Transcription:
A Holistic Approach to Cancer Care and Symptom Management

Dr John Leonard:  Welcome to Weill Cornell Medicine CancerCast, conversations about new developments in medicine, cancer care and research. I'm your host, Dr. John Leonard. And in this episode, we'll be talking about a holistic approach to cancer care and symptom management.

I'm very happy to have today's guest here with me, Dr. Chiti Parikh, who is the Executive Director of the Integrative Health and Wellbeing Program at Weill Cornell Medicine and New York Presbyterian Hospital. Dr. Parikh is board-certified in internal medicine and integrative medicine with additional training in functional medicine, medical acupuncture and ayurveda. Dr. Parikh's approach combines cutting edge Western medicine with the ancient wisdom of Eastern traditions for a truly holistic and integrative approach to patient care.

So Chiti, thank you for joining us today. This is a really a topic or a set of topics, I should say, that is of great interest to our patients as you know. You deal with cancer patients as well as many others with the approach you bring to care. And certainly, the quest for knowledge of our audience is really high in this area. So thanks for joining us.

I wanted ask you, integrative health and integrative medicine is a very broad area, how did you find yourself in this discipline of medicine?

Dr Chiti Parikh: So what drew me to integrative medicine was I actually grew up in India and I always joke around that I probably learned to meditate before I learned to walk. So combining Eastern and Western approaches was nothing new for me.

And when I went through medical training, I realized that Western medicine is very good at treating acute symptoms and what Eastern medicine is very good at is addressing the whole person , not just the body, but also the mind, feeling somewhat connected with the community.

So I thought, why not combine the best of both worlds? Why can't we practice the best of cutting edge Western medicine and bring in the wisdom of Eastern traditions that has been around for thousands of years? So that's exactly what drew me into this field and that's what I bring to my patients.

Dr John Leonard: So before I get into some thoughts about what patients should consider these types of approaches, first, I'm going to ask you what is ayurveda? That's a new term for me and maybe for some of our audience. What is that area?

Dr Chiti Parikh: Yeah, thanks for bringing that up. Ayurveda is the traditional Indian medicine. It comes from the Indian sub-continent and has been around for almost 5,000 years. It goes far back. And it's very similar to traditional Chinese medicine and acupuncture is part of traditional Chinese medicine. So when you think about acupuncture, traditional Chinese medicine or Oriental medicine, or ayurveda, these are all health sciences that go back thousands of years and you can compare them to our Western medicine approach.

Dr John Leonard: So the term integrative health, there are a number of other terms that are used, as you talk about this kind of group of medicine. The terms that come up include, as you know well, complementary medicine, alternative medicine. Maybe kind of give us your take on how you think about these and how patients should think about these as part of their care particularly if they have a diagnosis of cancer, but perhaps for other scenarios as well.

Dr Chiti Parikh: Certainly. So the term integrative has evolved a lot and it started out as the term alternative medicine. Then it became complementary medicine. And now, it's referred to as integrative medicine. And I'll give you a simple example to highlight the key differences between these terms.

So for instance, let's say I was recently diagnosed with high blood pressure and I went to my primary care doctor and they prescribed a medication for me, but I was hesitant. So I said, you know, "I decided not to take the medication, but instead I decided to take some herbs or supplements." So I chose to do something that was an alternative to what conventional medicine recommends.

On the other hand, let's say I started taking the blood pressure medication. But on the other hand, I also started thinking about losing some weight and exercising every day. So I started walking and cutting down on my salt intake. But the person who prescribed me the medication, my primary care doctor, doesn't necessarily know about my exercise regimen or what kind of diet changes I am actually making. So that is complementary, where someone is practicing the conventional medicine approach. But on the side, they're also doing something else to help their underlying condition. Whereas integrative medicine brings all of these approaches that are evidence-based under one roof.

So now, when I go to my doctor who diagnosis me with high blood pressure, besides prescribing a medication, they're also counseling me on my diet, my exercise and helping me reduce my stress level, because we know that all of these components play a role when it comes to addressing and treating high blood pressure.

So that's what the integrative approach really is. It's combining all of the evidence-based medicine into one treatment plan for the patient and customizing it to what they need.

