In this interview, Natural Medicine Journal Publisher Karolyn Gazella discusses the challenges and solutions associated with enhanced integrative care for cancer survivors with integrative oncologist Dr. Matt Mumber. More than 15.5 million cancer survivors are currently living in the United States, with more than two-thirds alive five years after their diagnosis. And yet, most survivors report side effects long after treatment and many experience significant distress and fear of recurrence. Mumber describes how an integrative approach can help all practitioners serve the special needs of cancer survivors in their practice.
Matt Mumber, MD, is a board certified radiation oncologist with the Harbin Clinic in Rome, Georgia. He received his medical doctorate from the University of Virginia and he also did a fellowship in integrative medicine with the University of Arizona. He is the coauthor of the book Sustainable Wellnessand the editor of the textbook Integrative Oncology: Principles and Practice. Mumber is the director of medical affairs of the iTHRIVE Plan.
iTHRIVE is an online web application that creates personalized wellness plans for cancer survivors that focuses on five key areas: diet, movement, environment, rejuvenation, and spirit. Cancer centers, hospitals, and clinics can license the iTHRIVE Plan to help meet the special needs of their cancer survivors. iTHRIVE also helps cancer centers meet the Commission on Cancer Mandate. For more information, visit iTHRIVEplan.com.
Karolyn Gazella: Hello, I'm Karolyn Gazella, the publisher of the Natural Medicine Journal. Today our topic is cancer survivorship. My guest is radiation oncologist, Dr. Matt Mumber, who's also the editor of the textbook, Integrative Oncology. Before we begin, I'd like to thank the sponsor of this podcast, who is iTHRIVE Plan. That's ithriveplan.com. Dr. Mumber, thank you so much joining me.
Matt Mumber: Oh, thanks for having me. It's always good talking with you.
Gazella: Yeah, well, you know I've been reading research clearly showing that cancer survivors say they have unmet needs and they have special needs. Take us through what some of those needs are, specific to cancer survivors.
Mumber: The diagnosis of cancer is really a whole-person diagnosis. People wonder about, first thing they wonder, "Gosh, am I to somehow blame for this diagnosis?" I think people think about that. Of course, various levels of lifestyle and choices they've made throughout their life. Whether they're smokers, how they've generally eaten, what environment they live in. What their family history is, so they think about all of that, obviously. Then stress weighs in on it. When people get the diagnosis, they have a lot of stress. Then people maybe even think about compounding the fact their lives are stressful, well maybe my stress caused the cancer. That type of thing. That all impacts them and then the physical aspect of it. Of course, we're all, as whole people, we have a physical body that we inhabit.
We have our minds and our spirits, our heart, our emotions, and pretty much all of those are impacted by cancer diagnosis. The physical aspects, people can feel different, they can have symptoms related to the cancer or actual problems. Bleeding, pain and other issues that are outside of normal function. Then, for example, just the fatigue that comes along with having a cancer diagnosis, because fatigue is multifactorial, too, and tends to weigh on people emotionally. Then that has a physical ramification.
The stress and so forth can cause problems with how we eat, drink, move. How we sleep at night. How we relate to others. Different things like sexuality and other aspects that we take for granted as just people walking around being healthy. One of my teachers says that he really enjoys, every now and then, takes time to enjoy the fact that he doesn't have a toothache, because when he has a toothache, it's kind of all-encompassing, so we can be happy our non-toothacheness. I think people with cancer often feel that way. "Gosh, if I could just get a break from having cancer," because once you have cancer you're kind of a cancer patient and you're a cancer survivor, so it really does define who you are.
It's a very much of whole person oriented type of thing. Of course there's all the practical matters, financial, social, and so forth. It really does affect people in a multifactorial way. Perhaps because of the general stigma that's associated with a diagnosis of cancer, for then has been for decades, perhaps more than most of other types of chronic illnesses.
Gazella: I think you may be right, and then there's this issue of fear of reoccurrence. I read in one study saying that upwards of 90% of cancer patients, even if it's not valid, they're afraid. They're so afraid of a reoccurrence of getting cancer again.
