Transcript Disclaimer – Please note that the following transcription has been machine generated by an AI software and therefore may include errors or omissions.

Robin Daly
Hello and welcome to the second series of Cancer Talk, the podcast that explores the benefits of integrative oncology, an approach that brings together standard oncology practice for the raft of lifestyle and complementary approaches in order to provide broader, more holistic care to improve quality of life and outcomes for people with cancer. I’m Robin Daly, founder of Yes to Life, the UK’s integrative cancer care charity, and one of the hosts for the podcast. Series 1 of Cancer Talk was aimed at initiating conversations about integrative oncology and bridging the gap between mainstream and integrative medicine practitioners. And the Series 1 episodes are still available from Yes to Life.org.uk forward slash podcasts and major podcast platforms.

Dr Penny Kechagioglou
Hello, I’m Dr. Penny Kechagioglou. I’m an NHS clinical oncologist and co-host for the broadcast and in addition to treating patients with all the regular modalities in use within healthcare, I have a passion for integrating evidence-supported lifestyle and complementary medicine into patient protocols. I’ve witnessed first have the enormous benefits this can deliver to patients and their carers. So in series two of the broadcast we are planning focused conversations with healthcare professionals, working directly with people with cancer and applying integrative oncology in contemporary clinical practice with the aim of strengthening the clinical voice and evidence for integration, influencing the wider community including academia and research and beating the case for an integrated UK model of care.

Robin Daly
I’m delighted to be back hosting another Cancer Talk

Dr Penny Kechagioglou
Hi Robin, it’s great to be here with another wonderful guest.

Robin Daly
Yeah, so we’re looking a bit further afield for our guests to the US where over there some things that in the UK we’re still pushing hard for in the field of integration that kind of take over granted maybe over there a little bit. Would you like to introduce our distinguished guests?

Dr Penny Kechagioglou
Surely, I’m delighted to have Dr. Santosshi Narayanan, who is an associate professor in the Department of Palliative Rehabilitative and Integrative Medicine at the University of Texas MD Addison Cancer Center in Houston. And Dr. Narayanan is an integrative medicine doctor, and she’s involved with a lot of research. And I’m sure she will tell us all about her practice and her work with the Society of Integrative Oncology and what can we learn from her, really.

Robin Daly
So I want to ask a question about that very long job title that just came out of there. It lumps together three areas of medicine in one department, palliative, rehabilitative, and integrative medicine. So I assume it’s because these are felt to be interconnected. Do you want to elaborate a bit?

Dr Santosshi Narayanan
Absolutely. First of all, thank you so much for having me here today with both of you. It’s an absolute pleasure and honor to be here. And I’ve known you, Dr. Penny, for a while, and it’s always been a pleasure to work with you. And thank you, Mr. Robin, for putting this together and helping us both, Dr. Penny and Robin. I appreciate it.

Dr Santosshi Narayanan
So I guess if I understand your question correctly, your question is about what do we do with this department of palliative, rehabilitative, and integrative medicine? So, Indiana Anderson has several departments, and as you might be aware, we are humbled and honored to be world’s number one cancer center, University of Texas, Indiana Anderson Cancer Center. And we have different divisions and departments.

Dr Santosshi Narayanan
And the Department of Palliative, Rehabitative, and Integrative Medicine is specifically focused on quantity of life for cancer patients. So we have colleagues for practice palliative medicine or supportive care, which focuses heavily on the symptom management part, which is pain management and other symptoms. And the rehabilitative medicine focuses on rehab, like pre-op rehabilitation and also during the cancer journey. And cancer rehab is a big specialty. And integrative medicine approaches the person, the people, the cancer people suffering from cancer, as a whole person, in other words, kind of approaching them in a holistic manner, which involves their physical well-being, mental well-being, their social well-being, psychosocial and spiritual aspects, which are important. And we also consult patients on several things. And we collaborate with different departments. We collaborate with psychiatry, pain management, and other teams within MD Anderson, and of course, with multiple oncology teams.

Dr Santosshi Narayanan
And within our own department, we collaborate with our rehab colleagues and supportive care colleagues to make sure that the patient is taken care of as a whole person, and not as just a person with cancer, so that the humanity, the focus, is on the entire human, both physical and M.O.G.