Dr John Leonard: So before we get into the details of certain aspects of integrative medicine, clearly, some areas that no doubt have benefit to patients and have been well-studied and well-supported, and I know those are areas that you and your team are very expert in.

But it seems to me like there's some areas that come up that patients hear about that may be attractive for one reason or another, but perhaps are less well-established and, in some cases, even concerning or potentially detrimental. Before we get into the more proven and the more established areas, kind of how patients should think about approaching this kind of field or the broad category to make sure that they're pursuing directions that are more robust or more, I don't want to say legitimate, but at least more evidence-based as you alluded to versus some of the other things out there that perhaps might be less well-established or even concerning.

Dr Chiti Parikh: Absolutely. That is a very important point to make. So the reason why integrative medicine or just this whole field has become so much more popular, especially over the last decade or so is because of two reasons. There is certainly much higher public interest in some of these modalities, but also there's significant amount of research that have come on board in the last 10 years.

And I'll tell you what has been the key driver behind this. So I want to introduce a very important resource for our audience, and that is NCCIH. It stands for National Center for Complementary and Integrative Health, which is one of the subsidiaries of National Institute of Health or NIH.

To give you an idea, NCCIH came about back in the '90s. And when it was created, the funding for NCCIH was only a couple of million dollars, which is not a lot considering the amount of money it takes to do thorough high quality research. But in 2020, the funding for NCCIH over time has grown significantly and is now up to $150 million.

So because of this additional funding over the last decade or so, that has really helped bring up a lot of high quality evidence behind many different modalities that we'll discuss today. So what I always counsel my patients on is be very mindful of where you're getting your information. So a place like NCCIH is an excellent source of information if someone wants a quick summary of research behind different modalities.

So let's say someone is interested in acupuncture, but they're not sure what is the research behind it, what can it really help with? You can actually go to NCCIH's website and just type in acupuncture, and it will give you a summary of the latest research behind acupuncture. Not only that, it will also give you a guide on ongoing current research trials, that if someone is interested in, they might even be able to participate in these trials.

And the other resource is Society for Integrative Oncology. About five years ago, several top researchers in the field of cancer across the United States and Canada came together from top institutions, such as Cornell, Columbia, Sloan Kettering, MD Anderson, University of Michigan, and all of these top researchers came together and they developed a system to review the latest evidence behind several integrative therapies. And they put together their guidelines, which are also endorsed by the American Society of Clinical Oncology. So this list of guidelines gives you a sort of a summary of the best evidence behind modalities that can really make a difference when it comes to supporting patients who are going through cancer care.

So these two resources, Society of Integrative Oncology and NCCIH are two excellent resources that can give you the most updated, the most scientific evidence behind different therapies. And the information on these websites, it's very easy to read and it's really fascinating the amount of research that has come out and how easily it is available and accessible to general public.

So instead of reading just a blog post or some comments on social media or something like that, I really empower my patients by giving them the best resources where they can spend some time researching and finding for themselves whether certain therapies are actually evidence-based, safe and effective, or are they sort of questionable and can do more harm than good.

And always, always discuss with your doctor, whether it's your primary care doctor or your oncologist before beginning any type of modality or taking any vitamins and supplements. And especially at Cornell, we have our Integrative Medicine Center. So often oncologists at Cornell will refer patients to us and we're happy to dig deeper into these topics and figure out what would be the most effective and safe therapy for our patients.

Dr John Leonard: So that sounds like a great resource and a great way for patients to get an entryway into sorting out what areas might be helpful to their individual situation. And I hope that people will take advantage of that, because it sounds very, very useful.

So over the next few minutes, I want to take a couple of different topics. And I recognize that, you know, you probably can give lecture for an hour on each one of these, and there's a lot of literature, but I want to give people a little bit of a preview or a little bit of a summary of the high points of some of the key areas that often come up in patients' questions and sometimes in patient care, because there are some benefits.

So the first one of those is acupuncture. Can you describe to everyone what are the key areas that acupuncture can potentially be helpful with? And perhaps what's involved with actually doing acupuncture? People may have a view of some of the media presentations or thinking of all these needles what tends to be involved in that type of procedure and how it can be helpful in the big picture, particularly for cancer patients?