Mumber: That's right. No doubt.
Gazella: You've just mentioned a lot of factors. Is this the reason why the American College of Surgeon created the Commission on Cancer Mandate, and you can talk to us a little bout about that Commission on Cancer Mandate?
Mumber: The Commission on Cancer is a wonderful organization, their real mission is to make all of the hospitals that participate in their system as good as they can be. First things they start with were very conventional, let's make sure we have accurate data. Let's make sure people are being treated in facilities that have up-to-date conventional types of processes and that they're recorded and they're followed over time so we can then get feedback and learn and grow with regards to how we're doing in the conventional care of cancer patients.
Then about the time that the Institute of Medicine started to branch out and look at things like cancer survivorship and psycho-social screening, and integrative approaches ... what I would call integrative approaches. They started saying, "Gosh, this is just as important as the conventional. We've got that under control. We've got that to the point where we have standards, we really need to create some standards that affect more of this whole person, outside of the what we do to people," type of scenario. That's really when they started to build these criteria, starting with patient navigation, trying to identify access to caring disparities that people face. Then moving on to actual distress screening, so that we can find a way to identify the stress, almost like another vital sign. Recognize distress and then intervene early before it becomes a problem.
Then moving past when we've gone through active treatment and people that have been treated definitely and curatively and they've done active treatment. Like I said, they're always cancer patients. Cancer survivors now. How do we address that survivorship such that we can make sure they're getting appropriate screenings, that they understand what's been done to them and ultimately what they need to do in order to stay connected, to try to decrease recurrence rates and to function in a way that gives them the best chance of surviving long term.
Gazella: Speaking of these special needs, it certainly seems that because of the sheer number of cancer survivors, pretty soon there's going to be 20 million cancer survivors alive in the United States alone. It certainly seems like their care is spilling out into other medical disciplines, well beyond oncology. I'm wondering what role can general practitioners or integrative practitioners play when it comes to meeting the special needs. Physical, mental, emotional, special needs of cancer survivors.
Mumber: Medicine, I think is evolving. Medicine has evolved from being purely focused on the downhill, what we do to somebody, and has really become more of a partnership where we are able to focus on the commonalities that make us all human and to do so in a way that is therapeutic. For the physician, the physician can bring the power of themselves as they are, what they do to help stay healthy. They can bring in a compassionate way to the doctor patient interaction. Primary care has led the way in this, with the primary care patient center medical home concept. That's now actually something that's billable and is paid for through Medicare, where you can get a group of people together and you can give them ideas and ways to help prevent certain illnesses, for example diabetes, heart disease. Haven't done it so much with cancer yet, because that hasn't filtered into the primary care mechanism, but it's happening and it's a good way for that to happen, because there's only so many oncologists available and there's a much larger pool of primary care doctors.
Prevention has really been in the purview of primary care physicians. There's really 3 types of prevention. Primary prevention in order to try to prevent diseases before they come up. Secondary prevention to prevent disease when people are high risk group, for example prevent heart disease or lung disease from people that are already smokers. Then finally tertiary prevention, which means when people already have an illness or have a diagnosis, for example, cancer, we try to decrease the chance of that recurring or having it again. The primary care center medical home is mainly focused on the primary prevention, somewhat in the secondary prevention and then it also filters over into the tertiary prevention.
In each of those groups, one of the foundational principles that I found to be true in my life is that there's tremendous power in getting groups of people together with similar experience. It's kind of like if I went, no matter how compassionate I am, if I went and tried to sit down with a group of pregnant women and talk with them about what it's like to be pregnant and to be able to have a baby and so forth, I would just be ... There's no way I would add anything that would mean anything to anybody, but if you get a group of pregnant women together, they're going to be able to speak a language that women who have gone through that experience will have. I think that's a very powerful thing and that's filtering into medicine more and more, it's getting reimbursed by Medicare through the primary care patient center medical home.
It's filtering into oncology care. Certainly there are specialty oncology medical homes, as well. However they tend to focus more on what to do during therapy, how to support patients during therapy and it really hasn't filtered over into the tertiary prevention model. I think as a field, medicine in general is evolving a very positive way, mainly it costs so much to have illness, right?