Robin Daly
Interesting. So quality of life is kind of the uniting factor, if you like, that brings these three disciplines together.

Dr Santosshi Narayanan
Absolutely, yes. There is a lot of overlap in what we do and there is also uniqueness in what we do and the main focus is quantity. But if you look at the studies, there have been several studies which shows actually that interventions such as yoga helps with not only quality of life, but it can also help with stress reduction. And we know that reducing stress can improve the lifespan of cancer patients. That’s been shown too because stress reduces the lifespan and it increases both mortality and morbidity. So indirectly, there are other benefits as well, but our focus is symptom management, but there are so many other benefits that patients derive from seeing us.

Robin Daly
Right. Yeah, it’s a hugely undervalued area of medicine, the quality of life is just largely overlooked in this country, I think. And we’re pushing hard for that to be changed.

Dr Penny Kechagioglou
Tell us about and talks about you mentioned patients are having integrative medicine approaches during their treatment. I know you mentioned about the rehabilitation component, but you mentioned also what you offered during their treatment. So maybe you can describe us a day in the life of a cancer patient going through treatment and what else do you offer concurrently?

Dr Santosshi Narayanan
Sure. Thank you for that question. It’s a wonderful question. So in terms of what we do in integrative oncology or integrative medicine center, usually patients are referred to us by the oncology teams or supportive or rehab teams or any other teams with an MD Anderson. And the reasons why patients are referred to us is multifold. So we recently looked at the paper looking at what are all the reasons for which the physicians or the providers are referring the patient to us. So what we found is providers and patients have very important concerns such as pain, which is one of the top reasons for a girl. Other symptom management is another reason, an integrative approach for seeing us. They want a holistic or integrative approach and a focus on the overall health, which includes questions that patients have like, what can I eat when I’m going through this cancer? Is sugar bad for me or is it a myth?

Dr Santosshi Narayanan
Should I exercise or should I just take rest? How can I take care of myself and my family? Should I isolate myself like socially because I’m prone to infections or what am I supposed to do? So a lot of things like this are what patients are concerned about because they want to live well. The cancer is something that people are going through, which troubles their life in a very big way, changes people’s lives in all ages. And all the sentient young adults have different kinds of unique challenges and other adults have different challenges. So there are so many challenges that these patients use. So back to your question about what exactly we do. So when patients are referred to us, we take a thorough history, which includes what is their diet pattern? What are they doing for every sick and well-being? How is the mental health? So we use a tool called ESAS, which is called Edmonton Symptom Assistance Core, and which was put together by our department chair, Dr.

Dr Santosshi Narayanan
Many, many years ago and has been widely used and published and validated tool. So we ask the patients to rate from a scale of 0 to 10, how is their symptom and where would they rate their symptom? On a scale of 0 to 10, 0 being no symptom and 10 being severe within the last 24 hours. So that gives us a very quick overview of what the patients are dealing with and where should we focus on. And we also ask the patient, what is your top two concerns that you have to see it? That is called MICA, measure yourself, a questionnaire. And when we ask the question, patients give us top two reasons for seeing a top two concerns for what they want to be addressed during the visit. So once we understand their symptom profile and their top two concerns, what we do is we go through different areas of their life and counsel and we use a model called Five Circles. So the first circle is about what can we do for the diet.

Dr Santosshi Narayanan
Second is exercise. Third is stress management. Four is sleep. Five is symptom management. In addition to these five areas, we also counsel people on supplements. So many patients want to take hubs and supplements. Their family members tell them to take it. They read on the internet of how different people cure their cancer. So they want to know and they feel like they have no guidance on what to do. So we counsel the patients on the pros and cons in a scientific manner so that the patient is empowered and they feel listened to. They understand that not all supplements may be safe for them. They understand that it can interact with chemo and they make an informed decision. So these are all the things that we do in our clinic when we see a patient. And in addition, we also use non-conventional therapies such as acupuncture, massage and other therapies to help with patient symptom management.

Robin Daly
And it’s a very well-developed and rounded program. I mean, you know, looking in a really, truly holistic way, which is fantastic. Yeah, dive for that kind of stuff inside a hospital here. Amazing. So how long have you been developing this program?

