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 Memorial Sloan-Kettering.
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 overarching goal.
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 solely complementary.
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 for investigation.
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 no homeopathy.
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 cosmos.
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 immune system?
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 alternative therapies.
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 losing one.
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.