Chapters Transcript Video The science of integrative oncology Historically, cancer treatment has always been modality-focused or treating the cancer cells or the tumor tissue, remove them by surgery, treat them with chemo. But what we can do more is uh treating cancer patients as a whole person level, which means their, the rest of their body, the rest of their mind, their quality of life, their symptoms, their enjoyment of life. So that's the area uh there's a lot of work can be done and UCI. Uh, it's a young institution, so there's the mindset is different, uh, they're not afraid of experimenting things, also, uh, incorporate, uh, new cutting edge technology in this. Hi, I'm Lindsay Carrillo, Business Development director at UCI Health. Hi, I'm Doctor Sunil Verma, Associate Chief Medical Officer of Ambulatory, and I'm also an otolaryngologist here. Welcome to Physician Huddle by UCI Health. Today we're joined by Doctor Gary Dang, our new program director for integrative oncology at UCI Health, and also the director of clinical affairs at the Susan Samuelli Integrative Health Institute. Welcome, Doctor Dang. Thank you. Nice to be here. Tell us a little bit about what, what you do and what brought you here to UCI Health. So I've worked for about 23 years in New York City's Sloan Kettering Cancer Center, uh, building their integrative oncology program, and UCI has this major initiative and drive to incorporate integrative whole person care model, first into their cancer center, next to the whole UCI health system. So, I was honored to be approached and uh I think this is uh UCI helps give us a great open space to build something innovative, transformative, and that really attracted me. So, here I am. So you talk about innovative and transformative. How different is the program that you're putting together compared to what's been offered here at UCI Health or just what's here in the region? So the way I frame it is, historically, cancer treatment has always been modality focused or treating the cancer cells or the tumor tissue, remove them by surgery, treat them with chemo. But what we can do more is uh treating cancer patients as a whole person level, which means their, the rest of their body, the rest of their mind, their quality of life, their symptoms, their enjoyment of life. So that's the area, uh there's a lot of work can be done. And UCI, uh, is a young institution, so there's, the mindset is different. Uh, they're not afraid of experimenting things, also, uh, incorporate, uh, new cutting edge technology in this. So, I think this is a great place for me to be. And is this what you're trained in? Are you a trained medical oncologist or tell me. I was trained in internal medicine, but I've been working in the cancer field for 30 years, first at MD Anderson Cancer Center, then at Sloan Kettering Cancer Center. And what I do is mostly supporting cancer patients going through treatment, so that's universally applicable to every cancer patient regardless what diagnosis they have and what treatment they're going through. So you were brought here to basically build this program from scratch. How do you do that? How do you come in and say, I know what I need. I know the building blocks. Take us through that process or like other physicians who are facing the same thing, like, oh, OK, I'm here to just start a program. Uh, UCIA Health has already have a very robust and strong integrated health program, which is the Susan Samuelli Integrated Health Institute, which in my opinion, is the best of the kind in the country, um. But their oncology component has been underdeveloped. So when I came in, I take my expertise and experience, uh, which I accumulated while I was working in New York City, because when I first started 20 years ago, it was a budding emerging field, not a lot of people know about that, so you have to overcome initially, some resistance or skepticism. Uh, eventually you win people over and demonstrate the value that you can provide both for patients and also for the institution. So, I basically use the same approach here, uh, first, uh, but I'm, I think I have the advantage that now is different from 20 years ago, the whole healthcare landscape has changed, people's appreciation of this whole person approach has been changed. So I find my job is a lot easier now because I'm standing on the shoulder of giants who has existed already in this institution. Uh, the first thing you do is, you know, make friends and let people know what you do and what you have to offer. And secondly, you Develop clinical program that's really help people because when patients do better. You gain tractions in the clinical world. Also, I do a lot of research projects and collaborate other investigators within UCI Health and by doing collaborative research, people get to know the science behind what we do, so they know it's not just a feel good medicine, there are actually a lot of scientific evidence supporting this approach. Uh, do patients find you or do