Dr. Richard T. Lee: New Pain Guidelines for Cancer from SIO/ASCO

In this episode, I sit down with Dr. Richard T. Lee, who was an instrumental member of the committee to analyze and review the health literature related to integrative approaches to manage pain in patients with cancer. The Society of Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO) published the guidelines developed by the committee. The guidelines recommend and rate the level of evidence for specific integrative approaches, like acupuncture, acupressure, hypnosis, and massage, to manage pain from cancer. Dr. Lee is the Medical director of the Integrative Medicine Program at City of Hope. As an oncologist, his philosophy is all about treating the whole patient by bringing together Western medicine with integrative therapies. 

Watch the full Interview here: https://vimeo.com/803488908 

Below are links to topics discussed in this episode:

Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology–ASCO Guideline https://ascopubs.org/doi/pdf/10.1200/JCO.22.01357
Understand the 2022 ASCO/SIO Cancer Pain Management Guidelines  https://howwehealcampaign.com/wp-content/uploads/2023/08/SIOASCOCancerPain-PG-V2.pdf  

American Society for Clinical Oncology (ASCO) www.asco.org 

Society for Integrative Oncology (SIO) www.integrativeonc.org

National Cancer Institute www.cancer.gov 

Check out the book: "Healing and Cancer: A Guide to Whole Person Care"
Visit https://www.healingandcancerbook.com/ for more information.

Connect:
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LinkedIn: Alyssa McManamon

Visit Healing Works Foundation www.healingworksfoundation.org for more information.

Dr. Wayne Jonas is a board-certified physician and Dr. Alyssa McManamon is a triple-board certified hematologist/oncologist. The opinions expressed on this show are those of the hosts and guests and do not necessarily represent the views and opinions of their places of employment, the Department of Veterans Affairs, or the United States government. The opinions expressed on this podcast are meant for entertainment and education and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Wayne Jonas and Dr. Alyssa McManamon have no relevant financial disclosures.

Transcript

Please note that this transcript is produced electronically and may not be an accurate representation of what was said. It may not be reproduced, edited, altered or modified in any way without prior written permission. Any use of quotes or excerpts from this interview requires explicit permission from Healing Works Foundation. Please contact us at healing@healingworksfoundation.org if you would like to use any part of this transcript for quotes or other purposes.

“How Healing Works with Dr. Wayne Jonas”

Interview with Dr. Richard T. Lee--New Pain Guidelines for Cancer from SIO/ASCO

Wayne:

Hello everyone and welcome to our next installment of How Healing Works. I'd like to introduce my guest, Dr. Richard Lee to the program. Dr. Lee is an oncologist and the medical director of the Integrative Medicine Program at City of Hope in California. As the medical director, he provides comprehensive cancer care using both conventional and complementary treatments, which we'll discuss. We're delighted to have him with us today to discuss a new set of guidelines for healthcare that providers can use on pain management for cancer patients using integrative approaches. These guidelines were released the past fall by the Society of Integrative Oncology and the American Society of Clinical Oncology, ASCO and SIO. And they were just published this month in the Journal of Clinical Oncology. They recommend several complementary therapies for cancer and cancer treatment pain. Dr. Lee was a member of the committee to review the health literature and the research literature and to help develop the guidelines. Welcome Dr. Lee, and thank you very much for being on the show.

Dr. Richard Lee:

Thank you, Wayne, I really appreciate the opportunity to be here and represent the committee that published the SIO and ASCO pain guidelines on integrative therapies for cancer patients.

Wayne:

Well, pain in cancer, both produced by the cancer and also by the treatment sometimes is a major issue around the country, so these are very, very important guidelines. We always need more in our toolbox and especially drugless approaches if we can because of some of the problems that are produced by treating pain with drugs, although we need to combine them both. Before we get into talking about these guidelines and what they add, I'd like my listeners to know a little bit about who we're talking to and where, then about you. Now, you're a physician, you're an oncologist, and you're also then got additional training in integrative oncology. Can you tell us a little bit about how this happened? How did you get into this? Why did you get into being a physician, an oncologist? And then finally why did you begin to look into integrative oncology?