Dr Santosshi Narayanan
So the program has been developed by many of my colleagues even before I joined the department. So our program has been around for almost more than 10 years. And I joined integrative medicine department in 2018. And I actually joined MD Anderson eight years ago. And when I joined MD Anderson, I really felt that integrative medicine is something that is very important for patients because patients are suffering. So when I put together a clinical trial to study meditation, the effect of meditation on the cancer patients hospitalized, I really felt that this is where my heart is. I want to take care of the patients in a way which encompasses the whole person. And I found out about integrative medicine and I joined this department. And it has been such a pleasure. And it has been very fulfilling. And I’m so grateful to be part of the department. And in our integrative section, we have several different colleagues who work with us.

Dr Santosshi Narayanan
We have psychologists, we have meditation or mind body specialist, yoga therapist and music therapist, we have a nutritionist, we have a physical therapist, and we have the research team. So our team consists of several members who play a unique role. We are all working towards the being of our patients.

Robin Daly
Fantastic. And we’re definitely going to want to talk to you about research because you’re obviously very keen on it. I’m just interested, obviously there’s lots of research that goes into particular interventions and the effects they have. Do you have any statistics for the overall effect of taking the integrative approach of your patients as set against standard treatment alone?

Dr Santosshi Narayanan
Yes. That study that requires, I think, a comparison of patients who are being seen in the integrative medicine center versus people who have not been seen. And actually, that is the current protocol that I’m working on. So, I’m working on a project in which we are seeing, comparing the cancer patients with GI cancers, gastrointestinal cancers, and patients who have actually seen us versus patients who have not seen us to understand the differences between the two groups. So, correctly, the reason I wanted to look at this is because currently, I know that we have been mainly focusing on breast cancer patients, almost 50% of our patients are breast cancer patients, and majority of our cancer patients are women.

Dr Santosshi Narayanan
And this is because, first of all, I feel integrative medicine, women accept integrative medicine much more based on the research. We do not know the reasons of why this is the case, but it could also be because that breast cancer patients are mainly using integrative medicine services more than the other cancer patients. So, in terms of the breast cancer patients, there are several timelines in their cancer journey that we get involved. Often, we get involved just after diagnosis. And just after diagnosis, we play a different role. We actually help them deal with their emotional psychosocial issues of being diagnosed with cancer. And many of these patients tend to be young with small children and are working full time, and they’re struggling with managing their cancer, their home life, their professional life, so many things.

Dr Santosshi Narayanan
And we also work on weight management for this particular group of patients. So, we have published papers on how our weight loss programs have benefited our patients with breast cancers and also other cancers. Also, we have published on the group classes. So, we have group classes that we offer for several patients from different cancers, and even caregivers participate in it. And when we look at our group classes effect, we found that even one class of yoga or meditation programs or tai chi has given them symptom benefit, like their symptoms have shown to have some improvement, their distress has improved even after one group class. So, some of our publications focuses on improving their symptoms before and after. We do the ethos that I was talking about before the intervention and after the intervention, and we see that there is a benefit that is seen in cancer patients.

Dr Santosshi Narayanan
And going back to the breast cancer patients that I was talking about, so before the treatment, there is a different level of involvement. During the treatment also, we support with acupuncture, for example, for chemo-related nausea. And if there is a body image issue from surgery, we have a psychologist who can counsel them. We do massage therapy if patients are experiencing body pain and generalized muscle pain when they’re going through treatments. There is also studies which shows that, for example, AI, aromatase inhibitors, which is hormone therapy, is often used by breast cancer patients who have hormone-positive cancers. So, one of the side effects is joint pain. And acupuncture helps with AI, which is aromatase inhibitor-related joint pain. So, we do acupuncture for that. So, there are so many things that we do, both before work, during, or after treatment, in breast cancer patients.

Dr Santosshi Narayanan
And we also do this for other patients, but it still needs to be developed. And it still needs to be widely known in breast drop the cancers. And that is some of the work that we are currently doing to develop more protocols, to develop more awareness, and to talk more about this so that all cancer patients can benefit from these interactions.

