What Is Integrative Cancer Care?
Find out what it means to be a conventionally trained, integrative medical practitioner, and learn how integration between professionals is providing greater support for people undergoing cancer treatment in this episode of
‘Ad Hoc with a Doc’
Watch the video or see the transcript below - scroll all the way to the bottom to pick out some of the key quotes from their conversation along the way:
Rubin: Hi I'm Dr. Dan Rubin, back with another edition of Ad Hoc with a Doc.
I'm privileged to be here with my colleague, Dr. Heidi Rula. You work at Ironwood Cancer Treatment and Research Centers; we met because you and I are practicing right here together in Scottsdale, Arizona and I know you're also at the Chandler clinic?
Rubin: Practicing integrative oncology - I practice naturopathic oncology, you’re a medical doctor, I'm a naturopathic doctor, but we do meet in the middle, and we have a lot of very similar philosophies about how to approach the person with cancer. Tell us about where you got your integrative training.
Rula: I started here as a family doc trained in Arizona, University of Arizona med school, and trained downtown Phoenix as a family doc. And it was really kind of from my experience as a family doc that I kind of understood that in order to really help people and attribute that to true healing, you know, I needed to look at health in a different way than just kind of a conventional tool.
So, I did Dr. Weil’s integrative fellowship at the U of A in Tucson, and it was really from there that kind of launched me into this whole world of Integrative Medicine.
Really, one of the impetuses to work with cancer patients started with my own mother who had colon cancer.
She was diagnosed with a stage 4 colon cancer over 18 years ago, and I was a family doc at that time. Really was not into the, you know, integrative area of health at that point; and it was my frustrations kind of working with her and being able to find different supportive services - she was really kind of more of a holistic person herself, really like natural medicine…
Rubin: How long ago was this?
Rula: This was about 18 years ago, here in the valley.
Rubin: So, like 2001.
Rula: So, at that time there were very few kind-of integrative types of services.
Rubin: Yeah, it was building.
Rula: And so you know, her medical oncologist, at that time, really knew nothing about how to support a patient with any of these natural products to help maybe ease the side effects of her chemotherapy, or just kind of help with her overall sense of wellness going through her treatment.
So we were, kind of, left alone in terms of trying to navigate that whole piece of Cancer Care.
So, after my mother passed, that left me at a place where I felt that my tools that I had as a conventional doc weren’t going to be adequate for me to truly treat patients. So, doing that integrative fellowship, I then launched into being the medical director for the U of A's integrative health center in downtown Phoenix. So, again, that brought together a more collaborative model of health care.
Rubin: Was that more of a family practice-base?
Rula: Yeah, it was primary care, it was an integrative primary care center.
Rubin: Which is a great background for oncology.
Rula: Correct; so, I mean you know, we had nutritionists, we had health coaches, we had chiropractor we had…
Rubin: No naturopathic doctors?
Rula: No, because we were part of a study that you know, we were trying to look at how this model could be replicated across the country and some states didn't license naturopathic doctors, and so they were worried that we wouldn't be able to replicate the model in those states. But certainly, there was a conversation about being able to bring in naturopathic doctors, because we think that, obviously, that would be a wonderful part of delivering care. So, at that point, no, we didn't have naturopaths, but I think it was on the wish list.
Rubin: It was on the wish list, wonderful.
Rula: But it was really from there, you know, after that center, we ran that for about four years before we lost funding; and that kind of left me looking for where I could practice again. And I think, you know, that calling to work with cancer patients really came through and I've worked with Ironwood on how we could start a program for them.
Rubin: Yeah, when did you start over at Ironwood?
Rula: I started last May of 2018, so it's been a little over a year now.
Rubin: And how have patients received you?
Rula: Um, I think that I've been very well received. People are really, um, they’re feeling grateful to be able to have this type of service as part of their cancer care. A lot of them were really looking for that type of support, and previous to my joining, they didn't really have any place to go within the Ironwood organization. So certainly, I was able to fill kind of that need for so many of those patients.
Rubin: You know, one of the things we really wanted to talk about when you and I were sort of discussing what a good topic would be is: “What integration means” and that I've grown up as a physician under the integrative model, I've been in practice this is my 22nd year, and I've been all about integrative naturopathic oncology; and what I've been seeing is that there's less fear, it seems like, from a patient perspective bringing it up maybe to their conventional team. Whereas before, there used to be… they were fearful.
