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Join us as we delve into the growing interest in holistic approaches to cancer care with Wayne B. Jonas, a family physician. We explore the benefits of integrating complementary therapies, such as nutrition and exercise counseling, mindfulness, meditation, and yoga, into traditional cancer treatments. Wayne shares his expert perspective on how oncologists can effectively initiate these conversations early in the cancer journey and address challenges in incorporating holistic care. We discuss the evidence supporting integrative therapies, the role of health care team members, and strategies to make these therapies accessible and affordable.

Wayne B. Jonas is a family physician.

He discusses the KevinMD article, “Science supports it and patients want it: Bringing whole-person care to cancer treatment.”

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Transcript

Kevin Pho: Hi, welcome to the show. Subscribe at KevinMD.com/podcast, get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Wayne Jonas. He’s a family physician, and he co-wrote the KevinMD article “Science supports it and patients want it: Bringing whole-person care to cancer treatment.” Wayne, welcome back to the show.

Wayne Jonas: Thank you. It’s good to be here again, Kevin. Appreciate it.

Kevin Pho: We were talking offline, you were last on about a year ago. Go to KevinMD.com/podcast to search for Wayne’s name, story, and prior episode. But today let’s jump right into the KevinMD article that you co-wrote, “Science supports it and patients want it: Bringing whole-person care to cancer treatment.” What’s this article about?

Wayne Jonas: So this article is an attempt to summarize a new book that my colleague Alyssa McManamon, an oncologist, and I wrote about healing and cancer, bringing whole person care back into practice and cancer care, where we really talk about the need to pay attention to the person, not just the tumor.

When you get diagnosed with cancer, we have a whole industry that is driven largely by fear, around this idea that cancer is simply a cell gone rogue. Most of our treatments are focused on putting a hammer to it and trying to eliminate it. And in that process we have forgotten that there’s a person there, and that the cell is actually derived from the person, and that by supporting the health and well-being of the person, what matters to them in their life, you get optimal care, better quality of life, and even better length of life in those areas. So it’s an attempt to really rebalance the treatment of the cancer with the care of the person.

Kevin Pho: So tell us what the situation is like today with cancer care. You mentioned that a lot of the focus in today’s medicine is on the tumor itself, without the holistic approach to patients. So give us an example or story of what cancer care is like today, and what are you trying to fix?

Wayne Jonas: Well, if you get diagnosed with cancer, suddenly you go in and you get hit by an entire industry that backs up a huge system that tries to see if they can get rid of it immediately, as rapidly and quickly as possible. Usually, still, even today, even with the evolving immunotherapies and targeted therapies, which are great, by the way, but for the vast majority of people you get hit with chemotherapy, surgery, radiation, that damage the cancer obviously, but also damage the body and the person.

And depending on where you are in the cancer journey, sometimes the treatment can be worse than the disease. And sometimes the outcomes, if you’re an older person, may not be length of life, which that treatment is based on, but may actually be quality of life and the type of life that you have.

And so finding out what matters to the person right up front, right at the beginning, and then adapting that so that they can have the best quality of life, they can actually live their life and not get subsumed by an attempt to kill the cancer only, is what this is about.

And now this is supported by science, by basic science. We have a huge amount of information now. If there’s one thing the war on cancer did, by all the investments starting back at Nixon’s time and others, and the moonshot now, we have generated a huge amount of knowledge about the biology of cancer. And we know that it’s simply not a cell that just happens to behave badly, it is something that develops within an environment. It’s called the tumor microenvironment. There’s 10 to 12 hallmarks in biology that show how that works, with the macro environment, with your behavior, your lifestyle, your diet, et cetera, your sleep, your social support, all have an influence on that environment.

And that can have as much impact and influence on what happens to the cancer and what happens to you as the treatment itself. And so the science supports it, patients are looking for it in these areas, I can tell you a little bit about that, but it’s also the right thing to do. Most oncologists know this and they want to do this, but they’re really caught in a system that still focuses on the hammer.