Dr Chiti Parikh: In the last few years, acupuncture has become very popular in mainstream media. And like you mentioned, there's a lot of images that people must have seen with someone getting acupuncture with needles all over their body. So one of the first things I like to introduce my patients when it comes to acupuncture is understanding that acupuncture is part of traditional Chinese medicine, which again goes back thousands of years.

And the concept of acupuncture is to balance your body's own ability to heal itself. So optimizing the body's ability to heal by reducing things that are getting in the way such as inflammation and optimizing the body's ability to reduce stress hormone levels and optimize healing.

Acupuncture is provided by a licensed acupuncturist. And these providers are actually trained for several years and they learn acupuncture in accredited schools across the country. And there are also many physicians who are trained in performing acupuncture and they're all licensed to practice it. So, first thing you always want to make sure that if you're getting acupuncture, that it is by a licensed provider.

And the most recent research studies, detailing acupuncture's use and efficacy, have focused on certain key symptoms that many cancer patients experience either from the cancer itself or as a side effect from the chemotherapy or other types of treatments, they might be undergoing.

And some of the most common symptoms such as nausea, vomiting, dry mouth, fatigue, anxiety, depression. All of these have been shown in recent studies to be significantly alleviated by the use of acupuncture. And the benefit of acupuncture is that the symptom relief can be relatively quick and also it is safe and effective.

So sometimes patients might be limited by the number of medications they can take. So if medications are not always an option or the medications are not working as well, modalities such as acupuncture can be a great adjunct. I really love introducing the concept of using acupuncture early on with my patients to address some of the early signs and symptoms, whether it's again from cancer itself or from side effects from treatment. So addressing things like nausea, vomiting, fatigue early on can really help patients go through the entire course of treatment and help them tolerate the treatment better so they can get the right dose for the right duration that will be best for them.

Dr John Leonard: So when you referenced nausea and pain as an example of places where acupuncture can help. Those are, unfortunately, relatively common problems for cancer patients at one time or another, yet it seems to be a minority of patients that actually go through the process of trying acupuncture. Are there particular people or patient profiles that should perhaps ask about this? It seems unlikely that everyone who's going to have nausea from chemotherapy is going to jump to acupuncture in addition to their nausea medications. the other question is do these tend to be one-time things? Are they things that people do once a month, every few weeks? What's the usual course for some of these situations?

Dr Chiti Parikh: I typically recommend acupuncture early on for patients who are going on treatment therapies that are going to have the largest profile of side effects. For instance, if they're going on chemotherapy followed by radiation, then we expect a multitude of some of these side effects. So instead of having to take medications with each and every side effect, something like acupuncture can address many of these symptoms altogether.

So patients who are expecting multiple side effects from pain to nausea, vomiting, fatigue, acupuncture can be a one of those things that can address a lot of these symptoms very easily. An acupuncture treatment regimen is typically about commended by the person doing the treatment and offering starts out as a weekly treatment. And it can often be increased depending on the timing of the chemotherapy regimen. So sometimes we might even recommend coming in twice a week during the days and weeks you're getting active treatment. And perhaps on the off weeks, you can come in maybe once a week or once every other week. So it is really customized to the individual and depends on the symptoms they're having and the severity of their symptoms. But on average, one session a week is what we recommend.

Just to give you an idea, there was a recent study actually with patients with advanced gynecological cancers and they reported a significant reduction in pain even after just five to seven treatments sessions. And what was really interesting that the effect of a reduction in pain actually lasted up to 10 months, even without further treatment. So you can see that even within five to seven treatments, there can be significant benefits the patients will see, and the effect can be relatively long-lasting versus some certain medications, the effect can be immediate, but you might have to take the medication on an ongoing basis to get the relief you're looking for.

That's why acupuncture is a great adjunct to our current armamentarium when it comes to different medications and things we can do to alleviate symptoms. So I always recommend acupuncture as one of the first things as planning to address some of the side effects that we anticipate that will happen as the treatment progresses.