They didn't want to step on toes, or they didn't want to aggravate their conventional team. And I was always like, ‘Look, you're hiring all of us. You're the one who is bringing us onboard…you're the chief, we're here to help you. Have to be honest, always interested in transparency in protocols, those types of things.
But we also luxuriously live in a state where naturopathic doctors are licensed and have a board of medicine, there's the integrative program, not all people around the United States and the world have that luxury and so there is still some pushback that conventionalists have towards the notion of integration.
Have you felt that there are certain ways that, or figured out, or talked to patients, that there are certain ways that people can introduce this subject to their conventional team if they're interested in integrative oncology?
Rula: Yeah I think, obviously, just asking the questions right? And many physicians, especially in the newer trained physicians, who are a little bit of the younger generation, have become more and more familiar with incorporating some of these Integrative type services in…
Rula: So we're seeing less resistance in the younger generation of physicians. They may have seen it in their training programs where, in the hospital or clinic experiences, they may have had that. And we're just seeing that patients are utilizing integrative services in record numbers compared to where they have before.
So it's almost a mandate on conventional medicine to really come up to speed with what some of these services are in really looking at the data, right? Because we're seeing more and more studies to show benefit to these services and how, again, integration can really allow for better outcomes.
Rubin: It's a great point because as an ND, I felt like it was a mandate - to use your word - that I know what’s going on in the conventional world because I'm co-treating, and it didn't feel…back in the day, it wasn't reciprocated. And now, with more relationships, you know, we're getting referrals from the conventional side, I think there are certain people who are more comfortable with it.
And so it sounds like people don't need to have that fear, or they shouldn't be apprehensive: one, they need to be very open about what their intent is what they want for their life, how they want to approach things, and also, with more and more people being exposed to it; it's more of a norm.
Rula: Yeah, and I think patients are becoming a stronger voice in their own healthcare. I think obviously, with the internet being what it is, in terms of patients really now educating themselves in terms of what kind of services are out there outside of kind-of the conventional path, that they can now have a conversation with their doctor as, you know, these are some of the things they want to look at.
And then they can choose, you know, if they have a physician they feel they can collaborate with, and maybe that physician isn't completely familiar with these services, but at least they're open to kind-of exploration, then they can kind of feel that at least they have a good partnership where they can have open communication. You know, maybe bring data from what their other team of complementary practitioners are doing, so that there’s that continuity of care.
You don't want to have care delivered in these silos where you don't know what each person is doing, and there's really - there can be conflict between utilizing some of these different services. So, I think it's finding that practitioner that you can collaborate with, right? I think that's the biggest, and regardless if you're using integrative services or not…
Rubin: You mean ‘you’ as the patient, finds?
Rula: Yeah; if you’re a patient, you want to feel that you can be able to talk to your physician…
Rubin: - Yes –
Rula: Say, ‘this is what I'm doing,’ have them be open to…again, maybe they don't need to endorse what you're doing, but at least be open to you bringing in some of those services, or you utilizing some of these other practitioners.
Rubin: So, I just love that you're an integrative practitioner at a big Cancer Center that has multiple locations, and your patients are so fortunate to be able to have access to you; but there's so many people that don't. And there's people, like I said before, that may be stuck with, and I use the word stuck, with physicians who arein silos, and don't…and I hear this a lot…believein what I do, for instance, or maybe in what you do, and I scratch my head because I don't understand where ‘belief’ comes in medicine, I mean things are, or they aren't.
Rula: Yeah, I mean, as a kind-of conventionally trained physician, many of them are used to getting their information from certain sources, right?
Rula: And when it comes outside of those areas, they don't feel comfortable with that information. So a lot of them, you know, a lot of the pharmaceutical studies you know, they're following those, those are things they're comfortable with; the new drug recommendations that come down for treatment protocols and things like that, but when it's coming like from the nutritional literature, or it's coming in from other things you know, these aren't areas that they really are connected with, they're not following the nutritional literature.
So there may be some excellent studies that are showing benefit for the specific cancer or condition that a patient is dealing with, but it may not come onto the radar of that conventional physician.