Kevin Pho: Now, you’re a family physician. What would be an example of a patient, for instance, that would be treated for cancer perhaps at the expense of quality of life? So what would be an example of that?

Wayne Jonas: Well, there’s a lot of examples of that, and new treatments that come out have to now check for quality of life, and have to look at, is this tolerable toxicity, for example, that goes on from a treatment. But it’s more than simply the toxicity.

If a person engages in wellness, let’s take for example fatigue. There’s a guideline that just came out from ASCO, the American Society of Clinical Oncology, and the Society for Integrative Oncology, we were co-sponsors of that, on fatigue. And they showed that actually movement, exercise, even a small amount, not necessarily the American Heart Association’s 150 minutes of moderate exercise, but even getting out and walking 30 minutes a day, simple, even gentle walking 30 minutes a day, can have an impact on function, on quality of life, and can reduce the side effects from cancer.

How many people talk about that, though, when they go in to get the cancer treated? They usually talk about, well, just rest, we’ll give you drugs to mitigate those side effects. But they don’t focus on how to enhance your wellness components that can equally, if not in some cases better, reduce those side effects and help you incorporate those types of things into your life. Same way with sleep, same way with diet, same way with social support, which has a huge impact not only on quality of life but even the chances of how long you live.

Kevin Pho: So what specific interventions are you proposing as part of the holistic approach?

Wayne Jonas: So the first step in holism, this is not boiling the ocean, Kevin, this is not like adding everything to the pile. The first thing is really finding out what the person wants. OK? And they don’t always know what they want. If they’re young, they may say, all right, I want everything, not knowing what everything is. And so you have to work with them through the process to find out what matters. If they’re an older individual, they may want to have a particular experience or a particular event or a particular relationship for as long as possible.

I’ll give you an example of this. I had a man with advanced bladder cancer consult me recently, and he thought that his oncologists were terrible, he was on the wrong therapy, they didn’t coordinate what was going on, et cetera. And I spent 30 minutes with him exploring what was the most important thing in his life right now that he wanted to make sure he did.

As it turns out, his daughter was supporting him, but she lived over an hour and a half away from where he lived, and to get that support it was a big burden on her, and he hated that. He knew that was a process he was trying to avoid. What he ultimately needed to do is, he needed to move closer to her without losing the good care that he was actually getting. He was on the right treatment for his cancer, but nobody had talked about what he needed in order to get his most important outcome, what mattered to him.

And so then we had to arrange for a warm handoff to another oncologist, without missing a beat for his treatment, and allow it to be done closer to where his daughter was. She happened to be getting married, often the case where there’s an event going on, and so that he could be there, not be a burden, and yet still rely on her support. That’s an example of paying attention to what matters.

The second thing is paying attention to four areas of a human being that we know facilitate well-being, quality, and happiness. And those have to do with the external environment that you’re in. We know that nature, and the social environment, the economic situation, can make a difference. We know that behavior, sleep, nutrition, activity, et cetera, those wellness activities continue to support you whether you’ve been diagnosed or not. We know that social and emotional support, so I ask all of my patients, like this person I just told you about, where’s his social support?

That was the key aspect for him. In order to find out what really works you have to do the mental and the spiritual component in those areas. So that’s what we’re talking about when we talk about whole person care. And then just having a system to support that. It isn’t the oncologist, it’s their team. And in the book we write about team members and we give lots of examples of how that’s being done around the country, in systems really all around the country, with practical tools that are on our website on how to actually do it.

Kevin Pho: Are you finding a substantial number of oncologists aren’t asking what the patient goals are? And if so, why is that happening?

Wayne Jonas: You know, I think oncologists are really trapped in many ways, like much of medicine is, more and more in sort of a volume component. There is an explosion of new information just about cancer treatment going on, and it’s very hard to just keep up with it, as well as keep up with the volume of folks you have to see. Most physicians are now employees of systems that are paying attention to the bottom line, and they want to see you generate revenue. And that’s very difficult, to ask these deeper, more subtle but more important questions for quality of life and for person-centered care. And so it’s a real challenge to do that.