Dr John Leonard: The next area I wanted to move to is one that really has been an important, and I don't want to say popular, but getting a lot of attention in that, the issue of medical marijuana. Patients may come to their cancer treatment or their cancer situation. Some of them have never used marijuana in the past. Some have used it for other purposes, perhaps their own enjoyment before they received a cancer diagnosis.

And often patients say, "Can I continue this?" or "can I try this?" and it seems to me like the issue comes up most commonly. And I have to say, in my practice, it tends to be the patient asking about it, more so than the doctor in many cases, rightly or wrongly. But it seems like nausea and pain are probably the most common scenarios where people ask about that. So what are your thoughts and recommendations about that and who should consider medical marijuana as a treatment approach?

Dr Chiti Parikh: So medical marijuana has been in the news or marijuana in general has been in the news recently a lot, especially with a lot of states legalizing recreational use of marijuana. But I want to highlight a key difference between a recreational use of marijuana and medicinal use of marijuana. There's a key difference here.

When marijuana is used as medicine, it is highly regulated by the state and each state has their own regulation when it comes to which diagnosis that it's approved for. So I'll speak for New York State. So in New York State, there's a whole list of conditions that medical marijuana is approved for it. One of them is cancer.

As you mentioned, medical marijuana is very effective and is a great adjunct to treat symptoms such as pain, nausea, vomiting, and also anorexia. So when it comes to medical marijuana, there's key differences in how it's used. So people always have the image of smoking marijuana, right? But medical marijuana in New York State is actually available in tablet form. So it can be used in a tablet or a capsule form. It can also be used as a tincture, sort of a liquid drops that go underneath your tongue, or it can be used as a vaping pen. There are many different modes of delivering the medical marijuana depending on the effect you're looking for.

So when someone is experiencing severe pain to a point where they cannot take anything orally, because they're extremely nauseous or they're vomiting, then the vaping part of medical marijuana can be very helpful. And this is very different than vaping tobacco or something like that. The vaping pen is essentially using the oil for medical marijuana and just vaporizing it. So it doesn't have any harmful substances that you would typically see in other recreational vaping. So this is often a lifesaver for certain patients who really cannot take anything orally and they don't have access to IV medications at home.

The other thing is personally I've found medical marijuana to be very effective in some of my patients who suffer from neuropathy. Neuropathy is one of those common effects that we see from certain chemotherapy drugs and can be very challenging to treat. And some of the effects of the neuropathy can even linger on after you have successfully completed the regimen of chemotherapy.

And I find certain types of medical marijuana combinations to be highly effective to treat neuropathy. It can also help in nausea, vomiting. And it can actually help a lot with stimulating appetite. Some patients do struggle with maintaining their weight when they're going to chemotherapy, because they're just not able to eat the same amount, keep anything down either because of ulcers in the mouth or nausea. And they have a really hard time trying to eat because their appetite is just gone. And medical marijuana can really help with improving appetite and help you maintain the weight. So these are the conditions that I often use medical marijuana in patients.

And also I think about medical marijuana is a good option for slightly long-term use when it comes to addressing some of these symptoms because things such as pain, neuropathy can linger on many weeks, even after chemotherapy or radiation treatment is over. It's not a good idea to be on opiates for a long period of time. So medical marijuana can be an option to help patients transition off of opioids much sooner than they would have otherwise.

I think as medical professionals, we can certainly do a better job at including medical marijuana as part of our treatment plan for our patients. It is safe. And especially as we focus on reducing opioid use, it can be a big ally for us and can really be a blessing for certain patients struggling from really challenging conditions such as neuropathy.

Dr John Leonard: So many of our listeners are in different parts of the country or the world, but just very briefly for those that are in New York, that's where we're located. What is the procedure that's needed to arrange this in New York State?

Dr Chiti Parikh: So, this is a common procedure across many states. So just so you know, over 40 States in the United States have a medical marijuana program. And it's very soon to be 50 states even the next year or two. So no matter where you are getting care, I think medical marijuana is far more accessible than it used to be.

The first thing I encourage you to do is go on your particular state's medical marijuana website. And there, you can find a provider under a directory that is trained in using and prescribing medical marijuana. And you can even ask your oncologist or your primary care doctor if they work with a doctor that is trained in prescribing medical marijuana.