So, I think, when you start bringing studies from someone, and maybe it's not in the type of clinical trial, a randomized, placebo-controlled clinical trial, double-blinded, you know, is what the only, the only type of study…
Rubin: Right, the ‘Holy Grail’ of how you get information.
Rula: And so, some, if it's not coming within that type of package, they feel less comfortable with the data.
Rubin: Well, let’s talk about that, because, I feel like that's still living in a silo.
Rubin: You know, you can't just rely on blind, placebo-controlled, you leave out any creativity, you leave out tons of “n’s”, and what I mean by ‘n’ is people that are out there…not everybody in those studies and those numbers studied, come to the study exactly the same way…
Rula: I think we're finding that that model of research doesn't work for a lot of the different questions that we have.
Rula: And so, it's not the only way to study something, and I think we can get some very valuable, relevant information, in other types of clinical models, but we just, again, we have to be open to the fact that not every study is going to work by doing that type of…
Rubin: And there's a lot of times I'll hear patients come in and say, ‘well my doctor said that it doesn't matter what I eat, or if I exercise or not, and just go eat whatever you want,’ which I know that we can refute that based on study, but also, like, we know what a human being needs to be healthy, and what it takes to be healthy. And there's certain foods that just, you know, are not supposed to be in our body.
Rula: Yeah, absolutely.
Rubin: And so that brings me to the notion of research.
I appreciate research, we participate in research, but, and I've said this before, in public forum or in a lecture, because I get asked the question a lot about what we do, and where's all the research? And not every way that we approach each patient…because I still see each patient as an n-of-one. Each patient, regardless of their main diagnosis, still comes to that diagnosis differently; and if I don't respect that as a naturopathic oncologist, I can't give them what I think they need only. And if I only follow the literature, what literature is out there, based on their cancer and the drug they're on, the person gets lost.
Rubin: And we like the person to rise above their diagnosis; and I don't think that I could truly do what they're seeking me out to do.
Do you run into that, or do you have any issues with that in your work?
Rula: Well yeah, I mean, absolutely. I think there's a lot of things that we know are beneficial, looking at mechanisms maybe of using whether it be diet, whether it be nutritional supplementation, you know, even mind-body therapies.
Rubin: IV therapies…
Rula: Yeah, I mean, again, there's a lot of information that we know, mechanistically, may be beneficial, but at this point in time, you know, we don't have any large clinical trial to be able to support that. So, I mean, I use that whole tier of, you know, the more toxic a potential therapy could be, the more data, the more strength of that information you want behind that.
Rubin: Well said.
Rula: But if something has low toxicity to it and potential benefit, you're gonna be much more likely to utilize that therapy in a patient's care, knowing that: ‘Yes, I don't have strong data, but we have a lot of these different signs showing it might be beneficial,’ and I'm not gonna wait until somebody funds a big study to be able to incorporate that into their care.
Rubin: For the person sitting in front of me who needs help right now, right, very well said.
Rubin: Dr. Rula - the definition of integrative medicine…since you sit on many committees and groups and you're helping to define this please share that with us.
Rula: I mean, integrative medicine really is kind-of this evolving field that is now trying to be able to have a true definition, to say who truly is an integrative medicine doctor, from, and this is more a definition for people within the kind-of conventionally trained pathway.
So, there's a lot of, you know, naturopaths are integrative, and there's also practitioners who all kind-of work within this field of integration, but in terms of an integrative medicine physician along the conventional training path, we're looking now to have somebody who has some fellowship training behind them, not just saying that they did a weekend course here or there and you know are utilizing different supplements and other complementary therapies as part of the way they deliver care, but that they really havehadsome type of comprehensive training to be able to bring all these things together in a place where, again, it comes from a point of being trained how to do this.
Rubin: Got it.
Rula: So, we really like to see the fellowship component and we really want those physicians to be practicing in a way that is holistic, looking at that whole person care, the mind/body/spirit is a really important part. Being able to address lifestyle, it's not just you know: “I use supplements, so I’m an integrative physician.” It's really being able to say, we need to look at the whole component of lifestyle, bringing in other healing systems as part of how we deliver care.
Rubin: Is it becoming a specialty?
Rula: Yes, well you know there's now a board to be fellowship trained in integrative medicine, and part of the board requirements are that you have completed one of these fellowship training programs so you can be board-certified in integrative medicine. So that can also be a way to look at your conventional doc to see whether or not they truly meet that criteria.