Dr. Richard Lee:

Yes, it was a long journey and so I appreciate that opportunity to talk about that. I grew up in a small farming town in Illinois. My father was a family practice physician in a town of only 6,000 people. And so that experience really left me with an impression about the important role a physician plays in a community, and I really saw the impact of how a family physician can really help a community. And so that experience really made me think about medicine as a career. And he really practiced medicine probably the way it was practiced 50 years ago, plus not so much the way we practice it now, where he was really solo practice, he had a partner and he was really on call all the time. And so I saw it practiced in a different way, he would make home calls and really be there for his patients.

Dr. Richard Lee:

And so that experience was really a guiding light for me in terms of what I wanted to do. Then after deciding going to medicine, as I was completing my residency at Stanford, I had an opportunity to take time off because I wasn't quite sure what I wanted to focus on. I know I wanted to proceed in a fellowship, and so I actually had a year off, I had decided to go pursue oncology just because of the science, and I really felt like it was a field that made a major difference in patients' lives. And with that time off, I always wanted to do something different. My family is from Taiwan and my father had spent a little bit of time learning acupuncture, and so that had always intrigued me. And so with this time off, I decided to take that year to go abroad and I was fortunate enough to get a Fulbright scholarship, and so I was in Taiwan, a little bit in China with a focus of learning traditional Chinese medicine and really honing in on acupuncture as a modality.

Dr. Richard Lee:

So that experience really opened my eyes to the idea that there's something else out there beyond what I was learning in a traditional Western medical school. And where I learned acupuncture was at China Medical University in Taichung, Taiwan. And what's really unique about Taiwan is that they offer... they have a national healthcare system that offers both Western medicine and traditional Chinese medicine, and you can choose or you can do both. And the university I was at actually does both, and so medical students earn a degree in Chinese medicine and Western medicine at the same time. And so for me, learning and training there was really eye-opening to see how the two sides worked hand in hand together to help patients. And so although I hadn't planned on it, that experience made me really think about what I wanted to do within the field of cancer medicine and thought I should really take back what I learned and think about how do we bring that for cancer care.

Dr. Richard Lee:

And so doing my fellowship at the [inaudible 00:05:21] Chicago, I started to pursue this as an area of study and research. And then I found that many of the integrative therapies are really focused on quality of life and symptom management, so I pursued a fellowship in palliative care at Northwestern. And so that really helped hone my skills in terms of thinking about the impact these types of therapies can have for cancer patients. And then from there, I was really fortunate to go to MD Anderson and became the medical director for the Integrative Medicine Center. And that really helped again, kind of solidify my career and my trajectory. And now I've come full circle here to City of Hope to help build them an Integrative Oncology Program for the entire enterprise.

Wayne:

Wow, what a journey, that is a long journey, fascinating. So you started off seeing what whole-person care was like with your father. I mean, he had to take care of the whole person, social and emotional as well as the medical issues in a community, in that setting that's family medicine, right? In those communities, and then your eyes were opened up to other healing traditions that are outside of what we do in the West and realized there's some value in that and spent a whole year at that, but all grounded in high quality science and good conventional care in those areas. So is that what integrative oncology is, it's sort of a merger of evidence-based approaches from both conventional, some from traditional and complementary approaches that are brought to the table for optimizing the patient care? Is that it?

Dr. Richard Lee:

Absolutely, I think that's right on target. It's really bringing these two worlds together of the modern medicine and all the great benefits there, but it doesn't have all the answers and really saying that we should keep the door open to traditional medicines, complementary therapies. And I think what really differentiates integrative oncology from say more alternative or complimentary approaches is the fact that it's really grounded in evidence-based medicine. So really looking at the clinical research that exists to help inform us about the benefits and the potential harms and understanding how do we deliberately bring these two sides together in a way that has some synergy and provides even better optimal care for the patient?

