History, goal of therapy, seminar: What is Integrative Oncology?

The Integrative Oncology combines conventional oncology with evidenced-based complementary therapies. The main goal of Integrative Oncology is to reduce side effects of oncological treatments and to improve patient's quality of life. In addition, patients should be empowered with the ability to cope with the cancer disease and to develop lasting and individual strategies to strengthen his physical and mental fitness and to facilitate healthy lifestyle changes (Salutogenesis).

History

Integrative Oncology has its origin in the United States - David Eisenberg from Harvard showed in his two surveys in 1990 and 1997 [1] [2] that a growing percentage of the population let themselves to be treated with Complementary medical methods (42% in 1997). But only very little of them let their physicians know about it. Due to this insight, the National Center of Complementary and Alternative Medicine (NCCAM) is founded in 1998 as part of the US National Institutes of Health (NIH) to undertake research in Complementary Medicine with support from the government. The American Urological Association was the first oncological specialist society who fulfilled the high demand from patients and founded a working group in Complementary Medicine at the end of the 90s. [3]

Supported by Maurice Rockefeller, the Memorial Sloan-Kettering Cancer Center initiate one of the first departments of Integrative Oncology in 1999. Its Director is the psychologist Barrie Cassileth, also the founding president of the "Society for Integrative Oncology" (founded in 2003). In her mission statement, she clearly made the difference between this multi-discipline Specialist society and other not scientifically proved methods of "Alternative Medicine". [4] The goal of the society is to review researches in Complementary Medicine and different clinical practice, and to implement the result in oncological treatment. To achieve this goal, the first integrative oncological Medical Guideline was published in 2007 (revised and extended in 2009). [5]

Meanwhile most of the leading Cancer hospitals in the United States have founded Departments for Integrative Oncology, e.g. the Leonard P. Zakim Center for Integrative Therapies at the Harvard Medical School in Boston, the Memorial Sloan-Kettering Cancer Center in New York, the MD Anderson Cancer Center at the University of  Texas and the Johns Hopkins Medical Institutions in Maryland.

According to the German Cancer Aid (in German: Deutsche Krebshilfe) over 70% of cancer patients are interested in Complementary medical methods. [6] In Germany and in Switzerland there are the first Oncology departments which integrate complementary medical methods in standard oncological treatments, for example the Anthroposophical Community Hopsital Havelhoehe in Berlin, the Flider-Hospital near Stuttgart, the hospital Kantonspital St. Gallen, the hospital Paracelsus-Spital im the canton of Zurich und the Center for Integrative Medicine and Cancer Therapies in Oeschelbronn. Since 2004, the Chair of Complementary and Integrative Medicine at the University of Duisburg-Essen has offered consultation hours to Breast Cancer patients in Complementary Medicine at the University Women Hospital (a cooperation with the Essen-Central Clinic). A Department of Integrative Oncology is established at the Essen-Central Clinic in 2010 as a cooperation between the Breast Center and the Department of Complementary and Integrative Medicine, following the model of the Memorial Sloan-Kettering Cancer Center. In 2012, the Department of Gynecology joined the cooperation. At the University Hospital Frankfurt, integrative approaches are applied in the University Cancer Center (in German: Centrum für Tumorerkrankungen - UCT); at the University Hospital Jena there is an Out-patient Center for Complementary Medicine and Integrative Oncology. Integrative Oncology is also practiced in the interdisciplinary Breast Center at the Technical University Munich. 

A working group for "Prevention and Integrative Oncology" was established by the German Cancer Society in fall 2011.  [7]“. The German Cochrane Center has a working group "Biological Cancer Medicine" at the University Hospital Nuernberg. In October 2011 a consensus workshop in Integrative Oncology supported by the Robert Bosch Foundation took place in Berlin. Representatives from different institutes and traditions in Complementary and Integrative Medicine; and from different oncological Organization (e.g. AGO -  The Working Group of Gynecological Oncology; the German Cancer Society) joined the workshop. Representative agreed and reached consensus on the necessity and the content of a Complementary Medicine Training for Oncologists. [8] Moreover, the German Society of Complementary Medicine has established a Medical Guideline Office to integrate Complementary medical methods in the sense of Integrative Oncology in the Oncological Medical Guideline.

