Bridging the Gap. James Eugene Munson
blank, he asked if Chinese medicine could cure his cancer. This question provides the TCM doctor with an immense opportunity that benefits the patient in two ways. First, recognize that in this specific case the patient was seeking a fast, straightforward cure. Medical ethics override any discourse that insinuates Chinese medicine as a singular therapy to quickly eradicate his cancer cells. But this also opened a dialogue that informed him about the principles of Chinese medicine oncology for cancer management, and how it integrates with conventional treatments from acupuncture and moxibustion to herbal medicine. At the follow-up appointment, he shared his decision to opt for an alternative therapy at an “integrative cancer center” even though it was extremely costly and not covered by insurance. His understanding of the treatment was vague, but he was compelled by the case manager who reviewed his diagnosis and proposed the course of treatment. He was told “in two months you’ll be cured.” We asked questions about this protocol to determine its potential harm or efficacy and explore its parameters. However, he was uncertain as to what medicine, vitamins or supplements he would be treated with for those two months.
The outcome of this case is unknown, as the patient proceeded with the alternative therapy and did not follow-up. These interactions occur in TCM cancer management, and patients should feel empowered to ask questions, seek multiple opinions and ultimately make the best choice for themselves. Of equal regard, however, is the integrity of the clinician to listen and inform the patient within their scope of practice. The clinician’s role should never be to exploit or promise a healing outcome. An integral strength of Chinese medicine is its duality to observe the whole person, diagnose according to constitution and deliver medicine through skilled treatment protocols, which optimize the healing process. And in some cases, this aligns with curable outcomes as a result of balanced integration. This is the message we share with cancer patients.
This patient’s interaction provides insight as to why a singular, agreed upon definition of IO did not exist for many years. Countless medical disciplines and providers in cancer care had the autonomy to label a particular therapy or practice as “integrative” regardless of proven, therapeutic efficacy. Thus, the merge of a multitude of modalities interconnected to the framework of conventional medicine lead to variable interpretations of IO. What ensued was an ambiguous medical melting pot that ultimately impacts those navigating collaborative treatments. In response to this confusion, as well as an apparent demand by cancer patients seeking complementary therapies, the Society of Integrative Oncology (SIO) was established in 2003.
The SIO platform promotes communication among cancer providers, including classically-trained Western physicians, practitioners of Eastern medicine, naturopathic doctors, massage therapists, herbalists, social workers and professionals committed to cancer management and recovery. It is instrumental in the advancement of multidisciplinary systems of care. Regardless of discipline, members share a common goal that promotes evidence-based standards of integrative oncology. It proposes an awareness and sensitivity of the patient’s mental, emotional and spiritual wellness, while combining mainstream care and complementary therapies to treat the whole person.
The management of cancer requires a delicate balance of interventions focusing on two simple principles of equal measure: eradication of the disease and optimizing the body’s innate ability to heal. Biomedicine takes the role of “attack therapy” directed at the cancer cells, while complementary modalities aim to strengthen the cancer patient and potentiate healing. Illustrating these methods of integration are renowned cancer hospitals, such as Memorial Sloan Kettering Cancer Center (MSKCC), MD Anderson Cancer Center, Mayo Clinic, and Cancer Treatment Centers of America (CTCA). Each facility has implemented IO programs that encompass these elements of care reflected in its language, distinctive structure and tone, which are demonstrated by a wide variety of therapies and how they are defined. The most common modalities include acupuncture, mind-body medicine, yoga, Qigong, massage therapy, and nutritional and dietary advice. Despite the myriad differences among them, the philosophy of IO weaves through a system that is centralized around conventional medicine protocols, such as chemotherapy, radiation and surgery, which all may be supported by adjunctive therapies. With equal, if not greater value, is the premise that IO practices are founded in evidence-based medicine and scientific findings.
This philosophy is evident in a growing number of hospitals implementing IO practices. Program features display a variety of therapies and services that demonstrate the aspects of the integrative oncology paradigm. For example, the University of Texas MD Anderson Cancer Center offers therapeutic modalities such as acupuncture stating, “The Integrative Medicine Program engages patients and their families to become active participants in improving their physical, psycho-spiritual and social health. The ultimate goals are to optimize health, quality of life and clinical outcomes through personalized evidence-based clinical care, exceptional research and education. We provide access to multiple databases of authoritative, up-to-date reviews on the evidence and safety for the use of herbs, supplements, vitamins, and minerals, as well as other complementary medicine modalities.”15
The MD Anderson IM program was established in 1998 and is one of the earliest models of collaborative cancer care. A brief overview of their program characteristics will demonstrate standard clinical integration common to IO centers. The gateway to adjunctive therapy options begins with a consultation led by a Western-trained doctor who outlines various modalities, reviewing the benefits and risks. Nutritional counseling, oncology massage, exercise therapy, meditation, health psychology, music therapy and acupuncture are examples of services cancer patients may access upon physician approval. The primary function of these supportive modalities is to reduce side-effects of conventional medicine, improve quality of life, mental outlook, and optimize outcomes. IM practitioners collaborate weekly to review cases, devise treatment plans and maintain shared access to patient records.16 Its framework offers elements of integrative, patient-centered care in the management of cancer.
Closer examination of Chinese medicine’s role within this structure indicates vast therapeutic limitations. First, acupuncture is the only modality of TCM offered at MD Anderson. The literature explains its function is to reduce side-effects related to conventional medicine, such as neuropathy, hot flashes or dry mouth, and it also can promote well-being to alleviate stress.17 While acupuncture is effective for those ailments and should not be discounted, there is a significant lack of detail about the system of Chinese medicine. Yes, acupuncture addresses acute physical side-effects, but this occurs as the therapeutic outcome after diagnostic assessment of the whole person. The insertion of needles according to simple point indications grossly undermines the capacity of the medicine. A comprehensive diagnosis enables the practitioner to treat the symptoms, what is referred to as the branch in TCM, and simultaneously address the root, or underlying condition.
Unfortunately, this does not appear to be happening at the ground level. In October 2018, a news source for all things TCM, Acupuncture Today interviewed a licensed acupuncturist employed at the integrative medical center of MD Anderson. On the periphery, the picture of acupuncture as part of the integrative oncology model appears collaborative. Each practitioner treats 30–50 cancer patients per week, and clinical staff participates in interdisciplinary meetings to review cases. According to the source, “At these meetings, as an acupuncturist, I can openly discuss the pathology of cancer in Eastern medicine terms and share different ways we can intervene.”18 When acupuncture therapy is the only modality at the disposal of a trained Chinese medicine physician, what are the remaining interventions possible? The interview proudly highlights this union of disciplines, but in doing so, it also unveils definitive boundaries within its integration. These are evident in the following ways:
•Acupuncture therapy first requires pre-authorization by a medical doctor
•Development of the integrated treatment plan does not include the licensed acupuncturist’s presence and professional input
•Herbal recommendations or formulas are not permitted
•Moxibustion therapy is not allowed
The guidelines and procedures set forth demonstrate how the Chinese medicine practitioner is merely a technician. Such facts, again, illustrate a real discrepancy in the integrative paradigm. The merge of disciplines is also made clear by the practitioner’s approach to the language