Integrative oncology involves the use of evidence-based, complementary practices in addition to conventional, standard cancer therapies. Integrative oncology takes a "whole body” approach to treatment with recommendations and therapies that address environment, diet, exercise, supplements, and non-traditional treatments. While many complementary therapies improve quality of life, there is ongoing research to evaluate whether any of these treatments, in conjunction with standard therapy, may also improve survival.
While research is ongoing, solid, high level evidence for most complementary practices is still lacking. Therefore, we choose therapies that have potential benefit and low risk. Despite a lack of evidence, informed recommendations are still needed, because most pet owners will seek such therapies whether we recommend them or not.
First, it’s important to let owners know this is different than alternative medicine. Alternative medicine uses untested therapies outside of clinical trials, and human evidence shows that the use of alternative therapies instead of standard treatments significantly shortens life expectancy. Integrative therapies are used alongside standard treatments and do not replace them.
Environmental factors play a large role in the development of human cancer and likely are significant in the development of veterinary cancers as well.
The most prominent environmental factor associated with humans cancer is cigarette smoke, an indoor environmental toxin. Cigarette smoking alone accounts for up to 1/3 of all human cancers. While our patients don’t smoke, second-hand (inhaled) and third-hand (from residues on fur) smoke are also associated with development of disease. At least one study in cats showed increased risk of intestinal lymphoma for cats in smoking households. Other studies show association between oral cancers and smoke in cats and nasal cancers in long-nosed dogs. In humans, it has also been shown that infants whose parents smoke outside are exposed to significantly higher levels of environmental tobacco smoke (ETS) than the infants of non-smokers. Therefore, we recommend not smoking around pets, or, in a perfect world, we recommend that owners try to stop. It is as yet unclear whether vaping is any better than smoking and is therefore not recommended. Otherwise, herbicides, coal and kerosene heaters, paints and solvents, radon, and asbestos have all been associated with cancer development in veterinary studies. We recommend that owners assess their own household environments, perform testing, and make changes if needed to protect them and their pets. For more information,visit: https://www.niehs.nih.gov/health/materials/cancer_and_the_environment_508.pdf
Cancer patients require the same daily maintenance that other pets receive. Flea, tick and heartworm medications are imperative. Vaccinations should be maintained, though the scheduling may need adjustment to allow vaccines to be given when the immune system is good to receive them. Ideally, re-vaccination with core vaccines should be delayed until 1-3 months after the completion of chemotherapy, though there are indications of an immune system response from most pets to vaccinations given during treatment. There is also evidence of long-term protection for well vaccinated adult pets, which means it’s acceptable for many vaccines to be delayed. Rabies is a killed vaccine required by law, and the concern is whether the immune system will mount an appropriate response in a cancer patient undergoing chemotherapy treatment. The answer is most likely yes; however, titers should be recommended if there are questions of whether and when to vaccinate.
Regular exercise and maintenance of optimal body weight and condition are important for cancer patients. In humans, obesity is associated with several different types of cancer and is considered a significant risk factor. Obesity has been less well evaluated in veterinary patients but associations nonetheless have been made. During cancer treatment, it is recommended that patients work towards optimal body condition. An amputated osteosarcoma patient may do significantly better with 5-10 pounds less body weight. While cancer cachexia is a real and serious condition, it is less common in most veterinary cancer
During cancer treatment, grooming and bathing should be continued. For patients that go to groomers, owners should ask about appropriate timing to reduce risk of exposure to infectious agents that may cause disease and harm. If a patient is receiving IV treatment, it’s advisable to avoid the timeframe 5-7 days after treatment as that is the most common nadir point for neutrophils. It is ideal to check a CBC to make sure neutrophils are above 3000/ul.
Adding a new puppy or kitten to the family can be problematic for a cancer patient undergoing treatment. It’s common for pet owners to consider a new pet; however, puppies or kittens may not be appropriately vaccinated nor protected from severe and potentially lethal diseases. Recently, I had a canine mast cell tumor patient come in for progressive, multi-focal spread of mast cell tumor just a few weeks after a new puppy was purchased from a breeder. Lesions were biopsied, we diagnosed the most severe case of ringworm I’ve ever seen. Coughing or sick pets should be avoided.
