Building Resilience Through Integrative Medicine

The majority of patients with cancer will undergo surgery at some point during their treatment. Cancer surgery comes with a host of side effects, but integrative medicine, which combines conventional with complementary and alternative medicines, works to facilitate the body's innate healing response. It can minimize the side effects of anesthesia and surgery; enhance perioperative safety, comfort, and recovery; and give patients an improved sense of well-being during a particularly vulnerable time, according to Rosanne Sheinberg, MD, Assistant Professor of Anesthesiology and Critical Care Medicine at the Johns Hopkins University School of Medicine in Baltimore, MD.

"We want surgery to be a little blip on a patient's radar, not fraught with complications and adverse events," she said at the AONN+ Midyear Conference. "This requires a comprehensive, patient-centered approach."

Health status before surgery plays a major role in patient outcomes. One study found that medical treatments only account for 15% to 20% of a person's overall health, whereas behavior and lifestyle factors (tobacco/alcohol/drug use, diet and exercise, sexual behavior, sleep, stress), and social and economic impacts (education, employment, income, family and social support, safety) were major determinants of overall health.

Considering the weight of these factors, Dr Sheinberg argues for a different type of healthcare in the United States: integrative care. This type of healthcare takes into account broad concepts of health promotion, illness prevention, and healthy living and fosters a partnership between the patient and the practitioner during the healing process.

"As a medical system, we need to pay attention to these things that elevate our health and consider all of the factors that influence health, wellness, and disease, including body, mind, and spirit," she said.

According to Dr Sheinberg, a comprehensive, patient-centered approach to the surgical patient should take into account such factors as psychological preparation, perioperative nutrition, nonpharmacologic approaches to pain, prevention and treatment of nausea and vomiting, promotion of sleep in the hospital, and strategies for recovery. "Start with less invasive interventions, and work your way up if necessary," she advised.

Although stress is particularly common before surgery, its potential psychological and physiological consequences should not be taken lightly. Psychological distress has been correlated with poorer clinical outcomes after surgery, and physiologic stress can lead to insulin insensitivity, protein breakdown, and a catabolic state that hinders recovery from surgery. Therefore, stress reduction is vital in preparing a patient for surgery and the recovery process.

"We do so much body preparation, but we don't address what's going on in a patient's head—their worries, anx­ieties, rumination—we don't help them deal with any of that in a structured way," she said. "I think stress reduction is one of the most underutilized areas of medicine."

There is no "right" way to manage stress, but effective techniques include breath work (4-7-8 breath), meditation, biofeedback, clinical hypnosis, and guided imagery.

Guided imagery uses the communication links between the mind and body and can be incredibly effective when all of the senses are incorporated. For example, visualizing holding, smelling, and then biting into a juicy, sour lemon can induce salivation and quickly remedy a patient's dry mouth after anesthesia.

Evidence-supported therapies for pain include acupuncture; massage and physical therapy; chiropractic, osteopathic, and myofascial manipulation; cognitive behavioral therapy; stress management and other psychological therapies; yoga and other movement therapies; and aromatherapy. Of these, acupuncture has the most robust body of evidence confirming its role in pain management. Its benefits have long been established, but more recent systematic reviews and meta-analyses found it significantly decreased postoperative pain and lowered postoperative opioid usage and opioid-related side effects.

Nutrition is often overlooked in the perioperative care of surgical patients, but a nutritious diet can mitigate a host of risks associated with surgery. Ongoing or exaggerated stress response has consequences such as hyperglycemia and insulin resistance, which can lead to a higher risk of infection, in-hospital mortality, and perioperative heart attack. Proper nutrition can also lessen the risk of muscle loss, hypertension, tachycardia, and immunosuppression. "Since exaggerated stress response manifests in the body as inflammation, it makes sense to follow an anti-inflammatory diet around the time of surgery," she advised.

In addition to foods consumed, good perioperative nutrition should also place high value on limiting fasting, mobilizing patients, considering regional anesthesia when possible, and employing antinausea interventions. Dietary supplements such as vitamin C and zinc, as well as probiotics (avoiding use in high-risk patients) can also be beneficial in the prevention of surgical complications, with little risk of harm. However, botanicals with antiplatelet, sympathomimetic (stimulant), or sedative effects should generally be avoided before surgery because of the risk of adverse reactions with other drugs.

According to Dr Sheinberg, practicing integrative medicine allows patients to be proactive in their own treatment and recovery. "One of the biggest things patients hate when coming in for surgery is that they lose all control, but this gives some of that control back," she said. "We want to build resilience in our patients, so they can bounce back from surgery."