you get referrals mostly? Uh, how does the, how is the program built? I imagine at some point when you're at Sloan Kettering, patients would refer their friends or, you know, people maybe that they met even in the clinic or in an infusion center, but tell me more about that. So here in the first few weeks. The patient came to me earlier come from internal referral from the Samuelley Institute because they have a lot of patients that is a captured audience who are interested in integrated health, uh they're also their network. But after a few weeks, I got a lot of referral, actually right now, the majority of my referral patients referred to me came from my oncology colleagues, medical oncology, surgery, radiation oncologist, because they eventually know about my existence and also what I can do for them and for them and their patients. So right now, mostly internal referral, but on the other hand, I also got a lot of external patients from the area hospitals, because they find this is a unique feature offered by UCI Health that were not available or not available to the same degree of comprehensiveness or sophistication in other areas, and that I also, every day I have maybe 2 or 3 patients from outside UCI health. So word is spreading. Obviously this is a popular idea. This is something that is gaining traction in the ether, but you mentioned 20 years ago some of these things were considered like voodoo medicine, and you got some hostility from other physicians. Like, I, I can't imagine that would feel good to have your colleagues questioning you and your expertise or why would you even do this and tell us a little bit about how that journey has been for you. Yeah, so, um. Uh, I am also a licensed acupuncture, right? So, and when we first did acupuncture, Sloan Kettering Institute, uh, the cancer center, uh, in the inpatient setting, and the rounding attending would say, who are these people, what are you doing to my patients, putting a needle in them. So that was back then when acupuncture was like a niche uh modality, but nowadays, it's really mainstream standard of care, especially. Even ASCO, America Society for Interior of Clinical Oncologists, ASCO ASCO in their clinical practice guidelines, they recommend acupuncture for chemo-induced nausea and vomiting. Pain and uh eventually, we hope also for hot flashes and so on. The reason they were able to achieve that is because there's an abundance of clinical research from randomized controlled trials that there's so many of them that we can do meta-analysis, systematic reviews, and demonstrate the benefit. So, nowadays, it's really Not an issue. Uh, we're now pushing acupuncture research to the next level, which is not only showing acupuncture reduce symptoms, pain, headache, nausea, vomiting, hot flashes, insomnia, but also there are basic science laboratory research including animal studies showing it may Change clinical outcomes. Uh, one of the projects I'm actually doing right now is a National Cancer Institute funded clinical trials using acupuncture in patients with emerging sepsis, and we want to see whether providing acupuncture can reduce the deterioration rate and improve mortality. In my study, in my sepsis model, acupuncture can reduce mortality. So if we can reproduce that in human, we're really saving lives. With this simple modality, you may find this is far-fetched. How could putting a needle in people can actually Improve their reaction to infection. So, if you look at the literature, a lot of them are not widely known, but they are there and they are published on Nature Medicine or neuron or Nature, these first tier journals. In mice, when you do acupuncture, you basically stimulate, as a nerve stimulating modality and through the neurological circuitry. The vagal nerve gets activated and send a signal to the adrenal gland to make more dopamine. Also, it reduced the production of pro-inflammatory cytokines. And we know during sepsis is the uh inflammatory cytokines create hypotension and in clinic, we usually give them dopamine or epinephrine or norepinephririne to boost the blood pressure. And here, we hypothesize by doing acupuncture, you actually stimulate the endogenous production of dopamine. By doing that, you're seeing ahead, one step ahead of the body's deterioration. So, this illustrate an example that there is solid science in some of these, what was considered as complementary therapies and 20 years ago was considered just wishful thinking, but now we actually do have both basic science studies and clinical trial data to support them. With that kind of data. It is very easy for other physicians or researchers who have not been exposed to this. More holistic modalities to be comfortable and maybe even incorporate them into their patient's care. So, how do you know if you're, I mean, I imagine acupuncture, there's, I would imagine there's not a lot of MDs or physicians out there that are trained in acupuncture. I'm sure there's plenty though. So how do you know