Dr Penny Kechagioglou
It’s an amazing service and it’s so nice to hear your enthusiasm about seeing those positive outcomes on patients. And you mentioned that you get the referrals from oncologists. When you measure and you evaluate the interventions that you give, do you share that? Do you work closely as a team? Do they get to see those important outcomes? Because oncologists, you’ve said that some patients may not come to the service. Is that because they’re not referred to? Some oncologists don’t know about those services. How do you ensure that the learning is spread? That is my question.

Dr Santosshi Narayanan
Thank you. I think when we both met in Cyprus, when we both were giving a talk at the research and training workshop to SIRO, I know we had had the long discussion about this and how do we bring acceptance to our field, because often we are not thought of as a scientific field, which is well-based on evidence. And sometimes we are confused with alternative medicine and we are often written off that, no, you don’t need to go there. So that issue, I think, is pretty much kind of improved. I think we have come a long way, thanks to so many people’s efforts, my colleague, Dr. Lopez, Dr. Cohen. So many people have been involved in giving lectures, and I myself also go and talk to other departments. And we basically have done a lot of education and we present the data and we present the guidelines because we know that NCPN guidelines, National Comprehensive Cancer Network guidelines, support the use of integrative interventions in management of cancer.

Dr Santosshi Narayanan
And ASCO, American Society of Clinical Oncology, and FIO, Society of Integrative Oncology, have also developed guidelines, joined guidelines, as well as SIO guidelines, which support the integrative interventions in the care for cancer patients. So when we present the guidelines and when we present the science, they seem to value what we do. So they feel that this is not something that my patients are going to stop their conventional chemotherapy. My patients are going to actually benefit from talking to integrative medicine because they’re going a lot more about how to take care of themselves. Often, patients see oncologists for their cancer care and they discuss supplements, and they say that I want to do just the supplements and do only alternative medicine.

Dr Santosshi Narayanan
We don’t want to do chemo because chemotherapy is toxic. So that is one concern that oncologists face and also it’s a concern for everyone, patients, family, and the financial toxicity that comes from being out of pocket for a lot of treatments, which are unconventional. So when such patients are referred to us, we actually break it down. We actually do open communication. We listen to the patients and understand where they’re coming from. And often we understand that patients want a locus of control. They want to do something which improves their care. And sometimes there is a lack of trust. They feel that this is just given to us and we don’t have a say. So that is another issue. And the third issue which happens is some cancer patients see their family members go through very severe or very toxic kind of chemo side effects, and they feel that all the chemo or all the radiation treatments are going to make them feel that.

Dr Santosshi Narayanan
But we all know as providers or physicians that not all chemo has the same side effects. Some chemos do not have that much side effects compared to chemo use for certain cancers. So all of those concerns that patients have, we discuss them openly. So when we have open communication and build trust, then patients can understand where we are coming from. Sometimes I see patients who think that if they just do this, this, this vitamins, their cancer can be cured. But actually they have a very easily curable cancer which can be cured by just surgery and they’re done. But they decide not to undergo the surgery. So when we are, when we see such patients and when we openly talk to them, build trust and communicate, they actually go back to doing the surgery.

Dr Santosshi Narayanan
And your question of how close we communicate, so we write to the oncologist back, not in all cases if there is a standard treatment, but in certain cases, we actually communicate with them that your patient who do not want to undergo surgery have are open to undergoing the surgery. So please see them in a follow-up. So they communicate back with them. In straightforward patients, for example, if we see a patient for weight loss, so if oncologist refers to patients for weight loss to us, our weight management to us, the response will be, we will document and we share the notes and we have a wonderful electronic medical record system throughout our institution. So people can read our notes and they will get back to us if there is any question. And if there is any unique communication that needs to be made, we always reach out to them and they reach out to us and we all communicate with each other closely through our EMR, which is called MyChal and also through our email with MD Anderson. Bye.

Robin Daly
Amazing. Communication is everything, isn’t it? So great to hear you talking about this open discussion with patients about their situation. You’re right. Without trust, there’s nothing. I mean, you just, you haven’t got communication, so you need to build it. And once you do, well, then you see what happens when people, I mean, everybody is actually trying to save their lives. But if they’re not in a situation they trust, you know, they’re hesitant to do what actually makes sense.