The German Cancer Aid facilitated and supported a Germany-wide, multi-disciplinary Competence Network "Complementary Medicine in the Oncology - KOKON" from 2012 to 2015 as a collaborative research project. Involved are Department of Oncology in University Hospital Nuernberg (Chief), the Charité in Berlin, the University Hospital in Hamburg Eppendorf,  Munich and Rostock, the University of Frankfurt and Greifswald, the Hans-Bredow-Institute  for Media Research at the University of Hamburg,  the Essen Central Clinic, the Hannover Medical School and the Clinic for Tumor Biology in Freiburg. KOKON has the following tasks: to undertake an analysis, what kind of information cancer patients, the attending physicians, the nurses and the consultants need; to develop a training concept for specialists and cancer aid groups, to set up a specialist consulting proposal for patients in Oncological Centers, to establish a data bank of knowledge exchange on interactions, side effects and scientific evidence of Complementary medical methods and to create a central information platform for Complementary Medicine in Oncology. 

Form of Treatments

In the Integrative Oncology, the application of Complementary medical methods are subsidiary and always in coordination with the standard oncological treatments. These are:

• the classical Complementary Medicine
• the rational Phytotherapy
• the Anthroposophical Medicine
• the Homeopathy
• the Traditional Chinese
• the "Regularity Therapy" or the Mind-Body Medicine

with scientifically-proved effectiveness through studies.

Together with the patient, a team of different occupations develop strategies to explore and to strengthen the individual health-promoting potentials of patients (Salutogenesis).

Therapy Goal

Relieving side effects
Key aspect of Integrative Oncology lies in the relief of side effects. Part of the therapies can be carried out of patients as self-help strategies.  Goals are:

• Relief of nausea and vomiting [9] [10] [11] [12]
• to minimize climacteric symptoms as aftermath of anti hormone therapy, e.g.  through using Cimicifuga extract [13] [14], Acupuncture [15] [16] or  Intervention in group with Meditationen and breathing exercises [17]
• to minimize Fatigue symptom [18] [19] [20]
• to minimize mucosal changes  and mouth dryness [21] [22]
• to minimize changes to nails [23]
• to minimize diarrhea and constipation
• to minimize Hand-Foot-Syndrome and Neuropathy[24] [25]
• to minimize pain

To improve the quality of life
Acupuncture, Phytotherapy, exercising and above all the Mindfulness-Based Stress Reduction (MBSR) in Mind-Body Medicine with methods like meditation, Yoga, qigong and tai ji can help in case of insomnia, anxiety and depression. [26] [27] [28] [29] [30] [31] [32] [33] Positive results on quality of life of Breast Cancer patients can be showed in mistletoe therapy.[34]

Change of Lifestyle
Above all the "Regularity Therapy" and the Mind-Body Medicine aim to achieve a lasting and sustainable change of lifestyle and self-care in the sense of strengthening the health promoting potential of the patients.

Side Effects

As a whole evidence-based Complementary Medicine has little side effects. Attention should be paid to the possible interaction between herbal substances and the enzyme cytochrome P450 as well as P-glycoproteins which fulfill transportation function and has an influence on the metabolism. Cytochrome P450 3A4 is the main protective mechanism of the small bowel; it is responsible for the so-called "first pass effect". This is the main metabolic pathway for many drugs, for aromatase inhibitors lapatinib and tamoxifen used in chemotherapy as well as for the natural antidepressant St. John's wort. (Cytochrom P450 3A4 ist der Hauptschutzmechanismus im Dünndarm und verantwortlich für den so genannten „first pass effect“. Diesen Hauptmetabolisierungsweg für viele Medikamente gehen die in der Chemotherapie eingesetzten Aromatasehemmer Lapatinib und Tamoxifen, aber zum Beispiel auch das natürliche Antidepressivum Johanniskraut.)