if you're doing it right? I mean, what are the, I mean, it's a model like that where you're monitoring sepsis, I understand, but how do you know when, when you're doing performing acupuncture as an outpatient that you're getting the outcome that you want? Is it something that you can see real time or is it something that you get feedback from patients later on? Some of the effects you can see in real time, uh, some may be that day, later that day or later. And so when you do acupuncture, you have to find the correct body points and underneath the anatomy, there are special structures, usually, they're related to the neuro myofascia bundle. So you basically, if you hit the right spots, you create a, you tap into the neurological circuitry. And create a downstream effects. Uh, one example is for people with nasal congestion or allergy, and actually one of my family members had that problem and she has to use pumps every day. Uh, if she doesn't use it in the morning, she will be sneezing and with all this congestion. So we put a needle in the LI 20 point, which is next to the nose. I did that on her and she would say, oh, it opens up, and then I do another one on the other side, it's opened up and one treatment. It's gone I didn't have to do repeat treatment. She was free of that for what, what you're saying is you're going to get rid of otolaryngology as a discipline, you know, there's no sinus surgery apparently. I don't think you do surgery for nasal congestion, right? If you have a structural problem, tumor, acupuncture is limitations, you know, think about it's more anything that's tend to be regulated by the nervous system, like blood pressure, uh, this is basically a sympathetic parasympathetic reaction, right? So those can be, uh, acupuncture can help. And what I cannot explain is why one treatment will relieve this long-lasting problem. So we're doing a lot of neuroimaging studies like scanning people's brain, uh, functional MRI studies. There are also people studying neuroplasticity. Uh, basically, when you, it's almost like a switch, a stuck switch is turned to the other direction when you do acupuncture. And it's not a simple reflex, it's a one-time reflex because then when you don't do it, the nasal congestion will come back, but for some reason, it didn't and um when they studied acupuncture for uh using functional MRII study, they found uh one example, the limbic system where people has anxiety, fear, and so on. And they were depressed, the activity is suppressed by acupuncture at certain points, but acupuncture at other points, the other part of the brain actually get activated. So, think about it, it's a very ancient modality, uh, back then, people probably didn't know why it works, how it works, it's just they found, oh, by coincidence in real life, when you hit someone next to their nose, their, their nasal congestion got better. But eventually, now with modern research technology, we can have a better understanding of what it does, it does, yeah, which is the only way to convince physicians if you want them to do anything. Right? I mean, now I'm going to go and find a needle and find LI2 and put it in a patient. what happens. So you touched on a very important point, which is the technique, right? If you don't put it in the right place, you wouldn't have this effect. So this is the area, I think being a physician, we actually have the advantage of knowing the anatomy underneath the skin and I think that's, uh, that's very important. And how you know whether you're doing the right thing or not because you'll see differences. Another commonly used technique for using for acupuncture is pain relief. Lower back pain. And when I was doing a clinical trial at uh uh in New York, and we had a study with patients coming in, uh, walking, limping, coming in. And they did one sessions in the trial, we have a demonstration and then they walked out. So the front desk. If you didn't know, you would think this is staged, but front deck people was astonished, you know, these people couldn't walk and then they left walking. And so those are examples. I'm not saying it will work like that for everybody, for every conditions, but, you know, I'm just using the best example to show, but that's not enough. So that's why we do this randomized control study, you know, they're actually, the control arm is often sham acupuncture. To take away the placebo effects. So how do you do sham acupuncture? You use a needle that, uh, that's not, that's not penetrate the skin. Yeah, exactly, exactly. But, uh, I'm not sure you can do that with a knife, with a scalpel. Yeah, but this way we can tease out the placebo effects from the real effects. That's really amazing. Yeah, that, that's, that's pretty wild. So tell us, um. Tell us a little bit about what other tools you use. I mean, I think you and Lindsay have talked in the past about diet and exercise as being mainstays for improving health, and this is sort of like one of those things like everybody knows, but