NEW YORKBarrie R. Cassileth, PhD, is chief of Memorial
Sloan-Kettering Cancer Centers new Integrative Medicine
Service, which was officially opened April 1 of this year. As a
researcher, educator, and planner, she has worked in psychosocial
aspects of medicine and alternative and complementary therapies for
more than 20 years.
During her tenure as associate director of the Comprehensive Cancer
Center at the University of Pennsylvania, Philadelphia, Dr. Cassileth
pioneered proto-typic programs in patient and family support, home
care and hospice, and psychosocial research. She has published
widely, including 99 original papers and 37 books on topics targeted
to physicians, patients, and their families. Her book, The
Alternative Medicine Handbook: The Complete Guide to Alternative and
Complementary Therapies, was published by WW Norton in 1998.
ONI: What brought about this major move toward
complementary medicine at Memorial Sloan-Kettering?
DR. CASSILETH: It really isnt a major move, but rather
an extension of programs that have been in place for decades here at
ONI: Moving from support groups and family care to
complementary medicineisnt that a major step?
DR. CASSILETH: It really is not. When I was at the University
of Pennsylvania, we put a great emphasis on trying to help our
patients psychologically. What we have moved to here is an
understanding that there are many ways to help patients
psychologically, including using such things as music therapy and a
concentrated focus on spirituality or spiritual meditation, massage
therapy, and so on. That simply extends what we started in supportive
care several decades ago.
ONI: What comprises the Integrative Medicine Service?
DR. CASSILETH: The facilities are actually not up and running
yet, but they will be located at three places, on 65th Street, on
53rd Street in the spectacular and beautiful new Laurence S.
Rockefeller Outpatient Pavilion [see ONI, August ], and here in the
main Memorial Sloan-Kettering Hospital, itself. Sixty-fifth Street
will be our main outpatient center, including all of our rational
complementary therapies for cancer patients and family members,
regardless of whether they are affiliated with Memorial Hospital.
The funding comes from Memorial Sloan-Kettering. The 65th Street
center will be a fee-based set of activities that, we hope, will
become self-supporting to some degree.
ONI: How extensive is Memorial Sloan-Ketterings
commitment to this endeavor?
DR. CASSILETH: This is certainly not a mere gesture, but a
very strong institutional commitment to quality of life and to
bringing an emphasis on well-being, spirituality, and mind-body
concerns into mainstream cancer care. Including part-time therapists,
we may hire 40 to 50 people. We will create a service backed by
research and training programs that will be infinitely more extensive
than anything else in the world.
ONI: Could you outline a few of the programs?
DR. CASSILETH: We will have a full-fledged music therapy
program with a clinical service that will be free to inpatients, and
we will also have it in the outpatient sector as a fee-for-service
activity. We will continue to have art therapy for inpatients, and we
will bring it to the outpatient center as well. Many of the mind-body
therapiesmeditation, imagery, visualization, and
hypnosiswill be available.
We will also have acupuncture and biofeedback for pain management.
Acupuncture will be used for both pain relief and nausea control,
where it is known to have benefit. And there will be various forms of
body work therapies, with many different kinds of massage, polarity
therapy, herbal medicine, and counseling in nutrition. I should add
to the list classes in yoga and Tai Chi.
ONI: You mentioned spirituality . . .
DR. CASSILETH: Yes, spirituality is a vital part of this
program. There are a lot of supportive dataand it is a common-sense
conclusion that one could drawthat having a spiritual
component to your life is important. Most people, especially in times
of stress and fear, look toward a larger concept. There are data
supporting that if people have something of a spiritual life, and a
community of others who share their values, and attend ser-vices on a
regular basis, it is much easier for them to get through this time.
There are also people who believe that because spirituality and a
need for a sense of connectedness to a higher being of one kind or
another is so prevalent across cultures and across time that maybe we
are wired to be spiritual individuals, to have that need. So we
recognize the importance of a spiritual lifeas a major
component of an individuals being. The whole emphasis in this
program is to bring the mind and the spirit together. That is the
ONI: Will any of the therapies you are planning to bring in
be considered as integral components of cancer treatment?
DR. CASSILETH: No, they are all supportive. It is possible we
may eventually try some Chinese herbal remedies for pancreatic
cancer, but, with that isolated exception, everything is supportive
and aimed at enhancing quality of life.
ONI: So it is not alternative and complementary. It is
DR. CASSILETH: Thank you for that distinction. I have been
pushing it for years. By definition, it would be virtually impossible
for a major cancer center to offer an alternative therapy.