Dr Santosshi Narayanan
Yeah, as you mentioned, you’re very correct about the trust. Trust is very important, I think, and it’s good to develop a trust. And sometimes having another doctor, a third doctor in addition to, or second doctor in addition to the oncologist and the patient actually helps build the trust within the team. And it actually increases the trust with each other, the patient’s physician trust with us and also with the oncologist, and it benefits the patients. So it all boils down to what is the best that we can offer for patients. And that is the focus of integrative medicine. And I think that is the focus of the entire medicine, but especially integrative medicine focuses on patient, that’s the key.

Dr Penny Kechagioglou
So powerful to hear from you talking about how people change their views around medicine and initially come to you wanting no medications but actually with that communication and shared decision making they make the decision to go for surgery and I have experienced that in my practice and I think it’s so powerful and it’s down to really using all those skills that you’ve described how you take your history how you talk about what matters to people isn’t it

Dr Santosshi Narayanan
I think history taking thoroughly and then talking to patients about integrative medicine is something that I enjoy doing because I learn about the patients and board their priorities in a different perspective. So prior to this, my practice was mostly asking patients about their history in a different way, but now I get to focus on them and learn more about them and learn more about their emotional aspects of how they’re hanging with it. So I think it’s very powerful and I am so grateful to be practicing integrative oncology and I enjoy talking to my patients every day and helping them.

Robin Daly
That’s pretty obvious. Okay, so can I just be clear? So everybody who comes to MDN and is diagnosed with cancer gets offered the opportunity to go through your programs, all right?

Dr Santosshi Narayanan
That will be our goal. So thank you for bringing that up. I think that’s our ultimate goal. We really think that every cancer patients need an integrative medicine approach. But currently we are not very close to that goal. So currently we are a three physician team and we are adding a fourth physician. And while we are very busy service and we always have a kind of backlog because a lot of people want to see us and that’s why we are hiring another new physician as well, who’s very experienced in this care. However, right now not all cancer patients are CA guff. So it is based on the patient initiating the discussion with their oncologist, asking for, can I see integrative medicine? Or sometimes they bring up some concerns like I want to take turmeric as a supplement.

Dr Santosshi Narayanan
I want to use Ayurvedic supplement. I want to use traditional Chinese medicine supplements. Then the oncologist will refer the patient to us. Sometimes it’s an automatic referral. So with breast cancer, we have a project called breast health initiated. So patients with a higher BMI are automatically referred to us to talk about weight management. So in some cases, it’s straightforward. In some cases, it’s still based on the patient’s knowledge and the physician’s knowledge. This is especially important in head and neck cancer patients. We know that acupuncture helps with xerostomia or dry mouth. So previously we didn’t use to see that many referrals, but now many patients are referred from head and neck center to us to treat dry mouth with acupuncture.

Dr Santosshi Narayanan
So similarly, we are seeing GI and I think there is also, we see the research actually helps to get more patients to integrative medicine. For example, when I started this GI project, I was working with GI team and there are several supporters in GI, Gastrointestinal Oncology team for integrative medicine. So when I was talking to them about this project, I started seeing more referrals and these referrals are for symptom management, for discussion on supplements, for discussion on integrative or holistic approach, for pain management. So I think as oncologists become more and more aware, their acceptance is more and more. And one day I think integrative medicine will play an important role in a patient’s journey during the cancer and because it’s a difficult journey and they leave all the resources that they can get to improve the quality of life.

Robin Daly
Yeah, tough story. I’d like to ask you about your thoughts about, you already pointed out that it’s very heavily weighted towards women in integrative care. And that’s a sort of hugely societal level, I feel that imbalance exists. It’s just about how men see themselves and all this sort of thing. But it’s not good, of course, because men need support just like women do. It’s just they tend not to get it. We do have some thoughts about changing that balance, helping it to change.

Dr Santosshi Narayanan
I think men also accept this when it is told to them in a way that is more scientific. I think that the ratio of why women use more integrative medicine than men is probably because most of the research is done in breast cancer and most of the breast cancer patients seems to be women. So I think men will accept integrative medicine, they do accept, and prostate cancer patients actually use some of our integrative medicine services. So I think there is acceptance. Maybe we need to work on expanding the knowledge about integrative medicine and the research most importantly, the integrative research and other cancers. So similar to our current GI Oncology protocol that I’m working on, we do want to see, not just within our institutions, we want to see everybody in the world doing research and other cancers too. There has been a lot of research, but we just need to increase the number in other cancers.