Rubin: I think it's wonderful, because it's another meeting place for naturopathic medicine and conventional medicine, and I think the language is, it's more common, and it's easier communication, and I just, it's just been wonderful. It's been wonderful for patient care.
Rula: Yeah, I think utilizing the fellowship kind of model, I mean, they're incorporating naturopathic physicians as part of that training so that again, it becomes more collaborative. It's not conventional versus naturopathic, I think that we each play a valuable role in patient care delivery and acknowledging that more team-approach to health is I think the way health care is moving.
Rubin: Yeah, and you know, Dr. Alschuler, who we practice together and have for years, is on staff at U of A at the integrative program.
Rula: Yes, absolutely, she’s a valuable resource to all of our fellows who are going through this training.
Rubin: Wonderful. Regarding internet information; I often tell my patients it's okay to get information off the internet, but as long as you bring it to me.
Especially something relevant to treatment change or decisions you want to make; and a lot of people will send us information or send us emails and ask us questions, and I certainly ask them to be respectful of our time and our staffs time, because we can only answer so many things - responsibly and respectfully; and anytime they ask us a question, we’re responsible for their care.
And there's a lot of stuff on the internet that I just don't think is worth very much, and then, there's a lot that is worth a lot and can really help them. And so, I do respect if they would bring that in, or if they would preempt their visit with questions that they may have, or things that they're interested in, or taking a look at.
How do you handle that in your practice?
Rula: Well, I mean, I certainly have the same experience. So, you know, where patients on a daily basis are bringing in things that they have found on the internet. And so many friends and family are trying to do good for their loved ones to say ‘Please take this, I heard that it cures cancer,’ and so…so patients are bringing in all these different sources of information and saying you know, ‘Does this really work?’
So, I think that's an important question. To have some type of health professional help you navigate the literature, like where these sources are coming from, and what is the true data; because I think, a lot of times, if you don't have any kind of background in being able to evaluate some of these information sources, and you know, what kind of data is behind it, and understanding, maybe, some of the safety issues that go behind that.
Rula: You certainly can either be venturing into something that could be very toxic, that could interfere with what your current care is, or could be very expensive and really you know give you no benefit other than, you know, making you a little poorer.
Rula: But, I mean, I think utilizing some of the sources when a patient maybe doesn't have the professional to work with; I mean, certainly, Memorial Sloan-Kettering; they have an integrative oncology program there, where they've created on their site ways to look at some of these different natural products, you know, the evidence behind this whole thing.
Rubin: It's something, to help take a look at that.
Rula: I mean they get some of these you know therapies that are being recommended, I mean we have so many patients who are on B17 or, you know, apricot seeds that come in and say, ‘I'm taking this, is this okay? and I'm like, ‘Go look on there and they'll tell you, you know, these are all the studies behind why you probably do not want to do this…”
Rubin: Or if it’s legal in the United States…
Rula: Yeah, exactly. So, and uh, hydrogen peroxide therapy, I mean, you can look it up and you can kind of see, you know, what is the true evidence behind that, where, you know, somebody has evaluated it from a standpoint of - okay, let's really look at the evidence, and not just say, you know, ‘We have a couple of case reports of this curing somebody, so now let's utilize it.’
Rubin: Well thank you so much, this has been really informative, and I was wondering - if you had three tips, or more, for somebody who isn't yet but is interested in integrating their care, this is a patient…what would three of those tips be?
Rula: Yeah, I think number one - start out with your current physician, whether it be your oncologist or your primary care doc, and talk to them about your interest in being able to utilize maybe some of these other health systems or complementary about programs. So…so, getting an understanding of where their position is on that and seeing whether or not you could have some type of collaborative relationship on kind-of bringing some of these things together.
So, I think, certainly, that's helpful.
I think that doing a little bit of your own research, maybe, you know, connecting with somebody in your community that is offering some of those integrations, certainly that can help you be able to figure out if this is a direction you want to go. So, I mean, I think those would be the two things.
Rubin: Wonderful. Well thank you for being here, I really appreciate it; and for another episode of Ad Hoc with a Doc, this is Dr. Dan Rubin and Dr. Heidi Rula. Thank you.
Rula: Thank you.