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Integrative and Palliative Medicine Synergy: Structures and Solutions

Article  in  Journal of alternative and complementary medicine (New York, N.Y.) · September 2020
DOI: 10.1089/acm.2019.0398

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Cardinal Health Specialty Solutions Levine Cancer Institute
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 JACM
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 26, Number 9, 2020, pp. 775–777
ª Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2019.0398

Integrative and Palliative Medicine Synergy:

Structures and Solutions
Danielle Gentile, PhD, Sarah Blake, MSPAP, PA-C, Rebecca Greiner, PhD, PA-C,
Tiffany Kneuss, PharmD, BCGP, CPP, Latoya Spencer, DNP, MSN, RN, NE-BC,
Susan Yaguda, MSN, RN, Chasse Bailey-Dorton, MD, MSPH, and Armida Parala-Metz, MD
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Keywords: cancer, integrative oncology, interdisciplinary health care, palliative medicine, symptom management

and depression among other symptoms.5 When symptoms are

C ancer patients and survivors often experience high
symptom burden well addressed by integrative oncology
(IO) and palliative medicine (PM). IO is ‘‘evidence-based
cancer care that utilizes mind and body practices, natural
products, and/or lifestyle modifications alongside conven-
tional cancer treatments to optimize health, quality of life,
and clinical outcomes.’’1 IO is distinct from alternative
medicine that is used instead of conventional treatments.2 PM
‘‘improves quality of life for patients and families during life-
threatening illness through prevention and relief of pain and
other physical, psychosocial, and spiritual problems.’’3
These definitions reveal common philosophies among both
fields, which emphasize interdisciplinary person-centered care
to enhance quality of life and reduce suffering.4 Cancer and its
treatments are often associated with fatigue, pain, neuropathy,
nausea and vomiting, appetite changes, sleep disorders, hot
flashes, shortness of breath, sexual and fertility issues, anxiety,
controlled, quality of life and adherence to cancer treatments
(i.e., chemotherapy/biotherapy, radiation, and surgery) and
survival are improved.6–9
Within the Department of Supportive Oncology at Levine
Cancer Institute (an academic hybrid multisite community-
based cancer institute), 14% (255/1782) of patients with IO
visits (including clinical consults, healing touch, oncology
massage, and acupuncture) also visited PM between January
1, 2018 and July 31, 2019. There is limited data on how this
compares with other oncology settings, yet it reflects an
intentionally blended care approach. IO and PM can achieve
synergy when a flexibly defined business plan and innova-
tive solutions to barriers are in place. The purpose of this
commentary is to describe 10 structures that foster synergy
between IO and PM (Table 1) and five barriers and solutions
to integration of the two fields (Table 2). These structures

Table 1. Ten Structures For Integrative and Palliative Medicine Synergy

Structure Example(s) Benefits
1. Collaborative Weekly grand rounds describe clinical information, challenges, Diverse perspectives enhance
departmental and developments in each field. Weekly research meetings clinical practice and research.
meetings provide interdisciplinary feedback to researchers.
Interdisciplinary team meetings to discuss complex clinical
cases. Virtual participation is available for off-site attendees.
2. Referrals between When appropriate, PM patients are referred to IO for consult Holistic interdisciplinary care is
IO and PM and/or integrative modalities (i.e., acupuncture, healing delivered.
touch, and massage).
IO patients with complex symptoms are referred to PM.
Patients may also be referred from IO and/or PM to
additional services across the Department of Supportive
Oncology (i.e., nutrition, rehabilitation, senior oncology,
survivorship, navigation, and psycho-oncology).
(continued)

Department of Supportive Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA.