So after you find a provider, you make an appointment with them, you discuss your condition, your symptoms, and then the doctor will certify you to be able to get medical marijuana. It is a very quick process in New York State. When I see a patient for medical marijuana, it takes about five to 10 minutes to gather all the information and certify them online. The whole process is done online. It can also be done over the phone. And then the patients get a medical marijuana card in the mail or they can print it online. And once they get the medical marijuana card, they can go to a local dispensary.

So medical marijuana, at least in New York state is not available in your regular pharmacy. You have to go to state-certified dispensaries, which are actually very easily available nowadays because there's so many of them opening up. They're highly regulated by the state. So you go to the dispensary and then you obtain your medical marijuana products from that particular dispensary.

That is the typical process and the whole thing can be done within 24 to 48 hours. So it is becoming more and more accessible. I really encourage you to start your research by going to your state's medical marijuana website. And there, you'll have all the information you need to get started.

Dr John Leonard: Great. I now want to move to another area and I'm going to lump them together, although I know they're different, that is the concept of yoga and meditation as kind of an adjunct to care. How can these sorts of techniques be helpful to cancer patients?

Dr Chiti Parikh: They can be very, very helpful. And what I like about yoga and meditation is once you learn the basic concept, that it's something you can do on your own any time. It doesn't really require many resources versus other things such as acupuncture or massage requires you to go somewhere and sometimes can be costly versus yoga and meditation are very inexpensive to learn and incorporate into your daily routine.

So I'll start with yoga. Many studies have shown that yoga can be very effective in helping with fatigue related to cancer. Also it helps in improving your mood and we all know that exercise helps us feel good because of endorphins. But it can also help us prevent symptoms such as anxiety and depression.

In fact, one study found that practicing a seven-week yoga routine was able to reduce the likelihood of developing depression and anxiety by up to 65%. So it's a significant change. And if it can help us prevent anxiety and depression, it is really an amazing modality. It's often seen as a way of exercise. But it's more important to not only look at it as the way of exercise, but actually as a way to improve your overall physical function.

So functional well-being is very important as any oncologist or any doctor would know that we often take into consideration the underlying well-being of a person's physical health when we think about how well can that person go through chemotherapy. So that's why yoga is a great thing to incorporate into your daily routine to build up your physical strength and stamina. And yoga can be done, like I said, anywhere by anyone. It doesn't have to be something like turning yourself into a pretzel or doing a headstand. I always tell people that yoga can be done even lying in bed because one of the foundations of yoga is breath techniques and relaxation-based breathing techniques can be done anywhere by anyone.

And one of the great resources, if you're interested in learning yoga, is something called Yoga for Cancer. Yoga for Cancer is a nonprofit organization that certifies experienced yoga teachesr in certain training that is really focused on patients with cancer. So if you just go on Yoga for Cancer's website, you'll be able to find a certified practitioner in your area that you can work with to learn yoga movements for your well-being. So I highly recommend that resource.

And the next thing is meditation. And meditation is one of my favorite modalities, because once again, it can be done by everyone and anywhere. So, as we all know, you know, diagnosis of cancer can be a highly stressful event, not just for the person who is going through the cancer diagnosis, but also the family and friends for that patient, right? So meditation is something I really engage, not just the patients in, but I also encourage them to bring their caregivers, their family members, and I teach meditation to all of them, because it is a great tool for everyone because it can help address not just stress, but also reduce anxiety, improve quality of sleep and decrease fatigue.

So there's a lot of research behind meditation and I want to highlight one particular resource for you. It is a eight-week meditation course, which is called mindfulness-based stress reduction. And there is a ton of research behind this course. And one recent study that came out actually was conducted over five years. This was a randomized control trial, which is a very high quality research trial conducted over five years that looked at patients who had completed breast cancer treatment. And what they found with women who had completed breast cancer treatment, who took this eight-week meditation course experienced significant improvement in their depression scores and their physical and psychological well-being and the develop much better coping capacity.