Dr Santosshi Narayanan
I think when we increase the numbers, then we are going to see that all the patients, both men and women, are using integrative oncology and they’re penetrating from it. So that’s what needs to happen around the world.

Dr Penny Kechagioglou
And I think this society of interpretive oncology is also, you know, a catalyst in driving that collaboration, isn’t it? Because it’s sometimes important to do quite a diverse research and include populations from different parts of the world. What’s your thoughts on that?

Dr Santosshi Narayanan
great. I’m glad you brought that up. So as you know, Society of Integrative Oncology has played a very significant role in making sure that this reaches the globe. So I have opportunity to co-chair the Global Committee with Society of Integrative Oncology. So I work with Dr. Massimo Bonucci and Dr. Santosh Rao, the president, and our goal in Global Committee is to make sure that the entire globe is represented in the county. So we have several members coming from different areas or different regions. So we have Latin American representation, European representation, and we have people from India. We have an ambassador program. We have ambassadors for regions. So the ambassador’s goal is to reach out to several members in their community and talk about this and catalyze the research and clinical aspects of integrative medicine.

Dr Santosshi Narayanan
So I think this is important, and now we are working on even publishing this data. So first we are working on a European paper, then no middle-income countries, Latin America, and China, and India, and so many countries need it. And it is happening in a different way. So I was talking to several people of the committee members, and for example, China has traditional Chinese medicine. India has Ayurvedic medicine, and Iran has Appushian medicine. So there are so many aspects and so different aspects of traditional medicine, which is one of the goals of WHO when India’s G20 presidency is to learn more about traditional medicine. So I think the entire world is moving towards a new era where they are focusing on these and wanting to learn, and I think the time is right.

Dr Santosshi Narayanan
And Society of Integrative Oncology is perfectly positioned to bring everyone together and to learn from each other and bring the best of the worlds to patients. So we can take the best from all types of traditional medicine and research it and understand it in a scientific manner and give the best of the entire world and all the work that our ancestors have done in different countries, study them scientifically, and manage cancer both for quantity like survival, survivorship, and also quality of life. I think there’s so much to learn, and that’s the future of our field. And I see that Integrative Oncology can do much more, and I see our field growing in multiple dimension immunology space in terms of non-dissenter management with so many areas that we can do. Not that center management is not important, it is important, but there are so many aspects that we can handle if we unlock the potential of traditional medicine from different parts of the world and study.

Dr Penny Kechagioglou
Sounds very hopeful. And as you know, the BSAO, British Society of Integrative Oncology, we partnered very well with the SIO. We’ve got an SIO ambassador in the UK, and yeah, your message is very loud and clear. Great stuff.

Dr Santosshi Narayanan
Thank you, Dr. Penny, and it’s wonderful to be here and I would like to congratulate your efforts with BSIO and I know that you have been a co-chair and you have done a lot to put together the education aspects with the webinars and other efforts to develop this field. And we have two of our ambassadors in global committee as well who focuses on this, Dr.Nina and Dr. Katherine. So yeah, so thank you for being involved and thank you for being very active in making sure that integrative medicine reaches the cancer patient in your country. So thank you for that.

Dr Penny Kechagioglou
Thank you, we are very honored as well to be part of that movement.

Robin Daly
Fantastic. Well, it’s been so exciting to talk to you today. You’re so fired up about this stuff. Who wouldn’t want to be consulting you? Fantastic resource for cancer patients, and I hope your attitude towards cancer is something that spreads like wildfire, because that open-minded, really supportive, being there for people, that’s what integrated medicine means, really. As you said, the very best and everything for those patients, and I think it’s fabulous.

Dr Santosshi Narayanan
Thank you very much. And thank you for having me today. It was it was wonderful talking to you. And I appreciate all your efforts and putting this together. Thank you again.

Dr Penny Kechagioglou
Thank you so much. Take care.

Robin Daly
Thank you for listening to Cancer Talk. Do subscribe and look out for the next edition of our podcast. And if you have friends and colleagues interested in the development of UK Cancer Care, do pass on the details of Cancer Talk. Goodbye.