In complementary medicine, neither the Memorial program nor any other
program has a cancer cure in its desk drawer. This is an unfortunate
fallacy that members of the general public hold. I get a lot of calls
from patients saying, My doctor recommended chemotherapy; do
you have anything better? I wish we did.
ONI: Would you consider adding some sort of imagery or
visualization therapy to conventional therapy?
DR. CASSILETH: We are going to provide something like guided
imagery and such kinds of services. But we will make it very clear to
patients that this is not an effort to cure the cancer. It does have
an effect on quality of life.
ONI: What areas of research are you planning? And how will
you work with the Memorial research people?
DR. CASSILETH: The prospect of working collaboratively with
the senior people in the various areas of cancer medicine is one of
the aspects of this task that interests me the most, along with the
research itself. I am delighted that they all have been responsive
and have expressed interest. I come from a standard scientific
background and speak their language. I know good research and can put
together a good research protocol.
One of our protocols pertains to fatigue, which is a very serious
problem for cancer patients, particularly those who are undergoing
chemo. We are going to do a double-blind randomized
placebo-controlled trial to see whether hypericum, St. Johns
wort, will relieve fatigue. It hasnt been looked at before, but
we have some reasons to suspect that it might be effective. We will
look at patients who have already been treated successfully for
anemia but who are still fatigued.
ONI: But fatigue may be a symptom of depression. How do you
know which you are looking at?
DR. CASSILETH: That is precisely the point. We are going to
use a scale called the Profile of Mood States, which very neatly
separates depression and fatigue. But youre right; it is really
a difficult, circular problem. People who are fatigued get
depressedand it goes around and around. If hypericum works, it
will be wonderful. It is easy, nontoxic, with essentially no side
effects. It would be an inexpensive way to treat a very prevalent
problem. It is now believed that fatigue is the most commonly
reported symptom among cancer patients.
Another study will look at ginger and its ability to relieve the
nausea caused by chemotherapy. It works quite well for nausea
associated with pregnancy and motion sickness, but no one has studied
it in nausea associated with chemotherapy. This will be part of a
cooperative group trial, not just at Memorial.
We are also going to look into the possibility that music therapy
prior to a stressful event, specifically colorectal surgery for
cancer, will reduce the amount of pain, reduce length of stay and
recovery, and bring back all of the stats more quickly
and make people feel more comfortable. Well be doing something
very similar with bone marrow transplant patients.
In addition, we are using brain imaging to see where in the brain of
cancer patients music therapy has an effect. This has already been
studied in healthy individuals, but never in cancer patients. In
regard to brain tumor patients, it is an interesting issue. It is
possible that under the physiologic circumstances of cancer patients,
music therapy might light up areas of the brain that dont
respond under normal circumstances.
ONI: How do you select areas for research?
DR. CASSILETH: We look at what people are actually doing or
using, and we ask which of these therapies has some rational basis
I think soy, for example, is heavily utilized by women with breast
cancer. We know that it contains phytoestrogens, and so there may be
something in soy that would be useful for people after a cancer
diagnosis. We know that a soy-based diet is very good for lowering
cancer risk for healthy people, but there has been no work done to
look at it as an adjunctive therapy after a cancer diagnosis,
particularly for breast cancer. We are definitely going to look at
that. We will look at any rational complementary therapy, which means
ONI: Why not?
DR. CASSILETH: There is not a single scientist in the world, I
mean a real scientist, who believes in homeopathy. It violates all
the laws of science to think that with less than one molecule of a
substance, a homeopathic remedy can have any activity. If you want to
show me something that is inconsistent with all the laws of
physiology and biophysics, then you had better be able to show a huge
response in your research. However, in the research, homeopathy is
barely more than 50% positive. Most scientists see that research as
testing one placebo vs another.
ONI: When you go to Chinese or other ancient medicines and
such, you have no more proof of that either.
DR. CASSILETH: Absolutely true. In fact, James Randis
skeptics group in Philadelphia has had a $1.5 million reward
posted for years for anyone who can prove the existence of the kind
of energy postulated in the notion of Chi Gung, an energy that comes
out of one person that can then be manipulated by another individual.
You would think that someone would come along and try to prove it.
You talk to any of the scientists here at Rockefeller Institute or
any of the physicists who study energy, and they laugh at it.
