Integrative oncology in Cancer Care Continuum

1. Need for special JAIM issue

Across the world Integrative Oncology (IO) is gaining momentum with integrating the Traditional, Complementary, and Integrative Medicine (TCIM) systems in cancer management with the western mainstream or conventional medicine for comprehensive care. Cancer patients, survivors and caregivers have many unmet needs, and often are unaware of the evidence-based practices from these integrative systems. The recommendations and guidelines for such practices are based on the evidence Grade from published clinical studies for e.g. acupuncture and acupressure for general cancer pain and massage for pain during palliative care [1]. Still, there is a paucity of documented evidence of integrative practices in oncology settings and there is an urgent need for generating a body of evidence through well designed studies. Further, the utilization of pharmacological and non-pharmacological modalities of TCIM is substantial in cancer patients other than conventional care and that remains underreported. This necessitates the documentation, publication of such practices for evidence generation through robust research for better integrative cancer care. The Journal of Ayurveda and Integrative Medicine (JAIM) has timely responded by presenting this special issue on Integrative Approaches to Cancer Care and Research. We feel honoured to be the Guest Editors for this special issue. This was a great learning period for us and indeed a pleasure to come up with this issue. This issue includes various articles ranging from ‘Thought process’ to ‘Clinical Care’ i.e. thought leadership articles, case reports, reviews and studies related to TCIM mechanisms and interventions in cancer.

2. Integrative oncology (IO)

Cancer is one of the major causes of the mortality and there is increasing burden across the world including India. The present scenario demands affordable, accessible, and equitable cancer care as a priority. There are numerous reasons why the cancer patients, survivors, and caretakers seek nonconventional modalities, ranging from physical to psychosocial and other issues [2]. Broadly, the unmet needs of the patients are to reduce the toxicities, improve quality of life, and prevent cancer recurrence. The gaps in conventional care for cancer patients need to be addressed by integrating TCIM with conventional care at various time points of Cancer Care Continuum (CCC) which comprises all stages from prevention, early detection, diagnosis, treatment, survivorship, palliative care, and end of life.

As identified, IO is patient-centred, evidence-informed and utilizes mind and body practices, natural products, and/or lifestyle modifications from different traditions alongside conventional cancer treatments. IO aims to optimize health, quality of life, and clinical outcomes across the CCC and to empower the patients to prevent cancer progression and become active participants in their own care before, during, and beyond cancer treatment. Institutes across the world are working towards providing a comprehensive cancer care through research and practice based IO models. IO is the multidisciplinary approach that involves active participation of every component i.e. TCIM experts, oncologists, nurses, support staff, researchers, biostatisticians, and patients. IO addresses cultural and social perspectives along with the whole system approach of TCIM while integrating the TCIM with conventional care. Such integration is beyond merely adding to or replacing the formulations/drugs of the conventional medicine by natural products or other traditional/complementary medical practices.

3. Initiatives in IO

IO is getting worldwide momentum as seen in professional bodies like Society for Integrative Oncology who are fostering the activities of communication, education, and research by bridging the gaps between different disciplines. SIO has recently initiated an Ayurveda Interest Group, aiming to bring awareness of Ayurveda to the integrative oncologists and encourage collaborations for research in Ayurveda. Oriental countries like China have integrated the Traditional Chinese Medicine (TCM) with conventional medicine in cancer care. Western countries in USA, Europe, and Middle Eastern countries have models of integration based on research/clinical care based evidence.

In India, IO is still in an early phase of development. Government and non-government, private institutes are now offering services of Ayush (Ayurveda, Yoga and Naturopathy, Unani, Siddha, Homeopathy and Sowa-Rigpa) based IO care, in addition to many individual practitioners, based on research and practice/clinical care model. The 139th Report of the Department-related Parliamentary Standing Committee on Health and Family Welfare discusses the scope and role of Ayush in cancer care plan and research. The report recommends the integration of Ayush systems with modern medicine to harness its potential benefits for cancer patients. The report suggests the need for training of Ayush personnel in the domain, with adequate funding for infrastructure development and R&D [3].The Ministry of Ayush (MoA) and Indian Council for Medical Research (ICMR) are supporting integrative health research at the All India Institute of Medical Sciences (AIIMS) in various domains including cancer. A new Integrative Centre for Treatment Research and Education in Cancer (ICTREC) was initiated by the Tata Memorial Centre (TMC) under the Department of Atomic Energy. Their objective is to provide comprehensive cancer care including Ayush and conventional medicine.

The Central Council for Research in Ayurvedic Sciences (CCRAS), under Ministry of Ayush, Govt of India signed a Letter of Intent (LOI) in 2020 to collaborate with the United States NIH- National Cancer Institute, Office of Cancer Complementary and Alternative Medicine, (NCI -OCCAM). This effort has included a series of webinars with international presentations and discussions related to collaborations between Ayurvedic and Western medicine physicians and scientists to work together and develop research initiatives. NCI-OCCAM has also initiated a survey of U.S. Ayurvedic professionals that interact with cancer patients and will collect information about Ayurveda practices for cancer care. The results of the survey will help to educate allopathic and Ayurvedic practitioners and encourage more integrative oncology initiatives in the U.S and India.