Wayne:

Yeah, so that science-based approach is something that we bring to it in the West to help sort out what works, what doesn't work, why? And that type of thing, which is great. I mean, that's essential and one of the great contributions that we have in the West. I know that this is what the guidelines have done, haven't they? I mean ASCO has a long tradition of producing good evidence-based guidelines. SIO has been doing that too, but it's a younger organization and they did this one together, didn't they? Jointly to do that and really took a hard look of what does the research say? And how good is it in those areas? Can you tell us a little bit about what they found? I know ASCO had some guidelines on pain, but this one broadened that, again, used the same rigorous methodology to take a look at the evidence. What did they find? What did they say? Can you give us a snapshot?

Dr. Richard Lee:

Yes, yes. So absolutely, the Society for Integrative Oncology, along with American Society for Clinical Oncology came together and really helps work in a synergistic fashion to create these new guidelines focused on integrative therapies for cancer pain, which would hadn't been done yet. And so on behalf of the committee led by Jun Mao and Eduardo Bruera and others, we spent many, many months looking at all the data, really looking for high quality research clinical trials that were randomized addressing this question. And we looked at many different symptoms, excuse me. And so some of the key findings were that there is moderate level evidence and moderate strength recommendations that acupuncture can be helpful for aromatase induced arthralgias, which aromatase inhibitors are used commonly for breast cancer patients as after they finish surgery and chemotherapy and radiation.

Dr. Richard Lee:

There's also moderate level evidence to recommend the use of acupuncture, reflexology or acupressure and massage for musculoskeletal pain or cancer related pain. We also found that for patients undergoing a procedure that's associated with pain such as a biopsy, hypnosis can be another important tool in which to manage pain during that procedure that many patients have to undergo. And then lastly, in the area of pain during palliative care, a massage therapy was also found to have good evidence that it can reduce significant pain symptoms for our patients.

Wayne:

Yeah. So that's really a wonderful list of drugless approaches, which I know people are more and more interested in nowadays. So they were all pretty safe in these areas, I didn't know for sure if they all worked or not, but it's something that I think a lot of patients would be very interested in doing. A lot of oncologists would say, "Let me see if I can make them available." How does that happen? I know you're a practicing oncologist, you do some of these things in a conventional practice setting. How do patients get these? What are some of the challenges that they have and what do they need to do in order to try to make these kinds of things available for the treatment of their pain?

Dr. Richard Lee:

Right. Yeah, so there are some potential challenges that occur when thinking about how to bring about some of these therapies like acupuncture and massage as part of their overall care plan. One is finding the availability of a practitioner and preferably having a practitioner that has experience or training in working with cancer patients so that the acupuncture, massage therapy can be modified appropriately for safety issues. And then preferably you want to find a practitioner that is in communication with your oncology team, your cancer team. So you want there to be information being shared in both directions in terms of your overall care plan. So are you undergoing radiation? Or did you just have surgery a few weeks ago? There might be areas you might want to avoid for the procedure. And then another common challenge that patients may run into is really thinking about if they're able to find a practitioner, is it covered by insurance?

Wayne:

Yeah.

Dr. Richard Lee:

Now, where I was at previously in Cleveland, Ohio, oftentimes insurance didn't cover it except for limited indications. What I found here at say on the West Coast, in California is that insurance companies seem a little bit more forward-thinking and that there are several insurance companies that are covering things like acupuncture for certain indications such as low back pain or arthritis and other conditions, so I think depending where you are, you may find different levels of coverage. And then if there isn't potentially are there cancer centers that are offering it potentially at a lower rate or may have a sliding scale so that you're still able to access it. For things like acupuncture, people are looking at new models of delivery such as group acupuncture so that you really don't have to pay the full price, but you're with five or six other individuals and may be more convenient and practical in that sense. So those are some of the key things to think about and challenges that patients may run into as they think about some of these treatments, as they undergo cancer care.

Wayne:

Mm-hmm. So if an oncologist that doesn't normally know about these things and deliver them, I mean I wasn't trained in these things in medical school, and I don't think they still do it in most medical schools, but they want to do this, they want to open up and do more whole person or integrative care, to try to implement these guidelines. Are there some gaps or some areas or places they can go to get educated in these areas? Or do we need to do more of that?