Clients often ask about changing the diet. They often switch to diets recommended on the internet or to ones that claim to have the best ingredients. The truth is that they are held to the same, limited standard, and so it’s impossible to reliably know if one diet is any better than the other, as long as they all have the same AAFCO feeding trial evidence of safety. The rest is just marketing.
It’s generally safe to continue feeding commercial, non-prescription diets. However, to optimize nutrition, it may be recommended that a patient switch to a prescription diet, as these diets are held to higher nutritional standards. Two nutritionists I’ve consulted often recommend prescription gastrointestinal diets for cancer patients undergoing treatment.
Another consideration is a homemade diet. There are advantages as the owner knows the quality of the ingredients. Most all online recipes are not nutritionally balanced, and online diets have not been held to similar standards as commercial diets. Two websites that can help: https://www.mypetgrocer.com/ and https://secure.balanceit.com/. However, we recommend phone consultation with a board-certified veterinary nutritionist if an owner wants to home cook. One nutritionists, Dr. Lindsey Bullen, is willing to do phone consultations for a cost. There may be others willing as well. Dr. Bullen can be reached through the nutrition coordinator, Brandi Griffin, at (919) 600-6609 or email@example.com. For all diet changes, small amounts of the new diet should be added to the old diet over 1-2 weeks so that the ratios gradually change until the new diet is fed exclusively to avoid diarrhea.
General recommendations for feeding veterinary cancer patients:
- Target optimal body condition for cancer patients. This may mean gain or loss of weight through dietary modification. This can be done by switching diets or modifying quantities. You do not want to make your patient obese during treatment. Surprising as this statement may be, this does happen more often than cancer cachexia in my experience.
- Recommend a food with <9 grams of carbohydrates/100 Kcals for dogs or <5 grams of carbohydrates/Kcal cats. Cat diets (canned specifically), pediatric diets (puppy, kitten), feline diabetic diets, and recovery diets have the lowest carbs.
- If possible, increase the arginine and EPA+DHA omega-3 fatty acids in the diet. Gastrointestinal and recovery diets tend to have more arginine. Joint diets often have increased omega-3’s.
Picky eater recommendations include:
- Appetite stimulants - mirtazapine is common. There is a compounded 1.8 mg daily formulation available for cats. Entyce is new and still under evaluation. It is not recommended in ill, hospitalized cats.
- Nutritionist recommended food toppers to entice eating can include low sodium tomato sauce (no garlic, onion); low fat cottage cheese (1/2 tbsp adds 5 kcal); plain, lowfat yogurt; low sodium chicken, beef, or vegetable broth; Gerber’s baby food (chicken, beef, or pork); Fortiflora (dietary supplement). These should be no more than 10% of the daily Kcals for a patient.
- Switch bowls from metal or plastic to ceramic or glass. Some humans claim they taste metal when they receive chemotherapy and they do not like anything that reminds them of the taste.
Diarrhea recommendations include
- Bland diet
- 1-2 tbsp canned pumpkin in the diet
- RxClay is a product tested for chemotherapy-associated diarrhea.
- Metronidazole - while inappropriate use of antibiotics is a real issue, metronidazole often works quickly and well for chemotherapy associated diarrhea.
- Immodium - some use and recommend it. I mostly avoid it.
Believe it or not, exercise has some of the strongest evidence to support its use both to improve quality of life and extend survival in human cancer patients. It’s reasonable to assume the same might apply to our patients. General recommendations are at least 150 minutes of exercise per week.