If we can prevent it, the ounce of prevention, right? I think that's a good thing. I do think that's the wave of the future. How it's going to filter into oncology versus primary care, with regards to that tertiary prevention piece, I think that's still to be worked out.
Gazella: Yeah, I would agree. We're making progress though. It is all about serving these special needs of cancer survivors. Now you are the lead investigator on a study that combined patient navigators with an online tool. Can you tell us a little bit about that research and what the outcomes were?
Mumber: Yeah, yeah, so my research is mainly focused on the application and implementation of integrative approaches, especially those that focus on people being able to make and embrace long-term change, kind of what I think of as the difference between translation, which is just giving people information and hoping that they'll understand it. Maybe apply it, versus transformation, which is being able to actually apply information in one's life and make a major change in life. Initially, we started looking at, can we approach this with physicians, for example with integrative medicine approach. We did a study about a dozen or so years ago that was a computer-based educational program, did it in conjunction with the University of Arizona and the Georgia Center of Oncology Research and Education and GSSACO, Georgia's State Society of the American Society for Clinical Oncology.
Basically, we did a prostate cancer where they did integrative medicine, educational module, to educate physicians and provides, nurses, other providers associated with prostate cancer about different complementary alternative methods associated with prostate cancer. We found that that web based educational intervention was very successful. Kind of fast forward to this most recent study, the next logical step would be is there anything we can do to improve upon the ability of this translational information delivery to move more towards a transformational approach. Or what people think of is generally a transformational approach.
The study that we did was, basically, a randomized trial, a small pilot trial. We had 24 people, 24 patient navigators in the state of Georgia that were randomized in this trial to give 1 of either 2 arms. One was an educational, web-based modality that looked at educating about integrative oncology for a patient navigators. We had a bunch of didactic presentation. We had a weekly video presentation that people could watch with regards to how they eat, drink, move, manage their stress, based upon our sustainable wellness book that we had ... Heather Reed and I had written.
Then there were a variety of materials that were present. There was the ability to chat online. That was one arm of the study. The other arm of the study was to do all that, but to also to have the opportunity to do a residential retreat, which I've been facilitating those types of educational types of retreats for years. Focusing more on a variety of contemplative practices and a personal experience and providing those contemplative practices with people that have similar experience. In this case, patient navigators.
The word contemplative is often kind of confusing. It sounds kind of mysterious and mystical. Contemplative is a good way of thinking about, contemplative practice when we can be in a position in which our body and our mind and our heart are in the same place at the same time. That's likely a contemplative practice. One of the features of it are that the result of that is that it brings about a certain level of awareness. It brings about a sense of communion and it brings about a sense of connection.
We would sit with people. We had a three day residential retreat that Heather and I facilitated and basically just experienced a variety of things, like yoga, meditation, massages. Everybody loves massage. We did some creative art therapy, like picture drawing and interpretation of those things. We randomized the trial and the outcome measure was do people learn better when they have this in person interaction, then they do when they have more of an online interaction.
It was a very small study. The numbers hint that there's a slight increase in educational benefit with the in person interaction, in addition to the online interaction. However both interactions resulted in, just like our previous study, significant learning and ability to actually apply these integrative modalities. It was the next step in research with a more focused group. I do think that's it a pretty exciting trial, because it does show the value of somehow having that link to that group of similars. Now whether or not that needs to be based in person or whether it could be based online, with like an online chat that's real active, that's kind of another question, research question, but it was an interesting study.
Gazella: Yeah, sounds very interesting. You know the point with some of the emerging research is to reduce the burden of care. It reminds me of research that was presented at this year's ASCO [American Society of Clinical Oncology] with Dr. Hess from Switzerland, who used the web-based modification tool for cancer survivors and she demonstrated that distress was significantly reduced and quality of life significantly enhanced without a face to face visit. I'm just curious, is this in part the way of the future?