Dr. Richard Lee:

Yes, absolutely. There's always a need for more education around integrative therapies, both for oncology providers, clinicians, whether they're physicians or nurse practitioners or nurses, as well as for patients, to let them know that there is growing evidence through clinical research that these therapies can make a real impact and that we don't always have to rely on a prescription medicine to address symptoms such as pain. And so areas, the American Society for Clinical Oncology, ASCO, A-S-C-O.org, or the Society for Integrative Oncology, integrativeonc.org as well, have very good websites with information and provide access to these guidelines. And there's also the NCI, National Cancer Institute, Memorial Sloan Kettering, MD Anderson, have very good informative websites that can provide further education and understanding about the different therapies that exist and the evidence that is currently present.

Wayne:

That's great, we'll try to make those websites available to our listeners here so that they can access and take a look at that. So if I'm a cancer patient and I hear about this or I just go online and start looking around and I mean it's sort of a Wild West out there and you can get all kinds of things, it's hard to distinguish sometimes what's legitimate and what's not. These guidelines really help do that, so if they actually will look at that. If they see those guidelines and say, "Gee, I would like to make some of that care available in my own cancer care." Should they take these guidelines to their oncologist or the oncology team? Should they point them out? How do they approach and discuss this with their oncologist and the cancer care teams?

Dr. Richard Lee:

Mm-hmm. Yeah, so I think any patients that is interested in incorporating these types of therapies, I think a good start is to begin a conversation with your cancer team, whether it be the nurse or the physician to say, you recently were aware of some evidence-based guidelines, and then you may want to bring a copy of the article and let them know that the SIO and ASCO have put out these joint guidelines. Both of them have a strong reputation for being evidence-based and providing guidelines that are reliable and based on good data. And so I think most oncologists would see this and understand that if those organizations have put out a joint guideline that these are guidelines that can be relied on and come from a good base of evidence and something to think about. And so that I think is really the key is starting a discussion.

Dr. Richard Lee:

And then learning about what their experience is and if maybe they've worked with a massage therapists or acupuncturist or others, and so they might already have some contacts in the local community. And if not, you may want to explore and think about are there cancer centers in the area that might have an integrative medicine program or even an integrative oncology program in particular that might be providing services in your area?

Wayne:

Mm-hmm. That's great, I believe, and correct me if I'm wrong, that there are some patient summaries built into these guidelines. So if patients want to do that, they don't have to be too intimidated by going to the sites and finding that because there are places where they have summarized in lay language for patients and provided information on how to access that in that. Is that correct?

Dr. Richard Lee:

Yes, absolutely, that's correct, that's a good point.

Wayne:

Great, thank you. So let me ask you a couple other questions about the evidence levels in here. It's a bit of a challenge to get evidence in these areas, and there's a couple of reasons why. Many of them are behavioral, meaning they require pretty complex behavior, massage, yoga is a educational thing you practice on your own, hypnosis is in some ways like psychotherapy, music therapy, they're not a simple approach like a new drug that you can stick in and you can do a placebo and say, "Oh, well let's see if it's the drug or the placebo." It's hard to actually create controls in these areas, so that's one of the areas. How did the committee sort of through that to try to determine... How do you determine what's good evidence in these areas when you actually can't create placebo controls and it involves an educational component?

Dr. Richard Lee:

Right. Yeah, you're exactly right in the sense that integrative therapy clinical trials are more challenging to conduct than say your standard medicine where you can take a placebo pill versus the real medicine, and they look very similar. In this case, it's more challenging to have a placebo yoga intervention and a real yoga. The field is evolving and improving, and so there are growing ways we understand of how to conduct high quality randomized controlled trials. And oftentimes the control arm is what we might call an attention control, so there is a behavioral intervention, but it's really minimized and does not replicate exactly what yoga or hypnosis or massage would provide. And so as we learn better how to conduct these clinical trials so that we do have an appropriate control arm, again, it might be a wait list control where individuals are just waiting to receive the intervention versus a true kind of sham control, sometimes we can do sham acupuncture. Some of these studies utilize that type of control.