Not only that, besides the subjective benefits, researchers also found a significant increase in their T cell and NK cell activity. These cells are very important for your immune system. And they also saw a change in the lymphocytes scores. So again, you can see how something like meditation done in a formalized manner can have a significant impact on not just subjective experience in reducing stress and improving mental health. They're also objective markers of improving your immune system.

And MBSR course is offered at many different academic centers. Many hospitals are now offering mindfulness-based stress reduction courses. So I highly encourage you to go on MBSR's website and look for a location near you that offers this course.

Dr John Leonard: So the last area that comes up very, very often and I'm sure there's a lot of interest amongst our audience members in this is vitamins and supplements. This is obviously a big business. It's obviously something that is out there advertised. People are very interested in this area and it seems to me like there are some potential benefits and some potential pitfalls that can come up. So how do you advise people to approach this sort of area in their cancer care?

Dr Chiti Parikh: As you mentioned, the whole vitamin supplement industry is really a big business. It is a multi-billion dollar industry, right? So when you talk about business, their motivation and their sort of key strategy is earn the maximum amount of profit as they can. And they're often not regulated by the FDA. So they can get away by making claims that are often not substantiated by any research, versus there's a whole body of research that is supporting the use of vitamins and foods or diet or nutrition as a way to address a lot of the things that we're talking about.

I'm a strong believer in food as medicine. So if someone comes to me asking questions about supplements and vitamins, I always ask them, "What is the ultimate goal?" if the ultimate goal is to improve the overall wellbeing of someone's physical health, then I often tell them to start with nutrition first, because nutrition is foundational. No amount of vitamins or supplement can be used as a replacement for a proper diet. Hence, I always start with diet first and then, if needed, I will recommend certain vitamins and supplements after I do a thorough evaluation.

I treat vitamins and supplements with same level of seriousness as I treat medication. So if I'm prescribing a medication, first thing I want to know is what is it that I'm prescribing this medication for? So we must have a very clear picture and indication for why we're using a certain vitamin or a supplement. And I often rely on blood work and detailed lab tests to understand if someone actually needs a certain vitamin or not.

So if someone is taking vitamin D or B vitamin or multivitamin, I often start the diet first. Then I check their blood work to see if they're falling behind in certain vitamins. And if they are, I will recommend the appropriate dose to make sure that that is the right dose to treat the level of deficiency that they're encountering. And I repeat their blood work in a timely manner to make sure they're responding well to the treatment I'm offering them.

So that's why for my patients, I always tell them to treat supplements and vitamin with the same level of seriousness as medications. They're not benign. They can do harm when they're used in a dose that is out of range or that is used in a way that is not appropriate for the condition they are treating.

So anytime when it comes to supplements and vitamins, you must consult with your physician first and allow the physician to do a thorough blood work to see if you are lacking in any nutrition vitamins or micronutrients, and then supplement as you need to.

So I always start with food first. And if in question, I encourage my patients to meet with either their doctor or a dietician in our practice. So if your doctor can not give you the full picture, when it comes to nutrition or supplements, I recommend meeting with a registered dietician that works closely in the hospital that you're getting treatment. And there are many fantastic registered dietician that are experts in helping patients who are going through cancer treatment. They can take into consideration some of the side effects from chemotherapy you might be experiencing that might be limiting your ability to intake certain nutrients or absorption of nutrients. And they can help create a diet plan that might be most suitable to help you maintain your weight, but also maintain the amount of nutrition they should be getting throughout your treatment plan.

So again, always consult with the experts first and make sure you're taking these vitamins and supplements with the same seriousness as you would with any prescription medication.

Dr John Leonard: So vitamin D is one area that comes up a lot. I work with lymphoma and there've been studies correlating vitamin D levels with outcome. That being said, we're doing studies right now actually to see if supplementing vitamin D helps. I know people are mindful of that and it's a complicated area. What are some of the other more commonly relevant supplements or vitamins that one might want to ask about if they meet with a nutritionist or talk to their doctor? Ones that at least have a bit more data behind them or that you could consider thinking about in the right circumstances, as you said, under the appropriate guidance.