nobody does. And so, how have you studied this and how do you integrate that to the care that you provide? So we all know diet and exercise is important for diabetes, heart, heart disease, and so on, right? That's old news, everyone knows. What's interesting in that there are emerging evidence showing that actually changed cancer patients' clinical outcomes. That's another thing we want to take the research to the next level. And you know, it's interesting that you say that and I want you to continue on because patients always ask, is there something I can do? At this point in time to make my outcome better. And we often say, I often shrug my shoulders and say, well, make sure you do the surgery I recommend for your laryngeal cancer. But what you're saying is there's more out there. So sorry, please continue. Yeah, exactly, because number one, patients want something to do. This is a very empowering moment for them. And once they actually, you mentioned how could you diet, change diet and exercise, it's hard. But in cancer patients, it's actually not that hard because the diagnosis of cancer. Wake them up, you so you can do more. This is a life-threatening condition. In addition to getting surgery, chemo, radiation, there are other things you can do to contribute to your own treatment. So the studies, there was one study done uh published a couple of years ago uh at the EAO. What they did is they just changed people's diet, uh, lifestyle during neoadjuvant chemotherapy for breast cancer and they found for those who changed that, the complete pathological response rate, the PCR rate. Uh, in the group got chemo only was 30%, in the group who got chemo plus lifestyle changes, it was close to 50%. And of course, it was a secondary endpoint, so it needs to be confirmed by a larger study we did that's a primary endpoint, but this signal is important because if you think about something patients can do, can improve the response rate, that'll be great. And the other thing is there's emerging evidence showing we always in integrate health, we always talk about lifestyle changes, which is diet, nutrition, exercise, stress management, sleep and circadian rhythm, the biological clock, social environment, and positive things in life like fun, joy, meaning. So there are mice studies showing if you stress the mice or put the mice in social isolation, tumor grow faster because adrenaline stimulate angiogenesis, and again, this paper published on Nature Medicine. Also, uh the recent study, even here at UCI uh studying the circadian rhythm and they found when. Uh, again, they did it in the mice model. When the mice have to messed up circadian rhythm, tumor grow faster, their immunotherapy worked less well. So if you just change, and also when, when you give the therapy, immunotherapy or chemo, if you give it in the morning, it works better than give it in the evening because the cells, the cancer cell growth and also the immune function, uh, fluctuate during the day and you want to synchronize that with that. And again, these, if you, these are published on Nature Cancer, right? So, the thing is, if you ask most physicians, they wouldn't know about this because that's out of their area of expertise, sometimes they just have too many papers to read anyway, and they don't read this, so it is our job to show uh there's solid research out there and actually, these simple things can be incorporated into the overall care of cancer patients and possibly lead to a better outcome. But I also sort of think back, I mean, just in my last 24 hours of being exhausted and not sleeping well and talking about stress and then not eating. So, you must have a great lifestyle because you have to, I imagine at some point practice what you preach. Oh, I, I sure do because patients can see right through you if you're not authentic, right? Um, so, uh, that's why we always say if you want to change people's lifestyle, you have to change their mind. And they have to rearrange their life priorities. Sometimes we're too caught up on the little things we have to do and forget in the bigger theme of things, the bigger picture in my lifetime, what are really important and what are not so important. So, once we change people's mind, it's easier to change their lifestyle and we, we have different tools for each patients, when I see patients, when I interview them, uh we really are not looking at. Only their medical problem. We're looking at them more like a person or a friend. What would make this patient tick? What's important to them that you can use to motivate them and inspire them to make changes. Um, one example is oftentimes we say, well, you don't, if you, it's hard to diet and exercise, right? Don't do it for yourself. I know it helps your health, but don't do it for yourself. Do it for your children, for your grandchildren. Because they want to see a happy and healthy grandma. Who live longer and see them graduate. You know, that's a very powerful motivator. And so when you do