Mumber: I think it could be. I think, of course, that intervention what they did was really more of a psychologist or psychiatrist doing counseling with the individual. They did a good bit of that. They tried to, instead of having to take the patient's time because there's some access to care and disparity issues, in that study, 70% of the patients had an online presence. They were open to using that modality. The counselors would basically do counseling with the patient, instead of them being in a room, basically do it online.
I think as time goes on and as people have more penetrance and more of an online life, I do think that that's going to become more applicable. The current ... It depends on where you are, I guess. It depends on the age of your population and penetrance of internet use and so forth, but I do think that's a positive study. I do think it addresses some of the barriers that can occur, relative to actual time for both the therapist and for the patient, to actually sit down and do it, it's a heck of a lot easier than if you have to travel. Let's say you had to travel 45 minutes. There's also a stigma, I think, to especially the psychological counseling piece where people say, "Gosh, I've got to go to a counselor." It's almost like they're admitting some kind of a weakness.
That gets over that barrier as well. I do think it's going to have applicability in multiple methods. Just in the research that we did, relative to the many uses of the internet and how they pertain to educating people and bringing along. There's absolutely no doubt that the internet has revolutionized the ability to educate people, there's no doubt about it. It makes perfect sense that it would have the ability to be applied in this specific situation, to reduce the stress, to do things with cancer patients that require, in the past, that required face to face interactions, but to do so in a way that's much more practical and less costly, ultimately, than actually having to take the time to do that. Yeah, I think it has significant potential benefit.
Gazella: Yeah, I would agree. I'd like to talk briefly about the iTHRIVE Plan, which is an online tool. Now you in your clinic, the Harbin Clinic in Georgia, you're using the iTHRIVE plan in conjunction with a nonprofit called Cancer Navigators. I'm wondering what your experience has been with the patients who are using the iTHRIVE plan, in particular.
Mumber: Yeah, I think the folks that are using it really enjoy it. Basically, it's a plan that when we set them up, we just basically say, "Look, this is a plan that's written by cancer survivors for cancer survivors." What it does is it evaluates you in 5 different domains of your health, how you eat, how you drink, how you move your body, your spirituality and then how your environment affects you and what things in your environment may be lurking that you're not even aware of that could potentially influence you.
Basically, it's written in a way that there's a nice melding of really good, hard science that each one of the little action steps that are given, are discrete action steps. It's really hard for a patient, when they sit in a room for 15 minutes at a follow up visit where we're talking about, "Well, gosh, you got to do your screening here. You've got to come back for this appointment. Got any questions? Okay, hey, by the way, make sure to eat better, drink pretty of fluids. Exercise. Manage your …" It's such a big elephant, it's hard to bite off. What you do is you start off with one discrete action step. Each of those steps, to the extent people happen to have like a little scientific citation with them. It's very, very valuable.
The people that have been involved in it, they may not like every one of the steps, because everybody's different. Everybody has their own way of doing things. People have different expertise and so forth, but what I tell them is, "Gosh, if you have a set of action steps and one or two really hit home, that's a big deal," because just think about the difference between saying, "Oh, go ahead, eat better, drink better, move better, etc. Handle your stress," and then giving people an option of let's say 30 different steps that pertain to one of those topics. They can go around, in their own time, on their phone and look at each one of those steps and say, "I'm going to try that." It might really hit home and it might stick with them for the rest of their life.
It's a really beneficial thing. The feedback we've gotten has been very good. It has helped us, as well, in identifying people that are in distress that we wouldn't have known otherwise. As a part of that, they'll take a 15-minute survey that evaluates them in those 5 domains. Then one of the domains ... Then it has different symptom complexes like fatigue and pain and so forth. If they reach a certain threshold, then our nurse is identified. Our nurse calls them up and what that's done is it's allowed us to get them to specific services they would not have gotten to otherwise. It's a very beneficial thing on multiple levels. On the patient navigation level, to go back to the COC, well, what a great tool for being able to intervene and educate and identify access to care and disparities issue.
Some of those could be a person can't travel to do various things, so this is a great way of addressing that. The second piece, distress screening, we can identify distress, and appropriately manage it. The third thing, of course, this is a survivorship piece. Really the weakest part of survivorship, in the COC platform, has been that tertiary prevention piece. How you take care of yourself in order to decrease the chances of them coming back.