We’ve tried to create some tools and illustrate how it can be done in the book. In fact we have a whole chapter at the end of the book on how to implement these things into your practice improvement processes. We know, for example, that some of these things can actually save you money. Maybe not if you’re in a volume-based, fee-for-service kind of thing, you’ve got to do more procedures. But if you’re looking at the whole bundled care, if you’re looking at the value of the entire care that you provide to a person throughout the cancer journey, paying attention to the person and their wellness components can actually save money in those areas.

But your business folks, your system leaders, have to be convinced of that, and they have to see how it happens. So pay attention to that and begin to implement it in a way so you can document that kind of both savings as you improve health care and quality of life.

Kevin Pho: So walk us through a successful example where an oncologist may include some of the concepts that you mentioned in your book and incorporate some of those holistic concepts into their care. What would that look like?

Wayne Jonas: So we spent two years putting tools together with a network of oncology leaders from around the country, putting together practical tools and clinical scenarios that you could do this, as well as examples. And again these are all summarized in the book. I summarized some of them in your article there.

First thing they can do is take something called the personal health inventory, which we originally derived out of the Veterans Administration and then adapted for non-VA, and then specifically oncology settings. And it actually has a set of questions that you can ask, that, the patient I showed you before, took less than 30 minutes to do that.

So sometime during the intake process, talk to the patient about what matters to them and explore that with them periodically as they go through their journey. Inform them that getting engaged in their own care, through attending to sleep, paying attention to their nutrition, paying attention to activity, social support, those things can improve the quality and mitigate the side effects and improve their outcomes. And so revisit those periodically, and there’s a set of questions in the personal health inventory that I just mentioned in those areas.

And out of that you can integrate that into your cancer treatment plan. And there’s some examples in case conferences, for example, where they take those questions, they put them together with the tumor treatment, and then they have a discussion and come up with the optimal plan for a patient. So those are simple tools. First thing, take the personal health inventory and bring it into your own life, and then bring it into a discussion with your team, and then look at, how can we integrate this in the beginning, all the way through the end component of cancer care?

Kevin Pho: I’m a primary care physician like you. Is there anything that we can do for our cancer patients as an adjunct or supplement to what’s going on with their interactions with their oncologists?

Wayne Jonas: Yeah, absolutely. It’s interesting, most of these kinds of whole person discussions often go on in primary care, if you’ve got a good, trusted primary care relationship, because the oncologist often doesn’t have time to do it, or they’re not set up to do it. And so you end up talking about it with your primary care.

And so important communication and collaboration between primary care and the oncology team is essential. And in fact we give several model examples in the book where they’ve specifically done this, where they’ve set up either enhanced communication and interaction, or they’ve even embedded primary care physicians in the oncology center, so that they actually then are designated with this type of thing.

So I think there’s a huge role for primary care. And again, it gets back to integration and less disintegration and siloing of medical care, which is so frustrating in all of health care right now.

Kevin Pho: We’re talking to Wayne Jonas. He’s a family physician. We’re talking about the KevinMD article “Science supports it and patients want it: Bringing whole-person care to cancer treatment.” Wayne, as always, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Wayne Jonas: Yeah, so I think one of the most important things that you see in all medicine, and it’s talked a lot about but it’s a challenge, is the importance of relationships, of trusted relationships. Patients want to have confidence, and you want to have confidence that you know them. They want to know that you have their best interests, not just around the tumor but around them.

And so this process of exploring what matters develops those relationships. It’s rewarding, and so it enhances joy in practice and increases patient satisfaction. And as we’ve shown in the book, and I show in the article, the science supports it, from basic science all the way to clinical epidemiology. And so it’s just good evidence-based medicine.

Kevin Pho: Wayne, thank you so much once again for coming on the show and sharing your perspective and insight.

Wayne Jonas: Thank you, Kevin. Appreciate it.