that, they rearrange their life priorities and say, well, instead of flipping through social media, maybe I should do meditation and learn meditation to reduce my stress or maybe I spend the last half an hour of my day to relax my mind. And clear my mind so I can go to sleep better rather than working on what I have to do tomorrow, right? So there are all these little tricks that we call patient-centered, uh, you know, interview that we can incorporate. So, what's um, what's next? What's on the horizon in your field? So in the horizon in my field, um there are several, as I mentioned earlier, we want to take the research and clinical practice to the next level. One is to demonstrate hard outcome, hard endpoints in research. And so far, they are the so-called subjective uh soft endpoints, but they're emerging evidence as I mentioned. You actually can improve survival or treatment response rate. So that's the first. The second one is make it seamlessly part of standard of care. Uh, when we treat patients, we just, we treat not only their disease, we treat their whole person and we cover, we put, I put it this way, I put cancer in the context of this whole patient and I put patients in the context of their psychosocial, cultural context in their life. So, this is a little abstract, but we also have training program to teach residents and fellows to at least be aware of this approach. So when they see the patient next time, they, they put on different lens and uh and, and, and help those patients better. Let me ask you something. Almost all physicians, regardless of our specialty, are going to interact with friends, family, or patients that have cancer. What tools do you give to us who don't deal, frankly deal with cancer every day, to be better people or better physicians to manage and to work with patients? I think uh just the same as you're dealing with another loved human being, you listen to them, not just passive listening, you'll do so called active listening. What exactly why they're saying that, what's behind it, the words they're saying, what's important to them, and sometimes just listening is helpful, and then sometimes reaffirming that and then encourage them. That uh because cancer diagnosis is a big trauma and they feel powerless, uh, gives them a little bit power, a little bit self-control, saying, there are all these things you can contribute. And uh feel comfortable saying that because there are a lot of evidence uh uh that support this. So, if you just do that, uh, you'll help them a lot. You know, it's interesting you mentioned that I was with a head and neck cancer patient uh recently and they mentioned at the time of their diagnosis. The physician at the time, and I think we're all guilty of this, was just talking about outcomes and data and outcomes, but the only thing they walked away from in that visit was the doctor saying you're gonna be OK and I'm gonna take care of you, and the rest almost like went to the wayside, and I've been doing this now for 15 years, and that was not part of the education in medical school. The part of the education in medical school, I, at least what I gleaned. Maybe I'm too much of a mathematician was give them the statistics, give them the numbers, provide the realistic outcomes, and I'm now as I get more mature and more into my career, that's not always the best message to give. Sometimes what they wanna hear at the beginning is, I, I hear you this is, this, you feel powerless and I'm here to help you and I'm here to get you better and, and we're gonna do this together. So I, I don't know, maybe you've had, I'm sure you've had, you've treated many more patients than I have with this. But uh what have you learned in this field? Yeah, so what I was doing, uh, when I have a resident or fellow shadowing with me, they go and see the patient, when they come out, I ask them for a report. I don't ask them to give me their standard textbook report, you know, I said, number one, what's the status of this patient? 0, 55 year old woman with ovarian cancer in first-line carboplatin Paclitaxel treatment. And the next question, I said, that's enough. I said, next question is, what does the patient need and what does the patient want? The medical textbook or medical education teach us what the patient need. They need chemo, they need this medication to reduce side effects, but what does the patient want? They are, they, most of the time, they want exactly what you're just saying, you just said, the human part of medicine, what? Treatment they're getting, what does it mean to their life and what's important to them, right? Sometimes uh I use another example which I saw last month, uh, last month. It's a breast cancer survivors put on aromatase inhibitor to reduce breast cancer recurrence, right? Which is great. Cut the breast cancer recurrence rate by 50%. But the side effect of that medication, anastrozole, is diffused joint pain. So I asked, I asked her, what do you, what do you want in life? What gives