There is strong evidence in human medicine that mindfulness practices (yoga, meditation, massage, etc.) improve quality of life. We truly don’t know how to translate this to veterinary medicine other than to recommend belly rubs and petting in a way that your pet enjoys on a regular and daily basis. Pets are highly attuned to our stresses, and so mindfulness as a pet owner may have an impact on your pet’s quality of life. Please see the following article: https://www.sciencealert.com/your-dog-enjoys-praise-more-than-food-according-to-a-new-study
For patients with pain, acupuncture may help to play a role. It will not cure a tumor, but there are patients who are responsive to this modality. Discuss with your oncologist, as this therapy may play a role in pain management for certain patients.
There is no evidence-based research to suggest supplements improve survival in cancer patients. Anecdotal successes, small case studies, and in vitro (laboratory) studies indicate exciting possibilities, but rigorous clinical trials in cancer patients have not shown clear support. Some supplements can cause harm. Therefore I ask clients to discuss all supplements with me first. There is a group that has set some standards for the animal supplement market, and we recommend that you check whether supplements have been evaluated by this group: https://nasc.cc/members/. Some supplements to consider:
- Probiotics - The microbiome is defined as all of the microorganisms (bacteria, viruses, fungi) that inhabit our bodies. The microbiome is important, because our bodies contain many more of these microorganisms than human cells. It may be astonishing, but there are an estimated 30-50 trillion bacterial cells and only 30 trillion human cells per body. These trillions of microorganisms usually co-exist peacefully with us and some promote health; however, there are bacteria that can and will cause illness and disease. Alterations of the gut microbiome occurs in patients with certain diseases, and treatment to restore the gut biome to a more normal state has been shown to be a successful treatment for some diseases in both human and veterinary medicine. Why is this relevant to cancer? Recent studies (Vet Comp Oncol. 2017 Nov 20, J Small Anim Pract. 2017 Oct 13) have shown significantly altered gut flora in canine lymphoma patients when compared to healthy, normal dogs. It may be that cancer causes these changes, or it may be that these changes help, in part, to cause cancer. Also, chemotherapy and antibiotics both can change gut bacteria, and it makes sense to maintain normals as much as possible during and after treatment. Research is still early on the benefits of probiotics for veterinary cancer patients, but it is reasonable to recommend them based on research in both human and veterinary medicine. One recommended human product evaluated in the veterinary literature is https://www.visbiome.com/. There is a veterinary formulation of this product available. Veterinary probiotic formulations include Fortiflora and Proviable. For more information, the following lay article has information about human medicine: https://www.nytimes.com/2017/11/06/well/live/unlocking-the-secrets-of-the-microbiome.html?&moduleDetail=section-news-5&action=click&contentCollection=Health®ion=Footer&module=MoreInSection&version=WhatsNext&contentID=WhatsNext&pgtype=Blogs
- Omega-3 fatty acids - These are anti-inflammatory fats that can be found in flaxseed, walnuts, and fish-based diets. They can also be found in appropriate ratios to omega-6 fatty acids in various prescription kidney, digestive, and joint diets that can be prescribed. Fish oils are often recommended supplements. These should be mercury free and can be sprinkled on the food. The dose for a cancer patient would be, roughly, 70 mg/kg/day total dose divided and given with food. Please note the total daily dose in pets should be considered as supplements + diet. A dose higher than 100 mg/kg/day will make a pet smell fishy, and an optimal, combined (diet plus supplement) dose would be 130-180 mg/kg/day. Doses that are higher can be dangerous.
- I’m-unity (Turkey tail mushroom) - There was one study of dogs diagnosed with hemangiosarcoma that showed better than expected results. There were few dogs tested, and more research is needed to prove the benefit of this supplement. Happily, additional clinical trials are ongoing. This is a mushroom-based product and at least showed no harm. There are many formulations, but this is the website for the product involved in veterinary clinical trials: http://www.imyunity.com/
- Vitamins - There is little evidence to support their use and some evidence to support that they may do harm. It is best to receive nutrients through diet, whether that diet is a home-cooked one or whether it is a prescription diet that we have suggested. For patients who are not eating a standard, well-balanced diet, a daily multi-vitamin (Centrum or children’s vitamin depending on patient weight) may be considered. However, it is optimal to seek consultation with a board-certified veterinary nutritionist.