4. Challenges and opportunities in IO

Integration of TCIM into oncological practice involves multiple experts from various disciplines and cultures and hence there is need to have mutual trust and understanding for transparent discussions, and consensus for conducting the research and practice. There is a communication challenge in the translation of TCIM traditional texts and concepts for the mainstream scientific audience. Ayurvedic concepts such as Shatkriyakala, Prakriti, Agni and Ama provide profound contributions to the understanding of the disease process and could be explored as they are expressed in cancer patients undergoing or recovering from treatments [4]. Other barriers include financial constraints, ethical and medico-legal issues, lack of trained manpower in the domain, potential of herb-drug interactions and the availability of sufficient evidence for TCIM interventions in IO. There is progress in building IO capacity as described in one article in this Special issue which outlines efforts of Ayush expert in oncology in the integrative settings of a large city hospital with an Ayurveda treatment capacity [5].

This special issue includes various case reports by the Ayush practitioners describing the success of Ayurveda-based integrative approaches in the cancer cases as add-on and post treatment care for improvement of quality of life, disease-free survival, and overall survival. Examples include: the of use of Ayurveda interventions and routines for cancer recovery as seen in case reports on multiple myeloma, invasive ductal carcinoma of the breast, and anaplastic astrocytoma. Also, in the issue there are review of books related to Ayurveda and Cancer and a summary of a recent Conference on Ayurveda for Cancer. There are two scoping reviews of ayurvedic Rasayanas including the Maharishi Amrit Kalash Rasayana. However, the virtual special issue will include many other articles, currently in process.

In the process of reviewing manuscript submissions to this journal for this special issue, other challenges to expanding evidence-based research in TCIM became apparent from those submissions that were not accepted. There were examples of papers that needed more robust and transparent documentation by the TCIM practitioners and institutes engaged in cancer care.

Many well-meaning and inspired Ayurveda students and practitioners sought out experimental methods to accomplish their goals, either validating various herbs or extracts, in vitro – in cancer cells, in vivo-in animal models or in clinical use. Some of the problems that inhibited the acceptance of their manuscripts included the following.

• •Often there were major grammatical issues
• •Experimental details were lacking that would provide sufficient information to reproduce the experiments.
• •Often the experiments lacked in the rigor of having enough samples per treatments or to show reproducibility of the experiments by repeating the experiments multiple times.
• •There was a lack of controls in clinical and preclinical work.They may have omittted an untreated control. They may record ‘anti-cancer’ effects of a particular ayurvedic agent in cell culture or animals, when in fact the dose of the compound was too high and therefore toxic. Besides effects on cancer cells, normal cells should be included to confirm the agent mechanism is cancer specific and not just a toxic effect.
• •Some studies did not have sufficient data, some had superfluous data.
• •Clinical studies should follow standard reporting guidelines and should be registered at the Clinical Trial Registry sites viz. in India at https://ctri.nic.in and https://clinicaltrials.gov in USA, and the case reports should follow CARE guidelines (https://www.care-statement.org/), etc.
• •Address institutional ethics compliance such as adherence to IRB approvals and patient privacy.
• •If some activity of the ayurvedic test compound was found in the assay, the author should avoid premature statements of efficacy in humans.
• •Manuscript introductions should articulate previous work done in target agent using references and define the rational for using specific drug/herb.
• •The introduction should include primary objectives, secondary objectives, outcome measures.

An underlying barrier for rigorous research in TCIM may be the lack of financial support. An example is right here in this Special JAIM issue wherein all but one of the articles published had no external funding support for their work. In another case, the reviewers commented about a paper's lack of supporting data and that they would need further investigations for accepting the paper; the author claimed they were a small university and had no access to further funding for the work requested. It is important to support this resource of passionate scientists and TCIM practitioners and provide for them educational guidance and financial backing. Robust training courses are needed to support enthusiastic researchers through short term and long-term courses in pre-clinical and clinical research and practice/clinical care in IO. These programs should be part of oncology and TCIM training programs. TCIM should be further explored in screening, primary prevention programs, survivorship (post-treatment rehabilitation) programs, palliative care, and pain management.

The thought leadership article in this issue by veteran scientist Dr. Ashok Vaidya encouraged expanding the scope of TCIM beyond clinical complementary and alternative adjunct usage. IO should also include paradigm-shifting pragmatic translational research, such as ayurvedic pharmacoepidemiology, reverse pharmacology, ayurgenomics, ayurvedic biology, Ayurvedic concepts of stages of disease, and combinational therapies for immuno-oncology. When IO includes these preclinical studies along with clinical care, “bench-to-bedside and bedside-to-bench” it may lead to serendipitous discoveries of emerging targets of disease. The cross talks between integrative oncology and TCIM practitioners can be expanded with for further validation and identify leads for mechanistic studies and prospective exploration in well-desgined clinical studies to generated evidence. Publication and dissemination of such studies is pivotal for the progress of IO.

Such cross talks, exchange of ideas, and networking of stake holders and key players in the domain should be initiated through Consortium for systematic development of IO in timely and unified manner. We hope that this special issue will serve to initiate discussions on the theme of IO. We welcome the critical comments, suggestions, and discussions from the learned TCIM scholars, readers, researchers, oncologists, and practitioners.

Funding declaration

This review did not receive any specific grant from funding agencies in government, public, commercial, or not-for -profit sectors.

Author contribution

MSG conceptualized and prepared first draft. JTA reviewed and revised the draft. MSG and JTA finalised the draft.

Conflict of interest

Dr. Manohar S. Gundeti serves as a Research Officer (Ayurveda) at CCRAS-CARI and Dr. Julia T. Arnold as a Research Special Volunteer (retired) at the NIH-NCI-OCCAM. The contribution to this editorial was a personal activity of both the authors and the opinions expressed in this article are the authors' own and do not reflect the view of the CCRAS, Ministry of Ayush, Govt of India or the NCI, NIH, Department of Health and Hu­man Services, United States Government, respectively.