Integrative Oncology: Principles and Practice

ABSTRACT: Editor: Matthew P. Mumber, MD Publisher: Taylor & Francis, London and New York 517 pages Cost: $149.95

The emerging field of integrative oncology now has a definitive textbook, thanks to the Herculean effort of Matthew P. Mumber. Dr. Mumber regards integrative oncology as "the next step in the evolution of cancer care [including] the use of evidence based-tools [that] have their origin both in Western, conventional medicine and in complementary and alternative medicine (CAM) traditions." Mumber, a radiation oncologist from Rome, Georgia, completed the 2-year distance-learning Associate Fellowship in the Program in Integrative Medicine at the University of Arizona. Assembling a cadre of coauthors that includes a number of the faculty from the Arizona program, Mumber and his colleagues have created a truly comprehensive educational resource that will long be of value to the full array of practitioners caring for the body, mind, and spirits of patients with malignant disease. This evidence-based text will be of use to sophisticated patients, students, clinicians, and those interested in research possibilities in the emerging field.

As promised in the text's title, section I is devoted to principles, comprised of seven chapters dealing with principles of integrative oncology, clinical research and evidence, physician training in integrative medicine, the health of the healer, models of care, legal issues, and business assessment. These chapters contain useful pragmatic information and raise important issues that practitioners of integrative oncology at all levels need to comprehend. A description in the research chapter on the challenges to conducting randomized controlled trials in complementary and alternative medicine is particularly poignant: One cannot help but note later in the text that the levels of evidence supporting most of the recommendations are generally levels II-IV as opposed to being derived from well-controlled randomized controlled trials. This lack of level I evidence for CAM interventions also likely explains the lament of the pioneer integrative oncologist quoted in the business assessment chapter.

In my opinion, there is something deeply flawed about a healthcare system in which I, as an oncologist, can readily spend tens of thousands of dollars of Medicare funds to extend the life of an elderly man with advanced lung cancer for perhaps three or four months, utilizing expensive chemotherapy treatments, growth factors, blood transfusions, CT Scans, MRI Scans, and other costly diagnostic procedures…but I cannot find $100, or even $50 for an acupuncture treatment, a therapeutic massage, or a private counseling session for a frightened, terrified single mother of three children who is battling metastatic breast cancer—and who is sitting in the very next room.

Some useful tips for dealing with these sorts of frustrations are provided in the chapter entitled "The health of the healer: physician/health-care provider wellness." With burnout being an especially vexing problem in cancer care providers, we can all stand to review the contents of this well-written selection and take advantage of the final table's extensive listing of Web links to programs and activities to enhance personal wellness.

Section II provides the reader with information on the practice of clinical integrative oncology in an intricately woven way. Chapter 10 describes an overview of the eight modalities of intervention to be explored-physical activity, nutrition, mind-body interventions, botanicals, manual therapy, energy medicine, spirituality, and alternative medical systems (traditional Chinese medicine, Ayurveda, homeopathy)—in subchapters 10a through 10h. The author for each modality is responsible for the subchapters involving their area of expertise in the following chapters. Chapter 11 reviews the use of five of the above in cancer prevention, chapter 12 covers seven of the modalities in supportive care, and chapter 13 includes information regarding the use of four of the modalities in the actual treatment of cancer.

These chapters contain some very critical information and some truly outstanding tables that will serve as useful references for the practitioner of integrative oncology. For example, Table 11.5 in the nutrition subchapter of the prevention piece offers a comprehensive outline of phyto-chemicals and their proposed biologic mechanisms. The nutrition section of the next chapter also has a nice table on coping with treatment-related symptoms that alter diet. For anyone interested in obtaining a standardized accounting of dietary supplements their patients may be ingesting, Figure 12.1 offers an easy to reproduce form that will facilitate such data collection. Table 12.5 is another valuable resource—a compilation of recommended mind-body interventions for the relief of a number of symptoms with the level of evidence supporting the modality. The following table in the botanicals subchapter alerts us to possible herb interactions with chemotherapeutic agents possibly mediated via various cytochrome P450 isoforms—absolutely essential information for practitioners.

As if this interweaving of the modalities into chapters on prevention, supportive care, and antineoplastic therapy was not enough, chapter 15 looks again at the interventions and their use in a number of specific cancers including breast, prostate, lung, colorectal, and skin. Each of these chapters contains an elaborate table outlining the benefits of the modalities for primary, secondary, and tertiary prevention of each of the malignancies with the corresponding level of evidence for the intervention. Again, the absence of any real level I evidence in these tables should provide anyone interested in clinical investigation in integrative oncology with fertile soil for the development of research proposals.

Unfortunately, these tables in the final chapter are generally more comprehensive than the accompanying text. For example, the subchapter on mind-body interventions in lung cancer is all of one sentence. This reflects the paucity of evidence-based information regarding integrative interventions in patients with lung cancer overall, as well as an apparent exhaustion of the authors' subject matter in the preceding chapters leaving little left to say by the final chapter. The text of the later skin cancer chapter was bereft of any real data or useful information. Although remarkably well-orchestrated overall, one gets the impression that the warp and weave that the editor used to construct the section on practice became a bit threadbare by the end. The effort to stick to the elaborate structure of the interwoven modality sections throughout the last half of the text may have sacrificed some economy of scale; much of the information could have been condensed in a more digestible form.

The text is encyclopedic in the amount of information it imparts to the reader. It is extremely comprehensive and very readable. The information is imminently factual, well-supported with extensive references, and as evidence-based as possible. Aside from a parenthetical reference of Ganoderma lucidum being maitake instead of reishi, this reviewer found no factual errors in a cover-to-cover read. That said, I was a bit surprised to note a lack of discussion of the positive effects of lycopene in either the nutrition or botanicals section of the prostate cancer chapter and no mention of the association between beef and colon cancer.

The soy and breast cancer controversy was thankfully addressed; however I felt disappointed that I could not come away with more clarity after reading the discussion. I was also disappointed that the spirituality modality was only discussed in the overview in chapter 10 but subsequently disappeared as a missing thread in the ensuing text. The energy medicine sections seemed excessively long, albeit informative and well-written, in relation to the degree of evidence available supporting these interventions. Indeed, the author even comments that "energy practitioners do not align themselves to outcome... except in pain."

The section on alternative medical systems was often focused on acupuncture alone, not as an integrated traditional Chinese medicine intervention. This likely reflects the inability to date to convince NIH review panels that the whole system should be studied in a holistic fashion and not broken down into its isolated parts in the reductionist manner that study sections generally demand.

Integrative oncology is a thriving young field. The Society of Integrative Oncology (www.integrativeonc.org) will be convening its 3rd International Conference in Boston this November. The Society now publishes a journal, which, along with Integrative Cancer Therapies, will keep practitioners informed about progress in the field. Increasing numbers of academic medical centers across the country are establishing integrative oncology programs to join the ranks of the pioneers at Memorial-Sloan Kettering Cancer Center, M. D. Anderson Cancer Center, and the Dana-Farber Cancer Institute.

The National Cancer Institute has its own Office of Cancer Complementary and Alternative Medicine (http://www.cancer.gov/cam) devoted to funding clinical trials investigating integrative oncology interventions. Such resources are also available from the National Center for Complementary and Alternative Medicine (http://nccam.nih.gov). And now, thanks to the huge effort of Matthew Mumber, the field can boast its very own definitive textbook, which will remain an invaluable reference as integrative oncology continues to evolve in the future.

—Donald I. Abrams, MD