Dr Chiti Parikh: One of the most common ones people ask me about is obviously vitamin D and also B vitamins. And B vitamins can be very helpful, especially when someone is experiencing something like neuropathy, it is important that we measure levels of B vitamins to make sure they're at the right amount. And the nutritionist can guide them in different food sources that are very high in B vitamins.

Another one I commonly come across, especially in recent days is vitamin C, Vitamin C is often touted as a very helpful vitamin for your immune system. But with anything, I always tell people to keep in mind that the dose makes the poison. More is not always better. Just because vitamin C or any vitamin is good for you, it doesn't mean you take more and more.

The right dose at the right time can be very therapeutic, but the inaccurate or inappropriate dose can actually be harmful. So someone with a history of something like kidney stones or gallstones needs to be careful with using vitamin C. And anyone using vitamin D also needs to be careful because vitamin D along with other vitamins, such as vitamin A, E and K are fat-soluble vitamins. So when they're fat-soluble, that means you can actually overdose on these vitamins and get too much of it. So that's why it's very important to monitor blood levels of these vitamins and make sure you're taking appropriate amounts. And consult with your dietician to discuss different dietary sources of these vitamins.

And another one that often comes up is fish oil. So fish oil is common and many studies have shown that fish oil can have an anti-inflammatory effect. But again, there are certain supplements such as fish oil that need to be taken with caution because the fish oil can also thin your blood. If you're about to go through any type of surgery or if you're taking chemotherapy where your platelet counts might be suppressed or if you're taking any blood thinners, such as Coumadin or Lovenox, you need to be very, very careful in taking the supplements such as fish oil, because it can thin your blood and lead to higher risk of bleeding.

So these are the cautions that I would encourage our listeners to pay particular attention to and discuss either with their physician or with their dietician.

Dr John Leonard: Well, thanks for covering the key points of these major and important areas over the last 30 minutes or so. There's a lot to talk about. Any other kind of key takeaways that you think cancer patients should keep in mind as they think about managing the side effects of their cancer care and treatment and ways that integrative health approaches can be useful to patients?

Dr Chiti Parikh: Diagnosis of cancer can be very frightening and it seems like a long journey ahead. And what integrative medicine offers is a support system. It gives you options and really creative solutions to help easier journey along this path. And integrative medicine team members, whether it's your acupuncturist or your dietician or a physician, can work very closely with your oncologist and help you build a treatment plan that is customized to your needs.

So, whether it's focusing on nutrition or adressing symptoms like controlling stress, I just want our listeners to know that there's so many options out there that are research-based or evidence-based, that are safe and effective. So I really encourage you to keep an open mind and really look into some of these options that can be extremely supportive and can ease your journey along the way.

And also, it's not just about taking care of yourself during the treatment of cancer. As we know, thanks to modern advances, a lot of people are successfully beating cancer. So I also use integrative medicine modalities as a way to keep you healthy in the long run. So even after you beat cancer, some of these basic things that we talked about such as diet, stress management can be fundamental in keeping you healthy for many, many years to come.

Dr John Leonard: Well, I think you've also highlighted a theme that comes through many of our episodes on this program and that's the importance of a multidisciplinary team in the care of a cancer patient, where if you're treated at a center that can access all of the different practitioners and resources for patients that can come together and help the different dimensions of patient care, it really can make the journey easier for patients and improve outcomes. Examples, like the fact that we all have a shared medical record that we collaborate together, I think, at a center like Weill Cornell and New York Presbyterian is really nice to make these connections happen and to make sure everybody's in the loop.

So thank you, Dr. Parikh, for highlighting these issues for our listeners. I think it's been a very helpful discussion and I think we'll likely have you back in the future to talk in more detail about some of these topics because I know there's a lot more to cover, so thanks very much.

Dr Chiti Parikh: Thank you so much.

Dr John Leonard: I'd like to invite our listeners to download, subscribe, rate, and review CancerCast on Apple podcasts, Google podcasts, or online at WeillCornell.org. We also encourage you to write to us at cancercast@med.cornell.edu with questions, comments, and topics you'd like to see us cover more in depth in the future.

That's it for CancerCast, conversations about new developments in medicine, cancer care and research. I'm Dr. John Leonard. Thanks for tuning in.

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