775
 Table 1. (Continued)
Structure Example(s) Benefits
3. Highly trained Many professionals are trained, certified, or experienced in Optimal care is provided.
professionals oncology (e.g., oncology-certified nurses, fellowship-trained
integrative medicine physician and advanced practice
provider, fellowship-trained hospice and PM physicians,
board-certified oncology pharmacist, advanced oncology-
certified nurse practitioner, oncology-experienced music
therapist, and acupuncturist).
4. Philanthropy and Scholarships are available for self-pay integrative modalities All patients can benefit from
grants (i.e., acupuncture and massage). integrative modalities.
5. Collaborative Studies involve acupuncture (IO modality) for pain (often Methodological approaches are
research treated by PM). enhanced, recruitment is active
across multiple clinics, and
more patients can participate in
high-quality research.
6. Employee exposure Trainees, clinicians, and administrative support staff are Departmental culture explicitly
to IO and PM exposed to or cross-trained within IO and PM. values the synergistic benefits
of IO and PM.
7. Clear leadership Cohesive services are delivered across the institution by Both fields have designated
within each field clinical and administrative leaders. administrative and clinical
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leaders. Administrative leaders

provide expertise and advocate
for services. Clinical leads
ensure services are aligned
with clinical treatment goals.
8. Comprehensive The supportive oncology pharmacist offers medication review Patients benefit from potentially
clinical assessments and reconciliation (i.e., prescription, nonprescription, herbs, decreased risk of adverse
acknowledge IO and supplements) to identify drug-related problems. IO and effects, drug–drug and drug–
and PM treatment PM clinicians frequently communicate with each other (e.g., herb interactions, and
approaches ‘‘hallway consults’’) about the benefits of diverse treatment polypharmacy that may lower
modalities. costs and medication burden.
9. Executive Leadership advocates for IO and PM through recognition that Nonrevenue-generating services
leadership support both improve quality of life and may reduce hospital (e.g., music therapy) are
readmissions, and emergency visits.1 maintained.
10. The nation’s first Employees are oriented to Planetree principles that value Formal recognition of person-
outpatient Planetree quality of life and holistic care for patients, care partners, and centered care is consistent
designation: a health staff. with the core tenets of IO and
care certification PM.
of excellence in
person-centered care
IO, integrative oncology; PM, palliative medicine.

Table 2. Five Barriers and Solutions To Incorporate Integrative and Palliative Medicine
Barrier Solution(s)
1. Patients and medical professionals Patients and medical professionals are educated through written promotional
misunderstand the scope of IO and materials, the cancer resource center, and presentations (e.g., community forums,
PM. institution-wide grand rounds, support groups, and community events).
2. Additional health care visits are Visits are scheduled adjacent to other medical appointments (e.g.,
potentially burdensome due to already chemotherapy infusion) to maximize efficiency.
demanding health care utilization.
3. Services may be difficult to access Transportation resources and scholarships for self-pay services are offered.
due to transportation and lack of
insurance coverage.
4. Interventions by initial clinician may Clinicians communicate options, use validated symptom assessment, and electronic
mask efficacy of additional distress screening to determine patient preference for initial and subsequent
interventions. interventions. Clinicians and patients practice shared decision making.
5. Difficulty hiring scarce integrative Trainees (e.g., medical residents and fellows) rotate through IO and PM to
and palliative professionals with improve exposure, education, and promote interest in the fields. Residency
specialized training. and fellowship program directors, professional organizations, and conferences
are contacted during recruitment.
IO, integrative oncology; PM, palliative medicine.

776
 INTEGRATIVE PALLIATIVE STRUCTURES
and solutions may be adapted and implemented within other
health care organizations.
These 10 structures and five innovative solutions to barriers
allow IO and PM to converge as collaborative interprofes-
sional teams. The American Society of Clinical Oncology,10
National Comprehensive Cancer Network,11 and multiple
scholars4,12,13 emphasize the importance of PM within on-
cology. Likewise, integrative approaches to cancer care are
also recognized as beneficial.14,15 IO and PM can ameliorate
the physical and psychologic stressors that negatively impact
cancer patients’ and survivors’ quality of life. Both fields
value mental, physical, social, and spiritual well-being
beyond cancer treatment. The person-centered principles
of IO and PM also provide patient-empowerment opportu-
nities.16–19 Through strategic integration of the two fields,
holistic multidisciplinary health care is possible.
Acknowledgments
The authors thank Declan Walsh, MD, for his review of
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the article and members of the Department of Supportive
Oncology for their suggestions and support.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received to support this publication.
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Address correspondence to:
Danielle Gentile, PhD
Department of Supportive Oncology
Levine Cancer Institute
Atrium Health
1025 Morehead Medical Drive
Charlotte, NC 28204
USA
E-mail: danielle.gentile@atriumhealth.org