Dr. Richard Lee:

And that's what we're really looking for is looking at these well-designed, randomized controlled trials with adequate numbers to be able to provide a statistical power to really detect a difference. Is the modality really providing a specific benefit? Or is the benefit potentially more generalized and maybe not specific to that therapy? But we are finding that there's growing clinical trials like in hypnosis, very large phase three randomized trials. Acupuncture is driving more clinical trials in yoga, and so the researchers out there are really getting better and more sophisticated than their designs to really help us answer the question is, are these therapies effective for symptoms such as pain?

Wayne:

Yeah. Well, that's great, I mean trying to distinguish these things often from placebo is a challenge because we know that placebo involves a lot of benefit. It's one of the challenges in separating it, especially because it's behavioral, right? I mean belief, expectation, the ritual of care can sometimes produce significant benefit, and these might have a little higher ritual level than some of the drug treatments in those areas. It seems to me that for many oncologists and patients, but also oncologists that are trying to just decide, "Should I make this available or not?" What they really want to know, is it worth doing compared to just not doing it, just to doing what I do usual care. And are there studies that do that kind of comparison where they just say standard care with and without some of these kinds of approaches?

Dr. Richard Lee:

Oh, yes. Yes, and that's this kind of comparative effectiveness studies is also growing in popularity, where the comparison arm is more of a usual care. And so you have usual care versus usual care plus, in some cases, acupuncture and massage, and so I think those studies are also helpful. And we're also doing, excuse me, we're also doing some studies looking at the benefit... I apologize.

Wayne:

No worries.

Dr. Richard Lee:

Stop. Okay.

Wayne:

We got somebody calling.

Dr. Richard Lee:

I apologize there.

Wayne:

It happens.

Dr. Richard Lee:

But the usual care is a considered a reasonable control arm, and these comparative effective studies, oftentimes now the comparative arm is really standard of care. And so there might be a standard of care medicine that's utilized to see is the integrative therapy as good or if not better than what we commonly use say for chemotherapy, [inaudible 00:22:11] neuropathy for which there are limited options?

Wayne:

Yeah, So this isn't too unlike, in conventional care there are ritualistic or complex treatments that you can't really create a sham for, surgery, for example. And so the studies use the same kind of approach of comparative effectiveness research, where they're just comparing it to getting it or not getting it or comparing it to medical versus surgical or something like that. So it seems like that approach would be more appropriate to these kinds of care [inaudible 00:22:40] if the decision is just to try to make it available and not dig down into the underlying mechanisms of that. Now, I noticed in the guidelines that the vast majority of them were very safe, and the committee said, "Well, the harm is very low." And so it's very unlikely that you're going to get a negative benefit to effectiveness or harm to benefit ratio, which everybody wants to of course know. Is it you're going to get more harm versus good out of it.

Wayne:

And yet many of these practices also don't have a lot of economic engine behind them, there's not large companies that are going to make a big profit off of delivering hypnosis or a massage or something like that. And so getting the size of the studies, you mentioned that there's some phase three studies, large studies going on now around acupuncture and hypnosis. Good to hear that, but those are often slow in coming, aren't they? Because there's not folks that are funding that. Shouldn't we be screening these for safety and benefit and then making them available at the discretion of the clinic or the hospital or the insurance company if they're safe and might show some benefit as those larger studies are done compared to something that might actually harm you where you really need to know that upfront? Is that a strategy that the committee maybe considered in terms of future guidelines in these areas?

Dr. Richard Lee:

Right. I think that's a good question and I think there's kind of debate on both sides about what is the best strategy moving forward? Especially when the relatively harm is on the low side, especially with something like hypnosis where you're not looking at a lot of potential side effects. I do think that as we look at the potential harms, we are expanding our view in terms of what does that mean? And so for instance, if patients are pursuing acupuncture and they have to pay out of pocket for which there may not be great evidence, there could be a financial toxicity. And some of these programs do take a significant amount of time and energy to pursue, so acupuncture oftentimes is done two or three times a week. And things like mind body programs which exist such as mindfulness-based stress reduction, which if you look at the whole program, it takes over 20, 25 hours over six to eight weeks, which a newly diagnosed cancer patient may have limited time and energy.