Gazella: Right, and I'd like to talk a little bit about that, because you and I and Dr. Lise Alschuler wrote a paper that was published in the Natural Medicine Journal that shined a light on emerging research that's showing that survivorship care plans that only focus on the treatment summary and the follow up care are actually causing more distress, because they're not focusing on proactive prevention strategies that can empower the patient. What do you think is the solution to that, because that's kind of troubling, that even after the mandate, these SCPs are causing more distress?
Mumber: I think what's happened is that they've followed the general history of the medical model, ultimately. That is that we figure out what needs to be done and in our infinite wisdom, we then deliver it. We deliver it in the best way that we can, unfortunately the initial way we deliver almost everything in medicine is from the top down. From somebody who knows something better to somebody that doesn't know anything.
Somebody who needs help to somebody's who's going to be stronger and has the ability to get the help. Somebody who's broken to somebody who's going to get fixed. It's not unusual, it's a normal part of the evolutionary process of the way medicine is delivered over time. In the initial part of this, it's very important for us to get the conventional part right. It is very important that people get to their screenings, to make sure that people understand how important it is to eat well, to drink well, to manage your stress, to understand what radiation and chemo they got. How that might place them at greater risk, etc. those are all very important pieces of the puzzle.
However, if all we do is try to deliver information downhill and to a person that literally, all they know is what we're telling them, for the most part, it's going to create distress. It's going to create more distress than if we didn't tell them anything. It's almost like ignorance is bliss to a certain extent. When we overload people with information, without any real applicability of how it means something in their life, it tends to cause more distress. I think it's very important and over time, I think what we'll see is a progression for engaging the patient, engaging the patient in their own care. Engaging the whole person in their own care. That's where I think that it's going to evolve over time, naturally.
Gazella: I would agree with that. What would you like to see happen in the future, when it comes to getting these special needs met? Physical, mental, emotional needs met for cancer survivors in the future?
Mumber: Well, I think from a standpoint of Medicine. Medicine with a big 'M'. Not just medicine that we use to fix people, but medicine that serves the needs of all the participants that are involved. Not just the patient, doctor, community member, all aspects of the community in general. All people involved in it at all levels of their being. Physically, mentally, emotionally, spiritually, and all levels at which they experience life. As an individual person, as a family member, as a community member, etc. That's an integrative approach, a whole approach that addresses everyone at all levels of their being and experience.
That, again, that's a huge elephant. What we're starting with is the ground foundational stuff of what's the science of all these things. What do we need to make sure people have done in order to have just a basement, foundational understanding of what's required for basic science survivorship. Basic science 101. That's the level we're at right now. Going from not doing that at all to doing that is a big step. That's a big step. We don't want to minimize that. It's going to take time. However, ultimately, what's going to happen is that it's going to evolve over time and it's going to progress to the point where we look at the person not just as a patient and as a body, but we look at the patient as somebody who's a responsible participant in their care.
We take therapeutic advantage of their physical presence. Their emotional presence. Their mental and spiritual presence. We optimize their environmental existence such that it impacts everybody in the system. That is where medicine, that's what I'd like to see. I guess to say I'd like to see that is maybe a little self-centered. I think everybody would like to see that, right? It's just a matter of patiently, one step at a time, applying tools that we have that are capable of making incremental change at each of those areas.
For me, I have a lot of people, a lot of colleagues say, "Gosh, I'd look to do some kind of integrative approach." I think starting small and then growing organically with it makes sense and using tools that apply to yourself as an individual, as well as the patient, is a good place to start. Using systems that are in place that can increase communication, break down some of those access to care disparity barriers and move things forward in a way of increasing patient responsibility and participation in their health.
Gazella: I think that's great advice to practitioners who are looking to have a more integrative approach. Well, once again, I would like to thank the sponsor of this interview, which is iTHRIVE Plan. That's ithriveplan.com. Dr. Mumber, I'd like to thank you for joining me today.
Mumber: Happy to be here. Thanks a lot.
Gazella: Have a great day.
Mumber: Alright, you too.