Many herbal, but also synthetic drugs can therefore cause unexpected interaction with Chemotherapy or Radiotherapy: Cytochrome inhibitors imply that their effects increase, but the side effects are also severer. Cytochrome inducers, however, ensure that drugs are decomposed more rapidly, potentially it can even cause a treatment failure.[35] (Cyp-Hemmer bedingen, dass deren Wirkung ansteigt, dann aber auch die Nebenwirkungen schwerer werden. Cyp-Induktoren sorgen hingegen dafür, dass Substrate schneller abgebaut werden, das kann potentiell sogar ein Therapieversagen auslösen.)

Research

Research in Integrative Medicine and in Integrative Oncology in Germany and in Switzerland mainly takes place in university chairs of Complementary and/or Integrative Medicine. These are:

• Charité Berlin

  Professorship for Complementary Medicine at the Institute for Social Medicine, Epidemiology, and Health Economics (Professor Claudia M. Witt, MD MBA)

  Professorship for Clinical Naturopathy at Immanuel-Hospital in Berlin-Wannsee (Professor Andreas Michalsen, MD)

  Kneipp Foundation Professorship for Complementary Medicine and Vice-President of CHAMP  - University Outpatient Clinic for Naturopathy (Professor Benno Brinkhaus, MD)

  Working group Integrative Medicine in the Department of Pediatric Oncology (http://paedonko.charite.de/forschung/ag_integrative_medizin/)

• University of Bern

  Institute of Complementary Medicine - KIKOM (Stephan Baumgartner, PhD; Klaus von Ammon, MD)

• University of Duisburg-Essen

  Chair of Complementary and Integrative Medicine (Professor Gustav J. Dobos, MD; Professor Jost Langhorst, MD)

• University of Frankfurt

  Department of Complementary Oncology at the University Cancer Center (Jutta Hübner, MD)

• University of Cologne

  Institute of Scientific Evaluation of Naturopathic Methdos (Professor Josef Beuth, MD)

• Technical University Munich

  Professorship for Naturopathy and Complementary Medicine at the university hospital Klinikum rechts der Isar (on the right of the river Isar) (Professor Dieter Melchart, MD)

• University of Rostock

  Chair for Complementary Medicine at the Clinic and Policlinic for Internal Medicine in Rostock (Professor Karin Kraft, MD)

• University of Witten/Herdecke

  Chair for Medicine Theory, Integrative and Anthroposophical Medicine (Professor Peter Heusser, MD)

  Professorship for Research Methods and Information System in the Complementary Medicine (Professor  Thomas Ostermann)

  Professorship for Living Quality, Spirituality and Coping (Professor Arndt Büssing)

• University of Zurich

  Institute of Naturopathy

The clinics in Anthroposophical Medicine joined the "Network Oncology" to gather, interpretate and to evaluate cancer case studies in form of a tumor documentation. [36]

In-Patient Treatment/Specialist Out-Patient Center (Integrative Oncology)

• Essen: Clinic for Complementary and Integrative Medicine/ Senology Center of Essen-Central Clinic

• Frankfurt: Department of Complementary Oncology in University Cancer Center

• Hamburg: Out-Patient Center for Chinese Medicine at the Jerusalem-Hospital (Mamma Center)

• Herdecke: Complementary Oncology in the Community Hospital (http://www.gemeinschaftskrankenhaus.de/index.php5?page=412&lang=0)

• Jena: Specialist Out-Patient Center for Complementary Medicine in the Oncology at the Friedrich Schiller University

• Kassel/Bad Wilhelmshoehe: Habichtswald Clinic (http://www.1-onkologie.de/)

• Oeschelbronn: Center for Integrative Medicine (http://www.gemeinschaftskrankenhaus.de/index.php5?page=412&lang=0)

• St. Gallen: Hospital Kantonsspital (http://www.onkologie.kssg.ch/home/integrative_onkologie.html)

• Stuttgart (Filderstadt): Center for Integrative Oncology in the Filder-Hospital (http://filderklinik.integrative-onkologie-stuttgart.de/)