't necessarily dietitians in a cancer center for patients to see—they are an important part of an integrative care team. If you have to put together your own integrative oncology care team, I would say the dietitian would be just right up there. It's so important for patients because there's so much information and so much misinformation out there. And, to have that as your resource, I think that would be a definite person to put on your... I keep wanting to say "your zombie apocalypse team," but, it kind of is. You want to bring someone who knows about nutrition.

Tina: 44:11
Yeah. And there's an app called Eat This Much. Do you know about that? That's something else we can link out to. [see show notes above]. It might be useful for folks to just put in a game plan. Eat plants mostly; that's the bottom line. The bottom line is: eat color, eat plants. Protein requisites are between 0.8 and one gram per kilo of your desired weight. Just in general, we're not talking about gaining weight or losing weight. 

Leah: 44:43
I like how you know that. This is stuff I never had to even think about. Like, I got to let all of this stuff just flow out of my brain because I had somebody to do it, and they were amazing.

Tina: 44:58
Yeah. That'd be nice. 

Leah:
You're like, ‘why are you in this conversation anyway? You're a unicorn.’

Tina:
You know, nutritionally, I like Oldways. Their motto used to be "Health Through Heritage" because they look at the various lineages of our genetic makeup. So they look at whether you hail from Asia, from Africa, from Europe. Like, where do your genes hail from? That's all they're talking about, and they create these pyramids. It started with the Mediterranean diet. Now they have all these other ethnic diets. But in all cases, they're all very similar in that they're almost all plants, right? It's all largely plant-based, and then adequate proteins, adequate fats. So those pyramids are really useful. I think that's probably where I would steer people in my office. When I have all of five or 10 minutes at the end of a visit to help people find a way to eat well, I would say that's probably the primary recommendation I made.

Leah: 45:57
I hope that this information is helpful to people. I hope we've given enough information that people are more comfortable approaching their doctors about integrative therapies.

Tina: 46:11
Yeah, I think between our show notes and our website, we can link out to some resources that will be more useful from a practical standpoint.

Leah: 46:19
Yeah. Definitely. We can put, put links in the show notes as well as on the website. So you can find us on social media. We're on Instagram and Facebook, and sometimes we're on Twitter.

Tina: 46:33
And the "we" you mean is The Cancer Pod?

Leah: 46:35
That's right. And me. Okay. I am social media. All right. [laughter]

Tina: 46:40
You are. [laughter]

Leah: 46:43
No, The Cancer Pod, you can find The Cancer Pod on all social media out there. I'm so hip and we're on the Tik Tok too, even though I really haven't done much with that, but who knows, maybe I'll get inspired and do a dance.

Tina: 46:58
Yeah. Why not?

Leah: 46:58
With you, Tina. 

Tina: 47:00
I'll do it. You know what? 

Leah: 
I know you've actually been the one who's been wanting us to do a dance and…

Tina: 
You name it, man. Name the time and place, and I'll be there dancing. 

Leah: 
On that note, I'm Dr. Leah Sherman

Tina: 
And I'm Dr. Tina Kaczor.

Leah: 
…and this is The Cancer Pod. 

Tina: Until next time. 

This transcript has been edited for clarity.

 Thanks for listening to The Cancer Pod. Remember to subscribe, review and rate us wherever you get your podcasts. Follow us on social media for updates, and as always, this is not medical advice. These are our opinions. Talk to your doctor before changing anything related to your treatment plan. The Cancer Pod is hosted by me, Dr. Leah Sherman, and by Dr. Tina Kaczor. Music is by Kevin MacLeod. See you next time.