But the idea of meridians and such is, from my
perspective, a brilliant concept to deal with ones place in the
cosmos. The chi involves 12 main meridians, vertical channels of the
body, six on each side. These reflect the 12 main rivers of ancient
China. Each one contains 365 acupoints. It is all tied in together in
a brilliant creative way, making each individual part of a whole.
Now just think about it. Three thousand years ago, people were
wondering what does all this mean and how do I fit into this world
with the moon and the stars and the cosmos and the rivers and so on,
and they come up with this idea that the individual reflects the
environment, which, in turn, reflects the broader environmentthe
ONI: So what about the acupressure points along these meridians?
DR. CASSILETH: One thing we have learned is that these
channels dont exist. Many think that acupuncture does not work
at all. But the studies are irrefutable, even in infants and in
animals, showing that it can bring pain relief. You cant have a
placebo response in a horse, to my knowledge.
ONI: So the acupressure points coincide with something?
DR. CASSILETH: They coincide with something. We now think it
has to do with neurologic trigger points. Acupuncture is effective in
a very limited way. In Chinese medicine, it was thought to cure
disease. No one believes that anymore. But it does work for nausea
and for pain relief in some people with rheumatism, arthritis, or
lower back pain. But not for everyone and not for much beyond that.
Its no magic bullet. There is no medicine that works all the
time for everyone.
ONI: What about the connection between stress and illness?
DR. CASSILETH: The problem is that the relationship between
stress and disease is very clear in certain ailments such as heart
disease, but it doesnt hold in cancerunless someone gets
so depressed that they do not follow through on treatment. People who
experience severe stress are not more likely to get cancer than
anyone else, and cancer patients who have severe stress on top of
their cancer do not die sooner.
ONI: Hasnt it been shown that stress weakens the
DR. CASSILETH: Yes, but how much and for how long? Nobody ever
asks. The answer is that it weakens the immune system for 5 to 6
minutes. It has no impact. Patients will buy all kinds of products
sold to enhance the immune system. None of them has been tested, none
of them enhances the immune system, some are contaminated, and some
are problematic, but people take them anyway. The concept of boosting
the immune system has not been as useful as we all had assumed and hoped.
ONI: What else have you learned about patients seeking
alternative medical help?
DR. CASSILETH: We conducted the first national survey of what
patients are doing outside of mainstream cancer therapy, and what we
found shattered all of the stereotypes as to who would seek such
services. The patients turned out to be younger than expected and
much better educated, with a higher income than those who do not seek
We found that they seek alternative therapies early in their disease
course. About 10% of patients went directly to an alternative
practitioner after a tissue biopsy diagnosis of malignant
diseaseno surgery, no chemo, and no radiationstraight to
Tijuana or wherever.
The most important finding contradicted the stereotype that all
alternative practitioners are charlatans and quacks. Some are, no
question about that, but 51% of them were MDsalthough,
interestingly, none of them were oncologists. This is still true
today. The majority of physicians involved in complementary and
alternative medicine tend to be family practitioners or
psychiatrists. Its not really surprising if you think about it.
Psychiatrists are attracted to the notion of a mind/ body connection.
ONI: The charge against oncologists has been that they
focus on attacking the cancer and forget, or even abandon, the
patient, especially if it looks like the battle is going to be a
DR. CASSILETH: People do what they do, what they are taught to
do. Surgeons do surgery, and people in radiation therapy do radiation
therapywith very little overlap. There are very few
compleat physicians in the world any more.
The majority of physicians are terrified of patients who are dying,
because they see it as a failure. They dont know how to
interact with patients, and they dont know the main secret of
talking with cancer patients, which is that you dont have to
talk. You just have to listen.
All the programs I set up are geared toward this issuethat it
is not enough to take care of a tumorsimply not enough. On the
other hand, we cannot expect oncologists to know all about managed
care, pain management, end of life care, and all the psychosocial and
alternative and complementary things. Its simply impossible.
ONI: So the trend toward specialization will continue and
the notion of the physician/healer is a thing of the past?
DR. CASSILETH: It is impossible to bring it back again. The
more compressed the knowledge of physicians becomes, the more
interested patients will be in doing things on their own and seeking
help from complementary therapists.
Patients are not passive anymore, at least the younger ones. They
want the best surgeon for their operation, for example, but if they
dont like his bedside manner, they will supplement their care
by going to a practitioner they perceive as more caring. Its
not a matter of dissatisfaction with mainstream medicine. Its
that they want to play a larger role in their care.