Dr. Richard Lee:

And so I think the question is do they want to pursue that if they're involved in surgery and chemotherapy versus maybe what's the timing of that intervention and what would be more appropriate? And then do they spend their time and energy and potential finances on other therapies that might have more efficacy behind them if they're trying to manage pain? So I think for every patient it's a different calculus in terms of what makes the most sense for those in survivorship versus those in the middle of treatment. We may want to think about different approaches for those individuals and what might be best for them. But I agree that with interventions that have low potential for harm and have a reasonable chance for increasing benefit and quality of life that it'd be reasonable to consider.

Dr. Richard Lee:

And we do have in the guidelines, we do include recommendations for things like guided imagery, acupuncture, music therapy, for which there are weaker levels of evidence, but we did feel that the harm is relatively low and the benefit, it might be there. And so it'd be something to consider, especially if they maybe have already tried other standard of care approaches.

Wayne:

Right. Now, you make a great point, some of these types of approaches, even though safe are quite complex to deliver. And so patient preference then should come in to doing that. Rachel, are we frozen here?

Rachel:

Nope, we sure are good, we should be good.

Wayne:

Okay. Looks like it's just on my side, I'll keep going. So when I worked for Samueli Institute years ago, we did a lot of work doing these kinds of reviews that you've just described to us for the Defense Department and the VA, and many others, and they're pretty complex, they take a lot of time in itself talking about time and effort and energy, but I realized that there are other guidelines that have been funded by the Samueli Institute and others that are coming out. Could you tell us a little bit about those? What do we look forward to when it comes to more evidence-based guidelines in these areas?

Dr. Richard Lee:

Yes. So there are a total of five guidelines that are being funded by the Samueli Institute, so we're very appreciative of that funding to really help the field move forward and provide these kind of consensus practice guidelines. In addition to pain, we have committees working on anxiety and depression and integrative therapies. There's another one on fatigue integrative therapies. And lastly, another topic is looking at sleep and integrative therapies, so we hope that every year we'll be having a published guidelines to help everyone from patients to practicing cancer clinicians providing them what's the current level of evidence around these integrative therapies to help these very, very common symptoms that most patients will experience.

Wayne:

That's wonderful, I'm looking forward to those. And as I know many patients and many oncologists are too. Let me correct myself, these were funded not by the Samueli Institute, but by the Samueli Foundation, different from the Institute in those areas. And so looking forward to those coming out and gratitude to them for that. Well, listen, thank you very much for being so straightforward, comprehensive and for all the work that you're doing in this area. I think this is an important area, very beneficial. Is there anything you would like our listeners to know about, to find out more about this, access them or anything else you'd like to say?

Dr. Richard Lee:

Well, I wanted to say thank you again, Wayne, for inviting me and speaking on behalf of the committee. It was a very large undertaking, having this is my first time really doing a rigorous evidence-based review of integrative therapies for pain and other symptoms, it's the amount of hours and effort has really took a whole village and so appreciative of the entire committee, the Samueli Foundation and the committee chairs of Jun Mao and Eduardo Bruera. I hope it really encourages both clinicians, cancer clinicians, [inaudible 00:29:59] patients to really think outside the box. Like you mentioned earlier on, we don't always have to depend on a prescription, there are effective treatments out there to help patients manage their pain and potentially use less medications, which often come with more side effects. So I think these are great guidelines and I'm looking forward to seeing the upcoming guidelines coming out in the near future.

Wayne:

Well, thank you very much, this is an important step towards going in the direction of care of the future for cancer patients, and you have it now, and that's care of the whole person. And let's hope that becomes a standard part of care and you've contributed a lot to that, so thank you very much and look forward to talking to you again in the future.

Dr. Richard Lee:

Thank you, Wayne, appreciate it.