you pleasure and joy in life? He said, I don't do much, but I love golf and I play golf almost every day. This is a big part of bringing joy to my life. But with this medication, I cannot play golf because all the joints are stiff and hurt. Then what's the point for me to stay on this medication? So what we do is we gave her non-drug therapies including dietary changes, go to the anti-inflammatory diet, acupuncture. And physical stretching, there are lots of yoga stretching you can incorporate and by doing that, instead of just giving her Tylenol or ibuprofen all the time, which is not sustainable, she reduced her joint pain and she can enjoy golf. So, that's very important. What, ask yourself next time you see a patient, what does this patient need, which we, most of us, we all know, and also more important, what does this patient want and give it to the patients. What they want and you'll be thrilled and you get so much satisfaction. I don't know about you, Lindsay, but I'm thinking what I want, you know, I think I need to spend an hour with you outside of the in clinic or wherever it is. Do you do one on one therapy sessions for and and just take me out of all the stress that I that I clearly put myself in. I did wanna ask you though, so I think we all could do better on diet and exercise and stress management and love to hear your thoughts on that too. But I would imagine for cancer patients, those are unique challenges cause like, it's hard for me to get up, but I'm a pretty healthy person and get up and get. On my spin bike or whatever I got to do, and I'm not going through the effects of chemo, which is nausea and pain. So like, how do some of these folks, are, are they realistically able to incorporate these changes because it sometimes it takes a lot of energy and a lot of planning to change your diet, and I think that sometimes it's hard for folks who feel healthy. You're exactly right. So exactly, that's what they mean by. Uh, patient-centered intervention. It's not one size fits all. For one example, uh, I, I saw another patient on Monday who was debilitated, uh, because she has sacropenia, um, not eating, she's an advanced breast cancer patients. So she couldn't walk. I said, well, walk and she has a lot of abdominal bloating and all that. So we said, if you walk after you eat, your bloating will be better. It was simple, you can try it at home. After every meal, walk even in your apartment or house for like 5 minutes, you feel less bloated. If you eat and sit down, you'll have a hard time. So, a lot of what we do also incorporates some of the ancient wisdom from traditional Chinese medicine. In traditional Chinese medicine, they're saying, if you want to live to 1000. Walk 100 steps after each meal, right? So, I told her, I said, you know, try that. I know you, right now, you cannot do 100 steps. Do 1 step, 10 steps, and next week, you'll be able to do 20 steps. And then within 2 months, it's 100 steps. See, we tailor our intervention to the patient's capacity and rather than just say, oh, here's the guideline says 100 steps, you need to do 100 steps, which is not gonna happen. So just do the spin bike for 45 minutes, 45 seconds, and then, then you can do an hour and then you're going to get more. Thank you. What kind of optimism do you have for the future of cancer care, not only in Orange County, but you mentioned being a national leader, possibly like a worldwide leader. Like what's your vision of success here so, uh, We have the pieces. I want to put them together into a cancer care model. This is a whole-person integrative care model where we not only just treat them with anti-cancer treatment, but the whole person, both mind and body. And once we deploy that, we're gonna study that and document outcome. Like patients who did this, they do better both in clinical outcome, uh, both in quality of life and the quantity of life. Once we have demonstrated that. We disseminate it to the rest of the country, maybe even the world saying this is a new paradigm of treating patients that actually have a lot of benefits both for patients, also for healthcare providers and healthcare system. So that's my long-term goal and if I achieve that, I can retire early. Well, you, you, we don't want you to retire quite yet, OK? We just got you. So no, no, none of that quite yet. Well, thank you so much for spending your time with us. We're so glad to have you here at UCI Health. I'm really excited for this future that you have painted for us. It's my pleasure and thank you and uh I'd like to thank UCI Health for giving me this opportunity and this field uh to do something impactful. This has been Physician Huddle by UCI Health. Thank you for joining us. This was an episode of the Physician Huddle podcast by UCI Health, produced by Brett Shaheehan, Angelica Yugubi, and Victor Ting. For more episodes, information on clinical trials at UCI Health, or to refer a patient, view the show notes or visit clinical connection. UCIhealth.org. Created by
